Primary and Community Care: Improving Patient Outcomes

Baroness Finlay of Llandaff Excerpts

Thursday 8th September 2022 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, like others I congratulate the noble Lord, Lord Patel, on raising this crucial debate. I declare that I am a fellow of the Royal College of General Practitioners as a GP—indeed, a medically qualified Dr Finlay—and got my fellowship before moving to hospice work. I am also a patron of the Louise Tebboth Foundation to prevent GP suicides and am president of the Chartered Society of Physiotherapy. I will focus on family medicine specialists—GPs—but we must not forget the major impact that physios and others have on conditions through direct access.

I chaired the Independent Commission on Medical Generalism for the Royal College of General Practitioners and the Health Foundation. Our 2011 report concluded that the generalist approach is essential across healthcare and that if it did not already exist it would have to be invented, while work by Barbara Starfield showed that the health of a nation depended on the quality of its primary care services. I do not believe that that has been dented by Covid.

Patients are the raison d’être of healthcare delivery. People become ill at all times of the day and night, presenting with undifferentiated conditions. Some conditions progress rapidly, in others the course is fluctuating or resolves. In our communities, many people live, work and contribute to society with a broad range of chronic long-term multiple co-morbidities. Some have rare conditions. Differentiating abnormal from the normal requires diagnostic skills and risk-assessment experience. Good primary care training is essential, providing adequate experience in paediatrics, women’s health, acute and early presentations of serious illnesses and the complexities of medicine in the elderly—and now the workload of GPs has become increasingly linked to social problems in society and mental health.

However, the problem we have is that GPs are leaving practice faster than they can be recruited. The 27,500 whole-time equivalents GPs are made up of a workforce with a headcount of around 40,000. As the noble Lord, Lord Hunt of Kings Health, pointed out, there are now 2.5% fewer GPs than in 2019 and 5% fewer than in 2015, but the average GP is responsible for 16% more patients than 10 years ago. More patients need to be seen than there are 10-minute appointments in a day, let alone time for home visits.

Seeing 40 to 60 patients a day, many of whom have complex medical and social problems, for five days a week is unsustainable. GPs become burnt out and leave. They seek work in other areas in medicine, but often in much more administrative or peripheral roles. Many GPs develop an extended role, developing expertise in some branch of medicine, such as women’s health, diabetes or hospice work, or in emergency medicine departments as part of a portfolio of clinical work. They need to carry on working but feel burnt out with the workload of routine general practice.

The GP is the first point of contact for undifferentiated complex problems. They can provide a holistic and comprehensive service for the long-term and acute care of the population they serve in their communities. An integrated approach must address the whole person: the physical, psychological, spiritual and emotional aspects which have led to the condition that has presented. Importantly, there is good evidence that, where continuity of care is in place, there are better clinical outcomes at lower cost, with greater patient satisfaction. We desperately need more GPs—incoming newly qualified GPs—but also to find ways to retain our experienced, highly skilled doctors who are leaving the profession in large numbers.

These doctors are trained family medicine specialists, and they need parity of esteem with consultant specialists in secondary or tertiary care. From that position, some will need to be able to pursue particular special interests, which will support other services such as mental health—thereby combining the family medicine specialist’s interest with some days in community practice—where integration with social care provision is essential.

There have been efforts to increase the numbers of allied health professionals in primary care to help with the shortage of GPs. But there is increasing evidence that, unless these professionals are carefully integrated into the primary care team, they cannot replace the experience and value of a GP. They need support and nurturing. The incoming chair of the council of the Royal College of General Practitioners, Professor Kamila Hawthorne, wants to create associate membership of the college for those allied health professionals who contribute to the primary care team to ensure better integration and understanding between the different disciplines in proper team working. In GP clusters that work well, all disciplines coming together has been shown to improve clinical outcomes and decrease the burden on secondary care. Change will be embraced if those delivering care can lead it and funding issues cannot be ignored in terms of the way that people are paid and reimbursed for their services.

There are other disciplines and services in the community. Hospice home care teams and Marie Curie nurses can be an essential supplement to primary care provision, but they need to be involved early. As many GPs have an interest in palliative care, I hope that the specialty will reopen to those with MRCGP, rather than allowing entry to consultant level training only to those with RCP membership, because their mature clinical experience in the community is invaluable, especially for hospice at home.

We must recognise that the diagnostic, management and risk-assessment skills of the trained GP are essential for our communities and the NHS. Community work is not easy, but it can be very fulfilling if allowed to work properly. The employment of family medicine specialists, with parity of esteem with the hospital consultant body, would allow those who wish for a much more flexible career approach to develop their special interest roles while retaining a firm foothold in family medicine in the community, with all its complexities. Working with their communities, with their own patient population and with all aspects of social care, they can be community leaders.

In the pandemic, around 30,000 doctors were granted temporary emergency registration and over 9,500 have remained licensed to practice until now. At the end of the month, they must apply to restore their registration and for their licence to practise to remain. To date, around 8,000 have not acted despite a streamlined process being in place. Will the Government request NHS trust responsible officers to be available to doctors in their area who wish to relicense?

I have not focused on pensions, but it has aggravated the problem of the loss of GPs from practising. As judges have been given an exemption from the pension cap, will the Government review the pension cap for clinicians? It would be far more cost effective than gaps being filled by expensive locums or leaving services with gaps unfilled and a population without the healthcare it needs.

More medical school places, greater flexibility around revalidation and an ability to have flexible career paths could help supply and retention. However, the problems leading to attrition must be addressed, and the scenario from dentistry is the flashing warning light in front of our eyes.

[Lord Baker of Dorking (Con)]

Before the noble Baroness sits down, I thank her for a very interesting, well-informed speech. She identified the pressures placed upon GPs, which are not going to be relieved easily. Would she welcome what happens in a country such as France, where many—

NHS: End-of-life Care

Baroness Finlay of Llandaff Excerpts

Thursday 8th September 2022 Lords Chamber

[Lord Kamall (Con)]

I return the favour by thanking my noble friend for the meeting, but also for the frequent conversations we have had about mediation, for example. I know my noble friend is a qualified and experienced mediator. We are quite clear that the review has to attach no blame. We want to hear from as many people as possible. It will investigate the causes of disagreements in the cases of critically ill children between providers of care and persons with parental responsibility. It will look at whether and how these disagreements can be avoided, how we can sensitively handle their resolution, provide strong evidence and inform future recommendations to support end-of-life healthcare environments in the NHS. As much as possible, it will promote collaborative relationships between families, carers and healthcare. We can see it from both sides: as a parent, just put yourself in the shoes of someone who has to make these difficult decisions. Sometimes they feel that the medical profession acts like God; on the other side, there are medical professionals who believe that the parents do not really understand all the details. Let us make sure that we get this right.

[Baroness Finlay of Llandaff (CB)]

My Lords, I too thank the Minister for having met me earlier in the week to discuss this issue. When parents receive devastating news, they are in such a state of shock that communication with them, however sensitively undertaken, risks being misunderstood. Parents are unaware of the limitations on their ability to request interventions or transfer for their child, unlike when the child is at home. So will the Minister confirm that the review will take direct, in-person evidence from parents who have been in this terrible situation and who wish to contribute from their experience—not to apportion blame, but to improve care for others?

[Lord Kamall (Con)]

I thank the noble Baroness, Lady Finlay, for the conversations we have had since the passage of the Health and Care Bill. My officials have been incredibly appreciative of her bringing her expertise to this field and, in fact, for educating them—and me—on some of the sensitive issues that people have to deal with in these environments. We want the review to be as wide as possible; we do not want to cut it off; probably the only thing we want to avoid is blame. We want to do this in a sensitive way; we want to hear from the families; we want to make sure it is a balanced review, and we hope to take evidence for the review from as many people as have a view on this. That is why we are taking our time; we have to publish it by 1 October 2023.

Defibrillators

Baroness Finlay of Llandaff Excerpts

Wednesday 15th June 2022 Lords Chamber

[Lord Kamall (Con)]

The noble Baroness raises an important point: while we require defibrillators to be purchased when a school is refurbished or built, one of the things we are looking at is how we can retrofit this policy. We are talking to different charity partners about the most appropriate way to do this. What we have to recognise is that it is not just the state that can do this; there are many civil society organisations and local charities that are willing to step up and be partners with us, and we are talking to all of them.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare that I am patron of CRY, a charity that looks at cardiac arrest in the young. Of the 270 children who die each year, 75% of them would still be alive if a defibrillator had been readily available. Do the Government recognise that, as well as having a defibrillator in a school, one must also be on the sports ground because many of the cardiac arrests occur during athletic activities? Therefore, having only one in a school is inadequate. Will the Government consider asking Ofsted to ensure that there is a defibrillator on every sports ground specifically as well as centrally in every school?

[Lord Kamall (Con)]

As the noble Baroness rightly says, it is important that we get these defibrillators out as widely as possible, including in sports grounds, for the reasons she mentioned. We are looking at how we work with partners in this area; for example, the Premier League announced that it will fund AEDs at thousands of football clubs and in grass-roots sports grounds. Also, Sport England is working with the Football Foundation on this. The defibrillator fund will see AEDs in a number of different sports grounds. We are also looking at other locations and working in conjunction with Sport England and the National Lottery fund. Not only do we have to put defibrillators in place, but people have to know where they are and how to use them.

St George’s Hospital: Patient Deaths

Baroness Finlay of Llandaff Excerpts

Wednesday 18th May 2022 Lords Chamber

[Lord Kamall (Con)]

I understand the premise behind the assertion and the Question but, as I explained to the noble Lord yesterday, a number of issues are ongoing—the coroner’s inquest, an employment tribunal and a number of other reviews—which, sadly, I am not allowed to comment on. However, I can say at the moment that we are committed to improving the standard of patient safety investigations. We have set up the independent patient safety investigation service and HSSIB to look at this, as the noble Lord will know from the Bill, and we have a number of independent investigations guidance for standard operating procedures by NHS England and Improvement for teams to use.

[Baroness Finlay of Llandaff (CB)]

In the light of the criticisms levelled by the coroner over the structured judgment review in particular, will the Government undertake to require the royal colleges and the new bodies set up to look at the procedure used? Although it looked at case notes, it included neither full oversight of previous medical history nor direct observation of clinical procedures, surgical technique—including anaesthesia—and post-operative nursing, all of which have an impact on outcomes. We all know that clinical opinion varies; the point at which a procedure is judged as high risk versus futile varies from centre to centre and can vary within them from one surgeon to another.

[Lord Kamall (Con)]

The noble Baroness clearly draws on her own experience of this. First, we have to wait for all the coroners’ inquests to finish; I think 36 have been completed at the moment. There will then be reviews, to which there is a statutory guideline on when they have to be responded to. However, it is also important to recognise the differences between the coroners’ inquests and the work of the independent mortality review, which was not undertaken to determine the cause of death in individual cases or attribute blame to individual clinicians—it was looking at a number of procedures.

Folic Acid Fortification

Baroness Finlay of Llandaff Excerpts

Wednesday 6th April 2022 Lords Chamber

[Lord Kamall (Con)]

I think the noble Baroness is being a little unfair. It is quite clear that some of the delay has been due to elections, particularly when it has been necessary to consult across the devolved Administrations. Let there be no doubt. The Government are not against this; we are in favour of it. We are having to cover a number of issues—for example, the level of folic acid fortification to ensure that we add an appropriate amount without the side-effects that have been found in older people. We need to standardise the minimum levels of the existing four fortifications—calcium, iron, niacin and thiamine—and to consider exemptions from fortification for products that have minimal amounts of flour. Provisions have to be made for flour used to manufacture ingredients. We have to consider potential exemptions, for example, for micro-businesses and heritage millers. This consultation will start in earnest once the Northern Ireland elections are out of the way.

[Baroness Finlay of Llandaff (CB)]

My Lords, do the Government recognise that the early MRC trial and all subsequent trials have shown that folic acid must be taken before a woman becomes pregnant? Giving supplementation once someone is pregnant is too late because of the formation of the neural tube. Now, with modern haematological techniques, the problem of pernicious anaemia and the confusion with B12 deficiency does not apply nearly as much, because it is easy to measure the levels.

[Lord Kamall (Con)]

In the brief which I received yesterday the recommendation is for a daily supplement of 400 micrograms of folic acid during the first 12 weeks of pregnancy. I am told that this advice will remain. Certain women with a higher risk of an NTD-affected pregnancy are advised to take a higher, 5-milligram supplement. This is why we have to get the right level. Increasing folic acid in flour alone will not solve the issue.

Health and Care Bill

Baroness Finlay of Llandaff Excerpts

Consideration of Commons amendments
Tuesday 5th April 2022 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, as others have spoken fully to other amendments in this group, I will confine my remarks to Motion L1 in my name. I thank the Minister for the open-door policy that he has had and for his willingness on many occasions to discuss with me the problems for parents who can feel completely overwhelmed in the face of not being listened to by clinicians. I am also particularly grateful to the noble Baronesses, Lady Brinton, Lady Masham and Lady Stowell, for their helpful comments and advice behind the scenes, and to the noble Lord, Lord Balfe, who has shared with me his extensive experience on mediation.

In drafting my amendment to the amendment, I was particularly concerned that we must take evidence directly from parents, including parents whose dispute has not necessarily progressed to court. While it is quite extreme to progress as far as court, there seem to be a lot of parents who have felt completely overwhelmed in the face of personal tragedy. In an interview, Rob Behrens, the Parliamentary and Health Service Ombudsman, said about mediation:

“We’ve got to get better at communicating with complainants, better at learning from bad experiences, and better at using early resolution and mediation so that sometimes we don’t have to use adjudication at all.”


He went on to point out some of the cultural characteristics of the health service that make these encounters hard. He listed professional dominance, clinical hegemony, hierarchy and defensiveness as characteristics that make it particularly difficult.

I am grateful to the noble Baroness, Lady Pitkeathley, for flagging up parent carers. They often feel deeply disempowered because they are completely dependent on the help of others to manage a very difficult situation and so particularly inhibited in the face of any professional dominance; of course, there have been some stories in the press.

In response to the Minister, I will gladly be involved in developing the scope of this review. I hope that he will rapidly put me in contact with the official who will be responsible for it because we need to start as soon as possible. The government amendment stipulates a year—actually a very short time to run an inquiry—so it needs to happen quickly. I hope that there will be funding resources attached to this; it cannot be done on thin air or a shoestring. I hope also that there will be support for it to be done properly so that we can take evidence. Developing the scope of the review will be very important and I think there are parent groups who would particularly wish to be consulted at that early stage as well.

In the letter that we were sent, I note that the Government said:

“Should the review make recommendations for legislative change, and the Government agrees with those recommendations, we would seek to bring forward legislation where parliamentary time allows.”


I see that the Government have left themselves a small out, but, if this is to be a properly conducted review with clear recommendations, I hope that they will listen to that evidence and will not shirk at taking whatever steps are necessary.

I conclude simply by thanking the Minister, the Bill team and the other officials who have engaged in many hours of discussion on this issue. I look forward to working with speed on getting this review up and running.

[Lord Bradley (Lab)]

My Lords, I will speak very briefly to Motion Q: Amendments 105 and 105A. I declare my health interests as in the register, particularly my role as a trustee for the Centre for Mental Health.

I was disappointed that the Government did not accept my Amendment 105, which was passed in this House on Report, regarding mental health membership on integrated care boards. I repeat my thanks for the support I received for the amendment from Labour and Liberal Back-Benchers, particularly the noble Baroness, Lady Walmsley, some Cross-Benchers, and from my own Front Bench, my noble friends Lady Wheeler, Lady Merron and especially Lady Thornton, who has been tremendously supportive throughout. I am also extremely grateful for the continuing and unstinting support of organisations outside Parliament, such as the Centre for Mental Health and the Mental Health Foundation.

However, I am satisfied that the Government’s amendment in lieu, Amendment 105A, captures the essence of my amendment: that the voice of mental health should be at the board table at the inception of the 42 ICBs, and play a crucial part from the start in determining service priorities, budget and resource allocation, workforce growth and development, and commissioning arrangements, among other things. The chairs of ICBs will now have responsibility for the appointment of mental health representation and will be held accountable for their decisions. This House, the other place, external bodies, the public and I will all scrutinise these appointments very carefully.

The Government’s amendment, devised by the noble Baroness, Lady Walmsley, and passed on Report, will put a double lock on mental health representation because of its intention to review the skill mix and expertise of ICB membership in the future. We had further assurance in the Minister’s letter to all noble Lords, which said:

“We strongly agree with the principle underpinning Lord Bradley’s amendment and with his view that ICBs will be strengthened by having at least one member with knowledge of Mental Health on the Board. As it stands, however, the current drafting would create significant legal ambiguity, which is why we tabled an amendment in lieu in the Commons to ensure that the principle is maintained in a legally robust way”.


I am grateful to the Minister for this assurance, and I believe that in taking it together with the two amendments, the ambition for parity of esteem between physical and mental health will, as a result, take a further significant step forward.

The Government’s amendment in lieu of my amendment should ensure that the voice of mental health is heard clearly on ICBs and in the wider integrated care system, and that the mental health and well-being services needed and demanded by the public are at the heart of integrated health policy in the future.

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[Lord Rooker (Lab)]

My Lords, in our debate on 31 January, I made the point at some length that it was not possible to trust accreditation of products based on paper and supply chains. I assume that the Minister has been briefed on this. After that debate, on 3 March, he wrote a long letter to me and the noble Lord, Lord Alton, and towards the end of it raised my point about the supply of cotton-based products.

I had explained that it is possible, using the techniques of element analysis, to take a product and find out where the cotton was grown. You do not need paperwork to do that, or trusted supplier chains. The technique and the technology are there. You can find out whether it was grown in Xinjiang, another part of China, or another part of the world. The Minister said in his letter that bidders to the NHS supply chain will have to certify that they are better-cotton-initiative certified. That is the very thing that we need to avoid. You cannot trust paper-based systems of supply. You must use the technology to find out where the cotton is grown.

In the government amendment that has come from the Commons, paragraph 3 specifically refers to cotton-based products—so, given the final paragraph of the Minister’s letter, saying that the NHS supply chain does not have a contract to use the element-analysis services supplied by Oritain, what has happened since? Has there been any contact between the Department of Health and the NHS supply chain with the company that has the technology? I have no interest to declare here. I made it absolutely clear in the debate that this came out of a “long read” in the Guardian way back in September. The technology is there, not just in cotton but in other issues. Here I am just using it for cotton—the uniforms, the mattresses and the products. In subsection (3) of the new clause proposed by Amendment 48A, the Government are going to assess cotton. Have they done anything since our debate in Committee to make arrangements to use the technology, on the basis that you cannot trust paper-based supply chain accreditation? It is a simple question, and I would like an answer.

[Baroness Finlay of Llandaff (CB)]

My Lords, I rise very briefly to support Amendment D1, tabled by the noble Lord, Lord Blencathra. Last night I was part of a BMA web conference mounted by the Ethics Committee, of which I am an elected member, looking at the powerful evidence coming out of Xinjiang province in China. The concern is that, if we are purchasing products from there, we are complicit in the appalling human rights abuses that we were shown evidence of in this webinar. Therefore, I hope the House will support that amendment.

I return to the very important Amendment B1, tabled by the noble Baroness, Lady Cumberlege. This is not just a static situation. It is worsening. All that we have done is not just more of the same; we are actually sliding downhill rapidly. I want to give a little bit of data to the House to support that statement. There are now 1,565 fewer GPs than in 2015, meaning that there is a shortfall of 2,157 against the target that was set by the Government in their manifesto promise, in terms of where we are tracking to date.

The number of fully qualified GPs by headcount has decreased by over 600, so there are now just 0.45 fully qualified GPs per 1,000 patients in England, down from 0.52 in 2015. This means that each GP is responsible for about 300 more patients than previously. In terms of physiotherapy—I declare an interest as president of the Chartered Society of Physiotherapy—the model shows that 500 new physios are needed each year for multiple years to meet demand. There needs to be a trebling of the 6,000 NHS physio support workers. In nursing, the district nursing numbers have dropped from 7,055 in 2009 to 3,900 in 2021, which is a 45% drop. This is all going in the wrong direction. From the data that I could obtain, it looks as if three-quarters of nursing vacancies are filled by temporary staff.

This amendment, tabled by the noble Baroness, Lady Cumberlege, is crucially important. It would be a dereliction of our duty to ignore supporting that amendment, given all that we know and all the work that has gone on. That is not to be critical of the Minister and his team at all, because I am sure that it is not his personal wish that we do not have this in place—but we certainly do need a completely new approach to workforce planning.

[Baroness Tyler of Enfield (LD)]

My Lords, I wish to lend my support very briefly to Motion B1, moved so very compellingly by the noble Baroness, Lady Cumberlege. I simply wish to pick up and echo the telling point from the noble Baroness, Lady Harding, who I think broadly said that if you carry on doing the same thing, you are going to get the same results.

I have had a look over the last week at what results we are getting. We have had the frankly shocking revelations in the Ockenden review, highlighting the really severe implications for patient safety, particularly for women and babies, when there are just not enough suitably trained staff around to do the vital job that they are there to do. I looked at that review last night and found it truly shocking. In the last 24 hours, we have had a Care Quality Commission report looking at Sheffield Teaching Hospitals. It said that they lacked enough qualified clinical staff to keep women and infants safe from avoidable harm and to provide the right treatment. There is also today’s report—it may have been yesterday’s—from the Health and Social Care Select Committee, highlighting the critical NHS staff shortages affecting cancer services in England, meaning that too many people are missing out on that critical early cancer diagnosis which is so vital to their chances of survival.

I know those are the worst things happening and that there are lots of good things, but those things are not acceptable. Things like that are why public satisfaction in the NHS, as the noble Lord, Lord Stevens, said, is sadly going down. That is a real problem; it is the reason I so strongly support Motion B1 and why there is such strong cross-party support for it in this Chamber.

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[Baroness Eaton (Con)]

My Lords, I speak to Amendment 92B in my name. It seeks to reinstate essential, in-person safeguarding checks for girls under 18 when seeking abortion. I have no doubt that the noble Baroness, Lady Sugg, had the best of intentions when she brought her abortion-at-home amendment to your Lordships’ House in support of women’s right to choose in respect of pregnancy. Unfortunately, Amendment 92A leaves a glaring gap: that of the interests of young and vulnerable females. My Amendment 92B is simply about requiring a face-to-face consultation with a qualified health professional for girls under the age of 18.

This is an amendment purely about child safeguarding: specifically, minimising the risk of harm to children through the use of abortion pills. It is not an amendment about the moral question of abortion. There would be no change to where the pills are taken or administered. The amendment is supported by the NHS body made up of doctors and nurses who are the leading experts in the field of children safeguarding, the National Network of Designated Healthcare Professionals for children, or NNDHP.

The NNDHP, which supports safe access to abortion for young people, has released a statement saying:

“All children and young people—those under 18 and in care under 25—must be seen face to face, and the age of the other applicants must be confirmed. The purpose of this position is to clinically assess the mid-trimester risk and prevent coercion and exploitation.”


The network expressed particular concern that phone and video consultations

“enable unseen and unheard coercive adults to influence the patient”

and

“enable pills to be obtained under false pretences.”

These NHS child-safeguarding experts have also raised concerns about the effects of trauma and neglected birth, pointing to evidence of the home use of abortion pills resulting in highly traumatic incidents. These are traumatic episodes, and they point out that children do not have the emotional resources and the brain maturity needed to access support in these cases. Even worse, they are aware that the policy has led to the births of very premature but potentially viable infants.

The Royal College of Paediatrics and Child Health, the UK’s leading professional body for paediatricians, which represents more than 20,000 child health professionals in the UK and abroad, has backed the amendment. It has voiced its support for the amendment due to concerns about the risks to girls under the age of 18 with the at-home abortion amendment that passed in the Commons. The RCPCH has warned of a “glaring gap” in the legislation—namely, children and young people. Moreover, it has asked for children’s vulnerabilities to be taken into greater account as the Health and Care Bill reaches its final stages. The college points out that

“telemedicine can present particular challenges”

for children and young people, and points to the need to

“assess any safeguarding issues as part of the pathway for early medical abortions.”

I have mentioned the views of the NHS safeguarding experts and the royal college that specialises in children’s health, but I would like to end by touching on the story of a 16 year-old girl in his country that demonstrates the need for this amendment. The BBC reported on a girl called Savannah, who took abortion pills at home after a telephone conversation with an abortion provider. The clinic she had spoken to had calculated that she was less than eight weeks pregnant, but she was neither examined nor scanned. She took the pills and, when she felt terrible pain, she was taken to hospital. It was discovered that she was actually between 20 and 21 weeks’ pregnant, and she gave birth to a baby with a heartbeat. Indeed, she said, “My boyfriend said he could see feet”. Savannah said she had been left traumatised and said, “If they scanned me and I knew that I was that far gone, then I would have had him.”

It is hard to comprehend the trauma of an experience such as this for such a young woman. The BBC report highlighted how her case was just one of dozens. Surely, we in this House owe it to our young women and girls, our daughters and granddaughters, to do more to protect their safety and well-being. This is not an amendment nor a debate about abortion or a woman’s right to choose; it is about children’s welfare and enshrining in law the essential protections for girls under the age of 18. This Government, and, indeed, previous Governments, have rightly prioritised children’s welfare, and all of us in Parliament who make laws should keep this in mind.

I am pleased that my noble friend the Minister has understood the very real concerns of many noble Lords and professional bodies in the medical profession. He has expressed a clear commitment to us today to ensure that the concerns are raised and addressed. It is vital that regulations and guidance deal with the safeguarding of young women. My noble friend has committed to working with the Royal College of Paediatrics and Child Health and the NNDHP, and I hope that they will be consulted and will work with the Government to make sure that these extremely challenging and difficult conditions for young women are given great concern and protection in any further work on the Bill. Because my noble friend has given such reassurances, I will not push this to a vote this evening.

[Baroness Finlay of Llandaff (CB)]

I am grateful to the noble Baroness, Lady Eaton, for raising this issue. I should declare that some years ago when I was a GP, I was responsible for looking after three care homes with children with really quite profound psychological disturbance because of what they had gone through prior to being taken into care. I carefully read the briefing from the Royal College of Paediatrics and Child Health. It is very important to listen to that college in particular, which has put out a remarkably strong briefing that also takes account of children up to the age of 25 when they are care leavers.

The last time we debated this I was concerned about contraceptive advice. I therefore contacted an abortion provider to ask about the contraceptive advice provided and was assured that really sound contraceptive advice is part of the telemedicine procedure. Does the Minister have any data on the number of second-time and third-time abortions that are being requested through telemedicine, as compared with those from face-to-face consultation? Certainly, in my time in practice, when one provided contraceptive services, one always felt that when somebody was presenting for an abortion, somewhere along the line one’s contraceptive advice had failed—often because of coercion by the male partner, one way or another. But for those who are emotionally vulnerable it can be very important.

I will address in just one sentence the excellent speech by my noble friend Lord Crisp in relation to his Motion J1. I hope the Government will listen to it, because we cannot carry on allowing the tobacco industry to exploit public health in the way that we have.

[Baroness Barker (LD)]

My Lords, the noble Baroness, Lady Eaton, is a stalwart of these debates and she always takes a view that is contrary to mine. I say at the beginning of my speech that I do not question her integrity in any way at all, but I do question the briefing on which she has based her speech tonight—and I question the briefing from this particular college. It has a public position which says that young women should have the option and be

“actively encouraged to take up a face-to-face appointment”.

That is the policy now; there is no policy that says that people cannot and should not be allowed to have a face-to-face appointment if they need it.

Secondly, this amendment would require there to be a face-to-face appointment, whereas the position arrived at following the amendment moved by the noble Baroness, Lady Sugg, and in the Commons is that a teleconsultation can happen and that, at that point, if it becomes evident that there is a need for a face-to-face appointment, it must happen. As we explained when we debated this issue a few weeks ago, the greatest coercion is on women not to have an abortion rather than women being forced to have an abortion. Professionals, who took great care to design the telemedicine system at the start of the pandemic, made sure that they included safeguarding as an integral part of what they did.

The noble Baroness, Lady Eaton, is right in one respect and wrong in another. There was one case, within the first month of the scheme being set up, where a woman got her dates wrong. That was discovered and that case was used to change the questions and the training. I have to say that I take exception to her saying that there are dozens of cases, because in the peer-reviewed assessments that have been done in three countries, Scotland, England and Wales, that has not been seen to be the case. If anything, professionals have erred on the side of caution when they think that a woman might be approaching the deadline. I am afraid that in this respect I do not think the noble Baroness, Lady Eaton, is correct.

More to the point, throughout the discussions here and in another place, the professionals who have been responsible for not just delivering the services but for making sure that they are within ethical and professional frameworks and are monitored closely took into account all the ways in which they thought that young women and girls might be exploited. They took care to make sure that the services discovered that, and they have. They have found young women who have been trafficked. They have found young women who have been pressurised by partners. They have found young women who were prevented from going out to get contraception and therefore became pregnant.

I do not for one minute question the noble Baroness’s motivation, but I say to noble Lords that if they really want to protect young women and particularly girls, they should reject this amendment and accept the government amendment, which has been informed not just by the work of the noble Baroness, Lady Sugg, and others but by the majority of the royal colleges that practise in this field.

Ockenden Report

Baroness Finlay of Llandaff Excerpts

Wednesday 30th March 2022 Lords Chamber

[Lord Kamall (Con)]

I thank my noble friend for her points. I will take this opportunity to elaborate a bit on multidisciplinary training in the maternity workforce. Some £26.5 million of the £95 million invested in maternity services last year will allow training aimed at how multidisciplinary teams work together. There is a new core curriculum for professionals working in maternity and neonatal services—this is being developed by the maternity transformation programme, in partnership with professional organisations, clinicians and service users, to address variations in safety training and competence assurance across England. A single core curriculum will enable the workforce to bring a consistent set of updated safety skills and continue to learn. It is important that we have collaboration and close working relationships between midwives and obstetricians because that obviously benefits the mothers and babies within their collective care. The noble Baroness has already said that this has to be mother-centred and patient-centred.

I also thank my noble friend for highlighting the fact that the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists have been clear that the professions must work together collaboratively. We expect all maternity services to act on the recommendations.

We also have to make sure that staff feel able to and confident about speaking up, as my noble friend said. The Government have taken this issue seriously. In response to a recommendation from Sir Robert Francis’s Freedom to Speak Up review, we established the independent national guardian, to help drive positive cultural change across the NHS and, in addition, to provide support to a network of local freedom speak-up guardians. We will have to see how that works, what can be done better and how we can improve it. Putting in one measure will not solve all these problems. There is no silver bullet, but one of the reasons to put this in at local level is to see where it works and where it does not, and what we can learn from that.

[Baroness Finlay of Llandaff (CB)]

My Lords, I also thank the Minister for the very sensitive way in which he has dealt with this Statement and, like others, commend those parents who have fought for years to be heard. I also commend Donna Ockenden for an outstanding report that makes really harrowing reading.

To follow up on the question asked by the noble Baroness, Lady Bottomley, about training, it has struck me for many years that the competition between midwives and obstetricians is extremely damaging. It was there when I was a medical student and it has not changed. The bullying culture on the wards has I think been almost endemic and right across the system. I hope that the colleges will look at training jointly from day one, not just after qualification, because that team building needs to happen very early. The way the midwifery tutors and the obstetric tutors deal with their trainees must be integrated from day one and then follow on into continuous professional learning. So my first request is that that message goes back very clearly to the schools of midwifery and to the obstetric training courses.

My second point relates to the CQC, which has done a great deal to raise the quality of care across the NHS and is often to be admired. However, it is worrying that it took so long for it to realise that there was a problem. That would suggest that, internally, its benchmarking of what was normal was at a level that is actually unacceptable. I hope the Minister will be able to go back to the CQC and that the CQC itself will be supported to radically rethink the way that it looks at maternity services. I hope that it will be prepared to have some extremely difficult inspections, consultations and conversations with staff in some units that were previously thought to be doing well, but where it might discover that there is bullying and, particularly, this closed-ranks culture that was so evident in the way people responded to the report. But, overall, I think we are all grateful for the openness of this report and the openness with which the Minister has brought it to our notice.

[Lord Kamall (Con)]

I begin by thanking the noble Baroness, Lady Finlay, not only for her questions today but for the advice she has given me over a number of months since I started in this post. I have learned so much from the noble Baroness, especially from her courage to speak about her own professional experiences and admit where there are issues that need to be addressed. I am very grateful for that.

I completely take the point about working together from day one because, if you do that, you embed that culture of collaboration from day one, rather than just training people and then saying, “Oh, by the way, don’t forget to work collaboratively”. I think that has to be bred into the system and it is something we have to understand.

The other principle, which all noble Lords discussed in debates on the Bill, is the concept of a safe space. In an ideal world, we would find out who was responsible and they would be held to account, but what is really important is that we learn from that and the system learns from its failures. We have to encourage the ability to have a safe space where people feel confident about speaking up. We saw incidents where people felt bullied into not speaking up or where they withdrew their statements. If we can get this through the SHA and throughout the culture of the new HSSIB, this would be a really important first step. I thank noble Lords who, during the debate, pushed for the removal of certain bodies in order to make sure people felt comfortable coming forward.

On the CQC, there are real questions about the inspections in 2014 and 2016 and why it did not recognise safety concerns at the trust. Subsequently, the CQC did recognise the issues and place the trust in special measures. There was some progress made by the trust following this, and there were two subsequent visits. As a regulator, the CQC holds providers to account and makes clear where improvements must be made, but I think it recognises that there are lessons to be learned. There are lessons to be learned not only in government but across the health and care sector. It is important that we look systemically at how we work together and address some of those concerns.

Health and Care Bill

Baroness Finlay of Llandaff Excerpts

3rd reading
Wednesday 23rd March 2022 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, I hate myself for this, but I forgot two people. Half way through the Bill, we acquired a new advisor, Liz Cronin, who has done an excellent job, and there is Richard Bourne, who has been sat by my side, right through the Lansley Bill and this one. They have my thanks.

[Baroness Finlay of Llandaff (CB)]

From these Benches, I very briefly thank the Minister, the noble Baroness, Lady Penn, the noble Earl, Lord Howe, the whole Bill team and all the officials who have worked with them for the way that they have listened—repeatedly listened—as we made our points over and again and as they sought sometimes to try to understand what we were trying to get across and why. I also thank everyone across the House, on all the Opposition Benches, the Cross Benches and the Government Benches, who have worked with us as Cross-Benchers in a very collaborative way and made their own offices available for background support to all of us.

I echo the words of the noble Baroness, Lady Thornton: this Bill leaves us better. It has been a genuine pleasure to work on it. Some of us have worked on previous Bills, and I have to say that this was a more enjoyable and rewarding experience because the dialogue involved a better interchange at many points.

We have made some points of great significance, one of which was over palliative care, which has been dear to my heart. Palliative care has come of age. I think the House will be pleased to know that, on Friday morning, the annual meeting of the Association for Palliative Medicine has a specific session dedicated to understanding the changes and what it now needs to do in the light of those. The word goes fast from here, and that is very welcome.

I hope that I have not forgotten anybody in my thanks, which are open and sincerely expressed.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I rise very briefly, with the Green group having made quite a large contribution—certainly in hours—to this Bill.

This House has improved the Bill, but I feel I need to say that I have received in the last few days a significant number of emails. They are not part of a co-ordinated campaign; they are cries from the heart, many from long-term NHS campaigners who I have known for a long while. I quote just one of these, which says that:

“The Bill is still not in the interests of the public or indeed of the NHS itself as a comprehensive, universal public service”.


That is an expression of feeling that I am hearing very strongly. I hope that the Minister will listen to that and understand that there are very grave concerns out there among the public about the direction of the NHS.

The improvements that we have at least delivered, as other noble Lords have said, should stay, but the Government really need to safeguard this universal public service.

Health and Care Bill

Baroness Finlay of Llandaff Excerpts

Lords Hansard - Part 2 & Report stage
Wednesday 16th March 2022 Lords Chamber

Moved by

[Baroness Finlay of Llandaff]

172: After Clause 164, insert the following new Clause—
“Dispute resolution in children’s palliative care
(1) This section applies where there is a difference of opinion between a parent of a child with a life-limiting illness and a doctor responsible for the child’s treatment about—(a) the nature (or extent) of specialist palliative care that should be made available for the child, or(b) the extent to which palliative care provided to the child should be accompanied by one or more disease-modifying treatments.(2) Where the authorities responsible for a health service hospital become aware of the difference of opinion they must take all reasonable steps—(a) to ensure that the views of the parent, and of anyone else concerned with the welfare of the child, are listened to and taken into account;(b) to make available to the parent any medical data relating to the child reasonably required to obtain evidence to inform the parent’s proposals for the child’s treatment (including obtaining an additional medical opinion);(c) to allow the provider of an alternative treatment that is being advocated by the parent to provide evidence, in person or remotely, to the mediation process and subsequently to the court;(d) to demonstrate the reasons that significant harm would be likely to be caused by the proposed treatment; and(e) where the two parties are unable to resolve their difference of opinion, to allow for a mediation process, acceptable to both parties, between the parent and the senior doctor with overall clinical responsibility.(3) Nothing in subsection (2) requires, or may be relied upon so as to require, the provision of any specific treatment by a doctor or institution, and in particular nothing in subsection (2)—(a) requires the provision of resources for any particular course of treatment; or(b) requires a doctor to provide treatment that the doctor considers likely to be futile or harmful, or otherwise not in the best interests of the child.(4) In this section—“child” means an individual under the age of 18;“health service hospital” has the meaning given by section 275 of the National Health Service Act 2006 (interpretation);“parent” means a person with parental responsibility for a child within the meaning of the Children Act 1989.(5) Nothing in this section affects—(a) the principle of the best interests of the child,(b) the law about the appropriate clinical practice to be followed as to—(i) having regard to the child’s own views, where they can be expressed; and(ii) having regard to the views of anyone interested in the welfare of the child, whether or not a person concerned with the welfare of the child within the meaning of this section.”Member’s explanatory statement
This amendment aims to ensure that disputes between parents and doctors will be able to engage effective mediation.

[Baroness Finlay of Llandaff (CB)]

My Lords, we now come to the very real problem that relates to the power differential between a doctor and the parents of a sick child. I am most grateful to all who have met me and discussed the amendment, particularly some senior paediatricians and the charity Together for Short Lives, and for support from the Charlie Gard Foundation in redrafting this amendment.

The amendment has been carefully redrafted in the light of comments made on the earlier version. Everyone I have spoken to has recognised that problems sometimes arise. In its 2018-19 review, the Nuffield Council on Bioethics observed common themes behind disagreements—communication issues, differing perspectives on what kind of risks could justifiably be taken, feelings of powerlessness for both parents and staff, and delays in seeking resolution interventions. Among the recommendations is mandatory communications training, as in proposed new subsection (2)(a) in the amendment, and the timely use of effective resolution interventions such as mediation, as in proposed new subsection (2)(e). When parents, as most do, have looked up their child’s condition on the internet, they often come across suggested treatments on different websites or by talking to medical contacts that they have. Clinicians can feel threatened by that.

When parents are worried, they can come across as angry or difficult in their attempt to get information or get something done. All too often, they are labelled as overanxious. Yet, is it normal to be out of your mind with worry if your child, whom you adore, looks as if they might die.

This amendment tries to provide a route for everyone to communicate better, and for the temperature to be lowered. It applies where there is a difference of opinion between the parents and the responsible doctor when a child is thought to be nearing the end of life. When staff become aware of a difference of opinion, the clinicians need to listen to the parents, and others concerned with the child’s welfare, who may have important information to inform thinking. Parents who want to seek a second opinion want to know the results of tests, such as radiology, for example, and, at the moment, they must go through a complex and sometimes slow process to access the information. Sadly, some parents only find out what was in the clinical record after their child has died. Of course, if there is any suspicion of child abuse, subsection (2)(b) would not apply, as it would be outwith the “reasonable steps” criterion.

Where another clinician from a reputable centre is suggesting a treatment, they should be asked to explain it, and the evidence base behind the suggestion, to avoid distortion of messaging—hence, subsection (2)(d) of the amendment. Clinicians, in explaining why they oppose a proposal, need to be able to explain to the parents what the “significant harm” in the proposal is. When taking any clinical decision, harms and burdens are weighed up against potential benefit. If a child is going to be taken into care, the test is whether it is of “significant harm” to leave the child where they are, rather than be taken into care. In some ways, this is similar, because the clinicians are being asked to show that it is significantly harmful for the child to pursue the parents’ proposal, rather than continuing with the current management plan—when it often involves withdrawing treatment and is likely to lead to death.

Some hospitals have excellent ethics committees to involve early. The Nuffield Council report recognises that there are very real difficulties in the concept of best interest when deciding not to treat, as it is often not clear to the parents why abandoning the hope of improvement is in the interests of the child. In an overcrowded NHS, unconscious bias can skew towards wanting a service to clear beds, when prognosis looks poor. However, parents know that the child has no interests once they are dead. Nuffield recommends that the views of parents should be accorded considerable weight in decisions about their child.

When the two parties are unable to resolve their difference of opinion, such a case would now go to the court immediately. This amendment suggests that a

“mediation process, acceptable to both parties”

should be allowed when, and only when, earlier attempts at resolution have failed, as in subsection (2)(e). A mediation process would be between the parents and the senior doctor with overall clinical responsibility. It cannot be delegated to a junior in training or to one of the nurses on the ward. If mediation fails, then, as now, the case would proceed to court. The amendment is clear that no doctor or institution would be required to provide a treatment which they do not feel comfortable giving. This is the current law. The amendment is also clear that the overriding principle is the principle, as laid out in current law, of the

“best interests of the child”

being paramount. If the child is Gillick-competent, such an amendment would not apply.

Similarly, the views of others, such as a social worker or health visitor who knows the family may provide important information. As is the case now, that information must be listened to, as it may relate to some safeguarding issues or other information unknown to either the clinical team or the court. The early steps outlined in this amendment should improve the quality of communication between parents and the medical team, thereby decreasing the need to go to mediation. The mediation process is to try to decrease the number of cases going to court. I beg to move.

[The Deputy Speaker (Lord Russell of Liverpool) (CB)]

My Lords, the noble Baroness, Lady Brinton, is taking part remotely. I invite the noble Baroness to speak.

--- Later in debate ---

[Earl Howe (Con)]

My Lords, I first thank the noble Baroness, Lady Finlay, for having brought forward this important issue for debate and for introducing it in her characteristically informed and professional way. I assure her that I understand the issues she has highlighted and why she has done so. There is no doubt in my mind that the kinds of case that she has cited are extremely distressing and stressful for all involved, and can, on occasions, be contentious.

The Government agree that mediation is often a good route to take when there is such contention. Parents and clinicians should have access to high-quality, independent mediation schemes where they wish to do so. There are many mediation schemes available and we are very supportive of them.

The NHS already ensures access to mediation in many cases, and we strongly encourage it to continue doing so. But, at the same time, we need to ensure that those schemes are effective in the different contexts in which they are needed. Currently, organisations have the flexibility to offer mediation services earlier in a dispute or to prevent such disputes arising. They have the flexibility to tailor services specifically to the unique circumstances in which they are needed.

I hope the noble Baroness would agree that each case is unique. It is essential that everyone is able to have their voice heard, that there is a good understanding of different perspectives and that there is appropriate involvement of parents in decisions about the care and treatment of their child. Naturally, in that process, differences of opinion can and do arise.

The key to progress in this area is something deeply nuanced—human relationships. That is why I believe that, rather than legislation, our efforts are better directed at working together to develop systemwide solutions about how disagreements can be avoided or recognised early and, most importantly, sensitively managed. We need to ensure that in these difficult situations NHS trusts and staff are well equipped, well prepared and well supported to make that sure parents’ feelings and concerns are fully considered and supported, and that the relationship remains positive and constructive. We know that there are already examples of best practice and guidance but we need to do more.

To improve the outcomes of these difficult cases, we need to look at the whole process. We need to look at how best practice can be shared across the system to ensure that parents’ voices are heard throughout the process, not just in mediation, and how we can prevent disputes arising in the first place. In the rare cases when a dispute does arise, we need to focus on the quality of mediation schemes and not just prescribe that mediation is offered by default.

To look at how best we can embed best practice, training and advice on shared decision-making and dispute resolution across the system, the Minister for Patient Safety and Primary Care has agreed to chair a round-table event facilitated by the Nuffield Council on Bioethics. This will build on the work already being done by bringing together key stakeholders to agree actions that support the creation of healthcare environments that foster good, collaborative relationships between parents and healthcare staff. I have also offered to meet Connie Yates and Chris Gard to hear their experiences and discuss how we can support better collaborative relationships between parents and healthcare staff. I hope this demonstrates that the Government understand the importance of this issue and that we are committed to addressing it.

It is the Government’s view—I say this with some regret—that putting this amendment or another in the Bill will not help improve the outcomes of the very difficult, rare situations in which an unresolvable dispute arises. This is because efforts need to be focused on a holistic approach to dispute resolution to improve the process as a whole. Merely allowing for mediation to be available at the end of a dispute will not do this; either party could refuse it and allowing mediation will not, we think, drive the careful, sympathetic and considered work with parents and carers that this topic so urgently demands.

I recognise that these are difficult matters, but I think progress will best be made through practical, down-to-earth work across the system and by bringing in a wide range of perspectives. This is what I am now offering and I therefore hope that, in reflecting on that offer, the noble Baroness, Lady Finlay, will feel able to withdraw this amendment.

[Baroness Finlay of Llandaff (CB)]

I am most grateful to everyone who has spoken. I realise that the time is late so I will try to be very brief in responding. I appreciate the offer of Nuffield to host another round-table event. I believe it held one recently and it had its previous inquiry. The sad reality, however, is that over recent decades of trying to teach communication skills, things have not improved as much as they should. One of the reasons is high staff turnover, which means you educate one group and it moves on. Yes, things have to be sensitively managed, but the role models come from the seniors. We are not talking about the vast majority, who are doing really well. The problem is that the people who are not doing well are the very ones who do not take up the education and do not want to change. I believe we have now got to the point where we need to send a very clear message and put this in the Bill. I beg leave to test the opinion of the House.

--- Later in debate ---

[Lord Bethell (Con)]

My Lords, I am grateful to the noble Lord, Lord Alton. I join him and the right reverend Prelate the Bishop of Durham in paying tribute to my noble friend Lady Sugg for her work on women’s issues—work that I support in every way I possibly can. I think that this amendment is a useful amendment to this Bill. My noble friend Lady Sugg is right that the world is changing: science raced ahead during the pandemic, and many things that had not been tried before were tried. Clinical tools have become more sophisticated, practices are undoubtedly evolving and there are definitely lessons from the pandemic that are worth our consideration.

That is why I very much welcome an opportunity to stand back and reflect on what has changed since 1967, which the noble Lord, Lord Alton, referred to, when the current settlement on abortion was agreed. That was an incredibly important moment, when those with different views engaged with public opinion, clinical judgment, ethical analysis and spiritual leaders. I accept that that settlement made in 1967 will not last for ever. In fact, I agree with my noble friend Lady Sugg that the arrangements that have been in place for many years definitely need a second look. If we agree that the moment is right, I emphasise that any reconsideration of these issues should be done in a thoughtful, considered fashion and that we should engage the large number of people who have strong feelings, as well as expert opinion.

We need to do this because these issues are extremely complex and the evidence is conflicted, and they engage so many different strands of our emotional, spiritual and intellectual life. If this this debate this evening is a starting gun for that process, I would recognise its significance and ask the Minister to reflect on the moment in his comments.

However, if this amendment is a realistic attempt to bring about a significant long-term change to the clinical pathways of our health system, I would be extremely alarmed. Regarding the point made by the noble Lord, Lord Alton, on procedure, I have serious concerns. There is no value in blowing up the long-term arrangements that were agreed in 1967 in a late-night Report debate on an amendment introduced at the last minute to a Bill that is about the integration of our healthcare system. It would be a travesty if the easements that were brought in to cope with a global pandemic were used as a pretext for a long-term rewriting of our abortion laws. We were promised that that would not be the case, and it would be regrettable if this Government went back on those reassurances.

I draw to the attention of noble Lords the report by Gynuity Health Projects, published in March 2021, on its study of the efficacy of telemedicine abortion. It found that 5% of participants using the medical abortion treatment at home needed surgical intervention to complete the procedure. These are worrying numbers and are worthy of further investigation before the current situation passes into legislation.

My hope is that this amendment is regarded for what it should be: a testing amendment to stimulate debate and not a serious effort to overturn arrangements that need to be reformed, not overturned. That is why I call on the Minister to explain why this amendment should not stand, and on my noble friend Lady Sugg to confirm that she will not be moving her amendment.

[Baroness Finlay of Llandaff (CB)]

My Lords, I find myself conflicted over this amendment. I am probably the only person in this Chamber who has consulted women over abortions, signed forms for abortions and performed abortions and I have been with women during late abortions for foetal abnormality. It is a complex area. I have also had women say to me, in the privacy of the consulting room, just before they go, “I have never told anybody else this before”—they have then told me about the serious abuse that they have suffered.

My worry with the first part of the amendment, on remote consultation, is that you do not know who is on the other side of camera or who is standing in the room with the woman. You do not know whether the man is using fertility and sex as a form of abuse and is standing there threatening the woman to proceed in one way or another. We know that men refusing to use condoms is a common form of coercive control of women.

The abortifacient tablets, to which my noble friend Baroness Watkins referred, are a separate step. It is inhumane to expect women to take those and then travel on a bus or even go in a taxi. Knowing what has happened before, I cannot help feeling that there is another step. Yes, let the women have their tablets and take them in the privacy of their own home. It is not pleasant to undergo an abortion—nobody should think that it is—but those women also need support and contraceptive advice as part of the package. I am concerned that I do not see that in this amendment and I have been concerned that during the pandemic the ability of women to access contraception may have become more difficult.

This is a complex issue. It is about a pathway with many steps in it. I wonder whether we should return to it at Third Reading, rather than trying to take a yes or no decision tonight on something that has some merits but also some problems. We are not adequately going into them by having a short debate now.

[Baroness Stowell of Beeston (Con)]

My Lords, it gives me great pleasure to follow the noble Baroness, Lady Finlay, whose contribution reflects her extensive wisdom and knowledge in this area. I just want to say that I commend my noble friend Lady Sugg for her leadership in bringing forward the amendment. I, too, will listen to what the Minister says in reply this evening, but instinctively I support what my noble friend is seeking to achieve.

Care Homes: Evicted Residents

Baroness Finlay of Llandaff Excerpts

Thursday 10th March 2022 Lords Chamber

[Lord Kamall (Con)]

I thank the noble Lord for raising this issue. I am sure he will recognise, from when we have worked together on a problem, that the first question I ask officials is: what is the problem and what are we doing about it? When I asked this question, I found that my colleague Gillian Keegan, Minister for Care and Mental Health, has met relatives and residents’ associations to hear directly about their experiences and focus on how we could strengthen the CQC role. In addition, in the Living with Covid-19 strategy, we are reviewing a range of measures in place for homes, including visitor restrictions. The updated position will be set out in guidance by 1 April. We are encouraging representatives, patients and patients’ groups to come forward and feed into that.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my role as chair of the National Mental Capacity Forum. There are many people with impaired capacity in care homes, whose mental state is deteriorating through lack of stimulation, inability to be taken outside and lack of general overall mental activities. Does the CQC have any idea of the number of people with impaired capacity still subject to restricted visiting by their relatives?

[Lord Kamall (Con)]

The noble Baroness has identified a potential issue that we have to address, which is drilling down into detail. One of the things that the CQC does is to look at aggregate numbers of complaints and concerns. Of course, there is a Local Government Ombudsman who looks at this issue as well. We are looking at ways where that works and where it does not work, and at how we could improve the system. This is all part of the ongoing review to build up a better, integrated health and care system.