Health and Care Bill

Baroness Harding of Winscombe Excerpts

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

[Lord Patel (CB)]

My Lords, I support the amendment in the name of the noble Baronesses, Lady Merron and Lady Walmsley. I speak in support of the principles behind the amendment, which were well articulated by both noble Baronesses. Is it wrong in principle to have board members who have experience of NHS England’s areas of work, which I agree includes finance? No, but that cannot be totally exclusive of one side of the experience and expertise required. One of the board members suggested in the amendment should be from a public health background; let me take that as an example. That could be a public health director; I do not mind whether it is a public health director or somebody with public health expertise.

The reforms in the Bill are far reaching, but they are underpinned by the integration of health services to deliver on population health. The Government’s ambition is to extend healthy life by five years by 2035 and to have a greater focus on health prevention. Public Health England has been abolished and replaced by the Office for Health Improvement and Disparities. It is interesting that the name has changed, but I do not mind that. The word “inequalities” has been used hitherto but, if you use the WHO definition, “disparities” has the same meaning. The aim is to address inequity. The UK Health Security Agency has now been brought into being. It is right that there is strong public health involvement at local and regional level, as defined in the Bill, although it is not clear to me at this stage how this will work at regional level—no doubt we will spend some hours debating that.

Public health directors should be involved in developing strategies for population health at the local and regional level. There is a strong argument for public health representation on all integrated care boards—again, we will discuss these in amendments to come. At national level, the Government need to be much more joined up. The Department of Health and Social Care and the triumvirate of NHS England, the UK Health Security Agency and the Office for Health Improvement and Disparities needs to demonstrate an integrated model that the rest of the service is expected to deliver on. The ICBs will be in a clear accountability relationship with NHS England and NHS Improvement for delivering on all aspects of population health, yet neither will be accountable for public health, except in a limited case where NHS England will have responsibility. NHS England needs strong representation from and involvement of public health expertise, including at board level, to be able to develop indicators that assess the performance of ICBs, including for population health.

Turning to the part of the amendment that relates to public involvement, while there may be a difficulty in identifying an individual who can focus on the needs of patients, there are ways of doing this. The principle is that a board member chosen as a representative of patients’ voices knows that it is that individual’s responsibility to speak on their behalf. Of course, I am biased; I would say that the chief executive or, more appropriately, the chairman of Healthwatch England should be represented on the NHS England board. I fought the battle and lost—the noble Earl, Lord Howe, well remembers the point about Healthwatch being an important aspect, but we will come to that debate at a later stage. This time, I hope I do not lose.

I strongly support this amendment and the principle that representation on the NHS England board needs to reflect its work.

[Baroness Harding of Winscombe (Con)]

My Lords, I begin by declaring my interest, having very recently stepped down as the chair of NHS Improvement, which included both the NHS Trust Development Authority and Monitor. I am very supportive of the spirit of these amendments, and I could not agree more with the way in which the noble Baroness, Lady Merron, set out the importance of propriety in the appointment process and the skills, attitude and culture that the directors on the board of the new NHS England need to have. It is essential, as she said, to have a spirit of collaboration, integration and patient focus.

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[Lord Patel (CB)]

My Lords, I would like to ask a question of the noble Baroness, Lady Harding, who has what is accepted as huge experience at board level, on boards of different sizes. If it is right, no matter the size of the board, to have representation selected on the basis of experience, can it be wrong, no matter the size of the board, to have as board members people with experience in, let us say, public health or local authorities—because they have experience specifically in that area—as opposed to people who might have wider experience, including in finance or whatever?

[Baroness Harding of Winscombe (Con)]

I do not think that the noble Lord and I have a substantive disagreement. My concern is about prescribing in the legislation the exact recipe for the team; I am mixing my metaphors. After what we have all been through as a country and as a world, I completely agree with him about the importance of putting public health absolutely at the front and centre of our health and care system. However, legislating for the specific skills of the individuals who make up the board would be a mistake, because we want to create a team where people’s experience, background, style and cognitive approach create the magic that we are looking for. This is only one dimension of that; that is all.

[Lord Mawson (CB)]

My Lords, I was one of the people, along with Paul Brickell, who wrote for Hazel Blears the structure for the Olympic Park Legacy Company. I was involved in that project from day one—along with Lord Rogers, who, sadly, has recently died—and for 19 years. We thought a lot about this question because, in east London, we had to engage with six different boroughs around the 248-hectare Olympic Park. We knew that if we simply brought together representatives, many of whom did not have good working relationships or the necessary practical skills, to deliver that project, we would have another Olympic failure on our hands.

The structure that we wrote for Hazel Blears at that time suggested that we needed to bring the right people together for that project: for example, Keith Edelman, who had just successfully built the Arsenal stadium might be a rather important person to have on the board because he understood the detail about stadiums and how you run them—and we were about the build a half-a-billion-pound one. Or perhaps we would need someone like Nick Bitel, who had set up the London Marathon and knew something about sport and the politics of sport; I discovered a great deal about how complicated all that actually was. Or we might need on the board the most successful Labour mayors in that area—Sir Robin Wales of Newham and the mayor of Hackney.

I am very supportive of what the noble Baroness, Lady Harding, is saying. We built a team of the right people to ensure that we delivered a serious legacy on that 248 hectares in east London. I suggest that noble Lords go and have a look at what happened as a result. Empowering the chairman to choose the right team with the right skill set is absolutely crucial if we are to transform the NHS and make it fit for purpose in this century.

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[Baroness Watkins of Tavistock (CB)]

My Lords, I support the majority of these amendments. I declare my interests as president of the Florence Nightingale Foundation and chair of the HEE review of mental health nursing.

A lot of noble Lords have spoken about mental health in the most glowing terms in the last hour. I am extremely supportive of the amendments in the names of the noble Baroness, Lady Hollins, and our new Member, the noble Lord, Lord Stevens of Birmingham. I have put my name to Amendment 138 on keeping proper data and information on waiting lists for people not with mental health issues but mental illness problems. There are people in our country with severe, enduring mental illness who fail to get early diagnosis because they do not even get on to a waiting list to see a consultant.

I see many of these people in my work with the charitable social enterprise I chair, Look Ahead, which provides housing to people who have suffered homelessness, people with mental health problems and learning disabilities and those discharged from prison—having completed their sentence, I should say. So many of those people have had better mental health care in prison than they ever had in society, because we do not list the number of people trying to access these services. We know that the life expectancy of people with long-term mental health problems is so much lower than that of the majority of people with physical health problems, because of things such as drug-induced psychosis, if it is not treated quickly. Professor Murray of the Institute of Psychiatry has been talking about this since I did my PhD there, 30 years ago, and we have still not resolved it.

I emphasise, as an ordinary person who works and has spent nearly 40 years working on a day-to-day basis either training mental health nurses or working with people with severe enduring mental illness, that these amendments are essential if we are to provide good health services for tomorrow’s population.

[Baroness Harding of Winscombe (Con)]

My Lords, I too support this group of amendments, both the parity of esteem words and the funding actions that make it up. I will briefly address the possible objections to it: first, it is not necessary because the Secretary of State already has a duty to maintain parity of esteem; secondly, as I think the noble Baroness, Lady Tyler, mentioned, this is culture change and legislation cannot drive that. In this case, actions speak louder than words. Being clear on the financial actions, as the amendments of the noble Lord, Lord Stevens, are, is a hugely important step on our culture journey.

Even though actions speak louder than words, the words matter too. They particularly matter when, as so many noble Lords have said so eloquently, mental health is so easily forgotten. It is all too easy to forget the hidden pain, anguish and need. I fear it is still far too easy to forget the hidden waiting lists. The words in this group of amendments are just as important as the actions, to make sure that we do not forget and build on the ground-breaking work that many, like the noble Baroness, Lady Hollins, have led for decades. We are on that journey, but we are definitely not there. I urge my noble friend to consider and accept these amendments.

[Baroness Walmsley (LD)]

My Lords, a duty to establish parity of esteem between physical and mental health was, of course, inserted into the Health and Social Care Act 2012 at the instigation of the noble Baroness, Lady Hollins—if I remember rightly, we on these Benches were right behind her. That is not reflected in this Bill, as she said, despite the fact that the importance of addressing mental health issues has been so amply demonstrated by the rise of these problems during the Covid pandemic. The shortage of services to address them is of great concern—services which were already under stress before the pandemic started because of underfunding over many years.

Although the insertion of parity of esteem into the 2012 Act was welcome and significant, no legislation is enough without the resources in cash and people to make it happen. They have not been forthcoming in the amounts needed to match the growing demand. Like the noble Baroness, Lady Hollins, and my noble friend Lady Tyler, I too have heard concerns in the sector that the share of resources that are currently available might be cut over the next three years under the Government’s plans.

The situation is not good. Waiting lists, particularly for children and young people, have been growing. I understand that the average waiting time for a young person for a first appointment is something like 13 weeks and 18 weeks to get to a referral for treatment. It is a bit of a postcode lottery, because some young people get there quite quickly and some wait a very long time. The noble Lord, Lord Warner, is absolutely right that it takes a great deal longer for those waiting for a diagnosis of autism.

According to research from the Resolution Foundation, in 2000, 24% of 18 to 24 year-olds had a common mental disorder. That was the lowest rate of any age group at that time. By 2018-19, that figure had grown to 30% and, astonishingly, by April 2020 it was up to 51%. So, as we set up the new integrated care system, it is essential that we restate the equivalence of mental and physical health. We know, as the noble Baroness, Lady Jones, so eloquently reminded us, that each affects the other, but it is not enough to assume that that is understood in this legislation. It must be clearly stated in both Clause 16 and Clause 20, where the noble Baroness, Lady Hollins, seeks to add it to the duty of the ICSs to secure improvement in the quality of services. We support her, of course.

Perhaps at this point I will mention my little amendments in this group. Amendments 48 and 49 are two of those little amendments that would insert the words “physical or mental” illness into Clause 16, which specifies a list of health provision that the ICB must make for its population. Other noble Lords would insert similar amendments into other places in the Bill. I support all of them.

Amendment 76 would also insert parity of esteem into new Section 14Z38 in Clause 20, which refers to the duty to obtain appropriate advice. We put it there to emphasise the fact that mental health is a very specialised area, and often very good advice can be obtained from small community or not-for-profit social enterprises that deliver mental health services in the community where people work and live, often to very marginalised groups. Large organisations such as an ICS might very easily overlook such good advice about what is needed and where to put it. I support the amendment spoken to by my noble friend Lady Tyler that the triple aim must become a quadruple aim. Mental health needs to go right at the core of what we are trying to achieve.

There is an enormous and growing number of people in the country with poor mental health. The NHS cannot just treat its way out of the problem. There needs to be more focus on public mental health, much of which is addressed by the small community groups I just mentioned, the role of which we will deal with later with Amendment 148 and others. But without the specific acceptance of the parity of esteem duty in the Bill, there is a danger that the diagnosis, prevention and treatment of mental ill-health will continue to take a back seat. It must be in the statute.