Health and Care Bill

Baroness Hollins Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

[Lord Farmer (Con)]

My Lords, my Amendment 57, which the noble Baroness, Lady Masham, has mentioned, is also supported by the noble Baroness, Lady Walmsley. I declare my interest as a director and controlling shareholder of the Family Hubs Network Ltd, which advocates for family hubs and advises local authorities on how to establish them. I am also a vice-president of the LGA.

In speaking to my Amendment 57, I would point out that in Chinese medicine you traditionally saw the doctor when in health. They were paid a retainer to keep you that way and, if you became sick, they would not be paid until health was regained. This speaks volumes about alternative health paradigms to our own. Even if we never go that far, the prevention of disease and the maintenance of health should be an overriding priority for the health service.

In placing the duty to prevent the development of poor physical and mental health directly under the duty to promote the NHS constitution, it is my intention to make it a similarly fundamental duty. Prevention is always better than cure. Yes, prevention is already mentioned in the Bill, for example in Clauses 5 and 16, and elsewhere in Clauses 20 and 59. However I do not consider that it is given sufficient weight, particularly given concerns shared with me by members of the Family Hubs Network.

Family Hubs Network members work with existing integrated care systems and note that the main issue faced by these ICSs is the management and throughput of the frail, elderly population to address bed-blocking and the onward delays to elective surgery. Hence they can lean towards an acute hospital reactive care model. Family Hubs Network members are already seeing the consequence of this with, for example, few if any ICS strategies focusing on population health through prevention and early help, especially for children and families.

Indeed, more and more ICSs are seeing community-based contracts swallowed up by the acute hospital conglomerates. They rarely, if ever, hold the necessary cultural understanding of community care, prevention and early help, and their interests do not lie in these. Children’s health services, which would ideally be delivered in the community, can be drawn into acute hospital structures which are more reactive than preventive in nature. Yet in some cases these very same services, such as continence, speech and language, allergies and others, are being delivered in community settings, close to families, through integrated family service hubs. Given that many of these health needs are also psychosocial and practical, accessing them from such settings enables families also to receive local authority-commissioned early help. This surely is integration in action.

My amendment also specifies that health services should be available in the community where possible, to improve access and help prevent conditions from worsening. A local-by-default approach would cut down the number of patients required to make prohibitively long journeys when a service could instead be delivered in a primary care or local authority setting. We need a reverse Beeching for healthcare, where we reopen community hospitals. Out-of-area specialist mental health hospitals, which remove people from the social networks which help them get better more quickly, were in the news again this week. Local units have closed and there is a lack of care in the community, even though this is a far less expensive option and the setting in which many prefer to be treated.

Returning to the issue of our ageing population, a reactive care model is completely unsustainable. Unless we focus on preventing big-ticket items such as diabetes, depression, anxiety and dementia—the list is endless—the cost of providing healthcare will keep going up year on year, by even more than it already does. A preventive paradigm would ensure greater ruthlessness about educating parents and healthcare workers about the psychotic effects of high-strength cannabis, for instance.

The eminent professor, Sir Robin Murray, recently said:

“I think we’re now 100 per cent sure that cannabis is one of the causes of a schizophrenia-like psychosis. If we could abolish the consumption of skunk we would have 30 per cent less patients”—


this was in south London—

“and we might make a better job of looking after the patients we have.”

In 2019, Murray’s research team reported in the Lancet Psychiatry their finding that south London had the highest incidence of psychosis in Europe and singled out cannabis as the largest contributing factor. He expressed concern that some liberal-minded parents would rather see their children smoking pot than drinking, without appreciating the potential associated dangers and the social and economic costs. These multiply with skunk, which is several times more potent than the drug they might have been used to in their day.

It is not just parents who need educating, including about higher-strength forms: experts say that cannabis addiction is treated by health professionals as a low-risk soft drug, yet, since 2005, there has been a 777% increase in the number of those aged 55 and over who need treatment for it. When cigarettes’ contribution to the development of lung cancer was firmly established, action to prevent smoking was taken despite it being fashionable and popular—more than 60% of adult males smoked; now that number is approaching 15%.

When there is incontrovertible evidence that something harms mental or physical health, a duty to prevent would mean that such damaging ignorance was no longer allowed to prevail. Ditto foot-dragging on access: mental health care in the community has been talked about since we began to close asylums in the early 1960s, yet it is still in the NHS long-term plan. I am keen to hear from my noble friend the Minister why prevention should not be given prominence as a duty in the Bill.

[Baroness Hollins (CB)]

My Lords, it is a pleasure to follow the noble Lord, Lord Farmer. I really appreciate his remarks about Professor Murray’s work and his interpretation of it.

This is a Bill about integration, but how much integration will it actually achieve? We have spoken many times about wanting health and social care to work better together, but there is a difference between collaboration and integration. The former achieves two separate systems that, while better aligned in, for example, their information sharing, still operate without particular reference to the other. Those who use both systems continue to straddle a divide between the two and, too often, fall between those gaps.

Integration, on the other hand, speaks of synergy and of systems that enable one another and close the divide between the two, so that people can move between them without the terrifying leap of faith that currently exists. This is what will truly make a difference for those who use these services.

Unfortunately, the Bill in its current form will struggle to bring about this true integration. It requires the production of only a health outcomes framework, which will simply entrench the divide between health and social care, as both will continue to pull in different directions with different objectives, which are often conflicting.

Currently, health and social care sectors work towards two different sets of aims: social care is led by the well-being objectives of the Care Act 2014, whereas the NHS is led by various objectives set out in documents such as the NHS constitution, the NHS Oversight Framework and the NHS Long Term Plan.

An integrated service would mark a major shift in how the two systems view their role in supporting those who use their services. For example, it could see the NHS adopting an approach that was informed by ensuring the independence of its patients in a similar way to the principles that lead the provision of care and support. The greatest problems have been caused when health and social care start to gatekeep their domains: I have had to speak too often about the abhorrent placement of people with complex needs in in-patient units far from home, as a result of catastrophically poor alignment of health and social care support to meet their needs locally. I declare an interest as chair of the Department of Health and Social Care-appointed panel to oversee the discharge of people with learning disabilities and autistic people who are detained in long-term segregation.

I want to thank Mencap and Skills for Care for briefings on my amendments in this group. My Amendments 85 and 88 would place greater emphasis on the provision and quality of social care services and on the integration of health and social care services. I also declare an interest as president of the Royal College of Occupational Therapists. This is relevant because occupational therapy is a health profession that is equally at home in the NHS and in social care, and because occupational therapists have a role in tackling long-standing health inequalities through community rehabilitation and in prevention.

The history of health and care integration is littered with a natural reflex towards health and the pressing political priorities of the day. The ICB is primarily NHS focused and will hold responsibility for strategic planning and monitoring of services against the needs of an ICS population, but the answers cannot all come from health alone. We are in danger of missing an opportunity.

A duty to promote integration must include adequate provision for both health and care by taking a holistic approach. The outcomes from one will impact significantly on the other. Viewing the duty to promote integration through a health lens alone limits our understanding of what social care has to offer—think back to the debate on my noble friend Lord Mawson’s amendment on Tuesday. In some areas, integrated care system planning seems to focus mostly on integration within healthcare and not on integration between and across health-led provision and social care. At present, provider alliances are largely acute trust led.

Let us take discharge co-ordination as an example. It is currently suboptimal, with too few care co-ordinators, a lack of social care representation and feedback in assessment decisions, and a neglect of the resources and expertise of voluntary and independent providers.

The staffing context is complex. According to Skills for Care, there are 17,700 organisations providing or organising care, delivered through 39,000 establishments. Some 41% of those are residential, 59% are non- residential and 68% are CQC regulated. More than 6,000 organisations have fewer than four employees. That is a very broad church of employers. Not only does it make it much more difficult to communicate but social care lacks the infrastructure of the NHS to disseminate and co-ordinate.

My amendments propose strengthened provisions for ICBs to consider how integration benefits and can benefit from social care. My Amendment 89 would require ICBs to develop and publish a health and social care outcomes framework at least every two years to ensure that health and social care services are properly integrated.

ICSs present an opportunity to co-ordinate services, improve population health and plan on a system-wide basis to attract and retain staff with the right mix of skills. The ICS role should therefore ensure that the right staff skill mix is available to deliver this singular vision, a vision of person-centred and outcome-based care through multidisciplinary teams operating with and around each individual. Integrated care would mean that people would only have to tell their story once to receive high-quality, joined-up and seamless care. The approach each system takes to workforce planning will rightly vary to meet local needs and requirements, but that does not mean that their workforce plans cannot be measured against a joint outcomes framework. In collaboration with partners, Skills for Care has developed principles of workforce integration which address the above points.

The aim of this amendment is to ensure that health and social care do not pursue two different sets of objectives but work to a common aim to underpin transformation. I ask the Minister to reassure the Committee on these points. I believe these amendments will be helpful.

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[Lord Kamall (Con)]

These are all building blocks. I thought that might get a laugh.

In response to the noble Lord, Lord Hunt, ICPs were the idea of the Local Government Association, and we want to ensure that they work with the ICBs. Also, we must recognise that local authorities are accountable to their local electorates and fund many of the services for which they are responsible from local taxation. While we encourage local authorities and the NHS to work together as much as possible and pool their budgets where it is beneficial for local people, we are not mandating this, as this would probably require significant shift in how local authorities are held accountable for managing their money. One of the reasons why we have this strange ICB-ICP partnership is to ensure that it is at the right level and, beneath that, to have the health and well-being boards at place level. I sense the strength of feeling in the Committee, and I see the noble Baroness, Lady Hollins, giving a wry smile.

[Baroness Hollins (CB)]

I love this debate—it is brilliant—but it makes the point that this is an ideal opportunity to pre-empt a later Bill and get on with the job now where it belongs. Given the strength of feeling in the Committee, if we cannot reach a solution to this, I will bring it back on Report.

[Baroness Barker (LD)]

My Lords, I feel for the Minister in his position. He is right: people observing our proceedings will see us laughing, but in practice this is really serious. I talk to colleagues in local government who receive endless requests from the NHS to turn up to meetings and they do not go, and why? It is not because they do not think that it is important, but because local government has been hollowed out over the last 10 years to the point where it has very senior management and front-line staff, and does not have large numbers of people in the middle doing middle-management planning jobs that exist in the NHS. That was the reality before Covid and is the reality now. Each of those building blocks that the Minister is putting in may be some great stepping-stone to a nirvana for the NHS, but they are just another obstacle for local government. It is so important that we in this House are not tied to constituencies or particular areas of importance. Speak truth to power—to the Government. We are building something unsustainable that will not work.

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[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.