Health and Care Bill

Baroness McIntosh of Hudnall Excerpts

Lords Hansard - Part 1 & Committee stage
Thursday 13th January 2022 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, this debate has shown clearly that attacking health inequalities must go beyond the bounds of the NHS as the impact of external factors is massive. I remind the Government that in 2015 poor housing alone was estimated to cost over £10 billion. That was in part because of the poor housing but it was compounded by inactivity and, as a result, obesity.

We should look at the antecedents of complex problems. Marie Curie’s report Dying in the Cold revealed failures in healthcare, bereavement and grief and the challenges of providing care for those with complex needs. Learning difficulties and autism, for which we often do not know the underlying causes, are disproportionately prevalent among people who are socially excluded and at high risk of homelessness, yet for them managing homelessness alone is particularly difficult because of their overall vulnerability. It has been estimated that autism alone has a twelvefold prevalence in those who are homeless compared to the general population.

The antecedents of many of the problems go back to childhood. They carry a life sentence of their trauma, which feeds into worsening health inequalities, aggravating factors such as alcohol and drugs consumption and other behaviours. Unless we strengthen the wording in the Bill to monitor and do something about the data that comes forward, the proposal of my noble friend Lord Kakkar—it is essential that we address this as a core problem to be tackled—will not be realised. I hope that when the Minister replies he will provide some assurance that the Government will consider strengthening the wording in the Bill in the light of this debate.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, I wonder if I might be allowed to speak at this point for the simple reason that I am shortly due to take over from the noble Baroness, Lady Fookes, in the Chair and if I do not contribute now, I will not be able to at all. I have no special expertise to bring to the scrutiny of the Bill, therefore this is the first time I have spoken on it and it may be the last. I want to speak in support of the contribution of my noble friend Lord Howarth of Newport, right at the beginning of what has been a very long and extremely interesting debate but which, until recently, when my noble friend Lady Pitkeathley mentioned it, did not refer back to the points he raised.

In making my brief remarks, I draw attention to my own interests, which are mostly to do with the arts. I am thinking about what my noble friend Lord Howarth said about the arts sector and what it can contribute. I ask the Minister, when he comes to reply, if he would look to one side of his department—particularly towards the Department for Education and to the Department for Digital, Culture, Media and Sport—for further evidence, in addition to the very strong evidence my noble friend Lord Howarth put forward, of the impact of engagement with the arts, particularly on people suffering from often multiple disadvantages.

It is very clear that the data emerging in relation to education points to a strong impact on the health, particularly the mental health and well-being, of young people in education settings when they are able to engage creatively with the arts and arts practitioners. It would be very easy, in thinking about the huge diversity of issues that have been raised here which bear on health inequality, to see engagement with the arts as a “nice to have” extra—something that, if we get everything else right, we can perhaps add in. But it is more important than that, as the evidence is now strongly beginning to show. I therefore ask the Minister not to forget what my noble friend Lord Howarth said at the beginning of the debate in his reply, and to consider very seriously how health inequalities can be properly and creatively addressed by further engagement with the arts sector.

I will say one last thing, which perhaps seems not quite at the heart of it, but it is important. My noble friend Lord Howarth, in giving his examples, spoke about arts organisations, many of which are trying to contribute to this area. To be able to do that, they need people with skills who can deliver the work. Nearly all the people who can deliver the work and have those skills are freelancers. As we all know, they have suffered hugely in the last two years as a result of the crisis that we have all been through. Freelance workers in all sectors, but particularly the cultural sector, have had a very bad time and quite a lot of them have left. I add that as an additional thing to remember when we look at the expectations we can reasonably—and should—have of the arts sector. It needs to be able to properly support the people it has to engage to deliver the work that it can do.

Health and Care Bill

Baroness McIntosh of Hudnall Excerpts

Lords Hansard - Part 2 & Committee stage
Wednesday 26th January 2022 Lords Chamber

[The Deputy Chairman of Committees (Baroness McIntosh of Hudnall) (Lab)]

My Lords, the noble Baroness, Lady Brinton, will be speaking remotely in this debate. I should also alert the Committee that, should this amendment be agreed to, I will not be able to call Amendment 163 by reason of pre-emption.

Amendment 162A

Moved by

--- Later in debate ---

Amendment 163 not moved.

[The Deputy Chairman of Committees (Baroness McIntosh of Hudnall) (Lab)]

We come to the group beginning Amendment 164. The noble Baronesses, Lady Brinton and Lady Masham, will be contributing remotely to this debate.

Amendment 164

Moved by

--- Later in debate ---

[Baroness Wheeler (Lab)]

My Lords, Amendment 164 heads this wide-ranging group and probes how the proposed Care Quality Commission rating system for ICBs’ work in practice, with a particular focus on rare and less common conditions, although this debate is more broadly relevant to all aspects of the CQC’s role.

Amendments 178 and 240 from the noble Lord, Lord Sharkey, to which I have added my name, also relate to people with rare diseases and their access to innovative medicines and medicinal products, and the general need for awareness-raising about those conditions among health and social care staff. I remind the Committee of my role as vice-chair of the Specialised Healthcare Alliance. The noble Lord will speak to those amendments later.

The group also covers amendments on wider care and safety issues that impact on patients, including ensuring that liothyronine T3 is available to patients when it is prescribed by a doctor and the regulation of healthcare and associated professions. This includes safeguards to apply under the Secretary of State’s power to alter the professional regulatory framework; protecting the use of the title “nurse”; hospital food standards for patients and training for staff; reviewing the surgical consultants’ appointment process; and licensing aesthetic non-surgical cosmetic procedures in registering cosmetic surgery practitioners.

The noble Lords who have their names to these amendments will speak to them, so I will leave them to it and concentrate on my rare disease issues and the matters that our Front Bench team have added their names to. Returning to the CQC, and following on from the previous debate on Clause 26, on the amendment tabled by the noble Lord, Lord Lansley, regarding the role of the Secretary of State in setting objectives and priorities, overall, we welcome the extension of the CQC’s remit to ICBs but now need to understand how it will work in practice.

As it stands, the Bill establishes an overarching framework under which the CQC will need to determine for itself the quality indicators against which it will assess ICBs. My amendment raises the issues about the quality indicators relevant to those with rare and less common conditions. If the purpose of the rating system is to protect patients, it must help to ensure that national standards of patient care, where they exist, are being met. Under the NHS’s plans to jointly commission or delegate commissioning responsibility for specialised services to ICBs, set out in NHS England’s Integrating Care paper, an important assurance given is that specialised services will

“continue to be subject to consistent national service specifications and evidence-based policies determining treatment eligibility.”

Will the CQC ensure that services organised by ICBs are organised in line with these national specifications?

Moreover, people with rare diseases are concerned that if services are to be commissioned in some way by ICBs in future, rather than just NHS England, their voices may be lost. NHS England’s specialised commissioning team meets regularly with representatives of the rare disease community, including the SHCA, and it is important that ICBs can hear their views too. How will this happen and how will the CQC rating system act to ensure that this happens?

Finally, one of the key asks of patients with rare diseases to help deliver continuity in their care is that they have access to a named clinical nurse specialist, which is commonplace for patients with more common conditions. That continuity of care is an important marker of quality. Will the CQC rating system help to deliver it?

Beyond these questions are broader ones. If the bulk of the CQCs work will continue to focus on inspecting providers, can the Minister explain how it will ensure that its ICB ratings are not unnecessarily duplicative, given that providers will form part of ICBs? Also, the CQC looks at whether services are safe, effective, caring, responsive and well led. Given that the first three of these should continue to be the primary concern of those providing care, rather than of the ICBs organising it, how will the CQC ensure that the new rating system clarifies rather than dilutes this accountability? How will the CQC’s work align with the wider performance management of ICBs undertaken by NHS England? How specialised services will operate is a complex area and I am happy for the Minister to write to me on some of the specifics of my questions.

As I said, I will speak briefly to other amendments in this group, to which Labour Front-Benchers have added their names. Amendment 243, tabled by my noble friend Lady Merron, covers the important issue of the protection of the title “nurse”, and is supported by three respected medical and healthcare professionals whose contributions I look forward to. The recent Health Service Journal survey found hundreds of roles that do not require Nursing and Midwifery Council registration but use “nurse” in the job title. While “registered nurse” is a title protected by the NMC, “nurse” is not. The term may be used by anyone in the UK to offer professional advice and services, and people with no nursing qualifications or experience, or who have been struck off the professional register, may use it.

Obviously, this is worrying and even dangerous—a dangerous trend which potentially compromises patients’ health. What progress is being made on the Government’s review of healthcare professional regulation following their consultation last year? Surely we must follow the example of other countries, such as France and Australia, in giving the consistently most trusted profession in the UK the recognition and protection that it deserves.

My noble friend Lady Thornton has added her name to Amendment 258, from my noble friend Lord Hunt, to the welcome new Clause 145, on hospital food standards. It underlines the importance of investment in the food served to patients in hospital and other care and treatment settings. It is welcome because it specifies food quality and standards and stresses the importance of recognising staff skills, experience and training, as well as ensuring investment in NHS kitchens and catering equipment to ensure that the highest standards can be maintained.

On Amendment 266 from my noble friend Lady Merron, we seek to give the Secretary of State power to introduce a licensing regime for aesthetic non-surgical cosmetic procedures and to introduce an offence of practising without a licence. This area is crying out for regulation. The Department of Health’s own report has said that non-surgical interventions which can have major and irreversible adverse impacts on health and well-being are almost entirely unregulated. We fully recognise that this is also a highly complex policy area. However, I understand that noble Lords concerned about this issue had constructive and positive discussions yesterday with the Minister, and I look forward to the Minister updating the House on the scope and discussions of the Government’s ambition in this important area.

Finally, I offer my strong support for my noble friend Lord Hunt’s Amendment 176, which seeks to ensure that the general powers of the Secretary of State to direct the functions of NHS England include ensuring that when T3 is prescribed to patients with hyperthyroidism, the drug is made available to them. My noble friend rightly raises this issue at every opportunity, and I hope the Minister will have a bit of good news for him today and tell us that some real progress has been made. It is clear that many thyroid patients would benefit hugely from the declassification of T3 as a high-cost drug, back to a drug that is routinely prescribed in primary care. It is much cheaper now, and the many patients who were taken off the drug and continue to be denied it need to have it restored. The Government must ensure that the now updated NICE guidelines which reflect this new position are implemented consistently across the new NHS structures, rather than repeat the record of the nearly 50% of CCGs which failed to ensure that the drug is properly prescribed.

I will leave it at that, and I look forward to the debate.

[The Deputy Chairman of Committees (Baroness McIntosh of Hudnall) (Lab)]

I remind the Committee that both the noble Baronesses, Lady Brinton and Lady Masham, will be contributing remotely. I call the noble Baroness, Lady Brinton.

[Baroness Brinton (LD) [V]]

My Lords, I have signed two amendments in this very wide-ranging group. The first, in the name of the noble Lord, Lord Hunt, is Amendment 264 on the appointment of surgical consultants. As the noble Baroness, Lady Finlay of Llandaff, said in your Lordships’ House recently, 48% of advertised consultant posts last year went unfilled. Given our discussions about the workforce earlier this week, we need as many posts filled as possible and to remove any bureaucratic barriers to so doing.

Part of the problem at the moment is that trusts are having difficulties establishing appointment panels which can make these consultant appointments. Currently, the rules are too tightly drawn in the National Health Service (Appointment of Consultants) Regulations 1996 and the subsequent 2005 guidance. The members of all the royal colleges across the UK have a wealth of expertise, but the current legislation says that only members of English royal colleges can help trusts fill their appointment duties. In its helpful briefing, the Royal College of Surgeons says that the Royal College of Emergency Medicine, the Royal College of Physicians and Surgeons of Glasgow and the Royal College of Physicians of Edinburgh are excluded from being eligible to join these panels. This amendment would be a simple remedy and speed up the appointment of much-needed consultants, and I do hope that the Minister can agree to it.

I have also signed Amendment 266 in the name of the noble Baroness, Lady Merron, on the urgent need to ensure that practitioners undertaking non-surgical aesthetic procedures such as lip fillers, injectables, thread lifts, semi-permanent make-up, laser treatments, piercings and tattoos are properly trained and licensed. These treatments are easily available to members of the public, but without the safeguards required when being carried out in the health sector. I am afraid that we see daily in the press and media reports on the many problems when treatments go wrong, which can include infection, disfiguration and burns, among other serious issues. When treatments do go wrong, it is usually the NHS that has to pick up the pieces, so I believe it is very much in the interests of the Department of Health and Social Care to accept this amendment.

The signatories to this amendment have been working with the Chartered Institute of Environmental Health, alongside a coalition of public health organisations and industry representatives, so that we can make sure that a licensing scheme can be introduced for all non-surgical aesthetic procedures. This will enable the setting of appropriate standards, a level playing field for practitioners and, importantly, protect consumers in this sector.

[The Deputy Chairman of Committees (Baroness McIntosh of Hudnall) (Lab)]

I call the noble Baroness, Lady Masham of Ilton.

[Baroness Masham of Ilton (CB) [V]]

My Lords, I shall speak to Amendments 178, 266 and 293. Amendment 178, which was tabled by the noble Lord, Lord Sharkey, is important for people with rare and less common diseases. The amendments could be a lifeline for people who have rare conditions who use products that may be the only substances that work. There is an enormous selection of rare conditions. It can be a desperate situation when some medicines are developed but take a long time to be given the all-clear by NICE. Some medicines are not available in England on the National Health Service but are available in other countries, sometimes even in Scotland. That is devastating and frustrating.

I support Amendments 266 and 293, on the cosmetic surgery industry, which must be made safer. It is extraordinary that this business is only partially registered. Many people who have such a procedure take for granted that the practitioner will be registered and fully insured. There have been some disastrous results when things go wrong with a beauty procedure. I know of some plastic surgeons who work only in the National Health Service, as they do not want to be tarred with the same brush as uninsured cowboys. Amendments 266 and 293 deal with a wide selection of cosmetic procedures, some of which are psychologically important to many people. There is wide interest in making this trade safe and getting it registered. I hope the Minister realises that this is an important matter that needs putting right.

Health and Care Bill

Baroness McIntosh of Hudnall Excerpts

Lords Hansard - Part 2 & Report stage
Thursday 3rd March 2022 Lords Chamber

[Lord Lansley (Con)]

My Lords, I will not go on at great length because noble Lords have heard more than sufficient from me today, but this group brings us to what is known in the trade as the provider selection regime: that is, how the NHS goes about the process of commissioning services from a range of providers and the relationship between that and the choice that is available to patients. I am going to refer to my amendments, Amendments 98 and 99, and, without going on about it, I commend Amendment 80 in the name of the noble Lord, Lord Warner. Finding out whether people have actually experienced choice and whether that is helpful to them is a useful thing to do, and I am not sure whether it features in the current electronic referral system. It would be useful to add it in.

The words of Amendment 98 are in fact already in the regulations that the NHS currently lives by because, born of the previous experience when there were discriminatory payment arrangements for private sector providers relative to public sector providers—ie, more advantageous payment arrangements for the private sector than the public sector—in the 2012 legislation we legislated to prevent that happening in the future. The current Bill removes said prohibition on discrimination on the basis of the ownership, public or private ownership, of a provider.

Noble Lords might think, “Ah, this is trying to avoid us discriminating against the private sector.” This was actually included in order to prevent the Government or the NHS discriminating in favour of the private sector. There may be arguments for it in certain circumstances because NHS bodies often have, as it were, fully depreciated assets and to create additional capacity the private sector very often has to invest capital and has to meet the costs of capital as well as the revenue costs of providing services. None the less, we addressed all that and took the view that we did not want any discrimination: we wanted no competition on price, but we wanted competition on quality. That is why, to be perfectly frank, I am testing the Government’s intentions in omitting something that was a central plank of policy for the 2012 legislation.

On Amendment 99, if I recall there is language in the original White Paper from last year, which set the provisions for the Bill, which referred to “any qualified provider” and made it clear that it was the Government’s intention to maintain the existing choice arrangements and access to any qualified provider. Indeed, I think it said that it would “bolster” the system, although I am not sure whether that is happening anywhere. The amendment is really intended to test a particular issue that arose. I am a very sad person, and I was looking at the service conditions for the NHS standard contract; the noble Lord, Lord Stevens of Birmingham, will know them intimately. There is a point at which commissioners who are presented with people who wish to access other providers, who have a contract with another commissioner, are not required to extend that service to them. The way in which it was written in the standard contract was to talk about circumstances where the originating contract does not refer to the address—I think it said the postal address—included in the originating contract. My point to the Government is that this is absurd. There can be geographic limitations, but we should aim not to make them as limiting as the reference to a postal address in the originating contract would have made them.

The wider point is that, if one looks at the new provider selection regime, one sees that there is a process by which commissioners—the decision-making bodies commissioning services—go through a process of saying, “What are the circumstances of commissioning providers?” They ask whether it is circumstance 1, extending the existing arrangement; circumstance 2, going to a different provider; or circumstance 3, going to competition. The language of circumstance 2 is:

“where the decision-making body wants to use a different provider and the decision-making body considers it can identify a suitable provider without running a competitive procurement process”.

This is something that it will be readily able to do in many cases. A commissioner can say, “This is the circumstance. We want to go to a different provider and we know who we want to go to—that’s fine, we’ll give them the contract.”

Circumstance 3 is

“where the decision-making body cannot identify a single provider or group of providers that is most suitable without running a competitive process; or to test the market”.

The body could choose to test the market, but of course more than subtly. Whereas, in the past, the NHS tended to think that it needed to test the market in circumstances in which the legislation did not actually require it to, there is no such thing as compulsory competitive tendering in the 2012 legislation, or the regulations made under it. But now it has shifted completely the other way, and NHS bodies will be able broadly speaking to choose not to use competition at all. The question is whether that will really be sustainable. In the short run, access to the private sector may well be quite widespread, and there may well be a significant element of choice available to patients through the electronic referral service, but that may be closed down in years ahead, if these provisions are implemented in the way in which they are set out.

I issue a further warning to my noble friends. If you are a provider of services to the NHS and you believe that a decision has been made unfairly or inappropriately by the NHS, there is a standstill on the contract, you have 30 days, and you can send in a complaint, in effect, to the decision-making body, which then decides whether it has done the right thing. There is no independent process whatever, so it seems that the chances of providers resorting to law to challenge what they regard as unfair decisions on the part of decision-making bodies in the NHS rise dramatically with the implementation of these processes.

All that said, I hope what I can hear from my noble friends on the Front Bench is that what they said in the White Paper a year ago in February 2021 remains true: that they are going to sustain patient choice, that they will use the resources of NHS providers and beyond to enable us to fulfil our very demanding recovery programme, that they will think hard about whether the precise language in some of the respects that I have outlined is fair to providers, and that commissioners in the NHS will use their procurement capabilities to deliver best value for patients. I beg to move Amendment 98.

[The Deputy Speaker (Baroness McIntosh of Hudnall) (Lab)]

The noble Baroness, Lady Brinton, is contributing remotely.

[Baroness Brinton (LD) [V]]

My Lords, I start by commending Amendment 100 tabled by the noble Lord, Lord Warner, and I look forward to hearing him speak on it. It is an excellent idea to ask people how much choice they have actually had when offered treatment. I also thank the noble Lord, Lord Lansley, for explaining his two amendments, and I would like to say to him that he is not sad for carrying out his role in your Lordships’ House with interest and care. His expertise in matters that may leave others cold should be celebrated. The amendments of the noble Lord, Lord Hendy, ask that trade unions should be part of consultations on private providers, and that seems sensible.

I wish to focus, albeit briefly, on Amendment 106A, which proposes that Clause 70 be left out, and which will be spoken to later by the noble Baroness, Lady Thornton; I apologise to her that under the remote rules I have to speak first. I will confine my remarks to the views of the Delegated Powers and Regulatory Reform Committee’s 15th report, in which paragraphs 17 and 18 make plain its views about these proposed procurement arrangements and regulations. The first point that it notes is that the memorandum, at paragraph 481, says that

“full analysis has not been completed and there has not been time to produce a more developed proposal.”

Why on earth do the Government wish to bring into force legislation that they admit they have not had time to analyse, let alone produce a more developed proposal for? We from our Benches, along with other noble Lords, have repeatedly said that the Cabinet Office procurement Bill is likely to overtake the needs for NHS-specific procurement regulations.

Paragraph 17 of the DPRRC Report gets straight to the heart of the issue and provides a response to the amendments that the noble Lord, Lord Kamall, has tabled, starting with Amendment 101 in this group. It says:

“We do not accept that the inclusion of regulation-making powers should be a cover for inadequately developed policy.”


It is therefore more than a little surprising to see a slew of government amendments on this issue that, in the group under discussion, strengthen the powers under regulation.

Paragraph 18 of the Delegated Powers Committee report states that:

“Ministers would not ordinarily propose clauses in one Bill possibly requiring imminent amendment in a subsequent Bill without expecting to face questions. The House may wish to seek further and better particulars from the Minister concerning the possible effect of any Cabinet Office procurement Bill on the Health and Care Bill, and … to press the Minister on why it was necessary to include provision, based on inadequately developed policy, in the Health and Care Bill when the Government intend to introduce a procurement Bill.”


Not only have we tried this at an earlier stage, but there have been meetings between Committee and Report, and it appears that the Government are determined to press on. I know that the noble Baroness, Lady Thornton, has concerns about the Government’s intentions on the clause and its amendment; if she chooses to call a Division on stand part, we from these Benches will support her.