Health and Care Bill

Baroness Merron Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Baroness Merron (Lab)]

My Lords, I am glad to speak in this Second Reading debate on a Bill that has generated much anticipation and interest; the Minister’s comments today have also created much anticipation and interest. I am grateful to the many parliamentary colleagues, organisations, charities and representative bodies that have given their time to give their invaluable views and expertise to many of us in your Lordships’ House. I also thank the Minister and his team for making themselves available, and for the extensive work that they have already undertaken and will continue to undertake. I look forward to the maiden speech of the noble Lord, Lord Stevens of Birmingham; I wonder how he decided to choose this particular Second Reading in which to make it.

However, I am sorry to say that this is the wrong Bill at the wrong time, as it fails to deal with the real and immediate issues in the health and care system: scandalous social care provision; no workforce planning; no strategy for integration between health and social care; weak and underfunded public health services; and inadequate levels of funding. Regrettably, the Bill does nothing to resolve the democratic deficit around accountability in the NHS, and fails to put patients, their carers and the workforce at the heart of building back a better NHS. It is not about improving well-being or addressing the social determinants of poor health. Nothing in this Bill will make much difference to the long waits for people in pain and distress, or those who experience delays in waiting for an ambulance. As for it being the wrong time, we know that the pandemic is far from over. We still await proposals for social care integration, and the most vital issue—responding to the workforce crisis in the NHS and social care—is not even at the planning stage.

Let us remind ourselves that this Bill began as a legislative response to desperate pleas from the NHS to reverse some of the provisions in the Health and Social Care Act 2012, which made it impossible to develop the NHS Long Term Plan. There were demands to end compulsory competitive tendering for health care services and allow much greater co-operation and joint working between various bodies. Also, it was clear that the informal organisational arrangements that the NHS had developed in the sustainability and transformation partnerships needed to be put on to a statutory basis. These have become the proposed 42 integrated care partnerships.

So, a Bill that was expected in 2017 is now with us in 2021 with the addition of extensive new powers for the Secretary of State, which give rise to deep concern. These extend to direct involvement in service reconfigurations, which could be as purely operational as moving a clinic a few yards down the road. They refer to the transfer and delegation of various functions in relation to arm’s-length bodies, the regulation of healthcare and associated professions, and reporting on workforce needs. After Committee in the other place, out of the blue, the Government added a highly contentious new clause concerning the social care costs cap, which will doubtlessly stimulate many hours of debate in your Lordships’ House.

We acknowledge the proposals around information standards and information sharing; setting up, at long last, the Health Services Safety Investigations Body; the introduction of Care Quality Commission powers to investigate adult social care; the reference to medical examiners; food advertising to combat obesity; fluoridation; and the banning of virginity testing.

From these Benches, we broadly support those parts of the Bill that remove the worst of the 2012 Act, but will look to add key safeguards to ensure proper governance and accountability and prevent new arrangements being open to abuse around contracting, particularly with the private sector. However, as I mentioned earlier, we do not support most of the proposed new powers for the Secretary of State in the absence of a proper case being made for them. Of course, the Delegated Powers and Regulatory Reform Committee has reported on these issues; we will be looking very closely at its report.

It is a matter for regret, as I have said, that the Government did not bring forward legislation in 2017 to solve these problems with a far simpler Bill. Having missed the opportunity to act decisively at the right time, we now have to rush through a far more complicated Bill at a more complex time.

Part 1 mostly sets out yet another NHS reorganisation of commissioning on the back of many previous attempts to do likewise. Commissioning will still be conducted on many levels and be difficult to understand and manage. What the public will make of all this is unknown—but then, perhaps nobody actually asked them.

We know that, in Committee in the other place, the Government made a virtue of the flexibility of the Bill. This extends to changes to procurement and pricing, although no details are available. There is a similar lack of detail about what will happen at place, or indeed how “place” is to be defined, or how the two headed integrated care systems will function and how the money will flow.

The Part 1 new powers of the Secretary of State that are spread through the Bill were not what the NHS asked for. Ironically, one relative success from 2012 was the separation of NHS operational accountability from Ministers; the reasons for reversing this are hard to fathom. As any former Minister, including myself, will understand, it is mystifying as to why Ministers should seek such powers.

We will seek to include amendments that will strengthen the governance of integrated care systems by requiring stronger public, patient, carer and staff involvement as a right. We will seek to ensure that the best people are elected or appointed into key roles with due regard to diversity, fairness and transparency. We will seek to prevent the potentially undue influence of private sector organisations in commissioning, and ensure that contracts are awarded with a proper and transparent process that is as good as the Public Contracts Regulations that will be disapplied. Moreover, the Part 1 clause about discharging patients before they have had their social care needs assessed needs fundamental safeguards to ensure that we do not hear once again of an elderly person being returned in the early hours to a cold and empty home. This has to stop.

Let me turn to what is perhaps the most challenging clause, the one relating to workplace planning. If there is one thing about which there is universal agreement, it is the inadequacy of this clause. Having the right workforce across the health and social care sector is the issue of the day, and the response thus far is wanting. We need to see a more resolute approach that properly plans ahead across the NHS, social care and public health. This is not just about doctors and nurses but about the entire team, including cleaners, care assistants, lab technicians and catering staff. Last but not least, there is the last-minute new clause on the rules for calculating the cap on care costs, which will be robustly scrutinised and opposed by these Benches and by many others.

Of particular interest to me as a former Health Minister are a range of other welcome provisions dealing with virginity testing, fluoridation and hospital food, to name but three of the public health measures on which I used to work. However, it is disappointing to see a dearth of proposals on dealing with the increasing and unacceptable level of health inequalities that have been exacerbated by the pandemic and well highlighted by Professor Marmot over many years.

As was experienced in the other place, we know that there will be many more proposals for new clauses to cover other matters. This is surely a Christmas tree Bill, and decorations will surely abound. We will be glad to support the three new clauses proposed in the other place dealing with duties on reducing inequality, attention to waiting times and restricting the use of the term “nurse”.

Before I conclude, I wish to come back to the important matter of patient safety and the health services safety investigations body. We strongly supported the original Bill and were very disappointed when it suddenly fell off the Government’s radar. Despite efforts from across the House, Ministers were unable to explain where it had gone and why it was not being vigorously pursued in the light of the urgent imperative to embed the “lessons learned” culture into the NHS.

The aim of this body is of course to improve the quality of locally conducted investigations and to reduce the incidence of future harm to patients. The benefits cannot be quantified, but the expectation and the hope are that they will far outweigh the costs incurred by the investigations, avoid costs associated with correcting or compensating for harmful incidents, and encourage health improvement. I hope this will be a major contribution to patient safety.

In conclusion, I regret to say that, however this Bill is presented, it is in effect yet another NHS reorganisation. In the last 30 years, we have seen around 20 reorganisations of the NHS, and the British Medical Journal has observed that

“Past reorganisations have delivered little benefit.”


So the questions for the Minister are many. Why will this Bill be any different? How will the 85-year-old with multiple needs get better care based on them perhaps being treated as a whole person as a result of this restructuring? How will waiting times for elective surgery for cancer and mental health support be improved by this reorganisation? How will health inequalities, which have widened, and life expectancy advances, which have stalled, be corrected by this Bill? A real test for this Bill is: will it makes things better and, if so, for whom?

This Bill can do some good, but its timing is unfortunate at best and an opportunity missed at worst. The question remains as to whether this is the right Bill or the right time. However, if the Bill is to be implemented from 1 April, it has to be the best that we can collectively craft. We look forward to making a positive contribution to making it so.

Health and Care Bill

Baroness Merron Excerpts

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

Moved by

[Baroness Merron]

2: Clause 1, page 1, line 5, at end insert—
“(1A) The Board of NHS England must be made up of—(a) a Chair appointed by the Secretary of State;(b) five other members so appointed of whom—(i) one must be appointed to represent Directors of Public Health;(ii) one must be appointed to represent the Local Government Association;(iii) one must be appointed to represent the interest of patients;(iv) one must be appointed to represent the staff employed in the NHS; (v) one must be appointed to represent the integrated care partnerships;(c) one further member appointed by the Secretary of State after being recommended by the Health Committee of the House of Commons as a person with appropriate knowledge and experience;(d) executive members as set out in Schedule 1 to the Health and Social Care Act 2012.(1B) In making the appointments in subsection (1A)(a) and (b) the Secretary of State must have due regard to—(a) the need to ensure diversity and equality of opportunity; and(b) the need to ensure that no person who could be perceived to have a conflict of interest by virtue of their current or recent employment or investment holding in any organisation with any role in the delivery of services to the NHS may be considered for appointment.”Member’s explanatory statement
This amendment requires changes to the membership and composition of the Board of NHS England to reflect its new role under the Bill.

[Baroness Merron (Lab)]

My Lords, I am grateful to the noble Lord, Lord Patel, and the noble Baroness, Lady Walmsley, for their support.

This amendment seeks to define the composition of the board of NHS England to better align it to the new requirements set out elsewhere in the Bill. There must not be any doubt as to why board members have been appointed. In other words, their appointment must be made on their ability to contribute and add strength to the board, rather than—perhaps—because of those whom they already know. Key factors in the appointment of board members need to be an independent assessment of their value and meeting a fit and proper test of freedom from conflict of interests—things that I hope we would all agree on in your Lordships’ House.

Beyond that, we must also look at what the new NHS England board will be required to do. Other parts of this Bill deal with the powers and duties of this new version of NHS England, originally the NHS Commissioning Board. This is the clearest demonstration of the reversal of the 2012 Act, as the new NHS England bears no resemblance to its original predecessor—and that is a good start. The new NHS England will of course be an amalgamation of the old NHS England, Monitor and the NHS Trust Development Authority. It will commission some specialist services. It will be the regulator of a market that no longer exists. It will performance manage both commissioning for integrated care boards and provision of services by trusts and foundation trusts.

This is indeed a wide range of responsibilities, and how it sits with roles within the department unfortunately remains as vague as ever, with the ability of Ministers to micromanage depending on other parts of this Bill. However, the most crucial policy change is that the new NHS England will sit at the top of a system based on the integrated care boards being the major commissioners of services. The Explanatory Notes and the government pronouncements about these new integration bodies strongly assert their role as driving the reintegration of the NHS, repairing the worst of the fragmentation caused by the 2012 Act and dealing with aspects of previous legislation which had a somewhat market-centric view of our NHS.

This purpose drives what we now need from the new board members of NHS England. Those new board members must chime with this new philosophy of partnership and collaboration rather than markets and competition. In the new world, the NHS will still be bound, as it always has been, by its core principles: comprehensive, universal, free, and funded from general taxation. Board members need a demonstrable record of commitment to these principles. They should also have a commitment to the new values, which favour a stronger role for patients and the public to have influence, a view of the NHS as contributing to reducing inequalities and improving well-being, not simply being a sickness service, and greater alignment of NHS services provided through local government. The current make-up of the board is a chair and five other non-executives, all appointed by the Secretary of State and then the appropriate executive directors. Given the huge importance of the NHS, it is appropriate of course that the chair and at least some of the non-executives are appointed by the Secretary of State. This amendment deals only with the remaining non-exec members.

--- Later in debate ---

Amendment 3 (to Amendment 2) withdrawn.

[Baroness Merron (Lab)]

My Lords, the noble Earl, Lord Howe, hoped that his comments would be helpful and I reassure him that he is always helpful in the comments that he offers. Today, of course, is no exception.

As my noble friend Lord Howarth said, this has been a very interesting debate and it has certainly stimulated many angles of consideration. At a minimum, that has been extremely useful because what binds us all together in this debate, whether or not we agree with the amendment, is the wish to see the new NHS England perform to the highest order in terms of not only confidence but effectiveness. I know that we all want to move in the same direction.

Clearly, we have heard differences of opinion. I am grateful to the noble Baroness, Lady Walmsley, for speaking further to the point about representation. I say to my noble friend Lord Howarth that I did not interpret her as having reservations; her concerns were more about clarification, and I share them. The intent of the amendment was not that people should be consulting back and be a straightforward linear representative, but that they should represent and come from the area which we were discussing. The noble Lord, Lord Patel, made a particularly strong case for the importance of influence in public health; that was echoed by my noble friend Lord Brooke. We are all keen, I am sure, to see the ability to promote good health and well-being such that the NHS, as I said in my opening remarks, should not be focused entirely on dealing with ill health, important though that obviously is.

It is important that we get the right people in place to build the right team. It is crucial that they work together. I am sure that many noble Lords who are non-executives on boards know that a successful board is one that invites challenge, dissent and the widest range of voices. I certainly hope the new NHS England board will do this.

As the right reverend Prelate the Bishop of London so clearly put it, it is too easy for patients’ voices to be forgotten—this must not be the case. I know the noble Earl, Lord Howe, will do his best to ensure that those voices are well heard. Certainly, we in this House will continue to pursue that.

The areas outlined in the amendment from which we had hoped to seek representation remain as important as ever after this debate. I am sure that the noble Earl, Lord Howe, and the Minister will reflect on them in the context of the debate. I thank the noble Lord, Lord Mawson, and the noble Baroness, Lady Harding, for providing challenge, as is quite right and proper. I look forward to the new board of NHS England doing the job we all want it to do. In view of our debate, I beg leave to withdraw my amendment.

Amendment 2 withdrawn.

--- Later in debate ---

[Baroness Merron (Lab)]

My Lords, I feel that today’s debate on this important group of amendments should carry much weight because, at its core, this is about treating people as whole people and seeing them as physical, mental and social beings. Our welfare on each of those fronts is absolutely key to the others. It is not possible simply to treat one without regard to the others, and it is crucial that we enhance people’s well-being across our whole complexity as human beings.

I am glad to speak to this group of amendments because, as we have heard across all sides of the Committee throughout today’s debate, the reality is that, despite the best efforts encapsulated in the mandate, and many times in policy, we find that competing priorities, an avalanche of guidance and instructions, and events—the pandemic has been referred to several times, of course—mean that mental health services can be, and indeed have been, relatively left behind. As the Centre for Mental Health reports:

“Mental health problems account for 28% of the burden of disease but only 13% of NHS spending.”


In the debate today we have also asked ourselves: where is the accountability? For example, we know that in many clinical commissioning groups the actual spend on mental health was below what it was supposed to be, yet there have been no consequences. We need to address not just the finances but the mechanisms around it and the impact on individuals.

The founding National Health Service Act 1946 rightly spoke of a comprehensive health service that secured the improvement of both physical and mental health, and subsequent Acts, quite rightly, have confirmed this. In operational terms, the Government require NHS England to work for parity of esteem for mental and physical health through this NHS mandate, but we know, and have heard again today, that this requirement falls down when we go to a local level.

One way or another, we will all be familiar with a whole range of stories of people who have not been able to access treatment in a timely manner or who find that they are pushed around a system with very little effect and discharged from care before it is appropriate, with consequences that are all too clear to see. It is difficult to overestimate just how challenging this is, not just for the individuals but for local commissioners, because they face competing pressures in trying to deal with this.

As has been emphasised, this group of amendments is about not just getting on the road to financial parity, important though that is, but changing the culture and the whole means of monitoring and implementation, so that disparities can be addressed—indeed, if possible, so that difficulties can be headed off at the pass. It is a well-worn phrase, but it sometimes seems that mental health is a Cinderella service—the one that can be cut first, to the benefit of the more visible services. Some of the recent statistics show that one in four mental health beds has been cut in the last decade, while just last year 37% of children referred by a professional to mental health services were turned away. That is a shocking statistic that we need to move away from.

I thank noble Lords for promoting these amendments and for their contributions illustrating what they mean and the reason we need them today. The noble Lords, Lord Stevens and Lord Patel, made timely points about the impact of the pandemic. If this is not a moment for focusing more on mental health, I do not know what is. The challenge we have and the difficulty presented by the pandemic is that while there is a focus on cutting waits for operations—and we know that is important—this could be a reason for mental health services to get somewhat lost, when in fact the pandemic reminds us of the importance of mental health and the need for the NHS to meet the needs that there now are.

The amendment by the noble Lord, Lord Stevens, encourages and directs the actions necessary for transparency on expenditure. I recall that they were referred to in the debate as legislative levers, and that is indeed what they can be. For me, they encourage not just accountability and transparency but actual action and change—the change we need to see.

The noble Baroness, Lady Hollins, referred to parity of esteem having to be applied locally, not just at a higher level. That is the only way we will see a difference in mental health services and improve the mental health of people in this country.

The noble Lord, Lord Crisp, made reference to the fact that legislation is trying to catch up with where we are as a society, and the noble Lord, Lord Warner, referring back to the meeting he attended, said that the public are well ahead of the game. I believe that is true. Indeed, as the noble Baroness, Lady Watkins, said, we have to prepare for tomorrow. It is not satisfactory that we stay stuck in today, or indeed in the past.

In my view, these amendments move us on. They bring mental health services into real parity with physical health services, but they also connect mental and physical together. I hope they will find favour from the Minister.

[Lord Kamall (Con)]

I begin by thanking all your Lordships for the wide-ranging debate. I want to say how much more I learn, listening to the contributions in each of these debates, before I stand up to speak. I thank all noble Lords for their contributions. As the noble Baroness, Lady Merron, says, this debate carries some weight for our understanding that social, mental and physical well-being are equally important. We should not seek to suggest that one takes precedence over another. I also thank the noble Lord, Lord Stevens, for kicking off this debate with his encouraging and not critical amendments; I take them in that spirit.

Following on from that, and before I go to some of the specific amendments, I will just reflect on some of the contributions made thus far. I first thank the noble Lord, Lord Howarth, for raising social prescribing. I know we have discussed this a number of times since I became the Minister, with particular contributions from the noble Baroness, Lady Greengross, on the importance of art and music in helping to unlock the mind and touch the soul.

As has been made clear, social prescribing is a key component of the NHS’s universal personalised care, and I know that, crucially, this can work well for those who are socially isolated or whose well-being is impacted by non-medical issues. The NHS has mechanisms to ensure that social prescribing is embedded across England: for example, the primary care network directed at enhanced services specification outlines that all PCNs must provide access to a social prescribing service.

I also thank the noble Lord, Lord Patel, for raising the importance of the mental health of children and for making sure that we do not forget, even within mental health, that many sections of our society can quite easily be forgotten.

I agree with the right reverend Prelate the Bishop of London: we have come a long way. I remember as a child in the 1970s going to visit my uncle who was a psychiatric nurse at Claybury Hospital and looking at the patients, with the innocence of a child, and thinking, “These people don’t look ill to me.” We have come far since then. I remember the Rampton hospital scandal in the late 1970s, where the patients were treated appallingly, almost not as humans, and with a lack of dignity. The fact that today we are discussing the parity of mental with physical health shows how far we have come as a society.

We also spoke about loneliness and isolation. The noble Baroness, Lady Watkins, and I have had conversations about loneliness and some of the civil society projects that, for example, bring together lonely older people with children from broken homes so that both can benefit and learn from each other. I remember a story that I have mentioned in the past: in one of the projects I visited, a rather old man said, “I lost my wife five years ago and I had almost given up on life. The fact that I am now working with children from broken families and am almost being a mentor to them gives me a purpose to live—a reason to get up in the morning. I have no longer given up on life.” There are so many of these civil society projects, and no matter how we legislate, sometimes those local projects get to the nub of the problem in their local communities.

I have to pay attention when not only two former NHS chief executive officers but the former Chief Nursing Officer speak in the debate. The noble Lord, Lord Crisp, talked about the focus on outcomes, not inputs and how it is important to make sure that we are not gaming the system, mentioning mental illness and mental health but not doing anything effective about it.

Autism was mentioned by the noble Lord, Lord Warner, a former Health Minister. We are fully committed to improving access to and provision of health and care services for autistic people and people with a learning disability. I know that we have had at least one debate on the treatment of patients with autism and sometimes the terrible conditions they experience. That just shows how important this is.

I am trying to say that in many ways that the Government are absolutely committed to supporting everyone’s mental health and well-being and to ensuring that the right support is in place for all who need it. I therefore welcome the amendments which look to ensure parity of esteem across physical and mental health. I assure noble Lords that we support the sentiments behind these amendments and take mental health seriously.

Indeed, one of the considerations in weighing up the many arguments for further measures in response to Covid—from those who were asking for lockdown, for example—is that we also had to recognise that there was a mental health impact to lockdown. As a Government, we had to look not only at the societal and economic impacts but the mental health impacts within health considerations.

On the amendments, I will first address those tabled by the noble Baroness, Lady Hollins—I add my voice to those of the many noble Lords who have paid tribute to her work over many years in promoting this issue and ensuring that we take it seriously. I also pay tribute to the noble Baroness, Lady Walmsley, for making sure that we are informed about this. These amendments would explicitly reference both mental and physical health and illness in certain provisions of the Bill. I understand that the intention is to ensure that due attention is given to both “mental and physical health” and “mental and physical illness”. Indeed, you cannot separate mental and physical illness, as the noble Baroness, Lady Jones, said. We have moved way beyond “Pull yourself together, man” or a stiff upper lip attitude. We see how mental health plays a role, for example, in terrorism, with those who are recruited to be terrorists, or in those with eating disorders, or the number of people in prison who suffer from mental health issues. It is important that we fully recognise that.

Health and Care Bill

Baroness Merron Excerpts

Lords Hansard - Part 3 & Committee stage
Tuesday 18th January 2022 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I feel honoured to be a fellow Member of this House with the noble Baroness, Lady Finlay, because of her professional and political work in raising this issue before your Lordships.

I want to use a word that has not been used yet in this debate, and that word is “fear”. The noble Baroness, Lady Fraser, nearly used it when she said that people are scared. Anybody who has read the reports that say that only 50% of people who need palliative care receive it will feel fear: “Is it going to be painful?”, “Am I going to be able to bear it?” and, on the part of the carer and family members, “Is it going to be terrible for my loved one?”, “Am I going to be able to help them?”, “Am I going to be able to cope?” The physical pain is part of it, but, as the noble Baroness, Lady Hollins, said, the fear and the psychological distress make things a great deal worse. At a time when it is in our power to give people a good death, we are not doing it; that is a disgrace.

[Baroness Merron (Lab)]

My Lords, I think it is fair to say that the debate today across your Lordships’ House has shown that it is impossible to understand how specialist palliative care can be regarded in any logical, practical or humane sense as something so different. I am sure that the Minister will do his very best to address that in his consideration of these important amendments.

I am grateful to noble Lords for making this debate possible by bringing forward these amendments and making sensitive, informed and often personal contributions to underline the need to ensure that specialist palliative care features in the Bill. I am particularly grateful to the noble Baroness, Lady Finlay, for setting out the fact that if we are to say that the NHS is cradle-to-grave, that must absolutely shape how we approach such services. The noble Baroness and others, including the right reverend Prelate, talked about inequality and the fact that, when we speak of specialist palliative care, inequalities are not just in the course of someone’s life but actually to the very moment they leave this world. That really had an impact on me, because that surely is an unfairness too far for us to just stand by.

Taking action could not be more pressing a need. We know that the UK’s population is ageing rapidly. The Office for National Statistics predicts that, in 20 years’ time, there will be twice as many people over the age of 85, while Marie Curie’s analysis for Cardiff University has concluded that the number of people needing palliative care will rise by 42% by 2040. This is a challenge to our society which will not go away. As the noble Lord, Lord Patel, said, we should be able to live our lives in anticipation of a good death. The right reverend Prelate spoke of the difference of witnessing a good death, as opposed to a death that is less than what it should be.

It is important to say that, even before the pandemic, experts at the Royal College of Physicians, the Care Quality Commission, the health service ombudsman and Compassion in Dying were all sounding the alarm on how those approaching the end of their life, and their loved ones, did not, in so many circumstances, feel supported to make the decisions that faced them and that it was impossible to turn away from. They did not know what choices were available, and, sadly, were not given an honest prognosis.

The amendments in this group offer dignity to the greatly increasing numbers who will need this care, and would bring in moral and well-evidenced measures essential to providing the tailored care that is needed in the final stages of one’s life. This includes sharing information about a person’s care across the different professionals and organisations involved in that care, and providing patients and their loved ones with specialist advice, 24 hours a day, every day of the week—which expert practitioners, including those at Cicely Saunders International, have been crying out for.

My noble friends Lord Hunt and Lord Howarth, the noble Baroness, Lady Finlay, the noble Lord, Lord Patel, and others underlined the work, role and contribution of the hospice movement, and also spoke about their incredulity at the reliance on charitable funding. Who in this Committee can be surprised at that feeling? I hope the Minister will be able to speak to that absolutely crucial point because, even before the pandemic, many hospices were suffering from poor decisions from clinical commissioning groups, poor practice, and a lack of support and recognition of the vital role that they play. That impacts on the individuals who so sorely need their services.

Marie Curie reported that 76% of carers who lost a loved one during the pandemic felt that they did not get the appropriate care that they needed. This is an opportunity to fix the problem. Every day, pandemic or none, the quality and personalisation of specialist palliative care will dictate how dignified and comfortable —or not—the end of a life will be, and how much of a burden will be borne by the carers and loved ones: whether, as the noble Baroness, Lady Hollins, reminded us, those left behind are adults or children. These amendments seek to get it right, and the feeling of this Committee could not be clearer. I look forward to the Minister’s response.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)]

My Lords, as we reach the closing minutes of today’s debate and reflect on the wonderful contributions from across the Committee, perhaps it is fitting that we also talk about the final chapter of life, as the right reverend Prelate the Bishop of Carlisle said.

I thank all noble Lords who spoke very movingly today, particularly the noble Baronesses, Lady Meacher, Lady Hollins and Lady Walmsley, the noble Lord, Lord Patel, and my noble friends Lady Hodgson and Lady Fraser, who spoke about their own experiences. I also thank the noble Baroness, Lady Merron, for pointing out the 42% figure, which is very important to recognise. I thank the noble Baroness, Lady Finlay, for the engagement we had prior to this debate and for her helpful engagement with our officials and the Bill team. I hope that will continue.

What is interesting about this is that when I was younger, we as a society found it very difficult to talk about death. I was once told by my parents that the British find it very difficult to talk about death, except in faith groups. It is interesting that, over time, as we have become an ageing society, we are talking, as a matter of fact, about death. We talk about our wills, financial planning, and planning for care at the end of our life. It is appropriate that we recognise this. The fact is that, nowadays, when we look at the hospice movement, we do not think of it as a quaint little service or a charity; we think that it provides an essential service to help someone at the end of their life, and we recognise the difference between palliative care and end-of-life care.

I hope that I can reassure the Committee that the Government are committed to ensuring that people of all ages have the opportunity to benefit from high-quality, personalised palliative and end-of-life care, if and when they need it. I also pay tribute to the noble Lords, Lord Howarth and Lord Scriven, for their contributions. The noble Lord, Lord Howarth, talked about the role that the arts play in helping those at the end of their life, which he has talked about in a number of discussions we have had on this issue. Like the noble Lord, Lord Scriven, he made the point that while you want to see the state do more, you do not want to push or squeeze out the hospice movement, as we need the right balance.

Health and Care Bill

Baroness Merron Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

[Lord Mackay of Clashfern (Con)]

My Lords, I support these amendments, subject to the economic difficulties. As I listened to the local Baroness, Lady Brinton, I wondered whether the amendments might be strengthened by some reference to the timescale in which they must be implemented. That might have some beneficial effect for many people who are waiting.

[Baroness Merron (Lab)]

My Lords, I welcome these amendments, which relate to the National Institute for Clinical Excellence—NICE. I thank all noble Lords for tabling these amendments and for their contributions today, which certainly expanded my knowledge of the subject, as I am sure they did across the Committee. The debate has shown that there is a need for change, as I am sure the Minister has heard, to better equip the National Health Service to provide the patient what they need when they need it.

The noble Baroness, Lady McIntosh, spoke clearly about hurdles that must be overcome, whether they are bureaucratic, process, budgetary or administrative. All these hurdles get in the way of the end result: meeting the needs of patients. That, I believe, is what this debate is focused on.

NICE is well recognised as a partner to our NHS. Its objective approach and evidence-based analysis rightly gain respect. However, as my noble friend Lord Hunt said—he can now be called the first Minister for NICE—although the National Health Service is full of innovation, it is also slow to pick up on it; that point was emphasised by the noble Lord, Lord Warner. That begs the question: what kind of partner should NICE be to the NHS? Is it going to be an enabling partner, or will it frustrate at times? Of course, we all want to see NICE in that fully enabling capacity.

However, beyond what NICE approves in terms of treatments, pathways or otherwise, there must be procedures for it to implement and connect effectively to patients’ needs. We know that no system or set of procedures will ever be perfect; we have heard that today. Understandably, therefore, as the Minister has heard, pressure and a will for change—in a positive sense—is contained in these amendments. The noble Baroness, Lady Finlay, spoke about how important it is to have evidence-based healthcare and to have known guidelines and see them complied with, as is right and proper.

There are cautionary considerations to note in this debate; we have heard some of them. One is whether it is wise to put what in some cases appear to be operational requirements in the Bill. I am sure the Minister will address this. The new world is certainly paying a lot of attention to flexibilities. We want to make sure that anything contained in the Bill does not inadvertently work in another direction.

My understanding is that NICE guidance is mandated, in effect, with the guidelines somewhat less so. Amendment 54 contains a proposal to reinforce the intention that, once a treatment has been properly assessed and recommended, all patients should be able to gain the benefit. We know, and we have heard in this debate, that this does not always happen, and that clinical commissioning groups follow different policies. However, in considering the amendment at face value, it is important that we consider what impact this latitude might have. I am sure we are all keen not to accidentally invoke some kind of fallout, such as taking away all leeway from commissioners. At present, they can depart if they can set out an objective case for doing so; for example, with requests for certain drugs and therapies through individual funding requests.

Similarly, it would be unfair if a patient could cross an integrated care board border and receive a treatment that was not available in another ICB area. That would seem inadvertently to achieve what we do not want to achieve: the worst of a postcode lottery. Equally, if we have locally based approaches, the reality is that some localities will differ in their priorities and services. I know that we will return to this topic many times in our consideration of the Bill because the care that patients receive should certainly be equitable and fair and not based on where they live.

Health and Care Bill

Baroness Merron Excerpts

Lords Hansard - Part 1 & Committee stage
Monday 24th January 2022 Lords Chamber

[Baroness Neville-Jones (Con)]

My Lords, I shall speak briefly in support of this group of amendments, particularly Amendments 79, 81, 96 and 196, which concern both research and clinical trials. I am grateful to the noble Lords who have put their names to them.

As other noble Lords have noted, the Government have actually recognised the need for integrated care boards to have research among their general duties—but one would be hard pressed to realise from the Bill’s drafting that this was a priority. As the noble Lord, Lord Sharkey, said well, the drafting is weak. We need something much more explicit and action oriented. Frankly, “promote” is a vague term that can mean anything or nothing. We need action-oriented language of a kind that puts the NHS and the resources that this country has right at the centre of medical research.

We need an amendment of the type that my noble friend Lady McIntosh of Pickering has put down to give us a national research strategy and join up the national and local levels in achieving it. The noble Lord, Lord Kakkar, has given us many reasons why we need to move on the whole subject of research and make it central to the National Health Service’s mission. We need something that is explicit in charging the NHS to conduct research and enable relevant bodies to do so as well. The results should be exploited in healthcare. Linking research to local needs will also increase their relevance, and the adoption of these results and the obligation to report on them will ensure that things really happen.

I could not find in the drafting any reference to the need to do clinical trials. Surely this is a central element in research and could be extraordinarily advantageous to the UK. As the noble Lord, Lord Patel, has just said, the NHS has a database that is unparalleled in the world. It provides us with an extraordinary advantage. I recall that when I was on the Science and Technology Committee, we heard considerable evidence about the barriers that were put in the way by rather pettifogging EU regulations. I recall the desire, when free of these, to be able to conduct clinical trials. I am aware that some people argue that the UK market is too small, but, with our database, that is not the case—and we can ensure that we have co-operation from abroad.

It is very important that this becomes a central element in our research programmes. It puts us on the map internationally, and it ensures that the NHS, which, after all, is a great consumer of the public expenditure in this country, is also part of wealth creation. That should be part of the result of the research that it conducts.

I do not think that the Government disagree with the thrust of the thinking here, but I very much hope that they will agree that the Bill’s drafting, as it exists at the moment, is inadequate. I hope that, when my noble friend comes to reply, he accepts that the language on both of these elements needs strengthening, giving a central role to research and clinical trials in the NHS.

[Baroness Merron (Lab)]

My Lords, I am grateful to noble Lords for putting forward these amendments, all of which seek to strengthen the Bill and build on what the noble Baroness, Lady McIntosh, opened with: the need for clear lines of responsibility and for a joined-up strategy—in other words, for us to get to the point that we are looking for.

My noble friend Lord Hunt spoke of the embodiment, perhaps, of that through a chief innovation officer, who could be a reminder—not on their own—of the need to build in research and innovation as core throughout commissioning. I am sure that the Minister has heard that this debate is a cry for us to embed in the Bill and in our NHS not just a requirement for but a delivery of research and innovation to the appropriate standard to serve the country. It will not just happen on its own.

We have seen significant variation of opportunity for patients to engage in research and disparities in participation reported on geographic and socioeconomic lines, by ethnic origin and across different disease areas. This is due to the fact that the NHS has been unable to prioritise resourcing and delivery of research, which has been a particular feature over the past decade.

In the Bill, we have a major opportunity to embed a research-active culture—words used by the noble Baroness, Lady Harding—within the NHS which could build on the response to Covid-19, which the noble Lord, Lord Patel, emphasised. That response saw more NHS sites, staff and patients engage in research than ever before. Let us not waste this opportunity.

The Bill offers little different to the Health and Social Care Act 2012, which also did not and does not mandate clinical research activity, stating just a duty for clinical commissioning groups “to promote” research. Your Lordships will notice the similarity in wording in the current Bill. The noble Lord, Lord Sharkey, is quite right, as are other noble Lords, to speak of the weakness of just using the words “to promote”. This set of amendments is about how we make it actually happen. The amendments are about mandating integrated care boards to conduct research and to monitor and assess innovation, because without that, it will just not happen.

Legislation is indeed a critical element, but it is important to stress that it must be accompanied by the necessary infrastructure: for example, through staffing levels—to which we will return in our next debate—research capability, digital resources and tools and access to services, as well as efficient trial approval processes, the ability reliably to recruit patients, the offering of guidance and, of course, dedicated staff time for research. All of those will make the legislation actually mean something.

As well as a strengthened legislative mandate which moves beyond the current duty simply to promote research, it would support patients, clinicians and NHS organisations across the country to have equal access to the benefits brought about by research participation. This will be better for patients, give greater staff satisfaction and deliver economic benefits not just for the NHS but for the broader economy. The noble Lord, Lord Kakkar, talked about the life sciences being a major player as a contributor to our economic well-being and prosperity in this country—something also emphasised by my noble friend Lord Davies.

Such a mandate would also ensure support for levelling up and make it possible to address health inequalities. This in turn would support the ambition set out in the Government’s clinical research vision: to make access and participation in research as easy as possible for everyone across the UK, including those in rural, diverse and underserved populations. I hope the Minister will take the opportunity to reflect on the points made in this debate, because this group of amendments provides an opportunity to strengthen the Bill to actually deliver.

[Lord Kamall (Con)]

Like many of the debates on this Bill in Committee, this has been a fascinating one. It has been really interesting to hear from experts who themselves have engaged in clinical research. I start by thanking my noble friends Lady McIntosh of Pickering and Lady Blackwood and the noble Lords, Lord Sharkey and Lord Kakkar, for bringing this debate before the Committee today. I also thank the noble Lord, Lord Howarth, for his points about the arts and social prescribing.

Before I turn to the amendments, perhaps I could make two personal reflections. One is from my early academic career as a postdoctoral research fellow. I saw the benefit of taking the results of my research directly into my teaching. It made the courses more dynamic—it was not just a repeat of last year’s slides for this year’s students—and it showed what progress we were making in that field of research.

Health and Care Bill

Baroness Merron Excerpts

Lords Hansard - Part 2 & Committee stage
Monday 24th January 2022 Lords Chamber

We are a wealthy country. Traditionally, we have imported these skills, all too often from places that have a gross shortage—even far greater shortages than we have. We have to stop doing that. We have to train significantly more people than we need, because quite a number of them will, for whatever personal reasons, decide to go elsewhere, even if we are providing them with the best possible working environment we can. So we have to train vastly more people. That is our global responsibility.

[Baroness Merron (Lab)]

My Lords, I start by acknowledging—as I am sure we all do in your Lordships’ House—the value, commitment and contribution of the workforce who are the backbone of our health and social care services. We owe them our gratitude. The noble Baroness, Lady Finlay, and my noble friends Lady Whitaker and Lord Bradley are all absolutely right to acknowledge the breadth and depth of the workforce: that it is a team, and that each part of that team is absolutely connected with the other.

I very much agree with the noble Lord, Lord Kakkar, who said that this debate is absolutely central to all that we are here to discuss and to all that patients need from our health and social care services. I am extremely grateful to noble Lords who have tabled and supported amendments and spoken in this debate. All of them have made a compelling case for a workforce plan that will, if these amendments are taken on board by the Minister, feature a laser-like focus on valuing the entire staff team, along with providing planning, financial resources, responsibility, reviewing and reporting—all essential features of any effective strategy. This begs the question: if we see these pillars in a strategy in every other part of our economy and of the way that our whole society functions, why can we not have this for the NHS and social care?

I am glad to have tabled an amendment that calls for a duty on the Secretary of State to ensure that there are safe staffing levels—this was very clearly emphasised by the noble Baroness, Lady Walmsley, in her opening to this debate. This is extremely important because it places a duty where it ought to be and allows examination and transparency.

Of course, we all know that the situation we are discussing today is not new: the noble Lord, Lord Stevens, spoke to your Lordships’ House about a litany of unfulfilled promises and missed opportunities in workforce planning. The noble Baroness, Lady Harding, spoke of her efforts to resolve this and explained the need, which we see in these amendments, to introduce improvements to the Bill to resolve the matter of workforce supply against the demand that is there. All of that requires a lead-in time, and it has to be underpinned by the requisite funds—there is no shortcut to this. In England, we now have a whole website that is full of guidance, and NHS boards are required to take this into account, and yet there is no national workforce plan or credible plan for funding. Until there is, the ICBs will not be able to plan either. The noble Lord, Lord Warner, rightly pointed out that this is not an either/or situation: we need a national workforce plan, and it has to have the funds to deliver it.

I will draw the Minister’s attention to particular aspects of the amendments: explicit recognition of the need to consult with the workforce through trade unions; that planning must cover health and social care; that timescales for reporting should be testing but not too onerous; and that the financial projections in any workforce plan should be subjected to some level of independent expert verification, through the Office for Budget Responsibility, for example.

Behind all of these discussions, we started in a place highlighted by the noble Baronesses, Lady Masham, Lady Walmsley, Lady Watkins and Lady Bennett, and other noble Lords, who spoke of the crisis of the levels of vacancies that we now see and the impossibility of dealing with this without preparation and resource. Any national plan for the workforce needs to be built from the bottom up and not imposed from the top. I hope that the Minister will consider this when he looks at ways to improve the Bill.

I will raise a couple of related points. The scale of the workforce challenge is well established, but it goes far deeper than just numbers and structures. It goes to issues around workforce terms and conditions and career development, particularly in social care, which the noble Baroness, Lady Hollins, brought our attention to. It also has to deal with cultural issues; there is a clear indication that all is not entirely well in the NHS when it comes to diversity, whistleblowing and aspects of how staff are or are not nurtured and supported.

I have one final specific issue to raise, which we have heard about in the debate today and that I would like to extend: international recruitment. I ask that the Government do more to prevent international recruitment, particularly of nurses and midwives, from countries where it is unethical to recruit, and that this be a part of any future strategy. The existing code of practice on international recruitment is not legally enforceable, so when Unison or others report breaches of the code by recruitment agencies, there is no provision for sanctions to be brought against rogue operators. I ask the Minister to confirm that the code of conduct will be promoted and will be enforced.

The situation in which we find ourselves is fixable. I hope the Minister, in his response tonight, will show your Lordships’ House that he understands the situation, that he understands what needs to be done and that he will do it.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)]

Well, this has been another fascinating debate, and I welcome the contributions from all noble Lords speaking from many years of experience, including former chief executives of the National Health Service and former Health Ministers, medical experts and practitioners. I am grateful to the many noble Lords who have laid amendments in this group; there clearly is a strength of feeling, not only in this Chamber but in the other place. To cut a long story short, this will clearly require more discussion.

However, I am duty bound to give the Government’s perspective on this. We have committed to publishing a plan for elective recovery and to introduce further reforms to improve recruitment and support our social care workforce, as set out in the White Paper, People at the Heart of Care: Adult Social Care Reform. I take the point of the noble Lord, Lord Stevens, that he is aware of many expectations that have passed, and I hope that this time we surprise him. We are also developing a comprehensive national plan for supporting and enabling integration between health, social care and other services that support people’s health and well-being.

The monthly workforce statistics for October 2021 show there are record numbers of staff working in the NHS, with over 1.2 million full-time equivalent staff, which is about 1.3 million in headcount. But I am also aware of the point of noble Lord, Lord Warner, that it should not just be about the number of people working—it is about much more than numbers and quantity; it is about quality and opportunities. We are also committed to delivering 50,000 more nurses and putting the NHS on a trajectory towards a sustainable long-term future. We want to meet our manifesto commitment to improve retention in nursing and support return to practice, and to invest in and diversify our training pipeline, but also, as many Lords have said, to ethically recruit internationally.

On that, I want to make two points. The first is this. When I had a similar conversation with the Kenyan Health Minister and expressed the concern we had about taking nurses who could work in that country, the Minister was quite clear that they actually train more nurses than they have capacity for in their country—they see this as a way to earn revenue. There have been many studies on how remittances are a much more powerful way of helping countries, rather than government-to-government aid. With that in mind, we recruit ethically, and we have conversations.

The second point is also from my own experience. I was on a delegation to Uganda a few years ago and I remember speaking to a local about the issue of the brain drain and our concerns. We were talking about immigration, and he said, “You do realise, though, it is all very well for you to patronise me and say that I should stay in this country, but sometimes the opportunities are not here for me in this country. You talk about a brain drain; I see my brain in a drain”. Sometimes we have to look at the issues of individuals who are concerned that they do not have opportunities in their countries, even if the numbers dictate otherwise. Having said all that, we are committed to the WHO ethical guidelines, but I also think that we should be aware. Look at the way that, post war, the people of the Commonwealth came and helped to save our public services. I hope we are not going to use this as an excuse to keep people out, though I understand the concern that we have to make sure that we recruit ethically internationally.

Health and Care Bill

Baroness Merron Excerpts

Lords Hansard - Part 1 & Committee stage
Wednesday 26th January 2022 Lords Chamber

[Lord Bethell (Con)]

My Lords, I will briefly say that I am extremely optimistic about family hubs. They answer the challenge to solve the complexity around integration incredibly well. My noble friend Lord Farmer made the point that one cannot think of a better example of what integration looks like than family hubs. The noble Baroness, Lady Tyler, talked clearly and persuasively about the journey they have been on.

My noble friend has made the case for these amendments. Other noble Lords have made the case for updating the legislative framework. I ask the Minister to look carefully at what can be done to bring these laws up to date so that family hubs can thrive, as I believe they will.

[Baroness Merron (Lab)]

My Lords, I am grateful to the noble Lord, Lord Farmer, for introducing this important debate and to other noble Lords who have supported the amendments before us and spoken about how we can improve the support that families will receive through this Bill. As the Family Hubs Network rightly observes,

“prevention is simply listed in the Bill as one of several commissioning requirements of ICBs with no broad mention of children’s health”.

This group of amendments gives us the opportunity to sharpen this.

As we have heard, the issues that families face, in whatever form or shape, do not exist in isolation. In addition to the impact of financial, housing, social and other pressures, the physical and mental health of a child or young person affects the physical and mental health of not just their parents, but their wider family, and vice versa. It makes common sense to facilitate a healthcare system that is designed and resourced to actively take a holistic approach to the many issues that face children and those who care for them.

I cannot help but feel that the points raised today are not new. We have the experience of Sure Start to show us how effective properly integrated family services can be. As the Institute for Fiscal Studies confirmed:

“By bringing together a wide range of early years services for children under 5, Sure Start centres dramatically improved children’s health even through their teenage years.”


Early investment is crucial.

I hope the Minister will be keen to embed change in this Bill to replicate the success that we saw through Sure Start. The first step towards doing this is to make sure that integrated care partnerships are properly required to consider how family help services can be thoroughly integrated into our health and care system, so that family members—no matter what form those families take—are seen as both individuals and groups who have an effect on each other.

[Lord Kamall (Con)]

I thank my noble friend Lord Farmer and all noble Lords who spoke about their experiences. The creation of integrated care boards represents a huge opportunity to support and improve the planning and provision of services to make sure that they are more joined up and better meet the needs of infants, children and young people.

Before I go into the specific amendments, I make it quite clear, as my noble friend said, that the Government set out in their manifesto a commitment to championing family hubs. We want to see them across the country, but at the same time we must give democratically elected councils the choice to shape how services are delivered, bearing in mind some of the points made by the noble Lords, Lord Mawson and Lord Warner, whom I thank for their experience on this.

The Government agree that it is vital to ensure that ICPs work closely with a range of organisations and services to consider the whole needs of a family when providing health and care support. In preparing the integrated care strategy, the integrated care partnership must involve local Healthwatch and the people who live or work in the area. We are working with NHS England and NHS Improvement on bespoke draft guidance, which will set out the measures that ICBs and ICPs should take to ensure they deliver for babies, children and young people. This will cover services that my noble friend considers part of family help.

In addition, the independent review of children’s social care is still considering its definition of “family help”, and the definition published in The Case for Change may well be further refined as a result of ongoing consultation. It would be inappropriate to define the term in legislation at this stage, pre-empting the full findings of the review and the Government’s response to it. Also, it is important that there should be a degree of local determination as to what should be included in the strategies of ICBs and ICPs. In order for them to deliver for their local populations, a permissive approach is critical.

On Amendment 167, we agree that family hubs are a wonderful innovation in service organisation and delivery for families. The great thing about them is how they emerged organically from local councils over the last decade. I pay tribute to my noble friend for the key role he has played in advocating family hubs and bringing this innovation to the heart of government. The Government strongly support and champion the move but we are clear that they have to be effective and successful—they need to be able to adapt to local needs and circumstances. They also need to be able to operate affordably, making use of a diverse range of local and central funding streams.

In both these regards, local democratically elected councils should hold the ultimate decision-making power over whether to adopt a family hub model and how it should function. As such, I regret that we cannot support the amendment, which would place too much prescription on the decisions and actions of local authorities and risk imposing significant new financial burdens. For this reason, I ask my noble friend to consider withdrawing his amendment.

Health and Care Bill

Baroness Merron Excerpts

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

[Baroness Brinton (LD) [V]]

My Lords, the noble Lord, Lord Lansley, has set out the tensions underlying the Bill about returning to the Secretary of State powers over independent, arms-length bodies; specifically, in this amendment, the inspections carried out by the Care Quality Commission in its role as a regulatory body. He rightly reminded us of the current arrangements, which give the CQC the ability to set its indicators and which, frankly, work well. I will not repeat his arguments, except to say in a slightly wider context that almost every piece of legislation brought to Parliament by this Government has given Ministers more powers—including, as in Clause 26, the power to intervene and to change remits.

The noble Lord’s amendments maintain the independence that the CQC—and other regulatory bodies—need to be able to inspect and make rulings without fear of favour or influence from politicians, while ensuring that the CQC must consult the Secretary of State when it revises indicators of quality for the purposes of assessment. That seems to me to provide the requirement for the CQC and the Secretary of State to engage in dialogue, but without the political intervention outlined in Clause 26(2) and (5).

Can the Minister explain why the Government feel the need to remove the independence of the CQC—whether this is an issue of management, as the noble Lord, Lord Lansley, said—and how giving the Secretary of State these powers can maintain the independence of a regulatory body?

[Baroness Merron (Lab)]

My Lords, it is essential that we get the arrangements for the Care Quality Commission right throughout the Bill, and I am grateful to the noble Lord, Lord Lansley, for trying to do that through these amendments. If the health and social care provided is to be of the highest standards, we must ensure, through the powers of scrutiny and review in your Lordships’ House, that we enable the watchdog to have the proper tools and framework to achieve that, so I support the amendments.

As the noble Baroness, Lady Brinton, emphasised, this is about putting the responsibility in the right place to ensure that a key inspectorate can do an independent job and support proper integration and delivery. I hope the Minister will accept the good sense in these amendments.

[Baroness Altmann (Con)]

Can I briefly ask my noble friend whether part of the thinking behind the current wording might be that the remit of the CQC may need extending? For example, when it comes to private operators of social care, the CQC currently does not have the power to look at the financial stability of those operators. Is this provision perhaps based on the thought that the Secretary of State may need to widen the remit and powers of the CQC? If not, we will be returning to this at some point.

Health and Care Bill

Baroness Merron Excerpts

Lords Hansard - Part 3 & Committee stage
Wednesday 26th January 2022 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I have added my name to the amendments in this group, so ably introduced by the noble Lord, Lord Crisp. The noble Lord, Lord Lansley, asked: what is the problem to which Clause 54 is the solution? But I want to know why the Government think that Clause 54 is the solution to the real problem. The real problem is that, over recent years, the funding focus has been on revenue to support the greater demands made on the health service, and, apart from occasional injections of extra capital funding, capital budgets have been inadequate. In the meantime, hospital trusts of both types—foundation and NHS—have found it impossible to keep up with the need for repair and maintenance to buildings and plant and, crucially, to invest in modern technologies that would enable them to deliver more effective care.

An NHS Confederation survey prior to the spending review in October last year found that 81% of leaders said an insufficient capital settlement could impact their ability to meet estate and service safety requirements, and 69% of leaders said a poor capital settlement threatens their ability to fully embed digital transformation in their care and even hampers their efforts to maintain staff levels or keep appropriate records of patients who need elective care. Many of our hospitals and clinics are located in very old buildings and some certainly show it, but capital funding has not kept up with demand for years, and this new Secretary of State power in Clause 54 will not solve the wider problem. St Mary’s Hospital in Paddington will need £1 billion to repair the hospital or services could be shut in six to nine years. Many buildings on the site date back to the hospital’s founding in 1845. One part of the hospital can no longer be used, as the building will no longer support the weight of modern hospital beds.

Annual statistics show that each year we do not invest enough and the problem only becomes bigger. We must keep reminding the Government of the consequences of this. It is worth noting that many areas of the country with the worst health outcomes have older estates, so upgrading these estates will lead to better outcomes for these populations. This is a health inequality issue. The problems are not confined to England. I could tell noble Lords some terrible stories about my local hospital in Wales, where health is devolved. It is easy to find examples of maintenance issues from hospitals, as these get a lot of coverage. The headline “Hospital roof crumbling” is always of interest to local media. However, there are also thousands of small community hubs and mental health trusts that desperately need new and updated facilities and equipment too, and they cannot shout as loudly. The backlog currently stands at £9.2 billion, with half of that, as we have heard, described as involving a high or significant risk to staff and patients.

The new powers for the Secretary of State proposed in Clause 54 would restrict the spending of any individual foundation trust in the same way as NHS trusts are currently limited. This may appear to be fair, and I do not oppose the principle of the Secretary of State having the power. However, it appears to me to be contrary to the principle of freedom of the foundation trusts as outlined by the Government when they were set up, and certainly contrary to the agreement made by NHS England and NHS Improvement with the sector through the September 2019 legislative proposal mentioned by the noble Baroness, Lady Neuberger, which was the result of detailed negotiations with NHS Providers on behalf of their foundation trust members. The reason given by the Government is that this is in order to avoid the overall health budget being exceeded. However, the power needs to be a very narrow reserve power, to be used when all else has failed, and that is what these amendments would ensure.

The Health and Social Care Committee in another place has made it clear that the powers should be used only as a last resort. It has to be remembered that, if a repair needs to be done on the basis of health and safety but is not done, it is the trust that will be blamed for any harm that comes to staff or patients, not the Secretary of State. They are accountable, and that is right, but it does not help them to keep people safe. The noble Lord, Lord Crisp, has tabled this group of amendments to narrow the scope of the power, to ensure in outline what must be done before it is used and, crucially, in my opinion, to require the agreement of Parliament. Currently, the proposal, like many others in the Bill, cuts Parliament out completely. Where the Government are proposing to wipe out an agreement with the sector which is only just over two years old, there must be compelling reasons, mitigating actions and parliamentary scrutiny.

[Baroness Merron (Lab)]

My Lords, I am grateful to the noble Lord, Lord Crisp, for introducing this group of amendments and setting out for your Lordships that what we need to see is a reasonable system of checks and balances which will serve financial flows and objectives and where, if tensions arise, they can be resolved quickly, fairly and transparently. Certainly, these amendments provide for this.

--- Later in debate ---

[Lord McCrea of Magherafelt and Cookstown (DUP)]

My Lords, there is a process that the noble and learned Lord, Lord Mackay, outlined tonight for how this issue could proceed. I believe we should bow to his legal and learned knowledge concerning this matter.

I think society should give everything financially and provide palliative care to those who are in need at the end of life. I trust and pray that this House will send a clear message that we will do everything to ensure people live with decency and honour rather than telling them that we will help them to die.

[Baroness Merron (Lab)]

My Lords, this debate has probably exposed more that is not resolved rather than what is resolved. Having listened very closely to the passionate, informed and often personal contributions from noble Lords this evening, I feel there was some inevitability that that is where this debate would lie.

I want to touch on the two amendments before us. I am grateful to the noble Baroness, Lady Meacher, for clarifying that Amendment 203 is a probing amendment. I am reminded of when we debated these issues in the previous group where your Lordships’ House had great regard for ensuring that a patient’s final wishes should be respected as a kindness. This allows respect and dignity but is also practical in respect of reducing unplanned hospital admissions and other interventions.

There may well be merit in further consideration of the sentiments in the noble Baroness’s amendment that patients should have the opportunity for meaningful conversation about what matters most to them at the end of their life. Of course, the noble Lord, Lord Carlile, is also right about ensuring protection for those who are more vulnerable, and I am sure that, in the course of further discussions, those considerations will be made.

With regard to Amendment 297 put forward by the noble Lord, Lord Forsyth, obviously your Lordships’ House has heard, as I have, the depth and range of concerns and opinions across this issue. Such an important legislative change as proposed in this amendment would need to be its own topic, in its own Bill. I do not feel that any steps towards such a monumental change should be added via an amendment to a Bill that concerns itself entirely with other matters, as does this Bill.

In conclusion, whatever the views of noble Lords on assisted dying and however strongly held those views are, I believe that your Lordships’ House should do justice to it but that this Bill does not provide that opportunity.

Health and Care Bill

Baroness Merron Excerpts

Lords Hansard - Part 2 & Committee stage
Monday 31st January 2022 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, this group rightly began with an amendment about adequate provision in dentistry. As we have heard, there is currently a massive shortfall in provision of NHS dentists and indeed dentists as a whole, so much so that a charity called Dentaid, which normally works in the third world, is now working in Dewsbury and Batley—and possibly in other parts of the country that I am not aware of—because people cannot get free dentistry. The situation is made worse by the backlog of treatment caused by the pandemic, whereby dentists were at first unable to see patients and later had to reduce the number of aerosol-producing treatments they could carry out each day.

I have no doubt that the condition of the nation’s teeth has deteriorated during the past couple of years. Nearly 1,000 dentists left the NHS between 2020 and 2021, according to the BDA. However, problems with access to NHS dentistry predate the pandemic. Government spending on dental services has fallen by a third in real terms in the last decade, and the £50 million one-off injection of funding announced recently will barely make a dent in the unprecedented backlog that NHS dentistry now faces.

However, it is also well proven that fluoride, however administered, can strengthen tooth enamel and help teeth to resist decay. The 2018 report from Public Health England made that clear and did not report adverse effects. In Clauses 147 and 148, the Government intend to ensure that the whole country has access to drinking water with at least 1 milligram per litre of water, the level believed to be most effective in reducing tooth decay without the unwanted effects mentioned by the noble Lord, Lord Reay, and without waiting for local authorities to initiate schemes. I have to say that I believe Public Health England rather than the noble Lord.

I am always in favour of prevention and of reducing health inequalities, and it is claimed that this measure would do both, but there are some issues which I wish to probe. Currently only two areas in the country, Hartlepool and Braintree, have the optimum level of naturally occurring fluoride in their water. Other areas, covering about only 10% of the population, mainly in the north-east and Birmingham, already have schemes initiated by the local authority. I accept that a number of costly and bureaucratic barriers have been identified to more local authorities initiating such schemes, and I understand these clauses are an attempt to overcome them by making national regulations. These would remove some of the consultation costs from local authorities. However, some local authorities are reluctant to give up their local autonomy on this issue and believe their residents should be consulted before fluoridation occurs. This must be considered.

I have some questions for the Minister, which fall into two categories. The first is about costs and where they fall. We are told in the impact assessment that current schemes will not be affected, and existing and future capital costs will continue to be borne by the Department of Health and Social Care. What will be the additional burden on the funding of the Minister’s department of bearing the capital costs for every area in the country? I understand that regulations will allow for future costs to be shared by his department with water companies. What impact is that expected to have on the water bills paid by households, since the companies will undoubtedly try to pass it on to customers?

Water companies can well afford to pay these costs themselves, rather than take the money from the health budget. This is clear from the eye-wateringly high earnings of their leading directors. We know from a briefing from Yorkshire Water that the costs can be considerable. A few years ago, it did a feasibility study when only one area—Hull City Council—was looking into fluoridation. At the time, it estimated the capital cost to be £1.6 million to £2 million and the annual operation costs to be approximately £330,000 per year. These costs would have fallen on Public Health England and the local authority at the time, but under the new proposals they would be covered by the Department of Health and Social Care.

Over recent years, capital investment in water and sewerage services has been covered just by income from water bills, but investment in infrastructure has not been adequate, since we still have raw sewage being discharged into water courses and leaks wasting water at an unacceptable level. So, we can expect the companies to accept some of the cost of fluoridation themselves, without passing it on to the customer.

Can the Minister also say what is the plan for regular measurement of the fluoride content of water, and at what point in the delivery journey will it occur? What will this cost, and where will the cost fall? Will the Government allow companies to pass this cost on to the consumer too, although they can clearly afford to absorb it? The reason I ask is that water companies share water all the time and there is a possibility that, without frequent monitoring, the fluoride content delivered to customers could turn out to be either too high or too low to be effective.

The second category of question concerns what other proposals for reducing the incidence of tooth decay have been considered by the Government, as mentioned by my noble friend Lord Storey. I have dealt with the availability of NHS dentistry, but it is excess sugar and acids in the diet that cause tooth decay. Sadly, poor diet is a major problem, particularly among poorer children, for whom the most common reason to be admitted to hospital is the need for complex extraction of rotten teeth. Fluoride can, of course, can be administered in other ways: either applied by the dentist or by regular use of fluoride-containing toothpaste—fortunately, most toothpastes contain fluoride. However, many children eat too much sugar, drink too many acidic fizzy drinks and do not brush their teeth regularly.

As my noble friend said, there used to be a school dentistry service to check for problems, and dental nurses used to visit nurseries and primary schools to teach good dental hygiene. I have myself sat in on such a session and it was excellent, but I do not believe it happens any longer. Have the Government costed a return to these schemes? As for diet, we will be dealing with that in a later group of amendments. So, while accepting the potential benefits of what is proposed, I ask the Minister to assure the House of the cost-effectiveness of the measures, explain the impact on family budgets and tell the House what other measures are being considered to achieve the same ends, which we all want to see: better and more equal dental health.

[Baroness Merron (Lab)]

My Lords, I welcome the amendments in this group, which focus on the need for universal access to dentistry and the introduction of fluoride into water. As my noble friend Lord Hunt said, they are about treatment and prevention, which are equally important when it comes to considering how we tackle tooth decay and oral health. I am grateful to my noble friend, the noble Baronesses, Lady Northover and Lady Walmsley, and the noble Lord, Lord Young, for their support for these amendments.

--- Later in debate ---

[Baroness Walmsley (LD)]

My Lords, I declare an interest as a member of the All-Party Parliamentary Group on cancer and a great supporter of John Baron’s campaign on outcomes. Of course, as noble Lords across the Committee have said, the key to getting better outcomes is early diagnosis, rigorous audit, and proper dissemination across the country of what we know works. I certainly support what the noble Lord, Lord Moylan, is trying to do.

I do not oppose the government amendments outlined by the Minister, despite the rather unusual fact that they were only agreed with the Opposition Front Benches at the last minute—that is, this morning. I thank him for clarifying that; although cancer outcomes were the principal focus of Clause 4, they are not the only objective that should relate to cancer patients. The department has consulted with cancer charities, which, of course, represent many thousands of patients, to ensure that the new legislation meets their needs. Can the Minister say when the effects of Clause 4 will be reviewed and any action, if necessary, taken? Although generally approved by the sector, Macmillan is still concerned about how a focus on survival will affect those who, sadly, have terminal cancer and do not expect to survive. What they need is palliative care and measures to make the quality of their last few months of life as good as possible. Could this issue be a key part of any future evaluation of cancer care?

[Baroness Merron (Lab)]

My Lords, we are very pleased to support the government amendments that we have heard outlined. Crucially, they focus on cancer outcomes. As the noble Baroness, Lady Morgan, underlined, that includes survival, quality of life, experience of treatment, end-of-life care as well as diagnosis—in other words, the whole experience in treating somebody as a whole person on a journey that they may have to face. I congratulate the Minister on bringing the amendments forward. I also thank the noble Lord, Lord Moylan, supported by the noble Lords, Lord Aberdare and Lord Vaizey, and others, for highlighting the fact that pancreatic cancer has such an aggressive nature, and yet the symptoms are so silent and often misunderstood that it presents a particular challenge in the context of the care that we are speaking of today.

A focus on outcomes that covers matters other than treatment will be particularly crucial following the backlogs that the pandemic has inevitably led to, with delays in people seeking check-ups and treatment. Macmillan has let us know that more than 31,000 people in England are still waiting for their first cancer treatment, and it has also said of the Bill that for those living with cancer

“not a lot will look different.”

It is therefore crucial that the Minister assures noble Lords that stakeholders are supportive of the changes outlined in this group.

On the point about survival rates lagging behind those of other countries, that is not because the National Health Service is worse than other healthcare systems at treating cancer once it is detected but because it may not be as good at catching cancers in the crucial early stages. In other words, late diagnosis lies behind our comparatively poor survival rates. A key advantage of focusing on outcome measures is that it will give healthcare professionals much greater freedom and flexibility to design their own solutions, which could include running wider screening programmes and better awareness campaigns, and establishing greater diagnostic capabilities at primary care. A further advantage of this new focus is that it will better align NHS priorities with patient needs, which, after all, are core to our discussions on the Bill today.

I have a final and gentle word for the Minister to back up the introductory comment of the noble Baroness, Lady Walmsley. It is of course usual to consult the Opposition and others in advance to ensure that amendments are acceptable and do what is required—in other words, to strengthen the case. I know that this did not happen until very late in this case, and I am sure the Minister will not wish to repeat that practice. In summary, however, we very much welcome these amendments.

[Lord Kamall (Con)]

I thank the Opposition Front Benches for being so gracious given the fact that we notified them late and did not use the correct procedure. I apologise for that once again and I know that the Bill team also apologises for it. We are all on a steep learning curve, as I am sure all noble Lords acknowledge. I thank both noble Baronesses. I hope the lesson has been learned, and we will not have an excuse next time.

I will address Amendment 294 before I come to our amendments. I thank my noble friend Lord Moylan for tabling it. To reassure him, the pancreatic cancer audit is included in the national cancer audit collaborating centre tender, which is currently live. Some reporting timelines are included in the specification for this audit, developed in partnership with NHS England and NHS Improvement, but I am told that during a live tender the document is commercially sensitive and cannot be shared beyond the commissioning team, as this could risk jeopardising the procurement process. The future contract is anticipated to start in autumn of this year. However, it is not possible to confirm the timelines for a new national audit topic for pancreatic cancer until the procurement completes and the contractual deliverables are signed. Unfortunately, therefore, this cannot be aligned with the passing of the Act.

My noble friend will be aware that NICE clinical guideline NG85 recommends that pancreatic enzyme replacement therapy, or PERT, should be offered to patients with inoperable pancreatic cancer and that consideration should be given to offering PERT before and after tumour removal. NICE acknowledges that this is a priority area for improving the quality of health and social care and has included PERT in its quality standard on pancreatic cancer.

We have taken and will continue to take steps to support Pancreatic Cancer UK’s campaign to encourage greater uptake of PERT by doctors treating pancreatic cancer patients, in line with NICE guidance. We are in the process of commissioning a PC audit and, while the scope of this is not confirmed, we will certainly include this in the scoping of the topic. As I said, NICE acknowledges this as a priority area and, while its guidelines are not mandatory for healthcare professionals, the NHS is expected to take them fully into account in ensuring that services meet the needs of patients.

--- Later in debate ---

[Lord Warner (CB)]

My Lords, I will speak briefly in support of Amendment 289. It is worth remembering that the NHS used to have convalescent beds—I went to one as a boy, recovering from peritonitis. These have disappeared over time. When in the 1980s and 1990s nursing homes were set up in increasing numbers across this country, we found that they ended up on the means-tested side of the boundary between health and adult social care. In a way, the NHS lost out because these resources were on another side of the boundary, which was defended with jesuitical force to make sure that people did not drift into the NHS who might get care that was not means tested but free. We have ended up shooting ourselves quite badly in the foot by allowing these services to drift out of the NHS and into the adult social care system.

Shortly after the 2010 election, I facilitated a proposal from a few large nursing home groups to take recovering patients from hospital to free up acute hospital beds. This was rejected by the Treasury which thought it would lead to large numbers of people who were being means-tested getting free NHS care. In fact, they were two separate groups and the NHS was punishing itself by keeping people in beds in the NHS at high cost. We know that about 25% of the people who are in acute hospital beds should not be there—they need not be there clinically—but they are holding on to those beds because there is nowhere else for them to go within the NHS system. We have ended up unnecessarily blocking beds and spending a lot more money because we cannot put in place a service that the NHS badly needs. I suggest to the Minister that we revisit this issue in the interests of the NHS and its patients.

[Baroness Merron (Lab)]

My Lords, I thank noble Lords for the debate this evening and for the amendments put forward, which have focused on what I would call a complete continuum of care and support where people need it most; my thanks also to the noble Baroness, Lady Finlay, for leading the debate. What we hear tonight is the need to drive up standards and availability in what can be accessed for reablement and rehabilitation.

As the noble Lord, Lord Warner, reminds me, I fear that, over time, we have perhaps lost a broader range of provision, and the word “convalescence” has somewhat left our vocabulary. The amendment tabled by the noble Baroness, Lady Greengross, to ensure that accommodation is available to people who are in rehabilitation—people who no longer need to be in a hospital ward but cannot return to their own home—is creative and practical. I hope that the Minister will look at exploring that idea.

Health and Care Bill

Baroness Merron Excerpts

Committee stage
Friday 4th February 2022 Lords Chamber

I have asked a lot of questions, which I hope the Minister can answer, because I am confident that a well-drafted and well-evidenced measure of this kind could make a valuable contribution to reducing the scourge of childhood obesity.

[Baroness Merron (Lab)]

My Lords, today we have had a very extensive and impassioned debate, and we have heard in your Lordships’ House challenge and counter-challenge. I will seek to pick up the main broad points that we have heard about. What we cannot turn away from is the fact that two in five children in England are above a healthy weight when they leave primary school, while last year saw the fastest increase in childhood obesity on record.

Children with obesity are five times more likely to become adults with obesity, increasing the risk of developing conditions including type 2 diabetes, cancer, and heart and liver disease. As we heard from the noble Lord, Lord Krebs, the incidence of this is not equally spread. As we observe from the levelling-up White Paper, there is a huge need to tackle poor diet and obesity in order to reduce health inequalities and the damage that obesity causes, both in childhood and adulthood.

I welcome the provisions in the Bill that help people to make informed choices about what they eat and drink, but this should not be misunderstood. Choice can only really be choice if there is no distortion, and if those making the choices have the information they need. They need to be able to make decisions and be supported in doing that. When I look at the Government’s analysis, which suggests that a watershed on TV and online that introduced restrictions to prohibit advertisements for products high in fat, sugar or salt being shown before 9 pm could lead to 20,000 fewer obese children, I think that this is something that should not be dismissed. This is about not only the direct outcome but shifting the environment, so that we can manage the challenges we all face in supporting good health.

--- Later in debate ---

[Lord Sentamu (CB)]

My Lords, I support this amendment. I will tell a true story of a teetotal preacher who harangued his congregation that nobody should be drinking because it is dangerous, damages our health and damages everything else. “Alcohol should be banned,” he said, “and the best thing to do is go and drown it in the river.” Unwittingly, he then said, “Our final hymn is ‘Shall We Gather at the River?’ The beautiful, the beautiful river.” He did not see the contradiction in what he said. This amendment is full of clarity, clarifying areas that need to be put fairly clearly. The obligation that it puts on the Secretary of State and, incidentally, all of us is very clear. Because of the real danger in what overdrinking does to a lot of people, I say: no, we shall not gather at that river, that beautiful, beautiful river.

[Baroness Merron (Lab)]

My Lords, it is a pleasure to follow the noble and right reverend Lord, who reminds us of our obligations to assist with alcohol-related ill health. I thank the noble Baroness, Lady Finlay, and the noble Lord, Lord Shipley, for putting these amendments before your Lordships’ House today. The first is a probing amendment about the need to report on the consultation on alcohol labelling. It is absolutely right to raise this: consumers have a right to know what is in their drinks, to make informed choices about what and how much they drink. Currently there are no legal requirements for alcohol products to include health warnings, drinking guidelines, calorie information or even ingredients. Research by the Alcohol Health Alliance found that over 70% of products did not include the low-risk drinking guidelines, and only 7% displayed full nutritional information including calories. I certainly add my voice to welcoming the forthcoming consultation on alcohol calorie labelling. When can we expect to see this, and what is the reason for the amount of time that it has taken to bring it forward?

Amendment 296 requires the Secretary of State to make a five-yearly statement on the cost efficacy of alcohol services. As we know, rigorous impact evaluation is absolutely key to good policy-making and improving the lives of those who use alcohol services. At present, the Government cannot say that they are meeting their responsibility to tackle alcohol harm with the requisite financial commitment and in the right places. Perhaps the Minister will tell your Lordships’ House what evaluation measures are already in place.

Of course, the background to all this is that, since 2012, there have been real-terms funding cuts to alcohol services of over £100 million. Pre pandemic, only one in five dependent drinkers was believed to be in treatment, leaving a shocking four out of five without help. The pandemic has only worsened the situation. I hope that the Minister will agree that there is a need to do better to ensure that we know how policies and services help or hinder the treatment of problem drinking, in order that efforts and resources can be targeted to where they work best.

[Earl Howe (Con)]

My Lords, I pay tribute to the noble Baroness, Lady Finlay, for her work as chair of the Commission on Alcohol Harm. I thank her for this opportunity to set out the current state of play on the Government’s alcohol policy. I am the first to acknowledge the seriousness of the harms caused by the consumption of alcohol, which she pointed out.

Effective alcohol labelling is an important part of the Government’s overall work on reducing alcohol harm. I am pleased to tell the noble Baroness that the legal powers available to the Government are already sufficient to enable us to consult and report on alcohol labelling. The kind of power proposed in her probing amendment is highly prescriptive, and, from a purely practical point of view, would not allow for sufficient flexibility in the consultation process, which could make the process less effective.

As she knows, as part of the Government’s Tackling Obesity strategy, published in July 2020, the Government committed to consult on whether mandatory calorie labelling should be introduced on all pre-packed alcohol as well as alcoholic drinks sold in the out-of-home sector. I repeat that commitment today, and, as part of our public consultation, we will also seek views on whether provision of the UK Chief Medical Officers’ Low Risk Drinking Guidelines, which includes a warning on drinking during pregnancy, should be mandatory or continue on a voluntary basis. The noble Baroness, Lady Merron, asked when we might expect that consultation to be forthcoming. I am afraid I can say no more than “in due course” at this stage, which I realise is not wholly enlightening, but it is as far as I can go at the moment.

Turning to Amendment 296, which proposes additional reporting and government statements, we do not think a new reporting requirement is necessary. The Office for Health Improvement and Disparities already publishes annual data on estimated numbers of alcohol-dependent adults within local authorities in England. Health commissioners can use this data to estimate local need and appropriately plan their alcohol treatment services. Outcomes for local authority-funded alcohol treatment services are already published at local and national level via the national drug treatment monitoring system. The Office for Health Improvement and Disparities also provides a number of data tools to enable local areas to compare their performance against other areas and nationally, including the public health outcomes framework, local alcohol profiles for England and the spend and outcomes tool.

On funding, local authorities are currently required to report on their spend on alcohol services annually to the Department for Levelling Up, Housing and Communities. Through the “why invest?” online guidance, the Office for Health Improvement and Disparities already produces data and information on the return on investment for alcohol and drug treatment. The guidance includes cost savings data on treatment interventions in primary and secondary care and on specialist and young people’s treatment services. There is a strong programme under way to address alcohol-related health harms and their impact on life chances, and to reduce the associated inequalities which the noble Baroness emphasised, including an ambitious programme to establish specialist alcohol care teams in hospitals and to support children of alcohol-dependent parents.

Throughout the Covid-19 outbreak, drug and alcohol treatment providers continued to support and treat people misusing drugs and alcohol. OHID supports local authorities in this work by providing advice, guidance and data. OHID is developing comprehensive UK guidelines for the clinical management of harmful drinking and alcohol dependence. These aim to develop a clear consensus on good practice and to improve the quality of service provision. The work is expected to be completed later this year.

Finally, we are currently developing a new commissioning standard for drug and alcohol treatment which aims to increase the transparency and accountability of local authorities on how funding is spent. It will include requirements to commission services—

--- Later in debate ---

[Lord Crisp (CB)]

My Lords, I imagine that your Lordships’ House and Parliament generally very often have a choice in terms of the rightful tensions between, on one level, supporting freedom of action and speech and, on the other, balancing that against harms to individuals and society as a whole from smoking. I know that I am on the latter side of the argument in this case.

It is also worth noting that this is not about just the risk that comes from smoking—risk comes from many sources—but rather the scale of the risk and the impact that it has across the whole of the health system. Despite everything else that has been said about public health, it is worth remembering that this is the biggest risk and that half of the difference in life expectancy between people in poorer neighbourhoods and those in richer ones is due to smoking. That scale is the issue that we are talking about.

I was pleased to add my name to the four polluter pays amendments led by the noble Lord, Lord Young. On the notion that a payment or levy based on income—not a tax—will be used for reducing smoking, providing smoking cessation clinics and improving public health, I believe that this is a different arrangement from that consulted on by the Government in 2015.

I will make several other quick points that very much fit in with what has been said. First, this is about what the Government need to do if they are going to level up under the ambitious plans that were set out only yesterday for delivering improvements in life expectancy and the differences in life expectancy around the country—that is really important, and something will need to be done about smoking if those plans are going to be achieved.

Secondly, this is also about poverty: the average smoker spends £2,000 a year on smoking, and some new research suggests that this leads something like half a million households around the country into poverty. I have not studied that, so I only say “suggests”, but it seems to me to be an important point.

Thirdly, perhaps at one level, this started off for people as a lifestyle choice, but it is actually an addiction. I speak as a former smoker who made an enormous effort to give up. The average number of attempts before you give up is around 30, but I think that I probably exceeded that, and I can tell you the day on which I finally succeeded. It is an addiction, and this whole business runs on addiction—not on the occasional cigarette or the cigar at Christmas—and we should never forget that.

Fourthly, I ask whether the polluter paying is right in principle or just pragmatic. In a sense, it does not really matter: it is pragmatic. Over the last five years, NHS smoking cessation treatment services have been cut: about £23 million a year was spent on such campaigns, but now it is less than £2 million. There is not a lot of money around at the moment, obviously, and this seems a very pragmatic solution for finding money to support smoking cessation services—in addition to the fact that I would see it as being right in principle.

Finally, there is real evidence that those smoking cessation services work. Therefore, it would be money well invested in the future health of our nation.

[Baroness Merron (Lab)]

My Lords, this has been an interesting debate, and we have heard various views. I thank my noble friend Lord Faulkner for leading on this group of amendments, and I thank noble Lords for putting forward their amendments and views so that we can explore how we respond to the challenge of smoking.

My first point leads on very neatly from the comments of the noble Lord, Lord Crisp. Smoking remains the leading preventable cause of premature death. As the noble Lord observed, it is a matter where we should consider the scale of the effect and the fact that this is about addiction. It is not about free choice but is something that we must assist people to overcome. While rates are indeed at record low levels, there are still more than 6 million smokers in England, and the need to reduce this number is particularly important now, as smokers are more at risk of serious illness from Covid.

The economic and health benefits of a smoke-free 2030 would be felt most keenly among the most disadvantaged. However, as we heard from the noble Lord, Lord Young, at current rates we will miss this target by seven years on average, and by at least double that amount for the poorest groups in our society. So it is vital that we motivate more smokers to quit while reducing the number of children and young people who start to smoke.

Within this group of amendments, noble Lords have suggested a broad raft of anti-smoking measures, including information inserts and warnings printed on rolling papers, a consultation on raising the age of sale to 21 and a “polluter pays” approach which argues that tobacco companies should pay for smoker treatment programmes. All these measures can be underpinned by broad cross-party support and public support. Certainly, the All-Party Group on Smoking and Health is very supportive of this group of amendments.

The pandemic has posed new challenges to us, and there is a new group of people who started smoking but who otherwise would not have done so. We have been promised a new tobacco control plan, and I hope that the Minister tells your Lordships’ House when we can expect it. The labelling and information interventions contained within this group of amendments have a strong evidence base from other countries, as well as from research in the UK. I hope that the Minister will be amenable to them.

Picking up on a few of the points raised within this group, it is very shocking to note that more than 200,000 11 to 17 year-olds who have never smoked previously have tried vaping this year. It is a very strange situation that e-cigarettes and similar products can be given free to somebody under 18 but they cannot be sold to them. We do not want to see a situation where young people are brought to smoking by smoking substitutes.

In reference to the amendment that proposes a United States-style “polluter pays” model to fund all these interventions, including the restoration of lost smoking-cessation services, the noble Lord, Lord Young, described practical ways in which this could come about. Certainly, the Minister in the other place did not close the door to this idea in Committee. I hope that we will hear from the Minister some agreement towards this.

Amendment 270 promotes a consultation on raising the age of sale, because we know that the older a person gets, the less likely they are to start smoking. If this is to happen, it requires proper consultation with relevant stakeholders, not least young people themselves, including those who are underage. It must be rigorous in checking what will work. Attitudes to the incidence of smoking have changed over the years, but the direction now is firmly one way, and that is to prevent ill health and premature death. This group of amendments contains proposals to keep us moving in this direction, to assist those who smoke and to prevent those who seek to smoke, particularly those at the younger end of the scale. I hope that this group of amendments will find favour with the Minister.

[Earl Howe (Con)]

My Lords, I am grateful to the noble Lord, Lord Faulkner, and other noble Lords for bringing this discussion on tobacco control before the Committee today. In responding to these amendments, I begin by emphasising the Government’s commitment to the smoke-free agenda. Over the past two decades, successive Governments have successfully introduced a strong range of public health interventions and regulatory reforms to help smokers quit and protect future generations from using tobacco. Our reforms have included raising the age of sale of tobacco from 16 to 18, the introduction of a tobacco display ban, standardised packaging for tobacco products and a ban on smoking in cars with children.

The Government are committed to making this country smoke free by 2030, and we will outline our plans in a new tobacco control plan to be published later this year. As part of our Smokefree 2030 programme of work, I am pleased to announce that we have launched an independent review into smoking. The review, led by Javed Khan OBE, will make a set of focused policy and regulatory recommendations to government on the most impactful interventions to reduce the uptake of smoking and support people to stop smoking for good. I am sure he will consider many of the policies raised by noble Lords in today’s debate as part of his review, which is expected to report in late April.

The action I consider vital for the Government is to conduct research and build a robust evidence base before bringing any additional measures forward, such as those outlined in Amendment 276, which would impose a duty on the Secretary of State to make regulations requiring tobacco manufacturers to print health warnings on individual cigarettes and rolling papers. This evidence-base principle also applies before raising a proposal, even through a consultation such as that outlined in the requirement in Amendment 270 to consult on raising the age of sale.

Several amendments that have been put forward by noble Lords are not required, because relevant legislation is already in place. For example, legislation is already in place that prohibits the sale of tobacco and e-cigarettes to under-18s, including proxy sales, as outlined in Amendment 271, and provision to enable this to be extended to all nicotine products. While we support proposals further to protect young people from these products, we do not have the evidence base at present to suggest that free distribution is a widespread problem. We challenged the industry on this, and it claimed that it is targeting only smokers who are over 18 when it gives free samples. Whatever one may say about that, there would undoubtedly be reputational damage to businesses if they did give out samples to minors. I am sure that evidence in this area will be gratefully received by the department.

When looking at further regulation of e-cigarettes, we need to assess which policies provide us with the best opportunities to reach our bold Smokefree 2030 ambition. Once we have fully considered the evidence, the most ambitious policies will be included in a new tobacco control plan. I do not in the least intend to sound complacent, but it is worth noting that in 2018 regular use of e-cigarettes among 11 to 15 year-olds remained very low, at 2%.

The noble Baroness, Lady Finlay, referred to nicotine pouches. There are existing powers in the Children and Families Act 2014 which allow us to extend the age-of-sale restrictions to include any nicotine products, such as nicotine pouches, so the proposed new clause is not strictly needed in relation to sales.

We recognise the need to address disparities in smoking across the country and we are committed to helping people quit smoking and to levelling up outcomes, as referenced in the recent levelling-up White Paper. There is already a lot of good work going on within both the NHS and local authorities in this area, but it is a theme that we will be developing in our tobacco control plan.

Health and Care Bill

Baroness Merron Excerpts

Lords Hansard - Part 1 & Committee stage
Wednesday 9th February 2022 Lords Chamber

[Baroness Bennett of Manor Castle (GP)]

My Lords, it is a pleasure to follow everyone who has spoken in this group. I thank the noble Baroness, Lady Chakrabarti, for so powerfully and clearly introducing this amendment, to which I was pleased to attach my name. The case has been overwhelmingly made, so I will not go over the same ground but will add a couple of points and draw some things together.

It is interesting that we started the day with the ARIA Bill. Concern was expressed from several quarters of your Lordships’ House about public money going into ARIA and whether we would see public returns from that money. As the noble Baroness, Lady Chakrabarti, said, what we have seen so often is the socialisation of costs and the privatisation of profits in so many areas of research and knowledge.

I draw to the attention of any noble Lord who has not seen it a very useful briefing on this amendment prepared jointly by Just Treatment, STOPAIDS, Global Justice Now and Universities Allied for Essential Medicines. That brings out two points, and it is worth looking at the national and the international. We have tended to focus on the international. Nationally there are some fascinating figures. The NHS pays more than £1 billion a year for medicines, but two-thirds of the upfront costs of producing those medicines come from public funding.

That is the national side. Looking at the international side, we have talked about and focused very much on Covid, but we really need to think about the fact that we are now in the age of shocks, in a world that is environmentally extremely disturbed. That is certainly a factor in the appearance of Covid; we have seen SARS and MERS, and there is Ebola out there. We need to build resilience into our world. We are talking about changing so many different things, and whether it is supply chains, medical supply chains specifically, or anything else, we really need to think about preparing for that different world, with the focus on resilience, rather than on private profits as it has been.

The noble Lord, Lord Crisp, asked an interesting question: why do we see the UK, the EU and Switzerland lining up against the rest of the world? The answer is there in profits, in an ideology that says, “We have to organise everything for private profits and somehow the benefits will trickle down.” It is interesting that today Michael Gove has gone on the record as saying that trickle-down has not worked; it is a failed ideology. Of course, there is also the impact of those profits being fed into our political system and the influence that that money and that lobbying have.

I will finish with this final thought. The noble Baroness, Lady Chakrabarti, said—and I think this reflects what other noble Lords, particularly the noble Baroness, Lady Lawrence, and the noble Lord, Lord Crisp, said—that we have been utterly wicked in our behaviour towards the global south in the Covid pandemic in failing to ensure that it has crucial vaccines. We have also, as has become obvious with omicron, spectacularly shot ourselves in the foot. I say to those who will not accept moral arguments for this amendment: please look at the practical self-interest. No one is safe until everyone is safe.

[Baroness Merron (Lab)]

My Lords, I thank my noble friend Lady Chakrabarti for raising the crucial matter of countries and peoples left behind in terms of the opportunity to have a necessary vaccination programme available to them. My noble friend Lord Campbell-Savours spoke of the importance of supporting innovation, which is one of the ways in which we can ensure that, while my noble friend Lord Howarth rightly said that the subject requires exploration outside of the Health and Care Bill—something also commented on by the noble Lord, Lord Crisp, who emphasised, as do I, the need for the political will to make progress.

There is no doubt, as we have heard today, about the gravity of the issues at stake and the need to resolve them. It is the case that where public funding is provided there must be conditionality, although of course that may be complex to refine into legislation. There are of course additional issues when funding is also coming from the private sector along with a need to ensure a balance of interests. It would certainly be helpful to have a stipulation that avoided placing undue bureaucracy and restraint on smaller developments and small-scale research. We do not want to see the pace of research slowed down with researchers tied up in lengthy proposal writing, contract negotiations and legal agreements.

As my noble friend Lady Lawrence has said, we know that the pandemic is not over until it is over everywhere, so the amendment raises the opportunity to explore whether the immediate waiver of intellectual property rights would mean an end to the pandemic everywhere. It is relevant to assess what contribution or otherwise intellectual property rights make to the promotion of technological innovation and the transfer and dissemination of technology. There is an advantage for producers and users of technological knowledge and the consideration of rights and obligations, and that needs to be considered in the round.

In respect of the response and actions to a pandemic declared by the World Health Organization, while I understand the intention behind the amendment, in order to be consistent I would comment with some caution about the Secretary of State being compelled to immediately take actions, particularly without any form of oversight—something that we will return to later in Committee.

However, I hope that today we can obtain some reassurances from the Minister about the Government’s intentions and plans in order that we can find a way forward so that low-income countries and their peoples have access to vaccines both now and in future.

[Lord Kamall (Con)]

I thank the noble Baroness, Lady Chakrabarti, for bringing this debate before the Committee today and for the heartfelt speech that she gave. The noble Baroness will be aware of the view of this Government following her recent Question in the House on the subject of patient waivers. As my noble friend Lord Grimstone set out, the Government remain open to all initiatives that would have a demonstrably positive impact on vaccine production and distribution. However, we believe that waiving intellectual property rights would have the opposite effect. Doing so would dismantle the very framework that helped to develop and produce Covid-19 vaccines at the pace and scale now seen. It would risk undermining the continued innovation in vaccines and technological health products that is required to tackle a virus, especially as it mutates and evolves, so we believe that doing so would be a mistake.

Instead, the success of the Covid-19 vaccine rollout vindicates the value of public and private co-operation. While university research departments are great at research, large-scale manufacturing and global distribution are not their function, so we recognise the importance of their working with partners with expertise in this area.

The intellectual property framework is key to those efforts. It has incentivised the research and development that has led to the development of Covid-19 vaccines. It has given innovators the confidence to form more than 300 partnerships, an unprecedented number, and has contributed to the production and dissemination of vaccines and other health products and technologies across the world, with global Covid vaccine production now at nearly 1.5 billion doses per month.

I share the noble Baroness’s intention that research funded through taxpayer finances should benefit the taxpayer, but we do not consider that that is best achieved through particular constraints in primary legislation. Research contracts afford greater flexibility and more powerful levers than the amendment, through provisions such as those requiring the dissemination of intellectual property for patient benefit, revenue sharing with the Government of commercialised intellectual property, and requirements around access to medicines in the developing world. Contractual protection mechanisms in funding arrangements can also ensure that intellectual property funded by taxpayers results in the creation of taxpayer benefit.

Health and Care Bill

Baroness Merron Excerpts

Lords Hansard - Part 1 & Report stage
Tuesday 1st March 2022 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I thank the Minister for listening very carefully to what noble Lords from across the House have been saying about the need to recognise the parity of esteem between physical and mental health, and for giving us some reassurance that the funding for mental health will increase in the future. A lot of mental distress has been caused by the fact that many patients suffering from mental ill health have not been able to reach the threshold for access to services. The reason for that has been a shortage of resources and a properly trained workforce which can deliver the therapies required. At the end of the debate, I hope that the Minister will be able to assure us that those resources will be made available.

My noble friend commented that she hoped that the new standards would not have the unintended consequences of transferring delays from the initial diagnosis to further down the treatment pathway. That is a very important consideration. We will talk about the importance of increasing the NHS workforce later in our debates. However, will the Minister consider how focusing increased resources on early intervention and prevention will save both money in the end and a lot of distress, as dealing with it early will save patients having to go into more intensive therapies further down the track? It is very important that any increased resources—or, at least, much of them—are focused on early intervention and prevention. I hope the Minister can reassure us of this.

[Baroness Merron (Lab)]

My Lords, if the role of your Lordships’ House is to improve the Bill, I feel that this set of amendments will achieve this. I am grateful to the Minister and his officials for responding to the points which were made so powerfully in Committee and in meetings outside this Chamber. The range of amendments will take us further.

The Minister talked about the introduction of transparency and accountability, which are key in the efforts to improve the provision of mental health services. However, of course, improving transparency and accountability is not an end in itself; it is purely a way of getting us to the right place. What will be important is what this delivers. A step along the way to improving mental health services is definitely being made, but there is an awful lot more to do. For example, the Centre for Mental Health estimates that some 10 million additional people, and that includes 1.5 million children and young people, will need mental health care as a result of the pandemic. It would of interest to understand a little more about how the Government intend to make progress on this once the Bill receives Royal Assent. Will we see a recovery plan in the area of mental health services, backed by a long-term workforce plan, something which we will return to later?

On the policy to bring practice into line with aspiration, and on the funding for and redoubling of effort towards achieving parity, while we are talking about this on a national level, it would also be helpful for the Minister to clarify that it applies to all areas of the Bill’s implementation and that the new bodies set up by the Bill will be expected to treat mental health equally from the outset. For example, it would mean ensuring that the decisions about resource allocation, capital spending, waiting times and priorities were all taken on the basis that mental health must be valued equally with physical health.

The noble Baroness, Lady Tyler, was right to point out that we do not start in a neutral position, because we know that waiting times are considerable, standards of services need massively to be improved and the workforce needs to be strengthened in order to deliver those services. It is therefore extremely important that the Minister in putting forward these amendments undertakes to see the job through, so that we do not just have transparency and accountability for their own sake but we deliver for the many millions who will rely on those services.

[Lord Kamall (Con)]

My Lords, I once again thank not only noble Lords who spoke in this debate but those who engaged with us throughout the process. As the noble Baroness, Lady Merron, said, if the role of this House is to improve the Bill, we have learned much. As a relatively new Health Minister, I have learned so much from the various meetings that I have had with noble Lords, not only on this issue but on many others across the health and care spectrum.

I thank noble Lords who have engaged with me personally but also with my officials to make sure that we closed the gaps as much as we could. I am pleased to hear support from your Lordships for the package of amendments that I have brought forward, and I am grateful.

I stress that this package of amendments should be considered alongside the amendment placing a duty on ICBs to have an appropriate skill mix and experience necessary to deliver all their functions—I hope that noble Lords will look at those in that context—as we expect skills pertaining to the delivery of mental health services to be considered when meeting this duty at the ICB level as well as below that at place level. Many noble Lords have discussed the importance of place.

Amendment 184 would require the Government to report on our plans to improve mental health standards. Access to services is at the heart of the mental health commitments in the NHS long-term plan. The department, NHS England and NHS Improvement regularly report performance against existing waiting time standards in mental health, including improving access to psychological therapies services, children and young people’s eating disorder services and people experiencing a first episode of psychosis.

As noble Lords have acknowledged, last week NHS England and NHS Improvement took another step to strengthen mental health standards, publishing a consultation response following the mental health clinically led review of standards consultation. As noble Lords will know, this sought views on the proposed introduction of new measures, including five new waiting time standards, to support our ambitions to ensure that patients have timely access to community mental health care.

Health and Care Bill

Baroness Merron Excerpts

Lords Hansard - Part 2 & Report stage
Tuesday 1st March 2022 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I congratulate the noble Baroness, Lady Finlay, without whom this amendment would not have been laid by the Government —although I pay tribute to the Government for listening to her. As she said, it could be game-changing—I say “could be” because unless the resources are made available for these services and for training enough of the health professionals needed to carry them out and make them available everywhere, it will not be game-changing. I would like a reassurance from the Minister that adequate resources will be made available so that, as appropriate, ICBs can carry out the duty that will be put on them.

I was horrified to hear the noble Baroness, Lady Meacher, mention a hospice with half its beds empty. I hope additional resources will be provided for hospices. I clearly remember somebody saying in Committee that you would not expect to have a coffee morning or a cake bake to treat a broken leg; you should not have to do the same sort of thing for services at the end of life. I hope the Minister will bear in mind the possibility that additional resources should go there.

We have heard that services are patchy across the country, and I suggest that the worst patchiness is in services for people dying at home. I know it is not easy to provide 24-hour services and advice to a family doing their best to try to care for somebody dying at home, but it must be done. I am afraid I know friends who have had a very bad experience of that. The person at the end of life had a bad experience, and the family have never forgotten it. As the noble Baroness, Lady Finlay, has often told us, it is possible for everybody to have a good death if the right services are provided to them. That means a good experience too for the family, who simply want to know that they have done the best and that that has been enough.

[Baroness Merron (Lab)]

My Lords, from these Benches I am very glad to continue our support for palliative care being part of a comprehensive health service—literally from the cradle to the grave—no matter who you are, your age or where you live. I join other noble Lords in paying tribute and giving appreciation to the noble Baroness, Lady Finlay, for her assistance and professionalism over many years. I hope that the real tribute to the efforts of the noble Baroness will be in the delivery of real change to the quality of people’s lives—and their deaths. I add my appreciation to all the charities and hospices that have also been a force for good in seeking this change.

I welcome the government amendment in this area and, in so doing, I simply say to the Minister that I hope the Government have heard the number of questions asked today. Clearly, there is concern about the words “appropriate” and “reasonable”, and I will add a few questions to those already put to explore that further. I am sure the Minister understands that noble Lords are simply trying to ensure that what is intended will actually be delivered.

Can the Minister confirm how the Government’s expectations will be conveyed to ICBs, and how they will understand what is expected of them in terms of the nature of palliative care services that they would be required to commission? It would also be helpful if he could commit to providing a definition of “specialist palliative care” services, referring to the amendment tabled by the noble Baroness, Lady Finlay, so that we can see a consistent standard in provision of services across the country. My final question is: can the Minister confirm that it is the Government’s intention to communicate to all ICBs that they should fulfil the true requirements of this amendment, and can he tell your Lordships’ House how this will be monitored?

The right reverend Prelate the Bishop of London and other noble Lords have made it clear that we would like the matter settled by the amendment, but it is not entirely. I hope that the Government will not lose the opportunity to really make the transformation so that we can all expect, and have, a good death, as we would want to have a good life.

[Earl Howe (Con)]

My Lords, I am very grateful to all noble Lords who have spoken in this important short debate, but, in particular, I express my thanks to the noble Baroness, Lady Finlay, for the illumination that she shed on the reality of well-functioning palliative care services from her personal perspective.

Without repeating what I said earlier, the Government recognise and understand the strength of feeling on the issue of variation among access to palliative care services. I understand the line of questioning posed by a number of noble Lords on the strength of the imperative implicit in the government amendment. The noble Baronesses, Lady Brinton, Lady Meacher and Lady Walmsley, and the noble Lord, Lord Hunt, all had questions on that theme.

The first thing for me to say is that I agree with the noble Baroness, Lady Finlay: this is a game-changing amendment because it would specifically require—that is the word—integrated care boards to commission such services or facilities for palliative care, including specialist palliative care, as they consider appropriate for meeting the reasonable requirements of the people for whom they have responsibility.

Questions have been asked about the word “appropriate”. I do not think any other word could be fitted into this context; you have to talk about what is appropriate when the extent of need and the requirements of the local population inevitably vary according to the locality. It is for the board to judge what is appropriate to meet that need in the local area and what is appropriate to the nature of the palliative care provision that may exist in an area: for example, whether it is a hospital, a hospice, social care hospices or hospices at home—all the panoply of palliative care provision that noble Lords will be familiar with. My noble and learned friend Lord Mackay of Clashfern made a very helpful intervention on that issue, for which I thank him.

We therefore expect palliative care to be commissioned by every ICB. It will be for them to allocate resources to meet the needs of their population that they identify but, on funding more broadly, the House will know that there is a multifaceted funding pattern in the palliative care field. Palliative and end-of-life care services are delivered by services and staff across the NHS, social care, the voluntary and community sector and independent hospices.

We recognise the vital role that hospices and other voluntary organisations play in the delivery and funding of palliative and end-of-life care and continue to engage proactively with our stakeholders on an ongoing basis to understand the issues they face. Those are not bald words; as part of the NHS Covid response, over £400 million has been made available to hospices since the start of the pandemic to secure and increase additional NHS capacity and enable hospital discharge.

The noble Baroness, Lady Brinton, asked me about statutory guidance. A range of guidance is already available to commissioners about the provision of palliative and end-of-life care, including detailed, evidence-based guidance from the National Institute for Health and Care Excellence. We will continue to keep the guidance under review. NHS England and NHS Improvement have also made funding available to seven palliative and end-of-life care strategic clinical networks, which will support commissioners in the delivery of outstanding clinical care, with sustainability of commissioning as a guiding principle.

The noble Lord, Lord Howarth, and my noble friend Lady Fraser touched on transparency and reporting. I point to our later amendments requiring ICBs to set out how they intend to commission services and report on that in their annual reports. That will of course include palliative care. I can also give an assurance that we are not only looking at the guidance currently but will continue to keep the range of guidance available to commissioners under review.

In answer to the noble Baroness, Lady Merron, on the Government’s expectations in this area, I can say only that our expectations as of now are set out in this amendment and in the guidance we will issue, and the assurance that we will engage with in our dealings with NHS England.

I hope I have been able to reassure the House that the Government are absolutely committed to ensuring that people receive high-quality palliative care if and when they need it. I invite the House to support Amendment 16.

Health and Care Bill

Baroness Merron Excerpts

Lords Hansard - Part 1 & Report stage
Thursday 3rd March 2022 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I simply rise to say that I agree with all noble Lords who have spoken and look forward to the Minister’s reply.

[Baroness Merron (Lab)]

My Lords, I rise to share all the concerns expressed about the open-endedness of what is in the Bill and the concerns about the lack of protection for patient data. Clearly, there has been much debate and discussion, and I think it is right that we hear from the Minister.

[Lord Kamall (Con)]

My goodness—I thank noble Lords for their brevity. I am afraid that I shall not be as brief as I would want to be. I would like to confine myself to single-word answers, but I do not think that would give the reassurance that noble Lords are looking for.

I begin by thanking all noble Lords who have engaged with me on this, especially the noble Baroness, Lady Brinton, and the noble Lords, Lord Clement-Jones and Lord Hunt. As they know from our discussions, this issue is very close to my heart and something I feel very strongly about, so I welcome their pressing the Government on this and their continuous engagement—in fact, right up to this morning. I do not think that this is the end of that engagement but I hope to give some reassurances. I completely understand the interest in the integrated care boards’ power to disclose information that is personal data. I hope I will be able to clarify some of the intentions.

New Section 14Z61, inserted by Clause 20, recreates the section that applies to CCGs, which sets out the circumstances in which CCGs are permitted to disclose information obtained in the exercise of their functions. The clause in question already restricts ICBs’ powers to disclose information, by limiting these to the specific circumstances set out in the clause.

In addition, the existing data protection legislation, including UK GDPR, provides several key protections and safeguards for the use of an individual’s data, including strict rules and key data protection principles for the sharing of personal data. Health data is special category data—that is data that requires additional protections due to its sensitivity. For this type of data to be processed lawfully, a further condition must be met as set out in UK GDPR and the Data Protection Act.

In addition, the common law duty of confidentiality applies to the use of confidential patient information. This permits disclosure of such information only where the individual to whom the information relates has consented, where disclosure is of overall benefit to a patient or is in the public interest—for example, disclosure is to protect individuals or society from risks of harm or where there is a statutory basis for disclosing the information or a legal duty, such as a court order, to do so.

Every health and care organisation has a Caldicott Guardian—a senior person responsible for protecting the confidentiality of people’s health and care information and making sure that it is used properly. Caldicott Guardians decide how much information it is appropriate to share—they may decide that even legally permitted information may not be shared—and they advise on disclosures that may be in the public interest. They act in accordance with the eight principles, which are the framework to ensure that people’s confidential information is kept confidential and used appropriately. The UK Caldicott Guardian Council works closely with the independent statutory National Data Guardian, whose role is to advise and challenge the health and care system to help ensure that the public’s confidential information is safeguarded securely and used properly.

Nothing in the clause overrides the range of requirements in law that provide key protections and safeguards for the use of an individual’s personal data. I can also confirm that NHS England’s power to issue guidance for ICBs will apply to their functions relating to data sharing, and that may be a helpful route in making it clear to ICBs what their duties and responsibilities are, in respect of any confidential data they may hold, in a way that illustrates how legislation applies.

The effect of the amendment is to prevent the effective operation of the clause as drafted. This would prevent the ICB from effectively discharging its functions where it may be necessary to disclose personal patient data, including investigating complaints, making safeguarding referrals for patients whose welfare is at risk, complying with court orders and assisting criminal investigations. It would also risk a confusing data-sharing system where different rules apply to different organisations.

On Amendment 116, once again I thank the noble Lord, Lord Hunt of Kings Heath, for bringing this issue before this House. Our aim is to put data and analytics at the heart of NHS delivery and remove incoherence in the organisational leadership, for the benefit of patients and their outcomes. It is a solid recommendation for improving how health and social care data is used more effectively, closing that gap between delivery and the use of data to inform and improve services.

I understand that noble Lords fear that the movement of the statutory data functions from one world-class arm’s-length body, NHS Digital, to another, NHS England, which indeed runs the NHS itself, would result in a decline in the exercise of those functions. We feel that this fear is perhaps overexaggerated but I would be very happy to continue discussions on this.

However, that movement would be accompanied by the transfer of several thousand expert staff and all their supporting expertise and technology, along with the existing statutory safeguards, which would be preserved. NHS Digital and NHS England have a history of very close working on data, most recently of course in how the management of data has underpinned efforts to defeat Covid-19, through the protection of shielded patients and the management of data on vaccinations. The Government and Parliament held NHS Digital to account for the delivery of its functions, and they will continue to hold NHS England to account for the delivery of any functions which transfer.

As to the concern about a conflict of interest, the data collections which NHS Digital undertakes are the result of directions from either the Secretary of State or NHS England, and obviously the direction-making power of the former will continue to be relevant should the proposed merger take place. Directions include details of how data must be shared or disseminated. NHS Digital is required to publish details of all such directions and maintain a register of the information it collects. There is also a rigorous process for external data access requests and audits of how data is used.

The intention here is that such safeguards would continue when the functions transfer to NHS England and would make it very difficult for the organisation to suppress or otherwise refuse to make available any data which it is required to collect and disseminate in fulfilment of its statutory role. I hope, perhaps overoptimistically, that I have reassured the noble Lord, Lord Warner—clearly not—in terms of suppressing information.

There is a rigorous process for external data access requests. NHS England’s Transformation Directorate will be assuming responsibility for NHS Digital’s functions, and for accomplishing the alignment of delivery and data proposed in the Wade-Gery review. There will continue to be external, independent scrutiny—for example, by the Information Commissioner and the National Data Guardian—of the use by the NHS, and NHS England in particular, of health and care data.

I hope that I have given noble Lords some reassurance that these important issues have been considered by the department, and that they will feel able not to move their amendments when reached. Of course, given my strong interest in this subject, I am prepared and happy to have further conversations to make sure that we close any remaining gaps and for me push the department and NHS England as appropriate.

--- Later in debate ---

As the subject of nurses has been so powerfully addressed by the noble Baroness, Lady Jones, I shall also say something about that. I believe that Amendment 80 will serve nurses just as well as it will serve doctors and all allied health professionals. We on these will focus our votes on Amendment 80 in the hope that the noble Baroness, Lady Jones, is reassured and will not feel the need to move Amendment 82.

[Baroness Merron (Lab)]

This powerful debate has focused on two simple truths. First, without the full team of people in place at the right time, it will not be possible to provide the health, social care and public health services we need. The second simple truth is that this will not just happen on its own. I am therefore glad to have put my name to Amendment 80, joining the noble Baronesses, Lady Cumberlege and Lady Brinton, and the noble Lord, Lord Stevens, in so doing. I thank the noble Baroness, Lady Cumberlege, for her impactful introduction of the amendment. I share the view of the noble Baroness, Lady Walmsley, that this is the amendment to focus on, the one that will take us in the direction we need to go.

It is hardly surprising that the need for workforce planning has come up time and again during the passage of the Bill, and it is not going away. Workforce planning is at the core of all the plans, yet it remains unresolved and continues to cause considerable disquiet, including in the Health and Social Care Select Committee. We know this is an urgent requirement to tackle, and I hope that, even at this late stage, good sense will prevail and the Minister will be able to give the assurances that your Lordships’ House seeks.

The lack of sufficient staff, trained and able to deliver care, is the biggest issue facing the NHS and social care. Whatever claims are made about how many staff there are, they are meaningless unless posed against what is actually required. Since the Bill was published there has been universal opposition to the limited and inadequate provision in Clause 35. As my noble friend Lord Hunt noted, the Treasury’s robust resistance to publishing anything that sets out properly the gap between the number of staff required and of those in post is a badly kept secret. I regard that as short-sighted for all the reasons that have come up in the debate thus far.

It is reported that a record number of 400 members of staff are quitting the NHS every week. The United Kingdom has 50,000 fewer doctors than we need, and there are currently 100,000 vacancies. Workforce planning needs to be in place to give us the chance to assess and tackle the workforce crisis. Today we have the opportunity to put that right. As we have heard, the amendment is supported by a major coalition of some 100 health and care organisations. As my noble friend Lord Bradley said, it also takes strength from giving the opportunity to consult a comprehensive range of organisations and groups that know the reality of what is needed to run our care services. We should add our support to that.

I am grateful to the noble Baroness, Lady Walmsley, and the noble Lord, Lord Patel, for adding their support to my Amendment 81. It tackles the same problem, but from the bottom up. Without the foundation of a workforce plan, no ICB can plan anything properly, as they are required to do by other parts of the Bill. There is also the wider point that the national strategies or definitions of systems planning have no reality unless they transfer down to those who actually have to deliver the outcomes. We know that there are widespread and well-evidenced arguments in support of workforce planning. I urge the Minister to accept the wisdom and the reality of these amendments and to take the opportunity to fix a challenge that surely is not going away.

[Lord Kamall (Con)]

My Lords, I am grateful to noble Lords for bringing the discussion of workforce planning before the House today. Perhaps before I go further, all noble Lords will want to join me in wishing the noble Lord, Lord Patel, a speedy recovery. He definitely would have spoken in this debate if he had been able to join us. I should also say that I was particularly impressed by the double act of the noble Lords, Lord Hunt and Lord Stevens. Perhaps they will be known in future as the Morecambe and Wise of the House of Lords.

We all agree that the workforce is at the heart of our NHS and social care. It is right to ensure that we have the workforce that we need for the future to keep delivering world-class, safe and effective healthcare. Some noble Lords may not like to hear this, but I remind them that we have a record number of nurses. We continue to look at different ways of recruitment, and in response to Oral Questions I have referred to the way that we are looking at different pathways into nursing for British people. It is also a fact that we have always recruited people from overseas. Indeed, our public services were saved, post-war, by people from the Commonwealth coming to work in public services. I remind noble Lords that now we have left the EU we will no longer give priority to mostly white Europeans over mostly non-white non-Europeans. We will focus on ensuring that we have equality across the world.

I will not repeat what I have said about other issues, but if you are to have workforce growth, which we all want, it must be accompanied by effective, long-term workforce planning. That is why the department has commissioned Health Education England to work with partners to develop a robust, long-term strategic framework for the health and regulated social care workforce for the next 15 years. This includes regulated professionals working in adult social care, such as nurses and occupational therapists, for the first time.

Health and Care Bill

Baroness Merron Excerpts

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

[Lord Eatwell (Lab)]

My Lords, I rise to give my strong support to Amendment 108, and I do so because of the terms of the genocide convention to which this Government are committed and are obligated to support. It is important for the House to note that genocide is not defined solely as mass killing. It is also defined as

“causing serious bodily or mental harm … deliberately inflicting … conditions of life calculated to”

destroy the protected group

“in whole or in part … imposing measures intended to prevent births”,

and

“forcibly transferring the children of the group to another group.”

The Government are a signatory to the genocide convention, and I think the noble Earl, Lord Howe, is obligated by that signature to support this amendment.

[Baroness Merron (Lab)]

My Lords, it is impossible to turn away from the connection between procurement of products and services and the message and support that such procurement may give to those who seek to exploit, oppress, damage and murder.

I thank the noble Lord, Lord Alton, for introducing this amendment, in the name of the noble Lord, Lord Blencathra, who we wish well. Genocide and the abuse of human rights do not respect the imposed boundaries of government departments, and that is why it is appropriate that these amendments, which have extensive support both inside and outside your Lordships’ House, have been tabled today. Amendment 108 has cross-party support and if the will of the House is tested, we on these Benches will support it.

The NHS is the biggest single procurer of medical products in the world. It has a huge amount of leverage to be a force for good or otherwise when it comes to ethical procurement. It can starve abusive regions of resources. It can also remove a veneer of acceptability from those regions.

If we are serious about being global Britain and a force for good in the world, we need to act as such. It is surely wrong that, for example, we are using bandages which have been produced by forced labour. We must hold the Government to their commitment to provide guidance and support to UK government bodies to use public procurement rules to exclude suppliers where there is sufficient evidence of human rights violations in any of their supply chains. As expressed by my noble friend Lady Kennedy, this is about giving the Minister the opportunity to act. It is about focusing minds. I hope that the amendment will find favour with the noble Earl.

In Committee, my noble friend Lord Collins spoke of the need not to be tied down by a very strict legal definition of genocide. He also emphasised that we must focus on broader human rights issues. As the noble Lord, Lord Alton, said, we need to take a comprehensive, joined-up approach. Amendment 108 gives us this opportunity.

I thank my noble friend Lord Hunt for continuing to press home the need for action, as outlined in Amendments 162 and 173. We heard explicitly and movingly about the realities of how this affects people’s bodies, alive and dead, and the distaste and abuse related to it. It is surely right that UK citizens are safeguarded against complicity in forced organ harvesting as the result of genocide. Countries such as Spain, Italy, Belgium, Norway and Israel, among several others, have already taken action to prevent organ tourism in respect of China. We have the opportunity to do so today.

I hope that the noble Earl will feel able to accept these amendments. I am grateful to the noble Lord and his officials for the opportunity to discuss these matters. I hope only that your Lordships’ House can assist in improving this aspect of the Bill by taking action, as we should, about genocide and the abuse of human rights.

[Earl Howe (Con)]

My Lords, the amendments in this group bring us to three discrete topics which are nevertheless linked by a common thread—that of human rights. Because they engage us in issues of great sensitivity, I begin by saying something that may sound unusual. There is probably no one in this Chamber who is not instinctively drawn towards these amendments. All three are honourably motivated. In pointing out any shortcomings, I would not want noble Lords to think that the Government did not understand or sympathise with why they have been tabled.

I will start with the issue of organ tourism. Like the noble Lord, Lord Hunt, I find it abhorrent that individuals exist who are in the business—often the lucrative business—of sourcing human organs from provenances that are both illegal and supremely unethical. They then entice desperate and seriously ill people to go to a foreign country to have such organs transplanted within them. This idea is unconscionable. As far as we can, we should have no truck with it. The Human Tissue Act already prohibits the giving of

“a reward for the supply of, or for an offer to supply any controlled material”

in any circumstance where a substantial part of the illicit transaction takes place in England, Wales or Northern Ireland.

The Modern Slavery Act makes it an offence to arrange or facilitate another person’s travel, including travel outside the UK, for the purposes of their exploitation, which includes the supply of organs for reward in any part of the world. The law as it stands addresses a substantial element of potential criminality. How widespread is this criminality? What do we know about the scale of organ tourism as it relates to UK residents? I have obtained some figures from the department. In 2019-20, the last reporting year before international travel was curtailed by the pandemic, a total of 4,820 organ transplants took place in this country. At the same time, NHS Blood and Transplant data shows that only seven UK residents received a transplant abroad, many if not all legitimately, and had follow-up treatment in the UK.

Therefore I am thankful to say that the scale of the problem of illicit organ tourism, as it relates to UK residents, is small. If the noble Lord, Lord Hunt, were to say to me that one such case is one too many, I would agree, but the House should not support this amendment, because it is not right to support an amendment that could cause vulnerable transplant patients who receive a legitimate transplant overseas to face imprisonment because they may not have the right documentation. That is what the amendment could lead to. Checking such documentation and creating individually identifiable records for every UK patient who has received a transplant overseas would put healthcare professionals in an invidious and inappropriate position by blurring the line between medic and criminal investigator.

More to the point, it could also prevent those who legitimately receive an organ transplant abroad—particularly those from minority-ethnic backgrounds—from seeking follow-up treatment, for fear of being treated as a criminal suspect. Following that thought through, I say that the effect that this amendment could have in exacerbating health inequalities is likely to be far greater than its effect in deterring transplant tourism, especially, as I have emphasised, because there are already legal provisions in place covering most cases of organ tourism.

I listened with care to the noble Baroness, Lady Finlay, particularly regarding her examples of the exhibition that she went to. I join her in being somewhat incredulous that there could be consent to some of the exhibits that she witnessed. However, where consent has been obtained, it must be unequivocal. As I emphasised, the law as it stands now prohibits the exhibition of bodies or body parts where express consent cannot be fully demonstrated. I undertake to speak to the Human Tissue Authority, to see that, should there be another exhibition of this kind proposed, there is full transparency in the form of labels under each exhibit making clear how consent was obtained and what it consisted of.

Targeting those who receive an organ, rather than the traffickers and their customers who initiate or negotiate the arrangements, risks imprisoning vulnerable patients who may have been misled as to the provenance of their organ. That would be disproportionate. The Government’s view remains that the best approach is to continue targeting traffickers and their customers, while doing all that we can to help UK residents who are in need of an organ by focusing our efforts on improving the rates and outcomes of legitimate donations.

--- Later in debate ---

[Lord Kakkar (CB)]

My Lords, I declare an interest as a member of your Lordships’ ad hoc Select Committee on the Long-term Sustainability of the NHS. My noble friend Lord Warner has very clearly introduced the arguments summarised at that time, when your Lordships’ committee made its report, strongly supporting the establishment of an independent office for the sustainability of health and care, and I shall not repeat those arguments.

What was striking was Her Majesty’s Government’s response to that report and, indeed, to recommendations 32 to 34 in that report, which dealt with that specific question. To summarise, Her Majesty’s Government felt that that office was unnecessary and that the Office for National Statistics had much of the data publicly available to assist in this long-term planning activity. Clearly, that is not the case; it has not happened, and it is unlikely to happen.

It is essential, as we have heard, that such an office is established not only to deal with questions of workforce—my noble friend has identified the interview given by the right honourable Jeremy Hunt on the question of an independent office for questions of workforce—as sustainability of health and care goes far beyond workforce. A very careful and appropriately defined methodology and expertise needs to be brought together to ensure that we can plan on a definite basis and achieve the sustainability that every Member of your Lordships’ House clearly regards to be essential. I therefore hope that Her Majesty’s Government accept this amendment.

[Baroness Merron (Lab)]

My Lords, five years have passed since the ad hoc Select Committee on the Long-term Sustainability of the NHS, under the chairpersonship of the noble Lord, Lord Patel, recommended an office for health and care sustainability. I thank the noble Lord, Lord Warner, for bringing this amendment before your Lordships’ House. This is a clear direction to put sustainability at the heart of planning and is long overdue. So we on these Benches support the amendment, and I hope the Minister will accept this amendment as a way forward.

[Baroness Penn (Con)]

My Lords, I thank noble Lords for bringing this debate before the House today. As mentioned in the debate in Committee, the specific functions described in Amendment 112 are crucial functions that the Government are committed to ensuring are discharged. This commitment is underlined by the fact that there are already bodies and mechanisms in place to fulfil these functions. These are core components of the Government’s commitment to evidence-based health provision. This commitment has been made clear in many of the Bill’s provisions, in our wider programme of public health reform and in the proposals set out in the Government’s plan for health and care.

The amendment makes recommendations on both appraisal and scrutiny of funding and of social and demographic trends. With regard to the monitoring of trends, the department already publishes data relating to disease profiles, which incorporates demographic trends where relevant. This is supported by independent academic modelling from the Care Policy Evaluation Centre, CPEC, to produce projections of the long-term demand on adult social care services. As for funding, noble Lords will also be aware that successive Governments have used the well-established spending review process to set public service budgets. This takes into account the needs of service users, but crucially also considers the fiscal context and how healthcare expenditure balances with the range of priorities across government.

As noble Lords have noted, aligned to those spending decisions, the Office for Budget Responsibility already scrutinises the Government’s fiscal approach and our management of fiscal risks. For example, in October 2021 the OBR provided an independent analysis of the Government’s reform to the funding of adult social care in England and has announced that it will provide more analysis of the long-term implications in its next fiscal sustainability report. There is also, as noble Lords will know, a wide range of highly influential non-governmental bodies dedicated to the kinds of functions proposed for this new body—the King’s Fund, the Health Foundation and the Nuffield Trust to name just three. All of these contribute richly to the public debate on financial sustainability and on the size and composition of the workforce, as well as other related issues, and to the ability of this House to scrutinise government decisions on spending and policy.

The Government therefore do not think that the creation of a further body would add value. At this crucial time for the health and care system, we must proceed with the reforms we have outlined. For these reasons I hope that the noble Lord, Lord Warner, will feel able to withdraw his amendment.

Health and Care Bill

Baroness Merron Excerpts

Lords Hansard - Part 1 & Report stage
Monday 7th March 2022 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, I say very briefly that I hope the Government will look favourably on this amendment from the noble Lord, Lord Howarth, and others. I hope that they will build into a review an assessment of the cost efficacy because as well as all the positive aspects that we have heard about, we must remember that, if you can decrease medication prescribing, you will decrease not only costs but adverse side-effects, which also have a cost. All these initiatives tackle the problem of loneliness, isolation and not having contact with other people—people who may be able to empathise with the way that you feel about your condition when you are undertaking a common activity with them. That can become particularly important for the psychological well-being of patients as well as their physical improvement.

[Baroness Merron (Lab)]

My Lords, I congratulate my noble friend Lord Howarth on bringing this subject before your Lordships’ House again. I am grateful to noble Lords from all sides of the House for providing their support for embedding the conditions and opportunities for art, creativity and culture in improving public health. These amendments provide something of a focus for action and I hope will be regarded seriously as such.

We know that the practices relating to creative health can be very effective and good value for money. Some 20% to 30% of all visits to the doctor are for non-medical reasons; for example, social isolation or loneliness. Therefore, the potential that we have in the United Kingdom is huge. Indeed, evaluation of the Arts on Prescription scheme suggested an average return of £2.30 for every £1 spent.

These amendments support the idea that art-based approaches can help people to stay well, recover more quickly, manage long-term conditions and experience a better quality of life. I hope that the Minister will be able to take these amendments on board.

[Lord Winston (Lab)]

My Lords, if I may, I will introduce a slightly discordant note, seeing as my name has been mentioned. I did not intend to speak, but I do think we need to be a little cautious about all this. I congratulate deeply the noble Baroness, Lady Greengross, on her remarkable work in this area, and nobody would doubt for a moment that everybody here is speaking in very good faith and for the best of purposes.

However, as medical practitioners, we must say that the placebo effect is very powerful and can cure people or improve their health in all sorts of ways and with all kinds of activities, not only dementia. Feeling well is not a simple matter. One concern is that we might spend much more money than we expect on these activities, without coming to the gist of why and whether they work, rather than something that substitutes for them.

I remind the House of one thing. For many decades, the health service supported homeopathy. Homeopathy—like cures like—has been widely used across the world and many people have great faith in it. There is actually no evidence at all that it has any genuine medical or chemical benefit; it is probably essentially a placebo effect. I am not suggesting for a moment that we should not look at exercise, music and all the other things, but I implore the Government; if we do this on the health service, there is a duty to ensure that research is done as well, because we must have a health service that looks at evidence-based medicine. That is fundamentally important.

--- Later in debate ---

[Baroness Merron (Lab)]

My Lords, I am grateful to the noble and learned Lord, Lord Etherton, for so forensically and carefully introducing this group of amendments. The debate on the subject today, as on previous occasions, has been both rich and constructive. I hope it will lead to improving this clause; as we have heard, there are multiple issues in respect of its drafting. The main issue and debate today focused on coroners having access to protected information which has been shared in confidence under safe space conditions. Therefore, I will make my brief remarks in respect of Amendment 124, tabled in the name of my noble friend Lord Hunt and supported by the noble Baroness, Lady Walmsley, and the noble Lord, Lord Patel. We are all pleased to see the noble Lord, Lord Patel, back in his place.

It cannot be right, on the one hand, for someone to be compelled to give information and to do so on the understanding that they act within a safe space and would be committing an offence if they did not give information, yet, on the other hand, to enable that very information to be made publicly available. It is not the purpose or duty of HSSIB to act as a branch of the coroner. The coroner has multiple other avenues of access to information and powers of investigation. It does not need the access to this protected material simply because of the convenience of the existence of HSSIB. Therefore, I hope the Minister will understand this point and take it on board. If not, and if noble Lords are so minded to test the opinion of your Lordships’ House, these Benches will support the relevant amendment.

[Earl Howe (Con)]

My Lords, every day, the vast majority of NHS patients receive safe, effective and world-class care. Sometimes, though—and very sadly—errors occur which lead to harm. This is what the HSSIB will help us to address. The HSSIB will be an independent arms-length patient safety investigation body, with a statutory safe space and powers to discharge its investigative functions effectively across the NHS and the independent sector. This body will be one of the first of its kind in the world. Its independence will give the public full confidence that it will arrive at impartial conclusions and recommendations. The aim will be to drive improvements by learning and not blaming.

The provisions in the Bill were developed after considerable thought and scrutiny. We have had extensive stakeholder engagement, including an expert advisory group. The clauses, broadly in their current form, were scrutinised by a specific Joint Committee comprising Members of both the House of Commons and the House of Lords in December 2018. We accepted many of the Joint Committee’s recommendations—for example, to include independently funded healthcare within scope and to exclude local maternity investigations. The HSSIB had widespread support across both this House—when it was introduced in a previous Session and again during earlier debates—and the other place. I know that many noble Lords here today, having heard some of them, are enthusiastic about the prospect of a fully independent investigation body. I very firmly believe that we need to continue with the same enthusiasm and see this new body through to fruition. We should not delay this important work by rejecting this part of the Bill.

I honestly think that removing Part 4 would be a backward step. It would be greeted with dismay by those patient safety campaigners who have argued so eloquently for the creation of this body. The current investigation branch does not have the necessary independence or the range of powers to truly drive change as a world-class investigation body. This is what we are trying to address by creating a new body with all the tools it needs to thrive. By the way, those noble Lords who think that removing Part 4 and keeping things as they are will prevent access to information by coroners are wrong: coroners currently have such access, but without our proposed restrictions. Key to the HSSIB’s function is the creation of a statutory safe space, whereby non-compliance with those safe space protections can result in criminal sanctions.

I turn to the issue of access to safe space, which I recognise has caused concerns. We firmly believe that the only way to bring about a cultural shift in the NHS, so that people feel confident to share information and concerns are addressed promptly, is that there be a robust safe space. The current investigation branch does not have a statutory safe space. The Bill would create one, with tight restrictions. There are very limited circumstances when protected material can be disclosed—for example, if the HSSIB discovered information which demonstrated there was a serious and continuing risk to the safety of a patient or to the public—but this disclosure would occur only to the extent necessary to address those risks.

I know that direct access to protected material for senior coroners, as raised in Amendments 124 and 125, is an area of concern, but coroners have a unique role. A coroner’s investigation is an independent judicial process that aims to provide bereaved families with the truth regarding the death of their loved one—who has died, where, when and how—and enable society to learn from any mistakes that may have caused or contributed to a death. When a death occurs, and when that death requires coronial investigation for the sake of families and of the public, that work should not be hampered. It is an important principle that we should trust our judiciary. I am confident that coroners will take seriously their responsibilities to safeguard any safe space material that they may see. They are used to doing this; they already routinely handle sensitive, confidential material.

It is most unlikely that senior coroners will need to access safe space information on a frequent basis. Of the 57 national investigations conducted by the current investigation branch, 10 were investigated by the local coroner. However, only one gave rise to a request from a coroner for material held by the current investigation branch. Having said that, even though we expect requests for protected material will be rare, the principle of coroners having access when they need it is an important one.

--- Later in debate ---

The only point I want to make that has not been made so far by the other three speakers on the subject is that I spoke to the medical directors at both the NHS trusts I chair. In the case of UCH, we have three medical directors; at the Whittington, we have only one. All four, to a man and woman, are strongly supportive of this amendment and this direction of travel. They think it is important for both doctors and patients. It is not only to protect patients; it is to protect doctors and to make it really clear that doctors are being transparent in their practice about who is paying them and who is paying their research funds and putting that money into what used to be called, in my early days in the NHS, a “little slush fund”. If the trust medical directors support this, I really think we should encourage the GMC to think again, and I very much hope that the message to the GMC from this House will be that it should think again. I also very much hope that the Minister will look closely at this again and see how far he can take it, because there is really no doubt that this should be supported.

[Baroness Merron (Lab)]

My Lords, this group of amendments concerns the licensing of non-surgical cosmetic procedures and other important considerations, such as hospital rehabilitation accommodation and the doctors’ register of interests. They all relate to the interests of patients.

I shall address particularly the issue of cosmetic procedures and I start by thanking the Minister and his Bill team for giving so much support, showing such interest and bringing this into being today. I know we all welcome it; it is much appreciated. I am glad to have taken part in the meetings and to have tabled an amendment in Committee relating to cosmetic regulation. The amendments before us today have been very much welcomed by medical associations, because we all know that lack of regulation has been a ballooning problem. For example, the Save Face organisation received more than 2,000 complaints of botched procedures in 2020 alone and the true number, as we know, is likely to be higher.

The other point to make is that this is a fast-moving industry and I am glad that these amendments will be able to keep pace with an ever-changing landscape. We have seen a significant rise in recent years in the number and type of non-surgical aesthetic procedures performed in the UK. Practitioners, both medically and non-medically trained, are performing procedures without even being able to evidence appropriate training and the required standards of oversight and supervision of procedures that can be described only as high- risk. When they go wrong—and we have all heard the stories of intense and lasting damage from untrained practitioners carrying out procedures in unlicensed premises—we all know that it will then fall to the NHS to pick up the pieces. This, today, is a meaningful step in protecting more people from rogue operators.

I close by thanking noble Lords for their contributions not only to this debate but to shaping the legislation. Once again, I thank the Minister and his team for all their efforts. I hope we will come to see a much safer set of non-surgical cosmetic procedures than we have at present.

[Lord Mawson (CB)]

My Lords, just before the Minister stands, I rise to support Amendment 184ZA in the name of the noble Baroness, Lady Cumberlege.

Over the last 28 years, it has been my privilege to work with a fantastic team of GPs in the East End of London who are now responsible for 43,000 patients. I know what great GPs and doctors are like. If I am honest, however, I have also had to deal with a number of dodgy doctors, which is a very difficult matter to deal with. One doctor undertook female circumcision in his practice, unbeknown to the health authority for quite a period of time. He ended up marrying his practice manager and, some years later, he murdered her. Another practice, when I dug under the carpet, had bought a cheap fridge from B&Q and, over a period of three years, kept 10,000 injections at the wrong temperature and injected 10,000 patients with dead, illegal injections. Another doctor, as we learned when we took over his list, had countless ghost patients. As a result, I started to discover what ghost patients are. It took our team two years to sort out the realities of who were and were not real patients.

For the sake of GPs and patients, we need to protect them in the way the noble Baroness is suggesting. Doctors are flawed human beings like the rest of us, and we need to protect them from themselves and from us. It is really important that these things are taken seriously. This amendment puts its finger on a very important matter.

Health and Care Bill

Baroness Merron Excerpts

Lords Hansard - Part 2 & Report stage
Monday 7th March 2022 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I wish we were talking about restricting the advertising of gambling; that would have more effect on the health of the country than this. However, these are very important measures. Before I talk about the three major groups in this grouping of amendments, I thank the noble Lord, Lord Hunt, and my noble friend Lady Barker for raising the really important issue of nutrition to patients in hospital and people living in residential care homes.

The rest of the amendments fall into three broad groups. First are the amendments in the name of the noble Lord, Lord Moylan. While he was telling us the very sad story about the manufacturers of the Grenade bar, about how much protein it has and how little carbohydrate, I was wondering: what about the other major nutrient, fat? Noble Lords will remember from their biology lessons that, gram for gram, fat has twice as many calories as either carbohydrate or protein, and if you eat an awful lot of those bars, you will get fat—the “F” in HFSS foods. Of course, one “S” in HFSS foods stands for salt, and the noble Lord, Lord Krebs, has now told us exactly what is in that bar—far too much fat and far too much salt.

However, the noble Lord, Lord Moylan, raises a point which I raised in Committee: the nutrient profiling model is 11 years old. I asked the Minister whether there are any plans to update it, because companies really need up-to-date information about exactly what will fall within the ban and what will not. So I ask the question again: are there plans to update that 11 year-old guidance? We really do need it, because then companies such as the one mentioned by the noble Lord, Lord Moylan, and many others, will really know what they are dealing with. It certainly does not sound to me as though that bar will fall outside the restriction on advertising.

I have added my name to the amendments in the name of the noble Lord, Lord Bethell. I remember when, in Committee, the Government introduced this power to extend the deadline—they did not say how long for—and I asked what this was for and why the Government needed to extend the implementation of these restrictions. The Minister, the noble Baroness, Lady Penn, said it was just in case there were any hitches with the consultation. I think the noble Lord, Lord Bethell, is right and there is certainly a hint of long grass in what the Government were trying to do. I was a bit suspicious about it in Committee, and I still am. I support what the noble Lord, Lord Bethell, is trying to do.

All the industries concerned with these measures have had plenty of notice of what the Government wanted to do, and I think, once the detail comes forward, they will have had plenty of time. Perfectly reasonably, the noble Lord, Lord Bethell, is asking for that power that was taken to extend the deadline to be limited to just three months. That is quite enough.

As for the amendments from the noble Lord, Lord Black, I agree with my noble friend Lord Clement-Jones, although not necessarily for the same reason. Of course, there is a fairness issue here, but I think that, if the responsibility for implementation and making sure there was compliance was extended to online platforms, it would strengthen the objectives of these measures from the Government, which I support. Therefore, if he puts his amendment to the vote, we will vote for him.

[Baroness Merron (Lab)]

My Lords, we have had a considerable debate on these issues, in Committee and this evening in your Lordships’ House. From these Benches, we absolutely support the provisions to tackle obesity. The reasons have been gone over many times, but I make one point in respect of children—that children with obesity are five times more likely to become adults with obesity, and increase their risk of developing a range of conditions, including type-2 diabetes, cancer and heart and liver disease. It is incumbent on us to take the steps that are necessary.

Given the lateness of the hour—and I know that noble Lords wish to get to the question whether there is to be a Division—I shall focus my comments on the amendments relating to advertising, Amendment 151A, in the name of the noble Lord, Lord Black, and the subsequent amendments, to which I have put my own name. There has been a great clarity of argument as to why those amendments deserve favour, but the one that sticks out for me is about ensuring the effectiveness of the legislation that we are speaking about.

We already know that legislation can have a huge impact. For example, the soft drinks industry levy has led to manufacturers reducing 44 million kilograms of sugar each year from drinks in the UK. We also know of the support for the measure of the watershed for advertising of high-fat sugar and salt products—in other words, to protect children from those influences. We know that the measure is supported by organisations such as the British Heart Foundation, the Food Foundation and many other experts as being able to make the difference, because children are influenced by advertising. We should really be ensuring that children see adverts for healthier food and drinks.

Should the will of the House be tested on these amendments, these Benches will certainly be in support, because we feel that the Government should make sure that the proposed pre-9 pm ban on advertising unhealthier foods on TV, with a total ban online, has to be implemented effectively and appropriately across all media and platforms. If it is not and remains as it stands, it will not do the job that it is intended to do, and we will miss an opportunity, which we hope the Minister will reflect on, as the case has been made so clearly and directly.

[Baroness Penn (Con)]

My Lords, I thank noble Lords for this debate. I will turn first to the amendments in the name of my noble friend Lord Bethell. As noble Lords are aware, the Government introduced an amendment in Committee to enable adjustments to the date of commencement of the HFSS advertising restrictions, should emerging issues require it to be moved.

We will continue to work with regulators and businesses to ensure that guidance is produced promptly to support timely implementation; our intention remains to implement restrictions from 1 January 2023. We think that date balances ambition with the importance of sufficient time for business to prepare. However, limiting this flexibility to a period of only three months, as proposed by my noble friend’s amendment, would be counterproductive, as that timeframe may not allow us to respond adequately to any unforeseen challenges or ensure smooth delivery of this policy.

Turning to the amendments tabled by my noble friend Lord Moylan, I seek to reassure him that our current approach provides an overall assessment of the nutritional content of products, as it accounts for nutrients of concern as well as beneficial nutrients. As such, we consider it to be an effective mechanism for permitting healthier products to be advertised, while still restricting those which are less healthy overall. The detail of the products in scope will be underpinned by secondary legislation, which can provide the necessary detail and be adapted in response to future changes to products on the market. The Government will consult soon on this and other definitions included in the draft regulations, such as the small and medium enterprise exemption.

I turn now to the amendments on platform liability. The Government believe that the online advertising programme remains the best way to address such issues on an industry-wide basis, rather than in a piecemeal fashion. I am pleased to be able to confirm that the DCMS consultation, which should launch in the next fortnight, will examine the harms associated with paid-for advertising online and consider the measures that could apply to platforms and others in the supply chain in order to increase accountability and transparency.

It is our intention to legislate on those conclusions in this Parliament, as we share the view that it is the right time to put in place holistic measures to tackle platform liability. However, it is also right to bring forward powers in this Bill now, so that we can begin to tackle obesity via restrictions to TV, on-demand programme services and online, in line with current enforcement frameworks for advertising that are familiar to industry. Platforms are not able to pre-vet adverts in the same way that broadcasters can. We recognise that there is a need to address that issue, but to do so in the round.

Amending this Bill in relation to online platforms without wider consultation and at a late stage risks unintended consequences. Those could include undermining the clear responsibility of advertisers to adhere to the restrictions that we are debating; interfering with the competitive dynamics that apply across the online advertising supply chain; not addressing accountability and transparency issues that apply elsewhere in that ecosystem; the danger of the restrictions applying to a wide range of internet service providers beyond those intended, including intermediaries and publishers; and not providing regulators with the right tools, funding or structures to regulate effectively. Were this amendment to pass, the Government would need to consider very carefully whether implementation from 1 January 2023 remained possible. The risks posed by creating a more complicated regulatory framework are likely to result in a delay.

--- Later in debate ---

[Baroness Bennett of Manor Castle (GP)]

My Lords, I am also aware of the hour, and offer Green support for the amendment of the noble Baroness, Lady McIntosh. We are talking here about a cost-benefit analysis. Some of the costs on which I would focus, and their impacts, go beyond the narrowly medical impacts of the people who consume the water. The question I raised in Committee was whether people today actually consume tap water, and whether they will continue to do so. I made the point that 90% of people drank tap water in 1978, but that figure had fallen to 73% by 1998. I do not believe that there have been detailed national figures since then.

I thank the noble Lord, Lord Kamall, for writing to me in response to that debate and providing a set of figures which the Government had researched. I will note two of the figures which the Minister cited in that letter. One was a 2010 Ipsos MORI survey in the West Midlands showing that two-thirds of surveyed people supported water fluoridation if it was going to improve dental health. That, of course, shows that a third of people are not supporting it. This is the group about which I am concerned—a group which I have encountered many times and in many parts of the country. I do not agree with all their concerns, but that is a fact.

I noted that the Minister also cited a north-east survey from 2021 where 60% of people backed water fluoridation. As the noble Baroness, Lady McIntosh of Pickering, said, we are talking about people not having a choice about consuming that water, unless they choose to buy bottled water. Anyone going to a supermarket in Sheffield, particularly in its poorer areas, will see people buying bottled water in very large quantities. One of my concerns, and where I hope the cost-benefit analysis would come in, is looking at the sociological issues. The Government should be doing a great deal more to promote the consumption of tap water and to discourage the use of bottled water. However, as the Bill currently stands, it risks pointing us in the opposite direction.

The noble Lord, Lord Storey, talked in Committee about how Liverpool City Council had very successfully engaged in a targeted programme to address the most vulnerable communities and ensure that dental health was improved. It demonstrably was improved.

The Minister said, “Oh well, any local authority can do the same thing.” I point out to him that local authorities’ budgets are enormously overstretched—something we have addressed in the social care elements of the Bill in particular. Would the Government consider perhaps taking the money that might be spent on fluoridation and giving it to local authorities for targeted campaigns to reach the children who need it most?

[Baroness Merron (Lab)]

I thank the noble Baroness, Lady McIntosh, for moving this amendment. I feel that we have discussed these issues at considerable length at previous stages of the Bill, so I do not wish to go over old ground, other than to say that the Royal Society for Public Health, the British Dental Association, the Chief Medical Officer and many others are very much in favour of greater fluoridisation because, on balance, there is strong scientific evidence that it is an effective public health intervention. In other words, it is the single most effective way to reduce oral health inequalities and tooth decay rates, especially among children, and it is, as your Lordships’ House knows, recommended by the World Health Organization. On all these positive points, I am very much inclined to agree, and do not feel that the amendment before your Lordships’ House would be helpful to support that intervention.

[Earl Howe (Con)]

My Lords, I thank my noble friend Lady McIntosh for her clear introduction to Amendment 156. The first thing for me to underline is the point she made: the water fluoridation provisions in the Bill will simply transfer the power to initiate fluoridation schemes from local authorities to the Secretary of State. The Bill does not compel the expansion of fluoridation. Any future proposals to establish new schemes would be subject to funding being secured and public consultation, and I will come on to both those things in a second.

The noble Baronesses, Lady Finlay and Lady Merron, are quite right that the evidence is strong that water fluoridation reduces the incidence of tooth decay for both adults and children, but nobody is complacent about public health. We will continue to be under a legal duty to monitor the health effects of water fluoridation on populations with schemes and to report no less than every four years. Monitoring the evidence is a continuous process and involves colleagues from multiple disciplines, including toxicology.

The law here is explicit. Water companies are required to comply with legislation to protect employees, consumers and the environment from harms. The Town and Country Planning (Environmental Impact Assessment) Regulations 2017 and other legislation set out the thresholds and criteria for which an environmental impact assessment is already required in relation to developments. The installation of water fluoridation plants in some areas may fall within scope. Furthermore, the Environment Act 2021 will, when brought into force, place a duty on Ministers of the Crown to have due regard to the policy statement on environmental principles in our policy-making; hence new and revised policies will need to take into account their impact on the environment. I would like again to reassure your Lordships that the evidence is kept under review.

My noble friend referred to the case of McColl v Strathclyde, in which I think she said she was involved. Perhaps I could just state for the record that the plaintiff’s arguments in that case about the safety and effectiveness of fluoridation were all explicitly rejected by Lord Jauncey, who found that there was no convincing scientific evidence supporting that position. Since that ruling by Lord Jauncey, 38 years ago, it remains the case that there is no convincing scientific evidence of water fluoridation being harmful to health. Indeed, were we not to have any fluoridation, there would still be areas of the country where fluoride is naturally present in drinking water at a similar level to that achieved by a fluoridation scheme.

Health and Care Bill

Baroness Merron Excerpts

Lords Hansard _ Part 1 & Report stage
Wednesday 16th March 2022 Lords Chamber

[Baroness Walmsley (LD)]

Many thanks. I suggest to the noble Lord, Lord Naseby, that a lot more people will be dead from tobacco if we carry on at this rate. He suggested that, just because this measure was not in the Conservative Party’s manifesto, perhaps we should not carry it forward. Well, the Conservative Party does not have all the best ideas, although I congratulate the Government on the sugary drinks levy, which has been highly successful. We support the polluter pays amendment introduced by the noble Lord, Lord Crisp. I might call it the killer pays amendment because, make no mistake, this is a killer substance.

I happen to live in Wales so I want to raise a matter that has not been mentioned yet. I am glad that the Welsh Government have committed to a smoke-free Wales by 2030. However, although England announced its intention to go smoke-free by 2030 two years before Wales did, Wales has leapt ahead as regards action, which is why I hope that the Minister will either accept Amendment 158 or give adequate assurances. In the Green Paper of July 2019, the Government said:

“Further proposals for moving towards a smoke-free 2030 will be set out at a later date.”


Approaching three years later, still nothing has happened. There are no further proposals and no funding has been announced. In contrast, Wales has published concrete proposals, but many of the interventions require action from the UK Government. Examples include the polluter pays funding mechanism, which could help to fund tobacco control in Wales; raising the age of sale; and putting warnings on cigarettes and pack inserts. I am concerned that, by being so slow, the UK Government are undermining the ability of the devolved Administrations to achieve their smoke-free ambitions. We will support the noble Lord, Lord Crisp, if he chooses to put this amendment to a vote.

[Baroness Merron (Lab)]

My Lords, I am grateful to noble Lords for their contributions to this debate and for putting forward this group of amendments. In introducing Amendment 158 and the consequential amendments, the noble Lord, Lord Crisp, outlined that they would establish a consultation on a polluter pays levy whereby funds are raised by the scheme to pay for the cost of tobacco control measures to deliver a smoke-free 2030. This strikes me as wholly pragmatic; a wide-ranging consultation would undoubtedly help to strike the right balance between all the parties involved.

We know from this debate and many previous debates that tobacco use carries huge health risks, and disproportionately so for the most disadvantaged in society, whose likelihood of smoking is four times higher in the most deprived areas compared to the least deprived. If ever there was a case for levelling up, this is it. My noble friend Lord Faulkner rightly highlighted that we have seen cuts to stop-smoking services, and this group of amendments seeks to redress the situation in a practical way. It is vital that we motivate and support more smokers to quit, while reducing the numbers of children and young people who start to smoke. Greater action is clearly needed now.

The scheme proposed in this group of amendments would provide a well-funded and much-needed boost, and a consultation would allow this proposal to be tested, refined and shaped. I hope that the Minister will accept the opportunity of a consultation but if the will of the House is tested, these Benches will support the amendments.

--- Later in debate ---

[Baroness Walmsley (LD)]

My Lords, at the risk of being boring, I am one of those people who has been asking for this for the last 20 years. I started off asking for the number of units of alcohol in a bottle of wine. Every manufacturer of these alcoholic drinks knows exactly what goes into them. On the issue of labelling products from abroad, there are a lot of foodstuffs that come from abroad and they have to abide by British rules on labelling, so why not wine and spirits? It is time we did this. It is terribly important for public health, and I hope the Minister will say yes.

[Baroness Merron (Lab)]

My Lords, I thank the noble Baroness, Lady Finlay, for bringing forward Amendment 163, and thank other noble Lords for outlining their support for or concerns about it. The amendment refers to publishing a report on alcohol labelling to improve consumer knowledge.

Government data comparing pre-pandemic and post-pandemic figures has shown that sales of alcohol increased by some 25%. This is, as we know, a booming market and consumers need to be equipped with the right information to make informed choices. They have a right to know what is in their drinks and decide what and how much to drink. The consultation promised by the Government, with this in mind, remains something of a consultation in long-overdue waiting.

Currently there is no requirement for alcoholic drinks to include health warnings, drinking guidelines, calorie information or even ingredients. As my noble friend Lord Brooke said, this is very much out of step with any other information on what we consume. There is, as always, a balance to be struck between health improvement measures, consumer information and industry regulation, but this amendment supports a necessary move in the right direction and I hope the Minister will agree to it.

[Lord Winston (Lab)]

My Lords, as a doctor and a wine drinker, I have serious concerns about this amendment, particularly, for example, when it comes to the use of fine wine—I think there is broad understanding in the House of what that is—where, in every case, those bottles are labelled with the amount of alcohol. One has to accept that labelling bottles in this way does not change behaviour. We have had committees looking at behaviour change, and the only time we managed to induce behaviour change was with smoking—certainly never with labelling. That is the only time it happened and there were all sorts of reasons for that.

Much of the evidence for alcohol being harmful in minor doses is still dubious and, more importantly, there is real concern that a lot of the so-called evidence is not being put to the real test of whether it makes a difference to behaviour. I must say to the House that I think the noble Lord—I am afraid I do not know his name; my eyes are bad enough not to have been able to see his name on the screen—is right that this is unworkable. It would probably do all sorts of untold damage to what is, for me and no doubt many others, a very fine drink. We need to look seriously at whether we can simply label all bottles.

I just remind the House that there is one amendment that I could have put down. In in vitro fertilisation, embryos are cultured in culture media, which are in fact commercially made and a commercial secret—nobody knows exactly what the composition of those media is. My laboratory is looking at this at the moment. It is really interesting, because some of the products in those culture media may indeed be quite dangerous in terms of epigenetic effects. To me, that seems far more important to regulate than what we are trying to do here with bottles of wine, which is probably not really workable.

--- Later in debate ---

[Baroness Walmsley (LD)]

My Lords, as the noble Baroness, Lady Grey-Thompson, rightly said, the devil is in the detail. That is what Parliament does and it is what the noble Lord, Lord Forsyth, is asking your Lordships to allow Parliament to do.

Like many families across the country, my family has had discussions about the substantive issue of assisted dying. Different views have been expressed and no one has fallen out, but it is not around our dinner table that decisions must be made about an issue as serious as this; that is for Parliament. I trust Parliament, and I do not think it should be—as the noble and learned Lord, Lord Falconer, pointed out—for the Director of Public Prosecutions to make decisions about these issues. Assisted dying is happening and Parliament must decide how or if it should be done.

It has been suggested that this House should not instruct the Secretary of State to do anything. As we have gone through the Bill, we have asked the Secretary of State to do quite a lot of things; in fact, we have voted that the Secretary of State should do a lot of them. What happens to those amendments? They go to the elected House. I have great respect for the noble Lord, Lord Cormack, and I understand how important he feels it is that issues as controversial as this should be decided by the elected Chamber. Well, if we vote for this amendment, those issues will be decided by the elected Chamber. If this novel procedure of a draft Bill being laid before Parliament is used, I trust Parliament; there will be proper debate and I hope that what will come out of it will be a very measured piece of legislation that takes all the concerns into account. The game-changer that my noble friend Lady Finlay has successfully introduced to the Bill will be taken into account by the elected Chamber.

It is very important that people who want to have palliative care to ease their suffering at the end of life actually get it—everyone should get it; there should be no postcode lottery—but even in those situations there may be people who do not want it and instead want to do something else. It is for Parliament, not for my dinner table or anyone else’s around the country, to make that decision and to be given the proper amount of time to come up with something that I hope will reassure those who rightly have fears. They have fears because they do not know what Parliament will decide. If we give Parliament the opportunity, I am quite sure that even a draft Bill, however well drafted, will probably be amended as it goes through the elected House. What will come out at the other end will probably reflect public opinion—genuine public opinion, that is; I am not quoting any polls on either side—as they will have given serious thought to the issue and listened to everyone who wants or does not want this measure on the statute book.

We must give the elected Chamber the opportunity either to accept an amendment that we may pass tonight or to send it back to us, but at least we will have asked them to think again. This House does that very well. We ask another place to think again. I hope we will tonight.

[Baroness Merron (Lab)]

My Lords, I have listened very closely to the many passionate, informed and often personal contributions from noble Lords this evening. This debate has inevitably been about not only parliamentary process and legislative approach but consideration of assisted dying. I thank the noble Lord, Lord Forsyth, for opening the debate on Amendment 170, which proposes, as your Lordships’ House is more than aware, a new clause to bring forward a draft Bill on what the noble Baroness, Lady Campbell of Surbiton, described as a complex and difficult issue.

However, for me, the challenge of this debate is encapsulated in the contributions in the middle of it. The first, from the noble Baroness, Lady Davidson, was that not allowing time for discussion is not a neutral act. This was followed swiftly by my noble friend Lord Hunt taking a different tack, saying that allowing for this amendment is also not a neutral act, and it is that which your Lordships’ House has wrestled with this evening.

It is indeed a matter of profound moral, personal and legislative importance that we find ourselves dealing with in Amendment 170. The noble Lord, Lord Forsyth, will be seeking a Division and these Benches will approach this on free votes. It is a shame that this is not the case on the Government Benches. Your Lordships’ House heard from the noble Lord, Lord Baker, about the importance of principle, whereby matters such as this should be subject to nothing other than a free vote. I certainly share that view. I know that noble Lords will exercise their vote this evening with the greatest of care.

[Earl Howe (Con)]

My Lords, I must tell my noble friend Lord Forsyth that I am not with him on this amendment and nor are the Government. That has nothing to do with the issue of assisted dying, about which we each have our own views, but is about the proper process for bringing forward legislation and the roles and responsibilities of government on the one hand and parliamentarians on the other.

Governments are elected. The electorate then expect the Government to bring forward their programme of legislation, which Parliament then decides on. If alongside that process there is an issue that the Government do not choose to legislate on, but which happens to be close to the heart of an individual parliamentarian, that parliamentarian has the privilege of being able to bring forward a Private Member’s Bill for Parliament to consider. In each of those two legislative processes the roles, rights, responsibilities and privileges of the Government and of individual parliamentarians are separate. It is no more appropriate for a Government to force an MP or Peer to bring forward a particular Private Member’s Bill than it is for an MP or a Peer to force a Government to bring forward a government Bill. That includes a draft Bill. As my noble and learned friend Lord Mackay of Clashfern observed in Committee, draft Bills are brought forward by Governments only when there is an intention to legislate.

The Government have no intention of legislating on assisted dying; it is not part of our programme, nor was it part of our election manifesto. Equally, it is no part of our agenda to prevent an MP or a Peer bringing forward a Private Member’s Bill on assisted dying. The noble Baroness, Lady Meacher, has done just that because it is something that she feels strongly about. It is for her to persuade Parliament and the Government that her Bill is a good thing.

That is the proper process, and surely that is how it has to be. If it ever became possible for an MP or Peer to use a government Bill as a vehicle for obliging the Government to publish a completely separate Bill, even one on a subject which was in tune with the Government’s thinking, the due process of legislating would thereby be subverted. I ask noble Lords opposite how they would react if under a Labour Administration, an MP or Peer proposed to use a health Bill as a vehicle to oblige the Government to publish draft legislation, the purpose of which was to place all NHS hospitals into private ownership—or one might find an MP trying to use a criminal justice Bill as a vehicle to oblige the Government to publish legislation to bring back capital punishment.

My noble friend might say, “Well, in that circumstance, it would be for Parliament to decide whether or not to accept such an amendment”—but that is not the point. The point is that if one House of Parliament were to approve such an amendment and the other House were to follow suit, Parliament would thereby usurp the role of the democratically elected Government. The noble Lord, Lord Howarth of Newport, and my noble friend Lord Cormack were 100% right: it is for the Government to say what their legislative programme should be, not Parliament.

As the late Lord Simon of Glaisdale might once have said, this amendment is constitutionally offensive and it should be rejected on those grounds.

Health and Care Bill

Baroness Merron Excerpts

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

What was amazing for this young boy called Paul is that the parents are now great supporters of that hospice. They are able to talk to other parents and say that mediation is the best way; please do not polarise when facing such deep problems.

[Baroness Merron (Lab)]

My Lords, this eminently sensible amendment sets out various considerations aimed at ensuring that there can be effective mediation when there is a dispute over children’s palliative care. There has been considerable discussion to bring this amendment to its current iteration and I pay tribute to the noble Baroness, Lady Finlay, for her efforts around this, having already secured a meaningful amendment to ensure that ICBs must commission the palliative care services they consider appropriate.

Your Lordships’ House is aware that this amendment and debate come out of the heartbreaking situation of Charlie Gard and multiple other cases like his. I therefore know that this issue has to be handled and considered incredibly delicately, taking into account the best interests of the patient receiving care above all others.

Balancing the views of clinicians and parents is intrinsically and incredibly difficult, and particularly challenging to codify in legislation. This amendment is a rational measure to move towards achieving a better balance and keeping matters out of the court, as the noble Baroness, Lady Finlay, referred to in her opening. We certainly support its intent and I therefore hope that the Minister’s response gives it due justice.

[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.

--- Later in debate ---

[Lord Touhig (Lab)]

My Lords, I welcome the Minister’s statement—it really is very welcome—and declare an interest as a vice-president of the National Autistic Society. I also thank the noble Baroness, Lady Hollins, for her dedication, commitment and sheer endurance in pressing this matter of ensuring that those who support people with learning disabilities and autism are well trained. Training is essential if we are to help young people in particular to experience the kind of life that all of us in this Chamber take for granted. With the right support, young people with learning disabilities and autism can enjoy that quality of life. I do not intend to detain the House, but I will just share with colleagues some of my experiences of young people who have succeeded because they have had the right support.

I met an 11 year-old boy with learning difficulties at a special school. He said, “You’ve heard I’ve got learning difficulties?” I said yes. “My brother has too,” he said. “He is five; he’s got autism. I’m helping my mother help him.” I said, “Oh, that’s good.” “I’m off to comprehensive school,” he said. I said, “That’s good. Are you looking forward to it?” “Yes,” he said, “and I’ve decided on my career.” I said, “What are you going to be?” “I’m going to be a High Court judge, and I can tell you now, if you come up before me, you’ll get a lenient sentence.” The point is that the school had really worked hard, but the head said to me, “He worked hard too at overcoming these problems.”

I met Max at a joint meeting of the All-Party Group on Autism and the All-Party Group on Apprenticeships chaired by the late Dame Cheryl Gillan, who pioneered the Autism Act. Max worked for a housing association. When I went there, I could see how hugely supported he was, as he had been as a youngster, in his job by his colleagues. At that time, he was an amateur actor and had appeared on “Victoria Derbyshire”. That was then—now he is an actor, a producer, a public speaker, an ambassador for the National Autistic Society and a recipient of the Princess Diana award, awarded to changemakers for their generation. He has had that success because he had the right support.

Finally, I mention Louise—I have not met her; I have just talked to her. Louise had some difficult times early in her life. “You don’t look autistic,” somebody once said to her. She said that she was often humiliated by her teachers and those in authority, and when she tried to work, she had meltdowns and could not cope. She got her first job in her mid-40s. She is now working for a charity supporting people with autism, and she said to me, “Now I’m given the space, and they let me lead and I can flourish. I’m helping other autistic people improve their lives.” With the right support, quality of life has been given to that woman, now in her 40s.

My point is simple: given the right support and encouragement, people with learning disabilities and autism can have the same quality of life as we all in this Chamber would expect for ourselves and our families. I welcome the Government’s decision to support this amendment. There is still much work to do, but it is going the right way. I thank the Government, and especially the noble Baroness, Lady Hollins, for pioneering the work that we are talking about this evening.

[Baroness Merron (Lab)]

My Lords, I congratulate the noble Baroness, Lady Hollins, on bringing forward such a wise and sensible amendment, which follows a series of failings in the healthcare system, failings which might have been prevented if health and social care staff had had the proper training to meet the particular needs of those with autism and learning disabilities.

I consider this amendment to be about fairness—those with autism and learning disabilities may be treated as anybody may expect to be treated. I thank the Minister for her very positive response, and her and her team for working so closely with the noble Baroness, Lady Hollins, and others to achieve the training of the relevant staff and to ensure a voice on integrated care boards. This is a fitting and lasting tribute to the memory of Oliver McGowan, and I am sure that it will always be regarded as such.

[Baroness Hollins (CB)]

My Lords, I am very grateful, and I know that Paula and Tom McGowan will also be very grateful—as will many people with learning disabilities and autistic people—to the Minister and to all those working behind the scenes for reaching this point and accepting my amendment, as well as for committing to include a learning disability and autism lead on integrated care boards.

I understand that some small changes may be proposed to ensure workability. I look forward to working with the Bill team and Department of Health and Social Care officials to ensure that these changes further strengthen the intention behind Amendment 176. I thank noble Lords for their support.

--- Later in debate ---

[Lord Lucas (Con)]

My Lords, I entirely support my noble friend Lord Moynihan when he asks for proper accountability. That is what drives the few examples of successful cross-departmental co-operation. One of the recent missed opportunities is Defra not picking up on aspects of the Glover report that deal with people getting out into the landscape. To make a difference to that, Defra has to care and it has to be brought to account, but there also has to be a good enough mechanism to ensure that if Defra does propose to do something, someone is going to fund it. That would certainly apply too to schools’ collaboration with local sports clubs. Parents up and down the land want that to happen. But how is that going to be afforded? How is that going to be made to happen? Who is holding the systems accountable? There has to be some system whereby accountability and interest flow through—as my noble friend said, ideally, to Parliament—to make that happen.

I have written to the Minister on perioperative care, which is another example. How does the NHS collaborate with all the other people who might provide the support required for effective perioperative care? They are not in the NHS; it does not work that way. You can have a system that just involves spending the money and ticking the box because that money has been spent; or you can have one with real accountability, in which people care whether you get the results and are measuring that, and who feed that through to someone with a central interest in things. So I am really going to listen to the Minister with great interest on this.

[Baroness Merron (Lab)]

My Lords, I want to thank the noble Lord, Lord Moynihan—along with the noble Baronesses, Lady Morris and Lady Grey-Thompson, and the noble Lord, Lord Addington—for bringing forward this important amendment. It does strike me as strange that the UK does not already have a national plan in place to promote sport, health and well-being. If we are to tackle the acute obesity crisis in this country, a joined-up, forward-looking strategy at a national level is necessary. From these Benches, we support this amendment wholeheartedly. It offers huge potential to tackle obesity, poor mental health and a sedentary lifestyle in a joined-up way that sees people as whole people with different pressures and needs, but with the intention of focusing on prevention. So, I hope the Minister will be able to respond positively tonight.

[Lord Kamall (Con)]

I begin by thanking the noble Lords who initiated this debate tonight and my noble friend Lord Moynihan, the noble Baronesses, Lady Grey-Thompson and Lady Morris of Yardley, and the noble Lord, Lord Addington, for meeting with me yesterday, and with the Bill team and representatives from the Department for Education and DDCMS. What was really interesting was the experience that all four brought. The noble Baroness, Lady Morris, talked about her experience in government and how it was sometimes difficult to get departments to talk to each other, even though they all seemed to agree. We had two former Olympians, who spoke about their experience of elite sport. But how does that translate into grass-roots sport? How do we make sure we get people active?

What was also really interesting was when we spoke about the 2012 Olympics. Yes, we had them and there was some legacy of redevelopment in east London, but they did not really lead to a legacy when it came to physical activity. How do we make sure we avoid the so-called Wimbledon effect? We all know that effect: around the time of Wimbledon, you cannot get a place on a tennis court, but a few months later it is simple to do so. How do we make sure this is long term?

If you are going to tackle obesity, yes, we can reformulate food and look at other issues such as taxes and negative externalities to discourage the intake of calories. However, you also have to burn off calories at the same time through activity. It does not have to be elite sport. We are not all going to be Olympians—like the two noble Lords here who were—but that should not stop you. All too often, what happens at school level is that if you do not get into a top team, you give up because you are considered not good enough. It does not matter how good you are; it is the activity that counts.

The Government’s recent response to the National Plan for Sport and Recreation Committee report addresses clearly, we believe, the recommendations made in this amendment. I hope that noble Lords will take some reassurance from what I am about to say and the fact that we take this seriously. The Government agree with the committee’s overarching recommendation on the need for an ambitious national plan for sport and physical activity. We are firmly committed to increasing sport participation and physical activity levels, and to ensuring that everyone has access to opportunities to get active. It should not just be about elite sport.

I can confirm that the Government will set out their forward-looking strategy for sport and physical activity later this year. It will look at tackling levels of inactivity as part of our plan for recovery from the pandemic. We hope that this strategy will provide a unified, cross-government approach to driving participation, integrating with Everybody Active, Every Day, the School Sport and Activity Action Plan, and Sport England’s new strategy Uniting the Movement. Of course, while setting out a cross-government strategy will be welcome, it is equally important to set out information on the implementation. I can confirm that the strategy will set out further detail on implementation, including how to harness such action across government and between departments.

The Government understand the concerns that noble Lords have raised and recognise that previous Governments of all parties have not always got it right. They tried—it was not for lack of trying—but it is about the implementation and strategies in this area. However, we believe that lessons have been learned and I hope that our approach will have the intended positive impact.

After the conversation yesterday with noble Lords, during the post-meeting debrief I spoke to the officials from other departments and asked, “How can we make sure that this is truly cross-government?” Let me assure noble Lords that other departments have also been looking at this issue. The Department for Levelling Up, Housing and Communities and the Department for Transport also have important roles in helping to create health-promoting and more active local environments. I reaffirm the Government’s commitment to working cohesively on such actions.

I also assure your Lordships that departments involved in the sport and physical activity strategy take their responsibility to co-ordinate extremely seriously. This is being led by DCMS while, more broadly, the Government understand the utmost importance of getting this right—and we must not lose that. That is why I am delighted by the leadership of the Prime Minister on the Health Promotion Taskforce, supported by the Cabinet Office. That will enable the Government to consider all options open to them. I will come to this in due course.

The Government recognise that it is important to provide updates to both Houses on the progress of the strategy and will publish arrangements for that reporting in the strategy. I also assure noble Lords that the Government invite and welcome the continued scrutiny of plans to address inactivity, to promote sport participation and to improve people’s health through physical activity. Undoubtedly, the relevant committees in the House of Lords and the House of Commons will have an interest in any future strategy and its progress. I am sure noble Lords will also want to continue to ask Questions of Ministers.

We recognise the deep experience of noble Lords in this area and I know that that interest extends to the other place. Only last night, my honourable friend Gillian Keegan, the Minister of State for Care and Mental Health, responded to an adjournment debate on physical activity and health. On that point, I reiterate and acknowledge the benefits and importance of promoting that. We know the gains made in activity levels in some key populations, including women and older adults, before the pandemic have now been reversed, and the Government share the concerns of noble Lords on this matter.

Health and Care Bill

Baroness Merron Excerpts

Consideration of Commons amendments
Tuesday 5th April 2022 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I plan to address matters in the group that have not been addressed by my noble friends. They are workforce planning, reconfiguration and organ tourism.

First, on Motion K, on organ tourism, I congratulate the noble Lord, Lord Hunt of Kings Heath, my noble friend Lady Northover and others on their success in convincing the Government that something must be done about this dreadful trade. I also thank the Minister for listening.

On Motions B and B1, we support the noble Baroness, Lady Cumberlege, and will be right behind her when she leads us into the electronic Content Lobby on her Motion B1. It was made clear during earlier stages of the Bill that Peers across the House believe proper planning for training and providing a safe health and care workforce is essential. We also hear that almost 90% of trust leaders do not think the NHS has robust plans in place to deal with the workforce shortage. We are asking a lot of the NHS and care workforce at the moment; they are badly understaffed but, at the same time, are being asked to reduce the backlog of treatments that built up during the pandemic, while Covid-19 is still rampant in the population and thousands of patients are still in hospital with that as the primary cause.

In these circumstances, we have a desperate need for a reliable system to plan for and provide the staff we need, but nobody has confidence in the current system—if you can call it that. However, it seems that the Treasury has stuck its oar in. I find that rather odd, since neither the Bill as drafted nor the various amendments of the noble Baroness, Lady Cumberlege, have mandated the Treasury to fund the numbers of workers at every level who may be identified as necessary to deliver the health and care we need.

I accept that, when the yawning gap becomes clear between the numbers we have and the numbers we need for safe care, there would indeed be pressure on the Treasury to provide the money. However, it has been pointed out many times—including this afternoon, by the noble Baroness, Lady Cumberlege—that the NHS spends £6.2 billion every year on expensive agency staff, whose roles could be provided much more cheaply, and with better continuity for patients, by permanent employed staff. Considerable savings could be made to offset this.

It is significant that the Government are resisting the noble Baroness’s amendment. They know very well that the reviews she recommends would shine a light on the fact that the NHS and care systems do not know what they have got or need, and are badly short-staffed. The Government would be pressured to do something about it.

Since the Ockenden report, something else which is rather crazy has emerged. The Government have agreed to comply with all Ockenden’s recommendations, including on planning for and providing adequate staff in obstetrics and gynaecology. Hopefully, all maternity units will be safer in future, but it would be ridiculous to have a maternity unit adequately staffed in the same hospital as a cancer or stroke unit that was not. In voting for the amendment from the noble Baroness, Lady Cumberlege, we will attempt to save the Government from making such a dreadful and unnecessary mistake. We will be voting for safe health and care services in the future, in the interests of patients and staff alike.

On Motions C and C1, we support the amendment in the name of the noble Baroness, Lady Thornton, which she will no doubt speak to in a moment. In voting for this amendment, we will again be attempting to save the Secretary of State for Health and Care from getting himself into an awful pickle. There may be far too much temptation for a Secretary of State to use the powers in the Bill as it stands to meddle in matters far better decided by the professionals and local authorities on the ground. A clear process, which is rooted in local accountability, already exists for reviewing proposals for NHS reconfiguration—there is no call for the Secretary of State to be further involved except now and then if an election is in the offing. The Government have emphasised accountability throughout this Bill, but that accountability must be at the right level. Many of the decisions that might be made under the power that we are attempting to curtail today should be accountable to local people through those operating the local integrated care systems. By interfering, the Secretary of State may well corrode the very accountability that the Government say they want. We will be voting with the noble Baroness, Lady Thornton.

[Baroness Merron (Lab)]

My Lords, I sense a deepening of support in your Lordships’ House for the issues contained within this group. I start by thanking the noble Baroness, Lady Cumberlege, for introducing Motion B1. I also put on record my thanks to the 100 organisations which have indicated their support and got involved to make this an even better Motion for us to consider.

Yesterday’s Health and Social Care Committee report said:

“Neither earlier diagnosis nor additional prompt cancer treatment will be possible without addressing gaps in the cancer workforce”


through a workforce plan. The lack of staff, both currently and projected, is not restricted to the cancer workforce but extends to the total staff shortage of some 110,000 across the NHS as well as 105,000 vacancies in social care, while some 27,000 NHS workers voluntarily left the health service in just three months last year, the highest number on record.

As we have heard, just last week your Lordships’ House debated the Ockenden review, which I believe has provided great focus on the issue of workforce planning. The review shockingly laid bare the reasons why hundreds of babies’ lives were avoidably cut short or damaged and mothers died; to their great credit, the Government have accepted every one of the recommendations. The clear finding here is that we must safely staff our maternity wards, yet midwives are leaving the NHS in greater numbers than it is possible to recruit them. If the Ockenden review does not illustrate why we need a workforce plan then I do not know what does.

It is worth reflecting on what Motion B1 is not about, in case that offers some late reassurance to the Minister. Despite needing all of these things, it does not commit the Government to hiring thousands more doctors and nurses, nor does it commit to new funding for the NHS. It does not even commit the Government to finally publishing the workforce strategy that the NHS is crying out for—even though the NHS has not had a comprehensive workforce strategy since the Government’s plan was published in 2003.

What Motion B1 talks about is an independent review of how many doctors, nurses and other staff are needed in health, social care and public health, both now and for the future, and that the report, which must be brought before Parliament, must be informed by integrated care boards, employers, trade unions and others—people with expertise and a great contribution to make. This is not just a question of recruitment, important though that is, but one of retention. There is absolutely no way out of planning and preparation; without them, it is just not possible to magic up the necessary staff. Motion B1 is about facing up to the scale of the workforce challenge so that we can see safe and efficient health and care. These Benches will certainly be supporting Motion B1 if the will of the House is tested.

I turn now to Motion C1 in the name of my noble friend Lady Thornton. The inclusion of a clause about changes to reconfiguration shows that not all of the Bill was what the NHS was asking for. The powers in this clause are unnecessary and introduce a very considerable new layer of bureaucracy. Just about every commentator and representative group has said that this approach of an interventionist Secretary of State is quite wrong. As many have pointed out, the power that any proposal can be taken over by the Secretary of State takes us down a road of politicisation and will deter some from even trying to pursue necessary but controversial changes. It matters not that we are told that this power will be used only sparingly; if it is there, that will influence behaviour.

Given where we are in the parliamentary process, outright rejection of this provision would, of course, be problematic. Our alternative in this Motion is to say that, if the power is only rarely to be used—in exceptional circumstances, when intervention is justified—then the way to deal with this is to make that case to Parliament, to put it up for proper scrutiny and to show the evidence. If we are potentially to deprive people of their right to be consulted, then at least let Parliament do a proper job of examining this.

I now turn very briefly to Motions D1 and K. I thank the noble Lord, Lord Blencathra, for presenting Motion D1 today. It seeks to ensure that health service procurement of all goods and services avoids modern slavery; in other words, it takes us further than Motion D. I thank the Minister for the move forward contained within that Motion; however, if the noble Lord, Lord Blencathra, wishes to test the will of the House, we on these Benches will certainly be in support.

I congratulate my noble friend Lord Hunt and other noble Lords for their persistence in ensuring that Motion K is before us today. Again, I thank the Minister for being so responsive on this point. I hope that, in the votes that follow, your Lordships’ House will swiftly take the opportunity to ask that we might further improve this Bill.

[Lord Kamall (Con)]

I thank all noble Lords for their contributions and their constructive debate and engagement, not only this evening but throughout the process of the Bill. I thank noble Lords also for their agreement to the measures we have drawn up on organ tourism. I thank the noble Lord, Lord Hunt, for the way he pushed the Government, making sure that we were able to find a constructive way of closing that gap.

Health and Care Bill

Baroness Merron Excerpts

Consideration of Commons amendments
Tuesday 26th April 2022 Lords Chamber

Moved by

[Baroness Merron]

At end insert “, and do propose Amendment 29D in lieu—

29D: Page 42, leave out lines 14 to 19 and insert—
“(1) The Secretary of State must, at least once in every three years, lay a report before Parliament describing the system in place for assessing and meeting the workforce needs of the health, social care and public health services in England.
(2) NHS England and Health Education England must assist in the preparation of a report under this section.
(3) The organisations listed in subsection (2) must consult health and care employers, providers, trade unions, Royal Colleges, universities and any other persons deemed necessary for the preparation of this report, taking full account of workforce intelligence, evidence of trends in healthcare and demand for it, and workforce plans provided by local organisations and partners.””

[Baroness Merron (Lab)]

My Lords, I beg to move Motion A1 as an amendment to Motion A to insert the words as printed on the Marshalled List. My noble friend Lady Wheeler will speak to Motions D and D1 and I will focus my remarks on the issue of the health and social care workforce. However, before I do, I welcome the compromises reached on the reconfiguration of local services and on NHS procurement while avoiding modern slavery. I believe the constructive discussions that we have had have truly improved this Bill and I am grateful to noble Lords across the House and to the Minister for his efforts and commitment.

The importance of the workforce has been debated extensively, both in the other place and in your Lordships’ House. Once again, I am arguing for the importance of implementing a proper forward-looking plan. That I am doing this even after yesterday’s proceedings in the other place conveys just how strongly we feel on this issue. Over 100 organisations of healthcare professionals, think tanks, practitioners and patients have supported our efforts. They continue to press us to make the point that, without mandated forecasts of staff numbers, meaningful workforce planning—something that every other efficient organisation undertakes—cannot take place. They continue to despair at the Government’s now repeated refusal to demonstrate proper commitment to safely staffing our hospitals and other healthcare settings.

We all know that there is desperate understaffing. The staff know it; they feel the pressure and they see the adverse outcomes. The patients know it, often falling into a cycle of long waits, in pain and discomfort, because of staff shortages. Resolving this is quite straightforward. We need a national staffing picture, otherwise how will we know whether we are training enough staff to meet the needs of the country? Yet the Government continue to refuse to commit to producing such an assessment. They say that the necessary work has already been done, or is going to be done, but we, and stakeholders, vehemently disagree, and it is hard to follow the Government’s logic.

If the Secretary of State will not show leadership then NHS England must step up and produce its own requirements and projections, or the Local Government Association could commission such work across the country by local authority. Some way, somehow, every integrated care system and local authority will have to quantify their future workforce requirements and projections and plan for how these will be met.

The Government’s current drafting leaves open some serious questions. We do not know whether the plan will cover health and social care workforces. What is the intended timeframe of the commissioned NHS England plan, and will it be recommissioned once this period expires? Can the Minister confirm that robust data on staff numbers in our healthcare workforces will be published and, if so, when? I would be grateful for any clarification that the Minister can provide.

I deeply regret that the Government have felt unable to meet with parliamentarians—the Opposition, other political parties or indeed any of our experienced Cross Bench Members—even to discuss this issue. This is an irregular and unwarranted response. I hold out hope that, even at this late stage, the Government may see good sense in planning for the workforce that we need, instead of leaving it to chance. I beg to move.

--- Later in debate ---

I also remind noble Lords that at the beginning of the consultation we had an open meeting with the Minister for Care, Gillian Keegan, to answer all questions, including on the cap and the metering. Please let us grasp this opportunity or we could be waiting for another proposal. This proposal could wait, gathering dust on shelves for many years to come, like previous proposals. Let us grasp the opportunity and have the courage to address social care. I ask that noble Lords support our amendments.

[Baroness Merron (Lab)]

My Lords, in opening this debate, the Minister said that Motion A by and large did the job that Motion A1 seeks to do. I beg to differ, and so do more than 100 key organisations that work day in, day out on health and social care. Unless we plan and prepare to have the right workforce in place, it will continue to be the case that we do not have the right workforce, so what is happening now will simply continue. We will not be sure of safe staffing levels, nor have the people in place to give the levels of service that mean patients do not have to continue to suffer long and painful waits.

I remain deeply disappointed that on workforce, a central pillar of how we run our health and social care services, the Government have refused to even discuss this matter. I ask the House to agree to Motion A1.