Health and Care Bill

Baroness Neuberger Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Baroness Neuberger (CB)]

My Lords, I declare my interests as in the register, specifically as chair of University College London Hospitals NHS Foundation Trust and of Whittington Health NHS Trust, and as vice-chair of the UCL provider alliance. I am grateful to the King’s Fund and others for their briefings, and declare a further interest as a former chief executive of the King’s Fund. I add my congratulations to the noble Lord, Lord Stevens of Birmingham, on his superb maiden speech and share his concern that there is not a greater focus on mental health in this Bill, and indeed on the determinants of health and public health in general.

We have so little time to speak that I will simply support what many noble Lords have already said in asking for further assurances around workforce planning and education and training, given that we have an absolutely exhausted workforce and we face tough recruitment issues. If it is bad in health, it is completely dire in social care. I also echo what other noble Lords said about the Secretary of State’s new powers and the effect on the poorest of the way the £86,000 social care cap is designed.

I will focus on three specific things. The first is capital spending limits for NHS foundation trusts, because the present drafting differs significantly from what was set out in the NHS’s 2019 legislative proposals. I hope we can go back to those proposals, which were a sensible compromise between system and organisation. That is particularly important for specialised commissioning, given that ICBs are set up largely to be accountable to their local populations. In north-central London, only a third of our provider income and asset base relates to north-central London residents, so safe- guards are essential to ensure that ICBs have a statutory responsibility to maintain and develop specialised service assets, as well as those serving their populations.

The Bill appears to say that NHS England can pass many of its commissioning activities but not its responsibilities to the integrated care boards. Delegating complex commissioning arrangements for those specialised services where there is no evidence base for joining up pathways of local care will lead simply to a fragmented approach. Providers such as my own, UCLH, Great Ormond Street and others providing regional or national specialist services face the prospect of agreeing contracts with 42 ICBs rather than a single commissioner, adding significant bureaucracy and transaction costs. I wonder whether that can be sensible.

I am absolutely delighted that the membership of the ICBs will include, among others, representatives from local authorities. The guidance from NHS England states that it is expected that the local authority representative

“will often be the chief executive”.

This wording implies some flexibility, but there is a very strong case to be made for the local authority representative being one of the local council leaders, who are, after all, the elected representatives responsible for running local services, including children’s and adult services—precisely those services where we need improved integration with health, as many noble Lords have said. I hope the Minister can give us an assurance that each ICB will have the freedom and flexibility to reach this decision locally.

Lastly, most of us will warmly welcome the Health Service Safety Investigations Body. The Bill makes provision for creating a safe space within investigations to enable clinicians and others to provide information without the fear that that will be disclosed or used for disciplinary purposes. That is understandable, but the clause as drafted seems to cut across the unique constitutional role of the Parliamentary and Health Service Ombudsman to investigate complaints about the NHS and other public services.

The Bill prohibits the national ombudsman from accessing information held in the HSSIB safe space without seeking permission from the High Court. Schedule 14 appears to strip the ombudsman of long-held constitutional powers by being excluded from the safe space while the same exclusion does not apply to coroners. This would be the first restriction on the ombudsman’s powers since it was established back in 1967. It contravenes international standards set out in the Council of Europe’s Venice principles and the United Nations resolution on the role of the ombudsman, which was co-sponsored by the UK Government, and it will undermine public confidence in the administrative justice system, with patients feeling that they have less access to justice and public accountability when failed by NHS services—because we do not always get it right, as the noble Baroness, Lady Cumberlege, has made abundantly clear. I welcome the broad thrust of the Bill, but there is still much to clarify and change.

Health and Care Bill

Baroness Neuberger Excerpts

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

[Lord Bethell (Con)]

My Lords, I came face to face with the nation’s health inequalities every morning in the departmental Covid response group, the COBRA meetings and the COBRA gold, when we went through the hospitalisation details and ICU data and heard stories from the front line of how people who had comorbidities particularly associated with obesity were filling up our hospitals as the virus spread through the country in wave after wave. That health inequality hit this country hard in very real terms. It cost a lot of lives, caused a lot of misery and cost our health system an enormous amount of money. It cost this country and its economy a huge amount of money and it is time that we came to terms with that challenge and solved the problem.

As a number of noble Lords have pointed out, the NHS must step up to its responsibilities in this area. There are complex reasons for these inequalities; some are environmental, some are behavioural and some are to do with access. But the NHS and whole healthcare system must realise that it needs to be involved in all aspects of those, and prioritise and be funded accordingly. The Bill already does an enormous amount to change the healthcare system’s priorities. Putting population at the heart of the ICSs is one really good example of that.

To anticipate some of his remarks, I know that the Minister will point to the Office for Health Improvement and Disparities. As the noble Lord pointed out, however, it has a tiny budget and cannot take responsibility for the nation’s health. Our councils are stony broke, as I found in my experience of dealing with them over the last two years. There is no one else to do this; this is not someone else’s problem. This is to do with the British healthcare system, and it needs to stand up to that responsibility. Zero progress has been made in the round over the last few years and we have gone backwards in the last two years in a big way. We need to make this a massive priority.

This is a fantastic Bill; I am really supportive of it. It came from the healthcare system originally. In this one area, however, there is a graphic lacuna that needs to be addressed. The noble Lord, Lord Kakkar, put it so well in his inimitable way. The prioritisation of inequality must be put in the Bill and it needs to be heard throughout the healthcare system that this is the new, central priority that needs to be added to everyone’s job description.

If, for some reason, we do not do that there will be huge consequences. The healthcare system is unsustainable in its current form. We cannot continue to have a large part of the population carrying grievous comorbidities or disease and afflictions which are undiagnosed or not properly mended turning up in our hospitals at a very late stage and costing a fortune to mend. These health inequalities, whether they relate to disease, injury or behavioural issues such as obesity, are costing us a fortune. Only by putting tackling inequality on the face of the Bill can we really give it the priority it deserves.

I also say to the Minister that there is a sense of political jeopardy about this as well. We went into the last election committed to levelling up on health. We have gone backwards in the last two years through no fault of the Government, but if the Government do not step up to their responsibilities in this area, and if the NHS and the healthcare system do not change their priorities, the voters will judge us extremely harshly. For that reason, I urge the Minister to listen to this debate and look very carefully at ways of amending the Bill.

[Baroness Neuberger (CB)]

My Lords, I want to pay tribute, as other noble Lords have, to the noble Baroness, Lady Thornton, for her very thoughtful introduction. It is remarkable and absolutely wonderful to see consensus breaking out across the Committee. I will speak specifically to Amendments 152, 156 and 157 in the name of the noble Lord, Lord Young of Cookham, whose words on the need to make this really serious by stating it on the face of the Bill I echo.

I am a former chief executive of the King’s Fund and am currently chair of University College London Hospitals and Whittington Health. These issues are very dear to my heart and the hearts of those institutions. I also want to say thank you to Crisis for its briefing and add to the words of the noble Lord, Lord Young of Cookham, in praise of Pathway, which has done the most extraordinary work in this area over very many years.

I want to talk particularly about the NHS-funded Find & Treat service, which was set up 13 years ago and is run by UCLH, which I chair. This service was set up in response to a TB outbreak in London and aimed to provide care for people experiencing homelessness and people facing other forms of social exclusion. The service did exactly what it says on the tin: it went out and found people—and still does—who were at risk of contracting TB, wherever they were sleeping, and offered them diagnosis and treatment. Back in 2011, a study concluded that this service had been not only effective in helping to treat people with TB who were experiencing homelessness but cost effective in doing so, both in terms of costs saved to the health service and improved quality and length of life for the people receiving care. Fast-forward a decade and the evolution of this service meant it could be similarly mobilised at the beginning of the Covid pandemic. It provided urgent and necessary care to people who continue to experience the poorest health outcomes.

The King’s Fund published a report in 2020 on delivering health and care for people sleeping rough. It supported the need for inclusion health services to be provided much more broadly than at present. Importantly, it also concluded that local leadership is absolutely vital in crafting that approach and said that local leaders should model effective partnership working across a range of different organisations.

Embedding inclusion health—I cannot say I really like the term, but everybody knows what it means—at the level of integrated care partnerships will help ensure that our healthcare system can no longer ignore, forget or overlook people who are all too often considered “hard to treat”, despite proven interventions showing the opposite. It will ensure that integrated care partnerships and systems take that vital first step towards closing the gap of the most significant health inequalities in our society by having to recognise and consider people facing extreme social exclusion and poor health outcomes in their local areas.

We all know that there will be considerable discussion during the course of this Bill on the need not to be overly prescriptive and burdensome to ICSs and ICPs by way of legal duties. But ICSs and ICPs know all too well the realities of failing to support people with complex and overlapping needs. I know that the chair of my own North Central London ICS, Mike Cooke, is sympathetic to the spirit of these amendments and believes it is important that extra steps are taken to meet the health needs of the most excluded, such as street homeless people. The chief executive of UCLH, David Probert, and the chief executive of Whittington Health, Siobhan Harrington, concur in thinking that if we extend the aspiration to reach out to excluded groups to something that all ICSs, ICPs and systems must focus on, it would be hugely beneficial for planning and joining up systems to avoid inappropriate or unnecessary admissions and poor care planning. Plenty of people want to do this within our health system.

I support Amendments 152, 156 and 157 and look forward to working with the Government and colleagues across the House and within the NHS to ensure their success in achieving a critical and long-needed systemic change to our health and care system. Addressing the needs of the most excluded has to be on the face of the Bill.

[Lord Crisp (CB)]

My Lords, I will make three very practical points about the impact of some of these amendments. First, on tobacco, we have heard from at least two noble Lords that half the difference in life expectancy between the rich and the poor in society is due to tobacco. It seems a no-brainer that work on this has to be continued. I also make the point that it took something like 50 years after the evidence was first available for the control of tobacco to be put into legislation, despite the efforts of the noble Lord, Lord Young of Cookham. It is not a quick win; we need to persevere, keep the pressure on and keep this very firmly in NHS plans at all levels.

Secondly, I want to pick up on the vital point that housing needs to be much more integrated with health and care. Let me take us back in history to 1919 and the first Ministry of Health, which had responsibilities covering health, housing and planning for many years, understanding the very important links there. Covid has shown that a house and home is an absolute foundation for health and well-being in all kinds of ways. I will not labour that point at this stage in proceedings, but will pick up another that has not come up, which is how important housing is to the provision of NHS services.

Seven years ago, the Royal College of Psychiatrists asked me to look at the reasons for the pressure on admissions to mental health acute wards. I did so; I think it expected me to say that those wards needed more beds, but I came out saying that we needed more housing. I found that something like one-third of the patients in mental health acute wards in adult hospitals either had been admitted because there was nowhere else for them to go or were staying there because there was nowhere for them to live to be discharged to. Housing was the biggest issue. Of the 25 NHS trusts around the country, only about three had specific, strong links with their local housing associations. There is a really big pressure for integration there.

Thirdly and finally, I come to Amendments 152 and 157 about the so-called inclusion health services. I agree with my noble friend on the nomenclature and that the naming is rather awkward, but these are extraordinary vital. We have heard examples of services that work; the issue here is how we can make sure that those services are spread and used elsewhere. I remind the House that, when we talk about inequalities, we all, including me, talk in fairly general terms. If you have a quantum of money and invest it in the health of the well-educated middle classes, you will get a small gain. If you invested that same quantum of money in the needs of this group, you would have a massive gain. That should inspire us to keep the pressure on the Government to make sure that we put tackling inequalities absolutely at the heart of the Bill.

Health and Care Bill

Baroness Neuberger Excerpts

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

[Baroness Whitaker (Lab)]

I add my support for Amendments 172 and 214, speaking as a vice-chair of the All-Party Parliamentary Group on Speech and Language Difficulties and a patron of the British Stammering Association. These amendments, which again have the support of the Royal College of Speech and Language Therapists, would do much to safeguard the position of that now rare commodity— speech and language therapists. As has been said by both noble Lords who tabled the amendment, they do not all work in the NHS.

The view of the Department of Health and Social Care is that speech and language therapists should be added to the shortage occupation list, because the profession is facing a range of pressures, including increasing demand in mental health in particular. The NHS long-term plan identified speech and language therapy as a profession in short supply. The need for those therapists must be taken account of in workforce planning.

Similarly, Amendment 214 provides an incentive to ensure that there are enough speech and language therapists to meet current and future demand, which is just not the case at present. I remind noble Lords that meeting communication needs, as well as ensuring the ability to swallow safely—both at risk from a wide range of conditions—are an essential component of well-being, and often safety itself. I hope that the Government will look favourably on these amendments.

[Baroness Neuberger (CB)]

My Lords, most of what needs to be said about this group of amendments, which I support, has been said, and said brilliantly well—it has been a wonderful debate. However, I would like to make one more key point. I chair University College London Hospitals Foundation NHS Trust and Whittington Health NHS Trust. In the last two years, during Covid, much of my time has been spent not in your Lordships’ House but walking around both of those institutions, saying thank you and listening to my exhausted staff.

One of the key reasons for putting the issue of reporting to Parliament on workforce planning into the Bill is that our staff—not just their organisations but the individuals themselves—want it to be there. They know what the issues are; they live with the shortages and they know that it has not been thought through. My noble friend Lord Stevens made that very clear: it has not been thought through. If they are not taking early retirement, as some are, they are living with the consequences. We could and should do so much better for them, and for the long term—and our staff know that. For their sake, if for no other, we must put this on the face of the Bill.

[Baroness Bennett of Manor Castle (GP)]

My Lords, this has been an extremely rich and vital debate on crucial amendments, albeit conducted in two parts. I will briefly offer the Green group’s support for all of these amendments. I aim not to repeat anything that has been said but to offer some uniquely Green perspectives on this set of amendments.

I will take them in two groups, starting with Amendments 170 and 173 in the names of the noble Baronesses, Lady Cumberlege and Lady Merron. These are particularly important because they very clearly and explicitly lay out the responsibility of the Secretary of State. When I tabled some amendments last week on the Secretary of State’s duty to provide, they met with something of a frosty reception in some quarters—but it is clear from all sides of your Lordships’ House that it has to be the responsibility of the Secretary of State to ensure that there is a plan for the workforce. I stress that that is coming from all sides of your Lordships’ House.

It is worth referring to the King’s Fund briefing, which I do not think anyone has mentioned yet. I will quote one sentence:

“The measures in the Bill to address chronic staff shortages remain weak.”


That is what a respected outside observer says. Your Lordships’ House is seeking to plug that gap. The noble Lord, Lord Lea, suggested that this was all terribly difficult, and that is undoubtedly true, but a lot of people have been thinking about this for a very long time. I was at a briefing for the Royal College of Physicians before the pandemic, in person, with no masks in sight. It was more than two years ago and they were talking about the need for workforce planning, saying, “We know how this should be”. Indeed, on the Royal College of Physicians’ website, more than four score organisations are listed as backing these amendments for workforce planning. So the support is very much there.

That focuses particularly on the medical side of things, but I will refer also to the Age UK briefing. We have had some very valuable contributions about care workers from the noble Baronesses, Lady Verma and Lady Hollins, but Age UK considers that we need to look at this much more broadly. It is calling for a robust accreditation scheme for care workers working in CQC-accredited facilities. We need a different system.

I think it was the noble Baroness, Lady Hollins, who talked about how this is a low-pay sector, but we also need to talk about this differently and recognise that it is also a high-skill sector. I think of some of the care workers whom I have met: care workers who cared for doubly incontinent, aggressive, advanced Alzheimer’s patients, and who had done so for decades. Anyone who claims that these are not people with amazing levels of skill really is denying an obvious fact. We need to acknowledge the skills of care workers and to make sure that they are appropriately remunerated.

I want to pick up another, perhaps specifically Green Party, point that no one else has picked up on. I noted that the chief executive of NHS England was recently forced into a new deal with private hospitals, which she said did not provide good value for money. The deal provides more care in private hospitals to help recovery from the Covid pandemic; it sees the Government going against NHS England and deliberately pushing up the role of the market in healthcare. For those who deny that this is happening, I am afraid this is very clear evidence of it.

I turn to a report of the Centre for Health and the Public Interest, which notes that the great majority of private hospitals rely entirely on NHS staff contributing outside their NHS hours on a self-employed basis. We are talking here about doctors and associated health professionals such as anaesthetists and other clinicians. The NHS paid for their training, pays for their pensions and covers their insurance, yet we talk about private hospitals “helping the NHS”. Listening to this debate, I think that perhaps as part of the amendments on Report, we need to think in the context of workforce planning about the financial contribution to be made by the private sector to the cost of training to adequately recompense the NHS for what the private sector gets out of it to make profits.

Health and Care Bill

Baroness Neuberger Excerpts

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

[Lord Stevens of Birmingham (CB)]

My Lords, I will be brief. In response to the noble Lord, Lord Lansley, in fairness, there is logic to the broad direction being set out by the Government here. As the financial health of foundation trusts improves, their ability to seek self-generated capital investment will, in all likelihood, be much higher, looking over the next four or five years, than it has been during the more constrained financial circumstances of prior years. So it is not unreasonable to have a set of measures in the Bill that would enable Ministers to ensure that the NHS sticks with the capital expenditure, voted for by Parliament, for the NHS in any given year; nor is it unreasonable on the part of the Government to seek to ensure that there is a mechanism by which that capital can be allocated fairly across the country according to need, rather than purely according to an individual institution’s ability to finance it.

All that being said, rather than this being a fundamental matter of principle in the way that our last two discussions have been, these amendments have a lot to commend them. They are entirely pragmatic and put the right safeguards around what should be only an emergency power. As the noble Lord, Lord Crisp, laid out, that was the basis on which a consensus was achieved back in 2019. It provides good incentives at trust level for sound financial management and, frankly, it provides a bit of a pressure release or a safety valve against an overly artificially constrained capital settlement in certain years or parts of the country.

I very much hope that, in the constructive spirit with which I think these amendments are being advanced, this is something that the Government might consider favourably.

[Baroness Neuberger (CB)]

My Lords, I declare an interest as chair of University College London foundation trust. I want to echo everything that has been said. I do not really understand why what was a carefully negotiated agreement seems to have been reneged on. I think it would be great to have some kind of explanation from the Minister as to why that should be the case.

I rather agree with the noble Lord, Lord Lansley, that some of those freedoms for foundation trusts are essential, and that fettering foundation trusts too much will not do much good. I really want to agree with everybody and not waste any more time, but please can we have an explanation?

[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.

Health and Care Bill

Baroness Neuberger Excerpts

Committee stage
Friday 4th February 2022 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, I was—it is fair to say—flattered when the noble Baroness, Lady Cumberlege, asked me to co-sign her amendment, because I have admired all the work she has done, and I think her report, First Do No Harm, has had influence way beyond the group of patients she was looking at. Indeed, I was vice-chair of a NICE review, and we referred to it in terms of helping to empower the voice of the patients we had in that review process, which was, first, very important and, secondly, particularly helpful because they were very clear in their thinking, and they worked extremely hard.

I am also grateful to the noble Baroness, Lady Brinton, for referring to the General Medical Council’s briefing, because the GMC agrees that a solution to this needs to be

“Accurate, up-to-date, accessible and presented in a way that is useful for patients, so that they can have confidence in it”.

It also said that it must be “Enforceable”, and the GMC also wants it to be “Multi-professional”. However, I agree that we have to start somewhere. Your Lordships may think that the advantage of a local register is that it is more accessible, but the disadvantage is that doctors move around in different jobs, particularly trainees—but even consultants’ time in one post is now relatively short; it used to be a lifetime appointment.

It is important that, as a doctor, I am prompted to be completely open so that there can be no subliminal influence on my decision-making. The most dangerous influences are the subliminal ones—not the ones where you are completely open about what is going on. There has been a great clamp-down over recent decades on the pharmaceutical industry because of sponsorship and so on, and that has decreased influences on prescribing. But when it comes to using other products in medicine, the same can apply. I think that a register would help the profession itself in making clinical decisions. I do not see this in any way as inhibiting research; on the contrary, it would display who is research active and who is achieving results through their research.

A register would support the development of innovative healthcare and support novel thinking because it would be declared and open. It would also support the move that people should always publish their results, whatever they are.

[Baroness Neuberger (CB)]

My Lords, I support Amendment 283 in the names of the noble Baroness, Lady Cumberlege, and my noble friend Lady Finlay. Like my noble friend Lady Finlay, I want to say how grateful I am and how touched I was that the noble Baroness, Lady Cumberlege, asked me to add my support to this amendment. I also need to beg your Lordships’ indulgence: if we do go beyond 7 pm, which I sincerely hope we will not, it is actually the beginning of the Jewish Sabbath. I should not be here now, and I certainly cannot be here after 7 pm. I will pretend that I am just slipping out briefly, but I am vanishing at 7 pm whatever happens. Your Lordships will be very glad to hear that I am not going to talk until then.

When the noble Baroness, Lady Cumberlege, asked me to support the amendment, I said that I would consult with the medical directors at the two NHS trusts that I chair, the University College London Hospitals Foundation Trust and Whittington Health NHS Trust. I did exactly that, and I have never had emails back so quickly from the medical directors—there are four of them between the two trusts. The amendment was welcomed unreservedly; they really want this to happen. The medical directors had no doubt that this was both an ethical requirement and indeed something to be encouraged in how doctors think about their own practice. That is the point that my noble friend Lady Finlay made. It is something about the subliminal; it makes you start thinking differently and your reactions become different.

One of the medical directors pointed me to Patrick Radden Keefe’s superb book about Purdue in the United States, Empire of Pain, and said that in a way that is exactly the issue here. Some of the people clearly knew that what they were doing was totally wrong, but some did not realise that what they were doing was wrong, because they had not got the subliminal way of judging, because this was accepted practice. That is the really strong argument for this: we need to be able to encourage people to think differently. There are lots of doctors who desperately want it, as the medical directors at my two hospitals have made entirely clear.

I pay huge tribute to the noble Baroness, Lady Cumberlege, for her report First Do No Harm—as well as for the many other things she has done, but in particular for that report. It has changed the way that quite a lot of people think; it is quite hard to achieve that with a report and it is a very remarkable thing to have done. This is a national and international issue. We are concerned here only with the national, but we could—and should—set an international example of good practice.

After the Paterson review and First Do No Harm, this is now urgent. The GMC is obviously the right body to hold such a register, and I say so as a former member of the GMC. I was rather sad to see its somewhat lukewarm reaction in its briefing and I think that it has got this wrong. They are the right people to hold the register and to make it available to patients. The public must be able to access it. The employers, individual doctors, the Medical Royal Colleges and others must all play their part and, of course, other health professions must follow suit.

Let us start here. This needs to happen, and it needs to happen fast.

[Baroness Thornton (Lab)]

My Lords, I can only add to the last remark of the noble Baroness that this does need to happen. I can see why the GMC is so unenthusiastic, as it was in its briefing note, because it looks like it is probably about 300,000 people and that is a big job. However, the question that I ask myself is, if a large pharma or large manufacturer of medical products is having a national campaign that involves hundreds of clinicians across the country, how will we know that is happening if all the registers are local? It seems to me that that is absolutely the point. It has to be a national register and the GMC probably has to be persuaded. If it is not the GMC, we would have to set up something different, and that would probably be a ridiculous thing to do. So the noble Baronesses, Lady Cumberlege and Lady Finlay, are quite right: we have to make progress on this.

Health and Care Bill

Baroness Neuberger Excerpts

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

[Baroness Cumberlege (Con)]

My Lords, I thank the noble Baronesses, Lady Brinton and Lady Finlay, for supporting Amendment 184ZA, which I have tabled. I think the noble Baroness, Lady Neuberger, is going to speak—yes, she is—and I look forward to that. I very much hope that other noble Lords will want to support this amendment, too. They would be in very good company with the royal colleges and the remarkable past editor of the British Medical Journal, Professor Fiona Godlee, who has done a lot on this subject. We have also had contact with a host of doctors and some very rewarding conversations with them. Many feel it would actually be to their benefit to make this all transparent and accessible to the public.

I pay tribute to Simon Whale and Professor Sir Cyril Chantler, who have done sterling work on this amendment. I know that Sir Cyril is known to many in this House because he has so many qualities: of leadership, clinical management and research, and in lots of other fields. This is my one opportunity to pay tribute to him through the Bill.

I also thank my noble friend the Minister and his officials. They have given their precious time, working very hard with me and my colleagues throughout the Bill’s passage. I mention particularly the government amendments concerning the declaration of industry payments to doctors and others that my noble friend introduced in Committee, and which I thoroughly welcomed.

Turning to the amendment before us, I am delighted to say that together we have fashioned a form of words which reaches, I hope, common ground. Together with my team, we have constantly amended many amendments in discussing with officials what they thought was particularly important and what we thought was important. I think we have reached a happy place. My noble friend the Minister and his officials deserve praise and thanks for their tireless efforts and, unreservedly, I give those to them now.

In Committee, we debated an amendment on establishing a register of doctors’ interests. My noble friend made the point that this information should be collected locally by those who employ doctors, rather than nationally by the GMC. I understand what the noble Baroness, Lady Finlay, said about it making sense to have the GMC involved, but in the end we agreed that this information should be collected locally. The problem is that these declarations are often out of date or incomplete, and in some cases the information is not collected at all, so it is very difficult for patients and the public to find out where that information is—and now they will have to go to the employer of the doctor. Sometimes it is hard for them even to find out if it exists, so I understand the logic that has just been proposed by the noble Baroness, Lady Finlay, that the GMC should be the body that collects this information. However, we have had very strong pushback on this. So, in the end, we have agreed with my noble friend that this information should be collected locally and made available to patients and the public.

Amendment 184ZBB simply puts into law what should be happening already. It would require any organisation that employs, contracts with or commissions a medical practitioner to provide medical services, or provides practice rights—we put that in because we wanted to cover the private sector as well—to obtain from that doctor a declaration of his or her financial and nonpecuniary interests. This, as I have said, can be done locally and it will be done through the annual appraisal that trusts have to carry out with employees. I think the missing piece in this puzzle is the doctors’ regulator. This amendment requires the GMC to take reasonable steps to assure itself that doctors are providing this information locally: that is very important. Following discussions with the Minister’s officials, the amendment now also requires the CQC to assure itself that employers are collecting the information and publishing it. We think this is sensible and I am pleased that we are all agreed.

I hope this puts all of us—my noble friend, the GMC and those of us who have tabled this amendment and support it—on the same page. However, I would be very concerned if none of this was laid down in legislation. These requirements and responsibilities are clearly spelled out in law at present, and we see from the research that this leads to very patchy compliance. This is not acceptable to any of us. So, finally, this amendment is simple and clear and is aligned with the position of the Government and the GMC. It requires employers and doctors merely to do what they should already be doing, but are not in all cases. It places a light but important duty on the GMC and the CQC to assure themselves that doctors and employers are indeed doing what they should. This is in the interests of doctors. Indeed, Professor Carl Heneghan, in oral evidence to our review First Do No Harm, stated:

“I think it’s important that if I’m treating you, you know who’s paying me.”


We owe it to patients and the wider public to improve transparency and to ensure that nothing undermines trust in our medical professionals. I hope my noble friend the Minister will agree that this amendment does achieve this in a way that he can support and that it fulfils all our aims.

[Baroness Neuberger (CB)]

My Lords, I support the noble Baroness, Lady Cumberlege, in what she has just said, as well as my noble friend Lady Finlay and the noble Baroness, Lady Brinton. I pay tribute to the noble Baroness, Lady Cumberlege, for the extraordinary work she did on First Do No Harm, which led—gradually—to this amendment. I too pay tribute to Cyril Chantler, who I first knew when serving on the General Medical Council with him. I declare an interest as chair of University College London Hospitals NHS Foundation Trust and of Whittington Health NHS Trust. I am, as I just said, a former member of the General Medical Council, and I am somewhat surprised, I must say, that it has said yet again, including this afternoon by email, that it does not really support this.