Health and Care Bill

Baroness Walmsley Excerpts

Lords Hansard - Part 1 & Committee stage
Tuesday 18th January 2022 Lords Chamber

[Lord Polak (Con)]

My Lords, I am pleased to speak immediately after the noble Lord, Lord Hunt. I am sure that he has, like me, a feeling of déjà vu. We were here not so long ago talking about the Domestic Abuse Bill, when I and many Members here today urged the Government to put children in the Bill. I am pleased that the Government listened, although it took some time and a lot of effort—that is why I am pleased to support the noble Baroness, Lady Meacher, on Amendment 20. It seems clear to me that children should be front and centre in this Bill, as we made them in the Domestic Abuse Bill.

We have worked closely with Barnardo’s, which has advised many of us, and I know that it raises three issues here: to protect the needs of young carers; to mandate that the child impact assessment is undertaken by the Government within two years of the Bill’s implementation to assess its impact on children; and to clarify and prioritise the better care fund so that it can be used to achieve service integration for children. I do not want to take time—I just think that my noble friend the Minister may want to look at Hansard and our debates on the Domestic Abuse Bill. I am sure that he will find a way to put children front and centre in this Bill.

[Baroness Walmsley (LD)]

My Lords, this morning the Committee has heard from the noble Baronesses who have spoken to amendments many good reasons why it would be helpful to the Government’s agenda to improve services for children, if children were referred to explicitly in several places in the Bill. I hope that the Minister will be able to consider this matter and see whether there is anything that he can do about it.

I have Amendment 142 in this group. New Section 14Z57 in Clause 20 is about performance assessment of the integrated care boards; it contains several important measures, but one is one missing. This amendment would mandate that, two years after the Bill is implemented, a child impact assessment should be undertaken by the ICS annually to assess its impact on children. This would provide the information to enable NHS England to do the assessment which Amendment 141 requires it to do. I very much support all the amendments, particularly those that would gather information, publish it and enable its sharing, because that will help. We know that early intervention works, but we do not know where to intervene unless we know what is going on, and that is why these things are very important.

There is no duty in England for government to assess and publish the effects of legislation on children—neither is there a duty in this Bill on the ICS. It was in about 2010, I recall, that the then Government committed to regularly assess the effect on children of relevant legislation, although it is not mandatory to do so and it is often not done, despite the fact that Nadhim Zahawi, now Education Secretary, when he was Children’s Minister in the Department for Education said:

“The use of children’s rights impact assessments is widely promoted across the Department and wider Government”.—[Official Report, Commons, 24/6/19; col. 447.]


Well, I hope so.

Scotland and Wales have taken a slightly different approach; they have systems to assess the effect of devolved legislation on children. I have to say, as a proud resident of Wales, that those two nations have always led the way in relation to children’s rights.

As others have said, this is a very adult-focused Bill, but there are more than 12.6 million children aged 18 and under living in England, compared to just under 10.5 million of 65 year-olds and over—people like me. As drafted, the Bill does not explicitly recognise the health and well-being needs of those children and young people, who, as we have heard, have very specific needs and no voice and are often more dependent than adults on integrated services. They could benefit from the Bill perhaps more than any other group.

We know that around half of mental health disorders start at the age of 14 to 16 and that, although research has shown that around 30% to 40% of the risk of anxiety and depression is genetic, 60% to 70% is environmental—and we can change the environment. I am grateful to Barnardo’s for these figures. In addition, this generation, from infants to older teenagers, will have had their physical health and mental well-being impacted by the pandemic, and in just over a decade, over half of this group will have left school and entered further and higher education or the workforce. Other amendments will allow the ICBs to gather information and share it. This amendment would allow them to publish an impact assessment, which would help NHS England to publish what it has to publish.

The Government cannot meaningfully address the challenge of improving overall population health without tackling child health inequalities. The success of the Bill should be measured by its practical and tangible impact in ensuring children and young people’s access to timely and appropriate health and care services, and ultimately in doing what the Government want to do: improving health outcomes for the whole population.

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[Baroness Barker (LD)]

My Lords, I declare an interest as the co-chair of the All-Party Parliamentary Group on Sexual and Reproductive Health. At Second Reading, I said that it was not at all clear exactly what contribution the Bill would make to the strategic aims that all parties have to turn the NHS into a body that is preventive, forward-looking health promotion service, which concentrated far less on the acute sector and looks at population health much more strategically while making greater use of technology and, in doing so, seeks to reduce health inequalities. On day 3 of the detailed examination of the Bill in Committee, I am still no clearer about that.

In every set of amendments that noble Lords have put forward, they have tried to ascertain from the Government exactly how the Bill will achieve that aim—and, as yet, the answer is unclear. But if the Bill is about anything, it is about enabling those within the NHS, as well as patients and interest groups that work with them, to take what we have as a National Health Service at the moment and introduce into it new and innovative ways of looking at conditions, to build different pathways and processes of treatment in order to bring about the much-improved health outcomes that we believe are possible from the NHS.

In this amendment, I am very much influenced by the 2009 report from the Royal College of Obstetricians and Gynaecologists, Better for Women, which did exactly that: it took a longitudinal life-course investigation of women’s health needs. The report decided that the way health services have traditionally been provided is lacking, because it is by and large built on some fairly old established ways of thinking from a provider’s perspective rather than from the perspective of women and their partners. In terms of reproductive health, the RCOG report showed, with a number of different stakeholders, the many different ways in which we could look at women’s health and achieve far better outcomes.

The RCOG report started by looking at the data on reproductive health. Bear in mind that reproductive health is unique. It is perhaps the one area of medicine in which the people engaging with health professionals are, for the most part, not ill. They are in need of medical intervention and occasionally surgical intervention, but by and large they are not ill. They are going through a process that is natural but needs the informed intervention of health professionals. It is very different from other areas of acute medicine.

We have a national health service and all the years of experience behind that, yet we currently have very poor outcomes for women. Almost half of British women experience very poor reproductive and sexual healthcare. It is estimated that about 45% of pregnancies in the UK are either unplanned or there is ambivalence, and that is after decades of different Governments making concerted efforts to deal with unwanted pregnancies. The abortion rate is probably the highest it has been since records began and, crucially, access to contraception, and to particular forms of contraception, including long-acting reversible contraception, is now in significant decline. Also crucially, cervical screening for eligible women is at 70%, significantly below the national target of 80%.

This is largely due to one simple fact: we have completely fractured service provision. We know that reproductive health services were traditionally part of primary care; indeed, access to information about reproductive health services was part of the education service. We know that an element of women’s reproductive health will always have to sit in the acute sector, yet in all these years we have failed to build a coherent system that works with the three different elements—primary care, acute care and the education system—and in which women can access what, by and large, they know they need.

For some sections of our community, the outcomes are even worse. We know that the figures are much worse for women from black and minority ethnic communities. Eight per cent of abortions occur in women who report as being black, but that is in 3% of the general population. We also know that black, Asian and minority ethnic women also have much worse outcomes in maternity services. Only of late has that begun to be looked at and systematically analysed by one or two very good, interested professionals in maternity units.

The amendment, which calls for a national director, was tabled to highlight the case for having somebody in the leadership of the NHS who can look at the whole question of information for women, access to services and the different outcome statistics for different methods of arranging reproductive health services. We have different arrangements in the four nations of the United Kingdom because this is a devolved matter, so we can have comparative statistics to see which approaches work better.

If we follow the lead set out in the RCOG report, we can have an inclusive approach to women in all their diversity, and inevitably we will look at systems that are beneficial to men. Clearly reproductive health has a particular impact on the lives of women, but men are included too.

It seems to me that, if this Bill and the flexibilities in it are a route to better outcomes, this is perhaps one way in which we could try to have innovation at the centre. It impacts in different ways throughout the system, which hopefully will be integrated between local government, primary care and tertiary care. It is in that spirit that I beg to move the amendment.

[Baroness Walmsley (LD)]

My Lords, I support my noble friend’s proposal for this simple reason: it would enable focus on the very particular needs of women’s reproductive health. As we heard earlier in our debate, children have specific needs. Well, so do women, particularly with reference to their reproductive cycle.

I am particularly keen on the element of prevention of ill health. Many services for women focus on it. Obviously, we all have cause to be grateful for the breast and cervical screening services that are available; I was professionally involved with them many years ago. It is also, however, cause for concern that the number of women taking advantage of those important preventive services has been falling. A national lead would have the expertise, responsibility and ability to focus on areas where women need to be encouraged to take advantage of the services that are available to them.

There must be concern about the quality of maternity and perinatal services, given some of the dreadful cases that we have heard about and the poor quality that has been rife in a few centres in the country in the past. I hope that things are being put in place to improve that, but there is an element of prevention here too. Good-quality maternity services prevent women and their babies having a bad experience at the beginning of their life together. It is so important for the ongoing mental and physical health of the child that women can bond with their children and babies can bond with their mothers. That bonding starts at the very beginning, but it is less likely to happen with poor-quality maternity services, which of course cost the health services and the country later on.

These services are vital for preventing further problems not just for the mother but for the children. It is the sort of thing that a highly qualified and knowledgeable national lead can focus and advise on in trying to ensure that access to good-quality services is available to all communities in the country. My noble friend Lady Barker highlighted the difficulties that some communities face in getting those good services. I hope that the Minister will consider this amendment in a positive light.

[Baroness Thornton (Lab)]

My Lords, first, I thank the noble Baroness, Lady Barker, for introducing this amendment. Yet again, it is an indication that if this Bill actually presents the opportunities that the Government tell us it does, they need to accept something that recognises the opportunities that are being suggested to them across a whole range of issues, including children, about whom we have just had a very good debate.

The amendment would require NHS England to appoint a national clinical director for women’s reproductive health to provide the kind of clinical leadership that the noble Baroness, Lady Walmsley, talked about and to support this important area of women’s reproductive healthcare. In recent years, the Government have issued policy papers about women and health, so I would have thought that this particular proposal would chime with that.

We know that almost half of British women will experience poor sexual and reproductive care. It is clear that we can take the opportunity to improve this situation, particularly on the postcode lottery that some women face. I can certainly see, as the two noble Baronesses have said, that a single clinical director for the whole of the UK would give the area energy and focus, particularly for the 50% of women who have not had a good experience. We agree with the Faculty of Sexual and Reproductive Healthcare, which supports this amendment. I am glad of the opportunity to speak on this important issue, and I hope that the Minister may have some good news for us.

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Moved by

[Baroness Walmsley]

22: Clause 14, page 9, line 10, at end insert “within a period of three months following the publication of the list of initial areas.”
Member’s explanatory statement
This amendment sets a determinate period for the clinical commissioning group or groups to propose the constitution of the first integrated care board.

[Baroness Walmsley (LD)]

My Lords, I will also speak to Amendments 24 and 53 in my name. Amendments 22 and 24 are probing amendments about the time it should take to set up a new ICS constitution and who should do it if the local CCGs fail to do so. I also support Amendment 23 on the importance of consultation, which is in the name of the noble Baroness, Lady Thornton.

I welcome the short delay to implementation that the Government have announced. However, as the Minister probably knows, I am still dubious about whether the Bill is being brought forward at the right time. The NHS is currently in crisis, the staff are exhausted, many are absent through Covid illness or the need to isolate, and the Army and volunteers are being brought in to help. There is evidence that some of the shadow or non-statutory ICSs are not quite as ready as some noble Lords have suggested. Last year, nearly half of them did not publish board papers as they are supposed to do. This is a strong indication that they have not been holding routine public board meetings or joint committee meetings. They may say that they are not obliged to do so until the Bill is implemented, but NHS England said in a paper in 2019 that ICS partnership boards and joint committees, despite not then being statutory bodies,

“should be required to … Make decisions in public meetings … Minute and make public its discussions and decisions”

and publish board papers in advance of meetings. This followed the Commons Health and Social Care Select Committee recommending that

“we expect ICSs to meet the highest standards of openness and transparency in the conduct of their affairs by holding meetings in public and publishing board papers and minutes.”

It seems that this has not been happening.

At Second Reading, we heard the noble Lords, Lord Stevens of Birmingham and Lord Adebowale, as well as the Minister, assuring us that the NHS is ready for these changes, has been preparing for them for some time and, indeed, has been behaving as far as possible as if these statutory powers and duties to collaborate were already in place as shadow authorities. The passing of legislation, we heard, was just a small barrier to getting on with things. We are being asked to rubber-stamp the way they have done it, despite the amendments that many noble Lords have laid to ensure that people with the right skills and experience to achieve the ICSs’ mandatory objectives are appointed to the boards. I think that the noble Lord, Lord Hunt of Kings Heath, will have more to say about that.

What we do not want is a postcode lottery where some areas, which are already well on the way to getting their ICS running smoothly, are getting on with it, while other areas—perhaps those that have been particularly badly stretched during the pandemic and had their attention elsewhere—find themselves with gaping holes in their commissioning for an unacceptable period or even with the wrong people on the board.

That is why I have suggested in Amendment 22 that the relevant CCGs must set up the constitution of their ICS within three months of the passage of the Bill, which would give them time to appoint additional people to the board if your Lordships’ arguments persuade them, and the Government, that they need additional skill sets. In Amendment 24, NHS England can do it within the same period if the CCGs do not. The Bill says “within a reasonable time” but, if what I am being told about all the detailed preparation is correct, three months is a perfectly reasonable time.

Amendment 53, my other amendment in this group, refers to new Section 3A in Clause 16:

“Power of integrated care boards to commission certain health services.”


It changes the word “may” in subsection (1), which is about securing improvement, to the word “must”. It is a simple amendment, but it is fundamental to legislation that seeks to improve the way in which health and care services are provided through integration and collaboration. New Section 3A requires the ICB to commission services to improve its population’s physical and mental health and the prevention, diagnosis and treatment of their physical and mental ill health.

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[Baroness Thornton (Lab)]

Before the noble Baroness, Lady Walmsley, decides what she wishes to do with this amendment, I say to the Minister that this is very important; I cannot stress this enough. The noble Lord, Lord Lansley, and I are in agreement again about this. At the next stage of the Bill, the Government could find themselves in very serious trouble indeed if we do not resolve it between now and then.

[Baroness Walmsley (LD)]

My Lords, I appear to have opened a can of worms. I very much welcome the Minister’s commitment to go back to his boss and talk about some of the serious issues raised by noble Lords.

My purpose in introducing Amendments 22 and 24 was simply to ensure that once the Bill has passed through all its stages in Parliament and an implementation date has been reasonably proposed, from that point onwards there is reasonable coherence across the country so that there are no gaps in the proper commissioning of services and everybody gets on with it in a reasonably timely way.

However, noble Lords will remember that both at Second Reading and when I introduced this group of amendments I expressed my view that it is too soon, for a number of reasons—first of all, the state of the NHS. Also, as has been pointed out by me and other noble Lords, the Bill has not gone through Parliament yet. Last week noble Lords proposed a number of amendments about who should be on the ICB and what skill sets, knowledge and experience should be represented on it. It has become quite clear that, should this House decide to press those amendments, the shadow boards may have to look again at who they have appointed, because Parliament will have said that perhaps they need to appoint some more appropriate people to carry out the objectives that the Government have rightly laid down for them. It became clear to me that the three months I had suggested might not be quite enough, because of the consultation. It would not be the first time that noble Lords had laid amendments that were to some extent faulty but had stimulated an important discussion among other noble Lords.

I very much appreciate the Minister’s commitment to going back. I hope that, when he has those conversations, he remembers that noble Lords in this House are very supportive of the objectives of allowing local authorities to play their appropriate part in the establishment and running of these new boards, and allowing health and care people to work collaboratively in the interests of patients.

I want to say a brief word about Amendment 53. The Minister gave me several reassurances about where, in other parts of the Bill, there really is a duty to improve. I am afraid that he succeeded only in convincing me that changing “may” to “must” in the place I suggested in the Bill is totally consistent with what he says exists in other places, so I may come back to that at later stages.

Noble Lords will have their say about who should be on these ICBs. Things may have to change and appropriate time may need to be allowed for the now-appointed chairs of all the ICBs to make some corrective measures regarding who they have on their boards. I will leave all those thoughts with the Minister. For the moment, I would like to withdraw my amendment.

Amendment 22 withdrawn.

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[Baroness Thornton (Lab)]

My Lords, I rise only to say that I agree with my noble friend Lord Hunt. I will speak very briefly to Amendment 24 in the name of my noble friend Lady Merron, which would ensure the involvement of the integrated care board and the integrated care partnership in the appointment of the ICB chief executive. That seems to me to be sensible.

[Baroness Walmsley (LD)]

My Lords, I support that. I am glad that the noble Baroness, Lady Thornton, introduced Amendment 34. According to the Bill as it stands, the chief executive of the ICB could be appointed only by the chair—of course with the approval of NHS England. Like many of your Lordships, I have been on a board, including being the chair of a board, and as such, I always thought it good practice to appoint my chief executive with the help and approval of my board members. As an ordinary member of a board, I cannot imagine how I would have managed the relationship with a chief executive officer who had been appointed over my head only by the chair without any consultation with me or other members. If we want to encourage collaboration, that is not the way to do it at board level.

It is inconceivable that the mechanism would work in practice in such a situation. Indeed, it is vital that all the senior people who steer the ICS, the members of the ICB, and indeed the chair and members of the ICP, must have confidence in the chief executive; the word “confidence” was so appropriately used by the noble Lord, Lord Hunt of Kings Heath. How could that be if they had no involvement whatever in the appointment? It is a simple matter of good practice and I shall be very interested to hear what the Minister can possibly find to say against it.

[Baroness Chisholm of Owlpen (Con)]

My Lords, I know we have 10 minutes to go, but perhaps it makes sense to stop now in case noble Lords want to interject during the Minister’s speech.