Health and Care Bill

Baroness Walmsley Excerpts

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

[Lord Storey (LD)]

My Lords, I shall speak briefly on Amendments 224 and 261 and share my views on fluoridisation. I agree with the noble Lord, Lord Reay, that it is a pity we did not have a proper full debate on this matter.

There is a real problem among young children, particularly those in deprived communities, who have increasing levels of bad teeth—dental decay. You would think that as a result of that situation we would be trying to do something more practical about it, yet we see dental inspections in schools decreasing. When I was first a head teacher, the dental services would come in twice a year to inspect children’s teeth and would give a little note to the parents so they could go to their dentist. The second problem we face is that, as we heard from the noble Lord, Lord Hunt, you cannot find an NHS dentist, particularly in a deprived area, for love nor money. That is a problem for families that cannot afford to use a private dentist, even if one was available.

When I was leader of the council in Liverpool, all political parties together—I have to tell my colleagues—decided against fluoridation, so we took the view that perhaps there was a different way of doing it. We were setting up the network of children’s centres in the early 2000s. We therefore made dental health in the nought to five age group one of the highest priorities in the city council’s strategic plan. We also issued additional guidance to our primary schools, asking them to make encouraging better dental health a higher priority. As a result, 10 years later in 2013, the British Dental Association’s 10-yearly survey showed that a reduction of 28% in caries had been achieved in Liverpool’s schools. The targeted approach achieved an outcome double that identified in the York review as the average caries reduction from fluoridation. We will also have helped many children to develop lifelong good personal dental hygiene habits, which is a crucial part of the strategy.

Whether we have fluoridation or not, we need to be absolutely sure that the journey we are going on is correct. In the meantime, we should look at other ways. We should also look at what our colleagues in Scotland have been doing with their Childsmile project, which has been shown to be safer, less wasteful and more effective, and better value for money. I hope that at some stage we will revisit this issue and have a much longer and more considered debate.

[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.

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On the issue of face coverings in schools, the agency decided that it was going to happen without any consultation whatever with the Department for Education or local government and education premises. That is because it is not independent. It cannot make independent decisions; it was responding with a knee-jerk reaction based on what Ministers thought was correct. That is why it is important that the amendment in the name of the noble Baroness, Lady Merron, would put this body on an independent footing. So I support Amendment 281, as well as the well-thought-out and central Amendment 285 in the name of the noble Lord, Lord Warner, to meet the absolute crux of what this whole Bill is about.

[Baroness Walmsley (LD)]

My Lords, I too support the noble Lord, Lord Warner. I well remember reading the report of the House of Lords Select Committee on the sustainability of our health and care services in 2017 and being rather jealous that I had not been on the committee, because it struck me as a very interesting one and it produced a very thoughtful and hard-hitting report. The office for health and care sustainability was probably the most crucial of its recommendations. Indeed, I think it would help the Government in making their decisions, because the body itself would not make the decisions but be independent, report directly to Parliament—which I thought was crucial—and look forward as far as it needed to look in a rolling programme of forecasting, assisting Ministers to make the right decisions.

Given the ageing population, resulting from improved healthcare, it had become very clear that funding was not keeping up, and indeed might never keep up unless things were done differently. That is why the committee chaired by the noble Lord, Lord Patel, also recommended the sort of integration that is at the heart of this Bill. It also reported on the lack of alignment between the funding of health and social care, which has resulted in the current gap in pay, particularly in the care sector, and the consequent staff shortage.

This was an excellent recommendation and, unlike other recommendations in the report, it has not been taken up—yet. The key thing about the body is that it would be authoritative, independent and unable itself to meddle in delivery. I would have thought that any Government would welcome the existence of such a body to do a lot of the work to establish what needs to be done and when. Unlike politicians of any political colour, it would be trusted by the public and would be staffed by experts able to gather and analyse the data. All Governments have their own focus—all Secretaries of State for Health have their own focus—and their own political priorities, which often depend on whatever the latest scandal has been, resulting in pressure from the public. Public health is too important for this, so I therefore support this amendment.

[Baroness Thornton (Lab)]

My Lords, we have had an important debate here, and I thank the noble Lord, Lord Warner, both for bringing these amendments before the House and for explaining their background and the important role of the Select Committee. We have debated it several times in your Lordships’ House and everybody in the House, apart from the Government Front Bench, it seems, thinks it is a brilliant report that should be acted on. This seems to be an opportunity for the Government to take on board some of its major recommendations, and this is one of them. We would support that, and we hope that the Minister might have some good news for us on that.

I also wish to speak briefly to the amendment in the name of my noble friend Lady Merron. The argument has already been made by other noble Lords—I am having a slight sense of déjà vu because I am sure I made a speech along the same lines in 2011—about the importance of Public Health England having a statutory basis to its work to give it transparency and accountability. The last two years must show us that that is the right thing to do. That is why I agree with my noble friend’s amendment to put the new UK Health Security Agency on to a statutory footing. As far as I can tell, in the past 20-odd years since I came to your Lordships’ House, every time that various Governments have mucked about with public health, they have got it wrong. Let us use this opportunity to get it right.

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[Lord Vaizey of Didcot (Con)]

My Lords, I support the amendment of my noble friend Lord Moylan, which I was very proud to sign. I echo what the noble Lord, Lord Aberdare, said about knowing people who have died of this terrible disease. By coincidence, having signed the amendment, I had lunch with a friend whose brother suffers from pancreatic cancer. Luckily, however, he had it diagnosed extremely early because he had a blood test that identified the biomarkers that told him that he could have pancreatic cancer. He is now being treated and has a good chance of survival. Then, by coincidence, I visited my GP to have a blood test to test for prostate cancer. Luckily for me, the results were good.

I have a mild obsession about why we are not better in this country at implementing diagnostic procedures. When I went to see my GP to talk about prostate cancer, I asked her what kind of tests were available to me, as an NHS patient, for pancreatic or other types of cancer. As a layman reading the newspapers, almost every day there is news emerging of new blood tests that could identify cancer early. It is one of my trite dinner-party lines—I hesitate to say this, because there are so many experts in the Chamber this evening—that, in effect, one can almost argue that one has cured cancer if one is able to diagnose it early enough. That is why I welcome this emphasis on looking at outcomes rather than process in how we treat cancer. I hope that over time, it will shift the emphasis away from the treatment of cancer to how soon we can diagnose it.

I therefore support the amendment and ask the Minister a simple question: when will the test for pancreatic cancer be potentially universally available to NHS patients? I found it odd, talking to my friend over lunch, that his advice to me was to get myself on a trial as soon as possible to see whether I could get a test to get a diagnosis. It seems to me that we are lagging behind in the opportunity to diagnose cancer as early as possible and treat it as effectively as possible which, of course, will enable us to save a great deal of money.

[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.

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[Baroness Finlay of Llandaff (CB)]

My Lords, this group of amendments is concerned with rehabilitation services. Very briefly, because the hour is very late, I will set out why it matters so much.

People in hospital, as the Minister said previously, lose muscle mass at an alarming rate when they are confined to bed. They risk thrombosis, lose their ability to balance, their confidence and their social contacts, and can become lonelier, isolated from friends and family, and depressed as they see themselves able to do less and less. They then become terrified of going home and often feel quite dumped when they get home because there is a sudden cliff edge from being supported in an environment to feeling like there is no one there. That same cliff edge also happens for patients when they leave intensive care units and go from the very intensive care down to a general ward—so we have huge steps in our system at the moment.

Assessment in hospital, as has often happened, does not often make any sense, because people know their own home. So assessing whether someone can make a cup of tea in a hospital kitchen may bear no relationship at all to their own kettle, their own kitchen, the floor, where they keep things, and so on. They need to be in their own home to be assessed. In their own home, there are often trip hazards, if they are not detected, and if people are not supported to navigate around their own home and furniture, they will have a fall and end up back in hospital very quickly. They need seven-day support at home, because they need to have people whom they can contact.

The problem is that, at the moment, recovery and maintenance of personal independence, although central to the Government’s long-term ambition for social care services, just do not seem to be integrated. In the document, People at the Heart of Care, there is a reference on 68 occasions to the importance of the role of adult care services in maintaining independence for people at home in the community, but there is no mention of local authority rehabilitation services at all.

Rehabilitation services in the community are not subject to regular monitoring and inspection. There are no consequences for poor or absent provision beyond individual complaints, which is why this amendment proposes that they should be brought into the purview of the Care Quality Commission. In the other place, the Minister Edward Argar stated his belief that services were already covered by the existing legislation. But that is not the everyday experience in operation. For example, if we look at vision rehabilitation services, in an audit undertaken by the RNIB, half of the lead counsellors for rehabilitation had no idea that vision rehabilitation was in their remit.

I shall move on rapidly to Amendment 241, because these amendments are all linked. I should have said at the outset that these have been proposed and supported also by the Chartered Society of Physiotherapy, of which I am president. In this amendment, in large part, professions involved in local authority rehabilitation are regulated bodies with recognition in health, such as OTs, physios and speech and language therapists. But there are other people in local authorities involved in providing rehabilitation who are currently completely unregulated and unregistered, so the Rehabilitation Workers Professional Network is currently seeking registration with the Professional Standards Authority in order to take this group of staff on to a list of statutorily regulated social care staff.

Amendment 306, also in this group, would bring local authority reablement and rehabilitation activities, defined by care and support statutory guidance as tertiary prevention, into regulation and enable the Secretary of State to require information on how the service is operated. Anecdotally, there is wide, unwarranted variation in both the quality and breadth of service offered across England. There is no centralised reporting of performance. Bringing these services explicitly into regulation would enable NICE to develop guidelines and quality statements that could be used to inform the quality of provision of services, which, as I have already said, could then be properly inspected. We might then get nearer to having a level playing field.

I also have my name to the amendment of the noble Baroness, Lady Greengross, which is about hospital accommodation, and I will speak to it briefly. At the moment, we have a severe shortage of beds. We know that patients come out of ICU to general wards, and there are patients who cannot then be discharged to home. Often, they are in that twilight where they are really not well enough to go home. They need more rehabilitation, they need more support, but the hospital is deeming them fit to discharge because of the incoming pressure on their beds.

If we had some more step-down beds, we could provide care in much more imaginative ways, such as happens in some parts of Europe, where, for example, family members are expected to come in and help with some of the basic care—feeding, personal hygiene and so on—of their own relative, as they all get used to rehabilitating together, so that that person can go home with that family member understanding how to care for them and what to do, and therefore being able to support them better in the community and pick up early warning signs.

We need to learn from the military rehabilitation units and the new NHS national rehabilitation centre that is being built near Loughborough, because there is evidence that if you can move people through the system more appropriately and get them back home, they recover better and quicker and do not risk that deterioration I referred to at the beginning. A community rehabilitation plan would improve co-ordination, integration of rehabilitation units and community rehabilitation. I beg to move.

[Baroness Walmsley (LD)]

My Lords, numerous reports from Select Committees of your Lordships’ House have recommended that the NHS and care system do things differently in order to use resources efficiently while providing better care and independence for patients. It is well known that most of us cost the NHS more as we get older, particularly if we have multiple morbidities. This is why the Government launched the Ageing Society Grand Challenge—to achieve five additional years of healthy life by 2035. So your Lordships’ Science and Technology Committee looked into this and published a report on 15 January last year. Sadly, we had to conclude that the Government are not on track to achieve this.

Health and Care Bill

Baroness Walmsley Excerpts

Lords Hansard - Part 1 & Committee stage
Monday 31st January 2022 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, a very compelling and, indeed, conclusive case has been made by the noble Lord, Lord Blencathra, and other speakers in favour of this amendment, and I hope the Government will accept it. I particularly commend the suggestion made by the noble Lord, Lord Rooker, that the answer is there for us in science. I have only one question, because I have no intention of repeating all the excellent comments that have been made. This morning, I went into the Bishops’ Bar and picked up a box of lateral flow tests. On the box was written, “Made in China”. Can the Minister explain what efforts have been made to ensure that noble Lords, in their attempt to protect others and themselves, are not unwittingly supporting forced labour and slavery?

[Baroness Redfern (Con)]

My Lords, I rise briefly to support this amendment, and I apologise for not attending Second Reading.

This amendment requires the Government to perform a risk assessment on whether there is a “serious risk of genocide” in a region from which it is sourcing—not to make a genocide determination. It is the UK’s obligation under international law, as a signatory to the genocide convention, to perform such a risk assessment. We have heard many harrowing stories, which we find so difficult even to believe. Uighur identity is being erased: future generations are lost through forced birth-prevention measures, and millions have been detained, tortured and violated in concentration camps.

The incorporation of this amendment would send a clear signal to both the Chinese authorities and the international community that the UK is committed to ridding its supply chains of forced labour, fulfilling its obligations under international law and protecting Uighur people from genocide. The amendment is an opportunity to offer the Uighur community accountability for genocide and crimes against humanity, and I support it.

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[Baroness Bennett of Manor Castle (GP)]

My Lords, after this rich and informative debate, I will briefly make two points and offer the Green group’s support for all these amendments.

I share the shock expressed by the noble Baroness, Lady Tyler, and others that we are in a situation where in the House of Lords we are trying to put the situation back to what it was before because the Bill is making it so much worse.

I particularly want to address Amendment 269 about young carers. I should perhaps declare that I have never been carer—I have not been in that situation. But I want to share a little bit of what I learned from Sophie Dishman, who I met in 2015, when she was a student at the University of Sunderland. She told me that she became a carer at about the age of 12, but that it was only when she was 18 that she realised that she was a carer—a point that many others have addressed. As well as continuing to care, she created a campaign at the University of Sunderland to inform others about the situation and perhaps help others identify themselves as a carer. She produced a very clever, witty, attractive tote bag, with the line, “Being a carer at uni can be a lot to carry around”, a check list of all the things that you might have to do being both a student and a carer, and a useful leaflet, designed for staff in particular, showing signs that a carer might need help.

I want to make the point, which I do not think anyone else has made, that young carers are by nature people who have developed an enormous amount of capability, knowledge and skills. They are amazing individuals. It is not only the right thing to do but in society’s interest to make sure they are able, as the noble Lord, Lord Howarth, said earlier, to flourish and develop those capabilities. It is in our interest to do that.

I want to point to an article that has been out for only a couple of weeks, in volume 27, issue 1 of Child & Family Social Work. The headline is

“It’s making his bad days into my bad days”,

and the article is about young carers in the Covid emergency. This is where we are now. It is about just how much more difficult the withdrawal of services has made it for carers, particularly young carers. We have a huge, as yet uncertain, but certainly large, burden from long Covid, and many people will be taking on huge caring responsibilities because of it.

[Baroness Walmsley (LD)]

My Lords, if the noble Baroness, Lady Pitkeathley, is the general, we are all her foot soldiers. There have been some excellent speeches. In particular, the noble Baroness outlined for us what are, I hope, the unintended consequences of what the Government are doing in their proposals about discharge to assess. It does not seem right that it is up to this House to put back the rights and abilities of carers to do their caring without too much impact on themselves. I hope the Minister heard what the noble Baroness, Lady Pitkeathley, and others, such as the noble Lord, Lord Warner, said about that. We heard from the noble Baroness, Lady Hollins, how much worse the situation has been for so many carers—in particular those who care for people with learning disabilities or mental health problems—during the pandemic, when, unfortunately, it was necessary to withdraw certain services that they normally rely upon. I hope that, when we have heard the Minister’s response, we can come back to Clause 80 on Report if we are not satisfied with the Government’s response, because the situation is not good, even now.

I am grateful to Carers UK and Barnardo’s, which have given us some dreadful horror stories about the situation of carers when the person they care for is being discharged from hospital. One of the worst that I read about was when the carer was only told when the person being discharged was actually in the ambulance on the way home. They had to run around trying to get a commode, which that person would certainly need when they got home. The situation is so much worse for a young carer who does not necessarily know their way around the system in the same way that an adult carer might. Although I support all the amendments in this group, that is why I added my name to Amendment 269 in the name of the noble Lord, Lord Young of Cookham. It is all about the need to identify and ensure appropriate support for young carers before a patient leaves hospital. I really take on board my noble friend Lord Scriven’s view that you should not do it at the end of the stay in hospital: you should start thinking about it when the person goes into hospital.

Caring for a sick or disabled person, no matter how strong the bonds of love, is a difficult and exhausting challenge. It is hard enough for adults, the majority of whom, as we have heard from my noble friend Lady Tyler, are women; we have heard about the effects on their finances and pensions. Many adults do not feel equipped to do it adequately, and it is even harder for children. How can a child be expected to have the knowledge and skills needed to care adequately for an adult and, at the same time, benefit from education and prepare for their own future life?

We know that circumstances sometimes put children in this position, but it is essential that public services provide as much support as possible. However, we know that, although it is estimated that there might be around 800,000 young carers in the whole of the UK, sometimes even their school does not know who they are. In some cases, the young carers themselves prefer it that way, because they see it as a stigma or something that their friends might not quite understand; but it does mean, of course, that they do not get the help that they need, and neither does the person being cared for.

I agree with the noble Baroness, Lady Wheeler, that a proper assessment must be done either before the patient leaves hospital or very promptly post discharge. I hear all the problems about that; yet, carers, according to an ONS report in 2017, save the state more than £60 billion every year, which is more than is spent on formal caring—although it is not clear how much of that is saved by young carers. On the other hand, it has been assessed that a family with a young carer has an income, on average, £5,000 a year lower than other families—so these families are often poor too.

Local authorities already have considerable duties relating to identifying, assessing and supporting young carers, and we have heard of at least two very good schemes. Many of them do it very well, despite the fact that some of these young people are hard to find. However, it is essential that some duties also apply to the NHS, and they must not be lost in the move to integrated care systems. Adequate focus must be placed on these duties by the ICB having a rigorous system or framework to ensure a process for assessment. As my noble friend Lord Scriven pointed out, this is step one in ensuring that needs are subsequently met.

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

My Lords, I thank all noble Lords for their contributions to this debate. We are looking to move towards a more integrated care system for precisely some of the reasons that noble Lords have laid out: that a patient is discharged by a hospital but it is not done in an integrated way. As the noble Baroness, Lady Wheeler, said, during the pandemic local authorities and the NHS developed innovative ways to support better discharge from hospital to community care, and what we want to see is discharge to assess as one model. In some cases, it might be the best model: for example, where people are over the age of 80, the longer they stay in hospital, the more you see muscular deterioration. That is one of the reasons given for why, in some cases, discharge to assess might be the most appropriate.

Health and Care Bill

Baroness Walmsley Excerpts

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

[Lord Warner (CB)]

My Lords, I want to briefly make clear my support for this group of amendments and try to be consistent with what I said on the previous group. The only amendment which causes me to have pause for thought is Amendment 183. The NHS, perfect in every form of course, has been known to have its arteries fur up occasionally. Sometimes there is a need for scale in some services. I want to mention three or four services where scale, after clinical consideration, is important. Pathology is a good example, where we need to have more scale than many of the local pathology departments. Another one, which the Royal College of Surgeons has advocated, is elective surgery hubs, which may mean taking stuff away from a particular local hospital. Another good example is the issue of stroke specialisation, which is beneficial for patients. I have given you three examples where we do not want to totally neutralise the Secretary of State. Sometimes Ministers have a use; it may be few and far between, but occasionally they have some use. We do not want to say that you cannot ever be a catalyst for change. That seems a bit drastic in Amendment 183, and I ask the noble Baroness, Lady Cumberlege, to think about that, because sometimes scale is important, with clinical advice for the benefit of patients.

[Baroness Walmsley (LD)]

My Lords, I am in favour of surgical excision. I oppose the powers of the Secretary of State in Clause 40 and Schedule 6 to intervene in decisions on reconfiguration of health services. Far be it from me to want to protect Conservative Secretaries of State for Health from themselves, but I warn that if they use these powers they will eventually get the blame.

The noble Lord, Lord Stevens, gave a number of very good reasons why this clause should be deleted from the Bill. My reason is somewhat different. I think these powers are very dangerous. We have recently seen how the Government’s powers to provide or withdraw funding from a proposal, let us say, to build a new school or improve infrastructure in a particular constituency have got them into trouble. We have heard allegations made against Government Whips by Members of Parliament of actions which could be criminal offences of bribery. It is alleged that, in seeking to ensure support for their leader, they are threatening Members of Parliament that funding for their projects, which have already been declared to be in the public interest of their constituents, will be withdrawn unless they behave in a certain way, so political considerations would trump public interests.

Like the former Member of Parliament to whom the noble Lord, Lord Hunt, referred, all politicians know that the provision of a new hospital or clinic or, on the contrary, the closing of a healthcare setting are very sensitive considerations in elections. All parties ensure that the voters know their views on these matters at election time and in between elections. The Prime Minister knows this. Why else would he put such emphasis on his promise of 40 so-called new hospitals by 2030 if this were not the case? It makes a good headline, even if we know that some of them are not new and some of them are not hospitals.

The powers of reconfiguration sought by the Secretary of State in Clause 40 would give the Government the ability to change the decisions of those put in place locally and well qualified to make them in a non-partisan and needs-based way, thus allowing the Government to wield unwarranted political power. It is probable that this Government would not be able to resist doing so, for the wrong reasons, and it is incumbent on all parties to stop them by deleting Clause 40 from the Bill. Indeed, I do not think that I would be in favour of giving these powers to any Government of any political party; they are just too liable to be misused.

[Baroness Thornton (Lab)]

I think the Minister is probably getting the message by now. I shall speak to my Clause 40 stand part debate and the amendment in the name of my noble friend Lady Merron. Somebody said earlier that we can be sure that the proposals to allow greater powers for the Secretary of State to intervene in reconfigurations is not something that the NHS asked for. That is almost certainly true.

I congratulate the noble Baroness, Lady Cumberlege, on her great coalition- building; she is very good at building coalitions in support of the things that she cares about, and she has definitely managed to do that with this group of amendments.

Noble Lords have pointed out that, at the moment, we have a system which works. It may be slow, and it is absolutely true that it has processes which take too long, but there are elements of public and patient involvement through consultations. The changes made in 2012 under the noble Lord, Lord Lansley, brought in four tests and some rigour of external independent evaluation. The core of that process still exists. As a non-executive member of the board of the Whittington, I can say that this is exactly the kind of thing that we have been involved in in our own hospital.

The consultations might be improved, but they will not be improved at all by this proposal. In fact, I think that this clause is very odd indeed. It is a bad idea, and it adds nothing to the core of this Bill and its central aim, which is to grow place-based independent and innovative healthcare, and it probably needs to go.

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[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.

[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.

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[Earl Howe (Con)]

I am grateful to the noble Lord, Lord Crisp, for bringing this debate before the Committee. I have listened to him and other noble Lords with care. Before I turn to the detail, it may be helpful if I explain the reason why Clause 54 is in the Bill.

Clause 54 originated as a legislative proposal made by NHS England and NHS Improvement to the Government in 2019. In making this recommendation, NHS England, under the leadership of the noble Lord, Lord Stevens, worked closely with representatives of the foundation trust sector. The key principle behind this clause is a recognition that the interests of the whole system should be prioritised in decisions about capital spending while also respecting the freedoms and accountabilities of NHS foundation trusts.

The noble Lord, Lord Crisp, asked whether it was our intention that the power in the clause would be a last resort—absolutely yes. Clause 54 is a reserve power to be used only in extreme circumstances to avert the risk of a foundation trust pursuing its own private capital objectives—if I can put it that way—that are not prioritised at a system level. I say to my noble friend Lord Lansley that that is the potential mischief that the clause is trying to address.

The control will operate in the context of the new NHS capital regime, introduced in 2020-21, at ICS area level with planning at a system level to take a holistic view of the local healthcare needs and balancing the allocated operational envelope for providers at that level. Having a power to set capital spending limits for NHS foundation trusts, as can already be done for NHS trusts, ensures an equitable distribution of capital to better enable the investments with highest priority and that achieve the greatest benefits for patients.

At this point I will push back, in the nicest possible way, at the noble Baroness, Lady Walmsley, about the actual level of capital spend. At the spending review 2021, capital spending was set to increase over the Parliament to £32.2 billion for the period from 2022-23 to 2024-25. That includes a £5.9 billion capital investment for the NHS to tackle the backlog of non-emergency procedures and modernise digital technology. As a result, the Department of Health and Social Care’s core capital budget will reach its highest real-terms level since 2010.

[Baroness Walmsley (LD)]

Governments always tell us how much money they have spent, but the question is always: has it met the demand? The money that the Minister has just mentioned is to try to cover the backlog of elective procedures; it does not cover the backlog of repairs.

[Earl Howe (Con)]

There will be money to address the backlog of repairs within that total.

Of course, it is our intention that a capital limit would be imposed by NHS England only if other ways of resolution had been unsuccessful. I will take the Committee through some of the detail, because it is important.

Amendments 188 to 192 would further restrict how the power can be applied. Amendment 188 would modify the clause by inserting “individual trust”. This modification is unnecessary because new Section 42B already ensures that an order relates to a single trust.

Amendment 191 would limit the order to one financial year, but, instead of that, the guidance prepared by NHS England will set out that any capital expenditure limits will apply to individual, named foundation trusts. We envisage that most will apply for the period of budget allocation, which is a single financial year.

Amendment 189 would insert steps that NHS England must take before applying the control and limit when an order may be made. The amendment also links the power with the capital planning function held by ICBs in new Section 14Z54. That plan may not always relate to a single financial year and can be amended in year; for example, for big capital projects, the plan could be set for several years, and in such a scenario it would be difficult to determine whether a foundation trust exceeded the plan in the early years. Amendment 189 would undermine the ability to impose the limit in a timely way and would mean that any limit could realistically be applied only when an overspend had already occurred or was committed to. That would risk funding being unfairly taken away from other areas.

Amendments 190 and 192 contain a requirement to lay a report before Parliament alongside a statutory instrument containing the order. That would cause significant delays in the power’s application. There is already a requirement in the Bill for NHS England to publish any orders which place a capital limit on a foundation trust and for guidance to set out the circumstances in which it is likely to impose a limit. We expect the guidance will also state that representations made by the trust will be published by NHS England.

As I mentioned, it is our strong view, supported by NHS England, that the powers and safeguards in the Bill create a proportionate and fair balance. These measures will ensure that if a foundation trust were actively to pursue capital expenditure that is not aligned with local priorities or affordable within local budgets, there is a means to prevent this as soon as possible.

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[Baroness Fraser of Craigmaddie (Con)]

My Lords, I rise partly because my noble friend Lord Forsyth referred to me earlier and partly because I wanted to clarify what is happening in the Scottish Parliament. There is not actually a Bill in front of the Scottish Parliament. The Orkney MSP, Liam McArthur, carried out a consultation which was very wide-ranging and closed only at the very end of December. Liam McArthur has reported that the submissions to his consultation were wide-ranging and unprecedented, and I look forward with great interest to reading some of them. You can look some of them up. I commend the Scottish Partnership for Palliative Care’s website; its submission is published there. The Neurological Alliance of Scotland also published a submission—I declare an interest because I am a trustee of the latter.

Both those submissions illustrate that this is a very complicated issue, as noble Lords have acknowledged, and there are many things that need evening out before we even get to potentially having draft legislation—a Bill or whatever it is; I am still learning parliamentary procedure. I find it interesting that my noble friend Lord Forsyth mentions that there might be a majority for assisted dying in the Scottish Parliament. I remind him that there is currently a majority for independence in the Scottish Parliament, but that does not mean that the people of Scotland want independence.

In my short time in this House, I have seen many amendments that may have been worthy in their own right but were in the wrong place in the wrong Bill. I think Amendment 297 in the name of my noble friend—I feel very nervous suggesting this to such an esteemed colleague—may possibly be the wrong amendment in the wrong Bill.

[Baroness Walmsley (LD)]

My Lords, I rise to speak on my own behalf; I am not representing anybody. The substantive issue is a conscience issue. I do, however, support the amendment in the name of the noble Lord, Lord Forsyth, because I think it is a discussion whose time has come. I am very impressed and pleased that noble Lords have resisted the temptation to discuss the substantive issue this evening, because all of us here understand—unfortunately, many outside do not—that this amendment is not about the substantive issue.

However, I am somewhat disappointed that the noble and learned Lord, Lord Mackay of Clashfern, wishes to knock it out on a procedural point. I think it is much more important than that. The noble and learned Lord is a wily old politician, and he knows very well that if you want to defeat something, it is often a very good idea to try to get rid of it on a procedural point. He suggested that we should use the Private Member’s Bill procedure. He has been in this House long enough to know that very few Private Members’ Bills are taken up by the Government and given time, and if they are not given time, they are going nowhere. But it is clear that this country wishes to discuss the matter and have Parliament decide on it.

The noble Lord, Lord Moylan, suggested that we cannot put anything in the Bill that the Government do not want to do. I remind him that every time we defeat the Government on an amendment, we are asking them to do something they do not want to do—and we did it 14 times last week on the policing Bill.

I have one other point. The right reverend Prelate the Bishop of Carlisle talked about vagueness. I think the noble Lord, Lord Forsyth, has been deliberately vague, because it is for the draft Bill to be specific. That is important because we need something very specific to discuss, with specific powers and safeguards that Parliament has put in. Without that, we would have all the fear that we have around the country, much of which has been expressed in our inboxes in these last few weeks. People are afraid of what might be in the Bill and what Parliament might pass, and only if we have a specific set of proposals in front of us can we amend it to put in the proper safeguards. Parliament can then decide, and people can take their view about it. I think that will take away a lot of the fears of people who believe that there will be no safeguards, because I am convinced that this Parliament would put in proper safeguards. If it did not, a lot of noble Lords would suggest some that jolly well should be there, and rightly so. For those reasons, I hope the Minister will consider the amendment in the name of the noble Lord, Lord Forsyth.

On the amendment in the name of the noble Baroness, Lady Meacher, again, I am so glad that she said it is a probing amendment, because other noble Lords have suggested that the drafting would need to be changed to avoid some unintended consequences. I am quite sure that the noble Baroness would do that if it was more than a probing amendment. She is asking for something that patients need: choice at the end of life. I hear what the noble Baroness, Lady Finlay, said about what is already in place. She is an expert on this. It could well be that a conversation needs to be had about whether there needs to be anything further in legislation to strengthen the availability of what the noble Baroness, Lady Finlay, talked about, which sounds absolutely excellent. So I am not expressing a definite opinion on that amendment.

I hope the Minister will consider the amendment in the name of the noble Lord, Lord Forsyth, because we, as practical politicians, know that in the real world—in this Parliament—the Bill brought forward by the noble Baroness, Lady Meacher, is not going anywhere, but we need to have the discussion.

[Baroness Stroud (Con)]

My Lords, I believe it is really important to understand what Amendment 297 does and does not do. It is my understanding that this amendment instructs the Secretary of State—not Parliament—to lay before Parliament a draft Bill that would permit terminally ill, mentally competent adults legally to end their own lives with medical assistance. I listened carefully to my noble friend’s speech on the matter just before Christmas, and I hugely empathise with his own personal journey. But it is important for us to understand what this amendment actually does and does not do.

Health and Care Bill

Baroness Walmsley Excerpts

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

[Baroness Barker (LD)]

My Lords, as ever, it is a great pleasure to row in behind my former boss at Age Concern—the inspirational leader of Age Concern for so many years—to return to an issue that Age Concern and its successor body Age UK have for decades raised with successive Governments during successive NHS reorganisations.

It is important, at the outset of this debate, that we understand the true importance of NHS continuing care. On one level, an individual level, it is about enabling people who have long-term conditions to live dignified lives in the community. At a strategic level, in terms of healthcare planning, it is about keeping people out of acute hospitals, which is the most expensive form of care.

The reason why it is right, again, that we seek to put these amendments on to the face of the Bill is that, at an organisational level within the NHS, there has never been a full accountability path for NHS continuing care. That means that, when it comes to individual decision-making on the part of members of staff in relation to individual patients, the decisions fall down. We have not just wide variation between different organisations but wide variation between particular practitioners, who sometimes resort to using non-standard checklists to make decisions, with inconsistent decision-making.

As a result of that, it is hardly surprising, but a real condemnation of a long-term failure of the NHS, that there is a need for an organisation such as Beacon to exist. It is a social enterprise set up by the main charities that gives information to older people and their carers. It should not have to exist. The fact that it does, and that it is a profitable social enterprise business, is testimony to the extent to which older people and their relatives are being badly let down on this.

I hope that in raising this yet again we have shone a light on a part of the NHS system that goes to the heart of what this Bill is supposed to be about. If we do not make this an express responsibility of the NHS in the Bill, yet again it is just not going to happen.

[Baroness Walmsley (LD)]

My Lords, I, too, support the noble Baronesses, Lady Greengross and Lady Finlay. It is right that people should have the cost-effective continuing care to which they have a right. I have my name on the amendment tabled by the noble Lord, Lord Sharkey, and I intend to make some very brief comments about that, although I make the point that the need for us to be brief is the Government’s own fault, because they have not given us enough days in Committee—fewer in fact that in another place.

On the amendment, we refer to the 15th report of the Delegated Powers and Regulatory Reform Committee. I have rarely read such a hard-hitting report by this highly respected committee. One of the worst of the Henry VIII measures that it mentions is allowing zero scrutiny on allowing NHS England, merely by the publication of a document, to impose a financial liability on an ICB. It specifies the circumstances in which an ICB is legally liable to make payments to a provider under arrangements commissioned by another ICB. The Government claim that this is an operational matter. However, if you believe that an ICB should be in total control of deciding how its funds are spent in its area in order to fulfil its duties, you might think that this is an important thing—a legal liability to pay for something that another organisation has decided to commission is quite a serious matter. The DPRRC thinks so and so does the Constitution Committee.

In their response to the DPRRC, as quoted in Appendix 1 of the committee’s 16th report, the Government said that they

“recognise that the Bill contains a significant number of guidance making powers, powers to publish documents and powers of direction.”

They suggest that

“these are appropriate because they reflect the often complex operational details, which are better illustrated by examples and guidance rather than legislation.”

The Government go on to say that there is currently a precedent in the powers of the clinical commissioning groups.

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[Lord Hunt of Kings Heath (Lab)]

My Lords, Amendment 147 concerns the establishment of integrated care partnerships. Although the amendment is specifically about the membership of ICPs, I think that it is appropriate that I comment more generally on ICPs and their role. As I see it, the proposals on integrated care partnerships can be seen as an attempt to try to bind the NHS more closely into a wider system that delivers much wider services contributing to care and well-being.

Particularly at issue is the relationship between the NHS and its partner local authorities. If there is to be a genuine generational shift in thinking that moves the NHS from being a sickness service to one that contributes to the overall well-being of the public, that must be welcomed. Of course, there is a lot to do. At the heart of the issue must be who decides how the money is spent. Who sets the priorities and allocates funding down to place or to service line? If it is just the NHS itself through integrated care boards, that will not work. We have to widen the decision-making to ensure that other voices are heard.

What is missing is some assurance that integrated care partnerships are to have some focus not just on wider well-being but on the need to reduce inequalities and to leverage maximum social value for the area covered. Here, the skeletal nature of the Bill once again gives rise to many more questions than it answers. How are integrated care partnerships to be performance-managed? Will there be an executive? Where will the funding come from? Can the ICP actually deliver any services? Could ICPs be the hub for shared services across the NHS and local authorities?

We have so far heard very little about ICPs; there has been much more emphasis on integrated care boards. Many noble Lords have remarked that the Bill is too focused on the NHS. It is clear that, so far, much energy has been put into the establishment of ICBs and much less into the establishment of integrated care partnerships, which are due to be set up jointly between the NHS and the relevant local authority or authorities. That shows that the building blocks are flawed, because essentially local authorities should have been equal partners in the establishment of integrated care boards. If this was really an integrated Bill about the NHS and adult social care, surely local authorities would be equal partners with the integrated care partnerships on the integrated care boards.

I do not want to go over old ground, but the very fact that NHS England is excluding local authority councillors from the integrated care boards means that it does not want a serious NHS contribution on ICBs from local authorities. I can only take that as the reason for wanting to exclude local authority councillors.

Finally, I will make a general comment about ICPs. The noble Lord, Lord Lansley, raised this earlier. I fail to understand why health and well-being boards are continuing in parallel with the integrated care partnerships. I hope that we might at some stage get an explanation.

That brings me to my amendment. I have concerns about the neglect of primary care and I think that local representative committees have been an important part of the NHS since its foundation. I see no reason why they cannot be assured of some kind of presence on the new integrated care partnerships.

We had a very good debate last week, led by the noble Lord, Lord Crisp, on the role of primary care generally in these arrangements. The Minister said that it was important to consult the relevant primary care local representative committees, and that was why there was a provision under new Section 14Z52 to introduce a duty to consult anyone the ICB and its partner trusts considered appropriate when preparing the forward plan. But underlying my amendment is a concern expressed by the noble Lord, Lord Warner, who on Thursday asked whether the Minister was aware that the influence on key decision-making in the NHS was diminishing for primary care in general and GPs in particular.

In response, the Minister was clearly sympathetic to making sure that primary care was better represented and not dominated by acute trusts. He said that he was open to further discussions in this area and I hope that he will extend those discussions to the membership of ICPs as much as integrated care boards.

The Minister may say that ICP membership is best left to the local level, but I do not think that that is sufficient. We are fully entitled to agree the framework of the new arrangements. Primary care is at risk of being marginalised and that cannot be left to local discretion. I beg to move.

[Baroness Walmsley (LD)]

My Lords, as the noble Lord, Lord Hunt, said, Clause 21 is about representation on the integrated care partnerships, and new Section 116ZA specifies who should be on the committee of the partnership. The Bill currently specifies that one member of the ICP should be appointed by the ICB and one by each of the local authorities. The partnership is also free to appoint others. My Amendment 148 requires that one of these additional members must have responsibility for public health—and in that I include public mental health—and one must demonstrate that he or she can represent local voluntary organisations.

It is tempting in a Bill such as this to assume that all the members of these very influential committees should be from the major health organisations or local authorities in the area. However, there are many small community organisations run by charities or not-for-profit groups that play a very valuable role in providing services to local communities in a very cost-effective manner. Unless they are represented at ICP level, it is quite possible that their survival will be threatened by the new arrangements—and we heard in previous debates that they already do feel threatened. I am sure that the Government do not want that.

Similarly, public health has a major role to play in addressing many of the preventable diseases that contribute to health inequalities—and it looks after the tracing of communicative diseases. We saw the value of that recently when it was a great deal more effective than the national test and trace service at tracing the contacts of Covid-positive patients.

So, the work of both groups is very cost effective. If the ICB and the ICP are to use their resources efficiently and fulfil their duties to level up health inequalities, it is important that both groups are represented on the integrated care partnership. I echo the comments from the noble Lord, Lord Hunt: the Bill is quiet on the structure of and representation on the integrated health partnership. Given the duties that it is being asked to perform, it is perfectly reasonable for us to suggest that some of those important duties are properly covered in representation.

[Lord Davies of Brixton (Lab)]

My Lords, in speaking in support of my Amendment 150, the issue is simple. We have much to learn about ICPs; I associate myself with the remarks of my noble friend Lord Hunt.

My proposal is that the rules determining the membership of ICPs should be consistent with the rules for membership of ICBs. As the Committee will be aware, it has been agreed, with the amendment made in the House of Commons, that ICBs will not and cannot be controlled by the private sector, in any way. I believe that the Health Minister, Edward Argar, made the point of principle clear when speaking during the Commons Report stage. He said that

“ICBs will not and cannot be controlled in any way by the private sector, as NHS-accountable bodies guided by the NHS constitution and with NHS values at their heart.”

Let us just remind ourselves that the requirement added by the Government to Schedule 2 is that an ICB’s constitution “must prohibit” a candidate being appointed to it if the person making the appointment considers, in the Government’s words in the amendment,

“that the appointment could reasonably be regarded as undermining the independence of the health service because of the candidate’s involvement with the private healthcare sector or otherwise.”—[Official Report, Commons, 22/11/21; cols. 119-61.]

We might not agree with the wording adopted by the Government, as previously discussed, but the principle is accepted on all sides.

So, as with ICBs, we should have a parallel provision for ICPs. In this, I am simply following what the Minister said in relation to ICBs: he wanted

“to put the matter even further beyond doubt.”—[Official Report, Commons, 22/11/21; col. 116.]

I emphasise “even further”. The debate here is not really about the precise wording of any amendment; it is about the principle of extending to ICPs the same protection that, as has already been agreed, should be extended to ICBs.

I look forward to the Minister’s reply. It is possible that, given the way in which ICPs are appointed—on the one hand, by ICBs, which are already protected by the Government’s amendment to Schedule 2, and on the other hand, by local authorities—it might be suggested that the issue simply does not arise and that protection is already there. However, if only to put the matter even further beyond doubt, why not accept my amendment?

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[Lord Kamall (Con)]

I do not see it as a fix. The consultation was much wider than just NHS England. In November 2020, NHS England ran a public consultation on the structure of ICSs, including NHS staff, patients and members of the public.

[Baroness Walmsley (LD)]

May I ask the Minister whether councillors were consulted?

[Lord Kamall (Con)]

I do not know for certain, but I am sure their views would have been heard via the Local Government Association.

Health and Care Bill

Baroness Walmsley Excerpts

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

[Lord Kamall (Con)]

We recognise the strength of feeling in this House and in the other place. This will clearly require more work and more discussions. In that spirit, I ask the noble Baroness to withdraw her amendment.

[Baroness Walmsley (LD)]

I thank the Minister for his comprehensive response to this debate, which the noble Baroness, Lady Harding, suggested was probably the most important that we have had and will have in Committee on the Bill. Staff are absolutely central to the delivery of health services.

Unfortunately, in this debate we have heard about a great deal of failure. We have failed the staff because we have not provided them with enough colleagues for them to be able to do their work without feeling stressed, being worried about risk to patients, feeling burnout or wanting to reduce their hours or retire early. We have failed to provide enough GPs; we were promised 5,000 or 6,000 extra, but, as the noble Lord, Lord Patel, said, we have fewer than we had in 2015. We rely on 30% of doctors from abroad—an enormous number. Although I absolutely accept what the noble Lord says about the appropriateness of temporary training placements, opportunities and remittances going back to the countries from doctors and nurses coming here, it sounds a little excessive to me. Perhaps we need to do better in planning our own workforce.

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[Baroness Walmsley (LD)]

I have my name to Amendment 93 and Clause 70 stand part. As the noble Lord, Lord Warner, just told us, Clause 70 is a bit of a mess, and having listened to the explanation of the noble Lord, Lord Lansley, of why it is a bit of a mess, I do not find much need to say much more. However, on the issue of compulsory competitive tendering, I understood that the Bill will reduce its importance. I wonder how those things link together and whether the Minister can explain it to me.

On the amendment of the noble Lord, Lord Hunt, about diversity of provision, it is usual that those with the biggest voices shout the loudest and, in the health sector, it is often also those with the biggest budgets, such as the acute hospitals. We have this very valuable not-for-profit sector that has a small voice and a small budget—at least individually, although it adds up to quite a lot—and a great deal of it comes from the NHS.

As has been said, many of them are spin-offs, comprising former NHS staff who prefer to work in that context. There are an awful lot of them—about 15,000—and they feel particularly threatened by the Bill because, despite the fact that they are specifically mentioned in the ICS design framework as a vital cornerstone of a progressive health and care system, they are not referred to in the Bill and there appears to be little, if any, recognition of the potential impact of the new structures of provider collaboratives and place-based partnerships on their funding and, crucially, their involvement in decision-making. As others have said, that missing piece has caused a lot of suspicion and concern in the sector, and we must not lose these important organisations, because they really understand their client base: they are local, they are flexible, they are fleet of foot, they innovate and they are vital in providing services, in particular for those with complex needs. We must make sure that their voice is heard.

[Baroness Thornton (Lab)]

My Lords, this group is in two parts. The first part consists of the amendments tabled by my noble friend Lord Hunt. I need to declare an interest as a patron and the founding chair of Social Enterprise UK, and also as an associate of E3M, for public sector social enterprise leaders, particularly in the healthcare sector, so I have been living with this. Indeed, I must declare an interest as the Minister who helped take through the right to request in the NHS for our staff. I am very committed to these amendments, and to the need for social enterprises to continue to innovate and deliver in our health and social care system, which they do at the moment. There is a report due out very soon from the group chaired by the noble Earl, Lord Devon, on Covid and social enterprise; the way that social enterprises have delivered during Covid is stunning.

I turn to the amendments in the second part of this group, many of which have my name on them. I think that the noble Lord, Lord Lansley, and I find ourselves in broadly the same place: it is a mess. Our first thought was, “Why is this clause here?”, because it does both the things that my former noble friend Lord Warner—I still regard him as a friend—said. This clause does not tell us what is going to happen but it makes us extremely suspicious about what might happen. My amendments—and also, I think, the amendments of the noble Lord, Lord Sharkey—are about that suspicion. It is quite right that the regulatory committee also said that we needed to pay attention to this, because it gives the Secretary of State very wide powers and it does not tell us what the Secretary of State will do with them.

I have quite a long speaking note, but I do not intend to go into the detail now. I simply say to the Minister that if, by the next stage of the Bill, we have not resolved the issues behind this clause, the Government may find themselves struggling to get it, as it stands, through your Lordships’ House.

Health and Care Bill

Baroness Walmsley Excerpts

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

[Baroness Finlay of Llandaff (CB)]

I am most grateful to the noble Baroness, Lady Barker, for adding some clarification to the point that I was trying to make. I am not for or against any system; all I am saying is that the arrangements have to be in place so that nobody is jeopardised—and indeed, in the event of a patient being transferred from a private facility back into the NHS, that part of the NHS is appropriately recompensed, particularly if the patient comes from a long way away.

[Baroness Walmsley (LD)]

My Lords, the problem to which the noble Lord, Lord Warner, is suggesting a possible solution is the result of long-term underplanning and underfunding of staffing in the NHS, and underfunding also of the capital budgets of hospitals, which sometimes have to choose between mending the roof and buying a piece of equipment that would get patients through the system more effectively and efficiently.

On the comments from my noble friend Lord Rennard on self-management, it is of course not just better care that that produces—it is also very cost effective. I draw noble Lords’ attention to page 3 of the Bill, line 13, where one of the three things to which NHS England has to pay regard about the wider effects of its decisions is

“efficiency and sustainability in relation to the use of resources”.

The resources are much better and more efficiently used if the patient has a decent choice of the equipment and treatment that is most effective for them, and it is often a great deal cheaper.

I also agree with the noble Lord, Lord Lansley, that we need the guidance. We need to see it before Report, and I hope that the Minister will be able to provide that.

[Baroness Wheeler (Lab)]

My Lords, these amendments stress the importance of patient choice in health management, especially of their long-term health conditions, and I welcome and endorse what noble Lords have said on these key issues. The vital importance of patient choice and their right to be able to make informed decisions about their conditions and treatment, and to receive treatment within the 18-week standard waiting time set out in the NHS mandate, was pioneered by Labour and continues to be fully supported by these Benches, as I stressed last week in the group of amendments on the mandate and the NHS constitution.

The noble Lords, Lord Rennard and Lord Lansley, and my noble friend Lord Hunt have spoken about the importance of active self-management, where clinically suitable, for patients with conditions such as diabetes. Access to the latest technologies varies greatly across the country, and the call in Amendment 109 to ensure that the oversight framework for ICSs includes systems for measuring the numbers of diabetes patients accessing diabetes technology would help achieve greater consistency and better use by patients who could benefit from it, particularly in helping to keep them out of hospital or to prevent their conditions deteriorating.

As vice-chair of the Specialised Healthcare Alliance, I know that patients with rare diseases often do not feel sufficiently supported in terms of psychological support, health systems and information, physical and daily living, patient care and support, and sexuality needs. As they are often having to live with their conditions long term, they have considerable potential to be more expert in their conditions than many of the healthcare professionals they come into contact with, many of whom may not be familiar with their disease or condition. With appropriate support, therefore, such patients can manage their less intensive care needs themselves, delivering better health outcomes and reducing demands on the NHS. Efforts to promote the self-care of people with health conditions, as set out in Amendment 226, really have the potential to improve the care of people with rare diseases.

Amendment 72—moved with his usual expertise and clarity by the noble Lord, Lord Warner—reinforces the importance of patient choice and is highly relevant because of the growing and record waiting list that we spoke about last week during the debate on the mandate and constitution. Of course, Labour in the past has used the private sector as part of a comprehensive plan to reduce waiting times, as the noble Lord, Lord Warner, pointed out. He will also know that in reality the role played by private providers, and the costs involved in getting the waiting lists down to the 2010 levels before this Government took office, particularly for elective surgery such as hip and knee replacements, were modest compared with the huge investment in the NHS itself and Labour’s genuine commitment to public service solutions, increased investment, the use of targets and improvements in pathways and other efficiencies. As a result, the private sector relied more heavily on getting business from the NHS on NHS terms, not actually treating private fee-paying patients.

In sharp contrast, we have the complete absence of such a comprehensive or coherent plan from the Government to reduce the now-record waiting lists, as the noble Lord, Lord Warner, set out in moving his amendment. The Secretary of State has acknowledged that waiting lists could grow to 13 million, with the National Audit Office now predicting that the situation could get even worse than it currently is by March 2025. The Secretary of State promised in November to publish how the Government plan to meet the workforce requirements needed to address staff shortages—to which noble Lords have also referred to during the debate—and the record waiting lists, but we still have not had any sight of this.

So far, all we have had instead are last week’s press reports of the huge sums of money the Government want to hand over to the private sector, including disturbing reports of NHS England’s unease at the Secretary of State’s instructions to hand over £270 million to the private sector with no guarantees on numbers of patients to be treated or, indeed, whether any NHS patients will even get treatment. Our shadow Secretary of State, Wes Streeting, has made it clear that an incoming Labour Government would fully expect again to use the private sector to help bring down waiting times for treatment, but as part of a comprehensive plan to build and the support the NHS so that people do not have to go private because waiting lists are at record levels and they are suffering and in pain. People who cannot afford it always have to wait and remain in pain. That is not social justice and it is just not right.

We support the principle in this amendment. If long waits can be prevented, they should be, although there is a serious question about whether the private sector would in any event actually have the capacity to meet the demand that could be generated by the three-month stipulation for treatment in the amendment. We also agree that the Clause 68 regulations need to be published as soon as possible and I look forward to the Minister telling us more about that. By contrast, a far better solution, as Labour has always advocated, would be to invest in the NHS, help the NHS become more effective and efficient and build capacity so there would be far less need for private sector care.

Finally, the amendment’s requirement to ensure that private sector providers have a duty to provide NHS England with annual information on the services funded by the NHS and on patient choice would be a welcome development, for the reasons that the noble Lord, Lord Warner, set out. The more that is known about the use of private providers, the better and more informed the discussion about their role will become. I look forward to the Minister’ response.

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Moved by

[Baroness Walmsley]

83: Clause 20, page 17, line 25, at end insert “and to ensure the availability of sufficient well-trained staff to provide safe staffing levels.”
Member’s explanatory statement
This amendment draws the attention of the integrated care board to the need to ensure sufficient well-trained staff to comply with safe staffing levels.

[Baroness Walmsley (LD)]

My Lords, in moving Amendment 83 in my name, I want to speak to Amendment 86, also in my name, and to support Amendments 146, 170 and 171.

Everybody taking part in these debates, including the Ministers, would acknowledge the central importance of the staff of the NHS and social care, at every level, and their training, well-being and retention. However, it was clear from the evidence on the workforce to the committee and in debates in the House in another place that there is broad concern that planning for the provision of sufficient of the right staff in all areas has not been good enough. Given how long it takes to train a doctor, an allied health professional or a nurse, excellent forward planning is essential. Proposals were made in another place to improve that in the future but, unfortunately, the Government would accept only a mandated review every five years. This group of amendments is this House’s opportunity to try again, and I hope the Minister will be able to help us.

These amendments show that, in the opinion of noble Lords, the planning of health, public health and care staff must be based on an accurate, independently verified understanding of both the current situation and, as well as can be predicted, future need. Because the political responsibility lies with the Secretary of State, this information collection and planning must exist at the very top, as well as at NHS England and the ICS commissioning level. Clause 35 refers only to the workforce needs of health services, but Amendment 170 lays down detail on what the Secretary of State must do to fulfil this responsibility, not just for health but for public health and social care, since they are so interlinked. We look forward to the White Paper and legislation on social care and hope that workforce issues will be well covered in them, but we need to address it now, in this Bill, even though it would have been better to hear the Government’s proposals on social care first. Amendment 146 says what must be done at ICS level. Crucially, both amendments require appropriate consultation. But there is something I would like to add, and that is where my Amendments 83 and 86 come in.

Every hospital trust and primary care setting has done the work to identify and agree the safe staffing levels of each type and seniority of staff in each setting. This is based on an understanding of the local context and of the knowledge and skills needed for patient safety to deliver each treatment, and an assessment of how many patients can safely be looked after by each member of staff. This varies enormously from setting to setting—from a whole team of staff to each patient in operating theatres, to one-to-one in ICUs and premature baby units, and to several patients to one member of staff in less acute areas.

During the pandemic, we have seen these levels necessarily abandoned, with, for example, one ICU nurse being asked to care for two or even three patients at the peak. This has been an unusual crisis situation and services have had to be flexible, moving staff from one department to another, always, I hope, under the supervision of a staff member with the correct speciality. Hospitals have helped each other and ambulances have been diverted when no bed could be found for patients coming into A&E. That has been the advantage of having a National Health Service.

It has been very difficult for staff, and many have quit their jobs. We started the pandemic with tens of thousands of doctor and nurse vacancies, and the BMA has calculated that we currently have a shortfall of 50,000 full-time equivalent doctors—more than the number of unfilled posts. Our doctor-patient ratio is 25 years behind that of similar OECD countries. In the UK, before the pandemic, there was already a shortage of around 50,000 nurses, and still the healthcare system is nowhere near bridging that gap. In December 2020, a report by the Health Foundation, Building the NHS Nursing Workforce in England, said that the Government will need to exceed their target of 50,000 new nurses in England by 2024-25 if they want the NHS to fully recover from the coronavirus pandemic.

In January 2021, a survey by Nursing Times indicated that 80% of nurses feel that patient safety is being compromised due to this severe staff shortage, which is why my amendments focus on safe staffing levels. While there has been a good increase in the number of nursing students starting courses during 2020, this will not alleviate the issue of a lack of qualified nurses now or in the medium term. There are particular shortages among mental health and cancer support nurses. Cancer Research has also told us that one in 10 cancer diagnostic posts in England is vacant, which threatens the Government’s cancer target. There are also considerable shortages in other allied professions.

We have also seen a reduction in the number of in-patient beds in the last 10 years and bed occupancy rates well in excess of the recommended percentage. Even before the pandemic, some hospitals had no available beds at all during the winter period, leading to nearly every winter period being labelled a crisis. All this is because of the perennial failure to train enough staff.

Despite the increased use of technology, health and care continue to be people businesses, but there has not been enough effective planning to provide the workforce needed, not just for normal services but to provide the resilience needed for the winter and for future pandemics. This has partly been due to “leaky bucket” syndrome—the failure to retain staff because of the pressure and, in some cases, pay or pension issues. That must change. Health Education England is now to be incorporated into NHS England, and the Bill and the forthcoming social care legislation are opportunities to start again. We have one and a half million care workers, with high turnover. In order to improve retention, good training and a career path are needed.

I turn, however, to the detail of my amendments. Included in the duties of the new ICBs is, as set out in Clause 20, in new Section 14Z41, a duty to promote education and training. My Amendment 83 adds to that duty that it should train enough of the right staff to reach safe staffing levels in all areas. My Amendment 86 adds to new Section 14Z42, which covers the duty to promote integration, a duty to improve the ability of NHS and care staff to carry out their duties within safe staffing levels.

The latter amendment recognises the risk to staff themselves as well as patients when they are forced to work with fewer than the prescribed safe number of colleagues, or to extend their shift by many hours because there is nobody to take over. It is a risk to their physical and mental health and it certainly does not help the ability of student nurses and doctors to learn from their senior colleagues when they do not have enough time to breathe. It also causes burnout, leading to significant numbers of doctors and nurses considering leaving the profession or reducing their hours. Some 32% of respondents to the BMA’s April 2021 Covid-19 tracker survey said that they were now more likely to take early retirement, while half reported being more likely to reduce their hours.

I believe that safe staffing levels are part of the duty of care that employers owe to their employees in the health service. However, the Nuffield Trust, Health Foundation and King’s Fund have estimated that, by 2030, the gap between supply of and demand for staff employed by NHS providers in England could reach almost 350,000 full-time equivalent posts if nothing is done. Worryingly, that was based on pre-pandemic calculations. Overcoming unsafe staffing levels is an essential measure to ensure patient safety and to boost the well-being, morale and productivity of staff and, therefore, their retention. The Bill is an opportunity for the Government to take sustainable action to alleviate issues relating to workforce supply and demand in England.

The duties proposed in Amendments 146, 170 and 171 would be welcome, and I support them, but they are not enough. I think that safe staffing should be specifically mentioned among the duties of the ICB, and that is where my amendments would put it. I beg to move.

[The Deputy Chairman of Committees (Lord McNicol of West Kilbride) (Lab)]

My Lords, we have two noble Baronesses taking part remotely. I first call the noble Baroness, Lady Brinton.

Health and Care Bill

Baroness Walmsley Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

[Baroness Bennett of Manor Castle (GP)]

My Lords, this has been an extremely rich and informative debate on a diverse set of amendments. My contribution will be fairly brief, but I want first to reflect on the comments of the noble Lord, Lord Scriven, about the elephant in the room. He reflected on many other contributions about the lack of real integration of health and social care in the Bill, and the way the Bill is essentially written for health. I do not disagree with that identification of that elephant, but a second giant creature in the room is being ignored—let us call it a mammoth—which is the lack of adequate funding and numbers of people for health and social care. That means that those silos are seeking to defend their funding and resources, and reserve it for what they see as their core functions. They therefore find it very difficult to reach out and stretch into new areas even where that would have huge net positive impact overall.

To reflect on a couple of other things, I heartily endorse the call from the noble Lord, Lord Farmer, for a reverse Beeching for the NHS with the reopening of community hospitals. I am not sure whether he coined that phrase; I might borrow it, if he does not mind.

I will also comment on Amendment 51A in the names of the noble Baronesses, Lady Finlay and Lady Jolly, about emergency services going to everyone in the area. I see that the noble Lord, Lord Davies of Brixton, is in his place. This very much ties in with an amendment that he spoke to on Tuesday. He told a tale, which I will not repeat, about a case in which someone was denied a treatment in a neighbouring area that they desperately needed because of arguments about which area they were in. This is potentially a huge problem with the structure we are creating that has to be taken on board. Amendment 51A deals with the responsibility, but of course there also have to be funds to go with that responsibility.

It has not got a lot of attention, but I also commend Amendment 100 in the name of the noble Baroness, Lady Finlay, on the duty to promote rehabilitation. When we talk about dramatic medical interventions—the high-profile stuff—it is generally acknowledged, but always as an afterthought, that the person who has had that big dramatic intervention will not suddenly be cured tomorrow, in most cases. There is a long process of recovery. Indeed, I have put on my reading list Recovery: The Lost Art of Convalescence by Dr Gavin Francis, which has been glowingly reviewed in many places. That is something we all should be thinking about a lot more.

Finally, I come to Amendment 110, in the name of the noble Baroness, Lady McIntosh of Pickering, to which I attached my name because, as the noble Baroness said in her introduction, this is something that we have addressed again and again in the police Bill and the Domestic Abuse Act, but it is very acutely an NHS problem. I draw on an article from the Nursing Times on 24 December. It is an account of a nurse, who was called Claire in the article. When she was going through a checklist with a patient that had been provided by a charity—this was something extra added in from the outside, not core NHS—she realised that she herself was a victim of domestic abuse. She had said yes to more of the questions than the patient had. That is a demonstration of what the noble Baroness, Lady McIntosh, said: training is not given to medical professionals to see what is happening to themselves and to their patients. Maybe it is added in because a charity has managed to get something into the system, but it will certainly not be across the system.

We hope we are doing this Bill for the long term—although perhaps we are not so certain, as the noble Lord, Lord Hunt, said—but we have to note that this is happening in the context of the Covid-19 pandemic. I note that the NHS sexual assault referral figures for the first half of 2020 dropped significantly. That also picks up a great deal of domestic abuse, yet online searches for domestic abuse were up by 350% in the same period. We have an NHS that has been forced to focus on the Covid-19 pandemic, often drawing away resources that might have started to deal with domestic abuse anyway. We have a huge rise in the problem. Considering the moment we are at now, it is crucial that domestic abuse is in the Bill.

[Baroness Walmsley (LD)]

My Lords, this is an enormously important debate because it deals with my favourite word in health and care: prevention. Prevention is so important because it is cost effective. Although successive Governments give more and more to health services, no Government will ever be able to give enough to the NHS, because we have an ageing population and innovative medical interventions are getting more and more expensive, unless we do things differently and more cost effectively.

The noble Lord, Lord Black of Brentwood, outlined one very good, cost-effective intervention. It is an excellent example of something that has absolutely powerful evidence of its cost effectiveness but which is not being undertaken everywhere. I would like to know what evidence those areas that are not using fracture liaison services have that their way of doing it is better and more cost effective. I do not think they have that evidence. It is an example of where if you do not mandate it they will not all do it, and then they will not be spending their money effectively. I support the noble Lord’s amendment.

It is also very important that we prevent not just the second fall but the first, because, as the noble Baroness, Lady Finlay, said in her very important intervention, including what she said about tourist areas, which is very significant, people do die from falls. I had a very old friend who recently did. It was the first fall. I am afraid that person died because he had internal bleeding that nobody spotted. It is really important.

My noble friend Lord Rennard mentioned something really important that is pre-primary intervention: health education. If you know that you are likely to have good, strong, healthy bones from weight-bearing exercise and a diet that has enough calcium and vitamin D, you are much less likely to have the first fall. Fortunately for the Minister, that is beyond his remit. I am sure he is pleased about that, because he has quite enough to do. The Department for Education should listen to that.

My noble friends on these Benches have highlighted some other areas where effective prevention services are not being done properly. I think we were all struck by the chaotic situation that my noble friend Lady Barker highlighted; something really has to be done about that. A lot of good has been done but a lot more could be done, and, again, it would be cost-effective.

The noble Lord, Lord Layard, has suggested a very cost-effective intervention. If we diagnose and intervene on mental health issues early then we can prevent all kinds of more severe mental and physical health problems. I support the ratchet method that the noble Baroness, Lady Harding, referred to of increasing the amount of funding that goes there. Although the noble Baroness, Lady Watkins, rightly listed the number of times that the Government have put more money into mental health services, the question is: have they kept up with the demand and the backlog? I do not think they have.

We have an opportunity in the Bill to improve our measures to prevent ill health, as well as treat it, which is of course more cost-effective, especially when services are delivered by small social enterprises working at community level. I have added my name to the amendment from the noble Lord, Lord Farmer, because I believe these prevention services should be available as close as possible to those who need them most. If that does not happen then the people who need them will not access them, and health inequality will continue.

That is particularly important for those communities where health inequality is at its worst and where preventable diseases are most prevalent. For example, the services might include healthy weight management services, therapies to address less severe mental health conditions, and alcohol and drug addiction services, in addition to the usual GP services. The population groups are not just those in poverty but marginalised groups such as homeless people, those in temporary accommodation, refugees, Gypsy and Traveller communities, and others who may not be plugged into regular services, and that includes those in rural areas.

Many of these services are delivered very effectively by social enterprises or charities, where any surpluses are ploughed straight back into more services. Many of them also provide weekend services, which were mentioned as lacking by the noble Baroness, Lady Masham. Boards that do not ensure the survival of such services are really missing a trick that would help them to deliver their duty to level up health inequalities, because these organisations are usually very close to their communities and know exactly what is needed and where. They are not constrained by the regulations or the culture of large organisations, and are therefore more flexible and fleet of foot, and therefore very cost-effective.

On rural areas, I shall give your Lordships a brief example from my noble friend Lady Jolly, who lives in a very remote part of Cornwall. She says:

“We have a satellite surgery in our local village, it is in the ground floor of an old cottage. The pharmacist visits once a week, and a practice nurse visits once a week. When she is seeing a patient they have to switch the radio on so that no one can hear the conversation”—


because of patient confidentiality. In that village you have to drive 20 miles to reach a GP. That is the sort of place where we really need community access to health services of all kinds. It would be nice to think that the ICB would be aware of that and act accordingly, and it might perhaps be worth putting a duty in the Bill.

[Baroness Thornton (Lab)]

My Lords, this is an assortment of amendments that are all linked to the core of the Bill, which is about integration. The issues, as ever, are about whether it is appropriate to place such a detailed level of specification in the Bill, and where.

Amendment 50 seeks equity of access for fracture liaison services. In many ways the amendment by the noble Lord, Lord Black, supported by my noble friend Lord Hunt and others, is about the balance between a national mandate and local delivery in order to ensure that there is equity of access—in this case, for fracture liaison services. I would be interested to learn how the Minister believes such a thing could be implemented and assured, and in how we can best express that in the Bill.

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[Lord Warner (CB)]

Before the Minister responds to that, can I amplify what is being refused here by the Government? As I understand it, he is trying to rely on the Care Act to get local government to co-operate and integrate care with the great elephant, the NHS. This is asking a minor player to take on a major player with far more resources. Amendment 89, tabled by the noble Baroness, Lady Hollins, makes the NHS come back every two years about the outcomes. That is a fairly modest challenge to the NHS and I fail to understand why the Government cannot simply accept that in principle and then negotiate the drafting.

[Baroness Walmsley (LD)]

I am so sorry to delay the Minister again, but briefly. After we have pushed this Bill through Parliament, we will have an integration Bill and a White Paper and legislation on social care. When we have had this, those and those, can we come back to this?

[Lord Kamall (Con)]

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

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

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[Baroness Cumberlege (Con)]

I would like to say a few words and will start by complimenting the noble Lord, Lord Crisp, on all his amendments. I agree with the noble Lord, Lord Scriven, that these are not contentious. In fact, I do not think it would harm the Government at all to include these amendments in the Bill. They are trying to reinstate the primacy of primary care.

We all know that the glamour is not in primary care but hospitals—you have only to see where politicians like to be photographed; when they produce newsletters, they are always pictured in a hospital with a very sophisticated piece of new machinery that that hospital has bought. It is understandable, because that is so easy to recognise. With a photograph of a GP in a consulting room, you do not know quite where this is, who it is, or what he is doing. One can understand why the media goes for the picture of the hospital, because that is what people recognise.

In this debate and these amendments, we know that the absolute foundation of the NHS is primary care. It is so important and we have to build its primacy. I am a child of primary care; I grew up in it. My father joined the NHS in 1948. He welcomed it and thought it was a marvellous innovation. I had a very happy childhood as Dr Camm’s daughter; I had status in the community. Then I segued into being Mrs Cumberlege and my status plummeted—because I had married a farmer. We celebrated our wedding 61 years ago last week, so have had a diamond wedding. My husband said to me, “Julia, what do you want?”, and I said, “Well, it is a diamond wedding”. He delivered, and I was just delighted.

I will not extol the virtues of my father’s practice, but want to think of the role of the GP in the future and how it has already changed. In our practice, all the GPs are now part-time. They are men and women, and they have other lives to lead. None of them is a full-time GP, and that makes continuity of care quite difficult, because you are never quite sure whether they will be there or not. If you want an urgent appointment, of course you can get one, but it will probably not be with your GP. So that has changed.

There has been another change. My father built a health centre. In fact, it was the county council that built it, but he put all the pressure on to build it, and it was called the “health centre”. Today, it is not called that; it is called the “medical centre”. That is because the doctors are transactional. They just do what is in front of them. Health is not part of their remit, and it is our community that provides the health. It is the church which has the social work and provides a huge amount of the social services for our community. So things really have changed.

A very good paper was produced by the Royal College of General Practitioners, in June of last year, The Power of Relationships: What Is Relationship-based Care and Why Is It Important? It is such a good paper, and I recommend that noble Lords look at it before we have the debate led by noble friend Lady Hodgson on relation- ship care and what it means. The statistics show that people live longer with relationship care. They are happier. We have some really good evidence, but I shall talk about that when we come to that amendment.

I have been working with Sir Cyril Chantler, whom many people in this House will know. We have been talking about community hubs. We think they are a very good way of moving forward and getting together not only doctors but social care, voluntary organisations and all the community facilities to ensure that they are in a hub. We know that, with integrated services and boards and the work that is going on in integrated care, the populations are enormous. We have to break it down a bit to make it more accessible to people. The next time we have a chance to debate this matter, which will be in the context of relationship care, I shall talk about community hubs with populations of about half a million. We are already establishing maternity hubs. I have said to them, “No, not maternity hubs—you’ve got to make them community hubs; you’ve got to bring in all the other resources that are in the community, because they’ve all got something to offer, and we would all benefit.”

I hope that my noble friend the Minister will think seriously and work with his colleagues to try to ensure that these amendments, or very similar ones, are introduced into the Bill, because we need to ensure the primacy of primary care. I am afraid that it is not there now; it is all about hospitals.

[Baroness Walmsley (LD)]

My Lords, it is a great pleasure to follow the noble Baroness, Lady Cumberlege, and I am delighted that her status has now gone up again because of her ennoblement and all the excellent work that she has done. We really benefit from her knowledge and wisdom in your Lordships’ House.

I support the noble Lords, Lord Low and Lord Crisp, and want to make just one point. Correct me if I am wrong or if I am out of date—I am sure that some noble Lord will if I am—but I think it is the situation that if an acute hospital overspends, the NHS bails it out, whereas social care and primary care cannot overspend because nobody will bail them out. I think that says it all.

[Baroness Thornton (Lab)]

My Lords, in many ways we are drifting back to 1946, when the NHS started on three legs: hospitals, services such as health visitors and ambulances provided by local authorities, and services that were contracted out, such as GPs, dentistry, ophthalmology, pharmacy and so.

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[Baroness Bennett of Manor Castle (GP)]

My Lords, I join pretty much everyone else in commending the noble Lord, Lord Howarth, for tabling these amendments. I have attached my name to Amendment 67, although it could have been to any of them.

It is worth making two broad points. In her wonderful contribution on the last group, the noble Baroness, Lady Cumberlege, used the really key phrase,

“the community provided the health”.

That is what this group of amendments is talking about.

A couple of groups back, the noble Baroness, Lady Thornton, talked about how, if the health system is working for people with learning disabilities, it is working for everybody. If we bring in the kind of institutions, frameworks and supports that we are talking about here—if we think about stopping people getting ill and caring for ill people—we will make our communities vastly better for everybody. This is an important point to make.

Like most noble Lords, I could come up with a list as long as your arm of wonderful places I have visited. I will not, but I will mention one, which brings together three elements of this: creativity, nature and culture. The Green Backyard in Peterborough is the most wonderful space. I defy anyone to walk into it and not smile. It has amazing, colourful, moving sculptures powered by water, with food growing—amazing salads filled with flowers. When I visited, I spoke to the carer of another visitor. This visitor had very profound disabilities—she was blind and non-verbal—but her carer said, “I’ve never seen anything like it. After the first time we came to visit, the next Monday, which she knew was the day we visited, she was all packed up, dressed and ready to go out.” This was obviously catering to someone’s needs absolutely brilliantly, but it nearly got bulldozed and turned into a block of flats a few years ago. Luckily, it was saved, but that is the situation we so often find ourselves in.

I also want to mention Amendment 90, in the name of the noble Lord, Lord Howarth. The noble Lord, Lord Best, has already said a great deal on this, so I will seek to add just a couple of small points—well, one small point and one quite big one. There is something called the lifetime homes standard, which I learned about when I visited Derwenthorpe in York with the Joseph Rowntree Foundation. The thing I remember about it, because it was so simple and obvious, was that the two-storey houses there had all been built with a space between the joists so that, if you needed to put a lift in up to the first floor, where the bedrooms were, it was a really simple and low-cost thing to do. It was a very simple piece of design. This will not be covered in the Health and Care Bill, but this relates to so many aspects of our society. You could say that housing is a health issue. In the first group this morning, we talked about social care and how many people cannot leave hospital and go home because their accommodation is unsuitable. We need to think all the way along the line across our society to make sure that does not happen.

Finally, I want to pick out one or two words in this amendment, which talks about housing and urban environments. I thought here of the New Ground co-housing development in north London, which is for women aged over 50. One aspect of it is looking at how people can support each other, be good neighbours and form a community that can provide support. This morning, I attended a King’s Fund briefing talking about social care and there was a great deal of talk about the need for digital innovation and technology. I tweeted, “What about social innovation?” We have to think about how we organise our societies and urban environments so that people can form those kinds of communities. If you visit any area of new housing being built around the country, there is typically precious little in it to encourage that kind of community development. The housing point is obvious, as is the environment point, but let us not lose the community and urban structure points from that amendment either.

[Baroness Walmsley (LD)]

My Lords, it has been an excellent debate. We have heard about all the various kinds of arts and the effect of housing. We heard from the noble Baroness, Lady Morris, about sport and leisure. We heard about the importance of green spaces in helping us with our physical and mental health. The noble Baroness, Lady Finlay, rightly mentioned that loneliness kills. If one can address that, it affects not just one’s sense of worth and well-being, as has been said, but one’s sense of community.

Parliament is a community. It sometimes does not feel like it, because we have various groups, political parties, Members, staff and so on, but we also have a lot of all-party groups and this is significant. We have sports, arts and heritage, drama and music groups. I have been a member of the Parliament choir for 22 years and have found great solace in it—I really missed it during the pandemic.

Health and Care Bill

Baroness Walmsley Excerpts

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

[Lord Kakkar (CB)]

My Lords, I intervene briefly to support the amendment moved by my noble friend Lady Finlay. In so doing, I would like to put a question to the Minister. In the context of contemporary, 21st-century delivery of healthcare, how can it be justified that palliative care is not considered part of the continuum and has to be funded in a different way? How can it be that those specialists delivering palliative care are unable to integrate it into the broader considerations of delivery of healthcare in their institutions and systems? It seems completely counterintuitive that that continues to be the position in our country. If Her Majesty’s Government were minded not to support these amendments, it would be helpful to understand how they justify that position and justify differentiating palliative care from other services that are rightly fully funded by the state.

[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.

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.

Health and Care Bill

Baroness Walmsley Excerpts

Lords Hansard - Part 2 & Committee stage
Thursday 13th January 2022 Lords Chamber

I am aware that I have been quite technical, but these are really important issues that we want to get on the record. I gave the Minister prior notice of a question that I planned to ask, which refers again to a Health Care Without Harm Europe report. It produced a list of chemicals of concern that it says we should seek to phase out from the entire healthcare system. Quite a number of regional health groups, hospitals and medical groups across Europe have signed up to seek to ensure that the chemicals on this list, which has a very detailed and serious eight-point set of criteria, are phased out. Are the Government ensuring that NHS England takes account of and acts on this list, and takes the kind of steps that we are seeing taken in Europe to eliminate these chemicals of concern from our healthcare system?

[Baroness Walmsley (LD)]

I support these amendments and in particular the words of my noble friend Lady Northover. I too am a member of Peers for the Planet and, as a biologist, I have been devoted to trying to address climate change ever since I knew anything at all about it. I particularly support the noble Baroness, Lady Hayman, in her determination to mainstream the issue. It is not the responsibility of just Defra but every department of government and every single individual in this country.

From my work on the Science and Technology Committee, I was aware of the health service’s 5% contribution to our emissions, but also of what the NHS has already done and pledged to do under the leadership of the noble Lord, Lord Stevens. I confess I was a little surprised when I saw these amendments; I thought, given all that, “Why does the noble Lord think more needs to be done?” The noble Lord, Lord Stevens, knows more than I or any of us do about the health service, so if he thinks more needs to be done, I am with him. We absolutely should support these amendments.

I would like to ask the Minister one particular question. The NHS has a very large portfolio of property and the Prime Minister has promised 40 new hospitals in a certain period of time. Leaving aside the fact that some of the buildings promised are not hospitals and are not new, if we are building new buildings, I would like to be assured that all of them will be zero-carbon. That can be done and there is no excuse not to do it.

[Baroness Wheeler (Lab)]

My Lords, I congratulate the four noble Lords who have produced this excellent suite of amendments across the Bill to ensure that ICBs procuring or commissioning goods and services on behalf of the NHS are firmly focused on their responsibility for NHS England’s commitment to reaching net zero by 2040. It has been an excellent and informed debate, and one with much enthusiasm to reassure the noble Baroness, Lady Hayman.

We fully support the amendments and have little to add from these Benches following the expert contributions of those proposing the amendments and the other noble Lords who have spoken. I am sorry my noble friend Lady Young, who put her name to the amendments, cannot be here. She was a key member of our team during the recent passage of the Environment Bill, and her expertise and wisdom always guides and reflects our approach. The House is clearly interested in this vital matter, as we saw this week in an important Oral Question on the Prime Minister’s promise for a new, overarching net-zero test for new policies. Assuming the Government fully support the key commitment from NHS England, I hope that, in his response, the Minister will accept the need for the amendments and will not argue that the proposed new clause is unnecessary as NHS England already has a commitment that will percolate down to ICBs.

As we have heard, the power of public sector procurement is a massive issue and there is no bigger part of the public sector than the NHS. The NHS has such an important impact on other environment issues, such as waste, pollution and resource consumption, especially for plastics, paper and water. We should ensure we are on the front foot in using that impact to deliver the net-zero commitment.

The NHS has made a start, but there is much more to do. These amendments would reinforce the importance of action in these areas for the new bodies and processes that the Bill creates. The NHS is a big player and, as noble Lords have stressed, it can play a big role in tackling all of these climate change and environmental challenges. Procurement is a strong lever that the NHS can utilise in key markets, particularly in those areas where it is the sole purchaser. The noble Lord, Lord Stevens, was very eloquent on this issue and I look forward to the Minister’s response in the light of his contribution.

Like other speakers today, my noble friend Lady Young wanted to stress that action so far is only the beginning. In the light of the importance of climate change and other environmental challenges, we strongly support such a duty being in place for all the public and private bodies with significant impacts when future legislation comes through Parliament. We did that when inserting a sustainable development duty into the remit of every possible public body from the late 1990s onwards, but this time it has to be not only enacted but managed, delivered, tracked and reported.

As the Minister, the noble Lord, Lord Callanan, told the House this week, every sector of government needs to do its bit, and we need to hold them to that. These amendments are vital, since every public body will have to take further action this decade if we are to restrain temperature rises to two degrees—far less, 1.5 degrees.

Finally, I too thank Peers for the Planet both for its work and, especially for me, its excellent briefing. As noble Lords have stressed, the NHS has committed to net zero and aims to be the world’s first net-zero national health service. It is responsible for around 5% of the UK’s carbon emissions. That is why the NHS’s role and contribution to net-zero targets should be fully integrated into the Bill. I look forward to the Minister’s response and his detailing of how the NHS is to achieve its ambitions. I hope that he will acknowledge that its commitment must be in the Bill. These amendments present a vital opportunity to enshrine in law a commitment that I think most, if not all, would want to see delivered.

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[Baroness Walmsley (LD)]

My Lords, I support Amendment 17 from the noble Baroness, Lady Morgan. There are of course different waiting-list lengths in the different Administrations, but I take the point made by the noble Baroness, Lady Finlay, about fair funding. She makes a very good point about Wales.

I too have had experiences like those of the daughter of the noble Baroness, Lady Fraser, over my Covid vaccination status, because I live in Wales and the NHS app in Wales did not seem to speak to the other one. But, as the noble Baroness, Lady Bennett, said, that is something that needs sorting out at a different level.

As I said, I live very near the border in Wales, so I am acutely aware from personal experience that the nature, quality and resources of healthcare in England affect the people of the devolved Administrations. I accept what the noble Lord, Lord Lansley, said: it is not just about people near the border—Anglesey is not at all near the border—but in day-to-day working it affects people near the border very frequently.

These are of course devolved matters, but in their practical, day-to-day operation the borders are what people call “leaky”—in other words, people travel both ways for work, school, shopping, leisure and indeed health services. So, particularly in the border areas, it makes a lot of sense to do what the noble Baroness, Lady Finlay, said happens all the time: for GPs to be able to refer patients for a particular service to or from the devolved nations. That is why anything that affects the provision and quality of services in England also affects Welsh and Scottish people in particular. I suspect it is slightly less the case for people in Northern Ireland, although waiting lists there are particularly concerning.

So this is particularly important in relation to the location of specialist hubs, because the border areas of both Wales and Scotland are very rural and the distances and transport difficulties to their own hospitals can be long and difficult—even more so if the patients have to cross the border. We need to ensure that anything done in the Bill makes cross-referral able to continue as easily as it does at the moment.

What discussions have taken place with the devolved Administrations about the Bill? Are there any aspects of it that are still waiting for the agreement of the Governments of Wales, Scotland or Northern Ireland?

[Baroness Thornton (Lab)]

My Lords, I am very grateful to the noble Baroness, Lady Walmsley, because she has helped me to clarify my thinking about this group of amendments. Basically, they have good intentions and they make good points about the things that need to happen, but I am not absolutely certain they need to be in the Bill. I am also particularly grateful to the noble Baroness, Lady Finlay, for her very well-informed contribution about what actually goes on. There are of course problems in relationships between the devolved nations and NHS England, some of which are down to not being very well organised, some of which are down to arrogance on the part of the bigger ones, and some of which are down to the funding not actually being available—and some of them might be politically motivated too.

Amendment 17 opens some new thinking on the subject of integration, and accepts that devolution has given us different systems for care in Wales, Northern Ireland and Scotland, but seeks to ensure that what is done in one part of the UK—that is, England—does not adversely impact on other parts. The intention to bring collaboration between the nations is, of course, commendable.

I note that Amendment 205 places some requirements such that

“Welsh Ministers, Scottish Ministers and a Northern Ireland department must make regulations providing that the choices available to patients in England by virtue of regulations under section 6E(1A) or (1B) of the National Health Service Act 2006 (inserted by section 69 of this Act) are available to patients for whom they have responsibility.”


Again, we can understand the need for consistency, but I am unclear about how that will play out against the devolved nature of healthcare—so I think the case will have to be made out for that and, indeed, why that would be included in the legislation.

In a similar fashion, Amendment 301 looks to establish interoperability around the use of data across the whole UK. Again, that is a wholly worthwhile intention, and one that I would hope that the various authorities could collectively work on and agree. Once more, what the role is for primary legislation to address this point is not entirely clear, and I welcome the discussion. I look forward to hearing what the Minister has to say.

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That is why I find it hard to support the amendments, although, again, as I did on Tuesday, I very much understand and support the sentiment behind them.

[Baroness Walmsley (LD)]

My Lords, like the noble Baroness, Lady Thornton, I shall start with those who I think should not be on the board before I turn to those who I think should. To a great extent I support the noble Baroness’s Amendment 29, but with a small caveat that, if she wished to press it, might require a bit of redrafting. I will explain.

Additional provider medical services are very useful in many areas to fill gaps in primary care capacity. They may provide additional services from which other NHS primary care services have opted out, such as out-of-hours services or enhanced services beyond the capacity of local NHS GPs to deliver. In some areas they have taken over primary care services where NHS GP practices have become too small to be viable or all the partners have retired.

Some APMS services are commercial businesses with a responsibility to their shareholders to make a profit, and I do not think these should be on the board. However, some APMS contracts go to NHS entities, and I would not want to exclude those. Of course, we must remember that for many years GP practices have also been small businesses, sort of, operating within the umbrella and ethos of the NHS. They too need to clear their costs or they will close down.

That is all well and good. However, if the Government are serious that they want to exclude private sector interests from ICBs, they must surely agree to include in that ban non-NHS entities that hold APMS contracts. A failure to accept the amendment of the noble Baroness, Lady Thornton, must surely make us a little suspicious about the Government’s claim that their amendment inserted in another place would successfully exclude private interests from the board.

Amendment 29 would extend the range of those involved in commercial enterprises from being members of the board of an ICS beyond those that we have just discussed in relation to the noble Baroness’s Amendment 28. Amendment 29 would specifically exclude NHS GP practices and voluntary or not-for-profit organisations from the ban. There are many types of organisations that would be included in the ban, although they could be heard on the board of the integrated care partnerships. Those include: pharmaceutical companies; providers of medical devices, equipment or premises; people who own care homes; and many other essential services without which our NHS could not survive. However, their importance should not entitle them to influence the constitution, strategy or commissioning principles of the board of the ICS. They are important providers that will be appropriately involved in planning at other levels, but they should not be able to steer fundamental decisions without the suspicion that they might have a commercial interest in such decisions. Indeed, the ban proposed in the amendment would protect such companies from such a suspicion, so perhaps it would be welcomed by them.

Turning to those who should be on the board, I will not repeat what the noble Baroness, Lady Hollins, said in introducing her amendments, because she has done it extremely well, particularly emphasising the impact of integrated services on people with learning difficulties and people with autism and how they could benefit from better integrated services if we got it right. So, I support her amendments.

I turn to Amendment 37, to which I have added my name to those of the noble Baroness, Lady Thornton, and the noble Lord, Lord Patel, for the following reasons. According to the Explanatory Notes, each ICB and its partner local authorities will be required to establish an integrated care partnership, bringing together health, social care and public health. The constitution of the ICB as it stands in the Bill specifies that the board must include only a minimum of three types of people who the Government clearly believe are essential to the effective operation of the board. They are someone from NHS health trusts or foundation trusts, someone from primary care, and someone from one of the local authorities in the area. If it is okay to prescribe these members, would it not also be wise to prescribe a few other key people with appropriate knowledge in order to achieve the ICB’s objectives of bringing together health, social care and public health? This amendment therefore suggests five other nominees—not 15, bearing in mind the Government’s wish to keep the ICB to a manageable size. But given the powers of the board, I would think it essential to have people nominated from mental health, public health, social care, health trade unions, patients and carers to bring their knowledge to strategic decisions.

If the board is to comply with the ambition of parity of esteem for physical and mental health—which we talked about two days ago—it will be important to have someone with the knowledge of how mental health services are working, as my noble friend Lady Tyler emphasised. Public health is a very particular discipline, the importance of which has been amply shown during the pandemic, which also has a vital role to play if we are to improve the health of local people and level up inequalities. Social care provision should never be separate from or subsidiary to health, as it is intrinsic to the functioning of health services in every area, so it is inconceivable that any ICB should ever be without someone from that sector.

The NHS is a people business, which is why those who deliver the services and the patients who are on the receiving end should have a voice at the top. Similarly, those thousands of unpaid carers, without whom vulnerable people would use up more of the NHS’s scarce resources than they currently do, should be represented at the very top of these new organisations. Their contribution to the efficient use of the board’s financial resources is crucial.

If the objective is to encourage more integration and collaboration, how could it be right not to have these additional five or six groups of people helping to make the strategic decisions? If that is not the case, as has been said by other noble Lords, the board could be dominated by the large acute hospitals and primary care, and the integration objective of the Government, which I endorse, would fail. I look forward to the Minister’s reply.

[Lord Kamall (Con)]

My Lords, this has been an excellent and wide-ranging debate, and I really am grateful to all noble Lords who tabled amendments today.

With your Lordships’ leave, I turn first to Amendment 18 in the name of the noble Baroness, Lady Thornton. This amendment would mean that the relevant ICB and ICP would need to be consulted before NHS England is able to provide support and assistance to bodies other than NHS bodies. The NHS has, under successive Governments of all political colours—indeed, since its foundation in 1948—commissioned care from various sectors to help it be more responsive to patients’ needs, and particularly to help deliver the commitments set out in the NHS constitution.

The vast majority of NHS care has been—and will rightly continue to be—provided by taxpayer-funded public sector organisations. But experience before and during the pandemic has demonstrated how important it is for NHS England to have the power, as the Trust Development Authority currently does, to provide support and assistance to any providers of services on behalf of the NHS. This will ensure that independent providers can, if necessary, be commissioned to provide important additional capacity where needed.

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This test has deliberately been framed broadly to reflect the wide range of potential circumstances that would render someone unsuitable to sit on an ICB board. It has also been framed to require the appointing persons to apply an element of judgment, because we want what is best for the NHS at all times and that requires a degree of local flexibility. To guide this judgment and to make sure it is being applied appropriately, NHS England will have the power to issue general guidance on the appointment process. If necessary, we can introduce further requirements in connection with ICB membership through regulations.

[Baroness Walmsley (LD)]

I apologise for interrupting the Minister, but I want to ask him a question going back to Amendment 28 and the APMS contracts. If we were to bring forward an amendment that made it very clear that we had no objection to NHS entities or not-for-profit organisations with APMS contracts being on the ICB, would he take a more friendly approach? It would just eliminate those that take profit out of the NHS.

[Lord Kamall (Con)]

I thank the noble Baroness for that suggestion and for trying to narrow the gap that there clearly is. If an amendment were put forward, we would look at it very carefully and consider the unintended consequences from the way it is drafted. We will consider it but, as I am sure the noble Baroness appreciates, I can make no promises at this stage.

I turn to the point made by my noble friend Lord Hunt of Wirral about how provider input in the work of an ICB will be reconciled with assessing both the suitability and performance of providers. As my noble friend correctly noted, each ICB must make arrangements on managing the conflict of interest and potential conflicts of interest, such that they do not and do not appear to affect the integrity of the board’s decision-making processes. Furthermore, each appointee to the ICB is expected to act in the interests of the ICB. They are not delegates of their organisations, but are there to contribute their experience and expertise for the effective running of the ICB—a point made most eloquently by the noble Lord, Lord Mawson, my noble friend Lady Harding and the right reverend Prelate the Bishop of London. It is important that this is about expertise, not the trust or organisation that they are taken from, or their skills and knowledge, as the noble Lord, Lord Mawson, said.

We are also keen to allow ICBs to develop their own governance arrangements, which best take their local circumstances into account. We want to give them the flexibility to learn and develop as their best practice evolves, so that other ICBs could learn from that best practice where there are concerns.

To support ICBs, NHS England is working with them to issue guidance and to develop and make clear our expectations of ICB leaders—expectations that have been reflected in the discussions and fantastic contributions from many noble Lords. For these reasons, I regret that the Government cannot accept these amendments at this stage. However, I hope I have given noble Lords such reassurance that they feel able to withdraw their amendments.

Turning to the membership of integrated care boards, I will begin with Amendments 27, 37, 38, 39, 40 and 41. I am grateful to all noble Lords who have brought forward these amendments today. I understand the interest from all sides in this membership. Schedule 2 sets out the minimum membership of the integrated care board; it will need to include members nominated by NHS trusts and NHS foundation trusts, by persons who provide primary medical services and by local authorities of areas that coincide with or include the whole or any part of the ICB’s area.

I take the point of the noble Lord, Lord Bradley, about mental health. I am sure he recalls the debate on Tuesday, when noble Lords felt very strongly about this. I have offered to meet many noble Lords from across the Committee who indicated that they want to see this parity with mental health, which they do not believe is implicit at the moment, even if we believe that “health” refers to physical and mental health. Indeed, it refers to spiritual health in many ways. But we understand that we have to close that gap and I will make sure that the noble Lord, Lord Bradley, is invited to those meetings.

It is important for us that we are not overprescriptive, which is especially true of any membership requirement. Any extension beyond the proposed statutory minimum will risk undermining local flexibility to design a board, as my noble friends Lord Mawson and Lady Harding and others have said, in the most suitable way for each area’s unique needs, drawing on the best expertise, but not where they are from. It may also make the boards less nimble and less able to make important decisions rapidly if we overprescribe.

It is important to remind the Committee—I apologise if noble Lords do not appreciate the repetition—that we set a floor and not a ceiling. The ICB can appoint board members if it wishes. Local areas can, by agreement, go beyond the legislative minimum requirements. They will want to ensure they appoint individuals with the experience and expertise to address the needs and fulfil the functions. Areas are already doing this. For example, in south-east London the ICB is proposing to include three provider members—acute, community and mental health—and six place members, one for each borough. This approach is exactly how we want ICBs to use the flexibility available to them.

If, in time, some of the concerns expressed today by noble Lords become clear—such as issues being skated over, ignored or elbowed out by others with louder voices—we may need to add further requirements that relate to ICB membership, and there are regulation-making powers in place in Schedule 2 to allow the Secretary of State to do so. Furthermore, NHS England has the power to issue statutory guidance to ICBs. It could, for example, use this to recommend that each ICB should consider appointing a learning disability and autism senior responsible officer, as I know the noble Baroness, Lady Hollins, has asked for and has spoken about most eloquently many times, most recently in a debate a few weeks ago.

Taken together, our approach reflects our view and, I reiterate, the view of the NHS that we should not attempt to overlegislate for the composition of ICBs and instead let them evolve as effective local entities to reflect local need. Let us get the right balance between the top-down and bottom-up approach, and make sure that they are relevant to their local areas. I am afraid that these amendments are seen to take a different approach, by adding more people to the minimum requirements for the ICB, making them larger but not necessarily better. They also add additional complexity by introducing a significant number of members who are responsible for activity outside the NHS. We think these would be better represented on the integrated care partnerships, which have a broader remit. I come back to the point that it is about expertise, not which trust.

I will consider the comments made by noble Lords very carefully if some of the concerns have not been met, and will have future conversations, between this stage and the next, if they feel that we have not addressed their concerns completely. I regret that the Government cannot accept these amendments. I hope that I have given your Lordships some, if not complete, reassurance and that noble Lords will feel able at this stage to withdraw and not press their amendments.