Health and Care Bill

Baroness Watkins of Tavistock Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, I welcome the noble Lord, Lord Stevens of Birmingham, to this House and enjoyed his erudite speech—and I am supportive of the fluoridisation of water. I draw attention to my interests as outlined in the register, particularly as a registered nurse and chair of a small housing association that specialises in housing for people leaving care.

This Bill is welcomed by many health and care communities, and I support its emphasis on collaboration and integration between mainstream NHS providers, public health, social care, the voluntary sector and, in some cases, the independent sector. This will be essential to meet our health challenges and increase productivity. The Bill refers to patient-focused care provision, yet future success will be achieved only if people take greater responsibility for their own health based on public health advice. For this reason, I suggest that the term “person-centred care” is substituted in many parts of the Bill to emphasise the partnership in care between service users and professionals. How can this House be assured that the structural changes proposed will reduce health inequalities and ensure parity of esteem between mental health, learning disability and physical healthcare services?

There is a concern that in ICBs there may be an overrepresentation of local acute trusts. I support amending board structures to mandate representation for mental health and learning disability providers; a member of the local community to represent users and carers; and a nominee from social services and public health. This will be vital to achieve balanced decision-making and fair allocation of resource.

In 2020 the World Health Organization launched a vision for nursing, with a clear policy committing all nations to increase the proportion and authority of nurses in senior health positions. I hope the Government will consider this in their new structures.

I support proposed amendments to ensure that the Secretary of State must lay regular reports before Parliament outlining the system in place for assessing and meeting the needs of the health, public health and social care workforce in England. Reports should include independently verified workforce numbers—in full-time equivalents, not headcount—and should indicate the proportion who have been trained in the UK and those recruited from overseas. The World Health Organization is clear that while healthcare workers’ migration can be positive, wealthy countries should not be overreliant on recruitment at the expense of lower-income and middle-income countries. Reports should identify the number entering training in the UK and the number of leavers, and should provide information on retention, including examples of best practice.

The Bill introduces the NHS payment scheme, designed to enable the integration of service delivery. To realise this ambition, there must be central prioritisation of early intervention and timely discharge. In August 2021 there were 25,836 days of delayed discharges for mental health services; 32% were attributed to social care and 11% to housing. The proposed payments system may make it easier to prioritise proactive community care, but this priority needs mandating in order to ensure that the new payments scheme drives reductions in delayed transfers of care and does not simply continue to accommodate extra bed days in hospital.

Patient safety and the relationship to safe staffing cannot be overemphasised. Amendments are necessary to promote workplace health and safety, including in community settings; the supply of PPE and other safety equipment; and clear mechanisms for staff to raise and resolve concerns. Staff teams should include relevant skill mix, adequate time for clinical supervision and access to continued professional education in data management, new research findings and interpersonal skills to provide contemporary evidence-based practice. I look forward to working with others in Committee to ensure that amendments concerning the issues that I have raised are considered.

Health and Care Bill

Baroness Watkins of Tavistock Excerpts

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

[Baroness Watkins of Tavistock (CB)]

My Lords, I support the majority of these amendments. I declare my interests as president of the Florence Nightingale Foundation and chair of the HEE review of mental health nursing.

A lot of noble Lords have spoken about mental health in the most glowing terms in the last hour. I am extremely supportive of the amendments in the names of the noble Baroness, Lady Hollins, and our new Member, the noble Lord, Lord Stevens of Birmingham. I have put my name to Amendment 138 on keeping proper data and information on waiting lists for people not with mental health issues but mental illness problems. There are people in our country with severe, enduring mental illness who fail to get early diagnosis because they do not even get on to a waiting list to see a consultant.

I see many of these people in my work with the charitable social enterprise I chair, Look Ahead, which provides housing to people who have suffered homelessness, people with mental health problems and learning disabilities and those discharged from prison—having completed their sentence, I should say. So many of those people have had better mental health care in prison than they ever had in society, because we do not list the number of people trying to access these services. We know that the life expectancy of people with long-term mental health problems is so much lower than that of the majority of people with physical health problems, because of things such as drug-induced psychosis, if it is not treated quickly. Professor Murray of the Institute of Psychiatry has been talking about this since I did my PhD there, 30 years ago, and we have still not resolved it.

I emphasise, as an ordinary person who works and has spent nearly 40 years working on a day-to-day basis either training mental health nurses or working with people with severe enduring mental illness, that these amendments are essential if we are to provide good health services for tomorrow’s population.

[Baroness Harding of Winscombe (Con)]

My Lords, I too support this group of amendments, both the parity of esteem words and the funding actions that make it up. I will briefly address the possible objections to it: first, it is not necessary because the Secretary of State already has a duty to maintain parity of esteem; secondly, as I think the noble Baroness, Lady Tyler, mentioned, this is culture change and legislation cannot drive that. In this case, actions speak louder than words. Being clear on the financial actions, as the amendments of the noble Lord, Lord Stevens, are, is a hugely important step on our culture journey.

Even though actions speak louder than words, the words matter too. They particularly matter when, as so many noble Lords have said so eloquently, mental health is so easily forgotten. It is all too easy to forget the hidden pain, anguish and need. I fear it is still far too easy to forget the hidden waiting lists. The words in this group of amendments are just as important as the actions, to make sure that we do not forget and build on the ground-breaking work that many, like the noble Baroness, Lady Hollins, have led for decades. We are on that journey, but we are definitely not there. I urge my noble friend to consider and accept these amendments.

Health and Care Bill

Baroness Watkins of Tavistock Excerpts

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

Amendment 66 therefore seeks to make smoking and other modifiable risk factors to health the responsibility of integrated care systems and local authorities, which must work together if we are to improve public health, with all the benefits that follow, including helping to protect our NHS.

[Baroness Watkins of Tavistock (CB)]

My Lords, I am delighted to speak to this group of amendments, which I support; I am particularly delighted to speak to Amendment 156, as one of its co-sponsors. I very much support the comments of the noble Lord, Lord Young, who has highlighted the appalling health disparities faced by people who are the most socially excluded. I, too, ask the Government to recognise how amending the Bill in the way proposed would help them to realise their ambitions in this area.

We know that the level of ill health among people who would be considered under inclusion health is significant. We have heard the shamefully low average age of death for people experiencing homelessness in England and Wales. We also know that the life expectancy of Gypsy, Roma and Traveller communities is around 10 to 12 years fewer than that of the general population, although one study has found that this gap can be as high as 28 years. This disparity in life expectancy clearly demonstrates the devastating impact of extreme social exclusion.

It is clear to me that the health and social care system has a significant role to play in tackling the health inequalities experienced by these groups. These amendments would facilitate crucial progress towards that and encourage social enterprise involvement to reach the most socially excluded individuals. We have seen examples of this at the relatively new Plymouth dentistry school, where the training clinic has been set up as a social enterprise to serve some of the poorest people in Plymouth.

In relation to Amendment 156 in particular, we know that NHS services must be integrated with wider services to reflect how people’s lives work. A main aim of the Bill is integration, yet integration could not be more important for the groups that experience the most complex needs and require very effective, co-ordinated care. As I know from my time in nursing, there has been a historic lack of integration between housing, health and social care, yet housing is fundamental to reducing health inequalities. Without integration across these different systems, people will continue to develop acutely poor health.

People who experience social exclusion, and extreme health inequalities as a result, often fall through the gaps in the provision of primary and secondary care, mental health and substance misuse services, health and social care, and even health and wider systems, such as housing. For example, we know that people experiencing homelessness attend A&E six times as often as people with a home, are admitted to hospital four times as often, and stay three times as long. One study has found that homeless people attend A&E 60 times more than the general population. This has tragic results for the individual and also places incredible strain on our healthcare system.

We must act to alleviate the pressures on the NHS where we can. Severe and multiple disadvantage is conservatively estimated to cost society more than £10 billion a year. It is clear that the cost of doing nothing is too high, both to the individual suffering severe health inequalities and to the NHS. This amendment would help address these issues by ensuring that housing is considered by integrated care partnerships. It is non-mandatory, therefore speaking to the Government’s aims of enabling local decision-making and flexibility, but would ensure that partnerships think of the important role that housing plays by providing a stable place from which people can then engage with wider health services. A wide range of expert organisations are supportive of this amendment and related Amendments 152 and 157, including Crisis, Social Enterprise UK, Doctors of the World, and Friends, Families and Travellers.

The NHS must work effectively for all who are entitled to use it, including those who need it most. If we get access and outcomes right for the most marginalised in our society—those who experience the poorest health —we will likely get access and outcomes right for everyone. That is why I call on the Government to support the amendments in this group.

[The Lord Bishop of St Albans]

My Lords, Amendments 68 and 95 are in my name. I declare my role as president of the Rural Coalition. I support the broad drift of these amendments, which engage with the important issue of reducing inequalities.

Rural health and social care has often presented challenges in terms of proximity to services, the types of services available within a local area and the demographics of rural areas. It is complicated. Rural areas have a higher proportion of older residents, which is always a greater burden on healthcare services compared with areas with younger populations.

Furthermore, a variety of issues that feed into rural health and social care are beyond the remit of the Bill. In March 2017, Defra produced its Rural Proofing practical guidance to help policymakers assess the impact of policies on rural areas. At the time, this was a welcome initiative to ensure that rural interests were being adequately considered and, to quote the report, that

“these areas receive fair and equitable policy outcomes.”

Unfortunately, concerns have since grown among rural groups that this guidance has become a sort of bureaucratic box-ticking exercise in Whitehall that does not take into account the complexities of rural life.

Funding allocations are often the result of specific metrics or formulas, many of which disadvantage rural communities. For example, a 2021 report by the Rural Services Network, Towards the UK Shared Prosperity Fund, highlighted how many of the post-Brexit levelling-up funds disadvantaged poor rural areas due to way in which they measured poverty. The Department for Transport’s own 2017 statistics showed that, on average, travel from rural areas to either a GP or hospital was 40% longer by car and 94% longer via public transport when compared with travel in urban locations.

Further, 2017 figures from Rural England highlighted the higher rates of delayed transfer of care from hospitals in rural areas: 19.2 cases per 100,000 compared with 13 per 100,000 in urban locations. Analysis by the RSN has shown that, when compared with predominately urban areas, rural local authorities received significantly less grant funding per head to pay for services such as social care and public health responsibilities, in spite of the fact that they generally deal with older populations. Other problems include limited intensive care capacity in rural areas, the loss of local services through amalgamations, the relatively few specialist medical staff in rural areas, and the general staff shortage and retention issues facing rurality.

It is commendable that the Government have legislated in this Bill to introduce a duty on integrated care boards to reduce inequalities between patients with respect to their ability to access health services. My amendments would extend this principle and reduce those health inequalities with respect to where someone lives, whether it is an urban or rural area, and place a duty on ICBs to co-operate with each other for the purpose of reducing healthcare access inequalities. In effect, this is a statutory rural-proofing requirement.

This duty to consider rural access when reducing inequalities extends to co-operation between ICBs because rural areas often exist on the periphery of a large geographical region where patients in one area may reside closer to crucial services in a neighbouring board. Naturally, rural areas lack the economies of scale of urban areas, and greater cross-ICB co-operation will be required to utilise joint resources most effectively when delivering different services to rural areas that fall within border zones of ICBs.

One area where a collaborative approach between ICBs will be crucial for rural areas in the near future is the current reorganisation of non-emergency patient transport by NHS England, which will shift to ICBs shortly. Although rural areas undoubtedly are being considered as part of this re-organisation, patient transport is already a rural inequality that needs addressing. Putting rural proofing with respect to health care on a statutory footing presents a more concrete way to implement the existing rural-proofing guidance. The need for co-operation between administrative areas and for overall plans to be rural proofed will become more essential, particularly for secondary health services, if teams of specialist clinicians become increasingly consolidated in ever fewer locations.

Can the Minister outline how the Government intend to reduce the inequalities in healthcare access and funding that many rural areas face, and how they will effectively ensure that ICBs adequately rural proof their plans in line with the Government’s own guidance?

Health and Care Bill

Baroness Watkins of Tavistock Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

[Lord Layard (Lab)]

My Lords, Amendment 101B, in my name and those of the noble Baroness, Lady Watkins, and the noble Lord, Lord Alderdice, is a fundamental amendment to remedy the shocking imbalance between the provision of mental and physical healthcare. As was said in the debate last week, people with mental disorders who receive treatment are a minority—35% of children and 40% of adults—while for people with physical illnesses, the vast majority get treated. This is not parity of esteem; in fact, I think it is one of the greatest cases of discrimination in our public life. There is only one way to remedy it, which is that the funding of mental healthcare has to rise faster than the funding of physical healthcare. In other words, the fraction of NHS funding devoted to mental healthcare has to rise—it is a matter of simple logic. This is such a fundamental point of principle that it should be put into law.

The increase does not of course have to go on for ever, but only until the inequality has been eliminated and mental health is treated like physical health. In the words of the amendment, the rise should continue until

“people coming forward with mental health problems are as likely to be offered treatment as people with physical health problems”,

and, of course, to receive it within a period of time appropriate to their problem. Only then will we have achieved parity of esteem.

The amendment is a statement of principle. As we know, there are always problems of definition and interpretation with statements of principle, but such statements are common in our statute law. This is a sector, in financial terms, as big as the police service, and it is right that there should be legal principles governing it. If we want to secure justice for the sector, it needs a statement of principle. This is a stronger statement than any of those discussed last week, but if this is what we believe, it is what we should say.

The main argument for the amendment, as I have said, is one based on simple equity, but there is also a strong economic argument. Mental illness is mainly a disease of working age, while physical illness is mainly a disease of retirement. Half of all working-age disability and absenteeism is due to mental illness, so when we successfully treat mental illness, the savings to the economy and to the Exchequer are massive, especially when compared with the economic savings from the majority of physical healthcare. These economic savings were a key argument that led to the establishment of IAPT, Improving Access to Psychological Therapies, from 2008 onwards, and they have been verified in what has happened since in that service.

There is also another very important source of savings: savings to NHS physical healthcare. Psychological therapy has been shown to reduce the cost of physical healthcare for people with comorbid physical conditions. This can be seen in a major nationwide controlled trial done recently, which provided IAPT treatments to people with long-term physical conditions such as diabetes, CVD and COPD. This trial found that, within a year, the savings on physical healthcare covered the total cost of the psychological therapy—so the mental health service is saving money for the physical healthcare service. As a result, this approach is now being rolled out nationally.

So mental health is a classic case of spend to save, and extra spending is desperately needed. Some of it would fill the massive gaps in existing services, including for severe mental illness, and some of it would provide services to key groups of people who are barely helped at present, many of whom were referred to earlier in this debate.

First come the tragic children who fall below the CAMHS threshold, who are sometimes assessed and sent back home as not sick enough, but who desperately need help. For these young people, the Government are developing mental health support teams in schools, but the rollout is incredibly slow and the services also need to include a much higher level of expertise.

Then there are millions of people whose lives are wrecked by addiction to drugs, alcohol and gambling and who need psychological therapy. There are the victims and perpetrators of domestic violence, who have already been mentioned, and other forms of violence. So many of our social problems have a strong mental health component. There are good, evidence-based psychological treatments which NICE recommends for these problems, but they are not provided. They should be provided. Extra spending on mental health could massively improve our society.

There is one further point in the amendment. If we spend the money, we need to know what it is achieving. In IAPT we know the progress of 100% of those treated, but in most parts of adult and child mental health services we currently have very little quantitative data on what is being achieved. That has to change, so universal routine outcome measurement should be a reasonable quid pro quo for extra funding, but the extra funding is crucial. It is not enough to talk about parity of esteem. We must have a clear statement of how to recognise it and the funding principles to achieve it.

[Baroness Watkins of Tavistock (CB)]

My Lords, I rise to speak to this group of amendments with an emphasis on Amendment 101B, in the name of the noble Lord, Lord Layard, whom it is a pleasure to follow.

Last night, I went to the ballet and saw “Raymonda”, which has been placed in the context of the Crimea. It reminded me that Florence Nightingale took a hammer to a store-cupboard to get food and blankets for some of her patients because nobody knew what was inside it. She went on to be a leader in sound data for health- care, recognising that without data we could not plan for the future. This amendment emphasises measuring the outcomes of mental health nursing and other mental health interventions in order to ensure that we learn from practice and develop best practice cost-effectively. That is why I have put my name to Amendment 101B.

We need to look at similar patterns for care to those for physical illness. For example, the onset of paranoia and delusions which threaten the safety of an individual or those close to them could perhaps be equated with a suspected cancer where you wait for two weeks for an initial diagnosis. How many people are sectioned under the Mental Health Act for assessment because they have not managed to get an out-patient appointment for assessment earlier? I believe that is an example of discrimination against people with severe mental health problems. If we could get parity of access for assessment, it would be an extremely good beginning. I recognise that there are other physical and mental health problems that are less urgent, but I use that as a comparison.

Yesterday at a meeting concerning mental health reform after the pandemic, the Minister for Care and Mental Health Gillian Keegan and the chief executive of Mind were panellists. At that meeting, it was noted that investment in NHS mental health services currently increases year on year, largely due, I think, to action under the leadership of the noble Lord, Lord Stevens of Birmingham. It was £11 billion in 2015-16 and is £14.3 billion today and it will continue to increase, including an additional £2.3 billion by 2023-24. It was said yesterday that the Government will ensure ICBs will increase spending on mental health in their area in line with growth in their overall funding allocations to meet the mental health investment standard. To address backlogs, the Government have published their mental health recovery action plan backed by an additional £5 million to ensure that the right support is in place. This illustrates that the Government are committed to the improvement of mental health services. The amendment would place a duty to monitor this investment and evaluate its effectiveness. I hope that the Minister feels able to support the principle behind the amendment and will meet those of us interested in this area to try to find a summary solution to the issues we are raising on parity not only for mental health care but for the care sector that has been outlined so comprehensively by my noble friend Lady Hollins.

All the points that were made by the noble Lord, Lord Black of Brentwood, concerning osteoporosis could be made for drug-induced psychosis, schizophrenia and other severe mental illness problems. I hope that this Committee will be able to influence an amendment to the Bill that will ensure that the monitoring outlined in the amendment introduced by the noble Lord, Lord Layard, will be taken forward.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I have added my name to Amendment 50 tabled by the noble Lord, Lord Black, but I want to say how much I agree with Amendment 297J, tabled by the noble Baroness, Lady Barker, about the mess we have between local government and the NHS on sexual health services in general and the HIV services that she mentioned.

My view is that local government has a choice. It either accepts that it is part of a national service here and agrees to earmark funding allocations, or the service will have to go back to the NHS. The current situation is not working. Some local authorities are having to take on the responsibilities of others because some local authorities are not spending sufficiently. There is a movement of people, largely into the big cities, and it is an unfair system. We have to do something about it.

I also support the noble Baroness, Lady McIntosh, in her Amendment 110. Anyone listening to the debates during the recent passage of the domestic abuse legislation would have noted that one of the big challenges is the lack of integration among local agencies. I am afraid the NHS is a part of that and the noble Baroness’s amendment would give a very clear indication to the NHS that we expect more of it.

I have no doubt that, in winding, the Minister will say that Amendment 50 is not necessary because there is already a general duty on the NHS to provide fracture liaison services and the department is doing all it can to encourage the NHS to implement them. However, the dilemma for us is that the positive outcomes from those services have been known about for many years, yet progress in moving to the standard adoption of them through the country is very slow indeed.

As far back as 2010, the Royal College of Physicians produced an audit of the quality of clinical care of patients who had fallen, had a fracture and had been seen in a hospital emergency department. It reckoned then that only 32% of patients with a non-hip fracture received an adequate fracture risk assessment. Just 28% were established on anti-osteoporosis medication within 12 weeks. As a result, the Department of Health incentivised primary care services to initiate these treatments for relevant patients, but, by the end of the first year of that scheme, fewer than one in five patients were receiving the treatments.

Health and Care Bill

Baroness Watkins of Tavistock Excerpts

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

[Baroness Watkins of Tavistock (CB)]

My Lords, it is a pleasure to follow the noble Baroness, Lady Hollins, and I completely support what she and the noble Baroness, Lady Verma, have just said. Unless care wages equate with the minimum for personal care in the NHS, we will never resolve this problem. I have been told by the National Care Forum that that means approximately £13.50 an hour. I would like to see that on the record.

The main reason I rise is in support of Amendments 173 and 171, which reflect other amendments looking at the need to ensure that we get workforce planning right for the future. Although we are talking about the future, we are also talking about the immediate crisis in social care.

I was amused at 6.36 pm to get a message from NHS Professionals, which said: “Dear Mary, you are receiving this email because you are registered on our NHS pathway for professionals. We still have many new opportunities that you would be interested in, so please feel free to log in and see now.” I do not know whether the noble Baroness, Lady Chisholm, who is just walking in now, has had the same email from NHS Professionals, but we both logged on at the same time—and she is nodding she has. We will stay here for the time being.

The pandemic has placed a spotlight on the health and care workforce and the pressures it sustained. However, these pressures are against a background of persistent under-recruitment, under-retention and under-representation. This shortfall has serious implications for patient and staff safety, as well as the efficiency of health and care services. In part, as others have said, this has been ameliorated by overseas recruitment. However, as a co-editor of the World Health Organization’s State of the World’s Nursing report last year, I have to say that that is not sustainable or ethical. However, I particularly congratulate the Chief Nursing Officer, Ruth May, for her initiative that enables and encourages refugees to register as nurses in this country, which is clearly an ethical practice.

A strategy to comprehensively monitor and meaningfully respond to the shortfall is essential to support the recovery and development of a strong, safe and sustainable workforce. As it stands, I do not believe that the Bill adequately mandates the actions required to achieve this ambition. As others have said, across the NHS there is a shortage of almost 100,000 full-time equivalent staff, with nursing staff accounting for 40% of vacancies in England. In the last five years, we have seen less than a 10% increase in mental health nursing staff and a continual decline in learning disability services. I understand there is an NHS England ambition for 21,000 new posts across the mental health system. This appetite for expansion—with the view that it translates to a sufficiently staffed and skilled workforce—is welcomed perhaps more so than ever, as 2.8 million people, or 5% of the population, had contact with secondary mental health, learning disability and autism services during 2020 and 2021.

As we are all aware, the workforce shortage is not limited to the NHS. The turnover rate of registered nurses in adult social care is four times higher than in the NHS, with marked regional differences. Getting the right number of staff with the right skills therefore remains a challenge and requires urgent review to maintain quality patient care. In care homes, the shortage of registered nurses has caused some providers to renounce their registration to provide nursing care, forcing some residents to find new homes. In hospitals, high staff turnover and the use of agency staff have contributed to excessive restrictions and blanket approaches to care for people with learning disabilities and autism, for example.

We have also seen an impact on growing waiting lists. In the first quarter of this year, only 61% of children and young people with eating disorders were seen within one week for urgent review—a 72% reduction from last year and falling below the national standard. I therefore welcome the focus on children and young people’s mental health teams, including the proposed approach to facilitate a much better system in schools. However, such healthcare workers will need to be included in workforce reviews to facilitate a system-wide understanding of current and projected needs and resources. We should celebrate that so many people want to become nurses and encourage them to do so by investing not only in university places but in apprenticeship schemes that enable a wide variety of people from different cultural backgrounds to enter the profession.

While workforce data is collected monthly and subject to validation, it is segregated by sector, which makes some comparisons difficult. There are also known data limitations. In social care, only half of the workforce is recorded; in general practice, sessional practice nursing is not directly comparable with the main workforce; and in the independent health sector there is no complete estimate of the total workforce, despite the fact that it provides significant NHS services.

All this necessitates an imperative call for a workforce strategy that goes beyond a five-year snapshot of the NHS. Rather, a collective effort across the health and care labour market, including community nursing and midwifery, is warranted to annually capture and forecast workforce shortages and requirements over time, with a five-year government strategic response and annual update. Without these amendments, England risks a future health and care workforce that lacks the sufficient capacity, competence and diversity that is necessary to achieve more integrated care and safely promote health and support the changing needs of the population.

[The Lord Bishop of London]

My Lords, I will speak briefly on Amendments 170, 171 and 173. As a former Chief Nursing Officer, I recognise the challenge of ensuring the right number with the right skills of those providing healthcare to meet the needs and the future needs of the population. As someone who, while the Government’s Chief Nursing Officer, was given the objective of finding 60,000 nurses, I understand that it requires a whole-systems approach. I often felt it was about science and art—the science was in the work that went on nationally but the art was in the way it was applied locally on the ground. The noble Baroness, Lady Walmsley, talked about how work on the ground is often not about intuition because that is about experience and knowledge; it is about how it is applied on the ground. I also reflect on the fact that although it was my role with all those working around me to find 60,000 nurses some years ago, we are seeking to find almost the same number today. That demonstrates the fact that we do not have a sustainable model of workforce planning and that we need to do better.

We have already heard how the Bill requires the Government to publish a report that describes the systems in place for assessing and meeting the needs of the workforce. We have already heard that that does not go far enough. In meeting workforce needs, systems are required for both planning and supply, but that does not ensure that it will happen. I believe that we need a system that has accountability, that puts into place long-term planning, and that is funded.

The Secretary of State needs to be held accountable for both workforce planning and supply, because there are some things that only the Secretary of State can do. For example, if the workforce planning systems are not co-ordinated at a national level, there is often limited ability to respond to local variations on the ground, such as those between rural and urban settings or between professions or sectors. For example, responding to local variations may require national changes, such as in training or registration.

There are also parts of the workforce planning system for which only the Secretary of State can be accountable. For example, you can assess and put in place workforce plans but unless they are funded, it is done in vain. There are also actions that are often taken at a national level by government, which can impact on workforce supply and which only the Secretary of State can resist. We have seen national policy influence recruitment and retention: for example, as we moved away from the nursing bursary, as we have seen changes in immigration policy and in the challenges faced by the medical profession around its pensions. All those impact on recruitment and retention.

The Health and Care Bill must have embedded in it accountability for workforce planning and supply sitting with the Secretary of State. This will not only ensure good supply but will prevent staff shortages, improve patient safety and the quality of care. If this is not resolved, we will see those deteriorate.

Finally, on sustainability, we have heard how planning for the workforce takes time. We have heard how long it takes to take train a doctor or a consultant or even a clinical nurse specialty. These periods of training reach over the span of a Government. We need a system that does not just respond to the needs of a Government but beyond them, to ensure that our horizons are not limited by politics but by the needs of a population. Our workforce provides not just quality care to an individual but to a community. We have heard how, if we fail to provide the right workforce, we will fail the other aspirations in the Bill.

Health and Care Bill

Baroness Watkins of Tavistock Excerpts

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

[Lord Patel (CB)]

My Lords, I rise to speak to Amendment 243 in the name of the noble Baroness, Lady Merron, and Amendment 264 in the name of the noble Lord, Lord Hunt of Kings Heath.

Yesterday I was chastised—wrongly, in my view—for speaking at length. Such boldness requires training in speaking up, confidence in being right and using authority. The comments came from a government Whip, who happens to be a registered nurse. As a doctor, I am used to that. When a nurse speaks up, patient safety improves, health equity improves, collegial relationships are stronger—again, as a doctor I can vouch for that—and healthcare systems improve. This is because of their training. Not recognising legally the status that the title of “nurse” brings to those that are highly trained and qualified and on a nursing council register is wrong.

We all know what a nurse is; a nurse is highly trained, highly competent, can do the job well and is on a nursing register. Anybody else is not a nurse. It is right, therefore, that we recognise this and give it a legal status. Furthermore, the NHS and health providers should not employ anyone as a nurse who does not meet the above criteria. I understand that last year there were 195 advertisements for nurses in the NHS which did not say that the qualification of being registered was necessary. In my view, that is wrong. I strongly back this amendment, and I look forward to the contribution of my noble friend Lady Watkins.

Turning to Amendment 264 on the appointment of consultants in surgery, I am a fellow of the Royal College of Surgeons of England, the Royal College of Surgeons of Edinburgh and the Royal College of Physicians and Surgeons of Glasgow, so I speak on behalf of all surgical colleges. Let me give your Lordships an example: there is a surgical post empty in Birmingham. A highly qualified person, who was well-trained in Scotland and holds a fellowship of the Royal College of Surgeons of Edinburgh, is a key candidate for application but cannot be appointed because the Royal College of Surgeons of England cannot provide an assessor. On the other hand, there is a surgical vacancy in Glasgow, and the top candidate is a fellow of the Royal College of Surgeons of England but can be appointed without a Royal College of Surgeons of England assessor being there. That is a total anomaly.

A person can be appointed who is fully trained in Scotland, is a fellow of the Royal College of Surgeons of Edinburgh, works in Cambridge, applies in Cambridge, but you cannot have an assessor from the Royal College of Surgeons of Edinburgh. In all other specialties—the Royal Colleges of Obstetricians and Gynaecologists, of Ophthalmologists, of Radiologists, of Psychiatrists, of Anaesthetists, and in public health—the assessor can come from any part of the United Kingdom. This anomaly can be stopped very easily. I agree with the noble Lord, Lord Hunt of Kings Heath, that it is not a big deal; just change it in legislation. I do not know who opposes it.

[Baroness Watkins of Tavistock (CB)]

My Lords, it is a pleasure to follow the noble Lord, Lord Patel, on the term “nurse”, which is protected in law at the moment only for those who are a “registered nurse”. This means that anyone can describe themselves as a nurse, as the noble Baroness, Lady Wheeler, outlined. They can even describe themselves as a nurse if they have no qualifications or experience—or, perhaps more seriously, have just been struck off the register. As somebody who was a member of the forerunner to the Nursing and Midwifery Council, I can say that we do not strike people off the register lightly, so the risks of such people being at large and describing themselves as nurses are serious. For this reason, a petition was created calling for the title “nurse” to be protected further in UK law.

In the initial response by the Government to the petition, recognition was given that the protection of professional titles

“provides assurance to the public that someone using that title is competent and safe to practise.”

The response references a consultation by the Department of Health and Social Care on professional regulation, Regulating Healthcare Professionals, Protecting the Public. In the Nursing and Midwifery Council response to this consultation, the nursing regulator recognised issues around the limitations of “nurse” not being a protected title and said it did not think that its current powers are sufficient,

“given that they are primarily based around titles that are not widely understood by the public or used by the professions.”

This amendment is designed to ensure that there are sufficient regulatory levers to be able to protect the public in the future.

Nurses on the NMC register find it difficult to understand why the Government are reluctant to protect the title. As part of the statutory regulations of the Health and Social Care Act 2012, it was mandated that registered nurses would be part of the clinical commissioning group governing body. In Regulation 11 of the National Health Service (Clinical Commissioning Groups) Regulations 2012, the CCG governing body is required to include at least one registered nurse within its membership. This created a statutory commissioning role for nursing leaders in England that will be lost should this not be required within integrated care boards’ executive membership. Please can the Minister explain whether guidance will include a recommendation that there should be a registered nurse as part of the executive team on integrated care boards?

[Lord Kakkar (CB)]

My Lords, I support Amendment 264, in the name of the noble Lord, Lord Hunt of Kings Heath, to which I have added my name. In so doing, I remind noble Lords of my own interests, particularly as a fellow of the Royal College of Surgeons of England, a fellow of the Royal College of Physicians of London and an honorary fellow of the Royal College of Surgeons of Edinburgh.

This is a critical amendment, as the noble Lord, Lord Hunt of Kings Heath, indicated, strongly supported by my noble friend Lord Patel. Currently, the National Health Service (Appointment of Consultants) Regulations 1996, with additional guidance provided by the department in 2005, restricts membership of advisory appointments committees for consultants to certain royal colleges, as we have heard with the appointment of surgeons by the Royal College of Surgeons of England alone—and, indeed, for physicians by the Royal College of Physicians of London. This is an anomaly. The medical royal colleges across the United Kingdom are recognised in terms of the postgraduate training that they are able to supervise, the continuing professional development they are able to provide and, indeed, collaborate with regard to postgraduate examination which is required for provision of the certificate for the completion of specialist training. However, when it comes to the question of consultant appointment, there is this restriction.

Noble Lords might ask why it is important that this matter be dealt with. The provision by a medical royal college of a professional member to serve as part of the appointment process for a new consultant is critical. Those representatives provide expertise and insight with regard to the nature of the job description, the requirements for the individual post, and the assessment of individual candidates as part of the selection process on the day.

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I would love to hear the Minister say “Yes, go ahead”, because there is a demand here for urgent action.

[Baroness Watkins of Tavistock (CB)]

My Lords, I apologise to the Committee for omitting to say that I am a registered nurse on the NMC database. I think this is important in relation to Amendment 243.

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

[Lord Davies of Brixton (Lab)]

My Lords, I apologise for the confusion at the beginning of this debate. My understanding of the ways of this House is still a work in progress. I gave notice of my intention to oppose the question that Clause 80 stand part to provide the Government with an opportunity to explain more clearly than they have their intentions for the management of hospital discharge. I hope in so doing they can allay the concerns that surround the proposal to revoke Section 74 of the Care Act 2014. For example, there are the concerns of the National Care Forum, which points to the danger that

“the removal of an assessment prior to discharge will result in less priority to undertake the assessment once someone has left hospital—for someone needing support to remain in their own home, this is concerning.”

The process of hospital discharge is a crucial element within the integrated care system established by this proposed legislation. From the perspective of the service user, this is where it all comes together. It must be done right. The Explanatory Notes tell us that this clause introduces flexibility for local areas to adopt the discharge model that best meets local needs, including an approach known in England as discharge to assess, the argument being that people will be assessed at a point of optimum recovery, allowing a more accurate evaluation of their needs. Who could possibly object?

The first problem is that there is a widespread lack of trust in the Government’s motives and intentions on this, like on other changes in the Bill. It is possible to argue that the change means that people will be assessed where most appropriate. But it is also possible to argue that the change will facilitate premature discharge that is in the interests of the service provider, not the people receiving the service. As well as explaining and stressing the advantages of the proposed change, the Minister needs to tell us what the Government are doing to ensure that it will not lead to the disadvantages that many of those involved in the process fear.

The second issue that the Government need to address is that hospital discharge is still seen predominantly as a medical matter, with concern that insufficient attention is given to the social care aspects. A survey from December 2020 of social workers who were involved in hospital discharges made it clear that the vital contribution of social work in the multidisciplinary team was being marginalised by the medicalisation of people’s journeys out of hospital. Most importantly, social workers were found to feel that the voice of the individual, the person receiving the service, was being lost, indicating that arrangements were being made without consent or against people’s views and wishes.

It is also important to understand the context within which this change is proposed. On the one hand, there is the current crisis in social care. Even without the impact of the Covid pandemic, demand is outstripping supply, there are waiting lists for assessments of need and support, and local authorities are operating with significantly reduced budgets following a decade of austerity. On the other hand, there is the widely understood pressure on the hospital sector, with increased demand and mounting waiting lists. Both these factors are the result of the long-term underfunding of our system of health and social care. This will have to be addressed—just let it not be at the cost of the service user.

We must ensure that community health teams and social care teams have the resources they need to provide a needs assessment as soon as an individual is discharged. Too often, the issue of hospital discharge is discussed in terms of the needs of the service and not of the individual person.

[Baroness Watkins of Tavistock (CB)]

My Lords, it is a pleasure to speak on this group of amendments, but I want to focus particularly on Amendment 219. There are around 6.5 million unpaid carers in the UK, a number which increased to 13.6 million, or about one-fifth of the population, during the height of the pandemic. Some 1.4 million people provide more than 50 hours of unpaid care per week. Unpaid carers are often relied on to provide this care, yet receive minimal or no formal support themselves. Instead, many report feeling isolated, undervalued and pressured by the challenges of stress and responsibility. Being a carer is emotional and physical labour.

A lot has been said about the Carers UK survey, which identified that 56% of unpaid carers were not involved in decisions about patients’ discharge, with seven out of 10 respondents not being asked whether they were able to cope with having the patient back home and six out of 10 receiving insufficient support to protect their own or the patient’s health and well-being. This lack of support reflects the absence of a unified and systematic approach to identifying and supporting unpaid carers. It demands urgent remediation, especially as we know that unpaid carers are twice as likely as non-carers to have ill health, and the majority have reported worsening mental and physical health during the pandemic.

I endorse Amendment 219 because it talks about carers who work with people who come into contact not just with hospital services but with NHS services. In my work as a community mental health nurse, in many instances I saw that people were not admitted to hospital for years—which was actually a very good outcome—but their carers’ needs were just as great in supporting them with long-term problems in their own homes. This amendment would create a duty in respect of any person receiving NHS care, whether that is in the community or in hospital. The NHS must identify unpaid carers, particularly young carers, and ensure that their health and well-being are properly considered. This is a vital public health duty.

[Baroness Tyler of Enfield (LD)]

My Lords, I strongly support this group of amendments. I particularly endorse Amendment 269 regarding young carers, which was spoken to so compellingly by the noble Lord, Lord Young.

I wish to speak primarily about Amendment 221, to which my name is attached. It is about protecting existing rights of carers. I know that the point has already been made, but it is worth repeating. Amendment 221 would retain existing rights being taken away by this Bill as it repeals the Community Care (Delayed Discharges etc.) Act 2003. I find that a pretty extraordinary position to be in.

I want briefly to focus on the impact of caring particularly on women and employment, without in any way wishing to diminish the very important role played by male carers within the family. It is just a fact that women are more likely than men to be carers. According to some research conducted by Carers UK with the Universities of Sheffield and Birmingham, women have a good chance of becoming carers 11 years before men. Women are also more likely to reduce their working hours in order to care, and they are more likely as a result to have lower incomes and end up under-pensioned in retirement.

As we have heard, hospital discharge can be a pivotal moment for people providing care, particularly women. This amendment would ensure that assumptions are not made about carers’ ability to care, even when they may be working at the same time, that a solution is discussed and, ideally, agreed between families and services, and that carers are provided with the support they need to enable them to care safely and well. For those carers who are juggling work and care, which I can relate to personally, it is essential that their health and well-being are supported. This also has a positive benefit for employers. During the pandemic, the Carers UK research already referred to found an increase of around 2.8 million in the number of people who were juggling work and care, the majority of whom were women. Prior to the pandemic, some 600 carers a day were giving up work to care. During the pandemic, as the noble Baroness, Lady Pitkeathley, reminded us, carers have become the backbone of the care system, protecting the NHS and social care in many cases from collapse.

The Carers UK research also found that 72% of carers providing substantial care and working were worried about continuing to juggle care and work, and 77% of carers said that they felt tired all the time at work because of their caring responsibilities. During the pandemic, 23% of working-age carers providing substantial care had given up work, lost their jobs, lowered working hours or lost income if they were self-employed.

As the NHS works to reduce the backlog of care, hospital discharges will become ever more critical, as will support for carers. The two go hand in hand, and we must not fail those who have so selflessly shouldered such a heavy load.

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

[Baroness Greengross (CB)]

My Lords, I rise to speak to my Amendment 289, which would ensure that every hospital has sufficient accommodation to allow a bed for any patient who is rehabilitating and who no longer needs to be in hospital, but who cannot be discharged to their own home. Further, this amendment would place a duty on the Secretary of State to ensure that hospitals use any spare land owned by the NHS to build this accommodation.

For many years I have been an advocate for this type of accommodation. The NHS has struggled for a long time with a lack of available hospital beds, a situation made worse by the coronavirus pandemic. Having rehabilitation accommodation for people who need to be near a hospital in case they need to see a doctor, but who do not need the full services of an NHS hospital bed, which is considerably more expensive, would be of considerable benefit. In Scandinavia, patient accommodation of this nature has been part of the state health system since the late 1980s. Having patients stay in these facilities, which are designed to cater for people needing medical care, has delivered considerable savings to the public health system.

The cost of someone staying in one of these hotel rooms is less than a third of the cost of someone staying in a hospital bed. This is a great example of how the private sector, working in conjunction with the state, can enhance efficiency and deliver better public health outcomes. Over the last couple of years I have had the privilege of working with chartered architect Jimmy Kim, who has identified various opportunities throughout England to use NHS-owned land or vacant buildings for this sort of development. These sites could be given to the private sector to develop into non-clinical units, with a guarantee of a utilisation contract from the Government. At present, NHS trusts are spending money putting up patients in hotels, with rooms costing as much as £275 per night. One hospital has spent over £1 million on hotel rooms in the last three years. From a cost perspective, it would be better for the NHS to provide this accommodation in symbiosis with the private sector, rather than paying hundreds of pounds a night for hotel rooms or having patients stay longer in hospital beds which are not designed for the context of health rehabilitation.

We need to bear in mind the widening context of what a patient is in today’s society, which is one with dementia, adult-disabled, mental health issues and, progressively, those for whom the social services have yet to find suitable accommodation.

The need to reform both health and care is long overdue. The pressure to invest more in social care has been building up over many years, and Governments have been slow to respond. But part of this must also be looking at prevention and helping people to remain independent, which we can do through supporting rehabilitating patients and helping people to remain independent. We also know that pressure on our hospital system means that many people wait far too long to get treatments, while others stay too long due to there not being suitable accommodation when they are discharged. In too many cases, people end up in hospital for too long or in the social care system where, instead, the step-down accommodation that I am proposing in my amendment would be the most suitable option.

I would love to discuss this further with the Government as I believe that the concept has real merit, as it would reduce NHS costs and improve patient outcomes. My amendment would help the NHS save money and result in better outcomes for patients. I know that one such experiment is being developed now in London; I am really delighted to know about that and I think many patients will be too.

[Baroness Watkins of Tavistock (CB)]

My Lords, delayed transfers in care is an ongoing challenge for health and social care services, made worse with the pandemic. We need to remember that hospitals are for assessment and treatment. As other noble Lords have already said, extensive stay in hospital is not good for your health.

In February 2020, there were over 155,000 delay days in hospital, costing a significant amount of money. A majority of the delays—21%—were caused by delays in packages of care in patients’ own homes, while 18% were due to delays in receiving further non-acute NHS care. With over half a million emergency admissions in the same month, intervention is urgently needed to reduce systematic pressures and maintain safe and timely discharge.

I therefore particularly support Amendment 289 to optimise existing space and develop new accommodation for hospital patients who no longer require acute treatment. There are a range of options, including community hospitals, NHS nursing homes, contracts with not-for-profit social enterprises and, as my noble friend Lady Greengross has said, independent sector companies.

However, these issues are not new. I have in my hands a paper by Sir Cyril Chantler for the King’s Fund, The Potential of Community Hospitals to Change the Delivery of Health Care. The salutary point about this excellent paper is that it was written in 2001.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I rise very briefly, since I attached my name to Amendment 289, in the name of the noble Baroness, Lady Greengross. She set out the reason for the need for this service, but I just want to say explicitly—particularly given the next group of amendments—that I do not believe that independent providers, for-profit providers at least, would be the way of doing this, given the many problems that we have seen in social care, which are highlighted in the next group.

We still have, in some places at least, community hospitals and facilities in communities. These are things that ideally would be developed by the community for the community, being run for public good not private profit.

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

[Lord Crisp (CB)]

My Lords, I would like to use one example to illustrate the importance of Amendment 291 in the name of my noble friend Lady Greengross, and her call for a dementia care plan. It relates to the second point: that the plan must recognise the different types of dementia and their specific care. It is also true that it needs to recognise the different groups of patients affected by dementia and their needs.

I am thinking from personal experience of people with Down’s syndrome. Noble Lords may know that something like 50% of people with Down’s syndrome who reach the age of 60 also have Alzheimer’s; there is some genetic connection between the two. However, the field of dementia has not really caught up with this yet. This is a developing field. The real importance of the plan that my noble friend advocates is that it constantly develops as knowledge develops about particular groups of patients and how they are affected.

The truth today is that patients such as the person I am thinking of are too often let down by the system, because too few clinicians understand the links between the two diseases and the particular needs of people with Down’s syndrome who also have Alzheimer’s.

[Baroness Watkins of Tavistock (CB)]

My Lords, I support the majority of these amendments, but I want to reflect on something that my noble friend Lady Greengross said about the lack of treatment for people with dementia. In fact, there are emerging treatments, and having had the benefit more than 40 years ago of working at a second referral unit at the Maudsley Hospital, I know that people who present with dementia so often also have quite severe depression at the beginning of recognising that they are losing some of their cognitive function. That can be treated very effectively and people can be enabled to live much happier lives for the first part of their care.

I want to give one other example. As a clinical nurse, I was called to help a unit that had severe problems. I do not think there was any maltreatment, but there was certainly a lack of competence in care in the place that I visited. There was a gentleman who was tall and extremely thin who, they told me, had two people with him all the time because he was so agitated. They could not get him to sit down to eat and his relatives did not want him to have any medication.

I am pleased to tell noble Lords that I got involved and we got a consultant psychiatrist in. The family were persuaded that a small amount of anti-psychotic medication might improve the quality of this man’s life. It did; his agitation significantly reduced and he was able to sit to eat. He lived for only another nine months, but those nine months were much happier than they would have been without that medication.

Although I firmly believe in all the social prescribing that we are talking about, we do not necessarily need a dementia care plan; we need a dementia care and treatment plan with an associated workforce development plan. Will the Minister seriously consider those issues?

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

[Lord Shipley (LD)]

My Lords, now that we are on Report, I must remind the House that I am a vice-president of the Local Government Association.

I rise to speak to Amendments 63, 65 and 67 in this group, to which I am a signatory along with the noble Baroness, Lady Armstrong of Hill Top. I will not repeat the points made in Committee and this afternoon unnecessarily because I am confident that the Government are listening to what has been said and wish to see progress towards levelling up health outcomes and tackling health inequalities. It is the right thing to do.

I lend my support to three policy solutions in particular. The first is the significant opportunity presented by the forthcoming health disparities White Paper. The Government should not miss the opportunity that this presents because it can clearly set out how exactly they propose to lead on tackling the poor health outcomes of inclusion health populations. I hope that the Minister will work closely with the voluntary and inclusion health sectors to shape what the White Paper will say. Secondly, I support the idea of creating a task force from the Department of Health and Social Care and NHS England to help drive forward the Government’s work to reduce health inequalities for the most marginalised. Thirdly, I urge the Government to take this opportunity to update guidance to specify explicitly that the NHS does not exist in a vacuum and that secure, safe housing is critical to an individual’s health and well-being. I hope that the Minister will be able to confirm that statutory guidance and the White Paper will reflect all these matters.

Having said that, these three amendments—Amendments 63, 65 and 67—are still important. I welcome yesterday’s letter from the Minister, the noble Lord, Lord Kamall, explaining the package of government amendments now also proposed. I am pleased that that letter confirmed the Government’s commitment to tackling health inequalities. It is very positive to see the reference to “persons”, not just “patients”, in Amendment 3 as an important statement of principle both for inclusion health and to improve outreach, as the noble Earl, Lord Howe, said earlier.

Progress has been made following Committee but I still seek reassurance from the Minister that the Government will dedicate the necessary time and resource to tackling the poor health outcomes of inclusion health populations, who can all too easily fall through the gaps in provision.

[Baroness Watkins of Tavistock (CB)]

My Lords, it is a pleasure to speak to this group of amendments. I declare my interest as chair of Look Ahead, a housing association that specialises in working with people with complex needs. I am delighted by the Government’s new amendments in this area—I believe that they go a long way—but I am disappointed that housing appears to have been omitted from the government amendments.

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[Baroness Bennett of Manor Castle (GP)]

My Lords, I am delighted to contribute to this rich and important debate, and particularly to speak to Amendments 10 and 13 in my name.

Commenting on the words of the noble Baroness, Lady Meacher, about the importance of public health, I would stretch that much more broadly than the examples that she gave. It really ties to the previous group, where we were talking about how climate change and the nature of the environment are related to health. A public health approach really is talking about ensuring that we have a healthy environment, that we prevent illness and malfunction. If we do not have that approach in the ICBs, that is a real problem.

I agree with the noble Lord, Lord Bradley, that government Amendment 31 is useful but not sufficient to deal with the issues that are raised by this group of amendments. The Green group very much agrees with Amendments 9 and 12 and will support them should we get to that point.

I declare my interest as a vice-president of the LGA and the NALC, which may be relevant here. In speaking to Amendments 10 and 13, I declare exactly where I come from. It was the Royal College of Nursing that persuaded me that these amendments should be here. It is very much the college’s case that I now present.

To begin with a little bit of history, as part of the statutory regulations of the Health and Social Care Act 2012, it was mandated that registered nurses would be part of the governing body of clinical commissioning groups. If we look at Regulation 11 of the National Health Service (Clinical Commissioning Groups) Regulations 2012, we see that a CCG governing body must have at least one registered nurse within its membership. This will be lost if it is not required within the leadership of the integrated care boards.

This ties to a point made by the noble Lord, Lord Bradley, that sometimes there are very powerful forces in medicine. It also relates to the points made by the noble Baronesses, Lady Thornton and Lady Brinton, about the powerful force of private interests in medicine. Other truly important voices often get swept aside. It is worth noting that in the NHS in England, registered nurses are more than 49% of all professionally qualified clinical staff. They have a unique relationship with patients and clients which gives them a different insight to other professionals on how the service works, and in ensuring that measurement of performance reflects the interests of patients and clients.

In representative volume terms alone, the case here is very clear. Registered nurses lead, innovate, and deliver the largest proportion of care, and their leadership brings critical expertise, advice and challenge into boards. Without this clinical leadership, there is a risk that service design and delivery become a matter of financial accounting, without proper attention being given to quality and outcomes for patients and clients, or that there is a focus on the heroic interventions rather than on day-to-day care or on the importance of rehabilitation, on which we heard a lot of debate in Committee and which is an area to which our registered nurses bring particular skills.

It is not my intention to move these amendments, but I hope that the Government will listen to the case being put by what is a hugely important professional body and a hugely important body of professionals, and that we see action taken after this debate to make sure that registered nurses are represented.

[Baroness Watkins of Tavistock (CB)]

My Lords, I rise to speak to the amendments in my name and to support those of the noble Baroness, Lady Hollins, who earlier described the need to standardise the knowledge and experience of commissioners, given the potential significance of their decisions.

The Government rightly suggest that there must be some flexibility so that integrated care board membership best reflects the competences needed to commission for local populations. However, unless regulations stipulate essential criteria for members’ collective skills, knowledge and experience, we risk falling into old habits of medical paternalism. That will undermine efforts towards more integrated, holistic care and mental health needs may be given cursory regard. The voices of nurses—as so ably outlined by the noble Baroness, Lady Bennett of Manor Castle—and other professionals will not be heard.

I would like to share with the House a well-known quote in organisational management: “Every system is perfectly designed to get the result it gets”. We now have the opportunity to safeguard the diversity of experience in each integrated care board by establishing a minimum standard, imposed either by regulation or by statutory guidance, to ensure the system gets the result that best meets commissioners’ needs for local patients and populations across the country.

[Baroness Whitaker (Lab)]

My Lords, as well as supporting Amendments 9 and 12 and the rest of the group, I would like briefly to add my support for Amendment 31 in my capacity as patron of the British Stammering Association. This amendment is very much welcomed by the Royal College of Speech and Language Therapists, for all the reasons that we set out in Committee. It would do much to improve the expertise available for these damaging difficulties with the basic human need to communicate and the capacity to swallow, so I hope the Government adopt it—I am sure they will, because it is a government amendment. I am very grateful.

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

[Baroness Watkins of Tavistock (CB)]

My Lords, I rise briefly to support this group of amendments and to declare my interest as a fellow of the Royal College of Nursing. It is absolutely clear to me that, without the right staff in the right place, you cannot give the right care. This is the situation we are in at the moment, and we must get it right for the future. We are on an improvement trajectory, and there is an increase in the number of nurses employed in the NHS. However, this is not universal across all areas of the NHS, particularly in learning disability and mental health.

If we could get the Government to support Amendment 80, we could resolve the issue through guidance. On Amendment 81, I also speak for my noble friend Lord Patel, who unfortunately cannot be here today and who believes that an elegant solution as described by my noble friend Baroness Finlay, in terms of guidance subsuming Amendment 82 in particular, would enable directors of nursing, medicine and care to be responsible for ensuring that they have a safe staffing structure in the areas for which they commission care. That would be reported up every two years through the Secretary of State, rather than every five years, as indicated in Amendment 82. This would be a much more suitable solution.

[Lord Lansley (Con)]

My Lords, I will intervene. I was not intending to speak but I was prompted by a recollection arising from the reference to anaesthetists by the noble Baroness, Lady Finlay. I recall that the Centre for Workforce Intelligence produced in February 2015 a report on the future supply and demand of anaesthetists and the intensive care medicine workforce. I have just checked the report, and it projects for 2033 that the number of full-time equivalent staff required will be 11,800, and supply will be 8,000. Therefore, in February 2015, we knew of this set of projections produced by the CWI. It said, among other things, that there should be

“a further review in the next two to three years.”

However, the CWI was abolished in 2016 and its functions were restored, I think, to the Department of Health.

The noble Lord, Lord Stevens, did not refer to this directly, but we must bear in mind the general presumption that there has never been workforce planning, although in certain respects, there has. The report on anaesthetists is only one of a whole string of reports—I could list them, but I do not need to—produced by the Centre for Workforce Intelligence before it was abolished. Their main purpose was to say to Health Education England, “This is the level of education and training commissioning you should be undertaking in the years ahead”. As the noble Lord said in Committee, it did produce a set of proposals; it is just that they were not acted upon.

I just say this: legislation may be the right way to proceed now, but let us not lose sight of what is actually required, which is for Health Education England not to have its budget cut, as happened in 2016, but to have its budget increased and for that budget to be turned into an education and training commissioning programme that delivers the numbers of trained professionals in this country that we project we will need. It is no good saying, “Oh, we’ve never had planning; we passed a piece of legislation.” I am sorry, it could be a case of legislate and forget unless the money is provided and the commissioning happens. There have been organisations whose job it was to do it—Health Education England, the Centre for Workforce Intelligence—but they were not supported, and in one case, abolished.

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

The concerns that I and others have about this kind of at-home early medical abortion are not sufficiently mitigated by the amendment, and in-person visits to a clinic or medical centre continue to be vital. Supporting the vulnerable and creating thorough and effective legislation to do so must be our priority, hence my opposition to the amendment. I conclude by repeating my honouring of the noble Baroness, Lady Sugg.

[Baroness Watkins of Tavistock (CB)]

My Lords, I support this amendment, to which I have added my name. Evidence-based practice that utilises modern technology for the assessment and delivery of treatment for people who choose to take the first pill at home is cost-effective. I think we forget that the majority of healthcare workers, be they medics, midwives or nurses, try to provide person-centred care. Person-centred care means that some women will still be asked to come into the clinic to take that tablet because it is the best solution for that woman.

However, some women live in rural environments where there are very poor bus services. When I went to the women’s meeting at the UN three years ago with other Members of this House, young women representing the four country youth parliaments told harrowing tales of women who had been given the tablet in a clinic but had not got home before the spontaneous abortion commenced. We heard very good examples, particularly from some other countries in Europe, where taking the tablets at home was already normal practice.

The largest study on telemedical abortion in the world was conducted in the UK, covering 52,000 women both before and after the change—in other words, using the natural experiment that occurred as a result of lockdown. There was no change in adverse incidents, no change in successful completion rates, a reduction in waiting times, a reduction in gestation at treatment and it was preferred by women. This evidence was used by the US Food and Drug Administration to make the first tablet at home a permanent option at the end of last year. As the noble Baroness, Lady Sugg, has just said, the World Health Organization issued its international Abortion Care Guideline last week. Telemedicine and self-management of abortion outside a healthcare facility are both in there.

This amendment would enable better person-centred care for the majority of women, as well as for their families and often their partner who will be with them at the time—particularly for people who are perhaps having a third or fourth child which for clinical reasons is not advised. I therefore hope that the fact the majority of people here have a free vote means that they really consider what I have just said.

[Baroness Eaton (Con)]

My Lords, health and safety have arguably never been more front and centre in our nation’s thinking and approach to healthcare. The Government prioritising healthcare in one of their flagship Bills is therefore expected. I am proud of our Government.

As proud as I am, I feel equally perplexed as to why the amendment tabled by the noble Baroness, Lady Sugg, seeking to override the Government’s decision to end the temporary policy on at-home abortion would garner any serious consideration, given that it would contradict the aims of the Health and Care Bill by placing the health and safety of women and girls at risk. It also distracts from important matters in the Bill, for which the Bill was intended.

The provision allowing at-home abortion made alongside a host of other Covid regulations during an unprecedented global crisis was only ever meant to be temporary alongside almost all other temporary provisions of the Coronavirus Act that the Government are expiring or have already expired. The Prime Minister said that the Covid restrictions

“take a heavy toll on our economy, our society, our mental wellbeing and the life chances of our children”.—[Official Report, Commons, 21/2/22; col. 45.]


The health toll could not, in the specific case of the temporary provision allowing at-home abortion, be more apparent; it is a toll being taken on vulnerable women and girls. As highlighted by a submission to the government consultation on this matter, the lack of in-person consultation increases risks of potentially life-threatening conditions being missed, pills being prescribed beyond the 10-week limit, more women being coerced into a home abortion against their wishes and pills being obtained fraudulently.

These are not unwarranted concerns. Soon after the temporary policy was implemented, story after story emerged of the tragically painful experiences women underwent as a result of this policy. For example, a Telegraph article reported on a nurse whose at-home abortion led to extreme complications needing surgery. Indeed, there have been several cases of women taking these abortion pills outside the legal and safe time limit. For example, in May 2020 police investigated the death of an unborn baby after a woman took pills received by post at 28 weeks pregnant. Such cases are unsurprising given that abortion providers cannot ensure that at-home abortion pills are taken by the intended person in the intended circumstances and time. According to the American College of Obstetricians and Gynecologists, only half of women accurately recall their last menstrual period, again reaffirming that medical confirmation of gestational period is critical.

Given the vast evidence base highlighting how this policy has placed women’s health and safety at risk, an evidence base thoroughly reviewed by the Government in an extensive three-month consultation, I urge the noble Baroness, Lady Sugg, to withdraw her amendment but if she does not, I urge noble Lords to vote against it.

Health and Care Bill

Baroness Watkins of Tavistock Excerpts

Consideration of Commons amendments
Tuesday 5th April 2022 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, I wish to lend my support very briefly to Motion B1, moved so very compellingly by the noble Baroness, Lady Cumberlege. I simply wish to pick up and echo the telling point from the noble Baroness, Lady Harding, who I think broadly said that if you carry on doing the same thing, you are going to get the same results.

I have had a look over the last week at what results we are getting. We have had the frankly shocking revelations in the Ockenden review, highlighting the really severe implications for patient safety, particularly for women and babies, when there are just not enough suitably trained staff around to do the vital job that they are there to do. I looked at that review last night and found it truly shocking. In the last 24 hours, we have had a Care Quality Commission report looking at Sheffield Teaching Hospitals. It said that they lacked enough qualified clinical staff to keep women and infants safe from avoidable harm and to provide the right treatment. There is also today’s report—it may have been yesterday’s—from the Health and Social Care Select Committee, highlighting the critical NHS staff shortages affecting cancer services in England, meaning that too many people are missing out on that critical early cancer diagnosis which is so vital to their chances of survival.

I know those are the worst things happening and that there are lots of good things, but those things are not acceptable. Things like that are why public satisfaction in the NHS, as the noble Lord, Lord Stevens, said, is sadly going down. That is a real problem; it is the reason I so strongly support Motion B1 and why there is such strong cross-party support for it in this Chamber.

[Baroness Watkins of Tavistock (CB)]

My Lords, I support Motion B1 in the name of the noble Baroness, Lady Cumberlege. I will be brief and not repeat what others have said. However, it is worth noting that in the Statement on the Ockenden report, the Secretary of State for Health said:

“I am also taking forward the specific recommendations that Donna Ockenden has asked me to. The first is on the need to further expand the maternity workforce.”—[Official Report, Commons, 30/3/22; col. 819.]


That phrase could be repeated for every part of the NHS and social care workforce, so I believe that has changed the situation since the other House debated this issue.

The public are asking what the national insurance levy is for if not to increase the number of professional staff in training. We are turning away people who want to be paramedics and nurses, as my noble friend has just said, who want to train locally. Of course we should undertake ethical overseas recruitment as well, but we need both. I firmly believe that this amendment needs the full support of this House.

[Baroness Bennett of Manor Castle (GP)]

My Lords, it is a great pleasure to follow the noble Baroness, Lady Watkins, and to ensure that full support for Motion B1 has been presented from all round your Lordships’ House, including the Government Benches. The Green group also supports Motion C1 particularly strongly, and Motions D1, F1, G1 and L1, but I will speak briefly only to Motion B1 because it is so crucial.

In introducing this group the Minister spoke, as the Government often do, about the record numbers of staff in the NHS. I do not think anyone has yet mentioned the NHS staff survey conducted between September and November. Just 21% of nurses and midwives thought that there were enough staff in their unit to do their job properly and provide an adequate standard of care; almost 80% thought there were not enough. The noble Baroness, Lady Tyler, referred to the Ockenden report: that helped to highlight that, despite the fact that the Government have been trying to recruit more midwives, in the last year the number of midwives has actually gone down.

We really have to ask ourselves why the Government are so opposed to this amendment when there is such strong support for it around this House and among all the key bodies around the country. It may be that the Government have an ideological objection to the word “planning”, or that the Minister does, but this is about the future of our NHS and all the evidence says that this is an essential amendment. Surely the Government are not going to let ideology stand in the way of the future of our NHS.

I finish by commenting on the typically wonderful introduction to this group from the noble Baroness, Lady Cumberlege, who referred to the strong civil society campaign. The hashtag for it on Twitter is #StrengthInNumbers, and that says so much. We need the numbers and the facts so that we can get the numbers of staff in the NHS.