Health and Care Bill

Lord Bishop of Carlisle Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[The Lord Bishop of Carlisle]

My Lords, this is a health and care Bill. I will address certain specific aspects of that care that deserve further attention.

First, on integrated care, like the noble Lord, Lord Kakkar, I welcome the clear desire for integration, collaboration and local flexibility, and the placing of integrated care systems on a statutory footing. But can the Minister assure us that, in ICBs and ICPs working together to ensure co-ordination in the design and delivery of integrated care, there will be an adequate focus on prevention rather than just cure, especially in mental health needs, not least among young people with learning disabilities?

Secondly, there is pastoral, spiritual and religious care, which, as Covid has reminded us and NICE guidelines recognise, are essential aspects of care, especially at the end of life. In Clause 16, mention is made of commissioning “other services and facilities” in addition to the medical, dental, ophthalmic, obstetric, nursing and ambulance services previously mentioned. It is probably not practicable to list all 14 allied health professions in the Bill, but perhaps it could be made clear that these cover important aspects of care that ICBs should be expected, not just encouraged, to commission. That would certainly provide some reassurance for, for example, healthcare chaplains, who, among so many others, have done such valuable work during the pandemic.

Thirdly, there is palliative care. We need no reminder of the fact that we are an ageing population. A significant proportion of those with palliative care needs already do not receive the care they need. By 2040, the number of people who have such needs will have increased by up to 42%. One of the stated aims of this Bill is to reduce inequalities in the provision of care across the country. Therefore, I find it strange that there is no direct reference to palliative care services or the need for integrated care wards to commission such services in their areas.

Fourthly, there is social care. As the Minister has already reminded us, one of the biggest challenges facing social care, as with the NHS, is workforce planning and supply. We are all aware of the alarming statistics regarding vacancies, as well as morale. I am grateful that the Bill aims to improve this situation but, as almost all the briefings that we have received have emphasised, we need greater accountability, transparency and reporting on this issue. So I was disappointed to learn that a proposed amendment to Clause 34 in the other place was not accepted by Her Majesty’s Government. I am equally disappointed that no mention is made in the Bill of the pay of carers, which is obviously an indication of the extent to which they are valued in our society.

Finally, my right reverend friend the Bishop of St Albans much regrets that he is unfortunately unable to speak in this debate. He has therefore asked me to pass on his congratulations to the Government on bringing forward this important legislation, and to ask the Minister whether the aspiration to reduce inequalities between patients in respect of their ability to access healthcare includes inequalities between rural and urban areas.

Health and Care Bill

Lord Bishop of Carlisle Excerpts

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

[Lord Desai (Non-Afl)]

My Lords, as an NHS patient but not an expert, I will say one small thing about inequalities. Given the way in which the NHS is structured, with no money paid up front and with excess demand and inadequate supplies because of budget shortages, it is forced to allocate treatment by queuing—and queuing, obviously, means that people have to wait.

There is a fallacy that somehow the poor have more time than the rich. In my experience it would improve matters immensely if, when appointments are given, there was less delay in the patient seeing the person whom they are supposed to see. I know that, right now, there are standard regulations that cover these matters, so that people end up waiting three hours. I have done that. But my time is not as valuable as that of someone poorer. You do not measure the value of your time by your income. So it would improve matters if the allocation of services were made using communication devices. This would waste less of patients’ time and help them better access services.

[The Lord Bishop of Carlisle]

My Lords, I will speak on behalf of my noble friend the right reverend Prelate the Bishop of London. She has added her name to Amendment 65, and we on these Benches support the other amendments in this group that seek to reduce health inequalities. As we have heard, these amendments would help to ensure that the Bill does not forget the underserved and disadvantaged in our society, many of whom have been mentioned already.

In the Christian and Jewish faiths, there is a Biblical concept—shalom—which embodies a sense of flourishing, generosity and abundance. Shalom can be summarised as experiencing wholeness, or a state of being without gaps. This is reflected in the World Health Organization’s definition of health, which is about not only the absence of disease but mental, physical and social well-being. It is a vision for individuals and for the whole of society. Our efforts to design a more holistic health service are, in effect, aimed at achieving that sort of shalom. We see this clearly in the decision made to place 42 integrated care systems across the country. What is not yet apparent is the relationship of these systems and boards to the wider community.

This Bill must seek to involve local communities—and not just professionals—in the reduction of health inequalities. These amendments highlight the monitoring of both physical and mental inequalities, take account of the experiences of young people and children and place more emphasis on the strength of local interventions to help reduce and prevent health inequalities. I commend them wholeheartedly to your Lordships’ House and to the Minister.

[Lord Rennard (LD)]

My Lords, I rise in support of these amendments, in particular Amendment 66 in my name and those of the noble Lords, Lord Young of Cookham and Lord Faulkner of Worcester.

This amendment would expand the duties of integrated care boards. We want them to exercise their functions with respect to reducing inequalities relating to

“modifiable risk factors, such as smoking.”

Our aim is to help the Government achieve their manifesto commitments to reduce health inequality, level up and increase healthy life expectancy by five years by 2035. This amendment would mean that integrated care boards would have a responsibility to reduce inequalities in access to health services and the outcomes achieved. They would also be responsible, in consultation with partners such as local health and well-being boards, for drafting joint five-year plans to explain how they would discharge their responsibilities, including those to reduce inequalities.

At present, there are significant inequalities in both patient access to health services and in the outcomes achieved. The biggest causes of inequalities in health outcomes are behavioural risk factors, such as smoking, obesity and alcohol. As the noble Lord, Lord Young of Cookham, said, smoking alone is responsible for half the difference in life expectancy between the richest and poorest in society. It is a greater source of health inequality than social position and it remains the leading cause of premature death in this country.

We all hope that the integrated care systems will contribute significantly to reducing inequalities in smoking and other behavioural issues, but they are likely to succeed only if addressing such modifiable risk factors becomes a core function of the NHS, working in collaboration with local authorities. Amendment 66 would ensure this.

The difference in healthy life expectancy between those living in the most and least deprived areas of England is around 19 years for both men and women—in other words, almost two decades. Let us look at one place in particular. As measured by the index of multiple deprivation, Blackpool is, sadly, top of the table of the most deprived local districts in the country. Over the last decade it has consistently had one of the highest smoking rates in the country, at over 20%. Most distressingly, more than 20% of mothers in Blackpool are smokers at the time they give birth. So our amendment is needed because the recently published NHS inequalities strategy—which is impressive in parts—does not address the behavioural causes of health inequalities. In fact, it says nothing about them at all.

The Government’s inequality strategy sets out five clinical areas that are crucial to improving health outcomes for the poorest 20% in society. They are chronic respiratory disease, serious mental illness, early cancer diagnosis, maternity and—last but not least—identifying people with high blood pressure who need to be pre-treated to prevent heart attacks and strokes. In all these areas, behavioural factors such as smoking, obesity and alcohol very significantly increase the dangers to health. If appropriate action is taken, it can greatly improve patient outcomes and, at the same time, reduce pressure on our NHS.

To take just one example, chronic respiratory disease is caused primarily by smoking. It is estimated that smoking is responsible for 90% of chronic obstructive pulmonary disease, but one-third of patients diagnosed with COPD carry on smoking. There is nothing in the NHS England inequalities strategy about this, and no target for reducing smoking rates among those with chronic respiratory disease. Yet stopping smoking is the most effective and cost-effective treatment. Only by quitting smoking can those with COPD prevent further decline in lung function.

Smoking, obesity and alcohol are also causally linked to cancer and hypertension. People with mental health conditions die on average 10 to 20 years earlier than the general population. Smoking is the single largest factor in this shocking difference. The question we must therefore ask today is this: given that modifiable behaviour risk factors are core to all five identified clinical focus areas, why are they not included in the NHS England inequality strategy? Perhaps it is because the Government do not see addressing these population-level health risk factors as a core responsibility of the NHS.

Health and Care Bill

Lord Bishop of Carlisle Excerpts

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

[Lord Patel (CB)]

My Lords, I support Amendment 47, to which I have attached my name. I thank the noble Baroness, Lady Finlay, for her brilliant introduction to these amendments, and the other three speakers who spoke so passionately. We have debated this issue several times, and the time has now come that we should be angry about it. The time has come that we should have palliative care and hospice care being made a part of the NHS as a commitment on the face of the Bill.

I shall read the words of a government Minister in Our Commitment to You for End of Life Care—The Government Response to the Review of Choice in End of Life Care. The Minister, Ben Gummer, then Parliamentary Under-Secretary of Health, said this:

“A universal provision of good care will make possible what we should expect from our health and care system - a universal expectation of a good death.”


He went on to say:

“Cicely Saunders was articulating an ancient truth when she described her mission: that ‘we should see the last stages of life not as a defeat but as life’s fulfilment’. A good death - peaceful, dignified, reflective, compassionate, in the loving embrace of those closest to the dying person - is already a happy end for hundreds of thousands of people across our nation.”


The next line is important:

“In making this commitment, we make that promise universal, so that every dying person in England can live in anticipation of a good death.”


I ask the Minister: when that was written in 2016, was it an empty promise or is it likely to become a reality now?

We do not sufficiently value care for those for whom there is no cure. We do not value the short lives of children and young people who die prematurely and who will never be parents, let alone grandparents. Some Members here may have attended the annual reception held downstairs for parliamentarians by Together for Short Lives and other charities. They are attended by children and young people from the ages of three to 16, some using crutches, some using wheelchairs, some with tubes in their noses to supply oxygen, some undergoing IV treatment and some with IV pumps to relieve the pain. It brings tears to your eyes when you see them, but they all come with smiles on their faces, grateful for the care that they get—professional and dedicated care from professionals and volunteers.

So why do we rely for three-quarters of the funding for palliative and hospice care on the charity sector? Why is it that the Government fund only one-third of the care? Why, as the noble Baroness, Lady Finlay, said, do these charities have to sell cakes at village fêtes and second-hand books, toys and clothes for the money that they so fervently raise? Why can we not find the money?

Sue Ryder commissioned research into the total costs required to fund palliative and hospice care for every patient that needs it. They come to about £987 million a year. I should imagine that the transaction costs of the reforms that we are debating in the Health and Care Bill will probably cost several billion pounds. So it is possible for us to reorganise the health service at a cost of billions of pounds, but we cannot fund end-of-life care for those who are dying—children, young people and older people. We should be ashamed of that.

[The Lord Bishop of Carlisle]

My Lords, it is always a pleasure to follow the noble Lord, Lord Patel. I am pleased to give my wholehearted support to Amendment 47 and to Amendment 52, to which I have added my name, which compellingly requires the commissioning of specialist palliative care services in every part of England. Throughout my life and work I have often had the privilege of being present with families and communities, supporting people of all ages through the final chapter of their life, so I have seen at first hand the enormous difference that high-quality palliative care can make to their experience of dying, death and bereavement.

However, as the noble Baronesses, Lady Brinton and Lady Masham, pointed out, 90% of people might need such care, but as things stand at present only about half of them will receive it. What is more, it is all too often those in our most deprived communities who are dying without the help and dignity they deserve.

Health and Care Bill

Lord Bishop of Carlisle Excerpts

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

[Lord Ashton of Hyde (Con)]

The normal convention in this House is that if a Member is not present at the beginning and end of a debate, they should not speak. It is not right to read out someone else’s speech.

[The Lord Bishop of Carlisle]

My Lords, I recognise and respect the integrity and passion that underlie Amendment 297. However, I rise to agree wholeheartedly and briefly with those noble Lords and noble and learned Lords who have already expressed their significant reservations about it.

There are two problems in particular with that amendment. The first has to do with the many contentious arguments for and against any legislation permitting assisted dying, some of which have already been mentioned. Tempting though it is to rehearse some more of those, I am conscious not only of the time but of the fact that they have already been presented recently and at length, as we have been reminded by the noble and learned Lord, Lord Mackay, at Second Reading of the Assisted Dying Bill here in your Lordships’ House. The ongoing process of that Bill, however slow it may be, should not be undermined. We have also been assured that this is not primarily what Amendment 297 is all about. I might add that the terminology of that amendment is unhelpfully vague. “Vague” is a word that has already been used more than once in the debate today. For instance, we might ask exactly what is meant by “terminally ill” or “medical assistance”.

The second problem, which has already been persuasively argued, concerns the attempted use of this Health and Care Bill potentially, if not directly, to change the law on assisted dying. The proper place for any amendment of this kind should be Committee on the Assisted Dying Bill, not Committee on this Bill, which would be subverted were this amendment to be accepted.

With regard to Amendment 203 in this group, whether or not it is deliberately linked, it is evidently concerned to address the holistic needs of those approaching the end of their lives, and that includes, of course, talking about death. That is something that we would all wish to encourage. However, there is again an issue of vagueness in the amendment, as in Amendment 297. For example,

“wishes and preferences for the end of their life”

could include almost anything, from repeated albeit futile chemotherapy, through bucket list wishes, to assisted suicide. Who decides, and how, that someone lacks capacity for engaging in a conversation about their holistic needs? Who is a “relevant person”, as we have just been reminded by the noble Baroness, Lady Finlay? Then, in proposed new paragraph (c), what does

“having regard to the needs and preferences recorded in such conversations”

actually entail?

Most of what is proposed in the amendment is already covered in End of Life Care for Adults: Service Delivery, NICE guideline NG142, which was published on 16 October 2019. Perhaps it would be simpler just to require healthcare professionals to meet the requirements of that guideline, which would address the heart of the amendment’s stated, and laudable, objective.

[Lord Carlile of Berriew (CB)]

My Lords, it is a real pleasure to follow the right reverend Prelate and, given the similarity between his see and my name, I hope I may be able to slipstream some of his authority.

I entirely agree with the noble and learned Lord, Lord Mackay of Clashfern, and the noble Lord, Lord Moylan, that this is not a debate in which we should be having Second Reading discussions about the principle of assisted dying, and I shall absolutely not do so.

I start by saying a few words about Amendment 203. I was greatly relieved when my noble friend Lady Meacher immediately revealed it to be only a probing amendment, because I had taken the trouble of reading proposed new paragraph (b). This is not the occasion for me to indulge or deploy my inner Rumpole or Henry Cecil by telling your Lordships stories of frauds committed on families by greedy relatives and the like—although there are many to be found in the annals of the criminal courts, even from the time when I practised in north Wales. However, the words “another relevant person” are an absolute recipe for undue influence and ostensible but completely fraudulent carers. I am very surprised that my noble friend, for whom I have enormous respect, thought it right to present such a vague piece of drafting to the House on this occasion.

I am very concerned in relation to both Amendment 203 and Amendment 297 about parliamentary procedure and statutory integrity. I have huge regard for the noble Lord, Lord Forsyth, who is one of our very greatest debaters in this House, and so I listened to him with great care. It has been an unusual occasion to hear him relying on a Liberal Democrat Peer in Scotland and the Scottish Parliament. I am not sure that I have heard him deploy that juxtaposition before—and I am pleased to see that he sees the funny side of that himself. However, I beg him, before Report, to consider whether he has got his concept right or wrong, for I would say that, conceptually, what he proposes is wrong.

I do not want to repeat what was said so clearly by the noble and learned Lord, Lord Mackay, and the noble Lord, Lord Moylan—it does not need to be repeated, and I would diminish it if I tried to—but there are a couple of points to add. One was alluded to very graphically by the noble Lord, Lord Moylan. If, as a rule, one could table an amendment simply saying that the Government—or anyone else, for that matter, as the noble Lord suggested—should present a draft Bill to Parliament, it would be impossible to control. Reference was made to the 200 amendments tabled to the absolutely extant Bill of the noble Baroness, Lady Meacher—it is a living Bill and it can still be debated. It is extremely unfair to suggest, as one noble Baroness did, that those were wrecking amendments. Some of them may be, but the great majority of them are substantive amendments seeking to safeguard vulnerable people. That is one of the things that the private Members’ procedure is for. When a private Member presents a Bill to Parliament—and many have passed; it is not a futile gesture—it has to withstand the same parliamentary scrutiny that we give to the Government when they present Bills before Parliament, such as the police Bill, debates on which a number of us here have been taking part in recently.

Furthermore, let us suppose that the clause from the noble Lord, Lord Forsyth, was passed and that within the 12 months that followed the Government decided not to present a draft Bill to Parliament. I do not believe—though I may be disabused of this by greater judicial minds than mine—that the court would have the power, other than possibly to advise, to order the Government to present such a Bill to Parliament, because that would be a breach of the separation of powers. I do not believe that any judge, other than in a nightmare, would see themselves doing that.