Health and Care Bill

Lord Bishop of London Excerpts

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

[Baroness Walmsley (LD)]

My Lords, I wonder if I may make a slight clarification; I hope that the noble Baroness, Lady Merron, will agree with me. It is not that we believe that the people who we specify should be representatives of the sectors from which they come. Rather, given the functions of NHS England, the three of us who have signed this amendment feel that those with background knowledge of the sectors that are absolutely key to the success of NHS England should be on the board. They would be there not as representatives behaving in a unitary way, as the noble Baroness, Lady Harding, said, but having the background knowledge and information that can be shared with the rest of the board to make decisions.

[The Lord Bishop of London]

My Lords, I declare my background as a former government Chief Nursing Officer and non-executive director of a number of healthcare trusts. I was not going to speak, but I have listened to noble Lords’ comments today and I come down with the noble Baroness, Lady Harding, in saying that we should not stipulate what skills are required of a board too tightly. What is in front of organisations changes over time, so the chair needs to be empowered to change. However, one caveat is that it would be wise to consider having somebody on the board with a background in patients. I speak from experience as a clinical professional: we can too easily forget the patient and to see things through their eyes. Far too often, we see things through the eyes of the clinician, which is not always in the best interest of patients.

[Earl Howe (Con)]

My Lords, I am grateful to all noble Lords who took part in this short debate, and particularly the noble Baronesses, Lady Merron and Lady Walmsley, and the noble Lords, Lord Patel and Lord Howarth, for bringing these important issues before the Committee. As they made clear, these amendments seek to make changes to the membership and composition of the board of NHS England. Amendment 2 also outlines the conditions that should be met for the appointment process.

Like my noble friend Lady Harding, I am in sympathy with the spirit of these amendments. It is imperative that the membership of the board of NHS England is able to represent the diverse needs of patients and the populations they serve, as well as their twin functions of commissioning and holding commissioners and providers to account.

I was very much in sympathy with the principles and sentiments expressed by the noble Lord, Lord Howarth, in speaking to his Amendment 3. Executive members of the board are selected based on their expertise and ability to manage the delivery of NHS England’s functions. It is also important that non-executive members have the right skills and backgrounds to effectively support and challenge, and hold the executive to account.

I hope I can reassure noble Lords on the existing and planned board membership arrangements. We absolutely aim to ensure that the most suitably skilled and experienced candidates are appointed to the fully merged NHS England board. The legal provisions therefore need to be flexible, and I can tell the Committee that they already are. Existing provisions setting out the membership of the NHS England board in the NHS Act 2006 already provide the flexibility required for the fully merged NHS England to lead our more integrated health and care system.

I agree that robust governance arrangements are absolutely necessary to oversee public appointments, particularly to NHS England. Unlike appointments to integrated care boards, the appointments of the chair and non-executive members of NHS England are public appointments made by the Secretary of State. As your Lordships are undoubtedly aware, as public appointments, they are managed in line with the Governance Code on Public Appointments and regulated by the Commissioner for Public Appointments. These appointments are made on merit in a fair, open and transparent manner. In line with the governance code, they require due regard to be given to ensuring that they properly reflect the populations they serve, including a balance of skills, expertise and backgrounds—exactly as sought by this amendment, as I understand it. We are fully committed to the importance and value of both candidate diversity and equality of opportunity.

The commissioner works with government to encourage candidates from a diverse range of backgrounds to consider applying for public appointments. All public appointees are expected to uphold the standards of conduct set out in the Committee on Standards in Public Life’s Seven Principles of Public Life, as included in the Code of Conduct for Board Members of Public Bodies. The code sets out, clearly and openly, the standards expected from those who serve on the boards of UK public bodies and includes a clear process for managing any conflicts of interest.

--- Later in debate ---

The need for reinstating parity of esteem for mental health is even more important now than ever before, with increasing levels of complex mental health needs, growing unmet needs and a pandemic that has affected the young and healthcare workers—and we do not yet know what the mental health effects will be on those who have recovered and are suffering from long Covid health effects. It is therefore right that the Bill reinforces the need for NHS England, ICBs, trusts and foundation trusts to all have a statutory duty upon them to work towards achieving parity of esteem between mental and physical health. In my view, the issue is far too important to miss the opportunity to have it on the face of the Bill. I hope the noble Earl, Lord Howe, will not rely on a vote this time, but will accept the amendment in the name of my noble friend Lady Hollins, to which I have added my name. If the Minister is minded not to, I hope that, at the appropriate time, my noble friend will seek the view of the House. I will support her.

[The Lord Bishop of London]

My Lords, I am grateful to the noble Lords who have tabled the amendments in this group. I am very aware of the expertise that exists within this Chamber. As we have heard, mental health has not always been funded in the same way as physical health. However, we have seen improvements, not least in the way we speak about our own mental well-being. We have seen a reduction in stigma and an improvement in services, but the pandemic has taught us that there is a huge unmet need around mental health, and I suspect we will not know the full impact of the pandemic for a number of years. Clearly, those groups of people requiring support around their mental health will include us and our children as well as our health and social care workers.

I am aware that in our churches, we do a lot, like other faith communities and other community groups, to support people’s mental health and enable their mental well-being to flourish, not least through our faith activities and our worship. Churches put on many activities, such as dementia cafés; we make available our outdoor spaces for people to undertake gardening to improve their mental well-being; we do walking; we reduce loneliness and isolation, to name just a few. But we are aware that we are not mental health professionals. We walk with people, often in the early stages of mental illness or while they are waiting for referral, and what those within our churches know is that the length of waiting is getting longer. The wait for access to mental health services, particularly talking therapies, has got much longer.

The noble Lord, Lord Patel, and the noble Baroness, Lady Tyler, mentioned the figures; we see the personal impact of that, as people’s lives are put into great crisis and they struggle. Not least, it brings stress to their family and friends, and it impacts on their ability to earn. As has already been said, it impacts on their physical health as well. I recognise that we have increased our determination to ensure that there is parity between physical and mental health funding but I believe we require legislative levers to make this happen. Therefore, I support particularly Amendments 5, 12 and 136 as well as Amendment 99. As we have already said, we need legislative levers at every level to address this parity. My belief is that this will contribute to not just the mental well-being of the community but its physical well-being.

[Lord Crisp (CB)]

My Lords, it is a great pleasure to follow the right reverend Prelate, a former esteemed colleague, and I had better follow her and the noble Lord, Lord Stevens, in declaring an interest as a former chief executive of the NHS in England—as opposed to NHS England—as Permanent Secretary at the Department of Health and as an honorary fellow of the Royal College of Psychiatrists. I support most of the amendments in this group and shall speak particularly about Amendments 5, 12 and 136, about expenditure, and Amendments 91, 92 and 99, about parity of esteem and ICSs.

The most telling comment, I think, from my noble friend Lady Hollins was when she said that mental health is too often forgotten. It is a really sad point. I am struck, when I look through the amendments we are considering today, how the legislation is trying to catch up with where we have got to as a society and how we think about health. It is obvious with mental health. I thought the great speech by the noble Lord, Lord Howarth, emphasising the role of the nonclinical—the people outside the health system and their role in health—and of salutogenesis, the creation of health, not just pathogenesis, the dealing with disease, was really impressive. The other area where this is very obvious is where we are going to come to in a bit, talking about inequalities in a later group.

This is very much part of the new agenda, but it is interesting that we still have the overhang of what I think of as the 20th-century model of healthcare, which is about the acute sector, not the primary sector; it is an NHS focus; it is about doing things to people, rather than with people; and it is about illness. This Bill is, in a way, the first health Bill of the 21st century and it is really important that it sends out some very clear messages and that so many of these amendments can be picked up to make sure those messages are sent out very clearly.

I will pick up the detail very briefly. Amendments 5, 12 and 136 from my noble friend Lord Stevens of Birmingham on measuring and increasing expenditure on mental health—or at least showing the Government’s hand and revealing what they are expecting—and, later, the monitoring of it are fundamental. However, let me put in a caveat: they are pretty blunt. They are imperfect, because they are about inputs rather than outcomes and outputs, thinking of some of the things we talked about earlier. They can also be gamed.

Also, as the noble Baroness, Lady Jones of Moulsecoomb, said, physical and mental health are not distinct; actually, most people in civil society treat mental and physical health at the same time, so there will be some arbitrary distinctions. I remind noble Lords, as we all know very well, that there is a major problem for many patients with mental health problems in trying to access help with their physical health. As Professor Sir Graham Thornicroft has said, mental health diseases are killer diseases, because people die earlier—sometimes because of that impact on physical health.

These are imperfect measures. However, I support them as a blunt instrument for offering steering and pushing the system the right way. They are a real measure that will help bring about change and they should be supported at the macro level.

Amendments 91, 92 and 99 are about achieving parity of esteem within the integrated care systems, and it is right that they are broader based, because people have to make choices at a local level about what they are doing. It is really important that the planners on those boards take full account of mental health and achieve parity of esteem across the whole spectrum, from levels of investment right the way through to ensuring that people with mental health problems can access physical healthcare when they need it. As the noble Baroness, Lady Hollins, reminded us, in 1948 the first meeting of the World Health Assembly defined health as being about

“physical, mental and social well-being”.

It is time we got back to that.

I applaud these amendments and very much hope that the Minister will indicate the Government’s support for a much bigger emphasis on mental health in supporting these and other amendments.

Health and Care Bill

Lord Bishop of London Excerpts

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

[Baroness Tyler of Enfield (LD)]

My Lords, I shall speak very briefly to Amendment 38 in the name of the noble Lord, Lord Bradley. I have huge sympathy with the intention behind this amendment. Everything that we have talked about so far on mental health has pointed to the fact that unless there is a strong mental health voice on ICBs, the whole issue of mental health funding and the priority it has will not get as strong a voice as it should. I recognise that some argue that we should not overspecify the membership of new bodies but should allow each integrated care system the flexibility to develop based on its own set of local relationships, and I do not overlook that point. However, my natural sympathy is that it is only too possible for mental health concerns to be ignored when decisions are made about resource allocation and prioritisation without a strong mental health voice around the table.

However, I think I may have a way through this. We need to look back to the discussions we had on Tuesday about the overriding importance of mental health being explicitly mentioned in the triple aims. If such an aim were in place, I think we would be hard pushed to form an ICS or an ICB without mental health representation and we might be able to argue that it is not necessary, in those circumstances, to have it in the Bill. However, if that aim is not explicit, then the argument put forward by the noble Lord, Lord Bradley, is very strong indeed.

[The Lord Bishop of London]

My Lords, I rose on the first day of this Committee to speak to the membership of NHS boards. I rise today for a similar reason: I think it is very difficult to stipulate the membership of boards, just as the noble Baroness has said. However, as I said with NHS boards, I say with ICB boards that I think the voice of the patient is central. Along with my role as the Government’s Chief Nursing Officer, I was director of patient experience while I was in the Department of Health. As a nurse at that time, I believed I had a patient focus. However, I learned that my default was always as a professional and that the patient needs a voice and empowerment. While I recognise the clinical voice and would always want it on the NHS board and the ICB board, it does not replace the voice of the patient and the carer.

Health and Care Bill

Lord Bishop of London 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.

[Lord Warner (CB)]

My Lords, I have added my name to Amendment 146 in the name of the noble Baroness, Lady Merron, but I support all the amendments in this group. Taken together and perhaps integrated a bit better, they strengthen the focus in the Bill on workforce issues and workforce planning. I also congratulate the noble Lord, Lord Stevens, on his contribution to open government.

For too long, we have been preoccupied with the funding of our health and care system and have tended to assume—I confess that as a Minister I certainly did this to some extent—that if Governments made enough money available, we would be able to acquire the staff we needed, always forgetting, I think, that health and care is a highly labour-intensive industry, possibly the most highly labour-intensive industry in our country.

We were often very good at masking the shortcomings in our planning system by historically relying on recruitment from abroad. There were doctors from Africa, India and Europe, nurses from the Philippines and elsewhere, and we had a lot of staff coming in from the EU to work in our social care sector. Brexit and our national preoccupation with limiting immigration has changed all that, and that is before we calculate the effect of Covid on health and care staff recruitment. To give your Lordships just one example, pre-Brexit, 40% of the social care staff in London came from the EU. You simply cannot make that ground up very quickly.

Today’s reality for recruiting health and care staff is that we are operating in a highly competitive national and international labour market. That situation will not change any time soon. The probabilities are that we will have to pay more for staff and give more thought to our working practices and conditions. We will have to do a much better job of planning ahead and take much more seriously the training, support and recruitment and retention of this increasingly scarce resource—people.

I suggest that Ministers—I include all of us who have been Ministers—must stop political bragging about how many new doctors and nurses a Government will produce, often without the foggiest idea of how long it will take to do so. Ministers might want to give more consideration as to whether they have the right skills in the sector in the first place, before commissioning the training of highly paid, highly skilled professionals. We have not done a very good job of looking at the extent to which many of the jobs done by doctors could be done by other professionals. Our attempt to train nurses in prescribing has been only half-hearted in using the skills that we have paid for them to develop.

Health and Care Bill

Lord Bishop of London Excerpts

Lords Hansard - Part 2 & Report stage
Tuesday 1st March 2022 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I pay tribute to the noble Baroness, Lady Finlay, for her outstanding work in this area. I was very moved by the remarks of my noble friend Lord Howarth in tribute to the care given to Baroness Hollis, who was such a tremendous force for good in your Lordships’ Chamber over many years.

Can the noble Earl clarify the point that has already been raised? In the letter from Ministers of 26 February it was said that the amendment would add palliative care services to the list of services that an ICB must commission. On the face of it, the amendment seems rather more permissive. Proposed new subsection 3(1) in Clause 16 states:

“An integrated care board must arrange for the provision of the following to such extent as it considers necessary to meet the reasonable requirements of the people for whom it has responsibility”.


There is then a list, which starts with “hospital accommodation”, which the ICB must arrange for—then on page 17 are a couple of provisions that seem rather more permissive.

The nub of the issue is this: we have fantastic palliative care in the mainly voluntary sector as well as in the National Health Service itself, but it is very patchy. The health service has been very reluctant to give long-term certainty to hospices and other providers of palliative care services, insisting on short-term contracts. The real question to the noble Earl is this: will this change as a result of this amendment? Where is the beef that will actually get the message across that we expect the health service to do a lot better than it has been doing in support of palliative care services?

[The Lord Bishop of London]

My Lords, I declare my interests in the register. I join in thanking the Government for having listened in Committee. I hope that this will make a difference not just to the lives of those whose lives are shorter but also their families, so it is very welcome. I pay tribute to the noble Baroness, Lady Finlay, but also to my friend, the right reverend Prelate the Bishop of Carlisle, who put his name to Amendment 17.

As I say, I welcome this amendment. As the chair of the UK Commission on Bereavement, I have been reminded recently of the inconsistency of palliative care, which other noble Lords have spoken of this evening. It affects not only those who require palliative care but also their family and friends, and it leaves a legacy into bereavement, which we should not underestimate. I too was reassured to hear the Minister say that palliative care must be commissioned, but I share again the concern of the noble Lord, Lord Hunt. In Amendment 16, the word “appropriate” is used, and it is not quite the same thing. Could the Minister reassure the House about the Government’s expectations regarding the nature of palliative care services that the ICBs will commission? How will they ensure that that is delivered in a way that creates consistency? It is care that is rightly deserved by people in our communities, which also reflects the skill and hard work of our palliative care practitioners

[Baroness Fraser of Craigmaddie (Con)]

My Lords, I too congratulate the Minister and his officials on listening to the House and the strong representations he received in Committee on this issue.

I welcome the Government’s amendment. I add my tribute to the work of the noble Baroness, Lady Finlay, as well as the many Members of this House and the campaigns of organisations such as Marie Curie in getting us to this point. It is wonderful that the symbol of Marie Curie is a daffodil, and we are here today on St David’s Day being led by the noble Baroness, Lady Finlay of Llandaff. That is very appropriate.

I disagree with the noble Lord, Lord Howarth of Newport—this is an historic moment and a huge step forward. It is the first time in the history of the NHS that there will be an explicit requirement to commission palliative care. I declare my interests as chair of the Scottish Government’s National Advisory Committee for Neurological Conditions and a trustee of the Neurological Alliance of Scotland. Many people with long-term, progressive conditions have not been able to access palliative care at an early enough point. Not only would this ensure better outcomes for patients, but it would also be a better use of NHS resources. I hope that the result of the Government’s amendment will ensure that these people get better care, including the palliative care they need. I also hope that ICBs will recognise the difference that they could make.

I welcome the opening remarks of my noble friend Lord Howe about taking the criteria set out in Amendment 17 in the name of the noble Baroness, Lady Finlay, and to which I was happy to add my name. It provides a helpful set of guidance for ICBs to follow, based on standards. I echo the question of the noble Lord, Lord Howarth, on ensuring that we have the right reporting requirements. I am grateful to hear that the Government will be developing statutory guidance to ensure that we put the necessary tools in place. However, I have been concerned to learn, in my meetings with NHS England, how—as far as I have been able to ascertain—it reports on services, rather than medicines or specific procedures. When reporting on NICE guidelines for services, NHS England seems to rely on “noise in the system” to ensure whether they know that something is happening or not. I share some noble Lords’ worry about the word “appropriate”. If we develop statutory guidance based on the criteria set out in Amendment 17, I hope that the risks that the word “appropriate” might continue to see a postcode lottery will somehow be allayed.

Finally, given that ICBs are at different stages of their development, can the Minister and the department give careful consideration to the ongoing and direct communication to ICBs regarding this duty? Will they consider writing to all ICB chairs to ensure that they are fully aware of the duty and their responsibilities?

The Government have made a very important step forward today in giving people who are facing the end of their life the reassurance they and their families need. The focus now must be on ensuring that this amendment is used to its fullest by the ICBs, so that everyone who needs palliative care will benefit.