Health and Care Bill

Lord Crisp Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Lord Crisp (CB)]

My Lords, I first congratulate my noble friend Lord Stevens on an excellent maiden speech. I agree with him that there are substantial opportunities in this Bill, although some things are missing, some of which he referred to, such as mental health and determinants of health. As other noble Lords have discussed, however, I feel the complexity of some of these processes and the difficulty of getting one’s mind around how this will actually work.

I agree with so much that has been said about social care, particularly on the cap. I trust that your Lordships’ House will send this back to the other place rapidly for it to think again. I also agree with many points that have been made on the workforce, although I would make a single observation—that we need to pay attention to changing roles as well as to numbers. In the case of primary care, it will not look in 15 years’ time as it does now. This is for all kinds of reasons, including the way that nurses are taking on a much bigger role; they will continue to do so, and I suspect they will be the lead providers in primary care in 15 years’ time. That is a simple prediction that I may come to regret.

When you make a change such as this, you disrupt the system and some arrangements that used to work. There are two more specific points that I should like to explore in Committee. One is how we ensure that primary care—GPs, but primary care more generally—still has a significant role in approving plans. I recognise that there are practicalities around that, but it is vital that it retains some impact. I also think it is very important that foundation trusts can maintain sufficient independence of action. I know that the concern of NHS Providers is about control of capital in that regard. Some things need to be explored further.

However, my main observation is to follow other noble Lords in saying that we are talking here about integrating health and social care, but that is 20% of the issue; there is so much more outside that. We know all about social determinants; many have mentioned them. We know the massive impact of education, employment, training and housing—both positive and, I may say, negative—on health, and we know the science that underpins that: about relationships, how social isolation leads to dementia; how exercise, exposure to nature, and such aspects, make change. We need to capitalise on that.

I want to make two points that are slightly different from what others have said. First, this is not just about prevention. Prevention is about the causes of ill health; we need to be thinking also about the causes of health, and the two things are often run together in ways that are unhelpful. Creating health is about creating the conditions for people to be healthy and helping them to flourish. It is about human flourishing, eudaimonia, if one wants to go back to Aristotle.

The second point, which goes alongside it, is that the health of the individual is intimately connected with the health of the community in which they live. This is a point that the noble Lord, Lord Mawson, in particular, exemplified with his discussion about Well North, but also his early experience in Bromley by Bow. There are now examples all over the country of people starting to bring together the things that improve communities with the things that improve individual health. That is a vital part of the future. We have known that for years, but we have not known how to connect it properly with the NHS. I speak as a former chief executive of the NHS in England who failed to make that happen.

My question to the Minister is: how will the Government ensure that those other groups in society—voluntary organisations, housing associations, employers, schools, educators and so on—contribute to creating health and, thereby, supporting the NHS to do its vital work? We need to see health in terms of wonderful healthcare and services and prevention of disease, but also creating the conditions for people to thrive. The underpinning thought here is that our health as individuals is intimately connected with the health of our communities, of society at large and, ultimately, of the planet.

Health and Care Bill

Lord Crisp Excerpts

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

[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.

[Lord Warner (CB)]

My Lords, I support these amendments, particularly Amendments 5, 12 and 136, so powerfully spoken to by the noble Lord, Lord Stevens of Birmingham.

As a kind of self-appointed historian to this Committee, I will take us back to 2005-06. There was a massive public consultation, leading to the White Paper Our Health, Our Care, Our Say. A thousand people of diverse socioeconomic and age backgrounds gathered in Birmingham to vote on what the public thought were the top priorities for the NHS. Much to the shock of the six members of the ministerial team—including me—who attended that event, and the top management of what was then the Department of Health, led by the noble Lord, Lord Crisp, the public were several decades ahead of the political, managerial and clinical decision-makers of our revered NHS.

It has taken us a really long time to catch up. We have moved since then through a period in which, with great rhetoric, we have inserted into legislation a desire for parity of esteem between physical and mental health. However, no one of any political party has had the temerity to do what the noble Lord, Lord Stevens, has done in suggesting we should actually put our money where our mouth is. It simply has not been done.

The NHS, in my experience, is quite strong on doing things if you give it money. If we do not start putting into the allocations some requirements to at least level up, as the noble Lord, Lord Stevens, says, we will make no progress whatever with our rhetoric. I strongly support these amendments and hope the Government will listen very carefully to this House. I, for one, will be quite happy to march into any Lobby in support of amendments which give some financial equality of recognition to the needs of those with mental health problems.

While I am on my feet, I mention a group which is neglected even within the mental health set-up—those with autism. It is one of the great disgraces of this country that we have such poor arrangements for diagnosing young people, particularly girls, with autism. We need to do a better job of putting our money where our mouth is on that subject.

Health and Care Bill

Lord Crisp Excerpts

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

[Baroness Neuberger (CB)]

My Lords, I want to pay tribute, as other noble Lords have, to the noble Baroness, Lady Thornton, for her very thoughtful introduction. It is remarkable and absolutely wonderful to see consensus breaking out across the Committee. I will speak specifically to Amendments 152, 156 and 157 in the name of the noble Lord, Lord Young of Cookham, whose words on the need to make this really serious by stating it on the face of the Bill I echo.

I am a former chief executive of the King’s Fund and am currently chair of University College London Hospitals and Whittington Health. These issues are very dear to my heart and the hearts of those institutions. I also want to say thank you to Crisis for its briefing and add to the words of the noble Lord, Lord Young of Cookham, in praise of Pathway, which has done the most extraordinary work in this area over very many years.

I want to talk particularly about the NHS-funded Find & Treat service, which was set up 13 years ago and is run by UCLH, which I chair. This service was set up in response to a TB outbreak in London and aimed to provide care for people experiencing homelessness and people facing other forms of social exclusion. The service did exactly what it says on the tin: it went out and found people—and still does—who were at risk of contracting TB, wherever they were sleeping, and offered them diagnosis and treatment. Back in 2011, a study concluded that this service had been not only effective in helping to treat people with TB who were experiencing homelessness but cost effective in doing so, both in terms of costs saved to the health service and improved quality and length of life for the people receiving care. Fast-forward a decade and the evolution of this service meant it could be similarly mobilised at the beginning of the Covid pandemic. It provided urgent and necessary care to people who continue to experience the poorest health outcomes.

The King’s Fund published a report in 2020 on delivering health and care for people sleeping rough. It supported the need for inclusion health services to be provided much more broadly than at present. Importantly, it also concluded that local leadership is absolutely vital in crafting that approach and said that local leaders should model effective partnership working across a range of different organisations.

Embedding inclusion health—I cannot say I really like the term, but everybody knows what it means—at the level of integrated care partnerships will help ensure that our healthcare system can no longer ignore, forget or overlook people who are all too often considered “hard to treat”, despite proven interventions showing the opposite. It will ensure that integrated care partnerships and systems take that vital first step towards closing the gap of the most significant health inequalities in our society by having to recognise and consider people facing extreme social exclusion and poor health outcomes in their local areas.

We all know that there will be considerable discussion during the course of this Bill on the need not to be overly prescriptive and burdensome to ICSs and ICPs by way of legal duties. But ICSs and ICPs know all too well the realities of failing to support people with complex and overlapping needs. I know that the chair of my own North Central London ICS, Mike Cooke, is sympathetic to the spirit of these amendments and believes it is important that extra steps are taken to meet the health needs of the most excluded, such as street homeless people. The chief executive of UCLH, David Probert, and the chief executive of Whittington Health, Siobhan Harrington, concur in thinking that if we extend the aspiration to reach out to excluded groups to something that all ICSs, ICPs and systems must focus on, it would be hugely beneficial for planning and joining up systems to avoid inappropriate or unnecessary admissions and poor care planning. Plenty of people want to do this within our health system.

I support Amendments 152, 156 and 157 and look forward to working with the Government and colleagues across the House and within the NHS to ensure their success in achieving a critical and long-needed systemic change to our health and care system. Addressing the needs of the most excluded has to be on the face of the Bill.

[Lord Crisp (CB)]

My Lords, I will make three very practical points about the impact of some of these amendments. First, on tobacco, we have heard from at least two noble Lords that half the difference in life expectancy between the rich and the poor in society is due to tobacco. It seems a no-brainer that work on this has to be continued. I also make the point that it took something like 50 years after the evidence was first available for the control of tobacco to be put into legislation, despite the efforts of the noble Lord, Lord Young of Cookham. It is not a quick win; we need to persevere, keep the pressure on and keep this very firmly in NHS plans at all levels.

Secondly, I want to pick up on the vital point that housing needs to be much more integrated with health and care. Let me take us back in history to 1919 and the first Ministry of Health, which had responsibilities covering health, housing and planning for many years, understanding the very important links there. Covid has shown that a house and home is an absolute foundation for health and well-being in all kinds of ways. I will not labour that point at this stage in proceedings, but will pick up another that has not come up, which is how important housing is to the provision of NHS services.

Seven years ago, the Royal College of Psychiatrists asked me to look at the reasons for the pressure on admissions to mental health acute wards. I did so; I think it expected me to say that those wards needed more beds, but I came out saying that we needed more housing. I found that something like one-third of the patients in mental health acute wards in adult hospitals either had been admitted because there was nowhere else for them to go or were staying there because there was nowhere for them to live to be discharged to. Housing was the biggest issue. Of the 25 NHS trusts around the country, only about three had specific, strong links with their local housing associations. There is a really big pressure for integration there.

Thirdly and finally, I come to Amendments 152 and 157 about the so-called inclusion health services. I agree with my noble friend on the nomenclature and that the naming is rather awkward, but these are extraordinary vital. We have heard examples of services that work; the issue here is how we can make sure that those services are spread and used elsewhere. I remind the House that, when we talk about inequalities, we all, including me, talk in fairly general terms. If you have a quantum of money and invest it in the health of the well-educated middle classes, you will get a small gain. If you invested that same quantum of money in the needs of this group, you would have a massive gain. That should inspire us to keep the pressure on the Government to make sure that we put tackling inequalities absolutely at the heart of the Bill.

Health and Care Bill

Lord Crisp Excerpts

Lords Hansard - Part 2 & Committee stage
Tuesday 18th January 2022 Lords Chamber

I hope that the Minister does not need much persuasion on this. It is a very simple and a very necessary amendment, and he would certainly have the support of the Committee in entertaining it.

[Lord Crisp (CB)]

My Lords, I declare my interest as an adviser to Well North Enterprises, which was mentioned by the noble Lord, Lord Mawson. I congratulate him, and other noble Lords from different parts of the House who have spoken on this amendment, on making the whole issue extremely clear.

I will make a few very specific points. First, we have heard about great big projects making a massive different. Everyone in your Lordships’ House, I am sure, knows of smaller examples that are making a real difference, as well as the larger examples, and how the small examples are important and add up.

Secondly, this is about change happening locally, but it is also about what is happening globally. I have previously quoted, in this House, a saying by a friend of mine, who used to run the Ugandan health service, that “Health is made at home, hospitals are for repairs”. It is a powerful expression, and one might say that health is made at home and in the community, and in the workplace and in the school. It also contains the notion that health can be created; it is not just about preventing disease.

Noble Lords may like to know that, more recently, globally, the WHO published the Geneva Charter for Well-being at the end of December, which explicitly talks about the creation of a “well-being society”. So this is a global movement we are talking about, not just a local one—although, as the noble Lord, Lord Mawson, has continually emphasised, this is about the importance of practical changes at the local level.

I will make two final points. The big one is that when we think about the membership of the ICBs, it is important we have the insiders there—the clinicians and the people who know how the systems work—but we also need some outsiders there. Referring to the debate on the last group, this is not just about different skill sets; it is about different behaviours and doing different things in different ways. Those of us who have worked within the system are bound by the system and think in terms of the system and its regularities.

The sort of people the noble Lord, Lord Mawson, is talking about do not start by thinking about the system; they start by basing things on relationships and learning by doing—a point that he emphasised. So there are different ways of doing things, and it is important that, as these boards are constructed, they bring in people with that different approach, alongside the great knowledge and skill that NHS and other clinicians bring to this. I know that we will really achieve success by bringing together insiders and outsiders, and getting people working together and understanding how to do things.

My final point is that this amendment proposes having a person representing or drawn from these groups on the ICB. I recognise the debate that has been going on about tying the hands of local people about what is happening on these ICBs. I understand that as these things get larger not only are you including more voices but also, implicitly, you are including more vetoes. The health service has, over the years, suffered from having too many people with too many vetoes in terms of making change happen.

I understand the complexity and difficulty here, but the final part of my point is to ask the Minister a question. I asked him a question earlier, because—I do not know whether I am alone here—I am not sure that I understand how, in reality, all these bits will fit together and work together in this new structure. I know he committed, in an earlier part of the debate on the Bill, to providing us with a diagram and perhaps more of an explanation of how it will all work. I can see how the complexities of everything we are talking about here can be difficult.

The single point I want to reinforce is the importance of not just having insiders in the decision-making process, but also having more disruptive influences. It is not just about skill sets; it is about different ways of thinking and behaving, and a focus on relationships, not just on systems.

[Baroness Harding of Winscombe (Con)]

My Lords, I also rise to support the noble Lord, Lord Mawson, in his amendment, and congratulate him and his colleagues on the extraordinary work they have done.

I support the Bill precisely because integration will be key to delivering the health outcomes that we all seek. But I worry that, if the Bill is just rearranging the organisational deckchairs, with exactly the same people in different organisations with different three-letter acronyms, we will not change anything at all.

I think that, over the course of the nearly three days we have spent in Committee and on Second Reading, there is cross-party agreement on the nature of the problem we are trying to solve. In each debate we have had over the last two and a half days, whether on health inequalities, mental health, the social determinants of health, or person-centred digitally enabled care, there has been extraordinary cross-party agreement on the nature of the problem. As the noble Lord, Lord Clement-Jones, said, we are debating and disagreeing more on the means to the ends than anything else.

One of the means to the ends is local—genuine local ownership and leadership. Like many in your Lordships’ House, I have made the pilgrimage to Bromley by Bow and I have also been to St Paul’s Way. When I first joined the NHS, about five years ago, I was told to go to Bromley by Bow, and I was told by a number of NHS insiders how brilliant it was, but how impossible it was to replicate anywhere else. “Go and have a look at it, Dido,” they said, “because you’ll be amazed and impressed, but no one’s worked out how to spread it”.

What I have actually discovered, as we have heard today from people with far more experience of place-based leadership than I have, is that brilliant though Bromley by Bow is, it is not alone. There are fantastic place-based leaders in communities across the country. It is those local groups and leaders who we owe the exit from Covid to more than anyone else, I suspect.

I have had the privilege of working alongside them. I have been to north-west Surrey with the noble Lord, Lord Mawson, but also to Wolverhampton, to the Guru Nanak Sikh gurdwara, one of the first local testing sites for NHS Test and Trace. I have been to Gloucester and spent time with Gloucester FM, a local community radio station that for the first time in its existence got funding to run an advertising campaign to encourage people to come and get vaccinated in the local community. That was the first time it had succeeded in working collaboratively with the local NHS.

I have been across the country in the last two years talking to people from groups who feel excluded. Whether it is the Roma Gypsy community, Travellers, refugees, taxi drivers or faith leaders from a whole host of communities, all have told me—in both my previous role as chair of NHS Improvement and as executive chair of NHS Test and Trace—how in different ways they felt excluded not just from the NHS but from society in general. They also said, generally to a man and a woman, how hard the NHS is to work with when you are from a small, outside local group, as those of us who have worked in the NHS know.

It is with that knowledge base that I wholeheartedly endorse the spirit of the amendment of the noble Lord, Lord Mawson—but with a “but”. I have been consistent in the last two and a half days of Committee in being nervous about adding specific roles and experiences to what is now a growing list of characteristics and past experience we would all like to see in this new three-letter acronym NHS entity, the integrated care board.

I would like to post a question to the Minister. It is clear that we need these local voices—the grit in the oyster, as my noble friend Lady Cumberlege described it; the difference that the noble Lord, Lord Crisp, is referencing; people from outside the system—if this new reorganisation is going to be anything more than a rearranging of the deck chairs. How will we ensure that those local voices are genuinely heard in an integrated care board?

Health and Care Bill

Lord Crisp Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

[Lord Crisp (CB)]

My Lords, I shall speak to Amendment 112 and 17 others that are in my name. I am very grateful to the three noble Lords who have added their names to these amendments. These are terribly straightforward; it is the same point in a number of different contexts. As we put it in the explanatory statement, the amendments

“would require Integrated Care Boards to work with the four primary care services … when preparing and revising their five year plans, in the same way they are required to work with NHS trusts and NHS foundation trusts.”

It is a very simple, straightforward point and a matter of proportion. It is appropriate to give a similar level of influence and respect to primary care as we give to acute services.

I will mention that there are some practical difficulties —obviously, there are many more primary care services than NHS trusts—and come back to that at the end. If it is not obvious enough that we should do this, I want to pull out three points about why this is so important; I expect that others will mention other points. I am talking here about GP surgeries, as opposed to the other three services, although I totally endorse everything that my noble friend Lord Low just said about ophthalmology services.

First, if it is true, as Members across this Committee have argued for however many sessions it has been, that a large part of the future is community-based, then alongside public-health figures and their clinical work, it is primary care—nurses and others, not just doctors—who will be the essential guides and specialists to help all those place-based, arts, non-clinical and inequalities-busting activities that we have talked about for a considerable part of this debate. They have that key role.

Secondly, I was dismayed by the way the Government criticised GPs recently. Primary care is under enormous pressure and I do not understand why the Government chose to do that. A large part of the problem is that there are simply not enough primary care specialists of all kinds, including GPs, and I do not think any progress has been made towards the promised 5,000 extra GPs. Primary care is under enormous pressure throughout the country and, while I greatly welcome the focus in the Bill and in government policy on waiting lists, I believe that it will be here in primary care that we will see the real battle for the future of the NHS. It is really important that we give those who are doing so much in our services the respect, influence and prominence that they deserve.

My third and perhaps, in some ways, biggest point is that primary care is changing very fast in all kinds of ways; it is an area where there is enormous innovation. As the Royal College of GPs itself says about the role of the GP, there is a place for one-off consultations—a place for the GP on the railway station, or wherever, where you can have a very quick consultation—but there is an even bigger place for the sort of continuing role based on the relationships between a GP and their patient that we are familiar with traditionally and which I thought the noble Baroness, Lady Cumberlege, described so well in describing her father as knowing his patients “inside and out”. That relationship, however, is not just with individual patients; it is a relationship with the community. Many GPs have taken that role, but more are taking on the role of a relationship with their community.

Some GPs are rewriting this role so that it is more of a public health role in some ways. There is Sir Sam Everington at Bromley by Bow, whom the noble Lord, Lord Mawson, mentioned in his great, eloquent speech on our last occasion in Committee, and others such as Dr Gillian Orrow, who is bringing together groups in the community and leading Growing Health Together in Horley. Others are taking on wider roles, such as Dr Laura Marshall-Andrews in Brighton. People are thinking about their role in a very different and important way and I apologise for giving three southern examples—they happen to be ones I know very well, but I know that this sort of innovation is going on around the country. More generally, of course, we can think about social prescribing and the way that that is changing primary care.

Here is the really big point: these doctors, nurses and others in primary care are acting as clinicians, of course, but they are also agents of change. They are the animateurs, the facilitators enabling local health-creating activity. For that reason, we need to have people like them fully engaged in the planning and all the mechanisms of the new NHS structures so that they can have the influence needed for the future.

I come back to the practical note I made at the beginning. Of course it will be difficult to engage primary care appropriately in every way and there might not be the same structure and arrangements in every part of the country, but it is really important that we get these primary care inputs into the five-year plans, their monitoring, planning and discussion so that they can really influence what will happen in the future. I understand that the Royal College of GPs is in discussion with the Department of Health. I urge the Minister to encourage his officials to find a way to make this obvious thing, which needs doing, work. It is vital that we do not disfranchise a key and currently quite largely demoralised sector or, as importantly, lose their valuable contribution.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I have Amendments 117 and 218 in this group. I have also put my name to the series of amendments put forward by the noble Lord, Lord Crisp, but I start by endorsing what the noble Lord, Lord Low, had to say. I hope the Government will come back sympathetically in relation to that.

My Amendment 117 would ensure that primary care professions would have mandated roles within integrated care partnerships, with members appointed by each of the four practitioner committees: the local medical, dental, pharmaceutical and optical committees. Secondly —and this is very consistent with the amendments from the noble Lord, Lord Crisp—this would ensure that, in preparing their annual strategic forward plan, the integrated care board and its partner trusts and NHS foundation trusts would need to consult the relevant primary care local representative committees and publish an explanation of how they took account of those views when publishing their plan.

I have the same arguments as the noble Lord, Lord Crisp, and I will not repeat them because he put them so well. History has shown that, even when clinical commissioning groups were nominally under the control of GPs, they often found it very difficult to get the rest of the system to listen to their issues and concerns. I agree with the noble Lord that there is now so much pressure on primary care that there is a great risk that they will be ignored in the work of the ICBs in particular. That would be a great pity. It is not just GPs, but the other parts of the primary care world. The noble Lord, Lord Low, already referred to ophthalmologists and opticians, but there is also this conundrum about the ability of pharmacists to take some of the load off the system but there is also often the inability of the local NHS to talk to them and embrace them sufficiently.

I hope the Minister will be sympathetic. If he says that he is not willing to tell ICBs that they must embrace representatives of the local committees then there is now a clear conflict. He is saying that it is up to the local ICBs to decide, but it has become abundantly clear that NHS England is giving out very heavy-handed guidance about who should be on ICBs. I would make this point to him: you cannot have it both ways. Either you leave it up to ICBs and withdraw this guidance, or Parliament has a role and a right to determine the governance arrangements. The action of NHS England in being so heavy-handed, such as saying that local councillors cannot serve on ICBs, means that the argument he put forward really does not stand up any more.

I move to my Amendment 218. On this one I must remind the House of my membership of the board of the GMC. The noble Lord, Lord Crisp, talked about the crisis in workforce issues generally, which I am not sure we are going to get on to today now. In relation to GPs, it is very apparent that not only do we have a chronic shortage but there is a grossly inadequate distribution of GPs throughout the country. Recent data, published by NHS England in November, shows that the primary care network covering an area in Gloucestershire described as 4PCC and comprising Cadbury Heath, Close Farm, Hanham and Kingswood had an average list of 1,138 patients per full-time equivalent GP. There are some others with similar figures. At the other end of the scale, Shore Medical primary care network in Dorset had an average list of 7,317 patients per full-time equivalent GP. York Priory Medical Group PCN had an average list of 7,154 patients per full-time GP and the Marsh Group PCN in Kent had an average list of 7,040 per full-time equivalent GP. These are huge disparities and there are many other areas that have average lists of under 1,600 and plenty with averages of more than 6,000.

The situation is really reminiscent of the situation before the start of the NHS. That is why in 1948 the Medical Practice Committee for England and Wales started work. It was charged with ensuring equitable distribution and, to a large extent, I believe it achieved its objectives. It was abolished in 2001 and I had better confess to the House that, I am afraid, I took through the legislation abolishing it. However, we were at the start of a massive expansion in the workforce at that time and felt that at that point the kind of bureaucratic way in which the MPC worked probably was no long fit for purpose.

We have a real problem here and confirmation of the dire situation was provided recently in research by the University of Cambridge’s department of primary care. A team including Dr Rebecca Fisher found that the significant GP workforce inequalities I have talked about are increasing and that workforce shortages disproportionately affect deprived areas. If you look at the situation in deprived areas, practices often have lower CQC scores, lower quality and outcome framework performances and lower patient satisfaction scores. Patients in those areas often have shorter GP consultations despite the fact that they have more complex health needs.

General practice is paid according to how many patients they have, with an adjustment made for the workload associated with those patients. Since 2004, the global sum allocation formula, known as the Carr-Hill formula, has been used to make that adjustment. However, Fisher argues that the consultation length is a flawed proxy for need and that the formula has long been widely acknowledged to be incapable of accurately weighing needs associated with socioeconomic deprivation. In 2020, after accounting for need, practices serving deprived areas received about 7% less funding per patient than those in non-deprived areas.

There is also the targeted enhanced recruitment scheme. This offers trainee GPs a one-off payment of £20,000 when joining a practice in an area that had long-standing difficulty in getting more doctors. However, this has not made a significant difference and clearly is not the answer to this enormous problem.

In the amendment—and I am very glad to have the support of the noble Lord, Lord Warner, and the noble Baroness—I have proposed the creation of

“the General Medical Practitioners Equitable Distribution Board”

as a first step. I envisage the board being invested with discretionary powers of negative direction, as was the MPC. It would consider applications from primary care networks, and they would be expected only from adequately doctored, or more than adequately doctored, PCNs. It would be a way of intervening in the market and making it more difficult to appoint GPs in those areas that are already very well supplied with doctors.

I accept that this is not the only approach, but it is an approach that has worked in the past. Frankly, I do not think that we can carry on without some major intervention to try to spread the load, because it is clear that all the odds are stacked against you if you are in an area of high deprivation where there are many more patients per GP. You get burnout among the professions and things become very difficult indeed. It looks as though financial incentives are not the answer. Clearly, we need to get more GPs into those areas to lessen the load, and then improve the quality and outcomes. I hope the Minister will be prepared to take this back and give it some consideration.

--- Later in debate ---

[Lord Kamall (Con)]

I thank all noble Lords who spoke in this debate for once again increasing my understanding of some of the challenges within the system, in addition to briefings I have had thus far. I thank the noble Lord, Lord Low, for his patience and his just-in-time mode of operation and, more than that, for his contribution to the debate today. We appreciate that people with learning disabilities experience a higher prevalence of visual impairment than the general population, and that this prevalence increases with the severity of the learning disability. Children with learning disabilities are, for example, 28 times more likely to have a serious sight problem, and over 40% require glasses.

NHS England continues to responsible for the contracting of the NHS sight testing service. This will eventually be transferred to ICBs. Sight tests are widely available across the country through our very dedicated primary ophthalmic services workforce. Those eligible for a free NHS sight test include children, those on income-related benefits and those at particular risk of eye disease. We expect that those with severe learning disabilities should meet the eligibility criteria in other ways, and for these reasons we do not believe that, at this moment, extending eligibility further is necessary. Where those with learning difficulties are unable to access NHS sight tests on the high street, hospital eye departments also provide routine eyecare services and ongoing care. Children are usually referred on to hospital eye services via visual assessments delivered by specialists in special schools. Others are referred by GPs, school nurses or high street practices. We have also seen the development of special pathways in some parts of the country that cater specifically for adults with learning disabilities and we want to make sure that, via the NHS England central team, we share best practice on a national level, so that all regional teams and all ICBs can benefit from learning from the local initiatives and pilots.

NHS England also tells me that it recognises that more needs to be done to ensure equality of access. That is why the NHS long-term plan committed to ensuring that children and young people with learning disabilities, autism or both in special residential schools have access to eyesight, hearing and dental checks. In order to fulfil this commitment, there is a proof of concept programme building on the work by SeeAbility in London, which was launched in 2021, to provide sight tests and dispense glasses on school premises. My honourable friend the Minister for Care is due to make a visit to one of the schemes.

I now turn to the amendments on primary care providers. I understand noble Lords’ interest and that it has been widely acknowledged that CCGs, for example, are dominated by trusts, particularly for acute care. I take the gentle encouragement of the noble Lord, Lord Scriven, to understand that more, and particularly to make sure that the voice of primary care providers is heard. That is also the Government’s ambition. We support the idea that primary care should be integral to ICB planning, which is why at the moment at least one member of the ICB will be nominated by primary care providers in the area.

We all know that primary care service providers are predominantly independent entities that hold contracts with the NHS, unlike NHS trusts and foundation trusts, which are largely statutory entities. If all types of primary care service providers were named in the Bill, it would mean that every provider in the area of the ICB would have a duty to contribute to the development of the joint forward plan. We do not believe it would be a feasible option for all primary care providers to contribute to the plans, but I acknowledge the points made by noble Lords about how we can raise the profile and contribution of primary care providers.

I turn briefly to Amendment 117. We agree that it is important to consult the relevant primary care local representative committees, which is why we already have a provision under new Section 14Z52 to introduce a duty to consult anyone the ICB and its partner trusts consider appropriate when preparing the plan. There should also be a summary of the views expressed by anyone consulted and an explanation of how those views were taken into account. We expect members of the primary care sector to be consulted and their views summarised in this way. We understand that NHS guidance will provide for that.

We also want to allow ICBs to focus on arranging safe, high-quality care, and making an additional, explicit requirement in the Bill does not align with our desire to reduce the bureaucratic burden on ICBs. I understand that this is all part of the general debate about whether, if we accepted every amendment about who should be on the ICB, it would be more inflexible and unwieldy. These are conversations we should have in the round about the priorities for ICBs, what should be mandated, what should be in guidance and what the ICB’s duties are expected to be. I hope that we will have those conversations in the round so that we can come to some sort of consensus across the Committee.

[Lord Crisp (CB)]

The amendment in my name specifically requires ICBs

“to work with the four primary care services … when preparing and revising their five year plans”.

It does not specifically ask for a seat on the ICB. That is a different request. I hope the Minister understand that and will respond to it.

[Lord Kamall (Con)]

I thank the noble Lord for that clarification and also for the advice he has given me in my first few months in this job. I do appreciate his experience. I will take the noble Lord’s point back and make sure it is clearly understood by the department when we consider how we respond to it. We believe in working with appointed ICBs, but we expect primary care to be consulted.

NHS England has also stressed the importance of ensuring that there are robust place-based structures in place. We hope that the ICB will exercise functions through place-based committees, where a wider group of members can take decisions, and we expect that primary care, including individuals from medical, dental, pharmaceutical and optical committees, will be particularly involved at the place-based level under the principle of subsidiarity. We will have some influence on the drafting of the forward plan of the ICB. Additionally, guidance that NHS England publishes for ICBs will include the commissioning of primary care at the place-based level.

--- Later in debate ---

I will finish on a point that we talked about earlier today, the problems of funding social care. The funding cuts that local authorities have received over the past 10 years are such that it can be really difficult for them to find the money for this sort of activity in social care. I really hope that the powers that these amendments envisage ICBs having would go across the whole range of health and social care and will not just be limited to people in healthcare settings.

[Lord Crisp (CB)]

My Lords, I congratulate the noble Lord, Lord Howarth, on introducing this very important group of amendments and other noble Lords who have made some very interesting points, such that made by the noble Baroness, Lady Morris of Yardley: this is becoming received wisdom, whereas it might have been regarded as eccentric even five or 10 years ago.

I have three points to make. First, this is a Bill about integration and partnership. It would be good to have a clear message that non-clinical groups such as the ones we are talking about are part of that, in whatever is the appropriate way—a duty or obligation or something of that sort on in the Bill—without being too specific about the detail.

Secondly, the noble Lord, Lord Howarth, made the point that this is the rediscovery of ancient wisdom, not least, as the noble Baroness, Lady Barker, pointed out, through Covid. I am talking about human flourishing going back to Aristotle and many others in the past: the merging of that ancient wisdom with very modern evidence—more evidence all the time about things such as relationships, as well as the arts and everything else that has an impact on our health.

My third point is about impact. I co-chair the All-Party Parliamentary Group for Prescribed Drug Dependence. Last year, 17% of the adult population were prescribed antidepressants. That is a huge amount: when I see such a figure, I always have to remind myself that that means that 83% of us were not. However, 17% is a huge number, and the sort of things that we are talking about can reduce that number to the benefit of the people who would otherwise be prescribed antidepressants, making enormous economic savings, time savings and so on.

[Baroness Finlay of Llandaff (CB)]

My Lords, I strongly support this group of amendments. I would like to make sure that we realise that the medical humanities as a discipline have now been introduced in many medical schools. In my own, I was rather glad that AJ Cronin’s book The Citadel was introduced in general practice, particularly because, of course, he invented Dr Finlay, but there we are.

Quite seriously, we must not forget that loneliness kills. Loneliness is a true killer; it shortens lives. If people are not moving around well, they fall more and consume healthcare resources. Therefore, having green spaces and things such as sports for health, and so on is important. There is now also a body of evidence that the new intensive care units have used in the way that they are constructed, so that there is a view of outside spaces for those patients, rather than the total sensory deprivation that occurs to them in the very noisy and difficult environment of intensive care. Of course, music is used therapeutically during procedures and so on.

In the hospice world, lots of activities obviously go on in the day centres. As my noble friend Lady Greengross said, there is now good evidence for proper physiological mechanisms that explain why contact with these different disciplines—which were considered to be outside medicine—have a beneficial effect on healing, coping with pain and distress, resolving issues, reframing what is happening to you and so on.

I would like us not to forget that loneliness kills. Importantly, so many patients have said that they have a sense of personal worth when they are still able—however ill they are—to contribute to those around them and to a sense of community. These amendments go to the very heart of being human—that is, the inherent creativity within people that has been forgotten for decades in the provision of health and social care.

I can see that there are difficulties in bringing this into the Bill, but we should commend the noble Lord, Lord Howarth, for the sophisticated way in which he has worded some of these amendments. I hope that they can be built on as we go forward. This could save a huge amount of money for the NHS in the longer term. A huge number of side-effects of drugs could be avoided. People could be fitter. There would be fewer forms. There is a great amount of optimism behind these amendments.

Health and Care Bill

Lord Crisp Excerpts

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

Moved by

[Lord Crisp]

188: Clause 54, page 53, leave out lines 18 to 20 and insert—
“(a) an individual trust, and(b) the capital expenditure limit.”Member’s explanatory statement
This amendment along with the other amendments in the name of Lord Crisp to Clause 54 seek to deliver the legislative proposals agreed with NHS England and NHS Improvement in 2019.

[Lord Crisp (CB)]

My Lords, my five amendments to Clause 54 follow on quite closely from the discussions we have just been having about direction. I am very grateful to the noble Baronesses, Lady Walmsley and Lady Morgan of Huyton, and my noble friend Lady Neuberger for their support for these amendments.

The Bill introduces a new power for NHS England to set capital spending limits for NHS foundation trusts. There are two points of context that are worth exploring here. First, obviously the Bill is all about integration, partnership and collective action, within which individual parties need to retain some autonomy as well as giving out more, or perhaps pooling, some sovereignty at the local level. We should also be aware that at the national level NHS foundation trusts’ capital comes within the overall capital allocated by Parliament, and so recognise that, at the end of the day, there needs to be some kind of reserve, backstop power to set foundation trusts’ capital limits.

It is all about achieving the right balance. I understand that three years ago, as part of the thinking behind these wider changes in the NHS when they were being developed, NHS England and NHS Improvement agreed with foundation trusts a set of proposals for this that were set out in the NHS’s 2019 legislation proposals. I am sure my noble friend Lord Stevens of Birmingham can comment on that as appropriate. This clause cuts right through these agreements.

My explanatory statement makes the terribly simple point that what I am trying to do here is to

“seek to deliver the legislative proposals agreed with NHS England and NHS Improvement in 2019.”

I do not see why that is not happening. So, my first question to the Minister is: please could he explain what has changed since 2019 and why the agreement that was struck then is no longer good enough for the current circumstances?

Secondly, these capital freedoms are important. NHS foundation trusts need to be able to invest in order to deliver their services. They need to be able to do so for their boards to be able to exercise their own accountability, and they need to be able to plan. There is also a slightly softer reason why these are important as well, which is about motivation. It is very clear that working efficiently to generate capital to create that freedom is a significant motivator for clinicians within these trusts. I say that as somebody who led two trusts—not foundation trusts—into trust status in the 1990s, and I know how big an issue that is in terms of the staff within these organisations.

So, against that background, these directions should be exceptional and not the rule, and these amendments set out quite clearly ways to make this work in practice. Amendment 188 states that any direction must be about an individual trust and for a specific region and not in any sense a blanket action. Amendment 189 says that it should be used only after all other means of managing a capital expenditure problem have been exhausted; it must be very much a last resort. Amendment 190 says that NHS England should account to Parliament for the action, giving the reasons—telling the story, if you like—and publishing them so that they can be seen very clearly. Amendment 191 makes it clear that any directions should cease after one year, and Amendment 192 is more minor tidying-up. This is a very clear set of amendments which would put in place the 2019 agreement. I see no reason why that should have changed.

I have three questions for the Minister. First, why is this a change from that agreement? What has changed? Why can we not just have that agreement? Secondly, does the Minister agree that this must be very much a last resort, and therefore needs to be hedged round with these sorts of amendments? Thirdly, will the Minister ask his officials to look at this again, perhaps with the involvement of representatives of NHS foundation trusts and NHS Providers, as indeed happened in 2019? I beg to move.

[The Deputy Chairman of Committees (Baroness Henig) (Lab)]

My Lords, the noble Baroness, Lady Brinton, is taking part remotely. I invite the noble Baroness to speak.

--- Later in debate ---

[Earl Howe (Con)]

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

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

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

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

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

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

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

[Lord Crisp (CB)]

I thank the Minister for that reply. I have one point to make and one question. My point is that an NHS foundation trust may cover an area that is bigger than one ICB, and some of the bigger ones obviously do, so it does not quite work in the way that the Minister talked about. My question, and it is my final question, is: will officials re-engage with NHS Providers on behalf of NHS foundation trusts to discuss this matter further in the light of what we are saying so forcefully to the Government about pragmatic solutions to find a way forward to achieve the right balance and what the Minister has said in his response?

[Earl Howe (Con)]

I had not quite finished the remarks I was going to make, so perhaps the noble Lord will bear with me. I was trying to say that the measures will ensure that there is certainty for all providers about their capital expenditure. It will also prevent the need unfairly to take planned funding away from other providers, such as NHS trusts, where NHS Improvement and, in future, NHS England, set routine capital expenditure limits just to keep expenditure within system control totals, or national capital limits when a foundation trust exceeds its capital limit. Operational detail of how capital expenditure limits are set is best dealt with, we think, in guidance, where we can ensure flexibility and future-proof the provision, rather than in the Bill.

I hope that those remarks are helpful and will persuade the noble Lord to withdraw his amendment this evening. I say to him, as I did at the start, that I have listened carefully to the points he has made in support of his amendments, and points made by other noble Lords, and I undertake to take these points away for further consideration between now and Report. I am aware that my officials are working closely with NHS Providers on a number of issues, and I very much hope that we can resolve any points of difference to everyone’s satisfaction.

[Lord Crisp (CB)]

I thank noble Lords who have spoken in support of the amendment, for the very clear message that has been given. I also thank the Minister for that reply and those final remarks about thinking about this further and discussing it as appropriate with NHS Providers. On that basis, I am very happy to withdraw my amendment.

Amendment 188 withdrawn.

Health and Care Bill

Lord Crisp Excerpts

Committee stage
Friday 4th February 2022 Lords Chamber

[Lord Crisp (CB)]

My Lords, I imagine that your Lordships’ House and Parliament generally very often have a choice in terms of the rightful tensions between, on one level, supporting freedom of action and speech and, on the other, balancing that against harms to individuals and society as a whole from smoking. I know that I am on the latter side of the argument in this case.

It is also worth noting that this is not about just the risk that comes from smoking—risk comes from many sources—but rather the scale of the risk and the impact that it has across the whole of the health system. Despite everything else that has been said about public health, it is worth remembering that this is the biggest risk and that half of the difference in life expectancy between people in poorer neighbourhoods and those in richer ones is due to smoking. That scale is the issue that we are talking about.

I was pleased to add my name to the four polluter pays amendments led by the noble Lord, Lord Young. On the notion that a payment or levy based on income—not a tax—will be used for reducing smoking, providing smoking cessation clinics and improving public health, I believe that this is a different arrangement from that consulted on by the Government in 2015.

I will make several other quick points that very much fit in with what has been said. First, this is about what the Government need to do if they are going to level up under the ambitious plans that were set out only yesterday for delivering improvements in life expectancy and the differences in life expectancy around the country—that is really important, and something will need to be done about smoking if those plans are going to be achieved.

Secondly, this is also about poverty: the average smoker spends £2,000 a year on smoking, and some new research suggests that this leads something like half a million households around the country into poverty. I have not studied that, so I only say “suggests”, but it seems to me to be an important point.

Thirdly, perhaps at one level, this started off for people as a lifestyle choice, but it is actually an addiction. I speak as a former smoker who made an enormous effort to give up. The average number of attempts before you give up is around 30, but I think that I probably exceeded that, and I can tell you the day on which I finally succeeded. It is an addiction, and this whole business runs on addiction—not on the occasional cigarette or the cigar at Christmas—and we should never forget that.

Fourthly, I ask whether the polluter paying is right in principle or just pragmatic. In a sense, it does not really matter: it is pragmatic. Over the last five years, NHS smoking cessation treatment services have been cut: about £23 million a year was spent on such campaigns, but now it is less than £2 million. There is not a lot of money around at the moment, obviously, and this seems a very pragmatic solution for finding money to support smoking cessation services—in addition to the fact that I would see it as being right in principle.

Finally, there is real evidence that those smoking cessation services work. Therefore, it would be money well invested in the future health of our nation.

[Baroness Merron (Lab)]

My Lords, this has been an interesting debate, and we have heard various views. I thank my noble friend Lord Faulkner for leading on this group of amendments, and I thank noble Lords for putting forward their amendments and views so that we can explore how we respond to the challenge of smoking.

My first point leads on very neatly from the comments of the noble Lord, Lord Crisp. Smoking remains the leading preventable cause of premature death. As the noble Lord observed, it is a matter where we should consider the scale of the effect and the fact that this is about addiction. It is not about free choice but is something that we must assist people to overcome. While rates are indeed at record low levels, there are still more than 6 million smokers in England, and the need to reduce this number is particularly important now, as smokers are more at risk of serious illness from Covid.

The economic and health benefits of a smoke-free 2030 would be felt most keenly among the most disadvantaged. However, as we heard from the noble Lord, Lord Young, at current rates we will miss this target by seven years on average, and by at least double that amount for the poorest groups in our society. So it is vital that we motivate more smokers to quit while reducing the number of children and young people who start to smoke.

Within this group of amendments, noble Lords have suggested a broad raft of anti-smoking measures, including information inserts and warnings printed on rolling papers, a consultation on raising the age of sale to 21 and a “polluter pays” approach which argues that tobacco companies should pay for smoker treatment programmes. All these measures can be underpinned by broad cross-party support and public support. Certainly, the All-Party Group on Smoking and Health is very supportive of this group of amendments.

The pandemic has posed new challenges to us, and there is a new group of people who started smoking but who otherwise would not have done so. We have been promised a new tobacco control plan, and I hope that the Minister tells your Lordships’ House when we can expect it. The labelling and information interventions contained within this group of amendments have a strong evidence base from other countries, as well as from research in the UK. I hope that the Minister will be amenable to them.

Picking up on a few of the points raised within this group, it is very shocking to note that more than 200,000 11 to 17 year-olds who have never smoked previously have tried vaping this year. It is a very strange situation that e-cigarettes and similar products can be given free to somebody under 18 but they cannot be sold to them. We do not want to see a situation where young people are brought to smoking by smoking substitutes.

In reference to the amendment that proposes a United States-style “polluter pays” model to fund all these interventions, including the restoration of lost smoking-cessation services, the noble Lord, Lord Young, described practical ways in which this could come about. Certainly, the Minister in the other place did not close the door to this idea in Committee. I hope that we will hear from the Minister some agreement towards this.

Amendment 270 promotes a consultation on raising the age of sale, because we know that the older a person gets, the less likely they are to start smoking. If this is to happen, it requires proper consultation with relevant stakeholders, not least young people themselves, including those who are underage. It must be rigorous in checking what will work. Attitudes to the incidence of smoking have changed over the years, but the direction now is firmly one way, and that is to prevent ill health and premature death. This group of amendments contains proposals to keep us moving in this direction, to assist those who smoke and to prevent those who seek to smoke, particularly those at the younger end of the scale. I hope that this group of amendments will find favour with the Minister.

Health and Care Bill

Lord Crisp Excerpts

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

[Baroness Smith of Newnham (LD)]

My Lords, I support Amendment 297A in the name of the noble Baroness, Lady Hodgson, to which I have added my name. I shall speak briefly, given that that I am only an irregular participant on this Bill. This amendment is particularly important. I come to an understanding of general practice from a very different perspective from the noble Baroness, Lady Cumberlege, as somebody who has only either received the care of a doctor or seen my parents receive or not receive that care.

When I was a young baby, I was extremely ill. I realise in these days where people talk about conspiracy theories about vaccines that this might be something that should not go into Hansard, but I had a reaction to the smallpox vaccine and my mother went to the public telephone box and called the doctor. The family doctor who came was equally concerned and brought a consultant from the local children’s hospital to our home to see me. That would be the sort of gold standard that we could only dream of now. However, it is the sort of care that we need to be looking to in terms of having a family doctor or a doctor in the community who actually knows individuals. As the noble Baroness, Lady Hodgson, said, this is particularly so for the over-65s, when a range of issues might be beginning to affect them.

The situation today is so very different. The Minister in answer to an Oral Question a few weeks ago repeatedly said that everyone has the right to see a doctor in person and the doctor must give a clinical reason for refusing to have an in-person consultation. I assure him that this very rarely happens, because ordinary patients cannot simply ring up and speak to the doctor and say, “I need to see you”. They will get to a receptionist who will triage them and decide whether they feel that it is appropriate for this person to see the doctor, or to have a telephone conversation or maybe some other virtual consultation.

There is a real need, particularly for older people, to have the opportunity to know that there is a doctor who understands their medical situation and can join up the dots. Somebody who seems now to have low blood pressure might have that because of the previous set of medication that another doctor has prescribed for them. If somebody rings up and gets a telephone consultation or is sent a prescription without proper assessment, the danger is that the whole picture is lost and individuals’ lives can be blighted because they are not getting the medical care they need.

This is not the fault of any individual practice or of any individual general practitioner. However, we have ended up with a system where that traditional idea of a family doctor who knows their patients has disappeared, and somehow we need to get an element of that back. The other three amendments in this group in many ways fit as part of a suite because, if your GP knows that maybe you have early onset dementia or another sort of dementia and you need different types of therapies, they will know what to recommend.

Furthermore, if your GP knows that you have gone into a care home, visits you and thinks, “That person has lost a stone and a half in weight in the last six weeks”, a GP who knows the individual will be able to respond. Somebody who randomly sees a patient will not. I strongly support the amendment in the name of the noble Baroness, Lady Hodgson, and the other amendments in this group.

Finally, I note that the amendment in the name of the noble Baroness, Lady Hodgson, comes immediately after the amendment in the name of the noble Lord, Lord Forsyth of Drumlean. If anyone were minded to support assisted dying, they should certainly support the following Amendment 297A, because how on earth could any doctor reasonably say that we can sign somebody off when they have no idea who that individual is?

[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?

--- Later in debate ---

[Lord Howarth of Newport (Lab) [V]]

My Lords, this amendment raises major issues which warrant full debate outside the confines of the Health and Care Bill, but I am most grateful to my noble friend Lady Chakrabarti for providing us with this opportunity to consider them. I support the principle of the public health condition, as articulated in the amendment and as she described it.

The inflexible application of the intellectual property regime during the pandemic has been unconscionable. Huge numbers of people have died unnecessarily in low-income countries. Rich countries not only pre-empted and hoarded supplies beyond their reasonable needs but refused to relax the intellectual property regime to enable free manufacture of vaccines in low-income countries. South Africa and India led the appeal, on behalf of low-income countries, to the World Trade Organization to waive IP protections—patents, copyright, trade secrets. That appeal was rejected contemptuously and cruelly. The UK is among the culprits; the US and France support the waiver, but we do not.

The statement by the United Kingdom Government to the TRIPS council on 16 October 2020 is a piece of Mandarin cant: amoral, inhuman and disconnected from the realities of life and death for billions of people. Let me quote from it:

“Beyond hypotheticals, we have not identified clear ways in which IP has acted as a barrier to accessing vaccines, treatments, or technologies in the global response to COVID-19.”


The Covid crisis is not hypothetical. The refusal to support the free production of vaccines in low-income countries has had catastrophic consequences, yet still government Ministers repeat this theme.

The Government also said in their statement:

“A waiver to the IP rights set out in the TRIPS Agreement is an extreme measure to address an unproven problem.”


The pandemic is an extreme situation and the problem is staring at us—howling at us. At least 350 million cases of Covid have been confirmed globally, and estimates of the number of deaths from Covid range from 5.75 million to much higher figures.

The Government stated that:

“Multiple factors need to be considered … These include increasing manufacturing and distribution capacity”.


Indeed. But the response to this challenge by our Government was to cut aid funding massively, from 0.7% of GDP to 0.5% of a declining GDP.

The Government then said:

“The world urgently needs access for all to … vaccines … which is why a strong and robust … IP system … is vital.”


That is a non sequitur to end all non sequiturs.

The last quote I will give from the Government’s statement to the TRIPS council is this:

“The UK has played a leading role in … ensuring no-one is left behind”.


Do the Government really believe that? It seems to me to be beyond satire.

If we refer to Our World in Data, a website from the University of Oxford, for up-to-date figures, we find that in low-income countries 10% of people have had at least one dose of vaccine, while in high-income countries the figure is 78%. Africa has been most wretchedly left behind: on the continent of Africa 15.2% of people have had one dose and only 28% are fully vaccinated, whereas in the United Kingdom 78% of people have had one dose and 73% are fully vaccinated. It is not surprising that African leaders have complained bitterly of vaccine apartheid. How does the Minister refute that charge?

I feel profound shame at the behaviour of our Government; not only have they been morally purblind but they have been recklessly imprudent. Consider the economic consequences. The IMF has downgraded African economic prospects. Do we gain from the impoverishment of Africa? Think only of the implications for migration. Consider the diplomatic consequences. Africa has turned to China. How does our vaccine nationalism assist post-Brexit Britain to develop relationships around the world? Consider the health and economic consequences for ourselves. If we do not tackle Covid globally, we risk continuing damage to our economy, and our physical and mental health, as we reel in and out of lockdowns and restrictions. Consider the consequences for the world. Professor Sarah Gilbert has warned that the biggest threat is Covid spreading and mutating uninhibited in unvaccinated countries. No one is safe until we are all safe. Dr Hans Kluge, the World Health Organization regional director for Europe, last week demanded a drastic and uncompromising increase in vaccine sharing across borders. He stated:

“We cannot accept vaccine inequity for one more day—vaccines must be for everyone”.


The United Kingdom has not paid its fair share of funding to the WHO accelerator programme. The UK committed to donating 100 million doses through COVAX, but what we have actually done falls far short of that; at the end of 2021, the figure was 30 million doses. Does the Minister accept that our Government have acted appallingly? Will he accept Amendment 292 and will the Government incorporate its principles, wherever relevant, in policy and legislation?

[Lord Crisp (CB)]

My Lords, I wish to speak to Amendment 292 and specifically proposed new subsection (5)(c) on the TRIPS waiver.

I was going to make a few points of context but the last two speeches—indeed all the speeches so far—have set the context extraordinarily well. As the noble Lord, Lord Howarth, has just said, Our World in Data tells us that, as of an hour ago, 66% of the world overall has had one dose but only 10% of those are in low-income countries.

When this discussion has been raised before—for example, during Questions on Monday in your Lordships’ House—the Government responded that there were practical problems with the proposal. Indeed, there are practical problems and it is not a magic bullet, but it is a first-class starting point. It is also a point that we then need to follow up with political will. I do not understand why the UK and Europe—with the exception of France, which has just said no to the proposal—have not put forward a counterproposal starting from this point. Why have they not done what some other noble Lords have talked about—something similar to what the noble Lord, Lord Campbell-Savours, has suggested? Why not use this proposal as a starting point to do something for three big reasons?

The first of those reasons is the end game here. The end game is not about intellectual property but about dealing with the next pandemic, and the one after that. It is about having the ability to manufacture and make vaccines available around the world, quickly and rapidly, whenever there is a need for that to happen. That is what we are looking at.

Secondly, the point has already been made that the UK could play a much bigger role here and in the direct interests of the UK population. We are a global power in biomedical science and technology. We have produced some help; I note, for example, during our G7 presidency, the ability to offer some scope to other countries for sequencing variants. However, much more that is being done in this country could be expanded on. I think, for example, of the global pathological analytical service being developed in Oxford, which is basically a database for the sequencing of variants around the world, and is making the data accessible to everyone, free of charge; anyone in the world can send their data to it for analysis to be provided. So there are many things that the UK could be doing and offering as part of the development of a sensible plan for the future that responds to what low and middle-income countries are asking us to do.

The other big point here is that if the UK does not respond, others will. We have already seen the process of vaccine diplomacy during the pandemic, and the positioning of China and Russia in how they have been seeking to make friends and influence people through the use of vaccines. We can also see that countries will start helping themselves, and they in turn will break away from the consensus.

I am reminded of the very different epidemic of HIV/AIDS, more than 20 years ago. It is a very different disease, and the circumstances were very different. However, some of the responses were the same. To quote Dr Peter Mugyenyi, who was head of the HIV/AIDS response in Uganda in 2000,

“despite opposition by branded drugs manufacturers, and threats of punitive reaction, we took a decision to import and use low-cost generic ARVs from … India to save the lives of our patients”.

In a way, that says it all. Countries have that responsibility to their people, and they will go and do things.

Dr Mugyenyi goes on to say in the same article that at that point, the drugs were relatively expensive for Africa, but USAID, the US development agency, would not support their use in Africa because, it said, there was no ability to provide them to the population without the necessary supply chains. In an extraordinarily insulting and racist statement, the head of USAID said in 2001 that Africans could not use ARVs because they told the time by the sun. Two years later, President Bush moved that on, and President Clinton also intervened, with the result that antiretrovirals became cheaper. There is a process that will take place, whether we are a part of it or not. We do not know where this will end, but other countries will take their action.

The really important thing here is that the UK properly engages with this proposal, and puts in the counterproposal, whatever it is. It must be about working together, something along the lines of what the noble Lord, Lord Campbell-Savours, talked about: licensing it, working with people, learning from each other and building that infrastructure around the world, which, frankly, we need for the people of the UK as well as the people of the world.

I hope that in responding to this the Minister will talk about how he sees that development happening in the longer term and how the UK will have an impact on what we all see as a shameful position where we in our richer countries have been vaccinated if we have chosen to be, but in low-income countries people have not had that opportunity.

[Baroness Lawrence of Clarendon (Lab)]

My Lords, I have added my name to the amendment in the name of the noble Baroness, Lady Chakrabarti. It has been mentioned in your Lordships’ House numerous times that no one is safe until we all are safe. We have heard it many times in today’s debate.

I have voiced my concerns many times about the monopolies upheld by high-income countries that have chosen to retain scientific innovation and expansion by withholding the IP of the Covid vaccine. Low-income countries are in the position where they can manufacture their own vaccines, as there are more than 100 potential mRNA manufacturers across these countries ready to develop a vaccine, if they had access to the IP and the manufacturing know-how.

Too often the agendas of pharmaceutical companies are not aligned with positive public health outcomes. The public health condition aspect of Amendment 292 will help guide the Government to tighter stewardship around public funding to ensure that at the end of the development process, health treatments are both affordable and accessible to all concerned. I stand by the amendment in the name of the noble Baroness, Lady Chakrabarti, for this very reason, as its primary objective is to address the barriers that prevent poorer nations having adequate access to medicines at an affordable rate. We have heard many of your Lordships in the Committee today seeking to make the Government understand what is happening in lower-income countries and to support them and to ensure that action is taken when we say that no one is safe until all of us are safe.

Health and Care Bill

Lord Crisp Excerpts

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

[Baroness Walmsley (LD)]

My Lords, I thank the Minister for explaining the government amendments. I particularly welcome Amendments 88 to 91, because the Bill will now reflect the agreement made with the NHS foundation trusts in a much closer manner than in its original drafting. They are very welcome.

[Lord Crisp (CB)]

My Lords, I echo that statement and say how much I appreciate both the way in which the discussion was held and the end point whereby these amendments have now been placed in front of us.

[Baroness Thornton (Lab)]

I absolutely concur with the noble Lord, Lord Crisp, and the noble Baroness, Lady Walmsley, and congratulate the Minister on a concise and accurate proposal of these amendments. Long may this continue.

Health and Care Bill

Lord Crisp Excerpts

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

[Lord Farmer (Con)]

My Lords, in reintroducing this amendment, I want to pick up on comments made by my noble friend Lord Kamall in Committee. He said that he agreed with “the spirit” of my amendment and had been reassured since becoming a Health Minister by

“the number of people in meetings who have said that they want to move towards a focus on prevention.”—[Official Report, 20/1/22; col. 1811.]

Although the duty to improve continuously the quality of services and obtain appropriate advice includes those in connection with prevention, this in no way guarantees that it will be raised up from the current low bar relative to treatment.

I do not think it misuses the important concept of levelling up to apply it in this context. The thrust of my amendment is to level up the emphasis on addressing the precursors of illness with delivering care while it runs its course, as well as with what comes after, whether that is its sequelae, rehabilitation or palliative care. After all, the NHS is the National Health Service. Keeping people healthy and preventing ill health should be the first duty of integrated care boards, thereby fulfilling the purpose of the NHS. The chronic waiting lists and ever-increasing costs, which seem never to end, both flow from a culture that is reactive rather than proactive.

As my amendment states, a duty to prevent could mean, in many contexts, community health provision. A reverse Beeching for healthcare would help to nip in the bud any developing conditions and, when health needs have family implications, enable them to be treated alongside and integrated with early family help. Prohibitively long journeys to hospitals, in respect of which ICBs might choose to integrate health and health-related services to reduce inequality of access, will work against this prevention imperative, hence the need to give it primacy. A couple of examples will be helpful here. I will touch on how preventing, for example, childhood obesity and mental ill health will in no small part require improving family relationships, which is best done in the community.

The Leeds child healthy weight plan, established and led by Public Health England but multiagency in approach, focuses on prevention as it can be more difficult to engage families and see improvement once problems arise. Families on the plan took healthier steps in both the consumption of fruit, vegetables and sugary drinks, and physical activity, but they also reported a reduction in screen time and increased parenting confidence. Leeds has seen child obesity rates among reception-age children decline significantly as a result, particularly among the most disadvantaged children, over a period when similar cities and England have seen no change in this key area.

Secondly, in a recent major study of more than 43,000 children in children and young people’s mental health services, over half cited family difficulties, which were the biggest presenting problem. Again, community-based family support is vital for preventing mental ill-health.

In concluding—as noble Lords can see, I have not spoken for long—I want to stand back from this. The tragic events in eastern Europe indicate the need to spend more money on defence. Where will it come from if we do not cut our cloth differently? The prevention of ill health has to be a part of that. I beg to move.

[Lord Crisp (CB)]

My Lords, I will speak to Amendments 33, and 37 to 54. I thank the noble Lords who have added their names to those amendments.

There is a very simple point here. The purpose of these amendments is to make sure that primary care is as highly influential in the new system as, and not the poor relation of, NHS trusts and NHS foundation trusts. It is vital for the whole success of the entire Bill moving forward that primary care is able to play its proper part in the future. It is therefore very good indeed that the Bill includes having a representative for primary care on the board of ICBs—the integrated care boards. However, I will turn to the problem, which is exemplified by the first of these amendments.

Amendment 33 refers to a passage in the Bill which says:

“Before the start of each financial year, an integrated care board and its partner NHS trusts and NHS foundation trusts must prepare a plan setting out how they propose to exercise their functions in the next five years.”


There is no mention of primary care in that, which is where the amendment comes in, adding the words “and primary care”. It is worth just noting that this is an entire reversal of what is in a sense the current situation, where primary care has a big role within planning and the acute and NHS trusts more generally have a much lesser one. So this is a very big change. My first question to the Minister is that it would be helpful if he would explain why NHS trusts and foundation trusts are being treated differently from primary care. Alongside that, why and how will he make sure that primary care will be able to function as it should do in being equally influential with the other sectors?

I have already outlined the reasons for this in very broad terms, but I will pick out three or four points. First, it is so that their contribution can be made. Primary care is not just about what is happening in the out-of-hospital sector; it also has a significant role in what should be happening in the hospital sector and, of course, to pick up the point made by the noble Lord, Lord Farmer, it has a major role in prevention as well. Secondly, this is about morale. Primary care has very poor morale at the moment, and anything that seems to downgrade its role is important.

Thirdly, it is about messaging and the priority that is being given to the different parts of the system. Fourthly, there is another point here. Over the last—I guess—25 years, a number of GPs in particular have become quite adept at planning, thinking about the future and commissioning and so on. There is a great wealth of experience there, and that is experience of planning not just for primary care but for health services, and indeed prevention more generally. Then, of course, as I said at the beginning, this is about the direction of travel.

I am pleased to say that I have had some good discussions with the Minister, and indeed with officials, and I look forward to hearing what the Minister will be able to say in response to this. My request, and that of the noble Lords who have added their names to the amendment, could not be simpler. Why is it intended to treat NHS trusts and NHS foundation trusts differently, giving them apparently a more central role, and how will the Minister give the same level of influence to primary care as the Bill does to these other bodies?

[Baroness Finlay of Llandaff (CB)]

My Lords, I have an amendment in this group, but I support the thrust of the debate so far. I should declare that I am a fellow of the Royal College of General Practitioners, having previously worked as a GP.

The noble Lord, Lord Farmer, stressed the importance of trying to prevent ill health later on and to bring a population up to be less unwell than the current population is. We have to have a very strong primary care workforce to manage people in the community. There has been a great move to try to move people out of hospital and back into the community, but primary care is currently creaking under the load and social care services are not there to provide much of the support these people need. So primary care has to be factored in as a major contributor, the more we expect people to be looked after at home, nearer home and in the community. That can be particularly difficult in rural areas, where GPs are expected to take on much broader responsibilities. They might even be managing some of the accident services in the area, working with the ambulance services.

Health and Care Bill

Lord Crisp Excerpts

Lords Hansard - Part 1 & Report stage
Monday 7th March 2022 Lords Chamber

[Lord Howarth of Newport (Lab) [V]]

My Lords, I will speak to only Amendment 114, the proposed new clause on creative health. While I fully support Amendment 184ZB in the name of the noble Baroness, Lady Greengross, in view of the pressures of time today, I will not add to what I said on that subject in Committee. I am grateful to the noble Lords who have added their names to my amendment.

The term “creative health” denotes a range of non-clinical approaches to healthcare. These include working with cultural, natural and other community assets to effect a radical improvement of people’s experience at any stage in the life course. People receive expert support to engage creatively with, for example, the arts, crafts, museums, heritage and the natural world. There is a body of powerful evidence for the benefits of creative health, set out for example in the 2017 Creative Health report of the APPG on Arts, Health and Wellbeing and the World Health Organization Europe’s scoping review of 2019. Tapping into their own and others’ creativity has significant benefits for people in relation to a range of mental and physical health conditions, mitigating for example the distressing impacts of loneliness, anxiety, depression and dementia, as well as addictive behaviours and obesity. Health and well-being in social care settings also benefit significantly from creative health interventions. I detailed some of these benefits in speeches in Committee.

In the NHS long-term plan, the Government have already recognised social prescribing, and the National Academy for Social Prescribing has been established and made encouraging progress. With the establishment of the integrated care systems through the Bill, it is time now to examine a wider, systemic application of creative health approaches. In the new clause, I propose that the Secretary of State commissions a thorough review of the potential to integrate creative health fully within the new structures and the modern orthodoxies of health and social care.

I am sure Ministers will recognise the ways creative health can support them in their agendas. We know that creative health can help significantly with some of the most pressing, intractable and expensive problems in long-term health, including mental illness and obesity. It can reduce demand pressures on GPs, hospitals and pharmacological budgets. When adopted to support people working in the NHS and social care, it reduces staff turnover and losses. At very little cost it can support the prevention agenda, enabling people to have the confidence to take responsibility for their own health, and building resilience against ill health. Striking results are in evidence from creative health programmes in deprived communities such as Blyth and Grimsby. In such communities, through building confidence, energy, co-production, relatedness and social capital, creative health can prepare the ground to reduce health inequalities and improve productivity, serving the place-making and levelling-up agendas. So much more can be achieved if we develop creative health across the country.

These are the reasons why I believe it would be appropriate for the Government to set up the review described in the proposed new clause. If the Minister tells us today at the Dispatch Box that they will do so, we shall not need to legislate. I beg to move.

[Lord Crisp (CB)]

My Lords, I have added my name to the amendment from the noble Lord, Lord Howarth. He has made very powerful arguments, and I will add only three quick points.

First, I congratulate the noble Lord on the way he has championed creative health throughout the Bill, not just on this amendment, as well as the health impact of creative activity and beginning to move this into the mainstream.

Secondly, I have talked to a number of GPs about this, and they talked to me about the benefits they have observed: for example, of singing for respiratory health, of dancing for exercise and of gardening for contact with nature. Most involve some social engagement and all give meaning and purpose to life. For all these things there is some evidence base to show their impact on health. However, as the noble Lord, Lord Winston, said in Committee, we do not yet have decent evidence of the impact of specific creative health activities or of when and where they are most appropriately used. That is why it is very useful that the review specifically sets out to understand how and when specific creative activities impact on health and searches for the evidence and research requirements that will make this whole new approach as vital as it can be.

My third point is very simple. Throughout this whole process, it has been evident that we are reaching for new understandings of health from those that we perhaps had 10 or 20 years ago and certainly in the last century: an understanding that we need to pay great attention to healthcare and health services, an understanding that we need to pay a great deal of attention to prevention—by which I mean tackling the causes of ill-health—but also an understanding that we need to pay attention to the causes of health and the creation of health. That is another reason why this is such an important amendment. I hope the Government will look on it favourably.

Health and Care Bill

Lord Crisp Excerpts

Lords Hansard _ Part 1 & Report stage
Wednesday 16th March 2022 Lords Chamber

Moved by

[Lord Crisp]

158: After Clause 164, insert the following new Clause—
“Tobacco products statutory scheme: consultation
(1) The Secretary of State must, no later than six months after this Act is passed, consult and report on the desirability of making a scheme (referred to in this section and section (Tobacco products statutory scheme: supplementary) as a statutory scheme) for one or more of the following purposes—(a) regulating, for the purposes of improving public health, the prices which may be charged by any manufacturer or importer of tobacco products for the supply of any tobacco products;(b) limiting the profits which may accrue to any manufacturer or importer in connection with the manufacture or supply of tobacco products;(c) providing for any manufacturer or importer of tobacco products to pay to the Secretary of State an amount calculated by reference to sales or estimated sales of those products (whether on the basis of net prices, average selling prices or otherwise) to be used for the purposes of reducing smoking prevalence and improving public health.(2) The consultation must ask for views on a draft statutory scheme (or alternative draft schemes), which may, in particular, make any provision mentioned in subsections (3) to (6).(3) The draft scheme or schemes may provide for any amount representing sums charged by any manufacturer or importer to whom the scheme applies, in excess of the limits determined under the scheme, for tobacco products covered by the scheme to be paid by that person to the Secretary of State within a specified period.(4) The draft scheme or schemes may provide for any amount representing the profits, in excess of the limits determined under the scheme, accruing to any manufacturer or importer to whom the scheme applies in connection with the manufacture or importation of tobacco products covered by the scheme to be paid by that person to the Secretary of State within a specified period.(5) The draft scheme or schemes may provide for any amount payable in accordance with the scheme by any manufacturer or importer to whom the scheme applies to be paid to the Secretary of State within a specified period.(6) The draft scheme or schemes may—(a) prohibit any manufacturer or importer to whom the scheme applies from varying, without the approval of the Secretary of State, any price charged by the manufacturer or importer for the supply of any tobacco product covered by the scheme, and(b) provide for any amount representing any variation in contravention of that prohibition in the sums charged by that person for that product to be paid to the Secretary of State within a specified period.(7) The Secretary of State must lay the report before Parliament and a Minister of the Crown must arrange to make a statement to each House of Parliament setting out in detail any steps which will be taken to implement the findings of the report.”Member’s explanatory statement
This new Clause, along with others, would require the Secretary of State for Health and Social Care to carry out a consultation about a statutory scheme for the regulation of prices and profits of tobacco manufacturers and importers. Funds raised by the scheme would be used to pay for the cost of tobacco control measures to deliver the Government’s ultimatum for industry to make smoked tobacco obsolete by 2030 and for England to be smoke-free with smoking rates 5% or below.

[Lord Crisp (CB)]

My Lords, I rise to move Amendment 158 and note that the other three amendments in this group are consequential on this one.

These amendments would require the Government to consult on a statutory polluter pays scheme imposed on tobacco manufacturers to fund measures to reduce smoking prevalence and improve public health. In 2019, when the Government announced their smoke-free 2030 ambition, they promised to consider just this sort of polluter pays approach to raising funds for tobacco control. The amendments require the Government to fulfil this commitment by consulting on a statutory scheme and reporting back to Parliament within six months of the Bill’s passage. The scheme consists of two distinct parts: a levy raised from tobacco sales volumes, which would raise an estimated £700 million a year, and a price cap on tobacco products to prevent tobacco companies simply passing these costs on to smokers.

The amendments propose that funding from this scheme be used to pay for the tobacco control measures needed to achieve the smoke-free 2030 ambition. This includes greater investment in stopping smoking services, mass media public education campaigns, targeted support for disadvantaged groups, tackling the sale of elicit tobacco and preventing young people taking up smoking. There are three sets of arguments in this regard, which are all compelling. The first is the impact of tobacco on public health. The second, bluntly, is that this is in line with government policy. The third is the need for a pragmatic approach to where we are today and how we can achieve funding.

Let me just make a few points about the first of those, the impact of tobacco. First, smoking is, of course, the largest single risk factor in ill health and early mortality. Secondly, it is not a lifestyle choice; it may have been originally—as an ex-smoker, I know that—but it is also addictive, and addiction normally starts in childhood. That is why it is really important that we target younger people. Two-thirds of younger people who start smoking carry on into adult life. The current rate of decline is insufficient; smoking prevalence is coming down around the country but, currently, it would take until at least 2047 for the most disadvantaged communities to achieve the level required. Indeed, inequality is a big issue here. Given that so many noble Lords have spoken about inequalities in relation to other amendments to the Health and Care Bill, I just draw out that smoking is responsible for half of the 10-year difference in life expectancy between the richest and poorest parts of society. Whether one smokes or not has a far greater impact on life expectancy than a person’s social position in society.

This is a fundamental health issue—and there are costs. There are costs to the individual: it is estimated that the average smoker spends about £2,000 a year on smoking; and half a million households, a third of a million children and 183,000 pensioners are living in poverty because of the costs of smoking. There are also costs to the system. It is not just about mortality; it is very much about morbidity. We know, for example, that smokers are more than five times as likely as non-smokers to have microbiologically confirmed influenza and twice as likely to develop pneumonia. Similarly, we know that smokers who quit smoking have better treatment outcomes from day one for everything from cancer to cardiovascular disease, diabetes to dementia, maternity to mental health, stroke to surgery—to the benefit not just of those smokers, but the NHS that provides the service and, frankly, the economy by ensuring that people of working age can be more productive and not take so many days off sick.

Finally, in talking about the impact, I note that there is now enormous public support for these measures. In a recent survey, some 77% of the public supported making tobacco manufacturers pay a levy or licence fee to government for measures to help smokers quit and prevent young people taking up smoking. Nobody in your Lordships’ House will be surprised to know that a levy on tobacco manufacturers has also been endorsed by around 50 health organisations of many different sorts.

As I said at the beginning, there are arguments for these amendments that are about the impact of smoking, which are compelling in themselves. There are arguments that this is fundamentally in line with government policy and that the smoking target will not be hit in 2030 without something of this sort. There is also the very pragmatic argument that in a time of financial difficulty such as this, it is very often the longer-term measures that get cut. There is nothing longer term than making sure that we stop children smoking at an early age. We have, therefore, in this levy a very practical way forward. I beg to move.

[Lord Faulkner of Worcester (Lab)]

My Lords, I support Amendment 158 and the others in this group, to which I have added my name. Last Wednesday was national No Smoking Day, and there was an excellent event in a Commons dining room hosted by the All-Party Parliamentary Group on Smoking and Health—I declare an interest as an officer of that group—to celebrate the 50th anniversary of ASH. The star speaker was the Public Health Minister, Maggie Throup. She reaffirmed the Government’s commitment to achieving a smoke-free England by 2030 and rightly said that stop-smoking services would be at the centre of the forthcoming tobacco control plan.

NICE has estimated that, for every £1 invested in stop-smoking services, £2.37 will be saved on treating smoking-related diseases and reduced productivity. However, cuts to local public health budgets have disproportionately hit stop-smoking services. They have lost a third of their funding in real terms since 2015, accompanied by a decline in the number of smokers setting quit dates.

--- Later in debate ---

[Earl Howe (Con)]

My Lords, I am grateful to all noble Lords who have spoken in this debate and in the informative debate we had in Committee, on which I have reflected carefully. Let me first remind the House of what we are doing in this area.

We are committed to making England smoke free by 2030 and will set out our approach in a new tobacco control plan to be published later this year. As part of that work, we are exploring a number of regulatory proposals and have launched an independent review into smoking. The review, led by Javed Khan OBE, will make a set of focused policy and regulatory recommendations to government on the most impactful interventions to reduce the uptake of smoking and support people to stop smoking for good. It is in that context that I turn to the detail of these amendments.

As mentioned in previous debates, while I speak for the Government as a whole, tobacco taxation matters are ones for Her Majesty’s Treasury. As noble Lords will know, the tobacco industry is already required to make a significant contribution to public finances through tobacco duty, VAT and corporation tax. Through these finances we are able to fund local authority stop-smoking services through the public health grant and provide extra resources as part of the NHS long-term plan commitment to help smokers quit. As part of the annual Budget process, Her Majesty’s Treasury will continue the policy of using tax to raise revenues and encourage cessation through continuing with above-RPI duty increases on tobacco products. It is a proven and effective revenue-raising system.

I am as keen as anyone to find new ways in which to bear down on the prevalence of smoking and I am proud to have been instrumental in bringing some about. However, I am afraid that I cannot accept the amendment as it stands. The proposal may look simple on the surface but it is complex to implement. It may also take several years to materialise. Our strong preference is to continue with high tobacco taxation and excise as the best means and the most efficient process through which to generate revenue that can be put back into public services. However, I can tell the noble Lord, Lord Crisp—I hope that this will at least be of some reassurance to him—that the department’s officials will continue to work with Her Majesty’s Treasury to explore whether there are other innovative financing models that can be applied to the tobacco industry to support Smokefree 2030 and be as effective and efficient as the current taxation system. It may be—I do not know—that Javed Khan will come forward with recommendations in this area. We should allow him the necessary time to conduct his independent review.

I realise my reply will be disappointing to the noble Lords, Lord Crisp and Lord Faulkner, and my noble friend Lord Young, who are understandably passionate about this issue. I hope they will realise that we are very much on the same page regarding the overriding objective to reduce and eliminate the practice of smoking in this country. I hope I have provided some reassurance that the Government have listened and thought carefully about this proposal, even if we have not felt it right to proceed with it, in the end. As the noble Lord, Lord Crisp, would expect, we will set out our financial plans to support smoke-free 2030 in our new tobacco control plan. For those reasons, I ask him to withdraw his amendment.

[Lord Crisp (CB)]

My Lords, first, I thank those noble Lords who added their names to this amendment and spoke so eloquently in this debate, which covered a range of important issues that between them present a compelling argument for what is only a consultation. Secondly, I thank the other noble Lords who spoke during the debate, including those who spoke against the amendment, because having a proper debate allows us to pull out some important issues. I will return to that in a moment. Thirdly, I thank the Minister for the time that he and his colleagues gave to meet with us, and for our helpful discussions. I very much accept the noble Earl’s statement about us being on the same side and pushing in the same direction, but we need to get there.

That takes me to picking up some of the points that were made. I thought the contribution from the noble Lord, Lord Naseby, was very helpful. The point he made about how the numbers are coming down was terrific. It is great news—so let us accelerate it. We can get behind that and really shift it. There is a problem here, as with so much in public health, in that people talk about aggregates and averages. There is a real trap in aggregates and averages. The aggregate could come down to 5%, but 20% of people in the lowest socioeconomic group could still be smoking. That is the problem when you deal in gross numbers. I said in the debate that, according to Cancer Research UK, which is a reasonably reputable body, it would be 2047 before we saw that level of achievement among the lowest socioeconomic group in the country. Aggregates and averages are real traps in public health.

I understand the good faith of the Ministers in this House. However, and I think I speak for my colleagues on this amendment, we note that the Green Paper in 2019 promised to consider the idea of polluter or perpetrator pays—whatever is the right language for that. Almost three years on, we have not yet seen that happen. Not surprisingly, we are rightly suspicious of how these things can be kicked into the long grass and continue for a long time. If we are to achieve the 2030 outcomes for all the people for whom we want to achieve them, we need to accelerate. I believe the proposals put forward here are practical and implementable, as the noble Lord, Lord Young, spelled out.

In our discussions with Ministers, we offered a number of concessions, including the idea that it did not have to be precisely this scheme that was implemented, as they could consult on others. I am sorry the Government have been unable to accept that. On the basis of everything that has been said today, I would like to test the opinion of the House.

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Moved by

[Lord Crisp]

159: After Clause 164, insert the following new Clause—
“Tobacco products statutory scheme: supplementary
(1) The Secretary of State may make any provision he or she considers necessary or expedient for the purpose of enabling or facilitating—(a) the introduction of a statutory scheme of the type mentioned in section (Tobacco products statutory scheme: consultation), or(b) the determination of the provision to be made in a proposed statutory scheme.(2) The provision may, in particular, require any person to whom such a scheme may apply to—(a) record and keep information;(b) provide information to the Secretary of State in electronic form.(3) The Secretary of State must—(a) store electronically the information which is submitted in accordance with this provision;(b) ensure that information submitted in accordance with this provision is made publicly available on a website, taking the need to protect trade secrets duly into account.(4) Where the Secretary of State is preparing to make or vary a statutory scheme, he or she may make any provision he or she considers necessary or expedient for transitional or transitory purposes which could be made by such a scheme.”

Health and Care Bill

Lord Crisp Excerpts

Consideration of Commons amendments
Tuesday 5th April 2022 Lords Chamber

Moved by

[Lord Crisp]

At end insert “, and do propose Amendment 88B in lieu—

88B: Insert the following new Clause—
“Smokefree 2030 consultations
(1) The Secretary of State must, no later than the relevant date, consult on—
(a) any recommendations of the independent review into tobacco control announced by the Secretary of State on 4 February 2022 which in the opinion of the Secretary of State require consultation before implementation, and
(b) any other options for tobacco control considered appropriate by the Secretary of State.
(2) The Secretary of State and the Treasury must, no later than the relevant date, consult on one or more statutory schemes to regulate the price of tobacco products which fund delivery of— (a) the Government’s Smokefree 2030 ambition, (b) a reduction of inequalities related to health, and (c) improvements in public health.
(3) In subsections (1) and (2) the relevant date is the earlier of—
(a) the last day of the period of 6 months beginning with the day on which this Act is passed;
(b) the last day of the period of 3 months beginning with the day on which the report of the independent review referred to in subsection (1) is published; (c) 31 December 2022.
(4) The Secretary of State must lay reports before Parliament on the consultations carried out under subsections (1) and (2) and a Minister of the Crown must, within 12 weeks of completion of the consultation, arrange to make a statement to each House of Parliament setting out in detail any steps which will be taken to implement the findings of the reports, and the proposed timescales for doing so.””

[Lord Crisp (CB)]

My Lords, this amendment replaces the “polluter pays” tobacco levy Amendment 85 and consequential Amendments 86 to 88, which were passed by this House on Report by 213 votes to 154.

I very much thank the Minister for the time that he and other noble Lords and colleagues in the Bill team and Treasury have taken to explore with us opportunities for reaching an agreement. We are disappointed that we have not yet been able to achieve a compromise. I also thank other Lords very much for their support for this Motion, which has come from all sides of the House.

The reasons for moving this amendment are very obvious. They are about the impact of smoking on health and about inequalities and levelling up. First, Members of your Lordships’ House understand very well that smoking is the leading avoidable risk factor in health and is responsible for years of ill health—chronic illnesses, years of misery, early death and, for the country, loss of talent and productivity to the nation as a whole. What noble Lords may not appreciate—I did only relatively recently—is that it is also a leading factor, perhaps the leading factor, in the differences in health outcomes between different sectors of the population. Some 50% of the difference in health outcomes between those in the highest socioeconomic group and those in the lowest socioeconomic group is due to smoking.

--- Later in debate ---

[Lord Kamall (Con)]

I thank all noble Lords who have taken part in this debate and the debates throughout the day. We managed to stick to the point and tried to be as brief as possible. I am afraid I will not be as brief as the noble Baroness, Lady Thornton, but I will try to be briefer than I usually am.

I should just make some acknowledgements, looking at the whole group. First, on learning disabilities and autism, I thank the noble Baroness, Lady Hollins, in her absence, for her constructive engagement with the Government.

On tobacco, I once again urge noble Lords to reject Amendments 85 to 88 and 88B. The independent review is not scheduled for publication until May, when we will of course consider our next steps. I understand that the noble Lord told us to get on with it, but we do not want to pre-empt the independent review. As it is in the process of being drafted, we really want to make sure that we have proper consultation and agreement, both across government and across the UK with the devolved Administrations.

I hope the noble Lord is in no doubt that we are also committed to the tobacco plan and the reduction of smoking. We just do not feel that this is the right amendment, but the noble Lord may feel otherwise. Any changes to tobacco legislation proposed by the Khan review, a plan supported by the Government, will be consulted on. We firmly want to make sure we reach our smoke-free 2030 ambition or get as close to it as feasibly possible.

There is a debate about the polluter pays principle. I am sure the noble Lord, Lord Crisp, will recognise the debate about Pigouvian taxes, taxing negative externalities and who is responsible. Who is the polluter? In the car industry we tax the driver, as they put more petrol in. Should it be the smoker or the industry? There is a debate about this, but I hope these issues will be considered by the Khan review.

I also thank the noble Lord, Lord Sharkey, for his constructive engagement on reciprocal healthcare. I am pleased that we were able to narrow the gap and get to the same place.

I turn now to the telemedicine abortion issue. The Government felt that we should have gone back to pre-pandemic measures, but it was right that there was a free vote. We saw the results of the votes in your Lordships’ House and the other place, and we accept them. The democratic will of both Houses is quite clear. At the same time, we also accept that there were some concerns, as my noble friend Lady Eaton rightly said, about underage women being forced to have abortions and safeguarding. My noble friend Lady Verma also made a point about issues in certain communities; we know that these things go on in certain communities and that there are close relationships.

After the reassurances I gave at the beginning, my noble friend Lady Eaton said she was reassured enough not to push her amendment to a vote. I hope that remains the case and that my noble friend has not been persuaded otherwise. It is important that we consult, treat this sensitively and get the appropriate guidance, but the decision has been made by both Houses and we have to make sure that it works and that we address some of the legitimate concerns that noble Lords have raised in this debate.

Given that, I ask this House to accept the Motions in my name.

[Lord Crisp (CB)]

My Lords, let me first say how much I respect the Ministers and appreciate the time they have given to me and other noble Lords to discuss the “polluter pays” amendment. I really appreciate it and found it very useful. I think it was the noble Baroness—I cannot remember the name.

[Noble Lords]

Eaton.

[Lord Crisp (CB)]

No, forgive me. It was the noble Baroness, Lady Cumberlege—my apologies for that very public senior moment—who earlier commended the Ministers on their patience and good humour, right to the end of this long Bill.

I think there is very little difference between us and that what I am arguing for is very much government policy, but there still is a difference. Let me also thank the other noble Lords who have spoken in this debate for their support. I was reflecting on this difference while the debate was happening and, at bottom, it is about making sure that something happens. It is not just about consultation, which we did not discuss. It is about the timetable too. It is about ensuring that we have a consultation to a timetable and that there is scope for action.

It is also about the reality. The noble Lord, Lord Young, spelled out for us that we have seen cuts in tobacco control over recent years and that there was a commitment given to considering “provider pays”—I think it was two or three years ago. We are all familiar with the fact that things can slip. At the moment, I suspect that we are going in the wrong direction on tobacco control and that it is slipping down the agenda.

I am left with two questions. First, where will the funding come from for the action that needs to be taken to intervene on tobacco control, which is something that we all want? I absolutely accept the noble Lord’s point on that. Secondly, will action actually be taken? I was very struck at our meeting with the Treasury, which the Minister kindly arranged, to find that the Treasury officials are rather opposed to any levy, despite the attractions and success of the pharmaceutical levy referred to by the noble Lord, Lord Stevens, in Committee.

While there is also enormous waiting list pressure, which we all know about and which I suspect has already been discussed many times during these debates, how will we find the money for something that is going to have a long-term impact, as opposed to dealing with the emergency right in front of us? Of course, we will all be aware that an election will be coming in due course. I suspect some things will rise up the agenda and some slip down it. You do not have to be a cynic to think that this could slip very easily. Therefore, for those reasons, I want to test the opinion of the House.