NHS: Long-term Sustainability

Lord Crisp Excerpts

Thursday 18th April 2024 Lords Chamber

[Lord Crisp (CB)]

My Lords, I congratulate my noble friend on his excellent speech introducing this debate. I am very much looking forward to the maiden speech of the noble Baroness, Lady Ramsey of Wall Heath, bringing her great expertise to bear on this issue. I declare an interest, I suppose, as former chief executive of the NHS in England and Permanent Secretary at the Department of Health between 2000 and 2006, when I had the privilege to work with three noble Lords who are taking part in this debate: the noble Lord, Lord Reid of Cardowan, as Secretary of State, and then successively the noble Lords, Lord Hunt of Kings Heath and Lord Warner, in your Lordships’ House.

I want to make three points about the major reforms that are required, and a fourth point on implementation. I shall state them briefly at the beginning, in case I run out of time. The three reforms follow very much from what the noble Lord, Lord Scriven, just said: that we are using a 20th-century model of service delivery for 21st-century issues, and that must change. The second point is that the Government need to create a cross-sector health and care strategy and plans, of which the NHS is part. Thirdly, this needs to be underpinned by changes to professional education—that is fundamental, but it has not yet been mentioned and I want to say something about it. Finally, implementation needs to be based around a shared vision that motivates and involves people, and efforts to build consensus and momentum.

I say in passing that I very much enjoyed the speech of the noble Baroness, Lady Blackwood. It was fantastically important. I also know that the noble Lord, Lord Bethell, and others will be talking about the links between health and prosperity. A healthy workforce and a prosperous country are fundamental.

The first major reform is the need to change the model, with much more focus on primary and community care, support for carers and social care, and action by many people. It cannot be just the same model or a question of more GPs and nurses. Around the country now, we see community health workers doing outreach, the great programme of Growing Health Together in Surrey, and people creating the future. We need to build on those examples of what a new model of primary and community-based care will be.

I turn to the second major reform. I have spoken many times in the House about the African saying, “Health is made at home; hospitals are for repairs”. I have also been pressing the case for quality standards to include healthy homes. The NHS is dealing with many problems that it has not caused, and those need to be addressed at source. There needs to be a government cross-sector health strategy and plan, of which NHS and social care is a part. I suggest that that plan needs to focus on the aim of creating a healthy and health-creating society—and indeed a prosperous society while we are at it. The focus should be not just on dealing with the problems—by tackling such things as air pollution—but on creating the conditions for people to be healthy. Think of Sure Start, for example, which I know many noble Lords will be aware of. Such a plan would create the conditions for people to be healthy. That is why we should be looking at health as being about healthcare and the prevention of disease but also the promotion of the causes of health and creating the conditions.

The third major reform underpinning all this is a need to transform professional education. I am happy to be associated with a radical group of young professionals who are starting to drive this agenda, recognising that they will need different skills for the sort of model I am talking about, as well as retaining the basic science.

The final point is implementation. My experience as chief executive is that I was lucky to arrive at a point when two things had happened. First, the Government of the day brought people together to create a plan; they built energy and hope, and there is not much energy and hope around today. That hope and energy created good will that carried us forward two or three years. That good will lasted a really long time and allowed us to make radical changes, including bringing in the private sector and other things. It is very much harder today, obviously. As was already mentioned by the noble Lord, Lord Hunt, by the end of 2005 waiting lists were below 1 million, with a six-month maximum wait, and there was more improvement to come from then on. It is very much harder today. The NHS is in worse condition, although there is still good care being provided, as the noble Lord, Lord Patel, emphasised. But the Government must do something—whether it is a new Government coming in or this Government continuing—to bring people together around this problem and create a solution that people will buy into.

We must also deal with the presenting problem. We cannot just deal with the long-term. A new Government coming in will have to look at the waiting lists and how to handle that, but they must then pivot to health. Twenty years ago, I believed that we must talk about the issues people were presenting with, such as waiting lists and A&E, and then pivot to a focus on health. We never quite pivoted to health. It is time now to change from talking about healthcare to talking about health, which embraces healthcare but also prevention and the creation of health.

NHS: Performance and Innovation

Lord Crisp Excerpts

Thursday 15th June 2023 Lords Chamber

[Lord Crisp (CB)]

My Lords, I congratulate the noble Lord, Lord Scriven, on his excellent speech. It was good to hear him take on the big questions in terms of what this is all about, what it is for and where we are going. He reminded me of my friend, who said this to me the other day: “Did you know that primary care is based on a 1948 business model? What else in our society is still operating on such a model?” The noble Lord also reminded me of something that is very close to my heart, having spent the past 17 years working on health in African countries: how much we can learn from people who do not have our resources, our baggage of history and our vested interests. He made a strong point about the importance of investing in primary care and community care to move the whole system on.

I want to reflect on the people side of innovation and improvement, as well as on some of the innovations of recent years; there have been some massive innovations in recent years. I also want to talk about some of the barriers to this sort of innovation. Let me start with a few reflections on the past. The last time the NHS was in serious trouble was at the end of the last century; I became chief executive and Permanent Secretary at the Department of Health at the beginning of this century. In that period, a number of big changes were introduced. Some of them were service changes. We tried to get waiting lists down—does this sound familiar?—and worked on best practice in ophthalmology and orthopaedics, separating elective and emergency orthopaedics. It all sounds quite familiar in terms of the sorts of things that were being done but, importantly, these things were changing the way in which people went about doing their jobs. It was not about some wonderful, whizz-bang technology coming in from outside, although technology helps; let us be clear on that. Good knees and hips—the joints themselves—were important as part of this, but it was about people.

Interestingly, we also introduced a number of policy changes. One was about offering patients a choice: if they had waited more than six months, they could go to another hospital. We also introduced competition, with South African units coming in to do some work on elective surgery. I would be happy to show the Minister the graphs I am holding, but the really interesting point is that you barely had to have a South African doing three eye operations before there was a change in the behaviour of the people in the NHS. Very few people exercised that choice and the competition was pretty marginal, but, frankly, the system changed quite dramatically. It was all about people’s behaviour.

That theme—people’s behaviour and clinical leadership—is very big. Let me turn to one of the most radical things that happened in those years: the introduction of nurse and non-medical prescribing in 2003. It was deeply controversial. The medical establishment was broadly against it, but it was the palliative care physicians who came and lobbied me about it because, frankly, they did not want to be woken up in the middle of the night. They knew that their nurses were quite able to change the dose of opiates. This measure was controversial when it was brought in in 2003, but I suspect that new medical students and doctors do not even know that nurses have not been prescribing for ever. It simply is not controversial now, yet many countries around the world, including most of our neighbours, do not allow anyone apart from doctors to prescribe. This was a big strategic change, and it came from clinicians.

Another change that has come from clinicians—this time, much more recently—is social prescribing. Again, it is something on which the UK is very much leading the way around the world. There are big and fantastic changes coming through from the people within the system and linked to it. It is really important that we acknowledge this. Some real, current examples of this include the virtual wards that are springing up all over the place. Again, these are examples of people inventing new ways of handling the system; things are very much helped by technology there.

What I want to touch on goes back to my point about learning from Africa. In the borough of Westminster, in 2021, community health workers modelled on the Brazilian model—not the African model—were introduced. Community health workers are local people who know their community and visit every house in their area once a month. They talk to people about health, they listen to them about health and they explore their health issues, after about six months’ training. It turned out that within six months there was a big increase in the uptake of immunisations, a big increase in screening and health checks and a reduction in unscheduled GP appointments. It was concluded that they were very effective at identifying unmet need, co-ordinating care—a very big issue—bridging health and social care and so on. From having four community health workers the borough of Westminster now has 30, and the programme is expanding at Bridgwater, Calderdale and Cornwall.

Two things about this are worth noting. This came about because of a British doctor, who is now at Imperial, who was working as a GP in Brazil. He brought this back with him to this country and spent years developing the ideas about how it would work. It would not surprise me at all if in 15 years’ time the front line of a lot of primary care was community health workers and then nurses and then doctors—a really radical change of the sort that the noble Lord, Lord Scriven, was talking about. So, there are big changes happening.

Outside the health service, too, there are non-health actors, such as the City Mental Health Alliance with the big companies in the City of London—all about nature and gardening, which I am sure noble Lords know all about. There is the Daily Mile in schools where teachers and pupils run a mile every day. There are 15,000 schools in the UK and many more globally doing that. So there is an awful lot of innovation and creativity, and these are all about passionate people making change.

It is true that the system needs external challenge from time to time; it must not get too cosy. But it is important for any Government to back their people. It is not always easy. Politicians, I know, of all parties are in a hurry and trying to push people into making change, but these innovations have basically come from within the system, from people who understand the detail. Understanding the detail is really important here, because it is easy to have big ideas about how things may happen. Too often, politicians will be talking about reform, when really they should be talking about evolution and taking people with them. Reform is something that tends to be done by you to other people. I think it is really important to get behind our health leaders and health people in all places, including the Derbyshire dementia team in Chesterfield, which I was talking about in Oral Questions.

Particularly at a time when people are exhausted—people have talked about a global epidemic of exhaustion in health systems—and demoralised, and there is a lack of vision around the world about what health services are, which the noble Lord, Lord Scriven, raised, there are some important things about the attitude towards where we seek innovation. None of that should detract from the extraordinary technological and scientific advances: targeted drugs; improvements in breast cancer treatment; the phenomenal changes in children’s cancer over the years; the enormous development, in my time, of catheter labs; how heart conditions are being dealt with differently; robot surgery; and so many more extraordinary things that we are able to do already compared with 15 or 20 years ago. We need both parts. We need technological innovation as well as human.

Let me now turn to the barriers to innovation on the people side. First, I will kick off with one of the issues: the financial rules, the constraints landing on our clinicians. I received a tweet—which I will not attempt to read on my phone in case it goes off wrongly—from a GP two days ago. He is somebody I know who does a lot of innovative work. He says that for four years he has been a clinical director of an ICN, and he thought that would be where he could make change happen, but he found it was about governance—a point the noble Lord, Lord Scriven, talked about—and that the financial rules meant that they kept returning to the GP contract, with all its constraints. The stuff they wanted to do was more community-oriented, inventive and innovative, about actually helping people with their health—to take a point from the noble Lord, Lord Addington—as well as with the immediate problem that they may have come into the GP surgery with, but the financial systems were getting in the way. I think that is a really big problem across the entire NHS.

The second problem that I want to talk about is that I get lots of people talking to me about the NHS, even though I left it 17 years ago, and the biggest complaint I hear is about the lack of joined-up behaviour. I mean joined up not between departments but between primary care and secondary care, or between the guy dealing with your knee and the guy dealing with your head or whatever—that whole issue of communication. Technology can help with that, no doubt at all, but we still have examples where people are using different record systems—the GP is using a different record system from the dementia care team, to go back to that particular story—and governance often militates against people working together effectively.

The final issue is the attitudes, behaviours and, underlying those, professional education—how people have been brought up within the system. The noble Lord, Lord Scriven, is quite right that we should be thinking 20 years ahead about what the jobs are going to look like. That means we need to change professional education profoundly. I know a lot of people are thinking about it, but I do not know that people are doing it.

We from the All-Party Parliamentary Group on Public Health recently published a report on this with a great title, not necessarily the best thing about it: Probable Futures and Radical Possibilities. We were saying, “Having looked around the world, this is what the future looks like and this is some of the radical change”. It picked up, and I am going to pick up, four points. The first is on technology:

“Science, technology and data will determine much of the framing and the language of health, shape how health workers think about health problems and possible solutions and how they act”.


It is going to be fantastically important and a much bigger bit of all professional education for the future.

The second point, which we heard a lot from young doctors in particular, was about the things not on the medical education agenda. There was no preparation around social prescribing. There is a great Beyond Pills campaign being developed by younger doctors and the College of Medicine. They are much more interested in a biological-psychological-social model than a purely medical model. Big changes are needed, and these are young people making these arguments.

The third point is on a set of skills. These are the so-called soft skills because they are difficult; they are the ones about teamwork, influencing people, relationships, participation and improvement science. It is worth remembering that in healthcare, as everywhere else, relationships trump systems. That is how you get around the systems and make them work. It is about learning about those soft skills.

The final point was that an awful lot of young people within the system—and this is around the world, not just the UK—feel trapped looking at a future of AI, technology, protocols and tougher management regimes, wondering what it will mean to be a professional in the future, feeling that they are just going to be turned into technologists, technicians, rather than the professionals of an older generation that many of us would recognise. They argue that there needs to be a much greater emphasis on relationships creating health; health workers as agents of change; facilitating change in patients, organisations and society; and being curators of knowledge.

So I would ask the Minister, in conclusion, whether he accepts that there needs to be more attention given to the financial rules guiding people’s behaviour in practice, particularly around primary care, but, secondly, to have a thorough look not just at numbers of healthcare workers but at the professional education that shapes them over so many years.

Dementia Palliative Care Teams

Lord Crisp Excerpts

Thursday 15th June 2023 Lords Chamber

Asked by

[Lord Crisp]

To ask His Majesty’s Government what plans they have to expand the use of dementia palliative care teams in England in accordance with the model introduced in Derbyshire.

[Lord Crisp (CB)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and declare a personal interest, as I have a relative who is cared for by the Derbyshire palliative care team which is as described in the Question.

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

The Derbyshire model is recognised as an example of best practice. The Derbyshire palliative care service toolkit has been widely shared by NHS England, which encourages regions to adopt good practice. Resources from the toolkit have also been published on the FutureNHS platform. It is a superb example of how better integration of the excellent services already available, not always requiring more funding, can have a positive impact on communities.

[Lord Crisp (CB)]

My Lords, I am grateful to the Minister for that very positive reply, with which I absolutely concur from my own experience. It is good to have the chance to say something positive about people working in the NHS at a time when it is under such great pressure.

As all noble Lords know, dementia is a dreadful and deeply distressing disease, or set of diseases. One in three of us will experience it and almost all of us will be affected, as family or as carers. It is a very complicated process that people have to go through. One of the issues I want to ask the Minister about is co-ordination of care and the help that is available to people. People looking after people with dementia need help with medication, with incontinence, with devices and aids, with falls, with hospital clinics and with a whole range of different issues, coming from primary care, social services and hospital care. The dementia palliative care team in Derbyshire provide the co-ordination. What needs to happen in cases where there is no such team? How can that care be co-ordinated or does it all land on the principal carers and the spouses and partners of the people concerned?

My second question is—

[Noble Lords]

Oh!

[Lord Crisp (CB)]

Sorry. I note the Minister’s point about the excellence of this particular team and the intention to spread the idea. How far do the Government think it will spread and be adopted in other parts of the country over the coming two or three years?

[Lord Markham (Con)]

I thank the noble Lord. I have an auntie with dementia in care in Derbyshire. The noble Lord is correct that it is a perfect example of a wraparound service that takes in all the facilities that people need. The intention is that we want to spread that everywhere. It is the responsibility of each ICB to set the right commissions in their local area, but we are spreading knowledge of the dementia model as far as we can. A big example is that we promoted it at the recent national clinical excellence celebration day in the Midlands.

Health Promotion Bill [HL]

Lord Crisp Excerpts

2nd reading
Friday 2nd December 2022 Lords Chamber

[Lord Crisp (CB)]

My Lords, I welcome this Bill and congratulate the noble Lord on promoting it. I very much support the focus on health promotion, physical activity and cross-government action. After all, the department is called the Department of Health and Social Care and not the department of health services and social care, and the noble Lord is the Minister for Health and not just health services.

Like the noble Lord, Lord Lansley, I will also be widening the debate slightly. I am particularly pleased that the Bill widens the debate on health. Too often, we talk just about health services and healthcare, and sometimes prevention, but we almost never talk about the third important area of creating health, of which health promotion is a part. All three are important and essential.

All of us understand what we mean by healthcare but it is important to distinguish prevention, which is about the causes of disease, pathogenesis and pathology, and about activities focusing on, for example, heart disease, stroke, cancer and tackling air pollution, and health creation, which is about the causes of health, salutogenesis, but not the causes of disease. I describe this as creating the conditions for people to be healthy and helping them to be so. Those causes include, for example, opportunities for social interaction; healthy working environments and development; being in touch with nature; having a meaning in life; relationships of all sorts; being well-fed and well-housed; the agency to act and decide, as opposed to alienation and anomie; and self-respect. We want healthcare, the vital services of the NHS, and the approach to prevention that this Government are moving on, but we also want the positives of actively creating health.

I have often quoted in your Lordships’ House the saying from a great Ugandan doctor:

“Health is made at home, hospitals are for repairs”.

Indeed, I know that the former Minister, the noble Lord, Lord Kamall, has quoted this back to me on occasion. It is a very valuable point. It is why I talk about a health-creating society and why I am promoting the Healthy Homes Bill. The first time I raised this in your Lordships’ House was in a Cross-Bench debate on 26 November 2015, when I moved that this House takes note of the case for building a health-creating society, where all sectors contribute to creating a healthy and resilient population. There were many powerful speeches from all sides of the House. I believe we need this even more than ever, and that we are not going to make progress on health unless and until we recognise that creating health is as important as disease prevention and healthcare. Obviously, there are links and overlaps, but let us recognise these very important distinctions.

It is also worth noting that health creation operates at four levels: the health of each of us as an individual is intimately connected to the health of the local community in which we live, to the health of wider society and to the health of the planet. I will think about this while turning specifically to the Bill and its focus on health promotion and sport. Health promotion as usually described is generally about the individual, lifestyles, activity and diet. It is also about the important point that the noble Lord, Lord Addington, made about walking, rather than physical activity in general, which has been recognised since the Greeks as being vital to health. As the noble Lord pointed out, what he is proposing is also about sociability and bringing people together, creating purpose and creativity. I am pleased to see that he has included nature in the Bill. It is also about self-respect, being successful and achievement. All these factors are for the individual as well as for communities: bringing people together, sharing and community facilities. It is also about opportunities in a wider sense, and sport has long been a driver for social mobility. As he has drafted the Bill, it is also about the planet, nature and the environment.

I commend the noble Lord for the Bill, with its focus on health promotion, sport and wider physical activity, and for promoting a national plan for sport. This is not the whole story—of course it is not; he does not present it as if it were—but it is a very important part of a health-creating society. As he said very eloquently in his speech, the public get this; this is a win-win because people will understand why the Government, in creating a health-creating society, are promoting sport in this way.

I ask the Minister whether the Government will recognise that they need to think about three distinct elements of health—health services, prevention and health creation; each distinct but linked to the others—and whether they will promote health creation. Finally, I say to the Minister that many people and groups around the country are actively involved in creating health. Would he be willing to meet representatives of the Health Creation Alliance, which brings many of these groups together?

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.

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 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
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 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 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.