Health and Care Bill

Lord Desai Excerpts

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

[Baroness Tyler of Enfield (LD)]

My Lords, my name is attached to six amendments in this extremely important group. I should like first to turn to Amendment 14 in the name of the noble Baroness, Lady Thornton, to which my name is attached. Other noble Lords have expressed support for amending the triple aim to explicitly include health inequalities, and I add my voice to that call. The examples given by the noble Lord, Lord Patel, and others about the real-life causes and impacts of health inequalities show just how important it is that we strengthen the Bill.

I would like briefly to highlight the specific impact of mental health inequalities, which are pervasive and deeply embedded. As the noble Lord, Lord Crisp, said in our debate on Tuesday, mental illness itself causes inequality. People with severe mental illness live, on average, between 15 and 20 years less than the general population. Black people are more than four times as likely as white people to be detained under the Mental Health Act. There are higher rates of suicide in the LGBT community, yet many in that community do not, or feel that they cannot, seek healthcare because of fear of discrimination. People with a learning disability often suffer with significantly worse physical and mental health than the general population.

The Centre for Mental Health Research has shown that it is often groups of people with the poorest mental health who have the greatest difficulty accessing healthcare that meets their needs and produces good outcomes for them. Unless an ICB is focused on which groups of people have the poorest health in the first place and understands why that is the case, it will, frankly, struggle to reduce the inequalities flowing from that.

Amendment 14 would amend the triple aim duties specifically for NHS England. Amendments 94, 185 and 186 in the name of the noble Lord, Lord Patel, to which I have attached my name, would replicate that explicit inclusion in the triple aim for integrated care boards, NHS trusts and NHS foundation trusts.

As the noble Lord, Lord Young, has said on health inequalities, regarding them as implied in the first element of the triple aim—to consider the impact of decisions on the health and well-being of the population—does not, in my view, get us any further than where we are today. Given the statistics that I have outlined and the fact, as we have heard, that the pandemic has made things a lot worse, we clearly need to go further.

I turn now to Amendment 65, regarding the role of local health systems. It seeks to strengthen the health inequality duty placed on integrated care boards by giving them a requirement to

“implement systems to identify and monitor inequalities in physical and mental health between different groups of people within the population”

of their area. As things stand, the provisions in the Bill will ensure that NHS organisations are required to address inequalities in a similar way to how CCGs currently do it. But we need to see more ambition. The provisions would be strengthened and not merely transferred. The current requirement to “have regard to” is not enough. Local health systems have a central role to play in addressing health inequalities. They are ideally positioned to understand the challenges in their areas and, to use the jargon—for which I apologise —co-produce local solutions with communities. The development of integrated care systems gives us a new opportunity for local areas to take population health and place-based approaches, so that the vulnerable groups who have been referred to do not fall through gaps.

There is a lot about health inequalities that we do not know; we suspect, but we just do not have the data. Amendment 65 proposes that the Bill includes clearer and more direct requirements for integrated care boards to focus efforts on identifying and monitoring those inequalities. Currently, the quantity and quality of data collected is inadequate for it to be fully disaggregated against the different protected characteristics and provide a real insight into the inequalities that exist. That is why I have attached my name to Amendment 61 in the name of my noble friend Lady Walmsley, which I strongly support.

Robust information and data are prerequisites for any action. Improved data collection—both on health services and on wider inequalities in the area—will lead to a far better assessment of what needs to be done, particularly in areas such as public mental health and the local NHS workforce. I will quote one statistic about GPs. A GP working in a practice serving the most deprived patients will, on average, be responsible for the care of almost 10% more patients than a GP serving a more affluent area. This simply cannot be right.

I will end by quoting from work we have already heard about—the work of Professor Sir Michael Marmot. It needs no introduction. He has demonstrated that efforts to address health inequalities will benefit society as a whole. The NHS Long Term Plan states:

“While we cannot treat our way out of inequalities, the NHS can ensure that action to drive down health inequalities is central to everything we do.”


I urge the Government to ensure that the Bill does just that.

[Lord Desai (Non-Afl)]

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

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

[The Lord Bishop of Carlisle]

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

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

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