Health and Care Bill

Lord Howarth of Newport Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

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

My Lords, I add my warm congratulations to the noble Lord, Lord Stevens of Birmingham. There is much to welcome in the Bill—but not Clause 140, which, by excluding local authority support from the calculation, means that poorer people will lose a larger proportion of their assets in paying for social care. Especially coming on top of the regressive national insurance levy, this is shockingly unfair. I also share the concerns expressed by noble Lords about the effectively untrammelled power that Clause 39 provides for the Secretary of State.

I strongly support the restriction on advertising of food and drink. It is right to curb abuses of commercial and media freedom by food and drink manufacturers that seek to wreck human health for their profits.

I very much welcome the centrepiece of the Bill: the replacement of the driving principle of competition with that of collaboration—not only between bodies within the NHS but between the NHS, local government and other community partners—and the statutory underpinning of place-based integrated care systems. While the Bill hardly begins to address the really big challenges for the NHS—integration of health and social care, workforce planning, prevention and health inequalities—ICSs point the way to making progress on all these.

I would like to describe one way in which some ICSs have already entered into fruitful partnership with non-clinical bodies. I declare an interest as chair of the National Centre for Creative Health, a charity that promotes creative engagement with the arts and culture in the interests of health and well-being. It was set up in response to a recommendation in the 2017 report Creative Health by the All-Party Parliamentary Group on Arts, Health and Wellbeing. A number of noble Lords took part in that work. The NCCH is working with NHS England and four ICSs: Gloucestershire; West Yorkshire and Harrogate; Shropshire, Telford and Wrekin; and Suffolk and north-east Essex. Our focus is on how cultural and community assets can mitigate the negative health impacts of social disadvantage.

Creative Health set out a mass of evidence on the health benefits of creative activity. It also demonstrated significant benefits for the health and well-being of NHS staff. Since 2017, the body of evidence has increased, as reported in the work led by Dr Daisy Fancourt at UCL for the World Health Organization and for the MARCH Network, funded by UKRI. There have been numerous other testimonies concerning the benefits of the arts for mental health during the pandemic. ICS leaders who have recognised this have been enthusiastic to work with the NCCH and local arts bodies to realise the potential of engaging creativity to further their health agendas, whether in preventive strategies or in assisting patients to recover better. Significant innovative work has been taking place—for example, in Suffolk, where sufferers from long Covid are being supported to improve their breath control through singing.

Psychosocial factors that contribute to health inequalities include isolation, lack of social support and social networks, lack of self-esteem, perceived lack of control, and doubt about the meaning and purpose of life. Engagement in music, dance, drama, pottery, art classes or reading groups can mitigate all those factors.

There are two aspects of the Bill on which I would be grateful for the Minister’s clarification and reassurance. Will integrated care boards have the freedom to include in their membership nominees of community bodies such as arts and cultural organisations, and will new procurement regulations permit ICSs to buy non-clinical services from arts and cultural bodies and individuals?

Professor Sir Michael Marmot endorsed the findings of Creative Health in these words:

“The mind is the gateway through which the social determinants impact upon health, and this report is about the life of the mind. It provides a substantial body of evidence showing how the arts, enriching the mind through creative and cultural activity, can mitigate the negative effects of social disadvantage.”


Of course, the Marmot agenda is far broader. The Marmot review estimated in 2010 that health inequalities cost £31 billion in lost production. The Treasury should recognise the investment case for fully resourcing ICSs. More than that is needed. Until the Government mobilise other departments alongside the Department of Health to address systemic environmental and social factors in local communities across the land, there will be no levelling up, poorer people will continue to suffer unnecessary ill health, and the NHS will continue to struggle.

Health and Care Bill

Lord Howarth of Newport Excerpts

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

Moved by

[Lord Howarth of Newport]

3: Clause 1, in section (1A)(b) insert—
“(vi) one must be appointed to represent providers of non-clinical services promoting health and wellbeing.”

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

My Lords, I fully support the objectives of my noble friend Lady Merron and her co-signatories to Amendment 2. However, as indicated in Amendment 3, in my name, I believe that it would be appropriate to add to the board’s membership a person representing a very important element of providers, who are always at risk of being overlooked when the NHS is, as is so often the case, under intense pressure.

There is a growing body of research evidence demonstrating that non-clinical approaches can be highly beneficial to health and well-being. Engagement of the creative imagination and with the arts, culture and nature has profound health-giving benefits, as well as leading to improved well-being. Other non-clinical approaches, such as engagement with sport or volunteering, are likewise beneficial. Moreover, they offer significant benefits in easing pressures on general practitioners and the wider healthcare system. Before the pandemic, it was estimated that one in five GP appointments was for non-medical reasons. A survey by the Royal College of General Practitioners in 2018 found that 59% of family doctors thought social prescribing could reduce their workload.

Non-clinical approaches can help us move away from the present state of affairs, in which we are under-doctored and over-medicated, and they will bring significant cost savings. The World Health Organization’s scoping review reported that evaluation of Arts on Prescription suggested an average return on investment of £2.30 for every £1 spent, through reductions in unnecessary prescribing and reductions in the use of health services, including emergency hospital admissions.

The potential benefits of such approaches have been recognised by the Department of Health, in the establishment of the National Academy for Social Prescribing and in the preventive strategy set out in the NHS Long Term Plan, which envisaged that:

“Within five years over 2.5 million more people will benefit from ‘social prescribing’, a personal health budget, and new support for managing their own health in partnership with patients’ groups and the voluntary sector.”


But that was under a different Secretary of State and before Covid and the huge growth in the backlog that is now absorbing so much of the energy and thinking time of the NHS.

These benefits are experienced not just by the individual; they are societal. A society in which fewer people are lonely and gloomy and more people are energised and filled with a sense of achievement, new self-esteem and optimism, and in which through shared activities they build social capital, is on the way to being what the noble Lord, Lord Crisp, and colleagues have characterised as a healthy and health-giving society.

We all acknowledge that to create such a society we must address the social determinants of health, as argued so compellingly by Professor Sir Michael Marmot. To do so requires not only the integration of the range of health and social care services but an integration of policy across Whitehall and between Whitehall and local, regional and devolved government, in full partnership. Place-based strategies for health are crucial. Integrated care boards, integrated care partnerships and the NHS as a whole must draw on a full range of resources and strengths.

If government fails to act across the board in addressing the societal issues that generate so much ill health and fails to develop a fully-fledged preventive strategy, we will continue to see the NHS beleaguered, insufficiently funded and struggling to cope, with endemic ill health on an enormous scale. We need to make the whole of government an integrated care system. The Department of Health cannot solve the problems of health on its own.

Meanwhile, we must give the best help we can to the board of NHS England by furnishing it with a broad membership along the lines proposed in these amendments, ensuring that, at the highest strategic level, representative voices of a wide range of contributors are heard, including those of the non-clinical providers who have such an important part to play. I beg to move.

[Baroness Walmsley (LD)]

My Lords, I have added my name to the amendment from the noble Baroness, Lady Merron, which I fully support.

Schedule 1 gives a dazzling array of consequential amendments to a vast list of other legislation, which must have taken some poor civil servant weeks to compile, but it does not tell us who will be the extremely important and influential additional people on the board—those who will steer the good ship NHS England along its course. Like any other ship, it needs a captain, officers and crew with the knowledge, experience, expertise and attitudes to steer the ship in the right direction and to enable it to fulfil its functions efficiently and effectively—in whose interests? Those of the patients, of course.

It is also important that nobody on board—let us say, perhaps, the pilot who steers it into port—should have the power to steer the ship not in the direction it should go but in a direction chosen in that person’s own interests. That is why the noble Baroness, Lady Merron, and those of us who support her have attempted to specify some of the kinds of people who should be at the helm of this organisation in the new world of integrated care services—and those who should not.

They should include someone to represent public health, especially given the recent experience of the pandemic and the certainty of others in future. They should include local government, given its responsibility for the crucial areas of social care and the social determinants of health outside the health service. They should ensure diversity and include people who can ensure that patient and staff interests are taken into account when decisions are made—after all, without staff there would be no service. They should include someone who can keep an informed eye on the way the ICSs are progressing. They should not include anyone with a financial or employment interest in any organisation that delivers services to the NHS.

This Government have a very poor track record in ensuring that people with a financial interest do not benefit from government contracts. We have had far too many of those scandals relating to the provision of PPE, testing kits and other products and services during the pandemic. Some of those have only recently been revealed. We must avoid that happening as we set up this new body, for which we all have such great hopes. That is why I recommend this amendment to the Minister and look forward to his response.

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

My Lords, I remind the Committee that I must call the noble Lord, Lord Howarth, who is taking part remotely, to respond to the debate on Amendment 3.

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

My Lords, I very much appreciate the recognition by the noble Earl of the validity of the concerns put forward by the proponents of these two amendments, and his acknowledgment that the board of NHS England must contain balance and diversity. I also recognise the force of the points made by the noble Baroness, Lady Harding, and the noble Lord, Lord Mawson: it is essential that the chair should have power to ensure that the board is cohesive. I noted that the noble Baroness, Lady Walmsley, had reservations about the principle of representativeness which is stated in Amendment 2.

We have had a very useful debate. In light of the reflections put forward in the debate, particularly what the Minister, the noble Earl, Lord Howe, has said, I beg leave to withdraw my amendment.

Amendment 3 (to Amendment 2) withdrawn.

--- Later in debate ---

[Lord Stevens of Birmingham (CB)]

My Lords, these amendments all relate to mental health, and I should perhaps start by following in the wake of my former colleague, the right reverend Prelate the Bishop of London, and declaring my former interest as an NHS chief executive.

I doubt whether anyone here needs persuading of the importance of mental health. Over the past decade, there has been a sea change in public awareness and attitudes and, at the same time, the NHS has begun to expand services to make good historic deficits, but it is not mission accomplished—far from it. The mission has just got a lot tougher. The pandemic has exacerbated and intensified mental health needs not just in this country but across the industrialised world. To take just one data point, we have seen a 69% increase in the number of young people being referred to specialist children and adolescent mental health services, including for eating disorders. At a time when, entirely appropriately, the focus is on cutting waits for surgical operations, we must make sure that mental health continues to get the focus, priority and constancy of commitment that it requires.

The purpose of this group of amendments is to ensure that that occurs. Having moved Amendment 5, I shall speak to related Amendments 12 and 136 in my name and those of the noble Baronesses, Lady Hollins, Lady Merron and Lady Tyler.

In a nutshell, our Amendment 5 would ensure that Government mandates to NHS England always contain explicit and transparent marching orders on mental health funding. I think it was a fellow called James Frick who said:

“Don’t tell me where your priorities are. Show me where you spend your money and I'll tell you what they are.”


That is why, in England, each year since 2015, mental health investment has been required to grow as a share of the NHS funding pie, and I am pleased to tell your Lordships that it has done so. The Minister should not take this amendment as a criticism; it is an encouragement to stay the course of putting our money where our mouth is, towards parity of esteem—or, if he prefers, levelling up between physical and mental health.

Of course, the mathematically minded among your Lordships might argue that if the share of NHS spending going on mental health keeps increasing, eventually we will have overshot what is needed. My response is twofold. First, in the real world, we are many years away from that happy state of affairs, and, in any event, the amendment does not require Governments to increase the relative share of resourcing for mental health; it simply requires them to be intentional and public about their mental health funding choices. It does not tie Ministers’ hands; it just requires them to reveal their hand. It means that the Government have to be clear about their asks of the NHS, and Amendments 12 and 136 mean that the NHS in turn has to be transparent in reporting on its delivery of them.

That is why these amendments command strong support outside this House from leading mental health charities, patients’ groups, and professions. Taken together, in practice the amendments represent spine stiffeners for the Government and accountability boosters for the NHS. I beg to move.

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

My Lords, I welcome the amendments in the names of the noble Lord, Lord Stevens, and the noble Baroness, Lady Hollins. The emphasis on prevention in her Amendment 13 is particularly important.

I will make two points. There is abundant evidence that the engagement of the creative imagination can benefit mental health through improving well-being, confidence and self-esteem. The Creative Health report of the All-Party Parliamentary Group on Arts, Health and Wellbeing discusses, for example, the work of Artlift, a charity founded by a GP, Dr Simon Opher, which delivers arts on prescription in Gloucestershire and Wiltshire. One participant said:

“I had split up from my partner, found myself without anywhere to live and couldn’t see my children. I couldn’t work as I wasn’t physically able to do the job and wasn’t in a position mentally or financially to start a building business again after going bankrupt. Since going to Artlift I have had several exhibitions of my work around Gloucester. I find that painting in the style that I do, in a very expressionistic way, seems to help me emotionally. I no longer take any medication and, although I am not without problems, I find that as long as I can paint I can cope. It doesn’t mean that depression has gone but I no longer have to keep going back to my GP for more anti-depressants, I just lock myself away and paint until I feel slightly better. I now mentor some people who have been through Artlift themselves and they come and use my studio a couple of times a week to get together, paint, draw and chat and I can see the benefit to them”.


The World Health Organization scoping review of 2019 synthesises evidence of the efficacy of the arts in preventing stress and anxiety and building self-esteem and self-confidence. A report to DCMS in April 2020 entitled Evidence Summary for Policy: The Role of Arts in Improving Health & Wellbeing, by Dr Daisy Fancourt of UCL et al, draws attention to

“a large literature of RCTs”—

randomised controlled trials—

“on the treatment or management of mental illness through arts involvement”.

Creatively Minded, a Baring Foundation report of 2020, maps 170 examples of organisations running arts and mental health projects in the UK.

Health and Care Bill

Lord Howarth of Newport Excerpts

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

[The Deputy Chairman of Committees (Baroness Barker) (LD)]

My Lords, the noble Lord, Lord Howarth of Newport, is taking part remotely in these proceedings and I now call him to speak.

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

My Lords, Professor Sir Michael Marmot’s work, to which my noble friend just alluded, has shown that health inequalities have widened across England in the last 10 years. The impact of these inequalities has been both exemplified and amplified by Covid-19. I support Amendments 11, 14 and others that address this massively important problem and I fully agree with my noble friend’s analysis.

Health is powerfully influenced by the social, economic and environmental conditions in which people live and work. Place-based and whole systems are therefore vital to improving health and reducing inequalities. This is recognised in the NHS Long Term Plan and the move towards integrated care.

Sir Michael endorsed the findings of the Creative Health report of the All-Party Parliamentary Group on Arts, Health and Well-being, which in 2017 documented over 100 studies on how the arts and creative activities have supported health. In 2019, the World Health Organization’s scoping review of the role of the arts in improving health and well-being provided evidence that creative activities could mitigate the detrimental impact of stressful environments and the negative health impacts of growing up in disadvantaged conditions. Engaging with the arts, the evidence shows, can improve social cohesion and lead to a reduction in social inequalities in deprived areas. It can build skills and mutual support, which can improve social mobility. The positive effects of the arts can make a particular impact on early years development, as is demonstrated in the evidence provided to DCMS by Dr Daisy Fancourt et al in 2020.

Social prescribing, through bringing people together in shared creative activity and voluntary work, helps to build social capital and better health and well-being in deprived communities.

Research by the MARCH network, a UKRI-funded research programme, has shown that the health benefits of engaging with cultural and other community activities are felt by all, regardless of socioeconomic status. We know that there is a social gradient in participation in cultural and community activities and that those living in areas of higher deprivation are less likely to engage in them. However, the MARCH research indicates that when individuals in areas of high deprivation do engage, the mental health and well-being benefits may be particularly great for them, even greater than for those who live in more affluent areas. Therefore, targeted investment in cultural and community opportunities in areas where people are likely to benefit most can help to reduce health inequalities.

For instance, in Manchester, the Natural Cultural Health Service of the Whitworth art gallery is encouraging activities by local residents from diverse backgrounds that promote physical and mental well-being. Contact, a theatre company, supported by the Wellcome Trust, offers a health and well-being space for use by local community groups. Manchester Camerata has moved its base to Pugin’s wonderful Gorton abbey, in a deprived part of the city. Its musicians are working to support people with dementia and the Camerata is providing a resident composer and musician for local schools. Evaluation has shown that encouraging children to express themselves through music-making has raised their confidence and self-esteem, with a positive impact on their schoolwork and all the implications for them and their community that can follow from that.

The Big Noise project, run by Sistema Scotland in Govanhill since 2008, provides free orchestral training to young people. Evaluation has shown positive health outcomes as a result of improved confidence, social and other skills and emotional well-being. Similarly, the Royal Liverpool Philharmonic has run its In Harmony project to improve the life chances of children through music, and since 2009 has benefited 2,500 children in the Everton and Anfield areas of Liverpool.

The cultural and VCSE sectors have a key role to play in reducing health inequalities and should be fully embedded at systems level and in the health decision-making process. Integrated care partnerships provide the gateway to making this happen.

The National Centre for Creative Health, a charity of which I am chair, is currently working in partnership with NHS England in pilot programmes with four ICSs with a specific focus on mitigating health inequalities. We are looking to establish how best to embed creative health into healthcare strategies. We are also hosting a further AHRC-funded research project called Mobilising Cultural and Natural Assets to Combat Health Inequalities. The outputs will support ICSs to maximise the potential of the arts and natural assets in improving health and reducing inequalities.

I hope the Minister will assure us that the Government recognise the indispensable role of the arts and culture, as well as engagement with nature, in mitigating health inequalities, and that the system created by the Bill—designed, I hope, with an unambiguous purpose to reduce health inequalities—will fully embrace such non- clinical approaches.

[Lord Patel (CB)]

My Lords, I thank the noble Baroness, Lady Thornton, for introducing this group of amendments. My name is attached to her amendments, and I have some amendments in my name; I thank noble Lords who have added their names. I will speak in particular to Amendments 11 and 14 but what the noble Baroness, Lady Thornton, said applies to other amendments, and I agree with them and have added my name to them.

Covid-19 has exposed and exacerbated existing health inequalities in England, and the Government have committed to “levelling up” the country. Progress on national NHS commitments related to reducing health inequalities has been slow in recent years, and NHS England has urged local systems to accelerate action to tackle health inequalities after the pandemic. A step change is clearly needed, yet the Bill’s current provisions on health inequalities amount to no more than the same: transposing existing inequality duties from CCGs to the new NHS ICBs.

One area where there is clearly scope for improvement is strengthening reporting on health inequalities. There is currently no explicit requirement for NHS England to publish national guidance about which performance data and indicators relevant to health inequalities should be collected, analysed and reported on by NHS bodies. The NHS’s current system oversight framework, as a means to define national priorities and monitor the overall performance of local systems, also includes little in the way of concrete measures on health inequalities, with those that are included being focused primarily on shorter-term Covid-19-related equity impacts.

The amendment in the name of the noble Baroness, Lady Thornton, addresses this. It would require NHS England to publish guidance on collecting, analysing, reporting and publishing data on all factors or indicators relevant to health inequalities. I hope the Government will commit to considering this amendment in order to drive more action on inequalities and enable better tracking of progress across different areas.

The only thing I would add to this is the NHS Priorities and Operational Planning Guidance that was published by NHS England just before Christmas—in fact, on 24 December; it could not be much nearer to Christmas. On page 6 of this, as one of the priorities for 2022-23, NHS England asks local health systems to:

“Continue to develop our approach to population health management, prevent ill-health and address health inequalities—using data and analytics to redesign care pathways and measure outcomes with a focus on improving access and health equity for underserved communities.”


It also states that in delivering all the NHS’s priorities, it intends to maintain the

“focus on … tackling health inequalities by redoubling our efforts on the five priority areas”—

already mentioned by the noble Baroness—

“set out in guidance in March 2021.”

It reiterates that ICSs will take a lead role in tackling health inequalities and notes:

“Improved data collection and reporting will drive a better understanding of local health inequalities in access to, experience of and outcomes from healthcare services, by informing the development of action plans to narrow the health inequalities gap. ICBs, once established, and trust board performance packs are therefore expected to be disaggregated by deprivation and ethnicity.”


On page 29 onwards there are further details about this.

Health and Care Bill

Lord Howarth of Newport Excerpts

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

[Baroness Masham of Ilton (CB) [V]]

My Lords, I thank my noble friend for this important debate. I strongly support the amendments which would ensure specialist palliative care, which should be available for all adults and children across the country should they need it.

Marie Curie suggests that while as many as 90% of people who die have palliative care needs, only 50% currently receive palliative care. Research reveals that of the 23 integrated care systems in England which have so far published their strategies, only six have identified palliative and end-of-life care as a priority area, as my noble friend has stated.

After long years when my husband had complicated conditions after a stroke, it would have been very helpful to have had some palliative care at the end. He died on a Sunday. The doctor would not come out. He died with me, in an A&E department. The doctor and nurse did their very best, but it was impossible to see his medical notes and the poor doctor was in desperation. It was a difficult situation as he passed away. This is one reason why a plan with some palliative care would be helpful.

I saw the struggles that the parents had when a young cousin of mine aged seven had neuroblastoma. They did everything they could. He was treated in Germany and England; they took him to the Children’s Hospital of Philadelphia, known for the treatment of neuroblastoma. He had spells in a children’s hospice in Yorkshire and, when in remission, went back to school.

Such parents, of whom there are many throughout the country, need support. I ask my noble friend Lady Finlay, a professor of palliative care, whether this support for parents or nearest and dearest comes under palliative care? I hope that the Government will see that palliative care should be included in this Bill.

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

My Lords, while we all treasure the hospice movement and revere Cicely Saunders and her disciples, the grim fact is that there are all too many parts of the country where hospices are lacking and, as the noble Baroness, Lady Finlay, explained, palliative care is limited and inadequate, or perhaps even non-existent. Of course, palliative care, available in every setting, must become a core responsibility of the NHS. We should not displace the hospices and the charitable ethos, but where hospices do not exist—mainly in poorer communities where fund-raising capacity is small—default provision should be made by the NHS. These amendments would secure universal availability of high-quality palliative care.

High-quality palliative care is, of course, not just a matter of technical skills in pain relief and so on. Dr Iona Heath, a past chair of the Royal College of General Practitioners, has written:

“The whole discipline of medicine has colluded in the wider … project of seeking technical solutions to the existential problems posed by distress, suffering and the finitude of life and the inevitability of ageing, loss and death. Sickness and death have gradually come to be regarded as failures of medicine, even by doctors themselves, rather than inevitable constituents of what it is to be human.”


At a round table on the arts and palliative care, dying and bereavement convened by the All-Party Parliamentary Group on Arts, Health and Wellbeing and chaired by the noble Baroness, Lady Finlay, Dr Viv Lucas—medical director of the Garden House Hospice, Letchworth—said that the role of doctors in this context is not to cure disease but to heal their patients. She said that this implies

“addressing the subjective experience of human suffering and facilitating a process of inner change—not about the technological doing to of the disease-orientated model but of being with, bearing witness.”

The hospice movement acknowledges creative work to be a vital human activity. Through the arts, we can transcend suffering, come to terms with our own mortality and enable our own healing. Artist Virginia Hearth has said:

“The arts offer us a way of making sense of the world and help us to define who we are and who we have been.”


There is an abundance of evidence cited in the World Health Organization scoping review of the benefits of the arts in end-of-life care, through opportunities for communication and emotional expression, reframing of the illness experience, and enhanced human connection.

Equally, the arts can help families watching their loved ones approach death and afterwards. At another APPG round table, the director of Grampian Hospitals Art Trust, Sally Thomson, read out a letter from a woman whose husband had been diagnosed with terminal cancer:

“To be given a terminal prognosis is devastating for both the patient and family. To take away your future, the opportunity to grow old and grey with your spouse and to watch your children grow and thrive. You lose your independence and your sense of self, your purpose and role in life. Yet in the midst of this suffering lies the Artroom. An oasis of positivity and fulfilment providing a different purpose. One of creativity and self-expression. It is a place where the self is rediscovered and allowed to flourish … It’s medicine for the soul and every bit as vital as drugs and chemotherapy. A life-fulfilling experience that has changed both our lives for the better.”


As Dr Rachel Clarke, a palliative care doctor, writes in her beautiful book, Dear Life:

“What I witness, over and over, in the hospice … is that there is nothing more powerful than another human presence … reaching out with love and tenderness towards one of our own.”

[Lord Patel (CB)]

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

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

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


He went on to say:

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


The next line is important:

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


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

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

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

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

Health and Care Bill

Lord Howarth of Newport Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

Moved by

[Lord Howarth of Newport]

59: Clause 20, page 16, line 20, at end insert—
“(1A) To this end, an integrated care board must engage providers of non-clinical services, including creative and nature-based services and other services in the voluntary, community and social enterprise sector, ensuring that it has effective channels for dialogue with these sectors.”

--- Later in debate ---

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

My Lords, in this suite of amendments to Clause 20, which lays down duties on integrated care boards, I am proposing that we should articulate a duty for ICBs to embrace non-clinical practice in their whole way of working. By non-clinical practice, I am referring to a range of services and interventions that promote human flourishing, such as: engagement with the arts and culture to stimulate the creative imagination; a healthy discovery of meaning, self and personal agency; engagement with nature to provide a sense of wholeness, wonder and well-being; physical exercise and sport to energise the body and mind; engagement in voluntary work to lift people from self-absorption and melancholy, and to enable them so they are useful and valued members of society; and meditation to impart calm and perspective. All this is ancient wisdom that is being rediscovered by more and more people. This rediscovery is, indeed, innovative and the Bill requires ICBs to promote innovation.

In no sense am I suggesting that such practices should substitute for modern medicine where diagnosis and good sense indicate that modern medicine is needed. Modern medicine achieves extraordinary things, but too often we resort to it without first considering non-clinical approaches. As a society, we are over- medicating; witness the almost exponential growth in the prescribing of antidepressants. Our national passion for the NHS should not be an addiction. The NHS needs, gently but firmly, to steer us into asking less of it and taking more responsibility for maintaining our own health. That should be a new norm built into the legislative framework for the NHS that the Bill provides. Unless that happens, the system will collapse under the burden of the demands and expectations that it has created.

Unless the Government systemically address the social determinants of health, we shall not have a healthy society. The Bill, harking back to the time of Aneurin Bevan, who as Minister for Health was also Minister for Housing, rightly describes the provision of housing as a health-related service. Amendment 90 goes further, to insist on well-designed housing and urban and green environments. Research evidence shows that living in greener urban areas is associated with lower probabilities of cardiovascular disease, obesity, diabetes, asthma and mental distress among adults, and obesity, poor cognitive development and myopia in children. In every place that ICBs serve, they should be promoting debate about what good urban design should mean and how it should be achieved. Encouragingly, in the new Ebbsfleet Garden City planners are co-locating cultural facilities alongside a health and well-being hub.

There is a substantial and growing body of high-quality research and evaluation demonstrating that creative health and other non-clinical approaches, as the All-Party Parliamentary Group on Arts, Health and Wellbeing said in its report, Creative Health,

“can help keep us well, aid our recovery from illness and support longer lives better lived … the arts can help meet major challenges facing health and social care: ageing, longterm conditions, loneliness and mental health”,

and

“the arts can save money in the health service and social care”.

Since the publication of that report in 2017, there has been increased recognition of this among health policymakers and in the clinical establishment. Research has been commissioned. The NHS long-term plan, with its new emphasis on prevention, acknowledged the benefits of social prescribing. The National Academy for Social Prescribing was set up. Link workers, linking GPs with community providers, are being funded, though not the community providers themselves. NASP has allocated £1.8 million to its thriving communities fund to increase the scale of social prescribing activities, and the Government have a £5.8 million cross-departmental project aimed at preventing and tackling mental health through green social prescribing.

However, this activity is still marginal and its funding almost indiscernible in the NHS budget. Amendments 104 and 105 make clear that an ICB has the power to fund non-clinical providers and that there must be financial equity between clinical and non-clinical providers. If the NHS will struggle to provide enough initially, the wider levelling-up strategy should enable that funding.

Non-clinical health providers cost a fraction of conventional medicine and represent remarkable value for money. The Evaluation Report of the Social Prescribing Demonstrator Site in Shropshire showed significant improvements in health factors such as weight, physical activity, smoking and blood pressure, and a reduction of up to 40% in GP appointments. Dance is inexpensive to lay on. As the Dancing in Time project in Leeds showed, by improving gait, flexibility and strength, it reduces falls among the elderly, who are expensive to repair.

To fail to invest on a reasonable scale in creative health and other non-clinical services is to look a gift horse in the mouth. This is recognised in some ICSs, with which the National Centre for Creative Health, a charity which I chair, is working on pilot schemes. In the Shropshire, Telford and Wrekin ICS, the personalised care team is using creative health and co-production methods with children and young people suffering from asthma. In the Suffolk and North East Essex ICS, clinicians looking for ways to support patients with long Covid have introduced singing for breathing, which is beneficial for lungs and loneliness. Creative Minds in the South West Yorkshire trust has developed creative activities that now benefit the physical and psychological well-being of 6,500 people a year. One user of the Creative Minds “Art for Well-being” programme, Debs Teale, a trustee of the NCCH, said:

“I am eternally grateful to … Creative Minds for giving me the wonderful opportunity to discover a mind released from the fog of depression. I have been five and a half years medication-free”.

--- Later in debate ---

[The Deputy Chairman of Committees (Baroness Barker) (LD)]

The noble Lord, Lord Howarth of Newport, is taking part remotely. I invite him to speak.

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

My Lords, I am extremely grateful to the considerable number of noble Lords who have taken part in this reflective, interesting and important debate. I am most encouraged by the appreciation that has been expressed all around the House for the importance of the considerations that I have sought to advance in this suite of amendments.

I am particularly grateful to the noble Baroness, Lady Barker, for her opening speech, which very much set the tone of the subsequent debate, and for sharing with us her memories of Google on a winter’s night. She made a particularly important point about evidence that is developing to demonstrate, for example, that the practice of mindfulness has benign effects on brain development. That is profoundly important for health. This needs to be understood and taken seriously by those who fund research and those who are pioneering practice within the NHS.

The noble Lord, Lord Best, may remember, as I do fondly, that, many years ago—I mention this particularly to the noble Baroness, Lady Bennett of Manor Castle—he showed me the Lifetime Homes project that he led when he was in charge of the Joseph Rowntree Foundation in York. He has been an advocate of the importance of well-designed housing for a long time and is a voice that is hugely respected on this, as on so many other subjects, in your Lordships’ House.

My noble friend Lady Morris of Yardley raised the important point that yes, we have come a long way and these ideas are no longer seen as eccentric, but, at the same time, unless policy is much more clearly enunciated and embedded, little, if anything, will really change. That is a question that the Minister did not adequately address, but I shall come back to it in a moment.

I was also grateful for the support from the noble Baroness, Lady Tyler, and the emphasis that she rightly gave to the contribution that the arts, creativity and other non-clinical services can make to the well-being of people in social care. I should mention that the charity Live Music Now, founded many years ago by Lord Yehudi Menuhin, has been supporting young professional musicians to perform in social care settings for many decades. That is hugely appreciated and beneficial. If his efforts were supplemented by those of the mother of the noble Baroness, Lady Walmsley—indeed, by the noble Baroness herself—so much the better.

The noble Lord, Lord Crisp, has thought more deeply about these matters than almost anyone else I know. Along with other noble Lords, he is a valued participant in the work of the All-Party Group on Arts, Health and Wellbeing. I commend to noble Lords a recent and beautiful article written by him in Prospect magazine, entitled, “What Aristotle can teach us about building a better society”. In it he writes so wisely and so well about health and human flourishing. As he will be aware, I am indebted to him for some of the language I used in my opening speech.

My noble friend Lady Pitkeathley made a crucial point about how essential it is that funding is provided to cover the core costs of the voluntary and charitable organisations upon which we so largely depend for the delivery of non-clinical services.

The noble Baroness, Lady Finlay, gave us the stark warning: loneliness kills. I very much appreciate her deep understanding and acceptance of the propositions that I and others have been making around creative health, and the support that she gave us in the creative health project.

The noble Baroness, Lady Greengross, made a particularly important, specific and practical recommendation that people should be referred for music therapy or other kinds of creative health interventions at the onset of symptoms of dementia without having to wait for perhaps many months for a formal diagnosis.

I am sure that the noble Baroness, Lady Chisholm of Owlpen, who was, after all, a nurse, personally appreciates the significance and value of what we have been talking about, even if she was briefed to bat away these amendments. She sweetened the pill by promising us a viewing of the YouTube clip of the Minister’s band.

I understand why the noble Baroness contended that the Bill should not be overly prescriptive, but, if that is so, I wonder how she answers the crucial question posed by my noble friend Lady Morris of Yardley: if we do not embed these duties—I would contend they are legislative duties—and responsibilities in the formal arrangements of the system, how are we going to get the step change and scaling up? How are we going to get the decisive shift in the culture to make non-clinical approaches truly integral to the practice of health and social care?

I was surprised when the noble Baroness, Lady Chisholm, advised us that these amendments could have the perverse effect of militating against a holistic approach, but she gave encouragement in what she said about the VCSE sector, in the willingness of the National Institute for Health Research to provide funding and in the thoughtful, extended observation she made about staff needs and the importance of housing. She said that housing is a local authority responsibility. Yes, that is technically true, but that is exactly the problem we debated earlier this afternoon, on which my noble friend Lord Hunt of Kings Heath energetically put forward his thoughts, supported by many other noble Lords. If the Bill continues to demarcate the responsibilities of the NHS and local government in the way it so far does, it will fail to achieve integration in very important respects—and surely we do not want that sort of failure.

It is precisely because of the pressures of Covid and of the backlog, which will make huge demands on NHS resources, thinking and energy for a very long time to come, that it is all the more important that we should enact into law a duty on ICBs continually, from the moment of their formal inception and sustained through the years to come, to operate strategies for the prevention of ill health and the positive creation of a healthy society, working in a multitude of ways with the populations they serve. I beg leave to withdraw the amendment and give notice that I do not wish to move any of the other amendments in this group.

Amendment 59 withdrawn.

Health and Care Bill

Lord Howarth of Newport Excerpts

Lords Hansard - Part 1 & Committee stage
Monday 24th January 2022 Lords Chamber

[The Principal Deputy Chairman of Committees (The Earl of Kinnoull) (CB)]

The noble Lord, Lord Howarth of Newport, is participating remotely. I invite him to speak now.

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

My Lords, if, as I hope, the Bill will be amended to establish a quadruple aim for the NHS—the fourth aim being the reduction of health inequalities—then it will follow that we must have systematic research into the origins and remedies of health inequalities. In this connection, we need to understand options for using cultural, natural and community assets within the changing structures of health and social care, in particular at ICS level. Research should lead to better understanding the relationship of such assets to health inequalities, with a view to health systems mobilising those assets in prevention and intervention strategies, particularly to benefit people living with complex needs in deprived areas. The spectrum of research receiving public funding needs to run from laboratory-based clinical research to public health and community-level action research. The system needs to build capacity at that latter end of the spectrum, training and providing funding and opportunity for new cohorts of such researchers.

Let me give a few instances of the kind of down-to-earth research that needs to be funded. How are improvements to well-being, including staff well-being, to be measured, valued and integrated most effectively with policy at ICS level? More research is needed on the cost-effectiveness of community-based programmes. More research is needed on the cost and health benefits of the link worker model in social prescribing and on financial models for integrating community assets into health systems. Social prescribing needs to be underpinned by robust research on what we might call dosage. How much of such activities should be prescribed, and for how long, to bring about measurable behaviour changes and health outcomes? More evidence is required regarding the sustained, longitudinal effects of engaging in non-clinical programmes across specific health conditions such as cancer, stroke, dementias, diabetes and heart disease.

Such needs are being recognised by UKRI and, under its umbrella, the ESRC, the NERC, the MRC and the AHRC. What is also striking is the growing international interest and evidence base for this kind of research, as demonstrated by the World Health Organization scoping review by Daisy Fancourt and Saoirse Finn, entitled What is the Evidence on the Role of the Arts in Improving Health and Well-being?, and the establishment of the WHO Collaborating Centre for Arts & Health, based at University College London. The aims of this centre are to carry out world-class research into how the arts, culture and heritage affect mental and physical health; to work with world-leading researchers in the UK and internationally to develop and improve arts and health policy globally; and to provide training opportunities, toolkits and resources to support development in the field, including facilitating opportunities for early career researchers.

Health and Care Bill

Lord Howarth of Newport Excerpts

Lords Hansard - Part 2 & Committee stage
Monday 24th January 2022 Lords Chamber

[The Deputy Chairman of Committees (Baroness Fookes) (Con)]

The noble Lord, Lord Howarth, is taking part remotely and I now invite him to speak.

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

My Lords, I support my noble friend in his aim, expressed in Amendments 93 and 211, to require that procurement practices by the NHS are such as to ensure diversity of provision and maintain social value. The case was made convincingly, I hope, in previous debates that the non-clinical and voluntary community and social enterprise sectors have important contributions to make to preventing ill health, both physical and mental, aiding recovery and reducing health inequalities. That being so, it is only common sense that the NHS, and ICBs in particular, should use their power and influence to ensure that there is a flourishing ecology of the community organisations that share their agenda. The NHS should engage with them, listen to them, enlist them and cherish them.

Although the value of community organisations to healthcare has long been obvious, that has been all too little recognised in the actual practice of the NHS. Responsibility here, however, does not rest only with the NHS. The non-clinical sector must help the NHS to relate effectively to it. The King’s Fund has been doing important work on contractual models for commissioning integrated care. This was the basis, for example, for the way arts and cultural organisations came together in Gloucestershire to enable the CCG to fund the work without having to deal with lots of small organisations and individual artists. In Suffolk, the CCG has provided administrative support and leadership in providing training for arts and cultural workers to connect to link workers. We cannot expect ICB commissioners to deal with a mass of organisations in the VCSE sector, but they can support that sector to develop suitable models of co-ordination. I think “market-placed development” is the bureaucratic term here. Organisations such as the National Centre for Creative Health and the Culture, Health and Wellbeing Alliance stand ready to support non-clinical providers to get their act together to enable ICBs to negotiate with them productively.

Health and Care Bill

Lord Howarth of Newport Excerpts

Lords Hansard - Part 1 & Committee stage
Wednesday 26th January 2022 Lords Chamber

[The Deputy Chairman of Committees (Lord Duncan of Springbank) (Con)]

I now call the noble Lord, Lord Howarth of Newport, who will be taking part remotely.

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

My Lords, I support the spirit of these amendments. The noble Lord, Lord Mawson, in his working life at Bromley-by-Bow and more recently in north-west Surrey, and in his very full speech, has demonstrated the significance to healthcare of the principle of subsidiarity, the freedom to innovate and the mobilisation of community resources. If ICSs are to mobilise the full power of place this must indeed be a governing principle.

Although there might be definitional issues to clarify, I particularly applaud the ambition expressed in Amendment 159A that resources should be used at local discretion to promote collaboration by local groups, and that the procurement processes should take account of the benefits of stable partnerships. How could anyone dissent from that? Yet, the experience of so many non-clinical and VCSE organisations is of chronic financial instability and of promising work being aborted because of policy discontinuity.

I will give one instance of damaging discontinuity of funding. The Alchemy Project used dance as a form of early intervention in psychosis. The project was developed jointly by Dance United, South London and Maudsley, and King’s College London. Two cohorts of participants were drawn from young people in south London boroughs where the rate of psychosis is very high. With no previous experience of dance, after four weeks they performed a specially commissioned piece at the Shaw Theatre and Sadler’s Wells. Academic evaluation demonstrated clinically significant improvements in well-being, communication, concentration and focus, trust in others and team working. The project helped participants to develop relationships with their peers and restore relationships with their families. The Alchemy Project had to be abandoned, however, when a fragile consortium of funders did not renew its funding. ICBs and ICPs will need to be less fickle and less prodigal, bolder in supporting innovation, and more consistent and farsighted in their relationships with their providers and communities.

[Baroness Cumberlege (Con)]

My Lords, I also support these amendments. Earlier in Committee, I described the noble Lord, Lord Mawson, as

“a man of infinite resource and sagacity, an entrepreneur and … a great achiever”.—[Official Report, 18/1/22; col. 1575.]

I am sure that, if noble Lords are not convinced, these amendments will further endorse my description.

I now add that the noble Lord is a very determined reformer. He has told us how the present systems serving the public are not fit for purpose. The Government are trying through this Bill to remedy that through greater integration and other measures. It was Edmund Burke who said that, if you want to preserve something important, you need to be prepared to reform it. Our systems are important and need reforming.

Amendment 159A is about the financial duties of the NHS in England and solidarity. In the previous debate, I mentioned Bromley by Bow, as the noble Lords, Lord Mawson and Lord Howarth, said. Bromley by Bow was the forerunner of other imaginative, ground-breaking and huge entrepreneurial schemes in the north of England, London and Surrey. The examples are breathtaking but they cost energy, hard work, original thinking and money. It is sad that these scarce resources are dissipated by the convoluted systems that we, the nation and the Government impose on burgeoning and, at the beginning, fragile schemes. However, Bromley by Bow is not one of these. It is well established but not secure due to having to navigate 41 different funding schemes, as the noble Lord, Lord Mawson, said. Huge effort and wasted time are spent trying to integrate these schemes for the use of a single neighbourhood centre.

I strongly support Amendment 210A. The noble Lord is right: he paints a compelling picture of the future, which will be realised only if our public health, prevention and provision of services collaborate in partnership with local organisations. They understand the history, dynamics and strengths that permeate their local place—their neighbourhood. The noble Lord is also right that, to thrive, ICSs will have to embrace the principle of solidarity, which is the essence of a successful project; that includes the financial duties of NHS England.

I have lived in my community from the age of five. In another debate, I said that my father, a GP, knew his patients inside and out. I, too, know my villagers inside and out in a different way. I treasure the relationships I have made with local organisations. We fight for every shop and organisation that is threatened. We welcome newcomers. We have produced a pocket list of 45 organisations with a mantra on the front saying, “Newick”—my village—“is here for you”. It goes on to say that there is so much going on in our village and there is something for everyone, whether you would like a new hobby, to make new friends or just give something back to the community. Get active, get involved and get happy.

I strongly support Amendment 210A, which urges local providers in particular to be prioritised. I certainly support that. This is not about get-rich-quick developers, who have no regard for the nature of the community in which they are going to build, building bricks and mortar. In our village, we fight for employment, which is absolutely critical in local communities. It reduces traffic problems and helps to mitigate global warming. Above all, it goes some way to generating happy communities. It generates the Government’s intention to make place an important component of a stable community. Surely that is what we all want.

Health and Care Bill

Lord Howarth of Newport Excerpts

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

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

I call the noble Lord, Lord Howarth, who is participating remotely.

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

My Lords, your Lordships’ Select Committee on the Constitution, of which I have the honour to be a member, has advised the House, as has the Delegated Powers and Regulatory Reform Committee, that this Bill is a skeleton or framework Bill. It provides a multitude of vaguely delineated powers and duties. It is often impossible for noble Lords to scrutinise these meaningfully because their meaning is so unclear

The Bill is also an instance of a growing tendency in the Government’s legislative practice to create “soft law”—that is, guidance, rules and directions which are not susceptible to parliamentary scrutiny but are, in, effect binding. It also creates “hard law”, which is not susceptible to parliamentary scrutiny, as in the Henry VIII power in Clause 15, but is subject only to the negative resolution procedure.

This manner of legislating is part of a pattern documented in a long series of reports by the Constitution Committee, drawing the attention of the House to Henry VIII clauses which are convenient to the Executive but subversive for parliamentary democracy, and to the creation of delegated powers enabling Ministers to bring in significant policy change subject to little or no parliamentary scrutiny. The DPRRC has reported that the Bill contains no less than 155 delegated powers.

What is egregious, however, are the autocratic powers that the Bill accords to the Secretary of State. I had sought to indicate that I wished to speak on the previous group, but there was some confusion, and the Chair did not invite me to do so. I hope therefore that noble Lords will bear with me as I take us back for a moment.

As the noble Lord, Lord Hunt, and others, noted Clause 39, entitled

“General Power to Direct NHS England,”


states:

“The Secretary of State may give NHS England directions as to the exercise of any of its functions.”


It goes on to say:

“The directions that may be given include a direction as to … when or how a function is, or is not, to be exercised”


and

“matters to be taken into account in exercising a function.”

The autocratic power provided by Clause 39 is exacerbated by Clause 64, which repeals the duties previously placed on the Secretary of State to respect autonomy within the NHS.

The mischief, which the noble Baroness’s amendments in this group seek to mitigate, is further compounded by Clause 40 and Schedule 6, which confer comprehensive powers on the Secretary of State in regard to reconfiguration of NHS services. Effectively these three clauses together confer upon the Secretary of State, with only the exception stated at proposed new Section 13ZD in Clause 39, mainly in relation to clinical discretion, absolute power over the NHS.

We are told that the Secretary of State has no intention of bossing NHS England around and that he needs powers to sort out failures within the NHS system. In our earlier debate today on continuing care, and in his response to the last debate, the Minister said it is not the Government’s intention to interfere unduly in the affairs of ICBs. However, in a letter to the Times today, referred to by the noble Baroness, the chief executive officers of the King’s Fund, NHS Providers and the NHS Confederation warn of the danger that the Bill may lead to politicisation of decision-making in the NHS, of the kind which the noble Lord, Lord Warner, described in the last debate and which the noble Baroness, Lady Cumberlege, has just explained. The fact remains that Clauses 39, 40 and 64 make the Secretary of State untrammelled master of the NHS.

With such power comes temptation, not least for Department of Health officials. What might “unduly” mean in practice? The Secretary of State may often refrain from interfering, but too often he, or officials acting in his name, may not. In any case, to accord the Secretary of State such excessive power is wrong in principle. The legislation should strike an acceptable balance between the autonomy which NHS leaders and managers need if they are to do their jobs well, responding as they judge appropriate to local needs, and a due accountability of the NHS to the Secretary of State and, through him, to Parliament. Here, however, we have neither. The Bill concentrates power over the NHS in the hands of a Minister who is poorly accountable to Parliament in the exercise of much of his power.

Health and Care Bill

Lord Howarth of Newport Excerpts

Lords Hansard - Part 1 & Committee stage
Monday 31st January 2022 Lords Chamber

While unpaid carers provide the bulk of care, and are often relied upon, they are not systematically identified, supported or included in the NHS. We know that there is good practice in certain areas, but it is neither systematic nor systemic throughout the NHS. This lack of recognition and support for carers hinders evaluation and measurements of effectiveness. Closer integration between health and social care means that we now have the opportunity to manage this. We need invisible unpaid carers to become visible, so that everyone in the NHS “thinks carer” in everything they do with the person who they are caring for. By so doing, it will help the carer to fulfil their role. That is what my amendment seeks to do.

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

My Lords, I too would have preferred to speak later in the debate. I am sure that there are other noble Lords who have tabled amendments from whom the Committee would have preferred to hear nearer the outset, but I understand that the Deputy Chairman of Committees does not the flexibility to allow this, and I am of course grateful for the opportunity to speak.

As we know, the Covid-19 pandemic has led to a substantial rise in mental ill-health across the general population. Not surprisingly, this effect has been particularly hard-felt among unpaid carers. Many carers, already leading confined lives, have struggled with lockdown. Young carers have suffered with the loss of schooling and, when schools returned, trying to ensure that the people they care for have been shielded from the virus. Many were unable to go back to school for fear of bringing the virus home. Many from disadvantaged backgrounds did not have the digital resources to enable home schooling to be effective.

As we consider these amendments, I would like briefly to bring to the attention of noble Lords some remarkable work with carers being developed in Kingston upon Thames by Kingston Carers’ Network. KCN provides a range of crucial services to some 4,000 adult carers and 700 young carers from five to 18 years old. An important element of this support is nurturing the creativity of carers. Recognising, from the SHAPER research programme, which I mentioned in a previous debate, the positive effects of the arts on mental health and well-being, KCN is working with Rosetta Life to introduce three arts programmes for carers. Poetry and conversation provides co-created poetry workshops for adult carers, demystifying poetry and making it easier to approach. Participants have written and shared online poems about the challenges of caring. They have all said they would like more sessions.

KCN is trying to secure funding to participate with Rosetta Life in an international project called HeArt of Care. The idea is to offer master classes in dance, art making, photography, poetry and song writing for both adult and young carers. The project will create a website showing positive representations of the grace, dignity, compassion and joy of care and caregiving. The groups that would participate with KCN are a network of carers from Tyneside, Bristol Black Carers, Caregivers India and the End of Life Care Centre, Rwanda.

Another project is Room2Dream. Rosetta Life has a partnership with Dream a Dream in India, which works with 18 to 21 year-old carers who live in extreme poverty. This is one of 16 partnerships between young people in the UK and young people in refugee camps, conflict zones, hospices and adolescent psychiatric care. Young carers are offered poetry and song-writing workshops; they are given classes in film-making to enable them to create films about their poems and songs, and share them with other young carers not only in India but in, for example, Rwanda, Syria, Zimbabwe and Nepal. KCN is currently trying to secure funding for this initiative too.

These fledgling projects highlight the potential of the arts to improve the lives of unpaid carers and to enable them to have a voice that will be heard nationally and internationally. We should ensure that the system created through this legislation will underpin such ways to strengthen the resilience of carers and, beyond that, to enable them to flourish. These amendments will help. I look forward to a time when public policy, far more reliably and generously, supports unpaid carers to have better lives while they do their crucial work.

[Baroness Pitkeathley (Lab)]

My Lords, for 25 years, I have been trying to bring the voice of carers into your Lordships’ House. I know, from the great amount of support I have received over those years, that the whole of your Lordships’ House agrees that we should recognise and value the enormous contribution of millions of people caring for families and friends, who do so much to support others, often at great personal cost. I make no apology for repeating the statistics: up to 13 million carers provide unpaid care worth £530 million a day, or £193 billion a year. They are indeed the backbone of our health and care system.

Ensuring that the health system identifies and supports carers in return is the least we can do, and that is the objective of the four amendments to which my name is added in this group. I am also very supportive of Amendment 217 moved by the noble Baroness, Lady Wheeler. I thank her for her excellent introduction. I am strongly supportive of Amendment 219 and am grateful to the noble Baroness, Lady Brinton, for tabling it.

As Members will know, I have long called for the NHS to have stronger duties towards unpaid carers. The NHS depends heavily on the role and input of people who care unpaid, usually family and friends but quite often neighbours, in supporting people with long-term conditions and disabilities in the community. Research by Carers UK shows that more than half of carers say they feel invisible to the NHS; more than half of carers providing significant amounts of care were not involved in decisions about hospital discharge; and the majority of carers, over 60%, were not given enough information and advice to care safely, at the point of hospital discharge, for the person they care for.

Placing a duty on the NHS with regard to carers is needed, as there is currently neither a systemic nor systematic approach towards carers in the NHS. As the noble Baroness, Lady Brinton, pointed out, a duty to carers would help greater integration between services. Currently, local authority social care sees carers as equal partners in care and very much part of the system, whereas carers can be invisible to the health system. This duty would also lead to direct benefits to the health system, including improved health and well-being, improved satisfaction with services, and reduced admissions and those all-too-frequent readmissions. More practically, it would avoid the significant omissions of carers in recent guidance on hospital discharge, to which I now turn.

Amendment 221 proposes to insert a new clause to protect carers’ rights. As it stands, Clause 80 is of great concern. Almost incredibly—I can hardly believe I am saying this—it removes from carers rights that have been hard fought for over many years and which were enshrined in the Care Act 2014 and the Community Care (Delayed Discharges etc.) Act 2003. Many of your Lordships will remember those Acts and the many hours we spent on them.

This Bill repeals the legislation giving carers the fundamental right to have an assessment and ensuring that the services provided make sure that discharge from hospital is safe. There are endless horror stories about unsafe discharges and this issue has been debated extensively in another place. Hospital discharge is one of the most difficult points in the care system for unpaid carers, who often take on caring responsibilities without the right support.

Through Clause 80 in the Health and Care Bill, the Government are seeking to pass legislation that would enact the discharge to assess approach mentioned by my noble friend Lady Wheeler, which has recently been deployed by NHS England, by repealing, as I said, the Community Care (Delayed Discharges etc.) Act 2003. Amendment 221, in my name and supported by the noble Lords, Lord Young of Cookham and Lord Warner, and the noble Baroness, Lady Tyler of Enfield—to all of whom I am very grateful—would ensure that, in advance of any patient being discharged from hospital, the relevant NHS body must identify and consult any carer who is about to provide or will be providing care. This would ensure that the local authority is not the only statutory body with responsibilities towards carers and that the NHS plays its equal part. It would also ensure that the carer in question has services that protect their well-being and that assumptions are not being made that they will automatically provide care—assumptions that are made far too often.

Carers’ organisations are extremely concerned that the inclusion of carers in this guidance for discharge to assess is insufficient to protect carers’ rights. I ask the Minister, on what evidence basis is the move to discharge to assess better for unpaid carers? The evidence seems to be that discharge to assess is worse. The Government’s own impact assessment of the Bill recognises that it will lead to many carers having to take on even more care. It states:

“There is an expectation that unpaid carers might need to allocate more time to care for patients who are discharged from hospital earlier. For some, this may result in a … reduction in work hours and associated financial costs.”


Are the Government really suggesting that carers go on to benefits—the carer’s allowance, for example, which is only £67 a week and recognised as a pathway to poverty?

I am sure the Minister is also aware that if a carer gives up work to care, they do not immediately get any benefits. That leaves them without any income at all. Or are the Government suggesting in their impact assessment that discharge to assess is better for carers by suggesting they take unpaid leave from work, in the process passing on the costs of hospital discharge to employers? Giving up work to care hurts the economy and costs businesses money in terms of recruitment and retention. So I would really like the Government to explain the thinking on this one, because I have lost count of the number of Ministers who have stood at the Dispatch Box and agreed with me that the best thing you can do for carers is enable them to stay in paid work as long as possible. So will the Minister please explain that to me—or better yet, be prepared to explain it to a group of carers that I am happy to arrange to meet him?

I turn now to Amendment 225, on the definition of a carer, which will be spoken to by the noble Baroness, Lady Hollins. It may seem unbelievable, but when I started in the carers’ movement in the mid-1980s, the word “carer” was unknown. Yes, it was not even in the dictionary, and every time you typed “carer”, your spellcheck corrected it to “career”. Now the word is everywhere and, in a way, the unpaid carers movement is a victim of its own success, because everyone wants to be called a carer and it is increasingly used to describe paid care workers. Carers themselves actually have difficulty in identifying themselves as a carer—“I’m not a carer, I’m a mother, a husband, a daughter”, is what they say. This lack of identification is an obstacle to them accessing support, so a proper definition is vital and it must be all-encompassing, as set out in the amendment. We fought very hard to get these definitions acknowledged in statute, for example the Care Act 2014, and it is important that the word “carer” encompasses parent carers and young carers.

I point out that the purpose of this amendment is not to create anything new. It uses only existing legislative references. Its purpose is to ensure that the definition of carers in the Bill is entirely clear, so I see no possible reason for the Government to reject it.

Health and Care Bill

Lord Howarth of Newport Excerpts

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

[The Deputy Chairman of Committees (Lord Brougham and Vaux) (Con)]

My Lords, I invite the noble Lord, Lord Howarth of Newport, to speak remotely now.

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

My Lords, I thank the noble Baroness, Lady Cumberlege, for tabling Amendment 284. If we are to avoid the risk of corruption and maintain full public confidence, it is vital that there should be full disclosure of payments by commercial interests to hospitals—I would have thought to all hospitals, not just teaching hospitals—research institutions and clinicians. It is a good maxim to follow the money and to be able to do so.

In regard to research, there has long been public concern about business interests suborning researchers whose judgments and pronouncements influence public understanding, sometimes with important implications for public health. Corrupt scientists certified that DDT and pesticides used in agriculture were not harmful to public health. Exposure of that by Rachel Carson in her book Silent Spring did not end the mischief. Bogus research evidence was paid for for decades by the tobacco industry in a rearguard action to persuade Governments and the public that tobacco was not harmful to human health.

Today, firms in the food industry deploy spurious evidence and arguments about the damage certain foods do to human health. They have lobbied Government with considerable success to the terrible detriment of human health—it is good that the Bill limits the advertising of unhealthy foods. Scientists, paid by energy firms, have abetted those who deny that climate change is manmade.

Disclosure payments in regard to research will help, but more is needed. The noble Baroness might have considered—and may yet consider—tabling another amendment needed to underpin research ethics. The data on which research conclusions are based should be held independently. The Engineering and Physical Sciences Research Council rightly now requires researchers to deposit data connected to the research they have funded.

There is huge pressure, in a competitive environment, on scientists to publish research, and there have been notorious instances of fake science—scientific discoveries announced that were made up and whose results could not be replicated by other researchers. A paper entitled Fake Science and the Knowledge Crisis published by the Royal Society said,

“it is especially important that the scientific world as a whole upholds the highest standards of ethical behaviour, honesty and transparency, aiming to sustain the gold standards of research integrity and validated information.”

However, the authors go on:

“Sadly, a range of forces are working counter to this aspiration.”


It is good that the pharmaceutical industry in the United Kingdom supports the transparency that the amendment calls for. We should certainly match the best standards and practice in the USA and Europe.

The NHS holds huge budgets for drugs, medical equipment and hospital building; big commercial interests are at stake. There is scope for corruption if the system is weakly regulated. The scandal of PPE contracts has led to widespread anxieties about the integrity of procurement. The public want to believe that the NHS is free of corruption, and I am sure it mainly is, but reassurance is needed. As the noble Baroness, Lady Brinton, reminded us. in the old saying, sunlight is the best disinfectant. We need the transparency that the amendment would secure.

The government amendments are, certainly at first blush, welcome. But, as the noble Baroness, Lady Cumberlege, noted there is a conspicuous difference in language between her amendment, which says that companies “must” publish payments, and the Minister’s amendments, which say that the Secretary of State “may” require or regulate. That slide of language is liable to weaken public confidence. I hope the Minister will explain why he has used the word “may” and not “shall” or “must”.

The government amendments are as elaborate as the noble Baroness’s is simple, and they prompt some questions. In the Government’s Amendment 312B, subsection (6)(b) states:

“The regulations may … create exceptions from requirements to publish or provide information.”


What would those exceptions be? Subsection (8) states that the Secretary of State may,

“grant an exception … in a particular case.”

What sort of case? Earlier in Amendment 312B, subsection (1)(a) refers to “payments or other benefits”. I ask the Minister whether the disclosure requirements he envisages cover benefits in kind, including donations to political parties. whether made by big pharma or small local donors.

I do not want to be cynical. How can the Minister reassure those who are?

--- Later in debate ---

[The Deputy Chairman of Committees (Lord Geddes) (Con)]

My Lords, the noble Lord, Lord Howarth of Newport, is also taking part remotely. I invite the noble Lord to speak.

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

My Lords, I pay tribute to the noble Baroness, Lady Greengross. No one has done more than she has to champion the elderly and the frail. I support all the amendments in this group but will speak only in support of Amendment 290.

There is much evidence of the benefits of creative activity to dementia. Some of this was set forth in the Creative Health report, and more recently in the document A.R.T.S for Brain Health, edited by Veronica Franklin Gould, the founder and now president of Arts 4 Dementia. I pay tribute to her passionate and indefatigable work.

As noble Lords, we have the opportunity to exercise our aging brains in trying to understand amendments to the Health and Care Bill. Others at our time of life take even greater pleasure and benefit to their health through music, painting, poetry, dance, drama and other art forms. Of course, that range of cultural opportunities is there for us too—the cultural scope of Peers is not limited to “Iolanthe”.

Veronica Franklin Gould has very well said:

“music-making provides a tool for a total brain workout”.

The mental activity of learning poetry, performing drama and creating painting or craft opens new neural pathways and connections. Research shows that creativity benefits the plasticity of the cortex, enhances cognitive abilities—perception, motor function and memory—and improves cardiovascular strength. In more humane language, engagement with the arts allows creative self-expression, offers sociability, reduces stress and increases resilience—all leading to joy and achievement. These are profound and measurable benefits. Arts 4 Dementia offers programmes in creative arts venues for people, from the onset of early symptoms of dementia. I draw the attention of the House to the very important work of Manchester Camerata, in partnership with the University of Manchester, in its Music in Mind dementia programme.

There can be years between the appearance of early symptoms and the moment at which someone receives a memory assessment and a diagnosis. This can be a lonely and fearful time, during which the arts can be particularly sustaining. Creative activity slows the deterioration of the brain. The benefits of engagement with creative activity continue for a long time.

Professor Martin Marshall, chair of the Royal College of General Practitioners, has recognised this. He said:

“The shift for us in general practice is not just engaging with the medical activities which are core, but to engage with social activities, and make sure the two are aligned.”


Will the Minister accept amendments to this legislation to ensure that the structures and requirements that it creates encourage, facilitate and drive the shift of which Professor Marshall speaks, and bring the crucial support of the arts and other forms of social prescribing to people with dementia and others? If he does not believe that the legislation needs amendment, will he explain how, as presently drafted, it will drive that change?

[The Deputy Chairman of Committees (Lord Geddes) (Con)]

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

--- Later in debate ---

[The Deputy Chairman of Committees (Lord Brougham and Vaux) (Con)]

The noble Lord, Lord Howarth of Newport, is also taking part remotely. I invite the noble Lord to speak.

[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.

Health and Care Bill

Lord Howarth of Newport Excerpts

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

[Baroness Brinton (LD) [V]]

My Lords, I shall speak to Amendment 17, to which I have added my name, but first I thank the Ministers for listening to the noble Baroness, Lady Finlay, and others, and for tabling Amendment 16. I also thank Together for Short Lives for its helpful briefing.

Your Lordships’ House had a moving debate in Committee that captured the practical and economic need for the wider range of provision of palliative care, and how ICBs can properly fund and plan for it. In Committee, the Minister, the noble Lord, Lord Kamall, said that

“ICBs will be required to have regard to the National Institute for Health and Care Excellence guidelines in their provision of services, as CCGs currently are … NHS England will continue to support commissioners of palliative and end-of-life care services through their palliative and end-of-life care strategic clinical networks. These networks support the delivery of outstanding clinical care by ensuring palliative and end-of-life care is personalised for all.”—[Official Report, 18/1/22; col. 1637.]

The noble Lord’s Amendment 16 provides the specialist services we sought, but it says only

“as the board considers … appropriate as part of the health service”.

Although I join other noble Lords in thanking the Ministers for the amendment, please can the noble Earl confirm that, although the wording of the amendment requires ICBs to commission palliative care “where appropriate”, it is his intention that all ICBs should deem it appropriate, and therefore all of them should commission palliative care services, including for seriously ill children and their families? We know that the provision of palliative care services is very patchy. Will he provide statutory guidance to supplement the amendment and support ICBs to interpret their responsibilities, including for children? When will this be available? What action will Ministers take to ensure that ICBs have the financial resources needed to fulfil the new duty? Finally, what action will the Minister take to ensure that there are enough professionals with the skills and experience needed to provide the palliative care for children that ICBs will have a duty to commission?

We covered all this in very moving stories in Committee. Can the noble Earl confirm that all I have outlined will be covered in regulations and statutory guidance?

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

My Lords, I am embarrassed to be called to speak ahead of the noble Baroness, Lady Finlay. I understand that the Deputy Speaker does not have discretion to make their own judgment about the sequence of speakers, but I hope this rule can be looked at. As it is, I add my thanks to the Minister, the noble Lord, Lord Kamall, for tabling Amendment 16. He and the noble Earl have graciously paid tribute to the noble Baroness, Lady Finlay of Llandaff. I am sure I speak on behalf of everyone by saying: so should we all. Her vision and persistence have beaten a path towards the progress we can now make.

Although the noble Lord, Lord Kamall, observed in his letter to us that it has always been a duty of the NHS to commission appropriate palliative and end-of-life care services, and that commissioning palliative care is a core function of integrated care boards, these obligations have hitherto been honoured perhaps as much in the breach as in reality. Provision has been patchy, shall we say? I think the noble Earl said that there had been “variations”; indeed there have.

I also acknowledge that the NHS does sometimes provide exemplary palliative and end-of-life care. Many noble Lords will know that my partner Patricia, Lady Hollis, died of cancer in 2018. I express my deep appreciation of the quality of palliative and end-of-life care she received at the hands of the NHS. I particularly express my profound gratitude to her NHS consultant at the Norfolk and Norwich University hospital, Nicola Holtom, and her team, and to others providing community services, because it eased Patricia’s path and made a huge difference to all of us who cared for her.

Sadly, for all too many, including cancer patients, this quality of service has not been available. Indeed, for some there has been no relevant palliative care and end-of-life service. This could therefore be a historic moment, but it is far from certain that it will be. I of course accept that Ministers are acting in good faith, but the indeterminate drafting of Amendment 16 leaves rather a lot of wriggle room. For an NHS which is always short of the resources that it needs and that is struggling to cope with its existing workload, it remains a danger that the provision of palliative care will be sparse. The language of Amendment 16,

“such other services or facilities for palliative care as the board considers are appropriate”,

does not make it clear that it will be an inescapable duty of ICBs to ensure that palliative and end-of-life care is a universal service and that there will be a duty on ICBs to provide high-quality palliative care.

The Minister indicated that he does not expect to agree to write into the legislation Amendment 17, in the name of the noble Baroness, Lady Finlay, which specifies in very useful detail what the nature of an exemplary service would be. He said that it would be better to do this by way of guidance. I am encouraged at least to know that it is the department’s intention to provide guidance and to set out models of how ICBs should set about fulfilling this duty. But what measures will be in place to ensure that this happens? What monitoring does he envisage? What reporting requirements will there be?

I have another question which I think is very important: how will the system enable patients and families to know what palliative care is available for them and how to access it? As things are, so often patients and their families are bewildered. They just do not know where to turn amid the complexities of the system, and they often feel discouraged by the responses they receive. They seem to observe the buck being passed between the NHS and social services and between different entities within those services.

I know that Ministers want to do the right thing, but it is important that we do not miss this opportunity to bring about the real thing. If we can be assured that the quality of provision will be as high as that envisaged in the noble Baroness’s Amendment 17, and that the department and NHS England will have systems to ensure that that is so, this could indeed be a transformative moment—a moment after which there will be the prospect that, instead of experiencing a bleak death, as so many people do, they will have a good death, and that will be an enormous consolation to their families, for whom, in their bereavement, the passing of a loved one is the greatest suffering.

Health and Care Bill

Lord Howarth of Newport Excerpts

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

Moved by

[Lord Howarth of Newport]

114: After Clause 80, insert the following new Clause—
“Creative health
(1) Within six months of the passing of this Act the Secretary of State must establish a review to consider and report on social prescribing and other creative health interventions, including—(a) the existing provision, quality and effectiveness of social prescribing and other creative health interventions,(b) the evidence base and research requirements,(c) the benefits in terms of preventing ill health and aiding recovery,(d) the impact on health inequalities, social value and communities,(e) barriers to innovation,(f) sustainability,(g) means to integrate creative health with other approaches to health care and social care, and(h) the potential to extend and improve creative health provision, including—(ii) the costs and benefits of doing so, and(iii) the resources and actions needed to realise this potential.(2) The Secretary of State must appoint as Chair and members of the reviewing committee individuals who appear to the Secretary of State likely to have an informed and independent view of the relevant issues. (3) The review must consult—(a) creative health practitioners,(b) people with lived experience of social prescribing and other creative health interventions,(c) charities working in the field of creative health,(d) the National Academy for Social Prescribing,(e) the Office for Health Improvement and Disparities,(f) Integrated Care Partnerships,(g) Royal Colleges,(h) NHS Providers,(i) the NHS Confederation,(j) Health Education England,(k) the Local Government Association,(l) social care providers,(m) Research Councils,(n) Academic Health Science Networks, and(o) others that the Chair of the review considers appropriate.(4) The review must make recommendations to the Secretary of State on the topics described in subsection (1).(5) The report of the review must be published within 18 months of the passing of this Act.(6) Within three months of receiving the report the Secretary of State must lay before Parliament a statement specifying how he or she intends to implement the recommendations of the review, including timescales and budget.”

[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.

--- Later in debate ---

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

My Lords, I am most grateful to noble Lords from all parts of the House who have supported this proposed new clause, whether they have spoken today or, in the interests of enabling the House to make progress with other important business, refrained from speaking.

I invite my noble friend Lord Winston to study the research and evidence that is already available. The proposed review would, of course, consult with the research councils, a number of which are also engaged in this field of research, commissioning important work.

I say to the Minister that of course I am glad the National Institute for Health Research is already considering social prescribing, but I point out that creative health goes beyond that and embraces a range of other important and proven approaches. Of course, the review would look at a whole range of other issues as well. Her particular focus on social prescribing, important as it is, neglects to address the full range of relevant considerations.

That being so, I am sorry that Ministers have not seen fit to take the lead in establishing the review proposed in the new clause. They are missing an opportunity to act in the interests of the health and well-being of our society. That being so, the National Centre for Creative Health, which I chair, will look for resources to enable us to lead the review ourselves. We will still, of course, want to engage with government and NHS England. I hope they will see value in that. In due course, we will make recommendations as to how to develop creative health approaches on a national scale, and we will seek to resume dialogue with Ministers. I beg leave to withdraw the amendment.

Amendment 114 withdrawn.

Health and Care Bill

Lord Howarth of Newport Excerpts

Lords Hansard - Part 2 & Report stage
Monday 7th March 2022 Lords Chamber

[The Deputy Speaker (Baroness Pitkeathley) (Lab)]

My Lords, the noble Lord, Lord Howarth, is taking part remotely. I invite him to speak.

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

My Lords, I congratulate the noble Baroness, Lady Bennett of Manor Castle, on bringing back this issue on Report; I was sorry not to be able to speak in Committee. We must also be grateful to the academics at the University of Surrey who followed the money and, a year ago, published their exposé, Careless Finance.

The noble quartet of the noble Baronesses, Lady Bennett, Lady Brinton, Lady Tyler and Lady Altmann, has previously provided the House with an excellent analysis of predatory financial manipulation of the social care sector by hedge funds and offshore entities. I just want briefly to underline certain points.

What we have been seeing is legalised theft. Financial operators are leeching, for their own profit and benefit, substantial proportions—16% to 20%—of the funds provided for social care by both the public purse and self-funding individuals; “grey gold”, the profits thus extracted are sometimes called. This racket, unacceptable at any time, has been perpetrated during a period when the Government have chosen to underfund social care lamentably. Because sufficient budgets are not available to local authorities, many people who should be eligible for social care are not receiving it and many who are in social care are experiencing threadbare services. The workforce is depleted and miserably paid.

It is in the context of this crisis that unscrupulous operators have been ripping off a broken system. In their greed they are putting the business survival of providers at risk. As Christine Corlet Walker, Angela Druckman and Tim Jackson of the University of Surrey have reported, we have been seeing a large-scale transfer of money from the poorest to the richest. As they say,

“the ongoing cost is the silent tragedy of the most vulnerable in society.”

Meanwhile, the Government have made little or no effort to address the problem, which indeed they do not appear to acknowledge exists. The noble Earl, Lord Howe—for whom personally I have great regard—in his response on behalf of the Government in Committee, said that the noble Baroness’s amendment to improve transparency was not proportionate or necessary. He suggested that the Care Act 2014 and the CQC’s market oversight scheme should take care of any problems. However, since the abuses continue, it is obvious that these policies have been ineffectual with regard to them.

The noble Earl also said that it was for local authorities to shape, oversee and manage the market, but only the Government can act to close opportunities for rogue investors to carry out these abuses. He suggested that BEIS was on the case, but BEIS has been inexcusably dilatory.

The Government claim to be fixing social care, but all they are doing is providing a meagre and delayed increase in funding for social care by dint of imposing extra tax on the poor. The only reform they are truly interested in is to relieve the affluent of the need to sell their homes to pay for care.

Even the Government are now exercised about the abuses by Russian kleptocrats. So too they should be very seriously exercised by the abuses of the social care system by unscrupulous investors. Can they not see the evils that have flowed from marketising the social care sector? As the noble Baroness has just said, on Wednesday, the House will debate the Economic Crime (Transparency and Enforcement) Bill. We should also be debating an overdue “social care financial abuse (transparency and enforcement) Bill”, brought forward by the Government.

[The Deputy Speaker (Baroness Pitkeathley) (Lab)]

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

Health and Care Bill

Lord Howarth of Newport Excerpts

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

[The Deputy Speaker (Baroness Henig) (Lab)]

My Lords, the noble Lord, Lord Howarth of Newport, is taking part remotely. I invite the noble Lord to speak.

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

My Lords, in moving this proposed new clause, superficially so bland, the noble Lord, Lord Forsyth, beckons us along a path which leads towards constitutional and moral anarchy.

What is dangerous constitutionally about this amendment is that it would undermine the way we do parliamentary government. Forcing the Government to lay a Bill before Parliament and to enable Parliament to consider the issue, as the proposed new clause requires, would be a coup. This Back-Bench amendment would usurp control of the parliamentary agenda from the democratically elected Government. In the last Parliament we saw Back-Bench MPs, with the collusion of Mr Speaker Bercow, contriving to set aside Standing Order 14(1), which gives precedence to business tabled by the Government, in order to substitute their own agenda on Brexit. I believe the noble Lord, Lord Forsyth, was very much opposed to that.

Parliament proceeds by precedence, and these are dangerous new precedents, as any noble Lord who sees their party as a party of government must surely agree. While it is for Parliament to interrogate government and hold it to account, it is not for Parliament to claim for itself the role of the Government. Parliament is incapable of governing and it should not dictate the parliamentary programme. If Parliament makes exceptions to that principle to gratify a faction of its Members in either House, and if the principle that it may do so becomes established through reiteration so that the Government no longer control the legislative agenda, the ability of Governments to govern will suffer. Our system of parliamentary government is battered and unsteady as it is; we should not injure it further.

The moral anarchy that lurks in this new clause is that it would legitimise in a new way the taking of human life by other human beings. I readily acknowledge that the noble Lord, Lord Forsyth, the noble Baroness, Lady Meacher, the noble and learned Lord, Lord Falconer, and other proponents of what they call assisted dying are motivated by compassion and kind intentions. I profoundly believe, however, that their approach misreads human nature and that legislation to permit assisted suicide would create more suffering than it would alleviate. The offspring of this compassion would be a coarsening of our society and a diminution of the value we place upon life.

Some people make a moral case for assisted suicide on the basis of personal autonomy. I understand the appeal: I want, or I think I would want, such choice and control for myself at the end of my life. But that is not a good enough argument. Our responsibility is not just to ourselves, or even to those individuals we love the most, but to our community. For a community to be healthy, it must have norms. It has been a norm in our culture to place an especial value on human life. We reaffirmed that value when we abolished capital punishment. Since then, we have subjected our society to decades of laissez-faire ideology and chaotic individualism, and among the consequences of that have been a dissolution of community bonds and new harshnesses.

If we continue to dissolve our traditional norms, we are at risk that there really will be no such thing as society. As we look at our society now, at lethal child abuse and domestic abuse, at murderous assaults on women, as we look across the world at the millions consigned to death in the pandemic by the refusal of rich countries, including our own, to share intellectual property and technology to enable poorer countries to have vaccines, and as we witness increase discriminate mass killing in Ukraine and Yemen and genocide in Xinjiang, do we really think we should be preparing to sanction a new class of killing?

The new clause requires that a vote in Parliament on the intended legislation must be a matter of conscience. Let us examine our consciences very carefully indeed as we consider the proposal the noble Lord has put before us.

[Baroness Meacher (CB)]

My Lords, I support Amendment 170 in the name of the noble Lord, Lord Forsyth, to which I have added my name.

As the noble Lord made clear, there is no realistic prospect of a Committee day for my Assisted Dying Bill. This makes the point that the current procedures limiting Private Members’ Bills to Fridays do not enable important legislation such as the Assisted Dying Bill to reach the statute book.

The noble Lord, Lord Forsyth, introduced his amendment brilliantly. It leaves me only to reiterate that we are not discussing the pros and cons of assisted dying this evening. The House is expected to rise at 1.30 tomorrow morning. I hope for the sake of everybody in this House that noble Lords on both sides of the assisted dying debate will resist the temptation to get into such a debate—that is not as what this amendment is about. We are debating whether it is acceptable that there is no procedure at present to enable the Westminster Parliament to test the willingness of both houses to pass such a significant and popular piece of legislation. We know that not only Scotland, which the noble Lord, Lord Forsyth, mentioned, but Jersey and even the Isle of Man have procedures to enable them to pass an assisted dying law, and all those three are likely to pass such legislation within the next one to three years.

We therefore ask noble Lords: do we really think it is satisfactory that the Westminster Parliament is hamstrung without a procedure for Parliament properly to debate a Bill to legalise assisted dying for terminally ill people who are mentally competent and who are suffering unbearably? For Westminster to be upstaged on such an important and popular human rights issue by our much smaller neighbours is surely unconscionable. Amendment 170 from the noble Lord, Lord Forsyth, deserves our support.