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.”

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[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”.

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[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.