Health and Care Bill

Lord Kakkar Excerpts

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

[Lord Shipley (LD)]

My Lords, now that we are in Committee, I remind the House of my interest as a vice-president of the Local Government Association. I rise to speak to Amendments 152, 156 and 157, to which I am a signatory. I will not repeat all the excellent points made by the noble Lord, Lord Young of Cookham, and others, but I hope the Government will accept that what is being proposed is central to the success of this Bill, and that is because the NHS does not exist in a vacuum.

We know that prevention and early treatment of people’s ill-health will help them, reduce demand for hospital beds and lead to a more efficient use of public resources. We know well enough that poor housing contributes to poor health. These amendments to Clause 21 present an opportunity for the Government to demonstrate their commitment to truly tackling health inequalities and, in particular, to ending rough sleeping, by the end of this Parliament in 2024. As the noble Lord, Lord Young, and others have clearly laid out, the beneficial impact on a range of groups experiencing social exclusion and poor health outcomes would be significant. That means that there must be integrated approaches between housing, health and social care at the point when integrated care partnerships create their healthcare strategies.

Research shows that an average local authority might have around 1,400 people a year experiencing multiple disadvantage, including support needs around mental and physical health, homelessness and contact with the criminal justice system. Around 58,000 people a year experience the most severe disadvantage. It is therefore essential that local integrated care partnerships consider all the ways in which health intersects with housing.

I was concerned to read recently that in July last year 77% of women leaving our largest women’s prison became homeless. Homelessness inevitably leads to poor health. As Professor Dame Carol Black’s recent review of drugs highlighted, unless housing and housing support needs are addressed, the health service will fail to improve people’s health consistently, regardless of how effective the commissioned health services may be.

We know this approach works. The Government’s welcome effort to vaccinate people who were homeless went alongside a push for not only GP registration but provision of emergency accommodation. This acknowledged the need to bring together support into housing alongside access to basic health services. Indeed, we have seen the Government revisit this approach just before Christmas, with the Protect and Vaccinate scheme. Since the Government have recognised the need for this integrated approach, I cannot see why they would object to these amendments that would help continue it.

Amendments 152, 156, 157 and others seek to make our NHS systems more effective in the delivery of services to the most excluded and marginalised in our society. As it stands, people are forced to attempt to navigate a siloed and fragmented health service that does not adequately address their complex health needs. For example, one patient with alcohol and other addictions, supported by Changing Lives, could not access mental health services until after his alcohol addiction was addressed. However, with the right support from Changing Lives’ inclusion health approach, this patient is now managing abstinence from alcohol and engaging with mental health support. Crucially, his experiences highlight the challenges in addressing substance misuse in isolation, without making support available to address mental ill-health at the same time.

The Government may argue that it will be sufficient to address these concerns in guidance, but I hope they do not. I acknowledge that guidance would be beneficial in ensuring that approaches to inclusion health populations are considered within integrated care systems. However, without legislation, tackling inclusion health would become nice to do rather than something that must be done.

A recent example of this is Covid-19 vaccine uptake among people who were homeless. We know that where inclusion health services existed, there was a concerted effort to ensure good vaccine uptake, but without these specialist services we simply do not know how effective vaccination programmes have been. The only data available from July 2021 show vaccination rates to be substantially lower among people who were homeless compared to the general population.

I am aware that commissioning strategies and services for inclusion health populations is already on the agenda of some integrated care systems, but we need all integrated care systems to play their part. Guidance will not be effective enough to ensure the provision of specialist support everywhere, not just in some places.

In conclusion, the level of complexity of the marginalised and excluded experience can be met only by embedding inclusion health throughout the health and care system at the highest levels. Legislation is the most secure way to achieve this. Otherwise, there will continue to be a postcode lottery in access to the right healthcare services for these groups, resulting in that “disease of disparity” the Secretary of State wants to address.

[Lord Kakkar (CB)]

My Lords, I first join other noble Lords in thanking the noble Baroness, Lady Thornton, for the thoughtful way in which she introduced this group of amendments. I support Amendment 14, in the noble Baroness’s name, and Amendments 65, 94, 186 and 195 in the name of my noble friend Lord Patel. This is a vital group of amendments, as your Lordships have already heard, because it is focused on inequalities. Clearly, no society, Government or Parliament can tolerate the inequalities that we see in both clinical outcomes and access to healthcare that have remained despite our remarkable healthcare system and the NHS. It is for that reason that it is absolutely right that, in the opportunity afforded by this Bill, inequalities are properly addressed.

More worrying is that, despite this country’s substantial investment in healthcare and the development of health systems over the past 70 years, these disparities in outcomes and access to healthcare described geographically and across different ethnicities and socioeconomic groups have continued to grow. That is despite all the success we have seen more broadly in delivering healthcare, addressing prevention and improving treatments.

It is also right to recognise that inequalities in outcomes and access to healthcare are best addressed at the local level. Through a focus on integration in not only the capacity of services but the capacity to integrate the development of policy and its execution across healthcare and through local government and the other elements of the state—education, employment, housing and so on—we will have the greatest opportunity to address social determinants of health. There has probably been no other health Bill presented to this Parliament since the creation of the NHS that provides the greatest opportunity to take that combined and collective approach.

It is therefore quite right that one turns attention to the triple aim. This is a laudable addition to the Bill, with an absolutely appropriate focus on promoting health and well-being, ensuring access to quality care for all citizens and ensuring the appropriate and effective utilisation of healthcare resources. Why not add to that triple aim a fourth clear objective to address issues of inequality? The triple aim does not mandate action, but it provides the context in which a framework should be developed locally, cognisant of the healthcare needs of the local population. An ideal framework would ensure that we drive collaboration and co-operation as required to focus activity and the allocation of resource and establish a local vision and determination to address health inequalities.

To fail to take this opportunity would be disappointing and, quite frankly, unacceptable. As we have heard in this excellent debate, if we fail to address these inequalities not only will they have a continuing and profound impact on health outcomes and access to healthcare for large numbers of our fellow citizens, but there are broader societal and economic consequences of continuing to accept inequalities in healthcare. I hope that, in answering this debate, the Minister will be able to confirm that Her Majesty’s Government are prepared to consider this issue and will put inequalities the heart of this Bill in the triple aim—becoming a quadruple aim—and will ensure that, at a local level, data collection and reporting become a primary focus of healthcare systems.

[Baroness Harding of Winscombe (Con)]

My Lords, I begin by declaring my interest as the recently departed chair of NHS Improvement. I support these amendments, especially those that seek to extend the triple aim, such as Amendments 14, 65 and 94, as the noble Lord, Lord Kakkar, just set out so eloquently. It seems there is no disagreement in the Committee about the importance of addressing health inequalities. Anyone who has lived through the past two years can see that plainly and clearly, as Covid has so cruelly highlighted the health inequalities in this country. The question is how we make sure this Bill genuinely tackles the issue that we all agree about so passionately. Why is it important, as just set out by the noble Lord, Lord Kakkar, to put the duty to address health inequalities in the Bill?