All 26 Lord Kamall contributions to the Health and Care Act 2022

Read Bill Ministerial Extracts

Tue 7th Dec 2021
Health and Care Bill
Lords Chamber

2nd reading & 2nd reading
Tue 11th Jan 2022
Health and Care Bill
Lords Chamber

Committee stage & Lords Hansard - Part 1 & Committee stage & Lords Hansard - Part 1
Thu 13th Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 1 & Lords Hansard - Part 1
Thu 13th Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 2 & Lords Hansard - Part 2
Tue 18th Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 1 & Lords Hansard - Part 1
Tue 18th Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 2 & Lords Hansard - Part 2
Tue 18th Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 3 & Lords Hansard - Part 3
Mon 24th Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 1
Mon 24th Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 2
Wed 26th Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 1
Wed 26th Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 2
Wed 26th Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 3
Mon 31st Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 1
Mon 31st Jan 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 2
Wed 9th Feb 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 1
Tue 1st Mar 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 1
Tue 1st Mar 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 2
Thu 3rd Mar 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 1
Thu 3rd Mar 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 2
Mon 7th Mar 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 1
Mon 7th Mar 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 2
Wed 16th Mar 2022
Health and Care Bill
Lords Chamber

Lords Hansard _ Part 1
Wed 16th Mar 2022
Health and Care Bill
Lords Chamber

Lords Hansard - Part 2
Wed 23rd Mar 2022
Tue 5th Apr 2022
Health and Care Bill
Lords Chamber

Consideration of Commons amendments
Tue 26th Apr 2022
Health and Care Bill
Lords Chamber

Consideration of Commons amendments

Health and Care Bill

Lord Kamall Excerpts
Moved by
Lord Kamall Portrait Lord Kamall
- Hansard - -

That the Bill be now read a second time.

Lord Kamall Portrait The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
- Hansard - -

My Lords, over the pandemic the NHS has worked wonders. Throughout the greatest challenge that our health and care system has ever faced, the extraordinary dedication, care and skill of the people who work in our communities and hospitals have been unwavering, and I am sure that the whole House would want to put on record our thanks and admiration for staff across the health and care system.

The Government believe that part of that thanks must be in the form of giving the NHS the Bill that it wants, the Bill that it has asked for and the Bill that it needs to take better care of all of us. Some may say that this is the wrong time for this legislation. The Government and, more importantly, the NHS disagree. The Bill builds on the progress that the NHS made during the pandemic. Under crisis conditions, the NHS evolved, finding new reserves of incredible creativity, innovation and collaboration. It rolled out an extraordinarily successful vaccine programme, it drew on our collective strengths to deliver a programme reaching every corner of the United Kingdom and it has continued to deliver.

But the NHS has told us that the current legislation contains barriers to innovation that the Government feel duty-bound to remove. The NHS has asked for more flexibility to enable local leaders to try out new things—not as a free for all but in ways that best suit local needs and ensure that the system can evolve. The NHS has asked us to protect and nurture the innovation and hard-won lessons of the pandemic, as we begin to build back better.

Much of the Bill is not new: it builds on years of work on the ground to integrate care, on the work outlined in the NHS Long Term Plan and on years of experience, effort and learning, and of the system pushing the legislation to its limits to do what is best. It also builds on the Integration and Innovation White Paper that we published in February 2021, and on the many consultations that we have held on different aspects of the Bill. The NHS asked for legislation to make it fit for the future, and we are delivering. The Government believe that this is the right Bill at the right time, with wide support for the principles of embedding integration, cutting bureaucracy and boosting accountability.

I am sure that noble Lords will agree that one of the biggest challenges facing the NHS is the workforce. The Bill proposes a duty on the Secretary of State to report on the workforce “once every five years”. The Government are asking the NHS to develop a 15-year strategic framework for workforce planning, and we are looking to merge NHS England and Health Education England to deliver this. We are on track to deliver on our promise of 50,000 more nurses by March 2024.

The Government believe that this Bill will also help to deliver adult social care reform. In September, we announced plans to invest an additional £5.4 billion to begin a comprehensive programme of reform. Last week, we published our reform White Paper, People at the Heart of Care. This sets out our vision for adult social care and our priorities for investment, with measures including a new £300 million investment in housing and a £500 million investment in the workforce, to bring tangible benefits to people’s lives.

The Government recognise that their amendment to the adult social care charging system was considered controversial. However, it is necessary, fair and responsible. Everybody, no matter where they live in the country, no matter their level of starting wealth, will have the contribution they have to make to the cost of their care capped at £86,000. Those with lower levels of wealth will be far less likely to have to spend this amount, thanks to a far more generous means-testing regime that we will introduce. To be clear, the Government believe that nobody will be worse off in any circumstances than they are in the current system, and many people will be better off.

Furthermore, without this change, two people with the same level of wealth, contributing the same amount towards the cost of their care, could reach the cap at very different times. This is not considered fair. A fairer system is to have the same cap for everybody, and then provide additional means-tested support so that people with less are unlikely ever to spend that amount.

At its heart, this Bill is about integration. It builds on the lessons of the pandemic, when the NHS and local authorities came together as one system and not as individual organisations. New integrated care boards and integrated care partnerships will build on the progress made so far to plan, to join up services and to deliver integrated care. We are grateful for the work done to develop these clauses by both the NHS and the Local Government Association.

We have listened throughout the Bill’s passage in the Commons to concerns that we are enabling privatisation. Nothing could be further from the truth. To put this beyond doubt, we amended the Bill in the other place to make it clear that that no one may be appointed to an ICB who would undermine the independence of the NHS, either as a result of their interests in the private healthcare sector or otherwise.

Many noble Lords will be aware of the integration White Paper announced in September and currently in development. I can assure the House that this will build on the integration measures in the Bill, to go further and faster and to deliver person-centred care. We expect to publish it in early 2022.

As I have mentioned, a key aspect of this Bill is removing bureaucracy where it gets in the way. While bureaucracy often ensures that there are processes and procedures in place, we all know how excessive bureaucracy can make sensible decision-making harder. We believe that health and care staff are able to deliver better when they are trusted and given space to innovate, with barriers removed. Every NHS reform has claimed to reduce bureaucracy, with varied degrees of success, but such reforms have often been top-down. These reforms come not from the top down but from the bottom up, giving the NHS what it has asked for. This includes introducing a new, more flexible provider selection regime that balances transparency, reducing bureaucracy and fair and open decision-making.

It is right that the day-to-day decisions about how the NHS is run, both locally and nationally, are free from political interference. However, it is also right that there is democratic oversight and strong accountability in a national health system that receives £140 billion of taxpayers’ money every year. The public deserve to know how their local health system is being run. Integrated care boards will hold meetings publicly and transparently, and the Care Quality Commission will have a role in reviewing integrated care systems.

The Bill also ensures greater accountability from healthcare services to government, to Parliament and, ultimately, to the public. Through new powers of direction, the Government will be able to hold NHS England to account for its performance and take action to ensure that the public receive high-quality services and value for taxpayer money. Equally, we must ensure that there are safeguards and transparency mechanisms in place. That is why the Bill is clear that the new power of direction cannot be used to intervene in individual clinical decisions or appointments. The public also expect Ministers to ensure that the system conducts reconfiguration processes effectively and in the interests of the NHS and, where necessary, to intervene. In such instances, the Bill provides a mechanism for the Secretary of State to intervene, subject to the advice of the independent reconfiguration panel.

As we all know, the health challenges that we face are not static, so the NHS must continue to be dynamic. As the noble Lord, Lord Darzi, once said:

“To believe in the NHS is to believe in its reform”.—[Official Report, 11/10/11; col. 1492.]


The Government believe that this Bill allows the NHS to meet the challenges of today and adapt to those of tomorrow. With this Bill, we can look beyond treating disease and focus on prevention with measures to promote good health, such as tackling obesity and stopping the advertising of less healthy products to children. This Bill includes a range of important additional measures, including the establishment of the Health Services Safety Investigations Body, or HSSIB—a world-leading innovation in patient safety—and legislation to ban virginity testing to fulfil the Government’s commitment to the most vulnerable.

The Government believe that the founding principles of the NHS—taxpayer-funded healthcare available to all, cradle to grave and free at the point of delivery—remain as relevant now as they were in 1948. To protect these values, we must back those who make them a reality every day of their lives by building and constantly renewing a culture of co-operation and collaboration. I commend this Bill to the House.

--- Later in debate ---
Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

My Lords, I put on record my thanks and gratitude for this excellent and wide-ranging debate. I hope noble Lords will understand that I may not be able to answer every point in the time available—unless they are prepared to stay here all night. I am grateful for the constructive and thoughtful contributions of noble Lords from all sides of the House. When I first entered this House, a noble friend who was a Minister here and in the other place said that, in the other place, you are probably one of the few experts on the Bill you are taking through, but in this place there will be at least one other expert. I disagree: there are many experts who will know far more about this than I do, but I look forward to learning from noble Lords across the House and listening to their expertise.

I echo those who praised the excellent maiden speech of the noble Lord, Lord Stevens. He will be a valuable addition to the House. I caution against describing him as a treasure, because the problem with treasures is that people want to lock them away, put them behind a glass case, or bury them.

The noble Baroness, Lady Merron, asked how the Bill would be different from previous reorganisations. I make it clear that this is not a reorganisation that comes from my office or my right honourable friend the Secretary of State’s office in Victoria Street. Instead, the Bill builds on the evolution up and down the country over the last decade led by the noble Lord, Lord Stevens of Birmingham, to deliver joined-up care.

This is the right Bill at the right time, as the noble Lord, Lord Adebowale, said. I was extremely struck by the contributions of the noble Lords, Lord Kakkar, Lord Adebowale, Lord Stevens, and my noble friends Lady Harding and Lord Hunt of Wirral, in support of the principles underlined in the Bill. I am grateful for their support. As the noble Lord, Lord Stevens, said, the Bill is not a cure-all; no Act of Parliament could ever be. However, it can set the framework for people to find solutions that work; that approach has been the guiding light.

I will now address some of the issues raised across the House. As the noble Lord, Lord Mawson, said, integrating services around people is the only sustainable way of delivering high-quality health and care systems and, more importantly, delivering improved outcomes for everyone. This has been a goal of health systems across the world, and it is at the heart of the provisions in this Bill, including putting new integrated care systems on a statutory footing. To meet that challenge, a key principle of the Bill is to ensure that the legislative framework is flexible and responsive to local population needs. It is right that local areas should be able to determine the arrangements that work best for them. Frimley is not Cumbria; we should not try to create a one-size-fits-all single model for both.

To protect this flexibility, I ask noble Lords to consider whether it is appropriate to add additional prescriptions on membership and duties for integrated care boards and integrated care partnerships, although we will, of course, be happy to consider suggestions for additional guidance and support for the system. In that spirit, I hope that I can reassure the noble Baronesses, Lady Tyler, Lady Walmsley, Lady Masham, and other noble Lords who raised this, that we are working with NHS England and the Department for Education on bespoke guidance in relation to children, including the vital issues of safeguarding, special educational needs and disabilities.

I thank my noble friend Lord Farmer for raising the role of family hubs, and for his sustained work in advocating for the family hub model. I assure him that this Government have committed to championing family hubs and we are working to roll them out. I also assure the noble Baroness, Lady Pitkeathley, and other noble Lords that we are fully committed to supporting carers, including consulting them in the development of services. I reassure the noble Baronesses, Lady Finlay and Lady Meacher, and my noble friend Lady Hodgson that integrated care boards will be responsible for commissioning palliative care services as part of a comprehensive healthcare service.

This may be a convenient moment to consider the question of parity of esteem, as raised by a number of noble Lords, including the noble Baronesses, Lady Thornton and Lady Watkins, my noble friend Lady Morgan of Cotes, the noble Lord, Lord Bradley, and others. References to health in the Bill will already apply to mental, as well as physical, health. Likewise, I hope that I can reassure many noble Lords, including the noble Lords, Lord Patel and Lord Desai, and the noble Baroness, Lady Walmsley, that tackling inequalities is deeply embedded in the Bill. Given the backgrounds of both my right honourable friend the Secretary of State and myself, we believe very strongly in tackling inequalities. At the same time, I remind noble Lords of the establishment of the Office for Health Improvement and Disparities, with the focus on disparities and tackling inequalities. It is important that we give our support in tackling disparities right across our nation.

Integrated care partnerships will plan to address local needs, including the wider determinants of health, and the triple aim places new duties on NHS bodies to consider the health and well-being of the people of England when discharging all their functions. I listened carefully to the concerns raised by the noble Lord, Lord Mawson, and the noble Baronesses, Lady Merron and Lady Pinnock, on the principle of subsidiarity—the role of place. We want to empower local leaders to support integrated and person-centred care at place level.

The noble Baroness, Lady Brinton, my noble friend Lord Lansley, the noble Lord, Lord Bradley, and others raised the question of why we are putting forward a two-board approach. This approach recognises the importance of integration, both within the NHS and between the NHS and its wider partners. I reiterate that this was co-designed with both the NHS and the Local Government Association. I hope that I can reassure the noble Lords, Lord Howarth and Lord Crisp, that ICPs—integrated care partnerships—will have flexibility to draw members from a wide range of sources including organisations with a wider interest in local priorities, such as housing providers and education, as well as art and culture organisations.

The noble Lord, Lord Kakkar, asked why the Bill provides for CQC assessment of integrated care systems. It is important that members of the public can understand how well their health and care system is collaborating and that their local hospital is providing a safe, high-quality service.

My noble friend Lady Blackwood and other noble Lords raised the importance of research. I assure the House that we share the objective of wanting to see research embedded in the health and care system, not only to improve healthcare outcomes but to contribute to the goal of making the UK a hub for life sciences globally.

To address the contributions from the noble Baronesses, Lady Bakewell and Lady Chakrabarti, I assure the House that we have no intention of opening the door to privatisation. As the King’s Fund has said, there is nothing in the Bill that is likely to drive more NHS funding towards private companies—a sentiment echoed by the noble Lord, Lord Adebowale. I also remind noble Lords that successive Labour and Conservative Governments have seen the value of collaboration between the voluntary sector, the private sector, social enterprises —as mentioned by the noble Baroness, Lady Thornton, and the noble Lord, Lord Kerr—and the state.

On integrated care boards, the right reverend Prelate the Bishop of Carlisle and the noble Baroness, Lady Walmsley, asked about transparency. Integrated care boards are covered by the Public Bodies (Admissions to Meetings) Act and will be bound by the principles of openness and proper public engagement.

I listened to my noble friend Lord Bethell with great interest. I agree that data sharing is essential to true integration. I know that many other noble Lords support this but they also, rightly, raised some concerns. The information provisions in this Bill are part of a wider range of commitments set out in the draft data strategy. We will ensure that the system has the ability and competence to share and use data appropriately and effectively to benefit individuals, populations and the health and social care system.

I listened carefully to the many contributions on social care from the noble Baronesses, Lady Thornton and Lady Campbell, and many others. Social care reform is a challenge ducked by generations. Successive Governments have commissioned reports on social care only to see them gather dust on bookshelves and never be enacted. This is the first attempt for many years to tackle a long-standing issue. Many noble Lords have spoken about it being ignored for 10, 20, 30 or 40 years. Anyone who has looked at the history of demographics and economic history will know that this challenge was coming a long time ago, yet successive Governments have kicked it down the road. We hope that this Bill, alongside the upcoming integration White Paper and the recently published social care White Paper, will go towards meeting that challenge. The social care White Paper sets out a 10-year reform vision that puts people at the centre of social care. It will ensure greater choice, control and support to lead an independent life with fair and accessible care.

We are backing that vision with investment. The Prime Minister has announced an additional £5.4 billion to begin a comprehensive programme of reform, including an extra £3.6 billion to reform the social care charging system, an extra £300 million of investment in housing, £150 million of additional funding to improve technology and increase digitalisation across social care, and £500 million of investment in the workforce. As technology improves, we hope that the nature of social care will change, enabling many more people to spend longer lives in their own homes with adaptations and better technology. Would it not be great if the United Kingdom were at the forefront of those technological developments?

I recognise the strength of feeling in relation to Clause 140, but I remind the House that it is absolutely essential that noble Lords look at the package of social care reforms as a whole. Our reforms will stop unpredictable and unlimited care costs, significantly increase the means test to help those with the least wealth and help people to plan for the future.

I hope that noble Lords will recognise that, as my right honourable friend the Secretary of State said in the other place, nobody will be worse off in any circumstances than they are in the current system and many people will be better off. The reforms mean that the Government will now support an extra 90,000 older care users at any given time. Comparisons have been made to previous proposals for reforms to the charging system. I remind noble Lords that many of these were not in fact acted on, partly due to concerns over unaffordable costs. Unlike previous proposals, our reform package is credible, deliverable and affordable.

There has rightly been much discussion of workforce planning for the NHS and adult social care. I have listened carefully to the contributions on this very important subject made by many noble Lords, including my noble friends Lady Harding and Lady Cumberlege, the noble Lord, Lord Patel, and the noble Baronesses, Lady Cavendish and Lady Thornton. Ensuring that we have the health and care workforce that this country needs is a priority for this Government, and the most recent figures show that there are record numbers of staff working in the NHS, including record numbers of doctors and nurses.

The Bill builds on this work. Clause 35 will bring greater clarity and accountability to this area. The department has also commissioned Health Education England to work with partners to develop a long-term 15-year strategic framework for the health and regulated social care workforce. For the first time, this will include regulated professionals in adult social care. That work will look at the key drivers of workforce supply and demand over the longer term and set out their impact on the future workforce. We anticipate publication in spring 2022. Supporting all this work is our recent announcement of our intention to formally merge Health Education England with NHS England. Such a merger will help to ensure that workforce is placed at the centre of NHS strategy.

I now turn to some of the wider issues raised during this excellent debate. I beg your Lordships’ indulgence, as time may not permit me to answer every point raised, and I commit to write to noble Lords whose points I do not address. I hope noble Lords will forgive me for the time I may take to write some of those letters.

On the power of direction for the Secretary of State, I am afraid I cannot agree with the characterisation suggested by some noble Lords. Instead, I would echo the former shadow Minister in the other place who said that

“the public think that the politicians they elect are accountable for the decisions taken in the interests of their health”.—[Official Report, Commons, Health and Care Bill Committee, 21/9/21; col. 393.]

We agree. I would also like to assure the noble Lord, Lord Stevens, that Ministers have no intention of requiring hospitals to report on the movement of a broom cupboard. I am afraid that is a mischaracterisation, albeit a witty one, of how Ministers intend to use their power.

We anticipate that Ministers will be involved only where decisions become particularly complex or a significant cause of public concern, or if they cannot be resolved at a local level. Local NHS commissioners will continue to be accountable to NHS England and for developing, consulting on and delivering service change proposals. However, we believe that strengthening democratic oversight will make it more likely that the right decisions will be taken. Any decisions will be based on the evidence and consultations that have taken place, and where the Secretary of State chooses to intervene they will, rightly, be accountable to Parliament and the public.

I welcome support for the establishment of the Health Service Safety Investigations Body and agree with the noble Baronesses, Lady Merron and Lady Walmsley, and others that it is essential that the HSSIB is an independent body and a safe space. This is what the Bill delivers. It was always difficult to achieve the right balance between openness and getting people to come forward so that we can make sure that we improve and learn lessons.

As raised by the noble Baroness, Lady Meacher, the Bill contains a number of delegated powers. Many of these are not new but simply reflect the replacement of clinical commissioning groups with the new integrated care boards. Far from a power grab by the Secretary of State, many of these powers will be exercised by the NHS.

The noble Baronesses, Lady Pinnock and Lady Jones, and my noble friend Lord Reay raised the question of fluoridation. I gently remind noble Lords that although tooth decay can be prevented or minimised by adherence to a healthy diet, water fluoridation is seen to be the only intervention to improve dental health that does not require sustained behavioural change over many years. It also disproportionately benefits poorer or more disadvantaged groups.

As many noble Lords have commented, prevention is in many ways better than cure. That is why we are so concerned about childhood obesity, a concern shared by noble Lords across this House. It is one of the biggest health problems this nation faces, and I am grateful to many noble Lords for the support that related measures have received today. We want to be quite clear that, as these measures are taken forward by local integrated boards and commissioners, we must rely on evidence, learn lessons and, when something does not work, try something else. We have to use the power of discovery to make sure that we are finally able to put obesity to bed or to reduce it on a significant scale.

I was also grateful for the intervention of the noble Baroness, Lady Brinton, in relation to reciprocal healthcare agreements. I hope I can assure her that such arrangements will be entered into only when they are in the best interests of the people of the UK and the NHS. The NHS is not, and never will be, for sale to the private sector, whether overseas or domestic.

I thank my noble friend Lady Cumberlege for her remarks and for her tireless work in championing patients, ensuring that the voices of patients and their families were heard in her First Do No Harm report. My noble friend continues to be a voice in the House for patients in general, and for the women and their families who have been so terribly affected by matters covered in her review. She continues to champion their cause and their calls for redress. We are committed to making rapid progress in all areas set out in our response, and we aim to publish an implementation report in the summer of 2022.

Finally, I welcome those, including my noble friend Lady Hodgson, who raised the issue of hymenoplasty. The Government agree that this is a repressive and repulsive procedure. We have convened an independent expert panel to make a recommendation on whether it should be banned. That recommendation will be published before Christmas.

This Bill is the product of extensive engagement with stakeholders across the health and care system, including partners in local government as well as the NHS. It will provide a platform that empowers local leaders across health and care to build back better and to continue to deliver a world-class service, fit for the 21st century and beyond. I urge noble Lords across the House to trust the judgment of our health and care staff as much as we value their commitment and their care. I know that noble Lords will work together to make this Bill better during the coming weeks and I commend the Bill to the House.

Bill read a second time and committed to a Committee of the Whole House.

Health and Care Bill

Lord Kamall Excerpts
Lord Cormack Portrait Lord Cormack (Con)
- Hansard - - - Excerpts

My Lords, in the absence of the noble and learned Lord, Lord Judge, I take it upon myself to echo the trenchant observations of the noble Baroness, Lady Walmsley. What do the Government think Parliament is? What do they think it is for? Again and again, we have these Bills—skeleton Bills, Christmas tree Bills, call them what you like, but one thing is abundantly plain: Henry VIII is sitting firmly on his throne issuing his diktats.

This is no way for a democratic Government to treat Parliament, especially the elected House. However, if the elected House will not fully protect itself, we have a duty to speak up for it. There are many who, because of the circumstance of their election recently in Parliament, perhaps feel a bit diffident, but we have a duty not to be diffident. We in this House have a duty to say, “This is no way to treat Parliament”, because we are in effect creating executive departments with dictatorial powers. That is inimical to a parliamentary democracy. It is plain wrong. I do not know how often I shall intervene in the debate on this Bill, but what I do know is that I do not like what I see.

I have enormous and genuine respect for my noble friend the Minister. He has already, very rightly, earned himself a reputation in this House as somebody who is anxious to learn about parliamentary customs and practices, and to listen and reflect. I beg him, as I look at him now, to please talk to his colleagues in the other place who have greater power within the department and say to them that there is real concern in this House—I am delighted to see my noble friend Lady Cumberlege nodding at this point—which has within it many medical experts, such as my noble friend Lord Ribeiro, the noble Lord, Lord Winston, who does not seem to be here this afternoon, my noble friend Lord Kakkar and many others who know about medicine and how things should be organised and who do not see it as their prime purpose to help a Secretary of State hang his baubles on the Christmas tree.

We have a chance—we have done it before in other Bills—to try to improve on this skeleton, this Christmas tree, and to put Henry VIII back in his box, which is where he should be put. I hope that as this Bill goes through your Lordships’ House it will be probed, scrutinised and improved.

Lord Kamall Portrait The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
- Hansard - -

I start by thanking the noble Baroness, and indeed all noble Lords who have spoken thus far. I will make a general point in response to my noble friend Lord Cormack. I recognise that I am relatively new to this House and that I have much to learn. I hope to learn much, not only from noble Lords who have more experience of the procedures of this House and of holding the Government to account but from many noble Lords from across the House with medical expertise and management expertise in the health and social care sector.

I also thank the noble Baroness, Lady Thornton, for bringing this debate before the Committee. Amendment 1 would mean that we could not commence the change of legal name from the National Commissioning Board to NHS England until after an impact assessment for each of the clauses in Part 1 of the Bill is published, while Amendment 315 would mean that we could not commence Part 1 until after the publication of an impact assessment for each clause’s impact on the risks, costs and benefits to patients.

I hope I can reassure the noble Baroness that my department has published the impact assessments. She acknowledged this and I accept that they were not published in the most timely way. I will endeavour to do my best to make sure that we publish these assessments with as much notice as possible. They are available for noble Lords to review on GOV.UK. I am very happy for the noble Baroness to take credit for the first impact assessment. We will endeavour to do better. We will also commit to publishing further impact assessments for secondary legislation made under the powers contained in the Bill, where those regulations will have significant impact on the health and care system or private businesses, to provide transparency and clarity to the system.

The amendment would also delay the commencement of Part 1 until at least six months after commencement regulations were laid before your Lordships’ House. This would delay the implementation of the key provisions contained in Part 1.

The NHS put forward its recommendations for legislation in 2019. It is preparing, subject to parliamentary passage, to implement the ICB provisions of the Bill from July 2022. We know that ICBs in effect exist in many areas, in whatever form of development, and it is essential that we put these on a statutory footing as soon as possible. The development of ICBs builds on years of development work in local systems to improve partnership working. Delaying the implementation risks a loss of momentum in establishing statutory integrated care boards and the benefits that they are intended to deliver. For these reasons, I ask the noble Baroness to withdraw her amendment.

Baroness Thornton Portrait Baroness Thornton (Lab)
- Hansard - - - Excerpts

I thank the Minister for that very gracious answer and start to our deliberations. I also thank in particular the noble Baroness, Lady Walmsley, and the noble Lord, Lord Cormack. I really was rather hoping that the noble Lord, Lord Cormack, would come in, as this is absolutely what he knows about. He is quite right. I hope that noble Lords who are experts in this will look carefully at the Bill and at the two reports I referred to, because they will need to guide us in our deliberations over the next few weeks.

Let us see what the impact assessment says—whether it works or not—and see whether we need to review certain parts of the Bill with a view to looking at the Constitution Committee’s report, for example, which also was published only yesterday. With that, and with the warning that this is the beginning and not the end of the discussion, I beg leave to withdraw the amendment.

--- Later in debate ---
Baroness Merron Portrait Baroness Merron (Lab)
- Hansard - - - Excerpts

My Lords, I feel that today’s debate on this important group of amendments should carry much weight because, at its core, this is about treating people as whole people and seeing them as physical, mental and social beings. Our welfare on each of those fronts is absolutely key to the others. It is not possible simply to treat one without regard to the others, and it is crucial that we enhance people’s well-being across our whole complexity as human beings.

I am glad to speak to this group of amendments because, as we have heard across all sides of the Committee throughout today’s debate, the reality is that, despite the best efforts encapsulated in the mandate, and many times in policy, we find that competing priorities, an avalanche of guidance and instructions, and events—the pandemic has been referred to several times, of course—mean that mental health services can be, and indeed have been, relatively left behind. As the Centre for Mental Health reports:

“Mental health problems account for 28% of the burden of disease but only 13% of NHS spending.”


In the debate today we have also asked ourselves: where is the accountability? For example, we know that in many clinical commissioning groups the actual spend on mental health was below what it was supposed to be, yet there have been no consequences. We need to address not just the finances but the mechanisms around it and the impact on individuals.

The founding National Health Service Act 1946 rightly spoke of a comprehensive health service that secured the improvement of both physical and mental health, and subsequent Acts, quite rightly, have confirmed this. In operational terms, the Government require NHS England to work for parity of esteem for mental and physical health through this NHS mandate, but we know, and have heard again today, that this requirement falls down when we go to a local level.

One way or another, we will all be familiar with a whole range of stories of people who have not been able to access treatment in a timely manner or who find that they are pushed around a system with very little effect and discharged from care before it is appropriate, with consequences that are all too clear to see. It is difficult to overestimate just how challenging this is, not just for the individuals but for local commissioners, because they face competing pressures in trying to deal with this.

As has been emphasised, this group of amendments is about not just getting on the road to financial parity, important though that is, but changing the culture and the whole means of monitoring and implementation, so that disparities can be addressed—indeed, if possible, so that difficulties can be headed off at the pass. It is a well-worn phrase, but it sometimes seems that mental health is a Cinderella service—the one that can be cut first, to the benefit of the more visible services. Some of the recent statistics show that one in four mental health beds has been cut in the last decade, while just last year 37% of children referred by a professional to mental health services were turned away. That is a shocking statistic that we need to move away from.

I thank noble Lords for promoting these amendments and for their contributions illustrating what they mean and the reason we need them today. The noble Lords, Lord Stevens and Lord Patel, made timely points about the impact of the pandemic. If this is not a moment for focusing more on mental health, I do not know what is. The challenge we have and the difficulty presented by the pandemic is that while there is a focus on cutting waits for operations—and we know that is important—this could be a reason for mental health services to get somewhat lost, when in fact the pandemic reminds us of the importance of mental health and the need for the NHS to meet the needs that there now are.

The amendment by the noble Lord, Lord Stevens, encourages and directs the actions necessary for transparency on expenditure. I recall that they were referred to in the debate as legislative levers, and that is indeed what they can be. For me, they encourage not just accountability and transparency but actual action and change—the change we need to see.

The noble Baroness, Lady Hollins, referred to parity of esteem having to be applied locally, not just at a higher level. That is the only way we will see a difference in mental health services and improve the mental health of people in this country.

The noble Lord, Lord Crisp, made reference to the fact that legislation is trying to catch up with where we are as a society, and the noble Lord, Lord Warner, referring back to the meeting he attended, said that the public are well ahead of the game. I believe that is true. Indeed, as the noble Baroness, Lady Watkins, said, we have to prepare for tomorrow. It is not satisfactory that we stay stuck in today, or indeed in the past.

In my view, these amendments move us on. They bring mental health services into real parity with physical health services, but they also connect mental and physical together. I hope they will find favour from the Minister.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I begin by thanking all your Lordships for the wide-ranging debate. I want to say how much more I learn, listening to the contributions in each of these debates, before I stand up to speak. I thank all noble Lords for their contributions. As the noble Baroness, Lady Merron, says, this debate carries some weight for our understanding that social, mental and physical well-being are equally important. We should not seek to suggest that one takes precedence over another. I also thank the noble Lord, Lord Stevens, for kicking off this debate with his encouraging and not critical amendments; I take them in that spirit.

Following on from that, and before I go to some of the specific amendments, I will just reflect on some of the contributions made thus far. I first thank the noble Lord, Lord Howarth, for raising social prescribing. I know we have discussed this a number of times since I became the Minister, with particular contributions from the noble Baroness, Lady Greengross, on the importance of art and music in helping to unlock the mind and touch the soul.

As has been made clear, social prescribing is a key component of the NHS’s universal personalised care, and I know that, crucially, this can work well for those who are socially isolated or whose well-being is impacted by non-medical issues. The NHS has mechanisms to ensure that social prescribing is embedded across England: for example, the primary care network directed at enhanced services specification outlines that all PCNs must provide access to a social prescribing service.

I also thank the noble Lord, Lord Patel, for raising the importance of the mental health of children and for making sure that we do not forget, even within mental health, that many sections of our society can quite easily be forgotten.

I agree with the right reverend Prelate the Bishop of London: we have come a long way. I remember as a child in the 1970s going to visit my uncle who was a psychiatric nurse at Claybury Hospital and looking at the patients, with the innocence of a child, and thinking, “These people don’t look ill to me.” We have come far since then. I remember the Rampton hospital scandal in the late 1970s, where the patients were treated appallingly, almost not as humans, and with a lack of dignity. The fact that today we are discussing the parity of mental with physical health shows how far we have come as a society.

We also spoke about loneliness and isolation. The noble Baroness, Lady Watkins, and I have had conversations about loneliness and some of the civil society projects that, for example, bring together lonely older people with children from broken homes so that both can benefit and learn from each other. I remember a story that I have mentioned in the past: in one of the projects I visited, a rather old man said, “I lost my wife five years ago and I had almost given up on life. The fact that I am now working with children from broken families and am almost being a mentor to them gives me a purpose to live—a reason to get up in the morning. I have no longer given up on life.” There are so many of these civil society projects, and no matter how we legislate, sometimes those local projects get to the nub of the problem in their local communities.

I have to pay attention when not only two former NHS chief executive officers but the former Chief Nursing Officer speak in the debate. The noble Lord, Lord Crisp, talked about the focus on outcomes, not inputs and how it is important to make sure that we are not gaming the system, mentioning mental illness and mental health but not doing anything effective about it.

Autism was mentioned by the noble Lord, Lord Warner, a former Health Minister. We are fully committed to improving access to and provision of health and care services for autistic people and people with a learning disability. I know that we have had at least one debate on the treatment of patients with autism and sometimes the terrible conditions they experience. That just shows how important this is.

I am trying to say that in many ways that the Government are absolutely committed to supporting everyone’s mental health and well-being and to ensuring that the right support is in place for all who need it. I therefore welcome the amendments which look to ensure parity of esteem across physical and mental health. I assure noble Lords that we support the sentiments behind these amendments and take mental health seriously.

Indeed, one of the considerations in weighing up the many arguments for further measures in response to Covid—from those who were asking for lockdown, for example—is that we also had to recognise that there was a mental health impact to lockdown. As a Government, we had to look not only at the societal and economic impacts but the mental health impacts within health considerations.

On the amendments, I will first address those tabled by the noble Baroness, Lady Hollins—I add my voice to those of the many noble Lords who have paid tribute to her work over many years in promoting this issue and ensuring that we take it seriously. I also pay tribute to the noble Baroness, Lady Walmsley, for making sure that we are informed about this. These amendments would explicitly reference both mental and physical health and illness in certain provisions of the Bill. I understand that the intention is to ensure that due attention is given to both “mental and physical health” and “mental and physical illness”. Indeed, you cannot separate mental and physical illness, as the noble Baroness, Lady Jones, said. We have moved way beyond “Pull yourself together, man” or a stiff upper lip attitude. We see how mental health plays a role, for example, in terrorism, with those who are recruited to be terrorists, or in those with eating disorders, or the number of people in prison who suffer from mental health issues. It is important that we fully recognise that.

Baroness Walmsley Portrait Baroness Walmsley (LD)
- Hansard - - - Excerpts

My Lords, I shall speak more briefly than I had intended, because this has been a very long debate, absolutely full of expertise, about a suite of amendments all of which have considerable merit. I know that both Ministers on the Front Bench have been listening very carefully and have noted the consensus across the Committee that this Bill will not succeed unless it addresses very clearly the disgraceful health inequalities in this country at the moment.

Health inequality affects quality of life, life expectancy and, in particular, healthy life expectancy, which has now stalled across certain demographic groups. As we have heard, it has been analysed brilliantly by Professor Sir Michael Marmot. It affects the well-being of the patient and their family. The really sad thing is that much of it is preventable. These things are particularly rife in the poorer parts of the country, because that is where the social determinants of health such as housing, referred to by my noble friend Lord Shipley and others, have most effect. We have heard a number of statistics about health inequalities, but I shall give your Lordships just one. People living in the most deprived areas of the UK spend almost a third of their lives in poor health, compared to only about a sixth of those living in the least deprived areas. That says it all.

Unfortunately, inequalities were not at the forefront of the Government’s response to the pandemic. They suspended equality impact assessments for legislation, resisted publication of evidence of the impact of the virus on BAME individuals—as pointed out to them eloquently by the noble Baroness, Lady Lawrence—and failed to provide adequate isolation support for those on low incomes, forcing them to go to work. The Covid pandemic has therefore seen the biggest shift in life expectancy in the UK since World War 2: a fall of 1.2 years in males and 0.9 years in females. It is therefore essential to heed Sir Michael Marmot’s words and “build back fairer” and not just “better”.

The noble Baroness, Lady Greengross, kindly mentioned the report of the Science and Technology Committee on healthy ageing. I was a member of that committee under the capable chairmanship of the noble Lord, Lord Patel. It became very clear from our witnesses that unhealthy ageing happens years before the person is old and depends enormously on their demographic and their lifestyle. For their sake and for the sake of the future of the NHS, for which no Government will ever be able to provide enough funding unless something is done on prevention, we must do something to level up the health outcomes of the nation. This Bill is a very good place to start all over again on that agenda.

I have added my name to Amendment 11, so ably introduced by the noble Baroness, Lady Thornton, whom I must congratulate on the way she analysed these issues at the beginning of this debate. I thank her for that. Also crucial is Amendment 14, so ably promoted by the noble Lord, Lord Patel, and my noble friend Lady Tyler. Amendment 11 is an attempt to ensure that NHS England produces guidance about the collection, analysis, reporting and publication of the data which makes transparent the performance of various NHS bodies on health inequalities. Without collecting that, we cannot judge the performance of those organisations. If it is not done consistently, we cannot assess an organisation’s performance in comparison to other similar bodies. That is why such guidance must come from the top. I know that the Government want each ICS to do its own thing in a way which it considers most appropriate for its area. However, for the important objective of levelling up health outcomes across the population, judgment of performance can be made only if the data is comparable between one ICS and another or one trust and another, so we cannot leave it to them to collect the data in any way they like.

Of course, there are big issues about the resources available for the collection and analysis of data, but such information is essential if improvements are to be made. Therefore, a duty to “have regard” to guidance published by NHSE would put pressure on the organisations to so arrange their finances as to ensure adequate resources for this, and, of course, it would be cost-effective.

I also have Amendments 61 and 63 in this group. They would insert “assess and” into new Section 14Z35 inserted by Clause 20, which covers the duty of an integrated care board to reduce inequalities in access to health services across its population and in the health outcomes achieved. Although it is well known that, in general, the lower the demographic the greater the health inequalities, this is by no means uniform, even across a single local authority, let alone across a large ICS area. Indeed, even within a single local government ward, which may be fairly affluent in general, there are often pockets of deprivation. Every local councillor knows where they are. In order to devise policies and deploy services geographically in a way that improves access and outcomes for those deprived communities, the ICS needs to drill down and do the detailed work to identify where they are and what factors are damaging health. It may be poor or overcrowded housing. It may be lack of access to shops selling healthy food. It may be lack of access to leisure and sports facilities in which to take exercise. It may be poorly performing schools or overstretched primary care services. It may simply be poverty, preventing people heating their homes adequately or buying nutritious food. In rural areas, it may be lack of access to pretty well everything, as the right reverend Prelate reminded us. Whatever it is, you cannot fix it until you know what and where it is.

That is one of the reasons why we reject the new power of the Secretary of State to meddle in the reconfiguration of health services locally, but that is a debate for another time. In cases such as this, an overview will not do, and local knowledge is key. That is why we believe it is essential to mandate an ICB to do the detailed research on which to base its commissioning decisions, so that it can fulfil the duty to reduce health inequality put on it by this Bill—once it has been amended by a lot of these amendments.

None Portrait Noble Lords
- Hansard -

Hear, hear.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

You have not heard what I am going to say yet.

I thank all noble Lords who have taken part in this debate; it has been fascinating. It has touched on a number of things that I feel strongly about personally. Before we go further, and given my background and that of my right honourable friend the Secretary of State, I want to assure noble Lords that we both feel very strongly about inequalities. I say that as someone who grew up in a working-class immigrant community. I was born at Whittington Hospital; I also accessed North Middlesex hospital and Chase Farm Hospital, with which I know the noble Baroness, Lady Tyler, is associated, though I am not sure I will get any more points for that, to be honest.

One thing I feel strongly about, and saw in many areas when I was an MEP for London, is where the state has failed, whichever Government was in power. I have worked with non-state, local community, bottom-up projects which understood the issues in their communities far better than any national or local politician—there was sometimes even a distance between them and their local ward councillor, as the noble Lord, Lord Mawson, and I were discussing the other day.

I thank the noble Baroness, Lady Thornton, not only for the thoughtful way in which she opened the debate and introduced the amendments but for pointing out some of the people who are often forgotten; for example, the homeless. I have worked with a number of local community homeless projects, such as the Hope Foundation in Acton and Vision Care for Homeless People. Perhaps I may also do a quick advert for the Take One, Leave One project, which is based outside Vauxhall station on Fridays, between 12 pm and 3 pm —people can leave excess clothes and homeless people can pick them up. I urge any noble Lords passing through Vauxhall station on a Friday to support this.

Sex workers, the Traveller community and drug users have been mentioned. Sometimes we think that these issues are remote from us and will not affect us—but everyone is only one of two steps away from homelessness. A broken family, mental health issues, your friends saying, after a while, “Actually, you can’t stay on my sofa any more”—where do you go? When I have met homeless people, they have quite often come from a very different place, not the stereotype that we often hear. They have come from quite a stable family, a good relationship, a good job: but two or three things have gone wrong in their life and suddenly they are homeless. It happens to many people who resort to such desperate measures.

Another thing I am slightly concerned about, if I am honest, is that when I was a young child growing up in immigrant communities, there was a distrust of authority. We see the difficulty, for example with the vaccine schemes, in trying to reach some of those communities. It was not only authority that we were quite suspicious of and concerned about but—I hope noble Lords will forgive me for using this phrase—white, middle-class do-gooders who thought they knew best what was best for us as working-class immigrant people and could tell us what was best for us, rather than listening to us and our real concerns. Quite often we felt that they had captured the agenda, and that was why the money and resources which were supposed to be helping us did not reach the people who needed help: it got captured by the white, middle-class do-gooders.

I pay tribute to the noble Lord, Lord Howarth, and the noble Baronesses, Lady Greengross and Lady McIntosh of Hudnall, for the emphasis on the arts and creative industries. Sometimes, music and the arts are a way of overcoming this distrust, learning about the culture of those communities and also aligning the culture and the issues with some of the very real problems and tensions we face. The noble Lord, Lord Desai, talked about prevention being better than cure. It is an issue we talk about constantly in the department, and the NHS also talks about it. The noble Lord, Lord Desai, as an economist, will acknowledge that economics is often simply about the allocation of scarce resources and finding the most efficient way of achieving that.

My late father once told me, “Never forget where you came from and what you were”, and this is one of the reasons I feel very strongly, as do many noble Lords across the Committee, about the issue of inequalities. How do we tackle this, what is the best way to do it? Will putting it in the Bill solve all the problems? Actually, it will not, but we can discuss how we can make it more effective, and not just feel, “Great, we’ve got it in the Bill, job done”. It has to be more than that. As the noble Lord, Lord Scriven, said, it cannot just be an institutionalised Gladys; it has to be more than that. So, I am deeply grateful that we gave this issue the time it deserves. It is really important for me personally. We want to tackle health inequalities and ensure that everyone has the same opportunity to enjoy a long and healthy life, whoever they are, wherever they live and whatever their background or social circumstances.

I hope I can assure the noble Baroness, Lady Greengross, with whom I have had a number of conversations about music and dementia. I have volunteered, perhaps rather rashly, to organise a fundraiser with my band and other bands for that. I hope that does not give me an excuse to lay the YouTube link to my band in the Library: I shall try to avoid that temptation.

However, to deliver on the commitment on 1 October, we launched the Office of Health Improvement and Disparities within the Department of Health and Social Care—the noble Lord, Lord Scriven, anticipated that I would say this—and we also set up a cross-government ministerial group to identify and tackle the wider determinants of poor health and health disparities. It is important that this cannot be top-down; we have to go to some of the social enterprises and local communities, but also we must not prejudge, prevent or duplicate the work of the integrated care systems in this. NHS England is already tackling health disparities through the NHS long-term plan. That sets out a clear intention to set measurable goals and to make differential allocations targeted at reducing health inequalities and disparities. This has resulted in funding increases to some of the most deprived parts of the country.

As we know, making sure that these deprived areas get the most funding does not mean it will trickle down to those who really need it; it could well be captured by some of the do-gooders I mentioned earlier. The noble Lord, Lord Howarth, talked about those targeted interventions. NHS England and NHS Improvement is also taking forward the Core20PLUS5 initiative as an approach to addressing health inequalities. This will focus on improving outcomes in the poorest 20% of the population, along with inclusion health groups and five priority clinical focus areas.

Baroness Wheeler Portrait Baroness Wheeler (Lab)
- Hansard - - - Excerpts

My Lords, I congratulate the four noble Lords who have produced this excellent suite of amendments across the Bill to ensure that ICBs procuring or commissioning goods and services on behalf of the NHS are firmly focused on their responsibility for NHS England’s commitment to reaching net zero by 2040. It has been an excellent and informed debate, and one with much enthusiasm to reassure the noble Baroness, Lady Hayman.

We fully support the amendments and have little to add from these Benches following the expert contributions of those proposing the amendments and the other noble Lords who have spoken. I am sorry my noble friend Lady Young, who put her name to the amendments, cannot be here. She was a key member of our team during the recent passage of the Environment Bill, and her expertise and wisdom always guides and reflects our approach. The House is clearly interested in this vital matter, as we saw this week in an important Oral Question on the Prime Minister’s promise for a new, overarching net-zero test for new policies. Assuming the Government fully support the key commitment from NHS England, I hope that, in his response, the Minister will accept the need for the amendments and will not argue that the proposed new clause is unnecessary as NHS England already has a commitment that will percolate down to ICBs.

As we have heard, the power of public sector procurement is a massive issue and there is no bigger part of the public sector than the NHS. The NHS has such an important impact on other environment issues, such as waste, pollution and resource consumption, especially for plastics, paper and water. We should ensure we are on the front foot in using that impact to deliver the net-zero commitment.

The NHS has made a start, but there is much more to do. These amendments would reinforce the importance of action in these areas for the new bodies and processes that the Bill creates. The NHS is a big player and, as noble Lords have stressed, it can play a big role in tackling all of these climate change and environmental challenges. Procurement is a strong lever that the NHS can utilise in key markets, particularly in those areas where it is the sole purchaser. The noble Lord, Lord Stevens, was very eloquent on this issue and I look forward to the Minister’s response in the light of his contribution.

Like other speakers today, my noble friend Lady Young wanted to stress that action so far is only the beginning. In the light of the importance of climate change and other environmental challenges, we strongly support such a duty being in place for all the public and private bodies with significant impacts when future legislation comes through Parliament. We did that when inserting a sustainable development duty into the remit of every possible public body from the late 1990s onwards, but this time it has to be not only enacted but managed, delivered, tracked and reported.

As the Minister, the noble Lord, Lord Callanan, told the House this week, every sector of government needs to do its bit, and we need to hold them to that. These amendments are vital, since every public body will have to take further action this decade if we are to restrain temperature rises to two degrees—far less, 1.5 degrees.

Finally, I too thank Peers for the Planet both for its work and, especially for me, its excellent briefing. As noble Lords have stressed, the NHS has committed to net zero and aims to be the world’s first net-zero national health service. It is responsible for around 5% of the UK’s carbon emissions. That is why the NHS’s role and contribution to net-zero targets should be fully integrated into the Bill. I look forward to the Minister’s response and his detailing of how the NHS is to achieve its ambitions. I hope that he will acknowledge that its commitment must be in the Bill. These amendments present a vital opportunity to enshrine in law a commitment that I think most, if not all, would want to see delivered.

Lord Kamall Portrait The Parliamentary Under Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
- Hansard - -

I thank the noble Lord, Lord Stevens, for the amendments and the noble Baroness, Lady Hayman, for her opening remarks. I also thank the noble Baroness for her suggestion yesterday that it might make my life a lot easier if I just accepted amendments. I understand that advice, having just gone through a two-hour debate on the previous group.

A number of noble Lords referred to how these amendments relate to our previous debate on inequalities. I point out that that is sometimes not quite in the way that we would expect. We might think there is a direct connection, but sometimes the green agenda can be seen to be for those who can afford it—as I explained before, for the white, middle-class, patronising people who tell immigrant working-class communities what to do and push up their costs. Anti-car policies push up costs for those in rural areas, and there are higher fuel costs as we replace gas boilers with potentially more expensive heat pumps. We have to be aware of those issues. In the long term, I am optimistic. I look forward to the day when we have solar power and wind power, with storage capacity, which will reduce costs.

Baroness Northover Portrait Baroness Northover (LD)
- Hansard - - - Excerpts

Will the Minister look at this globally and recognise that the poorest are affected the worst? When he talks about those in poverty, he should think globally.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I accept that point, but I also accept that, sometimes, one can be patronised, and I do not accept being patronised as I was in the earlier debate. One day, there will be cheaper fuel, and we can look forward to it, but we have to make sure that the transition along the way is not seen to push up costs for working people, because we all feel passionately about this green agenda.

Baroness Bennett of Manor Castle Portrait Baroness Bennett of Manor Castle (GP)
- Hansard - - - Excerpts

The Minister was talking about the impact of policies on the poor. Does he agree that many of the products—the fabrics, the chemicals—are manufactured in the poorest areas of the world, producing pollution that has disastrous impacts on some of the poorest people?

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I was going to come to the noble Baroness’s points, and I am grateful to her for raising these issues directly with me previously.

Turning to the amendments, I thank the noble Baronesses, Lady Hayman and Lady Young of Old Scone, and the noble Lords, Lord Stevens and Lord Prior, for bringing this debate before the Committee. There is no doubt that the NHS has a significant carbon footprint. There is no doubt that a poor environment has direct and immediate consequence for our patients, the public and the NHS. There is no doubt that it has an impact on the health of the nation. As the noble Baroness, Lady Hayman, pointed out, the NHS accounts for around 4% to 5% of UK emissions. If we go further, as the noble Baroness, Lady Bennett, said, that is 40% of public service emissions. Noble Lords are right to highlight the critical role that the NHS has to play in achieving net zero.

To support that work, NHS England—thanks in part to work already started by the noble Lord, Lord Stevens, who I know has had conversations with my right honourable friend the Secretary of State for Health and Social Care—is leading the way through a dedicated programme of work, as many noble Lords acknowledged. This includes ambitious targets for achieving net zero for the NHS carbon footprint by 2045 and for its direct emissions by 2040. This is ahead of the target set by Section 1 of the Climate Change Act 2008; we welcome that ambition and will continue to support the NHS in that.

--- Later in debate ---
Lord Mawson Portrait Lord Mawson (CB)
- Hansard - - - Excerpts

I thank the Minister. Can I just give an illustration about the local on this issue? I am certainly not an expert on climate change, but I am a practical person who worries a lot about granularity and the gap between a lot of talk I have heard over many years on all sides of this Chamber—with very large amounts of money cited, et cetera—and the realities in this building.

I am trying to buy an electric car at the moment, as a responsible citizen. When I went to have a look at the multi-storey car park below this building—the local—and wondered where I am going to plug it in when it arrives here, I ended up talking to one of the facilities managers, who was a very nice man. I asked him how many plug-in points there were underneath this building—again, the local. He said, “I don’t know, Lord Mawson, but I will look into this”.

He was diligent and came back to me. We started to have a conversation about it, and he began to suggest that I need to carry a cable in my car with a three-pin plug. I pointed out that my office is across St Margaret Street, in Old Palace Yard, on the third floor, so maybe I should run it across there with a carpet over it and up to the third floor to plug it in there. We had this amusing conversation. I said, “Well, go on then, tell me: how many are there in this building, where all this chatter and talk is taking place?” His answer was that there are two. I suggest that the gap between reality and rhetoric is very large indeed. If we are really going to deal with these issues—as we must—we must now become intensely interested in the NHS and in all the systems of government about practicality and the procurement machinery, which I suggest is not working.

I talked to one of the facilities people yesterday about my office, which has a light switch with a notice over the top of it telling you how to use it. It is completely ludicrous. She told me that that system is going to be different to all the systems here in the Palace of Westminster; none of it is joined up.

I think the Minister is right. The clue is in the local, but all our systems and our civil servants must now become interested in practicality and the local if we are really going to get serious about these matters. It is absolutely crucial to get procurement right, because without that, we will never deliver this.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I thank the noble Lord, Lord Mawson, for that intervention, and I completely agree. There are some incredibly inspirational projects going on in our local communities, tackling and addressing the green agenda, and sometimes, top-down, we may feel good about it in this place, but it really affects working people and those who face higher costs and we have to be very careful.

On the specific question of procurement, the NHS is already publicly committed to purchasing only from suppliers which are aligned with its net-zero ambitions by 2030, and last year, NHS England set out its roadmap giving further details to suppliers to 2030. This is supported by a broad range of further action on NHS net zero and we hope that by pushing this through at NHS England level, but also with ICSs, we can see some of that local innovation as local trusts and local care systems and even health and well-being boards respond to those local challenges—others could learn nationally. To respond to the question of the noble Baroness, Lady Walmsley, NHS England will publish the world’s first net-zero healthcare building standard; this will apply to all projects being taken forward through the Government’s new hospital programme, which will see 48 new hospital facilities built across England by 2030.

There is political consensus on green issues. and we should pay tribute to the noble Baroness, Lady Bennett, and the Green Party for making sure, over the years, that the green agenda has been put at the centre of British politics. We find green policies in all the election manifestos of the mainstream parties: that is in no small part due to the noble Baroness’s party and to the noble Baroness herself. So, even while we may disagree on how to achieve some of these things, there is no doubt that we are not going to reverse on our commitment. Whatever Governments are elected in future, all are committed to a carbon net-zero strategy and a cleaner environment. So, I must gently disagree with her that these amendments are necessary.

I would like to have further conversations with the noble Lord, Lord Stevens, given his experience, on why he feels that, despite all the great work that the NHS has been doing, these amendments are still necessary. I would like to have further conversations with him and others, but at this stage, I ask the noble Baroness to withdraw the amendment. Across the political spectrum, we must make sure that we are pushing the NHS to deliver, not only at the national level but at the ICS level and even lower, at the place level that the noble Lord, Lord Mawson, speaks so eloquently about.

Baroness Bennett of Manor Castle Portrait Baroness Bennett of Manor Castle (GP)
- Hansard - - - Excerpts

Before the noble Lord sits down, will he respond to the question, of which I gave him prior notice, about the document?

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I apologise to the noble Baroness—I am so sorry, but I am trying to juggle 300 devices. That is a slight exaggeration, if I am honest. We recognise the importance of ensuring that all chemicals in the NHS supply chain are appropriate and properly managed as part of the net-zero strategy. I think the noble Lord, Lord Stevens, even touched upon some of the chemicals that were used and some of the issues he looked at during his time at the NHS when it comes to chemicals. The NHS must also comply fully with the Control of Substances Hazardous to Health Regulations, the CoSHH regulations.

More broadly, although Defra is the lead department for harmful chemicals, the UK Health Security Agency feeds in its expertise in relation to restricting and banning chemicals, and we are grateful to it for that work. The UKHSA is also looking at each of those chemicals, which we hope in future can be replaced by less harmful materials and chemicals. I undertake to write to the noble Baroness in more detail than the short answer I have given her at this stage.

--- Later in debate ---
Baroness Walmsley Portrait Baroness Walmsley (LD)
- Hansard - - - Excerpts

My Lords, like the noble Baroness, Lady Thornton, I shall start with those who I think should not be on the board before I turn to those who I think should. To a great extent I support the noble Baroness’s Amendment 29, but with a small caveat that, if she wished to press it, might require a bit of redrafting. I will explain.

Additional provider medical services are very useful in many areas to fill gaps in primary care capacity. They may provide additional services from which other NHS primary care services have opted out, such as out-of-hours services or enhanced services beyond the capacity of local NHS GPs to deliver. In some areas they have taken over primary care services where NHS GP practices have become too small to be viable or all the partners have retired.

Some APMS services are commercial businesses with a responsibility to their shareholders to make a profit, and I do not think these should be on the board. However, some APMS contracts go to NHS entities, and I would not want to exclude those. Of course, we must remember that for many years GP practices have also been small businesses, sort of, operating within the umbrella and ethos of the NHS. They too need to clear their costs or they will close down.

That is all well and good. However, if the Government are serious that they want to exclude private sector interests from ICBs, they must surely agree to include in that ban non-NHS entities that hold APMS contracts. A failure to accept the amendment of the noble Baroness, Lady Thornton, must surely make us a little suspicious about the Government’s claim that their amendment inserted in another place would successfully exclude private interests from the board.

Amendment 29 would extend the range of those involved in commercial enterprises from being members of the board of an ICS beyond those that we have just discussed in relation to the noble Baroness’s Amendment 28. Amendment 29 would specifically exclude NHS GP practices and voluntary or not-for-profit organisations from the ban. There are many types of organisations that would be included in the ban, although they could be heard on the board of the integrated care partnerships. Those include: pharmaceutical companies; providers of medical devices, equipment or premises; people who own care homes; and many other essential services without which our NHS could not survive. However, their importance should not entitle them to influence the constitution, strategy or commissioning principles of the board of the ICS. They are important providers that will be appropriately involved in planning at other levels, but they should not be able to steer fundamental decisions without the suspicion that they might have a commercial interest in such decisions. Indeed, the ban proposed in the amendment would protect such companies from such a suspicion, so perhaps it would be welcomed by them.

Turning to those who should be on the board, I will not repeat what the noble Baroness, Lady Hollins, said in introducing her amendments, because she has done it extremely well, particularly emphasising the impact of integrated services on people with learning difficulties and people with autism and how they could benefit from better integrated services if we got it right. So, I support her amendments.

I turn to Amendment 37, to which I have added my name to those of the noble Baroness, Lady Thornton, and the noble Lord, Lord Patel, for the following reasons. According to the Explanatory Notes, each ICB and its partner local authorities will be required to establish an integrated care partnership, bringing together health, social care and public health. The constitution of the ICB as it stands in the Bill specifies that the board must include only a minimum of three types of people who the Government clearly believe are essential to the effective operation of the board. They are someone from NHS health trusts or foundation trusts, someone from primary care, and someone from one of the local authorities in the area. If it is okay to prescribe these members, would it not also be wise to prescribe a few other key people with appropriate knowledge in order to achieve the ICB’s objectives of bringing together health, social care and public health? This amendment therefore suggests five other nominees—not 15, bearing in mind the Government’s wish to keep the ICB to a manageable size. But given the powers of the board, I would think it essential to have people nominated from mental health, public health, social care, health trade unions, patients and carers to bring their knowledge to strategic decisions.

If the board is to comply with the ambition of parity of esteem for physical and mental health—which we talked about two days ago—it will be important to have someone with the knowledge of how mental health services are working, as my noble friend Lady Tyler emphasised. Public health is a very particular discipline, the importance of which has been amply shown during the pandemic, which also has a vital role to play if we are to improve the health of local people and level up inequalities. Social care provision should never be separate from or subsidiary to health, as it is intrinsic to the functioning of health services in every area, so it is inconceivable that any ICB should ever be without someone from that sector.

The NHS is a people business, which is why those who deliver the services and the patients who are on the receiving end should have a voice at the top. Similarly, those thousands of unpaid carers, without whom vulnerable people would use up more of the NHS’s scarce resources than they currently do, should be represented at the very top of these new organisations. Their contribution to the efficient use of the board’s financial resources is crucial.

If the objective is to encourage more integration and collaboration, how could it be right not to have these additional five or six groups of people helping to make the strategic decisions? If that is not the case, as has been said by other noble Lords, the board could be dominated by the large acute hospitals and primary care, and the integration objective of the Government, which I endorse, would fail. I look forward to the Minister’s reply.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

My Lords, this has been an excellent and wide-ranging debate, and I really am grateful to all noble Lords who tabled amendments today.

With your Lordships’ leave, I turn first to Amendment 18 in the name of the noble Baroness, Lady Thornton. This amendment would mean that the relevant ICB and ICP would need to be consulted before NHS England is able to provide support and assistance to bodies other than NHS bodies. The NHS has, under successive Governments of all political colours—indeed, since its foundation in 1948—commissioned care from various sectors to help it be more responsive to patients’ needs, and particularly to help deliver the commitments set out in the NHS constitution.

The vast majority of NHS care has been—and will rightly continue to be—provided by taxpayer-funded public sector organisations. But experience before and during the pandemic has demonstrated how important it is for NHS England to have the power, as the Trust Development Authority currently does, to provide support and assistance to any providers of services on behalf of the NHS. This will ensure that independent providers can, if necessary, be commissioned to provide important additional capacity where needed.

Baroness Thornton Portrait Baroness Thornton (Lab)
- Hansard - - - Excerpts

I really rather hoped the Minister would not go into whether or not I was suggesting that we should or should not be using private services. This is about who commissions services; this is not about who provides services. In my opening remarks, I said that a variety of providers is exactly what we have and will continue to have.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I thank the noble Baroness for that clarification.

The amendment seeks to exclude individuals whose GP practices hold an alternative provider of medical services, or APMS, contract from being a member of an integrated care board. While APMS contracts may not be appropriate for all GPs, they offer the ICBs, as commissioners, greater flexibility than other general practice contract types. As the noble Baroness, Lady Walmsley, acknowledged, the APMS framework allows commissioners to contract specific primary medical care services to meet local needs. APMS contractors include some private and third sector social enterprises and GP partnerships, which provide outreach health services for homeless people, asylum seekers and others. It is quite clear that none of this diminishes the commitment to ensure that care is provided free at the point of use, paid for by taxpayers.

All contract holders providing NHS core primary medical services are subject to the same requirements, regulations and standards, regardless of the type of contract. The Care Quality Commission, as the independent regulator, ensures that all contracts meet these standards.

Some GP partnerships concurrently hold a general medical services contract for core medical provision, as well as an APMS contract. Some individual GPs provide services for a range of practices. The concern is that this amendment would exclude GPs working for one or multiple practices which operate under APMS contracts from being members of the ICB.

NHS England’s draft guidance states that nominated members of an ICB will be full members of the unitary board, bringing knowledge and a perspective from their sectors, but not acting as delegates of those sectors.

This amendment would prevent some individuals being on integrated care boards, based on what type of NHS GP contract their practice holds. This could limit the ability of primary medical service providers to appoint an ICB member who understands the health requirements of the local population. This could reduce the diversity of GPs who could be appointed, based on their contract type. If we think of the unintended consequences, this may inadvertently exclude representatives with much-needed expertise in serving specific local populations and addressing their health needs.

Earlier, we talked about tackling inequalities. I feel very strongly that there are sometimes unintended consequences, where people think that they know better what is best for their communities. It would be unfortunate to exclude APMS contracts, or anyone who had an APMS contract and who had the expertise needed for those communities that are not receiving an adequate service, or for poor, immigrant communities. This could go against the goal that we all want to see of tackling inequalities.

I now turn to Amendments 29 and 30. I am grateful to the noble Baroness, Lady Merron, and the noble Lord, Lord Davies, for bringing this issue before the Committee. I understand the interest in the role of independent providers in the integrated care boards. I also understand the concern across the Committee to ensure that independent providers, including companies seeking to produce health and care products, should not be appointed to the board of ICBs. We agree. Integrated care boards will be NHS bodies whose board membership consists of a minimum of individuals nominated by NHS providers, GP services and local authorities whose areas coincide with that of the ICB.

Although, as has been acknowledged, service provision by the independent and voluntary sectors has been an important and valuable feature of the system under successive Governments, it has never been the intention for independent providers as corporate entities to sit on integrated care boards, nor for an individual appointed to be there as a representative of an individual provider, in any capacity. People must therefore be assured that the work of ICBs will be driven by health outcomes, not profit. However, we recognise that this is a matter of concern to many noble Lords, as well as to the other place. We have been keen to put this beyond doubt, which is why we brought forward the amendment on this very point at Report stage in the other place. This amendment makes clear that no one may be appointed to an ICB who would undermine the independence of the NHS as a result of their interests in the private healthcare sector, social enterprise or elsewhere, including the public sector.

--- Later in debate ---
Baroness Walmsley Portrait Baroness Walmsley (LD)
- Hansard - - - Excerpts

I apologise for interrupting the Minister, but I want to ask him a question going back to Amendment 28 and the APMS contracts. If we were to bring forward an amendment that made it very clear that we had no objection to NHS entities or not-for-profit organisations with APMS contracts being on the ICB, would he take a more friendly approach? It would just eliminate those that take profit out of the NHS.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I thank the noble Baroness for that suggestion and for trying to narrow the gap that there clearly is. If an amendment were put forward, we would look at it very carefully and consider the unintended consequences from the way it is drafted. We will consider it but, as I am sure the noble Baroness appreciates, I can make no promises at this stage.

I turn to the point made by my noble friend Lord Hunt of Wirral about how provider input in the work of an ICB will be reconciled with assessing both the suitability and performance of providers. As my noble friend correctly noted, each ICB must make arrangements on managing the conflict of interest and potential conflicts of interest, such that they do not and do not appear to affect the integrity of the board’s decision-making processes. Furthermore, each appointee to the ICB is expected to act in the interests of the ICB. They are not delegates of their organisations, but are there to contribute their experience and expertise for the effective running of the ICB—a point made most eloquently by the noble Lord, Lord Mawson, my noble friend Lady Harding and the right reverend Prelate the Bishop of London. It is important that this is about expertise, not the trust or organisation that they are taken from, or their skills and knowledge, as the noble Lord, Lord Mawson, said.

We are also keen to allow ICBs to develop their own governance arrangements, which best take their local circumstances into account. We want to give them the flexibility to learn and develop as their best practice evolves, so that other ICBs could learn from that best practice where there are concerns.

To support ICBs, NHS England is working with them to issue guidance and to develop and make clear our expectations of ICB leaders—expectations that have been reflected in the discussions and fantastic contributions from many noble Lords. For these reasons, I regret that the Government cannot accept these amendments at this stage. However, I hope I have given noble Lords such reassurance that they feel able to withdraw their amendments.

Turning to the membership of integrated care boards, I will begin with Amendments 27, 37, 38, 39, 40 and 41. I am grateful to all noble Lords who have brought forward these amendments today. I understand the interest from all sides in this membership. Schedule 2 sets out the minimum membership of the integrated care board; it will need to include members nominated by NHS trusts and NHS foundation trusts, by persons who provide primary medical services and by local authorities of areas that coincide with or include the whole or any part of the ICB’s area.

I take the point of the noble Lord, Lord Bradley, about mental health. I am sure he recalls the debate on Tuesday, when noble Lords felt very strongly about this. I have offered to meet many noble Lords from across the Committee who indicated that they want to see this parity with mental health, which they do not believe is implicit at the moment, even if we believe that “health” refers to physical and mental health. Indeed, it refers to spiritual health in many ways. But we understand that we have to close that gap and I will make sure that the noble Lord, Lord Bradley, is invited to those meetings.

It is important for us that we are not overprescriptive, which is especially true of any membership requirement. Any extension beyond the proposed statutory minimum will risk undermining local flexibility to design a board, as my noble friends Lord Mawson and Lady Harding and others have said, in the most suitable way for each area’s unique needs, drawing on the best expertise, but not where they are from. It may also make the boards less nimble and less able to make important decisions rapidly if we overprescribe.

It is important to remind the Committee—I apologise if noble Lords do not appreciate the repetition—that we set a floor and not a ceiling. The ICB can appoint board members if it wishes. Local areas can, by agreement, go beyond the legislative minimum requirements. They will want to ensure they appoint individuals with the experience and expertise to address the needs and fulfil the functions. Areas are already doing this. For example, in south-east London the ICB is proposing to include three provider members—acute, community and mental health—and six place members, one for each borough. This approach is exactly how we want ICBs to use the flexibility available to them.

If, in time, some of the concerns expressed today by noble Lords become clear—such as issues being skated over, ignored or elbowed out by others with louder voices—we may need to add further requirements that relate to ICB membership, and there are regulation-making powers in place in Schedule 2 to allow the Secretary of State to do so. Furthermore, NHS England has the power to issue statutory guidance to ICBs. It could, for example, use this to recommend that each ICB should consider appointing a learning disability and autism senior responsible officer, as I know the noble Baroness, Lady Hollins, has asked for and has spoken about most eloquently many times, most recently in a debate a few weeks ago.

Taken together, our approach reflects our view and, I reiterate, the view of the NHS that we should not attempt to overlegislate for the composition of ICBs and instead let them evolve as effective local entities to reflect local need. Let us get the right balance between the top-down and bottom-up approach, and make sure that they are relevant to their local areas. I am afraid that these amendments are seen to take a different approach, by adding more people to the minimum requirements for the ICB, making them larger but not necessarily better. They also add additional complexity by introducing a significant number of members who are responsible for activity outside the NHS. We think these would be better represented on the integrated care partnerships, which have a broader remit. I come back to the point that it is about expertise, not which trust.

I will consider the comments made by noble Lords very carefully if some of the concerns have not been met, and will have future conversations, between this stage and the next, if they feel that we have not addressed their concerns completely. I regret that the Government cannot accept these amendments. I hope that I have given your Lordships some, if not complete, reassurance and that noble Lords will feel able at this stage to withdraw and not press their amendments.

Baroness Thornton Portrait Baroness Thornton (Lab)
- Hansard - - - Excerpts

My Lords, I thank the Minister for his detailed response. I was disappointed with the first remarks he made because he resorted to the mantra that the Government tend to go to when the question of private sector interests in delivering healthcare is raised by this side of the House. That is a shame, because the questions that we have raised are legitimate. In fact, his friends in the Commons accepted the conflicts of interest that could arise from private sector interests being represented on ICBs. We were seeking to make sure that that is watertight and there is no way of it changing. That is a legitimate question to ask.

I thank the noble Lord, Lord Patel, and the noble Baronesses, Lady Walmsley and Lady Meacher, for supporting Amendment 37, which is the key amendment in this group as to who may or may not be members of the board.

The noble Baroness, Lady Hollins, made a powerful case for the interests of people with learning disabilities and autism being represented. We know that where health systems make the health of people with learning disabilities a central priority, the whole health system benefits from it. That has happened in some places—for example, in Manchester—and it demonstrates how we improve the whole system. It is an important point.

My noble friend Lady Bakewell made the point about Centene and Operose, and that is partly why I put forward my amendment on APMS. The Minister may recall that we raised this matter in Questions a few weeks ago, when I asked him to write to me about what system had been used to give that contract to Centene, or Operose, in Camden, the area where I live. Having served on the CCG in Camden, I was aware of the importance of who runs primary care and of who the GPs in our surgeries are. Having right and proper people and organisations running our primary care was one of the criteria that you would use as a commissioner when you were looking at who was running, and who might wish to run, primary care and GP surgeries. I was involved in that process. As I learn about the history and background of this organisation now running primary care and GP surgeries in the UK, I do not think they are right and proper people to be doing that.

If this amendment does not serve the purpose of stopping that happening, I ask the Minister and the Bill team to reflect on what we might need to do to ensure that those from the private sector, social enterprises and charities whom we commission to run parts of our health service are right and proper people to do so. The remarks made in that regard by the noble Lord, Lord Hunt, were very interesting and useful, as they often are.

The noble Baroness, Lady Meacher, made the point about public health. That is the theme running through this Bill: the need for public health to be represented. She was also absolutely correct to bring us back to the idea that clinical leadership is very important. Of course it is. The right reverend Prelate the Bishop of London asked some pertinent questions.

My noble friend Lady Pitkeathley raised the issue of social enterprises, which is close to my heart. I am the honorary secretary of the All-Party Group for Social Enterprise, which I helped to found 20-odd years ago. The APPG has just completed an inquiry, chaired by the noble Earl, Lord Devon, about the impact of Covid on social enterprises, which absolutely illustrates the points made by my noble friend and which I will share with the Minister when it is available.

The noble Baroness, Lady Finlay, made relevant points about Allied Healthcare. I think that the noble Baroness, Lady Walmsley, and I agree that the problem with APMS is that there is a lack of clarity and it is a bit of a loophole, and we need to look at it again. This may not be the Bill to do it in, but it might be.

With those remarks, and hopeful that the issue of who the members of the ICBs will be will run through our discussions for the next few weeks, I beg leave to withdraw the amendment.

Health and Care Bill

Lord Kamall Excerpts
Lord Mackay of Clashfern Portrait Lord Mackay of Clashfern (Con)
- Hansard - - - Excerpts

My Lords, I am sorry to intervene at this stage but I cannot let the opportunity pass to say, in my view, how important it is that children be particularly referred to and their circumstances be properly taken into account. We have very powerful legislation on the care of children, but the same is not true with health, and it is extremely important that that be kept in view. Apart from anything else, special staff and treatments are required for children, and I therefore strongly support this amendment. I am sorry that I was not able to do so at a more appropriate time, but I arrived a little later than I would have liked.

Lord Kamall Portrait The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
- Hansard - -

My Lords, I begin by thanking all the noble Lords who have tabled these amendments for debate, and noble Lords from across the House for their eloquent contributions. As the noble Baroness, Lady Wheeler, rightly said, it is important that, as the fifth-largest economy in the world, we treat all our citizens equally and give them the respect and access to services they deserve. As she also said, the strength of feeling across the House on the importance of this issue is clear, and this was amplified most eloquently by my noble and learned friend Lord Mackay of Clashfern.

With your Lordships’ agreement, I will look at some of these amendments from a different perspective. Each amendment touches on a different aspect of providing health and care for children. Before I turn to matters of detail, let me say that we believe that the Health and Care Bill’s proposals represent a huge opportunity to support and improve service planning and provision and ensure that they better meet the needs of infants, children and young people.

With your Lordships’ permission, I will start by addressing Amendment 20, which was spoken to so eloquently by the noble Baroness, Lady Meacher, the noble Lord, Lord Scriven, and my noble friend Lord Polak. It would clarify and prioritise how the Better Care Fund could be used to integrate services for children. I remind the Committee that the relevant legislation does not prevent the use of the Better Care Fund for the integration of children’s services. The disabled facilities grant within the BCF is already used to fund housing adaptation for individuals aged under 18 with disabilities. Some areas also extend the scope of their BCF-funded initiatives to include integrated services for children and young people.

However, we can go further. The Government believe that integrated care partnerships and integrated care boards represent a huge opportunity for partnership working. The Bill explicitly requires integrated care partnerships to consider whether needs could be met more effectively under Section 75 of the NHS Act 2006, which provides for arrangements to be made between NHS bodies and local authorities. The Government are also working on bespoke guidance on the measures that statutory bodies should take to ensure that they will deliver for babies, children and young people.

Turning to Amendment 51, I particularly welcomed the contribution of the noble Lord, Lord Hunt of Kings Heath, on vulnerable children. The amendment would require ICBs to share and collect information from partners when arranging for the provision of services for pregnant women, women who are breastfeeding and young children. I sympathise with the amendment, and in fact, I would go further: one of my three big priorities in my departmental portfolio, as the Minister for Technology, Innovation and Life Sciences, is to push digitalisation and sharing data. As all noble Lords have rightly said, that is not just for children’s services but right across the sector. We hear stories almost every day of something that could have been prevented, had data been shared more appropriately.

--- Later in debate ---
Baroness Thornton Portrait Baroness Thornton (Lab)
- Hansard - - - Excerpts

My Lords, I will speak to the amendments to Clause 14, which is a very important clause. There is absolutely no doubt about that, and the Minister can be in no doubt that that is exactly how we see it. It was touch and go whether we would have a clause stand part debate on this, and I am not sure that we were right not to do so, because this debate, particularly my noble friend Lord Hunt’s comments, has highlighted some serious problems.

My noble friend Lady Pitkeathley is quite right that the arrangements that we are seeking to put into statute, which have grown up over the last few years to allow areas to collaborate, were the right thing to do. In my area of the world, I have no doubt that it was important that the boroughs collaborated together, particularly in their relationship with and commissioning of services from the very big providers.

The question in Clause 14 is: what is going on with the arrangements that the Government are putting into statute? I am very pleased to follow the noble Baroness, Lady Walmsley, and to speak to Amendments 23 and 44 in my name. Amendment 23 addresses the vexed issue of boundaries for an ICB. In this Bill we are dealing with geography, whereas the 2012 Act dealt with GP lists. The area of an ICB is defined in terms of tier 1 local authorities.

Concerns have been expressed, because the NHS is often a bit clueless and sometimes very defensive about local government, its boundaries and its powers. Maybe the Minister will tell me I am wrong, but I suspect that one of the reasons why elected members have been precluded from the boards is that the NHS does not feel comfortable with the direct democratic accountability at that level. That is a great shame. I think it is wrong; accountability is extremely important.

How can we have an integrated service when social care is provided by local government, which is democratically accountable, and we want to integrate that with the NHS at a local level in an area to provide the best service that we can for that population and those patients? The almost offensive way of constructing a board that does not allow elected representatives is not acceptable.

My quite modest amendment seeks to change that situation for the future. There were exchanges in the Commons about this, and there have been meetings with disgruntled authorities that seem to have ended without agreement. We may need to take a step back and learn some of the lessons, perhaps from Scotland and Wales where more logical boundaries have been applied for their health boards.

We may learn a bit more about plans for integrated commissioning at this level when we get the promised but overdue White Paper on integration. It is possible that it will set up a third set of geographies, and who knows how that will line up? This seems to be the wrong way around. Our amendments at least elevate the need to consult with local authorities over boundaries to start off with. That is perhaps a pious hope, but we can agree that any future changes can be made only if the local authorities agree.

Amendment 159 arises out of lengthy discussions elsewhere. In the twin-striker model for ICS, we have the ICBs and the ICPs. We know almost nothing about ICPs; all that is said is that it is part of the “flexibility” and so should be valued. Referring back to my previous remarks, I just hope that local authorities will be genuinely involved in the ongoing discussions about ICPs, how they are set up and their governance. What we do know is that the ICPs will own the analysis of needs and the strategy that follows from that. What, therefore, is the role of local health and well-being boards?

There are echoes of 2012 here, as, during the consideration of the 2012 Bill, amendments were advanced on the same issue. In the 2012 version, it was the health and well-being boards that did the strategy and the CCGs that did the commissioning, at least of health. Nobody ever properly addressed how social care would be commissioned in any integrated way in a wider strategy. It was proposed in 2012 that the health and well-being boards had to approve the plans of the CCGs, and that was the glue that would hold the whole thing together. We know that that has not worked. It has sometimes worked on paper, but it is not the thing that has driven the work of the CCGs.

The answer so far for 2022 is that everyone will play nicely and it will all be resolved. I do not think that can possibly be the case when there is such a serious imbalance. Our Amendment 159 acknowledges that there just might be a dispute over whether some decision or plan of an ICB was genuinely aligned to the strategy that it was supposed to be following, so a process for resolution is needed.

I am not sure whether Amendment 44 sits easily in this group, but it is a matter on which assurance is needed. When foundation trusts came into being, they were rather bravely given the power to set their own terms and conditions for staff. One of them might have tried it, and it was not a great success. In general, despite whatever powers exist, almost every part of the NHS follows the Agenda for Change, the collective agreement that took 10 years to agree but which has stood the tests of time.

Now, as with CCGs, we have the power of ICBs to set their own terms and conditions. They are probably unlikely to do so, as it takes an enormous amount of work and the risks that it brings are probably not worth the effort. Without doubt, some staff are worried that they just might be the ones picked on for special treatment. The Minister will no doubt say that the ICBs need the flexibility, but surely, given the pandemic and everything else that faces the NHS, it would be much better to give staff certainty and confidence they will be treated properly.

We agree with the sentiments of Amendments 22 and 24, which try to ensure that agreement on ICB constitutions will be done promptly. We agree with the sentiments of Amendment 53, which echoes a previous amendment about the need to drive improvement. In my noble friend’s Amendment 45, he asks a legitimate question, which I think the Minister will need to answer.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

Once again, I thank all noble Lords for bringing this debate before the Committee today. There have been a wide range of views on the establishment of the ICSs and on what is currently going on in the NHS.

I will start with Amendments 22 and 24 from the noble Baroness, Lady Walmsley, which were supported very strongly by the noble Lord, Lord Hunt of King’s Heath, and on the ICBs’ establishment. I am grateful to the noble Baroness, Lady Walmsley, for bringing the amendments, and I understand her concerns about ensuring that ICBs are established in a timely way. We agree. We have had an interesting debate here. A number of people have said that it is really important, given that ICSs have already been established, that you put it on a statutory footing, but we are also being asked how they dare to go ahead and do this, because the legislation is not there yet.

In recognition of the fact that ICSs have been set up in some areas and are being established, we are trying to get the right balance. That is why work is under way to prepare existing organisations, including CCGs, for the transition once the Bill comes into force.

The noble Lord, Lord Hunt of Kings Heath, rightly asked whether NHS England is pre-empting Parliament. He raises an important point but I assure him that the powers necessary for establishing each ICB and publishing any statutory guidance cannot be made until the Bill has been enacted and the relevant provisions commenced. However, to ensure that ICBs are ready to begin work, NHS England is producing a range of draft guidance, including a model constitution, so that system partners can start work on preparations—but this does not have the power of statutory guidance. The guidance and the model constitution are based on the proposed requirements—

Lord Hunt of Kings Heath Portrait Lord Hunt of Kings Heath (Lab)
- Hansard - - - Excerpts

My Lords, I accept that but how can NHS England give guidance to say that no local authority councillor can be on the ICB? That is not for NHS England to say, and how can it do it prior to the Bill going through Parliament? It is for Parliament to decide these matters, not a quango.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I apologise to the noble Lord because I was coming to answer that point, but maybe in too long-winded a way. One issue that was clearly raised, and very strongly felt in the contributions from more than one noble Lord, was about banning councillors from sitting on boards. There is nothing in the Bill that expressly bans this. We recognise the points raised in this debate and will raise them directly with NHS England. It is not statutory guidance.

Lord Hunt of Kings Heath Portrait Lord Hunt of Kings Heath (Lab)
- Hansard - - - Excerpts

I am sorry but this is a very important point. They have made the appointments and are not going to start again, which of course they should, because this is an absolutely hopeless position. No one from NHS England has ever had the guts to come here to explain why they are making this decision, and who will believe it? The chair of the ICB is appointed by NHS England. They know that NHS England does not want local authority councillors on the boards. Who are they going to take notice of? They are going to take notice of NHS England. The Minister has to tell NHS England to stop sending out this ludicrous guidance and telling the NHS that the new arrangements will start from 1 July. It cannot possibly do so if we go through what is contained in Clause 14.

I sympathise with the noble Baroness, Lady Walmsley, but the fact is that we must have a three-month consultation process on the proposals. This is the problem we are in: none of this stands up because Parliament is being treated with absolute contempt by NHS England.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I hear the strength of feeling from the noble Lord. I will take this back to the department and discuss it with my right honourable friend the Secretary of State. I hope noble Lords are reassured by that. I may not get the perfect answer, but I will try. I understand the strength of feeling on this issue; no one can fail to do so. Let us put it this way: it was not subtle but direct. It is really important that, as the Minister here, I take this back and reflect the feeling of the House in my conversations with the Secretary of State, and his subsequent conversations with NHS England. I will take that back and look at the consultation process and the CCGs consulting all the relevant local authorities.

I understand the point made strongly by the noble Lord, Lord Scriven, that we have to be careful about prescribing in a top-down way how to work locally. I have always been a strong believer in localism and making sure that powers go down to a local level rather than being taken away. Let me again assure the noble Lords, Lord Scriven and Lord Hunt, and other noble Lords that I will take this back, because clearly there is concern. I had not appreciated the strength of that concern. At Second Reading the noble Lords, Lord Stevens and Lord Adebowale, said, “We are already doing this. It makes sense to go ahead and put it on a statutory footing”. But I have now heard the other side of the argument, and it suggests that I should go back and have a stronger conversation with, in effect, my boss—my right honourable friend the Secretary of State. I hope that gives some reassurance.

On Amendment 44, in the name of the noble Baroness, Lady Thornton, I assure your Lordships that we intend to provide as much stability of employment as possible while ICBs develop their new roles and functions. I hope that noble Lords are aware that there is already an existing commitment that staff transferring into ICBs will transfer across on their current terms and conditions in line with the NHS Terms and Conditions of Service Handbook. NHS pension rights will also be preserved. As a result, staff transferring into ICBs will not see any change to their existing conditions.

However, the Government are concerned about forcing ICBs to adopt conditions and practices that the ICBs do not believe work best for new staff. We believe that it is important to give ICBs flexibilities relating to staff terms and conditions; they are there for a reason. For example, when it is difficult to recruit and staff are going elsewhere, this would include allowing ICBs the flexibility to diverge from collectively agreed pay scales in order to attract staff from elsewhere or with unusual or valuable skills, or to reflect local circumstances. It will also give ICBs the flexibility to support joint working and bring in staff currently working in local authorities or foundation trusts, for example, supporting integration and the joint working approach that the Bill hopes to encourage.

I also note that ICBs having the independence and flexibility to choose whether to adopt collectively agreed pay conditions and pensions for new staff is not unique, as the noble Baroness, Lady Thornton, acknowledged. NHS foundation trusts, which are already free to exercise their discretion in adopting such conditions, overwhelmingly choose to honour and apply such terms to their staff unless there are good reasons to diverge.

On the proposals for very senior managers, existing procedures are in place to ensure that the most senior staff within the NHS are appointed with fair and equitable salaries. Proposals to pay very senior staff more than £150,000 must be similar to those for other equivalent roles or be subject to ministerial oversight.

The Government are in the process of finalising the procedures that will apply for ICBs. The specifics may differ but the effect and intention will be the same: to afford ICBs agency in setting pay at competitive rates so that we can continue to attract the most senior and experienced leaders, while putting adequate checks and balances in place to ensure appropriate use of taxpayers’ money and keep senior public sector salaries at an appropriate level. The Government believe that this amendment, which also asks for ICPs to approve annual salaries in excess of £161,000, is unnecessary. I am happy to have further conversations.

I now turn to the amendments on how the ICBs will function once established, starting with that in the name of the noble Lord, Lord Davies of Brixton, which relates to the question of treatment outside the ICB area. The new clause in question provides that NHS England must publish rules for determining the people for whom integrated care boards have responsibility. Importantly, this clause ensures that everyone in England is covered by an ICB.

We intend that the rules set by NHS England should replicate the current system for CCGs as closely as possible. This means that the ICB will be responsible for everyone who is provided with NHS primary medical services in the area—for example, anyone registered with a GP. It will also be responsible for those who are usually a resident in England and live in their area if they are not provided with NHS primary medical services in the area of another ICB.

It is important to remember that no one will be denied healthcare on the basis of where they live. We want to ensure that, under the new model, bodies that arrange NHS services—decision-making bodies—are required to protect, promote and facilitate the right of patients to make choices with respect to services or treatment. This means allowing patients to choose to be treated outside their ICB area. Choice is a long-standing right in the NHS and has been working well for some time. The Bill continues to protect and promote it. However, I am afraid that we have concerns about this amendment, as it places a requirement on providers rather than commissioners. It would not be reasonable to expect providers to provide services regardless of whether they were funded by an ICB to do so, and it is important that ICBs should be able to make decisions about with whom they contract and where they prioritise their resources.

On Amendment 53, in the name of the noble Baroness, Lady Walmsley, I hope I can assure the Committee that the Government are committed to ensuring continuous improvement in the quality of services provided to the public. As your Lordships will be aware, there is already a wider range of duties in relation to the continuous improvement of services. Clause 20 imposes on ICBs a duty as to the improvement in quality of services. Furthermore, the ICB must set out how it proposes to discharge that duty at the start of each year in its joint forward plan and explain how it discharged the duty at the end of each year in its annual report. I hope this goes some way to meeting the noble Baroness’s concerns.

Clause 16, which this amendment seeks to alter, recreates for ICBs the commissioning duties and powers currently conferred on CCGs in the NHS Act 2006. It ensures that ICBs have a legal duty to commission healthcare services for their population groups. It also recreates Section 3A of the 2006 Act, which provides the commissioning body with an additional power to commission supplementary healthcare services in addition to the services they are already required to commission. This power enables ICBs to arrange for the provision of discretionary services that may be appropriate to secure improvements in the health of the people for whom it is responsible—or improvements in the prevention, diagnosis and treatment of illness in those persons—so it is important that the clause remains as it is currently drafted.

The Bill will ensure that the existing local commissioning duties conferred by the NHS Act 2006 will transfer over to ICBs. This is set out in proposed new Section 3, which is also to be inserted by Clause 16 on page 13. I hope that the noble Baroness, Lady Walmsley, will be reassured that it rightly uses “must” rather than “may” when referring to the arranging of services. I can therefore assure the Committee that ICBs will continue to commission the services previously delivered by CCGs. That will ensure that service delivery for patients is not impacted.

Amendment 159 in the name of the noble Baroness, Lady Wheeler, touches on the important relationship between ICBs and ICPs. I remember that, when we had an earlier consultation, the Bill team had a diagram about how ICBs and ICPs would work together; It might be helpful if I ask for that to be sent to noble Lords so that all of us can have more informed conversations about the intentions of the amendments and the issues that noble Lords want to raise. I will make sure that that is done.

This amendment would add a requirement for the Secretary of State to make regulations to establish a dispute resolution procedure if an ICB fails to have regard to an assessment of needs, an integrated care strategy or a joint local health and well-being strategy in respect of the ICB’s area. The Bill was introduced to ensure that existing collaboration and partnership, working across the NHS, local authorities and other partners, is built on and strengthened; I recognise the concerns raised by the noble Lord, Lord Scriven.

We intend for these assessments and strategies to be a central part of the decision-making process of ICBs and local authorities. That is why we are extending an existing duty on ICBs and local authorities to have regard to relevant local assessments and strategies. The ICB and local authorities will be directly involved in the production of these strategies and assessments through their involvement with both the ICP and health and well-being boards at place—that is, at a more geographical level. As a result, they have a clear interest in the smooth working of the ICP.

More widely, there are several mechanisms to ensure that ICBs and local authorities will have regard and not intentionally disregard the assessments and strategies being developed at place in their areas. First, health and well-being boards have the right to be consulted.

Lord Lansley Portrait Lord Lansley (Con)
- Hansard - - - Excerpts

I just had a flashback moment. I remember being asked, or volunteering, a decade ago to produce a chart of the various organisations under the 2012 Act. I think that the King’s Fund did a rather good job of doing it back then; perhaps it might do it again, although it will find that it is more complicated this time.

The noble Baroness, Lady Thornton, asked a perfectly reasonable question that might simplify the process. If health and well-being boards do the same job as integrated care partnerships, in large measure, why cannot integrated care partnerships and health and well-being boards be the same organisation?

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I remember hearing in an earlier discussion on the Bill that nothing prevents that where they coincide. My noble friend and I have had conversations about health and well-being boards and where they sit. Given that, and given my noble friend’s experience of this issue, perhaps we could have a further conversation on this matter before the next stage to clarify some of the issues that he rightly raised in previous conversations.

At this moment, we believe there are mechanisms to ensure that ICBs and local authorities have regard to and do not disregard the assessments of the health and well-being boards. As my noble friend points out, that is for further conversations.

As noble Lords know, NHS England must also consult each health and well-being board on how the ICB has implemented its joint health and well-being strategies, so there is another level of reassurance there. The ICB must also include in its annual report a review of the steps it has taken to implement any relevant joint local health and well-being strategy and must consult the health and well-being board when undertaking that review. NHS England has formal powers of intervention if an ICB is not complying with its duty in any regard. That is sufficient to ensure that ICBs will have regard to both ICP and health and well-being board plans, but I understand the concerns raised.

Health and Care Bill Debate

Full Debate: Read Full Debate
Department: Leader of the House

Health and Care Bill

Lord Kamall Excerpts
Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

My Lords, I am grateful to the noble Baroness, Lady Finlay, for bringing these amendments before the Committee today. I am also grateful to all noble Lords, who have offered me two bits of advice thus far: first, “You can make your life a lot easier if you just accept our amendments”; and secondly, “Don’t worry about the other amendments, just accept mine; that’s who needs to be on the board”. I hope all noble Lords understand the sort of advice I have been given, as I consider my response.

The noble Baroness, Lady Finlay, raises an important point and there is clearly understanding and support for ensuring that there is primary care representation on ICBs. This is a topic that we have both discussed and are likely to return to. I am in danger of sounding like a scratched record, for those who remember vinyl—I am told it is making a comeback—but I hope not to, or to labour the point too much, by repeating the arguments we have already discussed at length.

We fully agree that the membership of ICBs should include individuals from a number of places and this is why we have set a requirement that ICBs should have at least one member nominated by the primary medical care providers on the board. The noble Baroness, Lady Walmsley, made a couple of very useful points here. The board should have available to it the talent and skill sets that it needs, but there should also be a balance that does not overwhelm any one set of skills. That is one of our concerns as we look at not overprescribing the make-up of the ICBs.

The noble Baroness, Lady Thornton, is absolutely correct that, given the debates we have had up to now, there will have to be more discussions on the ICBs between this stage and the next. I accept that; we will have meetings and roundtables to discuss this, and I know there might well be more amendments on the membership of the ICBs. Before those discussions, I would just reiterate at this stage that this is a floor, not a ceiling; it is a minimum requirement. ICBs are able to appoint individuals with those skills as they see fit, and we would hope that they would, to make sure that they meet the health requirements and tackle the health challenges of the local areas they cover. As the noble Lord, Lord Mawson, and my noble friend Lady Harding of Winscombe said last time we discussed these issues, it is important not to be overprescriptive and close off the opportunities to tailor boards to each local area. The noble Lord spoke very eloquently about his experience of building a board in a particular place, which might have been quite different, had it been in another place.

Turning to Amendment 41B, the noble Baroness, Lady Finlay, raised an important point about ensuring there is sufficient representation of clinicians with experience of public health and secondary care. We fully agree that ensuring that sufficient clinical expertise is available to the ICB is critical. We do so through a duty imposed on ICBs to seek advice from persons with a range of professional expertise in, for example, prevention, which noble Lords have said we should focus on, diagnosis or treatment in illness, and the protection or improvement of public health. This applies at every level of the ICB and impacts how it discharges its functions. As a result, I can assure the Committee that the clinical voice will be heard loud and clear at every level—not just at the ICB or ICP level, but in the health and well-being boards.

For the reasons I have discussed, I am afraid that I do not agree at this stage that the best way to ensure this would be by requiring two additional members of the ICB. This would take away the flexibility provided to ICBs and potentially inhibit their ability to respond to their own area’s local needs. Finally, I would not want to risk ICBs believing that their duty to seek clinical advice would be discharged solely by appointing two clinicians to their board—saying, “Okay, we have those two clinicians, that box is ticked”. The noble Lord, Lord Scriven, made a point about a staff member called Gladys, whose role ticked a box. We have to be very careful that we do not repeat that mistake with two tick boxes. Instead, ICBs should seek appropriate advice from subject matter experts. This may mean seeking advice from different clinicians for different issues and developing different models of seeking advice for different types of decision.

As I said earlier, we will have discussions about the whole ICB composition between this stage and the next. In that spirit, I hope the noble Baroness, Lady Finlay, will be a little reassured and feel able to withdraw her amendment.

Health and Care Bill

Lord Kamall Excerpts
Baroness Merron Portrait Baroness Merron (Lab)
- Hansard - - - Excerpts

My Lords, I think it is fair to say that the debate today across your Lordships’ House has shown that it is impossible to understand how specialist palliative care can be regarded in any logical, practical or humane sense as something so different. I am sure that the Minister will do his very best to address that in his consideration of these important amendments.

I am grateful to noble Lords for making this debate possible by bringing forward these amendments and making sensitive, informed and often personal contributions to underline the need to ensure that specialist palliative care features in the Bill. I am particularly grateful to the noble Baroness, Lady Finlay, for setting out the fact that if we are to say that the NHS is cradle-to-grave, that must absolutely shape how we approach such services. The noble Baroness and others, including the right reverend Prelate, talked about inequality and the fact that, when we speak of specialist palliative care, inequalities are not just in the course of someone’s life but actually to the very moment they leave this world. That really had an impact on me, because that surely is an unfairness too far for us to just stand by.

Taking action could not be more pressing a need. We know that the UK’s population is ageing rapidly. The Office for National Statistics predicts that, in 20 years’ time, there will be twice as many people over the age of 85, while Marie Curie’s analysis for Cardiff University has concluded that the number of people needing palliative care will rise by 42% by 2040. This is a challenge to our society which will not go away. As the noble Lord, Lord Patel, said, we should be able to live our lives in anticipation of a good death. The right reverend Prelate spoke of the difference of witnessing a good death, as opposed to a death that is less than what it should be.

It is important to say that, even before the pandemic, experts at the Royal College of Physicians, the Care Quality Commission, the health service ombudsman and Compassion in Dying were all sounding the alarm on how those approaching the end of their life, and their loved ones, did not, in so many circumstances, feel supported to make the decisions that faced them and that it was impossible to turn away from. They did not know what choices were available, and, sadly, were not given an honest prognosis.

The amendments in this group offer dignity to the greatly increasing numbers who will need this care, and would bring in moral and well-evidenced measures essential to providing the tailored care that is needed in the final stages of one’s life. This includes sharing information about a person’s care across the different professionals and organisations involved in that care, and providing patients and their loved ones with specialist advice, 24 hours a day, every day of the week—which expert practitioners, including those at Cicely Saunders International, have been crying out for.

My noble friends Lord Hunt and Lord Howarth, the noble Baroness, Lady Finlay, the noble Lord, Lord Patel, and others underlined the work, role and contribution of the hospice movement, and also spoke about their incredulity at the reliance on charitable funding. Who in this Committee can be surprised at that feeling? I hope the Minister will be able to speak to that absolutely crucial point because, even before the pandemic, many hospices were suffering from poor decisions from clinical commissioning groups, poor practice, and a lack of support and recognition of the vital role that they play. That impacts on the individuals who so sorely need their services.

Marie Curie reported that 76% of carers who lost a loved one during the pandemic felt that they did not get the appropriate care that they needed. This is an opportunity to fix the problem. Every day, pandemic or none, the quality and personalisation of specialist palliative care will dictate how dignified and comfortable —or not—the end of a life will be, and how much of a burden will be borne by the carers and loved ones: whether, as the noble Baroness, Lady Hollins, reminded us, those left behind are adults or children. These amendments seek to get it right, and the feeling of this Committee could not be clearer. I look forward to the Minister’s response.

Lord Kamall Portrait The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
- Hansard - -

My Lords, as we reach the closing minutes of today’s debate and reflect on the wonderful contributions from across the Committee, perhaps it is fitting that we also talk about the final chapter of life, as the right reverend Prelate the Bishop of Carlisle said.

I thank all noble Lords who spoke very movingly today, particularly the noble Baronesses, Lady Meacher, Lady Hollins and Lady Walmsley, the noble Lord, Lord Patel, and my noble friends Lady Hodgson and Lady Fraser, who spoke about their own experiences. I also thank the noble Baroness, Lady Merron, for pointing out the 42% figure, which is very important to recognise. I thank the noble Baroness, Lady Finlay, for the engagement we had prior to this debate and for her helpful engagement with our officials and the Bill team. I hope that will continue.

What is interesting about this is that when I was younger, we as a society found it very difficult to talk about death. I was once told by my parents that the British find it very difficult to talk about death, except in faith groups. It is interesting that, over time, as we have become an ageing society, we are talking, as a matter of fact, about death. We talk about our wills, financial planning, and planning for care at the end of our life. It is appropriate that we recognise this. The fact is that, nowadays, when we look at the hospice movement, we do not think of it as a quaint little service or a charity; we think that it provides an essential service to help someone at the end of their life, and we recognise the difference between palliative care and end-of-life care.

I hope that I can reassure the Committee that the Government are committed to ensuring that people of all ages have the opportunity to benefit from high-quality, personalised palliative and end-of-life care, if and when they need it. I also pay tribute to the noble Lords, Lord Howarth and Lord Scriven, for their contributions. The noble Lord, Lord Howarth, talked about the role that the arts play in helping those at the end of their life, which he has talked about in a number of discussions we have had on this issue. Like the noble Lord, Lord Scriven, he made the point that while you want to see the state do more, you do not want to push or squeeze out the hospice movement, as we need the right balance.

Health and Care Bill

Lord Kamall Excerpts
Moved by
Lord Kamall Portrait Lord Kamall
- Hansard - -

That the House do now resolve itself into Committee.

Baroness Thornton Portrait Baroness Thornton (Lab)
- Hansard - - - Excerpts

My Lords, before we formally move into Committee on the Health and Care Bill, I will raise a matter of general importance about the parliamentary process upon which we are embarked and seek guidance from the Government about a serious matter which is of immediate concern in the parliamentary process we are currently undertaking. I have no wish to delay proceedings so I will get to the point.

In August, the Government and NHS England issued a Readiness to Operate Statement guidance and checklist to all the relevant parts of the NHS concerning planning for the forthcoming legislation. On 19 January this was updated concerning the ICB establishment timeline, regarding the implementation date for the legislation moving from April to July. The words “subject to parliamentary process” may have been included in the guidance but the actions which flow from the NHS England guidance are contrary to those words. For example, it seems that the latest advice from the Government and NHS England confirms deadlines for appointments of leaders, chairs and boards, many of whom have been appointed, possibly involving the spending of public funds, long before the Bill has completed its passage through Parliament. Indeed, there are many other matters which are still subject to parliamentary process. This is pre-emption of parliamentary process.

The issues in the guidance are at the forefront of the Committee’s deliberations and it is possible that much may have changed before the Bill receives Royal Assent. Our scrutiny in your Lordships’ House is important, not least because both the Constitution Committee and the DPRRC have been highly critical of the Bill and the department. They have stressed the importance of the Bill receiving sufficient scrutiny, since it did not have pre-legislative scrutiny and is significant “disguised legislation”, including more than 60 delegated powers and directions which have no parliamentary process at all.

Noble Lords will be familiar with the rules governing preparation for the enactment of legislation. After Second Reading of a Bill, some work may be undertaken, but guidance from Her Majesty’s Treasury in May 2021 is very clear what actions can and cannot be taken. Box A2, point 4C, refers to:

“Expenditure which may not normally be incurred before royal assent.”


First, there is,

“significant work associated with preparing for or implementing the new task enabled by a Bill, eg renting offices, hiring expert consultants or designing or purchasing significant IT equipment”.

Secondly, there is,

“recruitment of chief executives and board members of a new public sector organisation”.

Thirdly, there is,

“recruitment of staff for a new public sector organisation”.

We understand that NHS England was advised by others not to issue this guidance. Will the Government confirm that: first, the legitimate role of this House in the scrutiny of legislation should be made clear to NHS England; secondly, the current guidance will be withdrawn and it will be made clear to NHS England that further action must await the completion of the Bill and Royal Assent; thirdly, it will be made clear that aspects of the changes within scope of the Bill can and may well be amended; fourthly, that adequate time will be allowed for proper scrutiny of the Bill? I shall be referring the guidance to the two said committees. If the Minister is unable to provide a response today, please can he confirm that he will respond in writing by the end of the week; otherwise, we will need to raise this again in your Lordships’ House?

Lord Kamall Portrait The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
- Hansard - -

I start by thanking the noble Baroness for giving me advance notice of her intervention today. It clearly reflects the mood and concerns of the House that we heard last week. We recognise the strength of the House’s feeling on this matter. I have spoken to my department, and it told me that it is meeting NHS England this week to discuss this matter, and I will update the House accordingly. On the request that the noble Baroness made, I commit to write to her.

Motion agreed.
--- Later in debate ---
None Portrait Noble Lords
- Hansard -

Oh!

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

The noble Lord has recovered.

Baroness Harding of Winscombe Portrait Baroness Harding of Winscombe (Con)
- Hansard - - - Excerpts

I am sorry—the noble Lord, Lord Patel, is here. I meant to say the noble Lord, Lord Bethell. I apologise for my senior moment.

I will begin again. I rise to speak on behalf of my noble friends Lady Blackwood and Lord Bethell, neither of whom is in their place. I should, out of an abundance of caution—particularly given how well I have spoken so far—declare the interests of both my noble friend Lady Blackwood and me, as the present and past chairs of Genomics England.

In speaking to Amendments 79 and 196, we wish to support the noble Lords, Lord Sharkey, Lord Kakkar and Lord Patel, in calling for trusts and integrated care boards to have a duty to conduct research and to report on the steps they have taken to deliver it. We know that there are excellent research-active NHS organisations in the UK, ranging from our acute tertiary university hospitals, such as Oxford, to our district general hospitals, such as Portsmouth.

There are many initiatives to promote research, such as Saving and Improving Lives: The Future of UK Clinical Research Delivery, which sets out a bold and exciting vision. In particular, my noble friends and I await with interest the Find, Recruit and Follow-up service, which plans to use digital tools to identify patients who may be suitable subjects for research. When speaking to patients, one of the refrains that we all hear most often is that they find it hard to find suitable clinical trials, and we welcome any initiative that can make it easier for patients to take part in clinical research.

As well as supporting patients in finding trials, we need to make it as easy as possible for them to participate. In some cases, the pandemic has accelerated a move towards remote monitoring tools—wearables and other devices that allow individuals to participate in trials while reducing the number of visits they have to make to hospitals. We welcome the NIHR remote trial delivery toolkit, which makes recommendations on how some of these positive practices can be continued and so broaden participation and promote patient retention in a beneficial way.

My noble friend Lady Blackwood, as a rare disease patient herself, knows that clinical research is often the only way for patients to get access to innovative treatment. Yet we are saddened to see, in the annual NIHR publication on initiating and delivering clinical research, that some trusts are still not delivering trials every quarter. We continue to see a large disparity in the number of trials being offered in each trust, which leads to a postcode lottery. Those individuals fortunate enough to be under the care of a research-active hospital have an increased chance of being recruited on to a trial, and therefore have better outcomes than patients under the care of less research-active hospitals.

Patients admitted to more research-active hospitals also have more confidence in staff and are better informed about their condition and medication. And as the noble Lord, Lord Davies of Brixton, has said, there is very clear evidence that research-active trusts deliver better outcomes—in part, I am sure, because of their ability to retain and energise staff, as the noble Lord, Lord Kakkar, has mentioned.

The last couple of years, however, have been challenging for the health research community. In 2020, the Association of Medical Research Charities predicted a £320 million shortfall in research spending, forcing many medical research charities to make tough choices about which projects to prioritise. Data also suggests that the UK has been slower to return to pre-pandemic levels of commercial clinical research compared with other European countries.

The Life Sciences Vision sets out the Government’s objective to be a science superpower, but this requires research to be embedded in every part of the NHS, including primary, community and mental health services. That will happen only if NHS organisations, including the new integrated care boards, have a duty to conduct research, as these amendments propose.

In addition, we all know that what gets measured gets done, which is why these amendments place a duty on trusts and ICBs to report the steps that they are taking to deliver clinical research in their annual reports or forward plans. This not only enables progress to be tracked but helps patients understand what research is being done in their area and will encourage NHS organisations to invest in research that meets the needs of their local communities and—

--- Later in debate ---
Baroness Merron Portrait Baroness Merron (Lab)
- Hansard - - - Excerpts

My Lords, I am grateful to noble Lords for putting forward these amendments, all of which seek to strengthen the Bill and build on what the noble Baroness, Lady McIntosh, opened with: the need for clear lines of responsibility and for a joined-up strategy—in other words, for us to get to the point that we are looking for.

My noble friend Lord Hunt spoke of the embodiment, perhaps, of that through a chief innovation officer, who could be a reminder—not on their own—of the need to build in research and innovation as core throughout commissioning. I am sure that the Minister has heard that this debate is a cry for us to embed in the Bill and in our NHS not just a requirement for but a delivery of research and innovation to the appropriate standard to serve the country. It will not just happen on its own.

We have seen significant variation of opportunity for patients to engage in research and disparities in participation reported on geographic and socioeconomic lines, by ethnic origin and across different disease areas. This is due to the fact that the NHS has been unable to prioritise resourcing and delivery of research, which has been a particular feature over the past decade.

In the Bill, we have a major opportunity to embed a research-active culture—words used by the noble Baroness, Lady Harding—within the NHS which could build on the response to Covid-19, which the noble Lord, Lord Patel, emphasised. That response saw more NHS sites, staff and patients engage in research than ever before. Let us not waste this opportunity.

The Bill offers little different to the Health and Social Care Act 2012, which also did not and does not mandate clinical research activity, stating just a duty for clinical commissioning groups “to promote” research. Your Lordships will notice the similarity in wording in the current Bill. The noble Lord, Lord Sharkey, is quite right, as are other noble Lords, to speak of the weakness of just using the words “to promote”. This set of amendments is about how we make it actually happen. The amendments are about mandating integrated care boards to conduct research and to monitor and assess innovation, because without that, it will just not happen.

Legislation is indeed a critical element, but it is important to stress that it must be accompanied by the necessary infrastructure: for example, through staffing levels—to which we will return in our next debate—research capability, digital resources and tools and access to services, as well as efficient trial approval processes, the ability reliably to recruit patients, the offering of guidance and, of course, dedicated staff time for research. All of those will make the legislation actually mean something.

As well as a strengthened legislative mandate which moves beyond the current duty simply to promote research, it would support patients, clinicians and NHS organisations across the country to have equal access to the benefits brought about by research participation. This will be better for patients, give greater staff satisfaction and deliver economic benefits not just for the NHS but for the broader economy. The noble Lord, Lord Kakkar, talked about the life sciences being a major player as a contributor to our economic well-being and prosperity in this country—something also emphasised by my noble friend Lord Davies.

Such a mandate would also ensure support for levelling up and make it possible to address health inequalities. This in turn would support the ambition set out in the Government’s clinical research vision: to make access and participation in research as easy as possible for everyone across the UK, including those in rural, diverse and underserved populations. I hope the Minister will take the opportunity to reflect on the points made in this debate, because this group of amendments provides an opportunity to strengthen the Bill to actually deliver.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

Like many of the debates on this Bill in Committee, this has been a fascinating one. It has been really interesting to hear from experts who themselves have engaged in clinical research. I start by thanking my noble friends Lady McIntosh of Pickering and Lady Blackwood and the noble Lords, Lord Sharkey and Lord Kakkar, for bringing this debate before the Committee today. I also thank the noble Lord, Lord Howarth, for his points about the arts and social prescribing.

Before I turn to the amendments, perhaps I could make two personal reflections. One is from my early academic career as a postdoctoral research fellow. I saw the benefit of taking the results of my research directly into my teaching. It made the courses more dynamic—it was not just a repeat of last year’s slides for this year’s students—and it showed what progress we were making in that field of research.

Health and Care Bill

Lord Kamall Excerpts
Baroness Merron Portrait Baroness Merron (Lab)
- Hansard - - - Excerpts

My Lords, I start by acknowledging—as I am sure we all do in your Lordships’ House—the value, commitment and contribution of the workforce who are the backbone of our health and social care services. We owe them our gratitude. The noble Baroness, Lady Finlay, and my noble friends Lady Whitaker and Lord Bradley are all absolutely right to acknowledge the breadth and depth of the workforce: that it is a team, and that each part of that team is absolutely connected with the other.

I very much agree with the noble Lord, Lord Kakkar, who said that this debate is absolutely central to all that we are here to discuss and to all that patients need from our health and social care services. I am extremely grateful to noble Lords who have tabled and supported amendments and spoken in this debate. All of them have made a compelling case for a workforce plan that will, if these amendments are taken on board by the Minister, feature a laser-like focus on valuing the entire staff team, along with providing planning, financial resources, responsibility, reviewing and reporting—all essential features of any effective strategy. This begs the question: if we see these pillars in a strategy in every other part of our economy and of the way that our whole society functions, why can we not have this for the NHS and social care?

I am glad to have tabled an amendment that calls for a duty on the Secretary of State to ensure that there are safe staffing levels—this was very clearly emphasised by the noble Baroness, Lady Walmsley, in her opening to this debate. This is extremely important because it places a duty where it ought to be and allows examination and transparency.

Of course, we all know that the situation we are discussing today is not new: the noble Lord, Lord Stevens, spoke to your Lordships’ House about a litany of unfulfilled promises and missed opportunities in workforce planning. The noble Baroness, Lady Harding, spoke of her efforts to resolve this and explained the need, which we see in these amendments, to introduce improvements to the Bill to resolve the matter of workforce supply against the demand that is there. All of that requires a lead-in time, and it has to be underpinned by the requisite funds—there is no shortcut to this. In England, we now have a whole website that is full of guidance, and NHS boards are required to take this into account, and yet there is no national workforce plan or credible plan for funding. Until there is, the ICBs will not be able to plan either. The noble Lord, Lord Warner, rightly pointed out that this is not an either/or situation: we need a national workforce plan, and it has to have the funds to deliver it.

I will draw the Minister’s attention to particular aspects of the amendments: explicit recognition of the need to consult with the workforce through trade unions; that planning must cover health and social care; that timescales for reporting should be testing but not too onerous; and that the financial projections in any workforce plan should be subjected to some level of independent expert verification, through the Office for Budget Responsibility, for example.

Behind all of these discussions, we started in a place highlighted by the noble Baronesses, Lady Masham, Lady Walmsley, Lady Watkins and Lady Bennett, and other noble Lords, who spoke of the crisis of the levels of vacancies that we now see and the impossibility of dealing with this without preparation and resource. Any national plan for the workforce needs to be built from the bottom up and not imposed from the top. I hope that the Minister will consider this when he looks at ways to improve the Bill.

I will raise a couple of related points. The scale of the workforce challenge is well established, but it goes far deeper than just numbers and structures. It goes to issues around workforce terms and conditions and career development, particularly in social care, which the noble Baroness, Lady Hollins, brought our attention to. It also has to deal with cultural issues; there is a clear indication that all is not entirely well in the NHS when it comes to diversity, whistleblowing and aspects of how staff are or are not nurtured and supported.

I have one final specific issue to raise, which we have heard about in the debate today and that I would like to extend: international recruitment. I ask that the Government do more to prevent international recruitment, particularly of nurses and midwives, from countries where it is unethical to recruit, and that this be a part of any future strategy. The existing code of practice on international recruitment is not legally enforceable, so when Unison or others report breaches of the code by recruitment agencies, there is no provision for sanctions to be brought against rogue operators. I ask the Minister to confirm that the code of conduct will be promoted and will be enforced.

The situation in which we find ourselves is fixable. I hope the Minister, in his response tonight, will show your Lordships’ House that he understands the situation, that he understands what needs to be done and that he will do it.

Lord Kamall Portrait The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
- Hansard - -

Well, this has been another fascinating debate, and I welcome the contributions from all noble Lords speaking from many years of experience, including former chief executives of the National Health Service and former Health Ministers, medical experts and practitioners. I am grateful to the many noble Lords who have laid amendments in this group; there clearly is a strength of feeling, not only in this Chamber but in the other place. To cut a long story short, this will clearly require more discussion.

However, I am duty bound to give the Government’s perspective on this. We have committed to publishing a plan for elective recovery and to introduce further reforms to improve recruitment and support our social care workforce, as set out in the White Paper, People at the Heart of Care: Adult Social Care Reform. I take the point of the noble Lord, Lord Stevens, that he is aware of many expectations that have passed, and I hope that this time we surprise him. We are also developing a comprehensive national plan for supporting and enabling integration between health, social care and other services that support people’s health and well-being.

The monthly workforce statistics for October 2021 show there are record numbers of staff working in the NHS, with over 1.2 million full-time equivalent staff, which is about 1.3 million in headcount. But I am also aware of the point of noble Lord, Lord Warner, that it should not just be about the number of people working—it is about much more than numbers and quantity; it is about quality and opportunities. We are also committed to delivering 50,000 more nurses and putting the NHS on a trajectory towards a sustainable long-term future. We want to meet our manifesto commitment to improve retention in nursing and support return to practice, and to invest in and diversify our training pipeline, but also, as many Lords have said, to ethically recruit internationally.

On that, I want to make two points. The first is this. When I had a similar conversation with the Kenyan Health Minister and expressed the concern we had about taking nurses who could work in that country, the Minister was quite clear that they actually train more nurses than they have capacity for in their country—they see this as a way to earn revenue. There have been many studies on how remittances are a much more powerful way of helping countries, rather than government-to-government aid. With that in mind, we recruit ethically, and we have conversations.

The second point is also from my own experience. I was on a delegation to Uganda a few years ago and I remember speaking to a local about the issue of the brain drain and our concerns. We were talking about immigration, and he said, “You do realise, though, it is all very well for you to patronise me and say that I should stay in this country, but sometimes the opportunities are not here for me in this country. You talk about a brain drain; I see my brain in a drain”. Sometimes we have to look at the issues of individuals who are concerned that they do not have opportunities in their countries, even if the numbers dictate otherwise. Having said all that, we are committed to the WHO ethical guidelines, but I also think that we should be aware. Look at the way that, post war, the people of the Commonwealth came and helped to save our public services. I hope we are not going to use this as an excuse to keep people out, though I understand the concern that we have to make sure that we recruit ethically internationally.

--- Later in debate ---
Lord Warner Portrait Lord Warner (CB)
- Hansard - - - Excerpts

I am sorry to interrupt the Minister. I have been listening extremely carefully to his response to these amendments and have to say, as gently as I can, that I did not hear many concessions to the points made by noble Lords across the Committee. Unless something really exciting is going to come in the last couple of pages of his brief—I have been watching him turn them over—I suggest that he needs to go back to those above his pay grade and bring home to them the level of distrust about whether the Government are serious about putting proper amendments on workforce issues and planning into this Bill.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

You can tell the noble Lord used to have my job, because he clearly anticipated the exciting bit—perhaps not exciting, but more practical—I was coming to. It is quite clear there is a strength of feeling on this issue—

Lord Lea of Crondall Portrait Lord Lea of Crondall (Non-Afl)
- Hansard - - - Excerpts

As a slight modification of the question that was put, one way that Ministers conclude such debates is by saying that they will write to noble Lords on specific questions, to make sure they have been dealt with.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

We recognise the strength of feeling in this House and in the other place. This will clearly require more work and more discussions. In that spirit, I ask the noble Baroness to withdraw her amendment.

Baroness Walmsley Portrait Baroness Walmsley (LD)
- Hansard - - - Excerpts

I thank the Minister for his comprehensive response to this debate, which the noble Baroness, Lady Harding, suggested was probably the most important that we have had and will have in Committee on the Bill. Staff are absolutely central to the delivery of health services.

Unfortunately, in this debate we have heard about a great deal of failure. We have failed the staff because we have not provided them with enough colleagues for them to be able to do their work without feeling stressed, being worried about risk to patients, feeling burnout or wanting to reduce their hours or retire early. We have failed to provide enough GPs; we were promised 5,000 or 6,000 extra, but, as the noble Lord, Lord Patel, said, we have fewer than we had in 2015. We rely on 30% of doctors from abroad—an enormous number. Although I absolutely accept what the noble Lord says about the appropriateness of temporary training placements, opportunities and remittances going back to the countries from doctors and nurses coming here, it sounds a little excessive to me. Perhaps we need to do better in planning our own workforce.

--- Later in debate ---
Baroness Thornton Portrait Baroness Thornton (Lab)
- Hansard - - - Excerpts

My Lords, this group is in two parts. The first part consists of the amendments tabled by my noble friend Lord Hunt. I need to declare an interest as a patron and the founding chair of Social Enterprise UK, and also as an associate of E3M, for public sector social enterprise leaders, particularly in the healthcare sector, so I have been living with this. Indeed, I must declare an interest as the Minister who helped take through the right to request in the NHS for our staff. I am very committed to these amendments, and to the need for social enterprises to continue to innovate and deliver in our health and social care system, which they do at the moment. There is a report due out very soon from the group chaired by the noble Earl, Lord Devon, on Covid and social enterprise; the way that social enterprises have delivered during Covid is stunning.

I turn to the amendments in the second part of this group, many of which have my name on them. I think that the noble Lord, Lord Lansley, and I find ourselves in broadly the same place: it is a mess. Our first thought was, “Why is this clause here?”, because it does both the things that my former noble friend Lord Warner—I still regard him as a friend—said. This clause does not tell us what is going to happen but it makes us extremely suspicious about what might happen. My amendments—and also, I think, the amendments of the noble Lord, Lord Sharkey—are about that suspicion. It is quite right that the regulatory committee also said that we needed to pay attention to this, because it gives the Secretary of State very wide powers and it does not tell us what the Secretary of State will do with them.

I have quite a long speaking note, but I do not intend to go into the detail now. I simply say to the Minister that if, by the next stage of the Bill, we have not resolved the issues behind this clause, the Government may find themselves struggling to get it, as it stands, through your Lordships’ House.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

My Lords, again, I have heard the excellent contributions that have been made, really holding the Government to account on a number of these amendments.

I begin with Amendment 93, tabled by the noble Lord, Lord Hunt. I assure him that social value is a very important matter for the Government. I know that this importance is echoed across the NHS, as the country’s largest employer and public service, and that we see the value of the excellent services and innovation that social enterprises, independent providers and charities bring to health and care—indeed, not just to health and care but to the wider economy. However, we do not think that this is an appropriate duty to put on NHS commissioners, or an appropriate addition to the triple aim.

We have been discussing the triple aim and other issues around how that ends up. We fundamentally believe that the focus of NHS commissioning decisions should be on offering the best possible treatments and services based on quality, rather than any decision being based on the type of provider, but, again, while recognising the diversity of non-clinical providers, especially social enterprises, voluntary organisations and charities. The duty of the triple aim is intended to be shared across the NHS. The aims represent a core shared vision of what the NHS should offer, and are intended to align NHS bodies around a common set of objectives and support a shift towards integrated systems. In this context we would not want to split the duty by adding a section relevant to commissioners, NHS England and ICBs, but not to trusts and foundation trusts.

On Amendment 211, in its long-term plan the NHS committed to reducing health inequalities and supporting wider social goals. Again, this refers back to previous debates on how we make sure that we really capture the essence of tackling inequalities in the Bill. We recognise that NHS organisations can contribute to social and economic development, and aim to reduce the impact of social determinants of health and reduce heath inequalities. It is with this in mind that social value, alongside sustainability, has been proposed as one of the key criteria which will be used for decision-making under the provider selection regime.

We believe that this amendment, at this stage, is not necessary, as alongside the role of social value as a key decision-making criterion, NHS England and NHS Improvement will produce guidance on applying net zero and social value in healthcare procurement, which includes taking account of social value in the award of central contracts.

The Cabinet Office social value model has been applied to procurement decisions taken by NHS England and NHS Improvement since 1 April 2021 and will be extended to the whole NHS system from 1 April 2022. Adopting the Cabinet Office social value model across the NHS complements strategic initiatives and policy within the NHS.

--- Later in debate ---
Baroness Thornton Portrait Baroness Thornton (Lab)
- Hansard - - - Excerpts

Will the consultation on outsourcing be published?

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I assume it will be but, as I am about to say on a number of other issues, there is clearly a lot to take back to the department, not only tonight but on the whole Bill. I pledge to take that back to the department.

Where there is only one possible provider or where the incumbent is delivering well, it is intended that the regime will enable commissioners to continue contracts in an efficient way. However, if a trust or foundation trust currently holds a contract or did hold a contract, it should not be assumed that it is or was always with the most suitable provider. It is the view of the Government and the NHS that patients should be able to access services based on quality and value, delivering the best possible outcome, rather than basing the decision on what type of provider they are.

Amendment 208 would require a competitive tender for contracts with an annual value of over £5 million. While we recognise the role of competitive tender—and expect that, in many cases, this may be the appropriate route—the NHS asked the Government for greater flexibility in tendering contracts. It is for local commissioners to select the most appropriate provider for a service and to do so in a robust way. We agree with the importance of open, transparent and robust decision-making. Regulations and statutory guidance made under the provision in Clause 70 will set out rules to ensure transparency and scrutiny of decisions to award healthcare contracts. Decision-makers will also need to adhere to any relevant existing duties, act with transparency and appropriately manage conflicts of interest. This and other aspects of the regime will provide sufficient safeguards to fulfil the important need for fairness when making decisions about the arrangement of services.

On Amendment 209, the Government’s position on trade agreements is clear. We have been unequivocal that the procurement of NHS healthcare services is off the table in our future trade negotiations. This is a fundamental principle of the UK’s international trade policy. In fact, it dates back to the days when we were a member of the European Union; this issue came up a number of times. I remember working in the European Parliament with colleagues from the Labour Party and elsewhere to ensure that this was part of our agreements. Therefore, we do not consider the noble Baroness’s amendment necessary. My department has worked with the Department for International Trade to ensure robust protections for public services. For example, in the recent UK-Australia trade agreement, it was clearly stated that the procurement of health services is not included in the scope of the agreement’s services procurement coverage. We will ensure that our right to choose how we deliver public services is protected in future trade agreements.

Amendment 212 would mean that the provisions of Clause 70 expired three years after the day on which they commenced. In 2019, the NHS provided recommendations to the Government and Parliament for this NHS Bill. These recommendations told us that

“there is strong public and NHS staff support for scrapping Section 75 of the Health and Social Care Act 2012 and for removing the commissioning of NHS healthcare services from the jurisdiction of the Public Contract Regulations 2015.”

The recommendations also voiced support for the removal of the presumption of automatic tendering of these services. Our intention is that, through this clause and the new procurement regulations to be made under it, we will deliver what the NHS has asked for: new rules for arranging services that work for the NHS, and, most importantly, for patients.

Baroness Thornton Portrait Baroness Thornton (Lab)
- Hansard - - - Excerpts

I am very sorry—I know it is late—but, frankly, these are not rules that will serve the locality. At the moment it looks as if these rules will be set by the Secretary of State and will serve the Secretary of State. That is what the Bill says at the moment; those are the powers that this clause takes.

--- Later in debate ---
Lord Warner Portrait Lord Warner (CB)
- Hansard - - - Excerpts

Before the Minister answers that question, could he make clear whether the primary concern of the Government is the interests of the patient or of the NHS? They could be in conflict. Much of what he has said implies that they are the same but they are not, and some of the issues on which the Minister is saying “We’re doing what the NHS wanted” concern me about where the patient’s perspective is in that kind of approach.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

The noble Lord raises a concern that I have heard a number of times: that we should be careful about saying “This is what the NHS wanted”—that the focus has to be about patients. We clearly take the view that this should be patient-centred and patient-focused. Indeed, I have had a number of conversations with many noble Lords about how we make sure that it is patient-focused. We understand, however, that concerns have been raised that Clause 70 may in part be a temporary measure, to be replaced or significantly edited by the Cabinet Office procurement Bill to follow. This is not and never has been our intention, but I understand the concern and recognise that there is value to aligning processes when such alignment is in the wider system interest. We continue to engage with the Cabinet Office on its proposals.

Amendment 213 would make regulations under Clause 70 subject to the super-affirmative procedure. I appreciate the intention behind this amendment. However, we do not feel at the moment that the super-affirmative procedure is necessary. As set out in our delegated powers memorandum, the powers created by Clause 70 are inserted into the NHS Act 2006, in line with the vast majority of regulation-making powers under that Act.

We know that there is significant parliamentary interest around the rules determining how healthcare services are arranged, so it is vital that we strike the right balance between democratic scrutiny and operational flexibility. The negative procedure provides that balance and ensures transparency and scrutiny. We will continue to engage widely on the proposals for the regulations to be made under these powers, to ensure that they will deliver—

Baroness Thornton Portrait Baroness Thornton (Lab)
- Hansard - - - Excerpts

I am sure that the noble Lord knows that there is actually no parliamentary scrutiny with the negative procedure—none.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

May I explain about the point made by the noble Lord, Lord Lansley, on Clause 70—

Lord Sharkey Portrait Lord Sharkey (LD)
- Hansard - - - Excerpts

Before the Minister abandons Amendment 93 entirely, could he explain why it is necessary to have, in this Bill—when there is another one coming along—regulation-making powers that are unconstrained and non-specific?

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

We do not believe that they are, but clearly there is a difference of opinion about it.

I would like to turn, however, to the point made by my noble friend Lord Lansley on Clause 70. The regulations that we create under Clause 70 will have a broader scope than those currently created under Section 75. The provider selection regime will include public health services commissioned by local authorities, thereby recognising their role as part of joined-up health services delivered for the public. While we always want to act in the interests of people who use our services, our regime recognises the reality that in some cases integration, rather than competition, is the best way to achieve this for the health service. Finally, removing the section and creating a new bespoke regime, is—despite the scepticism of the noble Lord, Lord Warner—what the NHS has asked for. There is strong public and NHS support for scrapping Section 75 of the 2012 Act—

Lord Lansley Portrait Lord Lansley (Con)
- Hansard - - - Excerpts

I am sorry—it is getting late—but will my noble friend at least, at some point, tell us: did Ministers ever challenge the NHS on whether what it was asking for required primary legislation? Did they ever ask, “What are you trying to achieve?”—and then let us, the Government and Parliament, who actually pass the legislation, see how it should be achieved? Or has Parliament in practice now become merely the cypher for the NHS?

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I take the point that my noble friend makes, and I completely understand the concerns; that is why it is important that I take many of the concerns raised today back to the department.

Clause 70 inserts a new Section 12ZB into the NHS Act 2006, allowing the Secretary of State to make regulations. I have a lengthy explanation here but, frankly, I am not sure that it will pass muster. If noble Lords will allow me to go back to the department—I may be a sucker for punishment, but I accept the concerns and I will go back—

Lord Warner Portrait Lord Warner (CB)
- Hansard - - - Excerpts

Would the Minister like a few of us to go along to the department with him?

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

As the noble Lord will recognise, when I was appointed to this job, I did say that I wanted to consult as many previous Health Ministers as possible, as well as people who have worked in the field. It is clear from this debate that more consultation and discussion are needed, so I would welcome noble Lords’ advice. On that note, I beg that Clause 70 stand part of this Bill and hope that the noble Lord will withdraw his amendment.

Lord Hunt of Kings Heath Portrait Lord Hunt of Kings Heath (Lab)
- Hansard - - - Excerpts

My Lords, the hour is late. We cannot have the extensive debate that we probably require. I shall be very brief. I should have declared an interest as president of the Health Care Supply Association, the NHS procurement professionals.

On social value, I am very grateful to the Minister because he said that guidance will be issued to the health service on this, which is gratifying. On social enterprise, my noble friend Lord Howarth, the noble Lord, Lord Warner, the noble Baronesses, Lady Bennett and Lady Walmsley, and my noble friend Lady Thornton of course, all referred to the value of social enterprises. The Minister is not convinced that we need to put anything in the Bill. The point I need to put to him is this: it is clear from intelligence from the health service what the people running what I call the shadow ICBs want. I do wonder what we are doing legislating when obviously, everything is up and running; it is very difficult to know why we are here tonight debating these issues. Clearly, the NHS wants it, so it has got it and it is Parliament’s job, presumably, to just legitimise what it is already doing.

Having said that, these integrated care boards believe that social enterprises are not to be invested in in the future. So, my appeal to the Minister is this: fine, do not put it in the Bill, but please get a message out to the 42 ICBs telling them not to be so silly as to think that they should carve social enterprises out of the new regime.

More generally, on procurement, it is very interesting to be debating with the noble Lord, Lord Lansley. We fought tooth and nail for days on Section 75 of the 2012 legislation. Along come the Government, now saying, “Oh, we’re going to get rid of it. We don’t know what we will replace it with, but it is all right because we can have some negative regulations which mean we can steam it through without any scrutiny apart from a desultory debate as a dinner-break business sometime in the future. Oh, and by the way, there’s procurement legislation coming along too, but we can’t tell you what will be in there.”

Somehow, between now and Report, collectively we need to find a way through. I confess to the noble Lord, Lord Lansley, that I am rather pleased to see Section 75 go. However, something has to be put in its place, or we will just leave the NHS to get on with it and await future regulations and legislation. One thing for sure is that the idea of leaving the Bill with Section 70 and not even accepting the noble Lord’s sensible suggestion of the super-affirmative procedure is quite remarkable, and clearly it will not run. Having said that, I beg leave to withdraw my amendment.

Baroness Wheeler Portrait Baroness Wheeler (Lab)
- Hansard - - - Excerpts

My Lords, I thank the noble Lord, Lord Sharkey, for opening this important group and moving Amendment 106, to which my noble friend Lady Thornton added her name. As he explained, the substance of this amendment was singled out by the Constitution Committee and highlighted by the Delegated Powers and Regulatory Reform Committee. I reinforce the Constitution Committee’s endorsement of the DPRRC’s recommending the removal from Clause 20 of the imposition of legal liability merely by publishing a document. We agree with the two committees that this is a necessary amendment, and I look forward to hearing from the Minister how these concerns will be addressed.

Somewhat paradoxically, Amendments 143 and 144 strengthen the powers of NHS England in its quest for top-down management and imposition. However, they sit within the wider context of describing how NHS England would be able to give directions to integrated care boards under Clause 20 and improve these provisions, so we support them.

The remaining amendments on NHS Continuing Healthcare underline how vital it is to address this urgent issue, although it is not central to the intentions of the Bill. I thank the noble Baroness, Lady Greengross, for ensuring this focus in the debate and for Amendments 133 and 139, which ensure that this crucial issue is specified under the ICB’s duties and included in its annual report and performance review accountabilities.

Today, we heard in detail about the widespread concern about and scale of the problems with the way in which the NHS Continuing Healthcare scheme works and is funded, and the arguments it leads to about who pays for what, as a shared responsibility between the NHS and local government. Patients and their carers feel they are the sideshow, not the central focus of concern, and are deeply traumatised and upset by the whole experience.

As a carer of a disabled adult myself, like my noble friend Lady Pitkeathley, I know, from meeting many other carers and their loved ones, their deep concern about this. The three things that cause most concern and upset, which one hears time and again, are, first, the huge problems with inadequately funded social care packages—or their absence—to meet basic care needs, and deep worries and anxieties about how the care cap will operate; secondly, the trauma of the discharge-from-hospital process for carers and their loved ones, which we will discuss later; and thirdly, NHS Continuing Healthcare, the postcode lottery of whether your loved one receives it or not, the huge bureaucracy around the application and allocation process, the long wait for a response and being stuck in the middle of an NHS local authority fight over funding. As the noble Baroness, Lady Finlay, stressed, there is an urgent need to tackle the accountability gap in this process.

NHS Continuing Healthcare is the absolute manifestation of what our Economic Affairs Committee report on the “national scandal” of social care funding called the “condition lottery”—in other words, the wide disparity between health conditions for which people receive healthcare that is free at the point of use and those for which users usually have to make a substantial contribution with “catastrophic costs”, in the committee’s words. As we heard today, dementia is the condition most cited in this regard, but many of us know of cases where people with motor neurone, Parkinson’s and other degenerative diseases have struggled to get NHS Continuing Healthcare funding, either for home care or support in residential homes.

We support Amendment 161, which ensures that the Care Quality Commission reviews must include this issue. However, I am unclear—and may well learn in a minute from the Minister—what role the CQC currently has in looking into all continuing care matters which traverse NHS and local authority boundaries. However, we support its involvement.

The amendment would also ensure that the CQC reviews include looking in depth at how NHS Continuing Healthcare is working under each ICB. That will mean that at last we can begin to develop the much needed strategic overview of this crucial area for thousands of people in desperate need of care and support.

Lord Kamall Portrait The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
- Hansard - -

My Lords, I thank the noble Lord, Lord Sharkey, and the noble Baronesses, Lady Finlay and Lady Greengross, for bringing this group of amendments.

I understand the intention behind Amendment 106, on payment to providers, which is to remove new Section 14Z48 in its entirety, but the section will allow NHS England to specify the circumstances in which an ICB is liable to make payments to a provider for services commissioned by another ICB.

The Government are committed to ensuring that delegated powers in the Bill use the most appropriate procedure, so that Parliament has due oversight of their use. We recognise that the Bill contains a significant number of guidance-making powers and powers to publish documents. However, we believe that they are appropriate because, as the noble Baroness, Lady Walmsley, said, they reflect the often complex operational details and the importance of ensuring that the guidance keeps up with best practice, especially as the system flexes and evolves. I understand the noble Baroness’s point about Parliament, but the issue here is whether, every time the system flexes, Parliament has to have another debate. The ICBs will be reading the guidance, not Hansard, and the guidance should reflect that.

Nor is it our intention to interfere unduly in the financial affairs of ICBs. Instead, the intention is to resolve specific circumstances, such as emergency services. The legislation makes it clear that each ICB has to arrange for urgent care services to be available for all people physically present in the area, not just for the people who are its core responsibility by virtue of their GP registration. I am sure noble Lords will agree that it would be neither fair nor in the best interests of promoting an efficient health service for the ICB to both arrange and cover the cost of all additional emergency treatment brought by visitors to the area, particularly in areas with high visitor numbers. A number of noble Lords referred to that principle in debates last week.

Instead, this provision allows NHS England to mandate a different payment rule for those services, ensuring that, where necessary, the ICB where a patient is registered will pay, rather than the ICB where they receive treatment. This ensures that the financial impact is felt in the right commissioning organisation and eliminates the risk of some ICBs having unreasonable financial demands placed on them—for example, during the holiday season.

The wording of this provision replicates almost exactly the National Health Service Act 2006 as amended in 2012, but it is updated to reflect the new ICB structure. As my noble friend Lord Howe mentioned to me, we had a massive debate about this 10 years ago, but the provision seems to have worked effectively in the CCGs, and we wish to continue that with the ICBs.

Amendments 143 and 144, in the name of the noble Baroness, Lady Finlay, are about NHS England directing ICBs. I understand the interest in ensuring that NHS England has the necessary tools to intervene in ICBs where necessary. However, we believe that NHS England already has sufficient powers to direct ICBs. NHS England already has certain powers to direct an ICB under Section 14Z59(2), and powers to intervene over ICBs in order to prevent failure and to ensure that the lines of accountability from ICBs through NHS England to Parliament are strong.

However, this power has a threshold in that it can be used only if NHS England deems an ICB to be failing to discharge a function or at risk of failing to do so. The threshold removes the possibility of NHS England overdirecting the system while retaining the power for use if necessary. This balances the need to prevent failure and to support accountability with allowing ICBs the autonomy they need to operate effectively.

Amendments 133, 139 and 161 expressly require that ICB annual reports and NHS England performance assessments of ICBs include specific consideration of commissioned services, including NHS Continuing Healthcare, which noble Lords have spoken about, and that the CQC reviews of ICSs include specific consideration of that. We agree with the principle, but we believe that it is already covered in the Bill. NHS England already has a key role in overseeing ICBs. For example, the Bill requires NHS England to assess the performance of each ICB every year, and ICBs are required to provide NHS England with their annual report. These reports will include an assessment of ICB commissioning duties, which would encompass any arrangements for NHS Continuing Healthcare.

In addition, as noble Lords are aware, Clause 26 gives the CQC a duty to assess integrated care systems, including the provision of relevant healthcare and adult social care within the area of each ICB. This would include the provision of NHS Continuing Healthcare. We intend the CQC to pilot and develop its approach to these reviews in collaboration with NHS England, but also with other partners in the system. This should ensure that the methodology does not duplicate or conflict with any existing system oversight roles.

With this in mind, we believe that these amendments are not necessary, because commissioned services, which we would expect to encompass NHS Continuing Healthcare, are already included in these clauses. I hope that I have been able to somewhat reassure your Lordships. For these reasons, I ask noble Lords not to press their amendments.

Lord Sharkey Portrait Lord Sharkey (LD)
- Hansard - - - Excerpts

My Lords, it is clear that new Section 14Z48 is an unambiguous abuse of delegated powers. It provides for a law to be created by the simple issuing of a paper. There is no real possibility of a coherent defence of this procedure and the Minister did not provide one, relying as he did on special pleading and the extraordinary notion that Parliament cannot handle complexity.

As the Bill stands, Parliament is bypassed and scrutiny is avoided. I remind the Committee that the DPRRC and the Constitution Committee have recommended the removal of this section. I again suggest to the Minister that if he wants to retain the powers set out in Section 14Z48, he should rework them between now and Report at least to involve scrutiny by Parliament via the affirmative procedure. If he does not, we will return to this issue on Report. In the meantime, I beg leave to withdraw the amendment.

--- Later in debate ---
Baroness Thornton Portrait Baroness Thornton (Lab)
- Hansard - - - Excerpts

I certainly cannot help my noble friend, but I live in hope that the Minister can. It smacks of a fix. The Minister might not be prepared to say on the Floor of the House what exactly the fix was between the various bits of NHS England and various bits and other parts of the machinery. I suspect that the noble Lord, Lord Lansley, might know better than the rest of us what that fix was.

I will comment on my noble friend Lord Davies’s amendment. The problem with it is that, as the ICPs are proposed in the Bill at the moment, they will not be spending any money or commissioning services. It is also important that they include the various important parts of our local health delivery systems, including pharmacists, dentists, GPs, social enterprises and the voluntary sector. As I read it, this amendment would exclude hospices, for example—which would be a ridiculous thing to do. So my noble friend might want to rethink that amendment, because it does not necessarily serve the intended interests of the ICPs.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I thank all noble Lords, especially the noble Lord, Lord Hunt, for the points they have raised. ICPs will play an important role in co-ordinating services, planning in a way that improves population health and reduces inequalities between different groups. It is right that we consider the best conditions for their success. I was asked where the idea for ICPs came from. It originated from the Local Government Association. We have had extensive consultation with both the LGA and NHS England. To be clear, councillors can sit on ICPs.

Baroness Thornton Portrait Baroness Thornton (Lab)
- Hansard - - - Excerpts

Is that the fix: that councillors are not allowed to sit on the ICBs, where the money is spent, but they are allowed to sit on the ICPs? That is not acceptable to me.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I do not see it as a fix. The consultation was much wider than just NHS England. In November 2020, NHS England ran a public consultation on the structure of ICSs, including NHS staff, patients and members of the public.

Baroness Walmsley Portrait Baroness Walmsley (LD)
- Hansard - - - Excerpts

May I ask the Minister whether councillors were consulted?

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I do not know for certain, but I am sure their views would have been heard via the Local Government Association.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

They were. Good. I got the answer just in time.

I will turn to Amendment 147, which would mandate a role for a member drawn from each area of primary care. With all amendments relating to the ICP membership, we want to be careful to give space for local areas to find a model of membership that works best for them. As the noble Lord, Lord Stevens of Birmingham, raised at Second Reading, it is right that in a country as large and diverse as ours, one size will not fit all. Therefore, it is right that local areas should be able to determine the model and membership that best represent their area.

We fully expect primary care professionals to be involved in the work of ICPs. Each partnership will need to involve a wide range of organisations and representatives from across the system, including professionals from primary medical, dental, pharmaceutical and optical backgrounds as they prepare their strategy. The department has published a draft list of representatives for ICPs to consider involving, which includes clinical and professional experts, including those from medical, dental, pharmaceutical and ophthalmic settings. The mechanism of how this is done will be down to local discretion. For example, one ICP may wish to formally appoint certain members, whereas a neighbouring ICP may wish to have an extensive range of consultees, and a third may decide to invite primary care representatives to join a subcommittee instead. We believe it is right that local areas are able to determine the model of partnership that best works for them, and this amendment would prevent that from happening.

A similar argument applies to Amendment 148. While we welcome the contribution of directors of public health and the voluntary, charity and social enterprise sector, I do think that we risk limiting the flexibility of ICPs. We expect public health experts to play a significant role, especially given their role in developing the joint strategic needs assessments that are crucial to guiding all planning, and their role in supporting, informing and guiding approaches to population health management.

Similarly, we expect appropriate representation from the voluntary, charity and social enterprise sectors, which will be able to contribute in respect of a number of different interests and perspectives. A number of noble Lords have spoken very eloquently about the reasons we should involve these sectors. We believe it would not be prudent, for example, to suggest that it may be appropriate for only one person to represent the local voluntary sector on a partnership, given the diversity of their involvement in health and social care.

I turn to Amendment 150, tabled by the noble Lord, Lord Davies of Brixton, and I also thank the noble Baroness, Lady Thornton, for her advice on that. I appreciate that the noble Lord might want to prevent anyone who works for, represents, or has a financial interest in a private health and care company, from being a member of an ICP. However, I would draw the noble Lord’s attention specifically to the recent experience of coronavirus, which showed that independent and voluntary providers were a vital part of the health and care picture. This amendment could exclude a significant part of the health and care sector, as the noble Baroness, Lady Thornton, rightly said. Given their scale and the central role they play, adult social care providers in particular would be potentially useful members of an ICP. It also risks leaving out, for example, dentists, pharmacists, opticians and many others working in primary care, and doctors other than GPs who work both in the NHS and privately.

We expect every ICP to have robust measures to ensure that formal conflicts of interest are managed carefully and transparently. It is also important to note that ICPs, as the noble Baroness, Lady Thornton, says, are not commissioners, and so will not be making decisions on the allocation of funds. Fundamentally, the ICP is working solely for the interests of people in the area. The experience of the health and well-being boards is helpful here, as they have similar flexibility in membership, and there have not been significant issues with conflicts of interest as they have developed their plans. We really expect the ICP strategy to be rooted in the people and communities they serve, and to be directly informed by the health and well-being boards and the joint strategic needs assessments. We are refreshing the health and well-being boards’ guidance to ensure that there are strong foundations in place at neighbourhood levels that the ICP can consult and build on.

Having said this, I thank noble Lords for their contributions on this important matter. However, as I have explained, we believe that these amendments run contrary to the principles of flexibility and subsidiarity that the Bill is based on, and therefore I hope that noble Lords will not press them.

Lord Hunt of Kings Heath Portrait Lord Hunt of Kings Heath (Lab)
- Hansard - - - Excerpts

I am grateful to the Minister. First, I thank my noble friend Lord Davies for his amendment. I think, notwithstanding what the Minister said about some of the technical details, the principle that he put forward is absolutely right: clearly, the consistency with ICBs that he mentioned is really important. I am also very sympathetic with the noble Baroness, Lady Walmsley, and her amendment on the importance of public health and voluntary organisations.

We come here to the principle that some of us continue to be puzzled by the architecture we see before us. The Minister says that this was consulted on and the Local Government Association is fine and dandy about it but, with respect, that is not sufficient in terms of your Lordships and the rigour and scrutiny that we need to put into this legislation. Frankly, as my noble friend Lady Thornton suggests, it looks much more like a fix between representative institutions to preserve the current arrangements as much as possible.

I remain somewhat confused about the structure. The Minister said that health and well-being boards will feed into ICPs, but why? Think about what he said about the role of integrated care partnerships; it sounded to me like the role of the health and well-being boards. I just do not understand the differences. I understand that, in some parts of the country where the ICP will cover a lot of local authorities, there is an argument that you should continue with health and well-being boards at the local level, but I do not see why they cannot be sub-committees of the integrated care partnerships; the Minister referred to that. Why on earth do we in Birmingham need a health and well-being board as well as an ICP? I simply do not understand it.

If the Minister believes that this should all be set out at the local level, why can people decide locally not to have a health and well-being board? He may say, “Ah no, you need a framework”. Our argument is that you need a framework in relation to membership as well. The compromise here might be to set out in legislation, as we will want to do, certain conditions around local governance and then leave it up to the local level. In relation to ICPs, however, we cannot leave it as it is. Having said that, I beg leave to withdraw my amendment.

--- Later in debate ---
Baroness Merron Portrait Baroness Merron (Lab)
- Hansard - - - Excerpts

My Lords, I am grateful to the noble Lord, Lord Farmer, for introducing this important debate and to other noble Lords who have supported the amendments before us and spoken about how we can improve the support that families will receive through this Bill. As the Family Hubs Network rightly observes,

“prevention is simply listed in the Bill as one of several commissioning requirements of ICBs with no broad mention of children’s health”.

This group of amendments gives us the opportunity to sharpen this.

As we have heard, the issues that families face, in whatever form or shape, do not exist in isolation. In addition to the impact of financial, housing, social and other pressures, the physical and mental health of a child or young person affects the physical and mental health of not just their parents, but their wider family, and vice versa. It makes common sense to facilitate a healthcare system that is designed and resourced to actively take a holistic approach to the many issues that face children and those who care for them.

I cannot help but feel that the points raised today are not new. We have the experience of Sure Start to show us how effective properly integrated family services can be. As the Institute for Fiscal Studies confirmed:

“By bringing together a wide range of early years services for children under 5, Sure Start centres dramatically improved children’s health even through their teenage years.”


Early investment is crucial.

I hope the Minister will be keen to embed change in this Bill to replicate the success that we saw through Sure Start. The first step towards doing this is to make sure that integrated care partnerships are properly required to consider how family help services can be thoroughly integrated into our health and care system, so that family members—no matter what form those families take—are seen as both individuals and groups who have an effect on each other.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I thank my noble friend Lord Farmer and all noble Lords who spoke about their experiences. The creation of integrated care boards represents a huge opportunity to support and improve the planning and provision of services to make sure that they are more joined up and better meet the needs of infants, children and young people.

Before I go into the specific amendments, I make it quite clear, as my noble friend said, that the Government set out in their manifesto a commitment to championing family hubs. We want to see them across the country, but at the same time we must give democratically elected councils the choice to shape how services are delivered, bearing in mind some of the points made by the noble Lords, Lord Mawson and Lord Warner, whom I thank for their experience on this.

The Government agree that it is vital to ensure that ICPs work closely with a range of organisations and services to consider the whole needs of a family when providing health and care support. In preparing the integrated care strategy, the integrated care partnership must involve local Healthwatch and the people who live or work in the area. We are working with NHS England and NHS Improvement on bespoke draft guidance, which will set out the measures that ICBs and ICPs should take to ensure they deliver for babies, children and young people. This will cover services that my noble friend considers part of family help.

In addition, the independent review of children’s social care is still considering its definition of “family help”, and the definition published in The Case for Change may well be further refined as a result of ongoing consultation. It would be inappropriate to define the term in legislation at this stage, pre-empting the full findings of the review and the Government’s response to it. Also, it is important that there should be a degree of local determination as to what should be included in the strategies of ICBs and ICPs. In order for them to deliver for their local populations, a permissive approach is critical.

On Amendment 167, we agree that family hubs are a wonderful innovation in service organisation and delivery for families. The great thing about them is how they emerged organically from local councils over the last decade. I pay tribute to my noble friend for the key role he has played in advocating family hubs and bringing this innovation to the heart of government. The Government strongly support and champion the move but we are clear that they have to be effective and successful—they need to be able to adapt to local needs and circumstances. They also need to be able to operate affordably, making use of a diverse range of local and central funding streams.

In both these regards, local democratically elected councils should hold the ultimate decision-making power over whether to adopt a family hub model and how it should function. As such, I regret that we cannot support the amendment, which would place too much prescription on the decisions and actions of local authorities and risk imposing significant new financial burdens. For this reason, I ask my noble friend to consider withdrawing his amendment.

Lord Farmer Portrait Lord Farmer (Con)
- Hansard - - - Excerpts

My Lords, I thank the Minister for his rather disappointing reply and those who supported these amendments, particularly the noble Baroness, Lady Tyler, and my noble friend Lady Wyld, for giving such clear definition to the services and the advantages of family hubs. I take to heart the advice from the noble Lord, Lord Mawson, about unintended consequences. I would quite happily talk to him about this. I also take the point from the noble Lord, Lord Warner, that it is nought to 19, not nought to five. Families have so many problems with teenagers, as we see on the streets today, and family hubs can be a non-stigmatising place where help can be got.

I agree with the noble Baroness, Lady Merron, about Sure Start. In a way, I have always said that family hubs are building on Labour’s Sure Start centres. However, it is not nought to five but nought to 19—in fact, nought to 25 for children who come out of the care system, et cetera, with special needs.

There might be concern that my amendments attempt inappropriately to set in concrete the policy of family hubs when it is constantly progressing. However, the changes I have described are not just about bringing the latest policy idea into the Bill. Absent of these references to places where families know that they can access help and be connected to the full gamut of local services and support, the Bill will not reflect the overarching direction of travel. Their inclusion requires health to be fully on board, which has not happened in the past, to the detriment of the success of previous policies.

Health and Care Bill Debate

Full Debate: Read Full Debate
Department: Leader of the House
Baroness Walmsley Portrait Baroness Walmsley (LD)
- Hansard - - - Excerpts

My Lords, I will be as brief as I can. I have a few words about some of the amendments in this wide-ranging group.

Amendment 243 would protect the title “nurse”. I know from family members that the qualification of registered nurse is always hard won, the result of very hard work. It involves rigorous basic training, often followed by further training in a specialty such as mental health nursing or surgery. The title provides a high level of trust among patients and the general population, because we know that a nurse must be registered with the Nursing and Midwifery Council, or a different responsible body for dental or veterinary nurses. There should therefore be clarity about who can use the title, and it could be sorted out very simply by the Minister—I hope he will do it.

A further anomaly, which the Minister can easily sort out in his reply, is that of the appointment of surgeons. I hope he will remove that anomaly as well.

I commend the work of my noble friend Lord Sharkey on rare diseases. I will not repeat what he said about what is needed, but I hope the Minister can give him some assurance.

I strongly support Amendment 266 on the need for a register for those who practise aesthetic non-surgical interventions. I will not repeat what my noble friend Lady Brinton and others have said about the reasons for this.

Amendment 293 requires a special register for cosmetic surgery. It is important that we have an up-to-date, comprehensive and rigorous method of assessing and registering the qualifications of surgeons safely to carry out cosmetic surgery. The question is: how is that done? I have received a briefing from the GMC, which tells me that it does not support the creation of a separate register for cosmetic surgery practitioners. Instead, the GMC believes that its proposal to move to a single GMC register that includes all doctors, anaesthesia associates and physician associates, and special annotation with work to develop relevant credentials, will provide additional assurance beyond that which could be provided by a separate additional register.

We are told that something better is coming down the track and that the forthcoming regulatory reform programme is intended to rationalise and streamline registration across all the UK healthcare regulators, and will allow the GMC to deliver an accessible, flexible and discretionary registration framework for all registrant groups. That is why the GMC believes that that will provide greater flexibility to develop and amend registration rules and improve its ability to innovate. Given the rapid development of new spheres of medicine and practices, such flexibility could be advantageous.

I understand that the GMC is now developing credentials with royal colleges and health education bodies, and that the first group of those is led by one on cosmetic surgery, plus four other disciplines. So, while I heartily agree with the intention of Amendment 293, I ask the Minister: when will the regulatory reform mentioned in the GMC briefing be completed? When will Parliament be able to see it and, in the meantime, how can we be assured that the current system gives the assurance on patient safety that is required?

I too support the noble Lord, Lord Hunt, on hospital catering and I too will resist giving my anecdote.

Lord Kamall Portrait The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
- Hansard - -

I thank noble Lords for their contributions and for sharing their knowledge and expertise—and, in the case of hospital food, not sharing their tales of inadequate and unhealthy food. I will try to answer as many of the questions as possible but, given the experience of the noble Lord, Lord Patel, of being advised by a nurse Whip, I am keen to make sure that I do not suffer those same warnings, as it were.

On rare diseases, specifying requirements in the way proposed by the amendment would restrict the ability of the CQC to collaboratively develop its assessments of integrated care systems. However, the Government are committed to improving the lives of people living with rare diseases. The noble Lord, Lord Sharkey, rightly talked about the UK Rare Diseases Framework that we published in January 2021, which set out our key priorities for tackling rare diseases. England’s action plan will be published at the end of next month.

I have had conversations with some in the life sciences industry who are keen on the fact that we are focusing on rare diseases and extremely rare diseases, and see that as a positive. One of the things that we are trying to do across government is to make sure that we are seen as a hub for expertise in rare diseases and especially rare diseases. One of my predecessors as a Minister suffered from a rare disease. The momentum is still there in the department to make sure that we tackle the issue.

Also, the CQC, through its ICS assessment methodology, will seek to understand how system leaders are monitoring and meeting the needs of the local population, including those with rare diseases. We expect the CQC, in collaboration with system partners, to use its experience as the independent regulator of health and adult social care in England to develop an approach to those reviews. I know that noble Lords may be tired of hearing this but it is important that the legislation allows the CQC flexibility to do so.

On Amendment 240, while the Government have sympathy with the need to raise awareness, we do not consider it appropriate to put such a requirement into primary legislation. I hope I have reassured the noble Lord about our programmes and our push to raise the profile of rare diseases and extremely rare diseases. We prefer that all healthcare professional regulators require professionals to have the necessary skills and knowledge to practise safely, including awareness of rare conditions. It is the responsibility of the regulators to determine what specific role they should play in raising awareness of rare and less common conditions.

On—and I apologise if I mispronounce this—liothyronine and the power of direction, the NICE guideline on the assessment and management of thyroid disease, as the noble Lord acknowledged, does not recommend liothyronine for primary hypothyroidism. NICE states that there is not yet enough evidence that it offers benefits over levothyroxine monotherapy, and its long-term adverse effects are uncertain. If new evidence was to emerge, I am sure NICE would consider it.

In addition, we must be careful not to override NICE guidelines. But, given the concerns raised by the noble Lord, Lord Hunt, and my noble friend Lord Borwick, I would like a further conversation, if that is okay, to see what can be done in this area, as well as where it is appropriate for me to act and what conversations would be appropriate, given the noble Lord’s experience as a Health Minister.

On Amendment 178, we are committed to further strengthening the innovation metrics and to improving our understanding of how innovative medicines and these products are used in the NHS. Noble Lords will be aware that following the publication of the final report of the Accelerated Access Review, the Government established the Accelerated Access Collaborative—AAC—last year. In fact, last year alone we helped over 300,000 patients access proven innovations, resulting in 17,000 fewer hospital admissions and 140,000 fewer days spent in hospital.

As noble Lords are aware, we published our ambitious Life Sciences Vision, which laid out our priorities. We want to make sure that the NHS is seen as a partner in innovation and that research is embedded into everything the NHS does. I know that this has been raised in relation to other amendments. We are currently developing implementation plans for delivering on these commitments.

As noble Lords acknowledged, NICE is in the final stages of the review of its methods and processes, and is proposing a number of changes that will introduce real benefits to patients, including rare disease patients. The Government are also committed to developing an innovative medicines fund, which my noble friend referred to, and a consultation on detailed proposals for the fund closes on 11 February.

Finally, our rare disease framework outlines the key priorities for rare diseases in the UK over the next five years. One priority area is to improve access to specialist care, treatments and drugs.

On hospital food, although we recognise the expertise and declarations of the noble Lords who spoke, we believe that this amendment is unnecessary because the issues are already covered, either as part of the ongoing work to implement recommendations from the hospital food review or in the NHS food standards document, to be published in spring 2022.

The Government are supporting NHS England to implement the recommendations from the independent review. These recommendations cover a broad range of issues, including nutrition, hydration, healthier eating and sustainable procurement. It is important for me to learn more about this as a Minister, given what the noble Baroness, Lady Barker, said about many people not receiving the recognition they deserve. It would be appropriate, perhaps, for us to meet and follow this up.

In addition, the Government already have sufficient legal powers and obligations to enable them to consult on proposed food standards, and we have engaged with NHS trusts, the food standards and strategy group, and the NHS food review expert group through the NHS food review. We will continue to do all this.

On Amendment 264, the regulations already allow trusts to seek alternative members to contribute to the process. They can be from colleges such as the Royal College of Surgeons of Edinburgh, the Royal College of Physicians and Surgeons of Glasgow and the Royal College of Emergency Medicine. However, the Government agree that the changes proposed by noble Lords in Amendment 264 would potentially be advantageous —to put it that way—and we have undertaken to review the situation with officials.

The National Health Service Act 2006 stipulates that consultation with affected parties must be undertaken before any changes are made. Therefore, before we jump to it and agree, we are required to consult the relevant parties. It does seem a clear-cut case, but we are still under a duty to consult.

--- Later in debate ---
Lord Patel Portrait Lord Patel (CB)
- Hansard - - - Excerpts

My Lords, the Minister suggested that, to have any changes in the appointment of surgeons, the department would have to consult first. I assume that the only body it would need to consult is the Royal College of Surgeons, which I understand is sympathetic to the change. If that is the case, it is a simple matter, so can it not be consulted before Report?

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

If it is as straightforward as the noble Lord suggests, I will see if that can be done.

Baroness Wheeler Portrait Baroness Wheeler (Lab)
- Hansard - - - Excerpts

My Lords, I thank noble Lords for their many expert and very informative contributions. It has been a fascinating debate on a number of issues.

On specialised care services and rare diseases, I note the Minister’s comments and thank him for some of his reassurances, but there were some issues that he did not cover, particularly in relation to my noble friend’s Amendment 178. However, I welcome the dialogue that is taking place on these issues, and the recognition of their complexity, and am very hopeful that that will continue. We will take stock to see if anything else needs to come back on Report. I also thank my noble friend Lady Pitkeathley for her support on this issue.

In the general debate, noble Lords will, I am sure, follow up on the points that they made, as the noble Lord, Lord Patel, just did. I thought the contributions of my noble friend Lord Hunt and the noble Baroness, Lady Barker, on the hospital food situation, really drove home the importance of this issue. We must make progress on it and move forward.

On the title “nurse”, strong support was expected and we certainly got it from across the House. I hope that progress can be made. The issue will not go away, as the Minister knows, and neither will the determination of my noble friend Lord Hunt to pursue the issue of the availability of T3 for thyroid patients. We hope that progress can be made on that, because again it is a situation that a must be addressed.

The noble Baronesses, Lady Masham and Lady Brinton, and other noble Lords made valuable points on the vital need for a licensing regime for non-surgical cosmetic procedures, again underlining the need for urgent, step-by-step progress, and demonstrating in particular why the current situation is unacceptable. Progress can be made. As the noble Lord, Lord Lansley, pointed out, it was seen in the recent Private Members’ Bill on Botox fillers. We need progress to be made, and steadily.

Finally, on the reference to when the review of the regulatory system will be completed—the noble Baroness, Lady Walmsley, also raised this—the issue was about timescales. We know there is a review. We are told that KPMG is on the case and has delivered its report, but we need timescales and action as soon as possible.

With those comments, I beg leave to withdraw my amendment.

--- Later in debate ---
Baroness Thornton Portrait Baroness Thornton (Lab)
- Hansard - - - Excerpts

My Lords, I am nearly convinced that I should have put my name to the opposition to Clause 39 standing part of the Bill.

We have had a very informed and interesting debate which comes to the heart of the balances of power that the Bill seeks to change. My noble friend Lord Hunt set out concerns over Clause 39, which gives general powers of direction to NHS England. Amendments 174A, 174B, 175A, 176A and 175 seek to mitigate the power and to put in safeguards. This is very much in tune with concerns expressed across the Committee, by the Delegated Powers and Regulatory Reform Committee, and by the Constitution Committee. Our amendments stop short of that from the noble Lord, Lord Lansley, and the noble Baroness, Lady Walmsley, but theirs is a more elegant solution in many ways. However, the Minister will need to explain why some powers of direction are required, and we on these Benches will listen very carefully indeed.

This is all part of the balance between the responsibilities of the Secretary of State, especially to Parliament, and the powers the Secretary of State has to enable them to discharge their duties. If there is a clear and consistent solution to this, we have yet to hear it. In a way, we are repeating debates we have already had in Committee. The Bill has been severely criticised as a clear and disturbing illustration of disguised legislation, and it will need to be changed. We will need to move on to proper talks about how to do that.

On whether Clause 64 should stand part of the Bill, the issue is a different one. The 2012 Act introduced the formal notion of NHS bodies having autonomy, and since 2003, foundation trusts have had some degree of at least theoretical autonomy. But in the years of austerity a lot of that has gone, and all trusts of all kinds are simply struggling to manage day by day. It may have been the noble Lord, Lord Stevens, who observed that the difference between a trust and a foundation trust was a distinction without a difference. For some years, the process of managing foundation trusts has been the same as for trusts.

We have been hearing in our recent deliberations about local flexibilities. Our scepticism about this has been strong, because it appears—and this group of amendments addresses this—that any flexibility will be as great as NHS England permits. Let us not reject autonomy. Why remove the duties to promote autonomy? Why not replace them, for example, as the noble Lord, Lord Mawson, said, with a duty around subsidiarity and localism?

I will not repeat what was said by the Constitution Committee, but it was very critical of the powers that the Secretary of State seeks to take. Indeed, I raise a different issue: the fact that I thought NHS England was undertaking implementation of the Bill before it has finished its passage through Parliament. It is all part of the same pattern. Since we have an undertaking from the Minister to respond to that concern, we will look for an undertaking from him to provide an explanation and perhaps further discussion about why he wants autonomy removed from the Bill.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I thank all noble Lords for their amendments and for challenging the issues around the power of direction. We believe that we must have the right framework for national oversight of our health system. Following the merger of NHS England with Monitor and the Trust Development Authority, NHS England will be one of the largest arm’s-length bodies in government, responsible for over £130 billion of taxpayers’ money. Without this power, we would be expanding the functions and responsibilities of NHS England without ensuring that there are enhanced accountability measures in place.

Accountability must run from NHS England to Ministers, from Ministers to Parliament, and from Parliament to the public. This is what the power of direction supports. Indeed, a number of politicians from different sides agree that if you walked out into Parliament Square and asked people who is responsible, they would expect us to have answers. Therefore, we want to make sure there is the appropriate power of responsibility.

I also want to give reassurances that we expect the situations where the Government issue directions to NHS England to be rare. Where it does happen, Ministers will of course ensure that the direction is clear, appropriate and has suitable timeframes. It is paramount that this power can be deployed quickly when required, and limiting it to specific instances, or prescribing a time limit as to its efficacy, would undermine the intent of these provisions.

That said, we agree it would be inappropriate to use this power to intervene in clinical decisions, and we have specifically exempted this in the Bill. For example, we have made sure that a direction cannot be given in relation to drugs, medicines or—interestingly, given our previous discussions—on treatments that NICE has not recommended or issued guidance on. The noble Baroness, Lady Thornton, and the noble Lord, Lord Hunt, rightly questioned the draft guidance that NHS England has given—we are trying to find a copy of that. However, we recognise the unique role the Secretary of State for Health and Social Care plays in the system. The Secretary of State could use the powers to request to see the guidance developed by NHS England before it is published, to ensure that NHS England is working effectively with other parts of the system, such as local authorities, given the concerns that both the noble Baroness, Lady Thornton, and the noble Lord, Lord Hunt, raised.

On Amendments 176A and 174A, we have already included a number of exemptions to the power of direction in the Bill to ensure the Secretary of State is not able to intervene in day-to-day operational matters. There is also no intention that the power will be used to direct NHS England on procurement matters. Any decision to exercise the power will be subject to and guided by general public law principles and general statutory duties. This means, for example, that Ministers will have to use regulations where they exist, as they do for procurement, and that the Secretary of State cannot direct NHS England to breach procurement regulations, since this would be unlawful.

In relation to allocations to ICBs, NHS England uses a formula to allocate NHS resources to different parts of the country based on long-standing principles of equal opportunity of access for equal needs and informed by the independent Advisory Committee on Resource Allocation. There is no intention to use the power to interfere in this process.

In relation to local organisations, I make the point that the Bill will provide more practical autonomy at a local level by strengthening local leadership and empowering local organisations to make decisions about their population, while also allowing for national accountability. This is the approach we want to take with this power: directing NHS England only on the functions it holds in respect of local bodies, to provide necessary support and assistance to them, especially if they are failing. It is also vital that a power of this nature is accompanied with appropriate safeguards and transparency requirements.

On Amendment 174B, which relates to public interest, the clause already ensures that all directions must be made in the public interest.

On Amendment 175A, the noble Lord, Lord Hunt, has called for directions to be laid in Parliament. It is already the case that any direction issued must be made in writing and will have to be published. This will allow Parliament to hold Ministers to account for use of this power.

On Amendment 175, Ministers already work in partnership with NHS England, and any direction made would come after close working and considered discussion. NHS England will continue to make the vast majority of its decisions without direction, consulting the Government as it needs to. We believe that this power provides additional transparency by ensuring that where Ministers direct NHS England, it is clear, published and available for scrutiny by all. Any direction will come after a considered discussion with NHS England and advice, including on the impact and deliverability of such a direction. Ministers will of course consider, with NHS England and others, that the priorities being set are the right ones and whether they are affordable. However, it is important that we do not put in place too bureaucratic a structure that would bind Ministers’ hands when decisions have to be made quickly.

I end by addressing the questions put forward by my noble friend Lord Lansley and the noble Baroness, Lady Walmsley, about Clauses 39 and 64 being removed from the Bill. Clause 39 is part of our ambition to put increased accountability for the Secretary of State at the heart of these proposals while committing to the NHS’s clinical and day-to-day operational independence. We reiterate that the power will add to the existing ways that the Secretary of State and NHS England work together. The mandate to NHS England, which has been an established means of providing direction since 2013, will continue to be the main place for strategic direction-setting.

--- Later in debate ---
Lord Warner Portrait Lord Warner (CB)
- Hansard - - - Excerpts

Before the Minister answers that question, could I add another? We have had 10 years’ experience of NHS England under three chief executives and a number of different chairmen. Can the Minister give any examples of where the powers the noble Lord, Lord Lansley, gave the Secretary of State have been inadequate for them to give direction to NHS England?

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

The Secretary of State cannot issue a direction to CCGs or ICBs on any of this using this power. We have been clear that direction cannot be given in relation to drugs, medicines or on treatments that NICE has recommended or issued guidance on. I gave the example of where we want this guidance—with the draft guidelines published for ICBs. The Secretary of State would be able to intervene and ask to see that guidance—

Lord Lansley Portrait Lord Lansley (Con)
- Hansard - - - Excerpts

I am sorry to interrupt my noble friend again but let us be clear: the Secretary of State would be asked to give a direction in line with NHS guidance. There is nothing in the exception in Clause 39 which says that the Secretary of State cannot give such a direction.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

If my noble friend will allow me, I will have to consider that and write, and make that available to all noble Lords.

We have included a number of exceptions to the power of direction in the Bill to ensure that the Secretary of State is not able to intervene in day-to-day operational matters. For example, there is no intention to use the power to direct NHS England on procurement matters.

On Clause 64, the rationale for removing these duties is twofold. First, the pandemic has highlighted the importance of different parts of the health and care system working together. The clause removes some barriers in legislation that hinder collaboration between system partners. It facilitates collaboration between NHS England and system partners and enables broader thinking about the interests of the wider health system. Secondly, removing the Secretary of State’s duty to promote autonomy will put increased accountability at the heart of the Bill.

Overall, these clauses encompass flexibility, allowing Ministers to act quickly and set direction, while balanced with safeguards and transparency requirements to ensure that they can be held to account. I understand that there are a number of concerns about this group of amendments and others. I am sure we will have a number of discussions, but in the meantime, I ask noble Lords not to press their amendments.

Lord Hunt of Kings Heath Portrait Lord Hunt of Kings Heath (Lab)
- Hansard - - - Excerpts

My Lords, this has been a very significant debate, because when the Minister referred to the fact that Ministers needed to have the answers, I realised that the intention is to go back to command and control from the centre. It was quite clear: that is the intention. I think that is very depressing, because I do not believe that the NHS is going to benefit at all. When he said that this will strengthen local accountability—oh no, it will not. There is no local accountability whatever in this structure. I am sorry to say this again, but the fact that the Government are taking local authority councillors out of ICBs is a visible demonstration that this is a centrally driven health service from the Department of Health.

Baroness Thornton Portrait Baroness Thornton (Lab)
- Hansard - - - Excerpts

I think the Minister is probably getting the message by now. I shall speak to my Clause 40 stand part debate and the amendment in the name of my noble friend Lady Merron. Somebody said earlier that we can be sure that the proposals to allow greater powers for the Secretary of State to intervene in reconfigurations is not something that the NHS asked for. That is almost certainly true.

I congratulate the noble Baroness, Lady Cumberlege, on her great coalition- building; she is very good at building coalitions in support of the things that she cares about, and she has definitely managed to do that with this group of amendments.

Noble Lords have pointed out that, at the moment, we have a system which works. It may be slow, and it is absolutely true that it has processes which take too long, but there are elements of public and patient involvement through consultations. The changes made in 2012 under the noble Lord, Lord Lansley, brought in four tests and some rigour of external independent evaluation. The core of that process still exists. As a non-executive member of the board of the Whittington, I can say that this is exactly the kind of thing that we have been involved in in our own hospital.

The consultations might be improved, but they will not be improved at all by this proposal. In fact, I think that this clause is very odd indeed. It is a bad idea, and it adds nothing to the core of this Bill and its central aim, which is to grow place-based independent and innovative healthcare, and it probably needs to go.

Lord Kamall Portrait The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
- Hansard - -

I thank all noble Lords and noble Baronesses for their contributions. I would be pretty blind or deaf not to understand the level of concern across the Committee. However, if noble Lords will bear with me, I shall try to set out some justifications. I preface my remarks once again by saying that I strongly hear the views of the Committee, and I welcome the fact that previous Ministers and Secretaries of State are warning us not to fall victim to this, as it were.

I start by explaining some of the justifications. It may be helpful to start with some of the observations. The public expect Ministers to be accountable for the health service, which includes service change. We see the new intervention powers enabling the Secretary of State to act as a scrutineer and decision-maker for reconfigurations, to intervene when, for example, they can see a critical benefit or cost to taking one or other course of action, or to take action where there is a significant cause for public concern. Having said that, we accept that public concern could well be a political one, so we understand the concerns expressed by noble Lords.

We expect this power to be used infrequently and, when it is used, it will be done proportionately and transparently. All decisions made using the new reconfiguration call-in power in the Bill must be published, which will ensure transparency and proper scrutiny. The new call-in power for reconfigurations will allow the Secretary of State better to support effective change and respond to stakeholder concerns, including from the public health oversight and scrutiny committees and parliamentarians in a more timely way.

I turn to Amendment 183. Given the role of the Secretary of State, it is proportionate to ask him or her to ask local commissioners to consider service change where there is concern. Once again, we do not expect this power to be used frequently, and all service changes, regardless of whether a Secretary of State has been a catalyst, will still be required to go through due process and where appropriate local consultation. Before any proposal was agreed, the planning and assurance for a proposal would still have to include strong public and patient engagement, consistency with a current and prospective need for patient choice, a clear clinical evidence base and support from commissioners.

I turn to a couple of points from my noble friend Lady Cumberlege and the noble Lord, Lord Stevens, who said that the powers were unnecessary, undesirable and unworkable. To look at the necessity of the power, the current system can lead to referrals coming very late to the Secretary of State, and the power will allow the Secretary of State to intervene earlier to avoid that. For example, my noble friend Lady Cumberlege referred to the Kent and Medway stroke services reconfiguration proposal. One reason why it was lengthy was the need to review the right options for the system. We are hoping that it goes something like this—that you could either knock heads together or, as someone put it more starkly, have a sword of Damocles over them to come to a decision more quickly. But once again we understand the concerns.

I turn to Amendment 180. It is vital that all local views, including that of the health overview and scrutiny committees, are represented in the reconfiguration. The new power in the Bill will not replace the important local scrutiny and engagement that plays such an important role in service change decisions, and a duty for those locally responsible for service change proposals to consult local authorities will remain. It is right that for commissioners and providers who are responsible for planning, assuring and delivering reconfigurations the duty to consult HOSCs and other local stakeholders continues. We are also introducing a duty for NHS England, integrated care boards, NHS trusts and foundation trusts to provide information and other assistance required for the Secretary of State to carry out functions. That will allow the Secretary of State to take into account local views. We expect the Independent Reconfiguration Panel to consider the views and carry on the way it works.

On Amendment 181, we recognise the importance of timely decision-making—

Baroness Thornton Portrait Baroness Thornton (Lab)
- Hansard - - - Excerpts

Is the Minister saying that the Government and his department do not trust NHS England to fulfil this function any longer?

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

No, we are saying that, where there is an issue and it is taking a long time, this measure allows the Secretary of State to come in in a more timely manner rather than waiting for a late referral.

Baroness Thornton Portrait Baroness Thornton (Lab)
- Hansard - - - Excerpts

Does the Minister think that will save time?

Baroness Cumberlege Portrait Baroness Cumberlege (Con)
- Hansard - - - Excerpts

My Lords, before the Minister goes on—just so I do not lose the thread here— could he tell us why the Independent Reconfiguration Panel has to go? What are the problems with it? Why do we have to move it off in order to bring in a politicised system with the Secretary of State making the decisions?

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I must clarify here. I have said that we expect the Independent Reconfiguration Panel to continue to consider views. We are not getting rid of it.

Baroness Cumberlege Portrait Baroness Cumberlege (Con)
- Hansard - - - Excerpts

So that presents a problem. What does the Secretary of State do, and what does the independent panel do? Is it a question of the scale of the change that is being proposed? Where are the boundaries?

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

The Secretary of State will be advised by the Independent Reconfiguration Panel, especially where there is a difficult decision that takes time, just as in the case of the Medway.

On Amendment 182, the Secretary of State’s decision-making process must already take into account the public law decision-making principles, all relevant information and his legal duties, including the public sector equality duty. The Secretary of State is also under several duties in the National Health Service Act 2006, including to promote a comprehensive health service and to support continuous improvement in services.

Lord Hunt of Kings Heath Portrait Lord Hunt of Kings Heath (Lab)
- Hansard - - - Excerpts

There are a lot of marginal seats, and there is going to be a general election in two and a half years—maximum. A lot of the reconfiguration proposals usually relate to smaller places with smaller hospital or DGHs because their viability is often in doubt. So it is quite clear to me that any MP, particularly government MPs, will immediately take any threat of that sort to their local services to the Secretary of State. That will not speed up the process; it will guarantee the opposite. The signal that I would get from the health service as a result of this is: “Forget reconfiguration proposals until after the next election because you ain’t going to get any through.” That is why we think this is a disastrous move.

When the Minister says there will not be many interventions, that is just nonsense. The moment that MPs know the Secretary of State has the power to intervene at any stage, they will be knocking at the door of the Government, who will wilt under that pressure, because that is what happens. Then they will go back and say, “We need to have an independent review of that before you start the process.” There are so many dodges available to a Minister, if you want to dodge making a hard decision in this area, that it will completely paralyse the health service. That is why this debate is so important because it is related to the last one; the result of Ministers gaining direct control will be to delay and reverse, and I am afraid that the hopes that Ministers have for a dynamic, forward-looking health service will come to nothing.

Lord Warner Portrait Lord Warner (CB)
- Hansard - - - Excerpts

My Lords, following on from the noble Lord, Lord Hunt, I ask the Minister to consider the point that I was trying to make about Amendment 183. The Minister and the Government have got this the wrong way round: if he is actually concerned about levels of efficiency, the supply of services and the issue of scale—and the issue of scale is a very real one—then he needs to be at the front of the process, not the end of it. It is a bit late in the day to be having these ideas about scale in a particular set of services when you have gone through the agony of the local consideration of reconfigurations. As a Minister, it would be better, if I may say so, to set out your views at the beginning with the clinical arguments for why this makes sense. Doing it at the end is bound to lead to suspicions. That is why I was asking the noble Baroness, Lady Cumberlege, to look at the wording of Amendment 183. I say to the Minister that he is putting his involvement at the wrong part of the process.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

We agree with the noble Lord. We do not want to waste time by being able to come in only late in the process. To avoid egregious uses of power, all uses are subject to public law principles and challengeable by judicial review.

We agree with the intention behind Amendment 216 but we do not feel it is necessary. Commissioners, NHS England, NHS trusts, NHS foundation trusts and a range of other bodies are required to have regard to the NHS constitution in performing their functions, as set out in Section 2 of the Health Act 2009, which goes wider than this proposed duty that would apply to the Secretary of State.

In addition, the NHS pledges that all staff will be empowered to put forward ways to deliver better and safer services for patients and their families. If a service change is material, the commissioner has a duty to consult with all impacted parties to understand their views and these existing engagement duties can encompass NHS staff. Anyone can respond to a public consultation and there is well-established process and precedent for taking these views into account. Beyond the pledge itself, it is the responsibility of an employer to ensure that staff are appropriately engaged and involved in service change decisions. The need to engage and consult is contained within organisational policies and relevant employment legislation.

I have heard what a number of noble Lords have said, especially former Ministers, Secretaries of State and others involved in the system, and it is quite clear that I need to go back and consult further. In that spirit, I ask that noble Lords do not move their amendments, and hope that I have explained the reasons why.

Clause 40 agreed.
--- Later in debate ---
Baroness Thornton Portrait Baroness Thornton (Lab)
- Hansard - - - Excerpts

My Lords, it is very gratifying that so many noble Lords have decided to come in to take part in a debate about NHS finances tonight; I am very grateful for that.

I shall speak briefly to Amendments 199, 200 and 202A in my name. Amendment 199 provides that the Secretary of State must set out rules for determining the price to be paid for NHS services. Amendment 200 ensures that the key policy documents covering NHS services are approved by the Secretary of State. Amendment 202A provides that the rules must be subject to parliamentary scrutiny.

I am very pleased that the complexity of NHS funding was not mentioned in great detail tonight, but there has been speculation about how funding may work and how the various financial responsibilities in and across ICSs may develop. What we think we know is that complex funding approaches, such as payment by results, will become less important. In Clause 70 and the associated Schedule 10, however, the Bill is wonderfully uninformative. It just says, “Out with the old”—the national tariff—“and in with the new”, the NHS payment scheme. I am again with the noble Lord, Lord Lansley, in saying that these questions need to be answered, because they will affect the regulations, procurement rules and so on.

The payment scheme—actually, I am not going to talk about the history of the NHS payment scheme at this time of night, but, unless the Minister can justify it and answer the questions posed by the noble Lord, Lord Lansley, this part of the Bill should be quietly dropped. We seem to have something that works, so why replace it with something that we do not know very much about?

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I thank the noble Baroness and echo her gratitude to all the noble Lords who have turned up for this group of amendments.

Before I turn to specific amendments, it may be helpful to make a few general points about the new payment scheme and explain why this clause should stand part of the Bill. For many years, the national tariff improved access to services and drove up quality across the NHS. The new scheme will build on that success. NHS England will continue to make rules determining the price paid to a provider, by a commissioner, for healthcare services for the NHS, or for public health services commissioned on behalf of the Secretary of State. Also, expanding the powers to enable NHS England to set prices for public health services, such as maternity screening, will allow for seamless funding streams for different care episodes.

However, we need to update the NHS pricing systems to reflect the move towards a more integrated system focused on prevention, joint working and more care delivered in the community. This will support a move from a “payment by activity” approach, towards an approach that promotes integration and early intervention, while discouraging perverse incentives for patients to be treated in acute settings. It will allow flexibility over the current pricing scheme, and allow rules to set prices, formulas and factors that must be considered when determining the prices paid. I assure noble Lords that, when developing the scheme, NHS England will continue to consult any persons that it considers relevant, which will include ICBs, NHS trusts and foundation trusts, as well as trade unions and representative groups. I share the sentiments of the noble Lord, Lord Davies, about the valuable role that trade unions play in a free society.

I turn briefly to the points made by my noble friend Lord Lansley. On regional variation, the NHS payment scheme will encourage commissioners and providers within an integrated board area to work together to agree prices that are in line with the rules set out in the scheme. To date, only one provider has applied successfully for local modification, and closer working within ICBs should remove the need for disputes. On paying different providers differently, there may be scenarios where it is appropriate to pay non-NHS providers different prices from those paid to NHS providers, to take into account differences, different starting costs or a different range of services provided. There may also be cases where the financial regimes of different providers make it appropriate to set different prices or pricing rules. When setting any prices, NHS England will aim to ensure that prices paid represent a fair level of pay for the providers of those services, as well as fair pay between providers of similar services. We will not introduce competition on price rather than quality. We hope that these changes will increase the flexibility and reduce transactional bureaucracy at the ICP level.

I must disagree with the proposal in Amendment 199. While the Secretary of State will remain responsible for setting out overall funding for NHS England, NHS England, alongside Monitor, has set the rules successfully since 2013. I cannot see the benefit of this duty being transferred to the Secretary of State, beyond separating it further from those making operational decisions in the system. Following that logic, we must also reject Amendment 202A. However, I assure noble Lords that the payment scheme will be published in the usual way, and your Lordships will of course be able to table Questions, secure debates, hold us accountable and ensure that the mechanism is scrutinised.

I turn to Amendments 201B and 201C. As part of the broad consultation duties, we expect NHS England to work closely with trade unions and staff representative bodies, such as the Social Partnership Forum, NHS Providers, the Healthcare Financial Management Association and all the royal colleges, when developing the national tariff.

On Amendment 200, I assure your Lordships that the NHS payment scheme will be published by NHS England following consultation. The Secretary of State will also have the general power to require NHS England to share the NHS payment scheme before publication, not to publish a payment scheme without approval, and to share the contents of the scheme should that be necessary.

On Amendment 201A, in setting the rules for the payment scheme, NHS England will of course want commissioners to consider staff pay, pensions and terms and conditions. NHS England will continue to take account of cost growth arising from uplifts to Agenda for Change. New Section 114C makes it clear that, before publishing the payment scheme, NHS England must consult any person that it thinks appropriate. Again, in practice we expect this to include representative bodies and trade unions. NHS England must also provide an impact assessment of the proposed scheme.

I hope I can reassure noble Lords that the department and NHS England remain committed to Agenda for Change. Independent providers will remain free to develop and adopt the terms and conditions of employment, including pay, that best help them attract and keep the staff they need. However, we expect that good employers would set wage rates that reflected the skills of their staff.

On Amendment 202, it is right that the commissioners and providers of NHS services should be able to make representations and, if they feel it necessary, object to pricing mechanisms set by NHS England in the payment scheme. That is why we have retained the duties to consult commissioners and providers. We have also retained the ability for ICBs and providers to make representations and to formally object in response to consultations on the NHS payment scheme, as they can with the national tariff.

The current prescribed thresholds are set by the National Health Service (Licensing and Pricing) (Amendment) Regulations 2015, and the current objection thresholds since 2015 have been set at 66%. My department consulted on these thresholds in 2015 and it remains the Government’s view that they are proportionate, preventing the delay of future payment scheme publications and giving the NHS the certainty that it needs to plan for future financial years.

If I have not answered all the questions from my noble friend Lord Lansley and others, I ask noble Lords to remind me and I will write to them. This has been a very important discussion—as we can see by the attendance—and I hope I have given enough reassurance to noble Lords for them not to move their amendments and have explained why the clause should stand part of the Bill.

Lord Lansley Portrait Lord Lansley (Con)
- Hansard - - - Excerpts

My Lords, I am most grateful for the Minister’s response to that short debate and for the other contributions. I shall certainly look at the Court of Appeal judgment—was it the Court of Appeal? —and try to work through precisely where the problems are. There are two ways of dealings with this issue. One is to scrap the national tariff and put in a new payment scheme. The other is to start with the national tariff and ask what the problems are and how we are going to deal with them, and I would quite like to work that through.

We may come back to this because there is an issue about how far the payment scheme is a national payment scheme and how far it becomes a local and varied one. That is a very interesting question, as is the way in which discrimination between providers may be implemented and for what purposes.

For the moment, though, I am very grateful to my noble friend for his response and for his promise to follow up on issues.

--- Later in debate ---
Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

My Lords, this has been a fascinating discussion and debate. I recall watching the debate on the Private Member’s Bill of the noble Baroness, Lady Meacher, a few weeks ago; I remember thinking that that was Parliament at its best. The arguments on both sides are fascinating—thank goodness I was not the Minister responding.

I thank my noble friend Lord Forsyth for assuring me today that we were not going to re-open the whole issue but talk only about the merits of the noble Lord’s amendment. Before I turn to his amendment, I will start with Amendment 203 tabled by the noble Baroness, Lady Meacher.

It is incredibly important that everyone at the end of their life, whether or not they have been diagnosed with a terminal illness, has the opportunity to discuss their needs, wishes and preferences for future care, so that these can be taken fully into account. There is ongoing work across the health and care system, as the noble Baroness, Lady Finlay, alluded to, to support this aim, including a commitment within the NHS Long Term Plan to provide more personalised care at end of life, and a recently updated quality statement from NICE on advanced care planning. In addition, we have established the ministerial oversight group on Do Not Attempt Cardiopulmonary Resuscitation, following the CQC’s review of this during the Covid-19 pandemic. This group is developing a set of universal principles for advance care planning to further support health and care professionals in having appropriate and timely discussions with individuals at the end of life. We believe that patient choice is a powerful tool for improving patients’ experience of care, and we intend to ensure that effective provisions to promote patient choice remain. However, I do not feel it is appropriate to specify the level of detail included in Amendment 203 in the Bill, and I hope the noble Baroness, Lady Meacher, will consider withdrawing her amendment.

Let us now turn to the amendment that has been much discussed. As many noble Lords have rightly said, it is a long-standing position that any change to the law on assisted dying is a matter for Parliament to decide, rather than one for government policy. Assisted dying remains a matter of individual conscience, on which there are deeply held and very sincere views on all sides. Sometimes these are informed by one’s own experience of family members; other times, these are informed by one’s faith. You can rationalise it, or argue, but people have very strong feelings on both sides.

Noble Lords are aware of the Private Member’s Bill of the noble Baroness, Lady Meacher, on this subject, and we look forward to further debate in Committee when parliamentary time allows. I will commit to discussing this with the Chief Whip, given the request that was made. But as this matter is so important and is a matter of conscience, we cannot take a partisan position. If the will of Parliament is that the law on assisted suicide should change, the Government would not stand in the way of such change but would seek to ensure that the law could be enforced in the way that Parliament intended.

Lord Forsyth of Drumlean Portrait Lord Forsyth of Drumlean (Con)
- Hansard - - - Excerpts

I am most grateful to my noble friend. Could he just clarify what he said? Did he say that there was a possibility that time would be made available for the Bill of the noble Baroness, Lady Meacher?

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I am afraid that I cannot give that guarantee. I will commit to speak to the Chief Whip about whether time could be made available.

None Portrait Noble Lords
- Hansard -

Oh!

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I was not expecting that reaction.

On Amendment 297, it would not be appropriate to include a commitment to bring forward new primary legislation in the Bill. Future Bills and the use of parliamentary time are decisions that are rightly made via other avenues. As I said, I will commit to speak to the Chief Whip—he is not very far from me at the moment.

A number of noble Lords spoke about definitions. It seems that tonight we have challenged the definition of “neutral”. I was told that if I did not support this amendment, it would not be a neutral position. Given that those who spoke in favour of the amendment tend on the whole to be in favour of assisted dying, would it be a neutral position if I supported it? Therefore, have we now got a subjective understanding of neutrality or, as I said in my PhD viva, a subjective view of objectivity?

For all these reasons, I ask the noble Lord to consider not moving his amendment, but I fully expect him to come back to it in future.

Baroness Meacher Portrait Baroness Meacher (CB)
- Hansard - - - Excerpts

My Lords, I thank the noble Lord, Lord Forsyth, for tabling his amendment. I was asked by other noble Lords to make it absolutely clear, and I have no problem with this, that I fully and strongly support his amendment. I did not speak to it because of time.

I thank a lot of noble Lords for being very good this evening about not addressing the great issue of assisted dying, because that would have been entirely inappropriate. Many noble Lords have been careful not to do that, so I am grateful to them. I am also grateful to the many noble Lords who have made clear their support in particular for Amendment 297. I was very clear about my own amendment; it is a probing amendment. I thank the Minister for his response and the Chief Whip for placing this at the very end of the day so that we did not spend 12 hours on it—I think we can all be grateful for that. I thank all noble Lords here tonight. I beg leave to withdraw the amendment.

Health and Care Bill

Lord Kamall Excerpts
Baroness Walmsley Portrait Baroness Walmsley (LD)
- Hansard - - - Excerpts

My Lords, if the noble Baroness, Lady Pitkeathley, is the general, we are all her foot soldiers. There have been some excellent speeches. In particular, the noble Baroness outlined for us what are, I hope, the unintended consequences of what the Government are doing in their proposals about discharge to assess. It does not seem right that it is up to this House to put back the rights and abilities of carers to do their caring without too much impact on themselves. I hope the Minister heard what the noble Baroness, Lady Pitkeathley, and others, such as the noble Lord, Lord Warner, said about that. We heard from the noble Baroness, Lady Hollins, how much worse the situation has been for so many carers—in particular those who care for people with learning disabilities or mental health problems—during the pandemic, when, unfortunately, it was necessary to withdraw certain services that they normally rely upon. I hope that, when we have heard the Minister’s response, we can come back to Clause 80 on Report if we are not satisfied with the Government’s response, because the situation is not good, even now.

I am grateful to Carers UK and Barnardo’s, which have given us some dreadful horror stories about the situation of carers when the person they care for is being discharged from hospital. One of the worst that I read about was when the carer was only told when the person being discharged was actually in the ambulance on the way home. They had to run around trying to get a commode, which that person would certainly need when they got home. The situation is so much worse for a young carer who does not necessarily know their way around the system in the same way that an adult carer might. Although I support all the amendments in this group, that is why I added my name to Amendment 269 in the name of the noble Lord, Lord Young of Cookham. It is all about the need to identify and ensure appropriate support for young carers before a patient leaves hospital. I really take on board my noble friend Lord Scriven’s view that you should not do it at the end of the stay in hospital: you should start thinking about it when the person goes into hospital.

Caring for a sick or disabled person, no matter how strong the bonds of love, is a difficult and exhausting challenge. It is hard enough for adults, the majority of whom, as we have heard from my noble friend Lady Tyler, are women; we have heard about the effects on their finances and pensions. Many adults do not feel equipped to do it adequately, and it is even harder for children. How can a child be expected to have the knowledge and skills needed to care adequately for an adult and, at the same time, benefit from education and prepare for their own future life?

We know that circumstances sometimes put children in this position, but it is essential that public services provide as much support as possible. However, we know that, although it is estimated that there might be around 800,000 young carers in the whole of the UK, sometimes even their school does not know who they are. In some cases, the young carers themselves prefer it that way, because they see it as a stigma or something that their friends might not quite understand; but it does mean, of course, that they do not get the help that they need, and neither does the person being cared for.

I agree with the noble Baroness, Lady Wheeler, that a proper assessment must be done either before the patient leaves hospital or very promptly post discharge. I hear all the problems about that; yet, carers, according to an ONS report in 2017, save the state more than £60 billion every year, which is more than is spent on formal caring—although it is not clear how much of that is saved by young carers. On the other hand, it has been assessed that a family with a young carer has an income, on average, £5,000 a year lower than other families—so these families are often poor too.

Local authorities already have considerable duties relating to identifying, assessing and supporting young carers, and we have heard of at least two very good schemes. Many of them do it very well, despite the fact that some of these young people are hard to find. However, it is essential that some duties also apply to the NHS, and they must not be lost in the move to integrated care systems. Adequate focus must be placed on these duties by the ICB having a rigorous system or framework to ensure a process for assessment. As my noble friend Lord Scriven pointed out, this is step one in ensuring that needs are subsequently met.

Lord Kamall Portrait The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
- Hansard - -

My Lords, I thank all noble Lords for their contributions to this debate. We are looking to move towards a more integrated care system for precisely some of the reasons that noble Lords have laid out: that a patient is discharged by a hospital but it is not done in an integrated way. As the noble Baroness, Lady Wheeler, said, during the pandemic local authorities and the NHS developed innovative ways to support better discharge from hospital to community care, and what we want to see is discharge to assess as one model. In some cases, it might be the best model: for example, where people are over the age of 80, the longer they stay in hospital, the more you see muscular deterioration. That is one of the reasons given for why, in some cases, discharge to assess might be the most appropriate.

--- Later in debate ---
Lord Warner Portrait Lord Warner (CB)
- Hansard - - - Excerpts

I am sorry to interrupt the Minister’s flow. I have been listening very carefully to this. What I do not understand is what happens if there is not enough resource in the local authority. Local authorities have had pretty poor treatment over the last decade compared with the NHS. If there is not enough resource to either do an assessment or meet the needs of that assessment, does it then fall to the NHS to plug the gap if it wants to get the person out of hospital? We would like a little more clarity on that particular aspect.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I thank the noble Lord for his question. The goal is to make sure that the NHS and local authorities work better together. The noble Lord talks about resources. One of the reasons for the levy—whatever one thinks of it—is to help plug that gap and to make sure that there is more money going into social care as well.

Turning to the points made about the term “carer”, we believe that the term is used to capture the whole spectrum of carers, including children and adults who care, unpaid, for a friend or family member. By not imposing a statutory definition, we avoid inadvertently excluding groups, and ensure that ICBs and NHS England promote the involvement of all types of carers and representatives.

Turning to the last amendment in this group, existing legislation already requires local authorities to carry out an assessment of need for all young carers upon request or on the appearance of need. This assessment must consider whether it is appropriate or excessive for the young carer to provide care, in the light of the young carer’s needs and wishes. Indeed, as some noble Lords have said, sometimes what happens is that the hospital may decide it is appropriate but those who are supposed to be doing the caring at home do not feel they have the ability.

We hope that under this, as part of the discharge planning, the current discharge guidance can set out any considerations that should be given to young people in the household who have caring responsibilities. We want to strengthen current processes in respect of young carers too. We are also working with the Department for Education to ensure that protections for young carers are reflected in the new guidance, including setting out where young carers should have a needs assessment arranged before a patient for whom they provide care is discharged, or as soon as possible afterwards.

Given the comments from noble Lords, especially the noble Baroness, Lady Pitkeathley, and the noble Lord, Lord Warner—sorry, I should say, General Pitkeathley and Major Warner—clearly there are still some concerns over how this will work. It would be worthwhile having some more conversations on this issue to better understand how we see integrated care working, where there may well be gaps in our understanding and whether we can help to close the gaps between the two sides.

Baroness Wheeler Portrait Baroness Wheeler (Lab)
- Hansard - - - Excerpts

My Lords, it has been an excellent debate and I thank all noble Lords for their contributions, all strongly supporting this important group of amendments, which would ensure that the needs of both patients and carers were fully taken into account in the discharge process and that Clause 80 does not just wipe away carers’ rights—legal rights that have been hard-fought for. Although I am pleased that the Minister talked about further guidance being developed and co-produced, I cannot see how that will address the problem of replacing carers’ rights, which are being taken out of this Bill and need to be included in it.

I am also a bit disappointed that the Minister did not respond to my noble friend Lady Pitkeathley or give her the reassurances that she was seeking over the deep concerns about the expectation in the current guidance that unpaid carers will need to take on even more unpaid work. She made her views quite clear on this: it is paid work that unpaid carers need, not to be forced on to or to stay on benefits. They can take up jobs only if they get the care and support that is needed in the home or from the services that they need.

Noble Lords have made it clear that the discharge to assess model has to be matched with proper funding and community and healthcare services. The noble Baroness, Lady Hollins, reminded us of the importance of this in respect of the carers of people with learning difficulties, who face particular problems in caring. It is also overwhelmingly clear that noble Lords strongly support the establishment and the carrying forward into the Bill of existing carers’ rights.

I hope the Minister will meet urgently with my noble friend Lady Pitkeathley, Carers UK and others involved in these amendments, both to address the fundamentally wrong assumptions in the guidance about the role of unpaid carers and to ensure that their existing hard-won legal rights that have been taken away will be included. He also needs to provide the evidence called for by my noble friend on the overall assumption the Government are making that the discharge to assess process is better for carers than the existing rights that they have; it is not. This is a key issue that we will return to on Report, so I hope some action will be forthcoming from the government discussions between now and then.

On my own amendment, I would like to have heard a lot more reassurances about the timescales and timelines involved in the discharge process. I thank the noble Baroness, Lady Altmann, and in particular the noble Lord, Lord Scriven, for his support, and for explaining why this issue is important and how, practically, it would work with local authorities. On young carers, I particularly thank the noble Lord, Lord Young, and everybody who has participated in that.

I remind the Minister of the point from the noble Baroness, Lady Meacher: in the discharge process and in the assessments of carers it is really important that the question be asked whether they are able to care and whether they want to care. I would like the Minister to take up that issue. I know that carers feel strongly about this, but quite often, even if they are asked, no notice is taken and they just have to get on with it and nothing else happens. I would particularly like to see a response to that.

On those few points, I beg leave to withdraw my amendment. I hope the Minister acts quickly to meet carers and their representatives.

Health and Care Bill

Lord Kamall Excerpts
Moved by
225A: Clause 4, page 2, line 35, leave out from “objectives” to “, and” in line 38 and insert “specified by the Secretary of State under subsection (2)(a) for NHS England must include objectives relating to outcomes for cancer patients”
Member’s explanatory statement
This amendment changes the focus of the cancer outcomes objectives so that they cover matters other than treatment (e.g. early diagnosis).
Lord Kamall Portrait The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
- Hansard - -

My Lords, I will also be moving Amendments 225B and 225C in due course. Clause 4 sets a requirement for the Secretary of State to include objectives relating to cancer outcomes in the mandate to NHS England, and for these objectives to have priority over other objectives relating specifically to cancer.

I first thank John Baron MP in the other place, who introduced this clause, and noble Lords for their support in ensuring that the Bill best delivers on our shared intention of improving outcomes for cancer patients. I also thank the cancer charities that have contacted me to express their views, and the noble Baroness, Lady Morgan of Drefelin, for her engagement. The Government have worked with Mr Baron, NHS England and stakeholders to ensure that we deliver the greatest benefits for cancer patients while minimising the risk of unintended consequences. Amendments 225A, 225B and 225C, tabled in my name, have the full support of Mr Baron, and I strongly encourage your Lordships to support them.

In recognition of the range of services offered to cancer patients, Amendment 225A will ensure that the scope of possible outcomes-driven objectives is broad enough to capture all cancer interventions, such as screening programmes or targeted lung health checks, not just those relating specifically to treatment. Connected to this, Amendment 225C will ensure that these objectives have priority over any other objectives relating to cancer, not just those relating to cancer treatment.

Amendment 225B, meanwhile, makes it clear that the objectives over which the cancer outcomes objectives have priority are those which relate specifically to cancer. When it comes to setting priorities for NHS England, including on cancer, it is vital to consider the outcomes that they should be directing the NHS to achieve. Improving outcomes means boosting survival rates—that remains our overriding aim. But the outcomes that matter to cancer patients are not limited to survival. They also include improving the quality of life for those living with cancer and the patient experience of those being treated.

We want to make sure the objectives we set benefit the outcomes of all cancer patients, whether the objectives relate to screening, early diagnosis or treatment. This is crucial as screening and early diagnosis interventions are one of the most effective ways of improving outcomes and chances of survival. I hope your Lordships can support these amendments.

Lord Moylan Portrait Lord Moylan (Con)
- Hansard - - - Excerpts

My Lords, I greatly welcome the amendments proposed by my noble friend. In fact, I put my name to the equivalent amendments earlier, proposed by my noble friend Lady Morgan of Cotes. I rise to speak to my Amendment 294, the purpose of which is to draw attention to the dire state of the services and treatment offered to people suffering from cancer of the pancreas—although I could also say that there are other, equally forgotten and equally deadly cancers, such as bile duct cancer, that deserve a debate as well. I am grateful to my noble friend Lord Vaizey of Didcot and to the noble Lords, Lord Patel and Lord Aberdare, for their support of the amendment.

Many of us have seen family members and friends fall prey to this disease. Pancreatic cancer is the deadliest common cancer. It affects 10,000 people a year across the UK, and more than half will die within three months. Three in four will die within a year. Vague symptoms, lack of a simple early test, and low symptom awareness among both the public and primary care professionals result in three in five people with pancreatic cancer being diagnosed at a late stage, when curative treatment and life-saving surgery are no longer possible.

Research into pancreatic cancer has been underfunded for decades: it receives only 3% of the UK cancer research budget, despite being the deadliest common cancer. The result is that pancreatic cancer has the lowest survival rate of all common cancers, with five-year survival rates less than 7%. Five-year survival in the UK lags behind the rest of the world, with the UK ranking 29th out of 33 countries with comparable data. These survival statistics have barely improved in decades.

In addition, there is an unacceptable variability of services for pancreatic cancer sufferers, depending in part on geography, with those living near the few specialist centres able to access some services barely available elsewhere.

I wrote last year to my noble friend Lord Bethell with a particular suggestion being promoted by the small but excellent charity Pancreatic Cancer UK. In due course, on 1 December, I received a reply from my honourable friend Maria Caulfield, who said that NHS England and NHS Improvement had launched an audit of pancreatic cancer services with a view to reducing variations in treatment and improving outcomes. That is wholly welcome. The information we have nationally on pancreatic cancer treatment in the NHS is woefully poor. An audit is a good place to start. But she went on to say that the first data were expected in 2023—not the report, not the action plan that we need, and not the funding allocation, merely the first data.

My amendment seeks to impose certain reporting obligations on the Secretary of State, but its real purpose, and the real purpose of this debate, is to inject some urgency into the Government and the NHS. We cannot afford to wait years just to begin to understand the state of pancreatic cancer treatment and care, let alone to take action to improve outcomes. Pursuing the audit with urgency and dispatch should be a top government priority.

There is one thing the Government could do right away that would at least alleviate the suffering of pancreatic cancer patients—and this indeed is the subject I wrote to my noble friend Lord Bethell about at the urging of Pancreatic Cancer UK. The symptoms caused by pancreatic cancer have a very distressing impact. In particular, people are often unable to digest their food, ultimately starving the body of nutrients and calories, leading to rapid weight loss, malnutrition and loss of muscle mass.

The solution to these symptoms is pancreatic enzyme replacement therapy—PERT. PERT comes in tablet form; you take it with your food. It replaces the digestive enzymes that many people with pancreatic cancer can no longer produce. Taking the tablet helps food to be digested and absorbed by the body, and can vastly improve people’s quality of life. It can also, crucially, help them to gain the strength needed to undergo treatment. If people have lost weight and are too weak, they are sometimes not able to have surgery for that reason. NICE guidelines clearly recommend PERT for people with pancreatic cancer, whether the cancer is operable or inoperable, and there is widespread clinical consensus on its effectiveness. It is widely available and is cost-effective: it costs the NHS just £7 per day per patient.

However, a recent study has shown that only half the people with pancreatic cancer across the UK are prescribed PERT. The May 2021 RICOCHET study, undertaken by the West Midlands Research Collaborative, found that 50% of pancreatic cancer patients were not being prescribed the tablet they needed to digest food. The key reason people are not being prescribed PERT currently is a lack of dissemination of specialist knowledge about pancreatic cancer and the benefits of PERT to general healthcare settings. PERT is more likely to be prescribed in specialist surgical centres than in general hospitals, meaning that people whose cancer is operable are more likely to be prescribed PERT than those whose cancer is inoperable, because people whose cancer is operable are more likely to be moved to a specialist setting.

However, three in five people with pancreatic cancer are not diagnosed until their cancer is at an advanced stage and no longer operable, so they will tend to be treated with palliative care in a non-specialist setting. This means they will be far less likely to be prescribed PERT than if they had been diagnosed early.

What I would hope to hear my noble friend the Minister say this evening is that without waiting for the results of the audit, he will immediately set a national priority that PERT should be routinely prescribed as a feature of pancreatic cancer care. Without setting this focus and without corresponding leadership from national and local health bodies, knowledge and expertise will continue to spread far too slowly for the people with the quickest-killing cancer.

--- Later in debate ---
Baroness Merron Portrait Baroness Merron (Lab)
- Hansard - - - Excerpts

My Lords, we are very pleased to support the government amendments that we have heard outlined. Crucially, they focus on cancer outcomes. As the noble Baroness, Lady Morgan, underlined, that includes survival, quality of life, experience of treatment, end-of-life care as well as diagnosis—in other words, the whole experience in treating somebody as a whole person on a journey that they may have to face. I congratulate the Minister on bringing the amendments forward. I also thank the noble Lord, Lord Moylan, supported by the noble Lords, Lord Aberdare and Lord Vaizey, and others, for highlighting the fact that pancreatic cancer has such an aggressive nature, and yet the symptoms are so silent and often misunderstood that it presents a particular challenge in the context of the care that we are speaking of today.

A focus on outcomes that covers matters other than treatment will be particularly crucial following the backlogs that the pandemic has inevitably led to, with delays in people seeking check-ups and treatment. Macmillan has let us know that more than 31,000 people in England are still waiting for their first cancer treatment, and it has also said of the Bill that for those living with cancer

“not a lot will look different.”

It is therefore crucial that the Minister assures noble Lords that stakeholders are supportive of the changes outlined in this group.

On the point about survival rates lagging behind those of other countries, that is not because the National Health Service is worse than other healthcare systems at treating cancer once it is detected but because it may not be as good at catching cancers in the crucial early stages. In other words, late diagnosis lies behind our comparatively poor survival rates. A key advantage of focusing on outcome measures is that it will give healthcare professionals much greater freedom and flexibility to design their own solutions, which could include running wider screening programmes and better awareness campaigns, and establishing greater diagnostic capabilities at primary care. A further advantage of this new focus is that it will better align NHS priorities with patient needs, which, after all, are core to our discussions on the Bill today.

I have a final and gentle word for the Minister to back up the introductory comment of the noble Baroness, Lady Walmsley. It is of course usual to consult the Opposition and others in advance to ensure that amendments are acceptable and do what is required—in other words, to strengthen the case. I know that this did not happen until very late in this case, and I am sure the Minister will not wish to repeat that practice. In summary, however, we very much welcome these amendments.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I thank the Opposition Front Benches for being so gracious given the fact that we notified them late and did not use the correct procedure. I apologise for that once again and I know that the Bill team also apologises for it. We are all on a steep learning curve, as I am sure all noble Lords acknowledge. I thank both noble Baronesses. I hope the lesson has been learned, and we will not have an excuse next time.

I will address Amendment 294 before I come to our amendments. I thank my noble friend Lord Moylan for tabling it. To reassure him, the pancreatic cancer audit is included in the national cancer audit collaborating centre tender, which is currently live. Some reporting timelines are included in the specification for this audit, developed in partnership with NHS England and NHS Improvement, but I am told that during a live tender the document is commercially sensitive and cannot be shared beyond the commissioning team, as this could risk jeopardising the procurement process. The future contract is anticipated to start in autumn of this year. However, it is not possible to confirm the timelines for a new national audit topic for pancreatic cancer until the procurement completes and the contractual deliverables are signed. Unfortunately, therefore, this cannot be aligned with the passing of the Act.

My noble friend will be aware that NICE clinical guideline NG85 recommends that pancreatic enzyme replacement therapy, or PERT, should be offered to patients with inoperable pancreatic cancer and that consideration should be given to offering PERT before and after tumour removal. NICE acknowledges that this is a priority area for improving the quality of health and social care and has included PERT in its quality standard on pancreatic cancer.

We have taken and will continue to take steps to support Pancreatic Cancer UK’s campaign to encourage greater uptake of PERT by doctors treating pancreatic cancer patients, in line with NICE guidance. We are in the process of commissioning a PC audit and, while the scope of this is not confirmed, we will certainly include this in the scoping of the topic. As I said, NICE acknowledges this as a priority area and, while its guidelines are not mandatory for healthcare professionals, the NHS is expected to take them fully into account in ensuring that services meet the needs of patients.

--- Later in debate ---
Lord Moylan Portrait Lord Moylan (Con)
- Hansard - - - Excerpts

My Lords, before my noble friend sits down, on behalf of people who are currently suffering from pancreatic cancer or who might be diagnosed with it in the next few months, is anything going to happen faster in relation to dissemination of knowledge and prescription of PERT as a result of this debate than would have been the case had we not raised this with him?

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I am afraid that I am not entirely sure of the answer to that, but I hope that we have raised awareness. I am very happy to have a conversation with my noble friend to see what more can be done, if anything.

Amendment 225A agreed.
--- Later in debate ---
Moved by
225B: Clause 4, page 2, line 39, after “relating” insert “specifically”
Member’s explanatory statement
This amendment makes it clear that the objectives over which the cancer outcomes objectives have priority are those which relate specifically to cancer.
--- Later in debate ---
Moved by
232: Clause 136, page 112, line 10, leave out “an Act of” and insert “a Bill in”
Member’s explanatory statement
This amendment makes a drafting change to reflect the fact that consent of the Secretary of State under section 8 of the Northern Ireland Act 1998 is given in relation to an Assembly Bill rather than an Assembly Act.
Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

My Lords, I will speak to two minor technical amendments, Amendments 232 and 312. These amendments, which are made to Clause 111, in relation to HSSIB, and Clause 136, in relation to international healthcare agreements, do not impact the policy of either clause. They simply amend the drafting so that references are made to an Assembly Bill rather than an Assembly Act in relation to Northern Ireland. I beg to move the first of these minor technical amendments, Amendment 232.

Earl of Kinnoull Portrait The Principal Deputy Chairman of Committees (The Earl of Kinnoull) (CB)
- Hansard - - - Excerpts

My Lords, the noble Baroness, Lady Brinton, is participating remotely and I think now would be a convenient moment for her to speak.

--- Later in debate ---
Baroness Thornton Portrait Baroness Thornton (Lab)
- Hansard - - - Excerpts

My Lords, I am extremely grateful to the noble Lord, Lord Sharkey. Several months ago, some of his staff came to talk to me about the international healthcare part of the Bill. I said pretty much what the House decided two and a half years ago, which the noble Baroness, Lady Brinton, described. I said that we would be very sceptical of it, because we had to cut a Bill in half all those years ago to take out the international bit and leave in the European and Swiss bit because of the powers that it gave the then Secretary of State to make agreements with persons—without specifying who they might be. I remember it very clearly. So when I saw that the noble Lord had put down clause stand part, I regretted that I had not put my name to it at that time, because I realised that we would have to address this aspect of the legislation. I will not object at all to the two minor amendments, as I realise that they are simply drafting amendments, but unless we can resolve this in some way which deals with the powers, I fear that we will return to this on Report, and we will certainly support a move to remove this clause from the Bill.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

My Lords, I am grateful to the noble Lord, Lord Sharkey, and others for their comments and for their engagement with the Bill team on this issue. We currently have only limited healthcare agreements with countries outside Europe. They support people from the UK to access medically necessary healthcare but do not always provide comprehensive cover for those who need it. The powers included in this clause will enable the Government to implement comprehensive reciprocal healthcare agreements with countries around the world, not just with the EEA and Switzerland. This will allow the reimbursement of healthcare costs and the exchange of data to facilitate a reimbursement process. By implementing such agreements, we hope that we can better support people when they are abroad. We have listened to concerns previously expressed in the House, so the Bill will also remove Section 1 of the Healthcare (European Economic Area and Switzerland Arrangements) Act 2019, which provided a freestanding payment power and enabled the Secretary of State to make unilateral payments for healthcare in the EEA and Switzerland. This is no longer needed, following EU exit.

We are replacing this power with regulation-making powers which can provide for payments to be made in two circumstances: one, to implement healthcare agreements, and two, in countries where there is a healthcare agreement in place but the healthcare falls outside the scope of that agreement and the Secretary of State determines exceptional circumstances exist to justify payment. These are not the same powers that were originally drafted in the 2019 Bill. We have listened to Parliament and limited the scope of the powers to those necessary to deliver the policy intention. We have, for example, revoked the unilateral payment powers, which would enable the Secretary of State to make wide-ranging payments for healthcare outside healthcare agreements. The UK recently successfully concluded a trade and co-operation agreement with the EU, which includes comprehensive reciprocal arrangements. Therefore we see this as an appropriate time to tailor existing powers so they allow us best to support the healthcare needs of UK nationals across the world.

We hope that these legislative measures will allow us to strengthen existing agreements with non-EU countries or form other healthcare partnerships should we wish to in future. This includes looking to improve our healthcare co-operation with key international partners, the Crown dependencies and our overseas territories. We also want to offer more healthcare cover to UK residents travelling abroad for tourism or short-term business purposes, similar to the arrangements available to them when they visit EU countries.

I take this opportunity to confirm that there are no Henry VIII powers in this clause; they were removed during the passage of the Bill in 2019 and have not been put back. In response to the question of the noble Baroness, Lady Finlay, the Bill requires consultation with the devolved Administrations over the drafting of regulations made under the powers in this clause, and we are pleased that the devolved Administrations have all agreed to recommend that legislative consent is granted for these provisions.

In addition, the negotiation of international health agreements is reserved, and the devolved Administrations have a role to play in implementing those agreements. That is why we laid amendments in the House of Commons on Report of the Health and Care Bill. These amendments give the devolved Administrations power to make regulations in the areas of devolved competence within reciprocal healthcare.

As we are all too aware, healthcare co-operation between countries is a vital aspect of the global society we are a part of. Reciprocal healthcare provides safeguards and support for our most vulnerable as well as greater opportunities to travel, for work or leisure. I thank the noble Lord, Lord Sharkey, for his suggestion that we have a meeting before Report for further conversation.

Amendment 232 agreed.
--- Later in debate ---
Moved by
232A: Clause 140, page 116, line 41, leave out from beginning to end of line 9 on page 117 and insert—
“(a) in relation to eligible needs met by a local authority, to any amount the local authority charged the adult under section 14(1)(a) or 48(5) for meeting those needs;(b) in relation to eligible needs met by a person other than a local authority, to what the cost of meeting those eligible needs would have been to the local authority that was the responsible local authority when the needs were met.”Member’s explanatory statement
This amendment de-couples the costs that accrue towards the care cap from the costs specified in the budgets and simplifies the drafting for determining those costs that accrue.
Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

My Lords, I will speak to Amendments 232A, 232B, and 234A to 234L in my name, made in relation to Clause 140. In the course of the detailed work on the operational guidance on charging reform in partnership with local authority representatives, it has become apparent that the existing legislative framework leads to unfair treatment of local authority-supported individuals in some areas and proffers incentives for self-funders in others. The intention of these amendments is to remove this. This applies even before this Bill, or whatever charging scheme we come up with, comes into effect.

Noble Lords may be aware that everyone who wants to meter towards a cap on personal care costs must have a needs assessment to ensure they have eligible needs. If there is a delay in the needs assessment through no fault of the person requiring care, they may wish or need to begin to pay for care before the local authority is able to intervene. At present, Clause 140 would enable self-funders to start metering from the point they request an independent personal budget, but the clause does not contain an equivalent provision for those whose needs are expected to be met by the local authority. These amendments will make the position the same for those whose needs are met by a local authority as for a self-funder, as well as clarifying that metering for those whose needs are being met by a local authority will be at the amount the local authority charges.

The amendments will also decouple how a local authority decides what meters towards a cap from the personal budget and independent personal budget. There are several practical benefits of this. Among the most important is ensuring that, having had an independent personal budget set by a local authority, nobody has a perverse incentive not to meet their needs. Without the amendments, somebody would meter the amount they are expected to spend set out in their independent personal budget even if they then purchased less care in order to save money.

The amendments also mean that any spending to meet agreed eligible care needs would meter towards a cap at the amount it would cost the local authority to meet those needs, where they are met by the local authority at the amount charged by it. This would happen even if it was omitted from the personal budget or independent personal budget for some reason.

Finally, there is an amendment to make a minor clarification of the circumstances in which an independent personal budget must be provided by a local authority and what the personal budget and independent personal budget must include.

I look forward to this debate and I am grateful to many noble Lords who, I am sure, wish to speak on this important matter.

Earl of Kinnoull Portrait The Principal Deputy Chairman of Committees (The Earl of Kinnoull) (CB)
- Hansard - - - Excerpts

My Lords, the noble Baronesses, Lady Brinton and Lady Campbell of Surbiton, will be speaking remotely. I invite the noble Baroness, Lady Brinton, to speak now.

--- Later in debate ---
Lord Davies of Brixton Portrait Lord Davies of Brixton (Lab)
- Hansard - - - Excerpts

My Lords, I just want to contribute to this debate. I fully support the remarks of my noble friend Lady Thornton. I was particularly struck by her dissection of this Government’s totally preposterous claim to have a plan for social care. They do not have a plan. All they have is a regressive tax and a broken promise.

I am tempted by the remarks of my noble friend Lord Lipsey to enter into a broader debate on these issues. Clearly, this issue is not going to go away. This is not the end and the issues that were raised will come back again and again until we move towards something fairer and more comprehensive. I cannot resist saying that I am unconvinced that deferred annuities will have any part in any sort of mass market provision of care. As a product, they are fatally flawed, in my view.

My noble friend’s remarks also made me think of the extent to which this debate is taking place while ignoring the key factor in these issues, which is housing or, rather, property management. That is really what we are talking about, but we do not mention it in the context of these debates, which is unfortunate. I am glad my noble friend raised these issues. However, I think the substantive point this evening is the imperative of sending this clause back to the Commons where they can reassess it with greater time than they were allowed initially.

Finally, I just want to highlight the revealing and outrageous statement by the Minister in the Commons, Mr Argar. He said the Government

“have always intended for the cap to apply to what people personally contribute, rather than on the combination of their personal contribution and that of the state.”—[Official Report, Commons, 22/11/21; col. 110.]

I do not believe that means-tested benefits are any more money being given by the state than my pension that I get from the national insurance scheme. It is outrageous to cast people as, in a sense, recipients of charity. It is their rights as citizens to have this money, and it is their money; it is not the state’s money. It reveals the Poor Law mindset of this Government.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

My Lords, I understand the concerns about the lack of debate in the other place on this issue. The Government are putting in place a package of reforms to be implemented in 2023. The introduction of the £86,000 cap on costs is part of a package through which we hope that no one will lose out when compared to the current system. I will get the source that the noble Baroness, Lady Thornton, asked me for. I think that is a reasonable question.

The Government believe that having the cap in place allows people to balance their personal responsibility of planning for later years and puts in place a system where we hope that no one faces unpredictable care costs. Without Clause 140, two people with the same level of wealth, contributing the same amount towards the cost of their care, could reach the cap at very different times, driven not by how much they are spending on their care but how much the local authority is. We wanted to address that perceived unfairness.

Instead, the Government made the decision to offer the same cap for everyone. However, the cost for people with more modest means will be reduced in two important ways: first, through means-tested support, including for those living in their home. This kicks in as soon as someone’s assets fall below £100,000, potentially right from the start of their care journey. We chose to offer the same threshold for means-tested support, no matter where somebody draws on care, because we want to support and encourage people to be able to stay in their own homes whenever they can. That was an ambition set out in our White Paper, People at the Heart of Care.

--- Later in debate ---
Lord Warner Portrait Lord Warner (CB)
- Hansard - - - Excerpts

The proposition in relation to the age of 40 was in the report; it has been around for 10 years. It is a bit late in the day to be coming forward with the suggestion that it was an inadequate proposition from the Dilnot commission. Ten years is a long time to discover truth.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

Perhaps I may move on to Amendment 235, on setting the cap based on the recommendations of the Commission on Funding of Care and Support and moving the implementation date by a year. For local authorities to make a change of this magnitude this year is undeliverable. They have told us that the original plan to implement for October 2023 is already an ambitious target.

Setting the level of the cap has been a fine balance. The Government have had to consider the longer-term cost of reform and what proportion of the future levy revenues to earmark for this purpose and other purposes. Retrospectively to impose a cap on care costs for everyone in the care system and to include their care costs during their lifetimes in the cap calculation is unfeasible.

I would like to have some further conversations with the noble Lord on Amendment 236A, if that is possible. I thank him for some of his suggestions to date. There is a real debate about how feasible a private solution is. I remember in an earlier debate the noble Lord rightly chastising me and saying that it was rather embarrassing for a Labour Peer to propose to a Conservative Peer a private sector solution. That hurt—but I completely understand. If it is possible, I personally would have been open to it, but the Government maintain that it is not feasible. We will probably need some more discussions.

This clause clearly needs a lot more discussion between now and Report. I could go into more arguments but, given that there was a lack of debate in the other place, I think that it needs more debate and more consideration overall. I am very happy to have more round tables with the Bill team, the charging team and noble Lords to explain the case, and for noble Lords to decide whether it is an acceptable case or still to disagree with it. With that in mind, I hope that noble Lords feel sufficiently reassured not to press their amendments at this stage and to allow the clause to stand part of the Bill. I beg leave to withdraw my amendment.

Amendment 232A withdrawn.

Health and Care Bill

Lord Kamall Excerpts
Relevant documents: 15th, 16th and 19th Reports from the Delegated Powers Committee, 9th Report from the Constitution Committee
Lord Kamall Portrait The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
- Hansard - -

My Lords, I should like to update the House on a matter that has generated significant concern. I have noted the strength of feeling in the House on the issue of, and draft guidance on, elected councillors being appointed to integrated care boards. I discussed this matter with NHS England and can confirm that it will revise its draft guidance to remove the proposed blanket exclusion of local authority members sitting on integrated care boards. I am informed that, although ICB members from local authorities are normally likely to be officials, local councillors will not be disqualified for selection and appointment to an integrated care board.

I welcome this development and hope that it demonstrates that the department and NHS England are actively listening and responding to scrutiny and debate in this House. I have also informed the noble Baroness, Lady Thornton, and asked for a meeting between the Labour Front Bench and NHS England on its preparations.

Lord Kennedy of Southwark Portrait Lord Kennedy of Southwark (Lab Co-op)
- Hansard - - - Excerpts

I thank the noble Lord for that information. Before we continue with the Committee on the Bill, I wanted to raise my concerns on the Floor of the House as to the importance of always treating each other with respect and courtesy. It is not the fault of anyone in this House that despite a majority of 80 in the other place, the Government have taken longer than expected to present several Bills to this House for our consideration. Although backed by the other place—I fully accept that—the Bills are very controversial in nature and quite properly attract considerable attention.

On a few occasions when considering the Nationality and Borders Bill last night and into the early hours of the morning, our standards slipped. We have another long day ahead of us today and another tomorrow before we all have a well-deserved break in the Recess. I hope that Members on all sides of the House, no matter what position they hold, will respect and pay proper attention to the advice and guidance as set out in the Companion. Committee is a conversation, different from both Question Time and Report. Shouting “question, question, question” from a sedentary position is unacceptable in Committee. Chapter 4 on the conduct of the House and Chapter 8 on Public Bills in the Companion are helpful and informative. I respectfully suggest that all Members regard it as essential reading.

--- Later in debate ---
Baroness Wheeler Portrait Baroness Wheeler (Lab)
- Hansard - - - Excerpts

My Lords, very briefly, we welcome the Government’s proposals on mandatory disclosure of payments, a companion piece to the previous debate that we had, as has been pointed out.

As noble Lords have always stressed, greater transparency is highly desirable and a very good thing. I am grateful to the Minister for listening to the voices of stakeholders and parliamentarians on this. Indeed, nine out of 10 medical professional bodies think that patients have a right to know if their doctor has financial or other links with pharmaceutical or medical device companies and they support stronger reporting arrangements, as contained in the amendments. I am grateful for the briefing I have received from the ABPI, which, as we have heard, also supports mandatory disclosure.

I also note that Amendment 312D refers specifically to the consultation with the devolved Administrations in Scotland, Wales and Northern Ireland and to obtaining the

“consent of the Scottish Ministers, the Welsh Ministers or the Department of Health in Northern Ireland … before making provision within devolved legislative competence in regulations relating to information about payments etc to persons in the health care sector.”

We would welcome the Minister reassuring us that full consultation is under way and setting out the timescales involved.

On Amendment 284, the non-government amendment leading this group, the intention of the amendment and the arguments put forward by noble Lords are extremely persuasive. The requirement for companies involved in the production, buying or selling of pharmaceutical products or medical devices to publish any payments made to teaching hospitals, research institutions or individual clinicians is a sensible measure that would complement the Government’s package, and I await the Minister’s thoughts on it, including on the one glitch underlined by the noble Baroness, Lady Cumberlege, on moving from “may” to “shall”.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

My Lords, I thank all noble Lords who took part in this debate, especially my noble friend Lady Cumberlege for her work on the independent review of medicines and medical devices, and other noble Lords who were involved in that. I know that she worked tirelessly to make sure that patients and their families have been heard and I pay tribute to her and her team. I also thank her for her lobbying—or reminding—me of the pledge that I made when I first became a Minister on championing the patient.

I welcome my noble friend’s amendment to increase transparency and promote public confidence in the healthcare system. The Government fully support the intention behind the amendment. That is why I will be moving Amendments 312B, 312C, 312D, 313B, 313C and 314ZB in my name. Before I do so, let me answer some of the questions.

All these amendments relate to the transparency of payments made to the healthcare sector. The Independent Medicines and Medical Devices Safety Review led by my noble friend Lady Cumberlege listened to the brave testimony of over 700 people to understand where improvements needed to be made to make the healthcare system safer for all patients, especially women. The Government have given the review deep consideration and accepted the majority of its nine strategic recommendations and 50 actions for improvement.

To improve transparency, the review recommended that

“there should be mandatory reporting for pharmaceutical and medical device industries of payments made to teaching hospitals, research institutions and individual clinicians”.

The amendments deliver on this recommendation by enabling the Secretary of State to make regulations requiring companies to publish or report information about their payments to the healthcare sector. The clause covers any person performing healthcare as part of their duties, benefiting patients and building on initiatives by regulators and industry. I hope that partly answers the questions raised by the noble Lord, Lord Stevens.

The amendment also allows for the Secretary of State to make regulations requiring that the information be made public and make further provision about when and how the information must be published. This could include requiring self-publication or publication in a central database. That ensures that we can adapt the system to improve reporting as necessary. To ensure that companies fulfil the obligation, requirements introduced by the regulations can be enforced using civil penalties.

There are benefits to this duty applying UK-wide, aligning with the approach taken by the pharmaceutical industry with its Disclosure UK system. As the noble Baroness, Lady Wheeler, referred to, the clause contains a statutory consent requirement, so we will work closely with the devolved Governments to develop regulations following the passage of the Bill. We will also work with patients, industry and healthcare providers to create a system that enhances patient confidence while maintaining a collaborative, world-leading UK life sciences sector.

A question was raised about the issue of “shall” versus “may”. The Government have not tabled these amendments in bad faith; we would not have tabled these amendments if we did not intend to work with them. It is the intention of my right honourable friend the Secretary of State to bring forward regulations under the clause to make sure that there is transparency. If that is not reassuring enough, perhaps between this stage and Report there can be some conversations to make sure that noble Lords are assured. It is for these reasons that I ask your Lordships’ Committee to support these amendments.

Lord Patel Portrait Lord Patel (CB)
- Hansard - - - Excerpts

Can the Minister confirm what he just said: that it is the intention to bring regulations? How strong is that intention? The “may” creates a problem.

Baroness Bennett of Manor Castle Portrait Baroness Bennett of Manor Castle (GP)
- Hansard - - - Excerpts

My Lords, can I add a question about timeframes to that? When can we expect the regulations?

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I have two points to make to the noble Lord. First, I have been advised that this is standard wording. Secondly, I have made the assurance at the Dispatch Box. It is here; it is on public record that the Government intend to bring forward regulations. On the timeframe, I will either write to noble Lords or arrange a follow-up meeting. I will make sure that there is some communication to bridge that gap.

Baroness Cumberlege Portrait Baroness Cumberlege (Con)
- Hansard - - - Excerpts

My Lords, I thank everybody who has taken part in this debate, particularly my noble friend the Minister for the work he and his officials have done to bring this into the Government’s remit. That is so important, because I learned through the passage of the Medicines and Medical Devices Act that we could incorporate the patient safety commissioner and some of the other things we wanted to achieve only through government amendments. My heart leaped when I saw these amendments and I thank the Minister.

I still think these amendments could be improved and it is important that we get the word “shall” in, or “might” or whatever others have said, rather than “may”. I was looking at the Oxford English Dictionary. My father-in-law was the publisher to the Oxford University Press, so the dictionary is very close to my heart. The dictionary says that the verb “shall” relates to the right or sensible thing to do, whereas the verb “may” is defined as a possibility.

--- Later in debate ---
Baroness Merron Portrait Baroness Merron (Lab)
- Hansard - - - Excerpts

My Lords, I thank my noble friend Lady Chakrabarti for raising the crucial matter of countries and peoples left behind in terms of the opportunity to have a necessary vaccination programme available to them. My noble friend Lord Campbell-Savours spoke of the importance of supporting innovation, which is one of the ways in which we can ensure that, while my noble friend Lord Howarth rightly said that the subject requires exploration outside of the Health and Care Bill—something also commented on by the noble Lord, Lord Crisp, who emphasised, as do I, the need for the political will to make progress.

There is no doubt, as we have heard today, about the gravity of the issues at stake and the need to resolve them. It is the case that where public funding is provided there must be conditionality, although of course that may be complex to refine into legislation. There are of course additional issues when funding is also coming from the private sector along with a need to ensure a balance of interests. It would certainly be helpful to have a stipulation that avoided placing undue bureaucracy and restraint on smaller developments and small-scale research. We do not want to see the pace of research slowed down with researchers tied up in lengthy proposal writing, contract negotiations and legal agreements.

As my noble friend Lady Lawrence has said, we know that the pandemic is not over until it is over everywhere, so the amendment raises the opportunity to explore whether the immediate waiver of intellectual property rights would mean an end to the pandemic everywhere. It is relevant to assess what contribution or otherwise intellectual property rights make to the promotion of technological innovation and the transfer and dissemination of technology. There is an advantage for producers and users of technological knowledge and the consideration of rights and obligations, and that needs to be considered in the round.

In respect of the response and actions to a pandemic declared by the World Health Organization, while I understand the intention behind the amendment, in order to be consistent I would comment with some caution about the Secretary of State being compelled to immediately take actions, particularly without any form of oversight—something that we will return to later in Committee.

However, I hope that today we can obtain some reassurances from the Minister about the Government’s intentions and plans in order that we can find a way forward so that low-income countries and their peoples have access to vaccines both now and in future.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

I thank the noble Baroness, Lady Chakrabarti, for bringing this debate before the Committee today and for the heartfelt speech that she gave. The noble Baroness will be aware of the view of this Government following her recent Question in the House on the subject of patient waivers. As my noble friend Lord Grimstone set out, the Government remain open to all initiatives that would have a demonstrably positive impact on vaccine production and distribution. However, we believe that waiving intellectual property rights would have the opposite effect. Doing so would dismantle the very framework that helped to develop and produce Covid-19 vaccines at the pace and scale now seen. It would risk undermining the continued innovation in vaccines and technological health products that is required to tackle a virus, especially as it mutates and evolves, so we believe that doing so would be a mistake.

Instead, the success of the Covid-19 vaccine rollout vindicates the value of public and private co-operation. While university research departments are great at research, large-scale manufacturing and global distribution are not their function, so we recognise the importance of their working with partners with expertise in this area.

The intellectual property framework is key to those efforts. It has incentivised the research and development that has led to the development of Covid-19 vaccines. It has given innovators the confidence to form more than 300 partnerships, an unprecedented number, and has contributed to the production and dissemination of vaccines and other health products and technologies across the world, with global Covid vaccine production now at nearly 1.5 billion doses per month.

I share the noble Baroness’s intention that research funded through taxpayer finances should benefit the taxpayer, but we do not consider that that is best achieved through particular constraints in primary legislation. Research contracts afford greater flexibility and more powerful levers than the amendment, through provisions such as those requiring the dissemination of intellectual property for patient benefit, revenue sharing with the Government of commercialised intellectual property, and requirements around access to medicines in the developing world. Contractual protection mechanisms in funding arrangements can also ensure that intellectual property funded by taxpayers results in the creation of taxpayer benefit.

[The remainder of today’s proceedings will be published tomorrow.]

Health and Care Bill

Lord Kamall Excerpts
Moved by
2: After Clause 2, insert the following new Clause—
“Spending on mental health
(1) The National Health Service Act 2006 is amended as follows.(2) After section 12E insert—“12F Expected mental health spending(1) The Secretary of State must, in respect of each financial year, publish and lay before Parliament a document—(a) stating, by comparison with the previous financial year—(i) whether the Secretary of State expects there to be an increase in the amount of expenditure incurred by NHS England and integrated care boards (taken together) in relation to mental health, and (ii) whether the Secretary of State expects there to be an increase in the proportion of the expenditure incurred by NHS England and integrated care boards (taken together) that relates to mental health, and(b) explaining why.(2) The Secretary of State must publish and lay the document before the financial year to which it relates.”(3) In section 13U (annual report), after subsection (2A) (inserted by section 29 of this Act) insert—“(2B) The annual report must include—(a) a statement of the amount of expenditure incurred by NHS England and integrated care boards during the year (taken together) in relation to mental health,(b) a calculation of the proportion of the expenditure incurred by NHS England and integrated care boards during the year (taken together) that relates to mental health, and(c) an explanation of the statement and calculation.””Member’s explanatory statement
This amendment requires the Secretary of State to publish any governmental expectations as to increases in mental health spending by NHS England and integrated care boards, and requires NHS England to include in its annual report information about such spending.
Lord Kamall Portrait The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
- Hansard - -

My Lords, in moving Amendment 2, I will speak to Amendments 57, 78 and 109 in my name. We have heard impassioned and compelling arguments here and in the other place for the need for greater emphasis on mental health in the Bill. We have listened and, as a result, have taken action. The result is the package of amendments brought before the House today. I take this opportunity to pay tribute to the many noble Lords across the House who have contributed to the development of these amendments and the advice we have received.

Let us first turn to defining health. I assure your Lordships’ House that this Government remain fully committed to delivering parity of esteem between physical and mental health. We want to support everyone’s mental health and well-being. We are very aware of the impact that the pandemic has had on a number of individuals and communities, particularly the impact on mental health and mental health services.

Amendment 109 removes any potential confusion as to whether references to health within the NHS Act 2006 include mental health. We have made it absolutely clear with our amendment that references to health includes mental health as well as physical health. I know noble Lords will acknowledge that it was our view that the current references to health in the Act would have included mental health, but this amendment is important because it sends a strong signal that health must not just be associated with physical health. Mental and physical health are equally important, and our legislation reflects that fully.

On the transparency and accountability of mental health funding, the Government remain committed to our ambitions in the NHS Long Term Plan to transform mental health services in England. The NHS Long Term Plan committed to increase spending on mental health services in real terms by at least £2.3 billion a year by 2023-24. For each year of the current spending review period, the spend on mental health will increase as a share of the NHS budget. This is in line with the Government’s ongoing commitment to grow investment in mental health services faster than the overall NHS budget. Our amendment seeks to bring added transparency to this commitment and will better enable Parliament, stakeholders and the public to hold the Government to account for meeting this commitment.

The Secretary of State will be required to publish and lay before Parliament, before the start of each financial year, a document setting out the Government’s expectation on mental health spending for the year ahead. This document, a Written Ministerial Statement, will set out whether the Secretary of State expects there to be an increase in the amount and proportion of expenditure incurred by NHS England and integrated care boards, taken together, in relation to mental health, with a supporting explanation. There will also be requirements for NHS England and ICBs to include in their respective annual reports information about such spending to clearly demonstrate performance against expectation.

I am very grateful to the noble Lord, Lord Stevens, as well as the noble Baronesses, Lady Hollins, Lady Merron and Lady Tyler of Enfield, for supporting amendments related to transparency and accountability of mental health funding in Committee, and for their constructive engagement since. I hope I have reassured noble Lords that this Government are committed to delivering parity of esteem between physical and mental health. I hope that our amendments address the issues and concerns previously raised and that the House will pass them today. I beg to move Amendment 2.

Lord Stevens of Birmingham Portrait Lord Stevens of Birmingham (CB)
- Hansard - - - Excerpts

My Lords, continuing the outbreak of consensus, a large number of mental health stakeholders welcome the fact that the Government have accepted these amendments, which draw heavily on amendments a number of noble Lords brought forward in Committee. I think I said at that point that they would represent a spine-stiffener for the Government in their commitment to ensure that mental health sees a growing share of the growing NHS budget and an accountability booster for the NHS. I think they do that.

However, before the Minister concludes on this item, will he say whether, when setting the mandate for NHS England for the financial year ahead—the mandate that will therefore be laid at some point within the next 30 days—the Government might set the mental health waiting time standards, the very welcome consultation on which concluded last week, in a way that other amendments in this group would look to advance? None of that should detract from the fact that these amendments have wide support outside this place and will make a real difference to mental health in the years to come.

--- Later in debate ---
Baroness Merron Portrait Baroness Merron (Lab)
- Hansard - - - Excerpts

My Lords, if the role of your Lordships’ House is to improve the Bill, I feel that this set of amendments will achieve this. I am grateful to the Minister and his officials for responding to the points which were made so powerfully in Committee and in meetings outside this Chamber. The range of amendments will take us further.

The Minister talked about the introduction of transparency and accountability, which are key in the efforts to improve the provision of mental health services. However, of course, improving transparency and accountability is not an end in itself; it is purely a way of getting us to the right place. What will be important is what this delivers. A step along the way to improving mental health services is definitely being made, but there is an awful lot more to do. For example, the Centre for Mental Health estimates that some 10 million additional people, and that includes 1.5 million children and young people, will need mental health care as a result of the pandemic. It would of interest to understand a little more about how the Government intend to make progress on this once the Bill receives Royal Assent. Will we see a recovery plan in the area of mental health services, backed by a long-term workforce plan, something which we will return to later?

On the policy to bring practice into line with aspiration, and on the funding for and redoubling of effort towards achieving parity, while we are talking about this on a national level, it would also be helpful for the Minister to clarify that it applies to all areas of the Bill’s implementation and that the new bodies set up by the Bill will be expected to treat mental health equally from the outset. For example, it would mean ensuring that the decisions about resource allocation, capital spending, waiting times and priorities were all taken on the basis that mental health must be valued equally with physical health.

The noble Baroness, Lady Tyler, was right to point out that we do not start in a neutral position, because we know that waiting times are considerable, standards of services need massively to be improved and the workforce needs to be strengthened in order to deliver those services. It is therefore extremely important that the Minister in putting forward these amendments undertakes to see the job through, so that we do not just have transparency and accountability for their own sake but we deliver for the many millions who will rely on those services.

Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

My Lords, I once again thank not only noble Lords who spoke in this debate but those who engaged with us throughout the process. As the noble Baroness, Lady Merron, said, if the role of this House is to improve the Bill, we have learned much. As a relatively new Health Minister, I have learned so much from the various meetings that I have had with noble Lords, not only on this issue but on many others across the health and care spectrum.

I thank noble Lords who have engaged with me personally but also with my officials to make sure that we closed the gaps as much as we could. I am pleased to hear support from your Lordships for the package of amendments that I have brought forward, and I am grateful.

I stress that this package of amendments should be considered alongside the amendment placing a duty on ICBs to have an appropriate skill mix and experience necessary to deliver all their functions—I hope that noble Lords will look at those in that context—as we expect skills pertaining to the delivery of mental health services to be considered when meeting this duty at the ICB level as well as below that at place level. Many noble Lords have discussed the importance of place.

Amendment 184 would require the Government to report on our plans to improve mental health standards. Access to services is at the heart of the mental health commitments in the NHS long-term plan. The department, NHS England and NHS Improvement regularly report performance against existing waiting time standards in mental health, including improving access to psychological therapies services, children and young people’s eating disorder services and people experiencing a first episode of psychosis.

As noble Lords have acknowledged, last week NHS England and NHS Improvement took another step to strengthen mental health standards, publishing a consultation response following the mental health clinically led review of standards consultation. As noble Lords will know, this sought views on the proposed introduction of new measures, including five new waiting time standards, to support our ambitions to ensure that patients have timely access to community mental health care.

--- Later in debate ---
Moved by
4: After Clause 4, insert the following new Clause—
“Duties in respect of research: business plan and annual report etc
(1) The National Health Service Act 2006 is amended as follows.(2) In section 13L (duty in respect of research), after “functions,” insert “facilitate or otherwise”.(3) In section 13T (business plan), in subsection (2)(a), after “13G” insert “, 13L”.(4) In section 13U (annual report), in subsection (2)(c) (as amended by section 69(4) of this Act), at the appropriate place insert—“section 13L;”.”Member’s explanatory statement
This Clause provides that NHS England’s duty to promote research etc includes doing so by facilitating research. NHS England is also required to explain in its business plan and annual report how it proposes to discharge or has discharged its duty to facilitate or otherwise promote research etc.
Lord Kamall Portrait Lord Kamall (Con)
- Hansard - -

My Lords, in moving Amendments 4, I shall also speak to Amendments 23, 58 and 79 in my name. Before I start, I really should acknowledge the contribution and engagement of a few noble Lords, in particular the noble Lords, Lord Sharkey and Lord Patel, and my noble friends Lady McIntosh and Lady Blackwood for their constructive engagement with me and my officials.

We have seen the power of research as we have made our way through the pandemic, and research will continue to be essential. I agree that research needs to be embedded in the very DNA of the NHS. Earlier this week, I chaired a round table with a number of research charities and other stakeholders, and we all talked about the importance of embedding research into the NHS. A bit like the challenge I had when I was in academia, when you wanted more time for research but at the same time were told to get on with your day job of teaching students, likewise many clinicians are under the same pressures in terms of the day-to-day delivery of healthcare while wanting time for research.

We know that informed research helps to improve healthcare and health outcomes. It brings benefits to patients, staff, the NHS and the wider economy. We believe that integrated care boards will play a leading role facilitating and enabling research and fostering a culture and environment for research to flourish. To this end, the Bill currently places a duty on each ICB that it

“must, in the exercise of its functions, promote … research on matters relevant to the health service, and … the use in the health service of evidence obtained from research.”

I have, however, heard clearly from noble Lords that they want to see a step change in research. That is a request, or a plea, that I agree with, so rather than directly funding or conducting research, ICBs will primarily facilitate and enable it. However, ICBs will also have the power to conduct, commission or assist the conduct of research. This could include hosting or being a collaborating partner in research infrastructure.

I also heard from noble Lords, particularly the noble Lord, Lord Sharkey, that it is not clear what a duty to promote research should involve. To that end, I have tabled Amendments 4, 23 and 79 to clarify that the meaning of “promote” includes “facilitate”. I once again thank the noble Lord, Lord Sharkey, for his engagement. This highlights that facilitation is a subset of the range of activities meant by promoting research while retaining the breadth of a duty to promote research.

The duty is broad and could be met in a number of ways. For example, when exercising its commissioning functions, an ICB may select providers which have a proven track record of being research-active or can demonstrate the intention and capability to participate in research. The provision is also flexible so that bodies can develop the processes and structures that work most effectively, but we anticipate that ICBs would have dedicated research offices or teams to support their role in research and to encourage the conduct of research.

To ensure that research is fully embedded in local systems, we expect ICBs to consider research when preparing, with the responsible local authority, a joint strategic needs assessment articulating local research needs where they identify them. We would also expect ICBs to ensure that the joint local health and well-being strategy sets out how research needs can be met by the ICB. We have tabled Amendment 35, which is to be debated in the next group, to ensure that the research duty, along with other duties, is given particular consideration during ICBs’ planning of their strategies. We have also tabled a package of amendments to provide increased transparency, accountability and oversight of the research duties.

During the debate in Committee, my noble friend Lady Harding remarked that

“what gets measured gets done”.—[Official Report, 24/1/22; col. 47.]

We agree. Amendment 4 requires NHS England’s business plan to explain how it proposes to discharge its research duty and requires its annual report to contain an assessment of how effectively it discharged this duty. We have tabled similar amendments for ICBs. Amendment 55, also to be debated in the next group, would require that ICB annual reports must explain how the ICB has discharged its research duty. Amendment 58 would require that the NHS England’s performance assessment of each ICB includes an assessment of how well it discharged its research duty. I beg to move.

Baroness McIntosh of Pickering Portrait Baroness McIntosh of Pickering (Con)
- Hansard - - - Excerpts

My Lords, I take this opportunity to thank my noble friend for listening and acting in the terms set out in the amendments in this group, which I support on research as far as they go. I have to express my disappointment that my noble friend has not seen fit to extend his bonhomie to NICE. I have therefore tabled Amendment 29, and I am delighted to have the support of the noble Lords, Lord Hunt of Kings Heath and Lord Patel. As set out by the noble Lord, Lord Kakkar, our thoughts are with the noble Lord, Lord Patel, who is unable to be with us today, and we wish him the speediest possible recovery. It is a great shame that he cannot be here today because we would all wish to pay tribute to his work historically as the forerunner of NICE. We are grateful to him for it. It is a great disappointment to me that he is not able to be here in person.

I also support Amendments 171 and 178 in the name of the noble Lord, Lord Hunt, but I shall leave the noble Lord to set them out.

My noble friend has set out that the government amendments set a responsibility on integrated care boards to respond annually and to measure the research work that they have done. Quite frankly, I am a little concerned and gobsmacked as to why my noble friend is not insisting that integrated care boards do the same as regards NICE. The key provision of my Amendment 29 is:

“Within 28 days of any medicine or device receiving market authorisation from NICE, an integrated care board must update its formulary to include that medicine or device.”


I have set out other provisions, but the other one to which I draw attention is in proposed new subsection (3), which says that every year an individual ICB must report

“in a publicly accessible format”—

to me that would mean it being accessible on its website—

“all medicines and devices that have been added and removed from their formulary over the previous year and maintain an active list of all medicines and devices available on their formulary.”

--- Later in debate ---
Baroness Thornton Portrait Baroness Thornton (Lab)
- Hansard - - - Excerpts

My Lords, I do not intend to speak about this for very long, because I feel that I am the least well-equipped person in the whole Chamber to do so—possibly with the exception of the Minister, which is often the way and is how I felt when I was a Minister; I would stand up to speak about research and other huge subjects and everybody else in the Chamber who had spoken certainly knew a lot more than I did, and that is the case here.

Noble Lords may recall that the starting point at Second Reading and in Committee was that there was no place for research in the Bill at all—so I congratulate noble Lords who picked this up and ran with it, and, indeed, the Minister and the Bill team on taking it on board and producing these amendments. That is helpful; as the noble Lord, Lord Kakkar, said, it is about the future and it is exactly the right thing to do.

I also agree with the noble Baroness, Lady McIntosh, and my noble friend Lord Hunt in their disappointment on the issue of NICE. They are quite right about the access and availability of medicine and devices to healthcare practitioners and that the system is still uneven; also, of course, nobody is asking how we are doing and whether it is working. It is a shame that these aspects have not been included in the Bill, but I suspect that the noble Baroness and my noble friend will probably live to fight another day.

Lord Kamall Portrait