Health and Care Bill

Lord Mackay of Clashfern Excerpts

Lords Hansard - Part 1 & Committee stage
Tuesday 18th January 2022 Lords Chamber

[Baroness Wheeler (Lab)]

My Lords, today’s debate has shown the strength and depth of feeling across your Lordships’ House that children and young people should be properly provided for within the scope of the Bill and not just as an afterthought, as many noble Lords have said.

Intervening in the early years of a child’s life is the most effective way of shoring up their good health and well-being as an adult. This group of amendments seeks to do just that, ensuring that our children are not sidelined in a healthcare infrastructure currently designed with adults, and just the NHS, in mind. This group also seeks to strengthen the Bill by including safeguarding, interagency working, service integration and data sharing, especially between government departments and the NHS and social care.

I thank noble Lords for putting forward these amendments, particularly the indefatigable noble Baroness, Lady Tyler, for her proposals across Clauses 20 and 21 to ensure the joining up of the roles and work of ICBs and ICPs in these crucial areas. Indeed, what is particularly striking about today’s debate is that the experience and contributions of noble Lords have joined up children’s needs across a whole range of service provision and support in a way that government structures currently fail to do. This is a major issue that needs to be addressed, particularly to address the needs of vulnerable children, as my noble friend Lord Hunt and other noble Lords have stressed.

If the Bill is to stand any chance of improving government health outcomes, it must start with the youngest among us all. Right now, in this, the fifth-biggest economy in the world, child health inequalities are widening, while 25% of children in the average reception class will be overweight. By the time those children are in year 6, it will be 40%. The all-cause mortality rate for under-14s in the UK is among the worst in Europe, and the World Health Organization tells us that 50% of lifetime mental illnesses start by the age of 14. Noble Lords will recall the debate last week about the need for robust mental health services, which include those around potential young suicides, self-harm and eating disorders. As the charity YoungMinds reminds us, after-care and follow-up are crucial although, sadly, ignored in current sustainability plans, as the noble Baroness, Lady Finlay, pointed out.

The Royal College of Paediatrics and Child Health has expressed particular concern that there is currently no duty in the Bill to include representation from children’s health and care services on integrated care boards. The noble Baroness, Lady Finlay, underlined in her Amendment 87 the importance of safe staffing levels and of this in driving forward improvements in child healthcare outcomes and ensuring that children and young people can access the care they need, when they need it and from the most appropriate person or team.

Barnardo’s is similarly worried about the absence of a child impact assessment, without which there will be no clear, objective idea of the impact of the changes in this Bill on young people. The right governance and rigorous evaluation, aimed at providing lessons learned for future service design and reform, can surely only be a good thing. We strongly support Amendment 142 on this issue, in the name of the noble Baroness, Lady Walmsley, which calls for the impact assessment to be undertaken within two years of the Bill’s implementation. It also emphasises the need for an annual report and debate in Parliament on the impact of changes, scrutinising, in the first year in particular, how the changeover from CCGs to ICBs is working in practice.

Following last week’s debate on the appalling backlog of waiting lists and the NHS’s duties under the mandate and constitution, I remind the Committee that last month’s National Audit Office report showed that more than 288,000 children and young people are waiting for NHS treatment, 86,000 of whom have been waiting for longer than the 18-week target I asked the Government to reaffirm.

Whether it is ensuring proper information sharing between care providers, safe staffing levels or clarifying how the Better Care Fund can specifically be used to better integrate children’s services, these amendments have compassion and common sense behind them. We have an opportunity in this Bill to give our children a healthier future. I hope that the Minister will agree.

[Lord Mackay of Clashfern (Con)]

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.

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

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.

Health and Care Bill

Lord Mackay of Clashfern Excerpts

Lords Hansard - Part 2 & Committee stage
Tuesday 18th January 2022 Lords Chamber

Against that background, I hope that I have said enough to persuade my noble friend to move her amendment when the time comes for it to be called and to persuade the noble Lords, Lord Hunt and Lord Clement-Jones, not to press theirs.

[Lord Mackay of Clashfern (Con)]

My Lords, the Minister is much in agreement with others that the leadership being enthusiastic for progress is important. I understand that nominations have already been made for the various positions that are likely to come up. To what extent has enthusiasm for digital transformation been a criterion in nominating those people? It is vital that the leader really believes in what is to happen if it is to happen at all. Therefore, it would be useful to know to what extent that consideration has applied in the prospective nominations of people for the local positions.

[Earl Howe (Con)]

Noble Lords will remember that, even 10 years ago, when I was appointed as a Health Minister, there was an acronym, QIPP, which stood for “quality, innovation, productivity and prevention”. While I think the acronym has largely fallen out of use, those four principles remain alive and kicking in the strategic thinking that happens at the top of the health service, and indeed in the department.

--- Later in debate ---

I remember that, back in the dim distant days when I was director of the association, and even when I was a community health council member 10 years earlier than that, 45 years ago, it was often the local community health council representative sitting there at meetings with the professionals and managers, all of whom speak their own language, which is rather different from that of the patients. They were being told things about the way in which the local service was operating and being delivered at the local level, which they would not have heard otherwise. That is why, at the centre of our deliberations, at both local and national level, the patient voice must be heard and properly supported and resourced.

[Lord Mackay of Clashfern (Con)]

My Lords, I strongly support that. It seems to me that the National Health Service is devoted to looking after patients. Therefore, it is very strange that there is no national voice for patients to speak to it. In a way, Healthwatch England fulfils that—but in a very awkward position.

I do not know exactly the relationship within the constitution of the committee and the CQC. For example, it may be important that knowledge that Healthwatch has goes to the CQC, but it must be much better for it to be independent at every level, national and local, and to not take part in any of the particular arrangements but rather independently give the pure voice of the patients, which it has received, as it were, from the people who have been served by the National Health Service, whether that is complimentary or otherwise, according to what has actually happened. That seems to me to be essential. I cannot think that it is effective to have a National Health Service with no voice to be heard at the centre from the patients.

[Baroness Walmsley (LD)]

My Lords, I quite often buy things online and, a few days after the product has arrived, I often get an email saying, “How did we do? Give us one, two, three, four or five stars.” That can be very irritating, and I suspect that, on the whole, people do not respond, unless the service has either been dreadful or brilliant—that is certainly so in my case. The voice of the patient is far more important than that and, if we are to assess the performance of different ICSs, the voice of the patient is absolutely fundamental to gathering the evidence, using which we can compare their performance.

A few years ago, I had to be in hospital, just for a few days. At the end of my treatment, when I was about to go home, I was handed a little slip of paper. I do not know if they still do this, but it had some kind of snappy title like, “Tell us how we did”. I thought it was totally inadequate, because here was I, as a patient, having had a general anaesthetic, feeling a bit wobbly, but crucially, having had only the experience of that particular treatment in that particular hospital. The beauty of Healthwatch is that it can compare the experience of patients, heard directly from those patients, of a lot of different treatments in different settings. It can bring together the voice of the patient and—absolutely crucially—it has the ear of the people who deliver those services and can authoritatively explain to them where they are doing well and where they are doing badly.

In this group of amendments, the noble Lord, Lord Hunt, and others have got it right in their suggestions about the level at which Healthwatch should have a voice: non-voting membership of the ICB, voting membership of the ICP and, crucially, independence from the CQC. The noble Lord, Lord Harris, put it very well: how on earth could Healthwatch criticise the CQC as the regulator if it is part of it? It is a little bit like asking a civil servant to criticise the Prime Minister, is it not? The noble Lord, Lord Hunt, and others who have spoken have got the level right at which Healthwatch should play its part in this great new world of integrated services. The view of the patient of the experience that they received at the hands of all the health and care services is absolutely crucial to being able to compare the performance of these bodies that we are setting up.

Health and Care Bill

Lord Mackay of Clashfern Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

[Lord Lansley (Con)]

I can see that my noble friend is eager to come in but I will conclude by answering the noble Baroness. I am not an expert, but I think the CQC has the powers—since it presently does it—to take account of the NICE quality standards and to incorporate specific indicators from those quality standards as part of its regulatory review. If the CQC was to attempt to introduce large-scale application of the guidance as a question in a regulatory review, I do not think the issue would be whether it had the power to do it, but whether it would make the headline conclusions it reaches in relation to healthcare providers increasingly difficult to interpret. At the moment, they are relatively straightforward to interpret. There is a small number of specific indicators in relation to services provided and they are either doing them or they are not. With guidance, it becomes much more complicated and many more value judgments have to be applied about the circumstances in which they are or are not complying. So, there is a real difficulty in going far beyond where we are now.

I will listen with great care when my noble friend the Minister responds to the questions I have asked.

[Lord Mackay of Clashfern (Con)]

My Lords, I support these amendments, subject to the economic difficulties. As I listened to the local Baroness, Lady Brinton, I wondered whether the amendments might be strengthened by some reference to the timescale in which they must be implemented. That might have some beneficial effect for many people who are waiting.

[Baroness Merron (Lab)]

My Lords, I welcome these amendments, which relate to the National Institute for Clinical Excellence—NICE. I thank all noble Lords for tabling these amendments and for their contributions today, which certainly expanded my knowledge of the subject, as I am sure they did across the Committee. The debate has shown that there is a need for change, as I am sure the Minister has heard, to better equip the National Health Service to provide the patient what they need when they need it.

The noble Baroness, Lady McIntosh, spoke clearly about hurdles that must be overcome, whether they are bureaucratic, process, budgetary or administrative. All these hurdles get in the way of the end result: meeting the needs of patients. That, I believe, is what this debate is focused on.

NICE is well recognised as a partner to our NHS. Its objective approach and evidence-based analysis rightly gain respect. However, as my noble friend Lord Hunt said—he can now be called the first Minister for NICE—although the National Health Service is full of innovation, it is also slow to pick up on it; that point was emphasised by the noble Lord, Lord Warner. That begs the question: what kind of partner should NICE be to the NHS? Is it going to be an enabling partner, or will it frustrate at times? Of course, we all want to see NICE in that fully enabling capacity.

However, beyond what NICE approves in terms of treatments, pathways or otherwise, there must be procedures for it to implement and connect effectively to patients’ needs. We know that no system or set of procedures will ever be perfect; we have heard that today. Understandably, therefore, as the Minister has heard, pressure and a will for change—in a positive sense—is contained in these amendments. The noble Baroness, Lady Finlay, spoke about how important it is to have evidence-based healthcare and to have known guidelines and see them complied with, as is right and proper.

There are cautionary considerations to note in this debate; we have heard some of them. One is whether it is wise to put what in some cases appear to be operational requirements in the Bill. I am sure the Minister will address this. The new world is certainly paying a lot of attention to flexibilities. We want to make sure that anything contained in the Bill does not inadvertently work in another direction.

My understanding is that NICE guidance is mandated, in effect, with the guidelines somewhat less so. Amendment 54 contains a proposal to reinforce the intention that, once a treatment has been properly assessed and recommended, all patients should be able to gain the benefit. We know, and we have heard in this debate, that this does not always happen, and that clinical commissioning groups follow different policies. However, in considering the amendment at face value, it is important that we consider what impact this latitude might have. I am sure we are all keen not to accidentally invoke some kind of fallout, such as taking away all leeway from commissioners. At present, they can depart if they can set out an objective case for doing so; for example, with requests for certain drugs and therapies through individual funding requests.

Similarly, it would be unfair if a patient could cross an integrated care board border and receive a treatment that was not available in another ICB area. That would seem inadvertently to achieve what we do not want to achieve: the worst of a postcode lottery. Equally, if we have locally based approaches, the reality is that some localities will differ in their priorities and services. I know that we will return to this topic many times in our consideration of the Bill because the care that patients receive should certainly be equitable and fair and not based on where they live.

Health and Care Bill

Lord Mackay of Clashfern Excerpts

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

[Baroness Young of Old Scone (Lab)]

My Lords, I think I am about to score a historic double whammy. I thought that I had stayed tonight to let some momentous words cross my lips that I never thought would do so—that is, I agree with everything that the noble Lord, Lord Forsyth has said—but, and I never thought I would say this, I also agree with every word that the noble Lord, Lord Warner, has said. How is that for a double whammy?

I do not want to delay the Committee, because it is late, but let me touch briefly on Amendment 203 in the name of the noble Baroness, Lady Meacher. I sat on the Commission on Assisted Dying, and we heard endlessly and quite heartrendingly from medical professionals, patients and relatives of those who had already passed away about the inadequacies of the discussion about choices at the end of life. At the moment, the legislation makes it almost impossible for healthcare professionals to open up that sort of conversation—we are not talking necessarily about assisted dying; we are talking about any sort of choices at the end of life. The amendment in the name of the noble Baroness is therefore much needed.

However, for heaven’s sake, on Amendment 297, the whole process of Private Members’ Bills is doomed to failure for something as important as this, which has been tackled by legislatures across the world. Yet we are frozen in this grand old Duke of York scenario, where we march up to the top of the hill at Second Reading on a Private Member’s Bill, then absolutely sod all happens after that and we all march back down again. We cannot continue to do that on a five-yearly basis for ever. This is not asking the Government to nail their colours to any particular side of the debate but simply to open up parliamentary time. I very much commend the noble Lord, Lord Forsyth—good grief— on his foresight in seeing this opportunity.

[Lord Mackay of Clashfern (Con)]

My Lords, your Lordships will know that I have known my noble friend Lord Forsyth as a noble friend and as a friend for many years. I know also that he is extremely good at putting forward a case—whether the case is well founded or not does not seem to matter too much.

We have a procedure in this House, which was established a long time ago, which says that government time is to be used for Bills presented by members of the Government. That is the rule generally. However, there is also a procedure for dealing with Private Members’ Bills. It has been used many times, and it has been used in connection with assisted dying during the present Session. We had a full day of discussion of the merits of that matter—exactly the merits of this matter; the arguments for and against are not for tonight. We are not here to argue for that amount of time; it took a whole day with quite brief statements being made to express different views about this matter.

The Government are a member of those procedures; they are a party to the procedures that deal with Private Members’ Bills. The Government are there so that they can be asked in the course of the proceedings to help. From time to time, they decide that what is in issue is so important generally that it should be given government time. That is the procedure that has been laid down, and as far as I know in this case so far, the Government have not been asked to give time. They said at the end of the debate just two or three weeks ago that they were neutral and waiting for a decision from Parliament. It is Parliament that takes a decision; a Private Member’s Bill is a proceeding in Parliament. It is not just Parliament dealing with government Bills—Parliament deals with Private Members’ Bills also, as well as other kinds of Bills, such as hybrid Bills.

However, this Bill was in Parliament in the Private Member’s Bill system, which is the system that exists just now. If my noble friend, with his skill, wants to suggest a different sort of procedure for Members’ Bills, he can go about it, but to try to break out of the present system a new system for this sort of Private Member’s Bill will produce a complete wreck of the present procedure when no new procedure is being introduced. The Government have from time to time given time for a Bill to be taken forward, which has reached the statute book. That is the procedure which is available now, and it is the proper procedure to ask for.

This procedure is about trying to put an amendment into a health Bill, which has no mention of this, to amend the law on assisted suicide. That is the essence of this—the heading in the amendment is “Assisted dying”—which would mean an unnecessary amendment to the law relating to assisted suicide in his country. There is no question about that. There is nothing about that in the Long Title of the Bill. This Bill is not the proper machinery for raising this matter. It is not my responsibility or an option to deal with the merits of the case. I made a speech in the debate two or three weeks ago towards the end. I think my noble friend was not able to be present, if I remember rightly.

[Lord Forsyth of Drumlean (Con)]

I was able to be there, but as we got only three minutes to debate it, I did not think it was possible to deal with the very complex issues in that time. My noble and learned friend is making the case against the amendment that it requires the Government to produce a Bill. It does not. It requires them to produce a draft Bill. If my amendment had said that the Government should bring forward their own Bill, then my noble and learned friend would be quite right, but I would not have been able to table such an amendment because it would have been out of order for the reasons he has given.

[Lord Mackay of Clashfern (Con)]

Exactly. A draft Bill is preliminary to a Bill; it is not there for the purpose of not being considered. A draft Bill is for making a proposal the subject of an ordinary parliamentary Bill, which has the same authority as a government Bill. All Bills are produced in draft; some are considered in draft in pre-legislative scrutiny. A Bill has to be in draft at some stage, but the object of producing this Bill is not that it should remain in draft but that it should be considered. The amendment does not say how long it should be allowed, but that is another matter. The point is that there is already a procedure by which government help can be obtained if it is asked for in the proper situation of Private Members’ Bills.

I think it is wrong in principle to consider the merits of this matter tonight. Some remarks have been made about that, and I refrain from making any remarks about it because I do not think that that is what is needed here. I submit that it is a view well founded on the rules that Private Members’ Bills are drafted by the private Member, are submitted and then are subject to procedure in the Private Members’ Bills system, including if the Government think it is right that they give additional time.

It is also questionable whether this Motion is in order, since the matter has already been discussed in this Session. There is a question about whether having have a separate procedure raising the issue in much the same form as it was considered some weeks ago is in proper order.

But my main point is about the procedure for dealing with Private Members’ Bills in our Parliament—we are not in the Scottish Parliament at the moment, and there may be some question as to whether my noble friend would like to be—and we have to apply the rules in this Parliament. In my submission, applying the rules of this Parliament, if we want help from the Government, it is to be asked for in the Private Members’ Bill procedures and the Government may, for all I know, be prepared to do something along the lines that my noble friend has suggested.

[Lord Moylan (Con)]

My Lords, I wish primarily to speak to the amendment standing in the name of the noble Baroness, Lady Meacher, but, before I do so, may I just reply, without any hint of rancour, to the comments made by the noble Baroness, Lady Hayter? She repeatedly described the amendments tabled to the Assisted Dying Bill as “wrecking amendments”. Certainly, my amendments are not intended to be wrecking amendments; the Bill raises very important consequences for the National Health Service, and my amendments are primarily about the effect on the relationship between doctors and patients. These are important considerations, and to call them wrecking amendments is a little unfair. I say that without any rancour at all.

Health and Care Bill

Lord Mackay of Clashfern Excerpts

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

[Lord Mackay of Clashfern (Con)]

My Lords, one has to start with the definition of the functions of the integrated care board in the Bill. It says:

“An integrated care board … has the function of arranging for the provision of services for the purposes of the health service in England in accordance with this Act”—


that is, in accordance with all the provisions of the Act. The idea that you must identify some of them in order that the thing should be perfect strikes me as damaging to the nature of the definition. For example, we had today at Question Time a Question about experts in eating disorders. Ought it be said that we must have an expert with clinical experience of dealing with eating disorders? Is it perfect without that? This is the nature of the board that is being set up: it has a generalised responsibility for all that the Act provides in relation to its area.

So far as Amendment 9 is concerned, it seems to me that the requirement in respect of conflicts of interest is part of the construction of the board itself. Therefore, it must be a restriction, if you like, on every committee and sub-committee of the board, because they are all part of the board and therefore subject to that definition.

[Lord Kamall (Con)]

My Lords, despite what the noble Baroness, Lady Thornton, said at the beginning about this perhaps being the end of the harmonious start to our debates so far, I feel that this has been a helpful and constructive debate. I am grateful to noble Lords for bringing these issues before the House.

Let me start with Amendment 9, as I understand the wide interest in the membership of the committees of the board and potential conflicts of interest. We firmly agree that conflicts of interest must be handled carefully, and have included multiple references to that in the Bill. We also recognise the concern that ICBs should not allow private providers to control commissioning decisions, which is why we added the amendment relating to private providers in the other place, in paragraph 4 of Schedule 2.

Furthermore, in the helpful discussions we have had with noble Lords since then, there has been mutual recognition that we need to balance the importance of protecting the core values and public nature of the NHS while not overly restricting the membership of ICBs. I am pleased that the amendment to Schedule 2 balances on that tightrope and gives appropriate reassurance. We think that it is reasonable to allow private providers and social enterprises to sit on some committees and sub-committees of the ICB, as barring them risks blocking sensible integration and joint working.

I am also aware of the mixed reactions to this amendment from stakeholders. Many noble Lords will have seen the NHS Providers Report stage briefing, which states that

“there could be circumstances where a local private or voluntary sector provider would be well placed to join a joint committee with a focus on integrated service delivery whereby the usual arrangements to identify and manage conflicts of interest would, and should, apply.”

It goes on to say:

“It does not seem reasonable … therefore to further restrict the membership of those committees in a way which is prescriptive in law.”


Further, the NHS Confederation stated in its Report stage briefing that this amendment

“risks critically undermining integration by reinforcing a rigid, out-dated purchaser-provider split and derailing the fundamental purpose of these reforms.”

As it so eloquently put it:

“The current reforms aim to facilitate collaborative working by bringing all partners in local areas around the table to plan the most effective and the most efficient way to deliver care. This, by its nature, involves bringing providers of services, alongside commissioners, into committees and sub-committees of the ICB to plan how care is delivered”.


Potential conflicts of interest are inevitable in commissioning, especially when we are looking to increase integration and bring multiple bodies together. The ICBs will be required to manage conflicts of interest as part of their day-to-day activities. That is set out in the Bill and will be part of their constitution as well.

For all committees, the board of the ICB will have to determine what functions they exercise, their membership, and the level of oversight of their decisions. The board of the ICB cannot delegate a function and claim to be no longer responsible for how it is discharged, and will be held to account for this by NHS England.

Also, ICBs will be clear and transparent about interests, and how they are being managed. We think that transparency will prevent poor decision-making. New Section 14Z30 makes it clear that an ICB must maintain and give public access to a register of interests for members of its committees or sub-committees. There must be arrangements in place to ensure that conflicts are managed not just for ICB members but within committees. The constitution of the ICB must also include the arrangements to be made to discharge the functions under new Section 14Z30 and a statement of principles to be followed by the board in this regard. This will all be supported by guidance from NHS England. We are quite determined to tackle conflicts head on and not shy away from this issue.

Health and Care Bill

Lord Mackay of Clashfern Excerpts

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

[Baroness Meacher (CB)]

My Lords, I shall speak briefly to add my very strong support for Amendment 17, promoting the provision of specialist multiprofessional palliative care services. I also welcome, and will comment on, the Government’s Amendment 16 on the same topic. Alongside all other noble Lords, I pay tribute to my noble friend Lady Finlay for her tireless work to improve palliative care services.

It is of course most welcome that the Government have tabled an amendment in this field, but their amendment leaves it to the ICB to decide what standard and extent of palliative care services are “appropriate” to meet what they deem to be the “reasonable” requirements of their populations—the Government’s words. What do these terms mean? Does the Minister accept that the amendment does not ensure that adequate specialist palliative care services will be available across the country? That is what we all desperately want to see. I hope that, in his response, the Minister can define these terms. What do the Government mean by “appropriate” palliative care services and a “reasonable” level of such services?

As I said in Committee, it is unbelievable that the NHS provides services according to need throughout our lives, until we are dying, when of course our health needs are at their greatest. At that stage, precious hospices have to raise their own money, as others have said in the past, to finance their doctors and nurses to care for the dying. Inevitably, hospital beds lie empty. Some 50% of beds in a hospice I visited recently were empty, because it simply did not have the staff to deal with patients in those beds. Can the Minister confirm that the Government will provide statutory guidance to supplement Amendment 16 and clarify what they mean by the terms “appropriate” and “reasonable”?

As things stand, I strongly support the amendment tabled by my noble friend Lady Finlay. As we die, we should all have high-quality palliative care services. We can then expect that, when assisted dying is legalised, a reasonably small percentage of dying people will suffer unbearably, despite benefiting from top-quality services, because of course there are situations when the best possible palliative care services have done everything they possibly can and yet certain patients suffer unbearably. We need a change in the law to ensure that those patients have control over the suffering that they can reasonably tolerate.

I look forward to the Minister’s response and, as I say, hope that he will clarify the definitions of the terms used in the amendment.

[Lord Mackay of Clashfern (Con)]

My Lords, this amendment adds a new paragraph to the new Section 3(1) set out in Clause 16 and it seems clear that what Section 3(1) says refers to all that follows it:

“An integrated care board must arrange for the provision of the following to such extent as it considers necessary to meet the reasonable requirements of the people for whom it has responsibility”.


One has to look at reasonable requirements in relation to everything in that list, with the first being “hospital accommodation”. The idea that there might be some areas with no hospital access at all is absolutely ridiculous. So this is a qualification, to be fitted in as paragraph (ga).

Immediately before it is another provision, which refers to services considered

“appropriate as part of the health service”.

That seems to suggest that it is absolutely essential that the needs and reasonable requirements of people who need palliative care are met. ICBs do not need to provide palliative care for the whole community, but are required to provide it for the proportion of people expected to require it, namely those getting near the gates of death. That is a reasonable interpretation of this clause.

I believe it goes quite a long distance in the way that the noble Baroness, Lady Finlay, and others for some years have asked for. I do not think it feasible to say that nobody in an area will require palliative care—unless its inhabitants are people who live for ever, of which there are only very few. It looks to me as though this is well constructed to ensure that palliative care must be provided where people die, in the area of the integrated care board.

I entirely welcome Amendment 17 from the noble Baroness, Lady Finlay, but the crucial amendment is provided by the Government and is written in a way that will be very difficult for any care board to try to escape, because it is very clear.

Health and Care Bill

Lord Mackay of Clashfern Excerpts

Lords Hansard - Part 1 & Report stage
Thursday 3rd March 2022 Lords Chamber

[Lord Mackay of Clashfern (Con)]

Before my noble Lord sits down, does “children” in this amendment include children in care?

Amendment 36 agreed.

--- Later in debate ---

[Lord Mackay of Clashfern (Con)]

My Lords, I am an honorary fellow of the two Edinburgh colleges and I strongly support this. It seems extraordinary that these very distinguished colleges which, as has been said, have an excellent record over many years in teaching people not only in this country but in many other countries should be excluded from playing a part in these appointments.

I also support Amendment 80 but would like to elaborate on it a little. I think Health Education England was set up, by the Act that we had before, with some degree of contention. It is a system that is supposed to help determine the future for the health service, with fairly elaborate provisions to that effect, as I remember from that Bill.

It is not at all clear to me how this assessment is going to be done. I see it has to be verified independently, in other words somebody independent of the whole system has to assess it for its accuracy. However, if you need Health Education England to do this for the medical professions particularly, why do you not need something similar to deal with the very complicated system of social care? Therefore, I think the whole system requires to be extended to cover something like Health Education England in relation to the whole area that this amendment covers. The Secretary of State sets up some kind of mechanism for report; it has to be a pretty elaborate mechanism if it is going to work. Therefore, I humbly suggest that something like Health Education England is needed to be the basis on which this assessment arises. Then, of course, you have to provide for the independent assessment of whether it was a good assessment originally. I support this amendment, but I think something more elaborate is ultimately required.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I will just speak to my Amendments 111 and 168. On Amendment 111, when the noble Baronesses, Lady Brinton and Lady Masham, and the noble and learned Lord, Lord Mackay, have already put forward the arguments, there is very little for me to say, but the exclusion of the Scottish colleges from the appointment process needs to be rectified. It is an irritant, a hold-up.

In Committee, the noble Lord said that we needed to go through consultation. That was a dreary and negative response. The Scottish colleges have done that. They have consulted and got the support of the Academy of Medical Royal Colleges, NHS Employers and the NHS Confederation. Surely the Minister can just accept this amendment. To simply say that there is no need for it and lots of consultation has to take place is just a ludicrous waste of time and money. This is the time to do it. He should bring an amendment back on Third Reading and be done with it. The noble Lord says that he wants to improve efficiency in the health service. I am afraid I take that with a pinch of salt, because he is just letting officials run riot around him in relation to petty, bureaucratic objections to this change.

Obviously, my other amendment is not major compared to Amendment 80, which is substantial and very important. The noble Baroness, Lady Cumberlege, has really put it forward with great force. Again, I think the noble Lord needs to take a more vigorous approach with the Treasury, because clearly that is where the objection to this is coming from.

My other amendment is about the terrible problem of GP distribution, or the wide variations. I am not going to tempt the noble Baroness, Lady Cumberlege, to come in on the GP issue—but the latest figures, for 31 December 2021, show, for primary care networks in England, the huge variation in the number of GPs. In 24 of the networks, the average list of registered patients for fully qualified full-time equivalent GPs is more than twice the national average. There are five primary care networks where the average is more than three times the national average; these are often in the most deprived areas. No wonder there is an issue of burnout, early retirements and a move to part-time working.

The Government’s response so far is the targeted enhanced recruitment scheme—an incentive for GPs to go into these areas. It is not enough; a much more substantive piece of work is required, and I hope again that the Minister will come forward with a positive response.