Health and Care Bill

Lord Mawson Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Lord Mawson (CB)]

My Lords, I welcome the direction of travel the Government are taking with this legislation. It is a direction of travel my colleagues and I set out on 36 years ago this year at the Bromley by Bow Centre in the East End of London. As our work today starts to go national and to scale, I thought it might be most helpful if I set out some reflections based on many years of practical experience in this space and offer encouragement to the Government to go much further.

While some have been writing reports and undertaking yet more research, my colleagues and I, through the Well North programme supported by Public Health England, have been building innovation platforms that test these ideas in practice. We have created practical projects in towns and cities across the country over the last six years, bringing together key people from the health service, local authorities, and the social enterprise and business worlds, creating a learning by doing culture and applying entrepreneurial principles to some of our most challenging health and social problems. The detail of our work can be seen on the web. Given the limitations today, I want to focus on the importance of place for one of these real projects, undertaken by people in a real place, but first I will give a few reflections based on real experience over 36 years.

First, the present machinery of the state and health service is not fit for purpose. It is not learning lessons from good practice and has little memory of what has gone before. This legislation needs to get underneath this broken machinery, understand in detail its failings and lack of delivery, and transform it. Secondly, a modern health and care service in an enterprise economy is all about people and relationships and the building of trust between people; it is not centrally about process. Thirdly, the health narrative is out of date. If 80% of the determinants of health are social rather than biomedical, we need to seriously focus on getting upstream in the prevention agenda. It is about a new relationship between the local hospital and the context in which it is set.

Let me take to you one of these innovation platforms in north-west Surrey. I declare my interests. Ashford and St Peter’s Hospitals NHS Foundation Trust sits within the North West Surrey Health and Care Alliance and is an anchor institution. Its focus on integration has placed it in a unique position to describe what works and what does not from the perspective of a place and the 450,000 people it serves. For this alliance, place is prime. First and foremost, subsidiarity needs to be more than just a principle. There should be a clear requirement for systems to demonstrably empower and delegate resources to place-based partnerships. Their learning is that, without tackling the wider determinants of health, it is impossible to shift the dial on the level of demand for healthcare, and this is a major contributor to the unsustainability of the health and care system.

One of the principles that is perhaps worth enshrining in the Bill is subsidiarity—passing responsibility and ownership as far down the chain as possible. Allowing individual staff as much autonomy as possible is a key element in reducing workplace stress and improving retention, enabling local areas to work out their own solutions.

The only way to act successfully against determinants of poor health is through engagement and activation of locally based resources, including the voluntary and charitable sector, statutory bodies such as borough councils, and the business sector, among others. Through placing out-patient physiotherapy services in private and local authority-run gyms and leisure centres, they have enabled individuals to reconnect socially, which they would not have been able to do in a hospital environment. They have de-medicalised the therapy and created the opportunity to get active through joining the gym, enabling people to take control of wider aspects of their well-being, as well as providing additional footfall, which drives business success and supports economic advantage and job security—win-wins all round.

The right solutions need to be developed with these communities and from within them. To do this in a successful and sustained way requires local intelligence, strong relationships and the freedom to act, which can come about only through the activation of place-based partnerships. The alliance view is that too much system interference, control and direction, even if well-meaning, gets in the way and works to prevent the active involvement of the voluntary sector, which has been shown to deliver five times as much benefit per pound spent as statutory services. In this alliance, the aim is that they are an equal partner.

Improved working together across the interface of health and social care leads to other benefits, and ICSs should have a duty to pursue these. In north-west Surrey, the hospital’s recruitment hub, set up during the pandemic to support furloughed members of the community, successfully appointed people into the hospital workforce, many of whom have now taken up permanent employment. As well as being good for the alliance, this means that local people can continue to make a positive contribution—a major determinant of well-being—and support the local economy. The hospital is now working with local schools to build ladders of opportunity from learning into careers in health and care.

The alliance has been successful in securing one of the six new Cavell integrated primary care centres in the country, in Staines. This presents a unique opportunity to bring together hospital services, primary care, social and business entrepreneurs, housing and the arts in a community setting. This team have focused together on their place and have been working together as a partnership for around five years. They have started to see the enormous potential that exists in this integrated care model.

Will the Minister agree to meet the chairman and CEO of this hospital trust so that we can share with him and the Government the lessons learned to date and the opportunities that have presented themselves, as colleagues in the alliance have simply joined the dots? A simple “yes” would do.

Health and Care Bill

Lord Mawson Excerpts

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

[Baroness Harding of Winscombe (Con)]

I do not think that the noble Lord and I have a substantive disagreement. My concern is about prescribing in the legislation the exact recipe for the team; I am mixing my metaphors. After what we have all been through as a country and as a world, I completely agree with him about the importance of putting public health absolutely at the front and centre of our health and care system. However, legislating for the specific skills of the individuals who make up the board would be a mistake, because we want to create a team where people’s experience, background, style and cognitive approach create the magic that we are looking for. This is only one dimension of that; that is all.

[Lord Mawson (CB)]

My Lords, I was one of the people, along with Paul Brickell, who wrote for Hazel Blears the structure for the Olympic Park Legacy Company. I was involved in that project from day one—along with Lord Rogers, who, sadly, has recently died—and for 19 years. We thought a lot about this question because, in east London, we had to engage with six different boroughs around the 248-hectare Olympic Park. We knew that if we simply brought together representatives, many of whom did not have good working relationships or the necessary practical skills, to deliver that project, we would have another Olympic failure on our hands.

The structure that we wrote for Hazel Blears at that time suggested that we needed to bring the right people together for that project: for example, Keith Edelman, who had just successfully built the Arsenal stadium might be a rather important person to have on the board because he understood the detail about stadiums and how you run them—and we were about the build a half-a-billion-pound one. Or perhaps we would need someone like Nick Bitel, who had set up the London Marathon and knew something about sport and the politics of sport; I discovered a great deal about how complicated all that actually was. Or we might need on the board the most successful Labour mayors in that area—Sir Robin Wales of Newham and the mayor of Hackney.

I am very supportive of what the noble Baroness, Lady Harding, is saying. We built a team of the right people to ensure that we delivered a serious legacy on that 248 hectares in east London. I suggest that noble Lords go and have a look at what happened as a result. Empowering the chairman to choose the right team with the right skill set is absolutely crucial if we are to transform the NHS and make it fit for purpose in this century.

[Baroness Walmsley (LD)]

My Lords, I wonder if I may make a slight clarification; I hope that the noble Baroness, Lady Merron, will agree with me. It is not that we believe that the people who we specify should be representatives of the sectors from which they come. Rather, given the functions of NHS England, the three of us who have signed this amendment feel that those with background knowledge of the sectors that are absolutely key to the success of NHS England should be on the board. They would be there not as representatives behaving in a unitary way, as the noble Baroness, Lady Harding, said, but having the background knowledge and information that can be shared with the rest of the board to make decisions.

Health and Care Bill

Lord Mawson Excerpts

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

[Lord Mawson (CB)]

My Lords, I did not want to speak in this part of the discussion but I will make a few comments. I absolutely support what the noble Baroness, Lady McIntosh, and the noble Lord, Lord Howarth, have been saying.

When I first arrived in Bromley-by-Bow 37 years ago this year, I found on my doorstep the largest artistic community outside New York and none of the systems had even noticed or understood its significance. Over the last 37 years, we have been exploring the whole arts and health agenda and the massive impact it can have on local people’s lives.

When we began to put the Olympic project together —as I said on Tuesday, I was involved in it from day one for 19 years—we took that really seriously and engaged with that large artistic and creative community in health, jobs and skills, education et cetera. That £1.2 billion development going on at the moment in the middle of the Olympic park, bringing together University College London, the London College of Fashion, Sadler’s Wells, the V&A, the BBC orchestra and others, is all about this innovation agenda. It is moving it to scale. If this is to happen, we need the systems of the state and the public sector to learn from this entrepreneurial behaviour, which is happening on the ground, in real places and now to scale, and to understand the detail of what it means for the macro systems of the NHS.

I will say more about place later today, but I thank the noble Baroness for making those points, and the noble Lord, Lord Howarth, because this is fundamental. It relates to the fundamental question: what is a human being? A human being is fundamentally a creative being. Health and creativity and, I suggest, entrepreneurship and doing things, are fundamentally connected.

[Lord Bethell (Con)]

My Lords, I came face to face with the nation’s health inequalities every morning in the departmental Covid response group, the COBRA meetings and the COBRA gold, when we went through the hospitalisation details and ICU data and heard stories from the front line of how people who had comorbidities particularly associated with obesity were filling up our hospitals as the virus spread through the country in wave after wave. That health inequality hit this country hard in very real terms. It cost a lot of lives, caused a lot of misery and cost our health system an enormous amount of money. It cost this country and its economy a huge amount of money and it is time that we came to terms with that challenge and solved the problem.

As a number of noble Lords have pointed out, the NHS must step up to its responsibilities in this area. There are complex reasons for these inequalities; some are environmental, some are behavioural and some are to do with access. But the NHS and whole healthcare system must realise that it needs to be involved in all aspects of those, and prioritise and be funded accordingly. The Bill already does an enormous amount to change the healthcare system’s priorities. Putting population at the heart of the ICSs is one really good example of that.

To anticipate some of his remarks, I know that the Minister will point to the Office for Health Improvement and Disparities. As the noble Lord pointed out, however, it has a tiny budget and cannot take responsibility for the nation’s health. Our councils are stony broke, as I found in my experience of dealing with them over the last two years. There is no one else to do this; this is not someone else’s problem. This is to do with the British healthcare system, and it needs to stand up to that responsibility. Zero progress has been made in the round over the last few years and we have gone backwards in the last two years in a big way. We need to make this a massive priority.

This is a fantastic Bill; I am really supportive of it. It came from the healthcare system originally. In this one area, however, there is a graphic lacuna that needs to be addressed. The noble Lord, Lord Kakkar, put it so well in his inimitable way. The prioritisation of inequality must be put in the Bill and it needs to be heard throughout the healthcare system that this is the new, central priority that needs to be added to everyone’s job description.

If, for some reason, we do not do that there will be huge consequences. The healthcare system is unsustainable in its current form. We cannot continue to have a large part of the population carrying grievous comorbidities or disease and afflictions which are undiagnosed or not properly mended turning up in our hospitals at a very late stage and costing a fortune to mend. These health inequalities, whether they relate to disease, injury or behavioural issues such as obesity, are costing us a fortune. Only by putting tackling inequality on the face of the Bill can we really give it the priority it deserves.

I also say to the Minister that there is a sense of political jeopardy about this as well. We went into the last election committed to levelling up on health. We have gone backwards in the last two years through no fault of the Government, but if the Government do not step up to their responsibilities in this area, and if the NHS and the healthcare system do not change their priorities, the voters will judge us extremely harshly. For that reason, I urge the Minister to listen to this debate and look very carefully at ways of amending the Bill.

Health and Care Bill

Lord Mawson Excerpts

Lords Hansard - Part 2 & Committee stage
Thursday 13th January 2022 Lords Chamber

On the specific question of procurement, the NHS is already publicly committed to purchasing only from suppliers who are aligned with its net-zero ambitions by 2030. Last year, NHS England set its road map, giving further details on the expectations of suppliers to 2030. Once again, I hope noble Lords will accept that as real progress.

[Lord Mawson (CB)]

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 (Con)]

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.

--- Later in debate ---

[Baroness Finlay of Llandaff (CB)]

I have two amendments in this group, so I will try to address them very briefly because of time. I am most grateful to the noble Baroness, Lady Thornton, for the way that she introduced this and would like to return very briefly to the issue of public/private potential conflict when public money is being spent, because there is an issue of probity around that. Having shared corporate accountability for the delivery, functions and duties of the ICS could be in conflict with the legal duties of company directors, as has already been pointed out, and therefore creates problems.

I know that the Government recognised this in the other place, but their amendment seems to fall short in two respects. It leaves to the appointed chair of the board the decision on whether a person with interests in private healthcare is incorporated into an ICB. The difficulty is that it provides a condition that their interests in private healthcare could undermine the independence of the health service, but it is very unclear how that will actually be measured. I can see that it would be a fantastic area for legal argument that a precedent had been set in one area that was being worked against by the chair of another ICB. I think this needs to be clarified, because they will be dispensing public money and there are examples already where different decisions have been taken. I will not go into those now because of time.

I turn briefly to the reasons behind the amendments I have put down and declare that I am president of the Chartered Society of Physiotherapy. I am most grateful to the noble Lord, Lord Bradley, for co-signing my amendments. There is a role in recognising that the allied healthcare professionals are the third-largest part of the workforce—the workforce is not just doctors and nurses—and are critical to the long-term plan for the NHS. They work across the health and social care boundary and out into the community. They are integral—physiotherapists in particular—to primary care, and speech and language therapists are essential for children and young people, particularly those with communication difficulties, and that of course includes those with autism and learning difficulties.

I also recognise, though, the problem that you cannot have everybody listed on a board and everybody wants their own so-called representation on it. It will be important that the terms of reference and the metrics by which the function of the board is measured and compared are very clearly laid out, to make sure that there is appropriate consultation at all times with those who are on the receiving end of healthcare, and that people such as allied healthcare professionals are appropriately involved in decisions for the patient groups on which they can have a major impact. Quite often they have a much more major impact than medicine or nursing will do in terms of a patient’s long-term quality of life, and rehabilitation in particular.

So I hope that the Government have listened to this debate and in particular will heed the important warning from the noble Baroness, Lady Thornton, in opening this debate and in the content of the amendments that she has tabled.

[Lord Mawson (CB)]

My Lords, I spoke on Tuesday about the structure that my colleague Paul Brickell, a Labour councillor in Newham at the time, and I, wrote for the then Government Minister Hazel Blears for the new company that would deliver the Olympic legacy in east London. I also described some of the key people who were invited to be directors of this company, with a clear vision and narrative, focused on delivery.

In east London live people from every nation on earth. Indeed, we did some research and we thought Greenland was not represented—but then we found a family in Newham that was from Greenland. Clearly, we could not have a representative from every nation on the Olympic Park Legacy Company, the OPLC—it was not possible.

At that time the noble Baroness, Lady Ford, was chosen as a Labour Peer by a Labour Prime Minister to be the chairman of the board. She was a very experienced player in the regeneration world from Scotland, not east London. I think that at the time she was a little embarrassed that I, an east Londoner, was not chairing it, given all the early work we had done on helping the east London Olympics happen. But I was not a Labour Party member and therefore could not carry the then Government with me, while she could. I was not concerned about this. My colleagues and I in east London were concerned about whether she had the knowledge and skill that could add real value to this important project and the public sector organisation that had been created. She was excellent and had an objectivity I could not possibly have.

We needed both things on the board: deep, local, practical experience and objectivity. I was asked to chair the Regeneration and Community Partnerships Committee, I think because she thought I knew quite a lot about these local issues and delivery, was trusted by local people and had a track record of delivering in place and in local neighbourhoods. Because my colleagues and I had delivered real projects with the local population, we did not know one thing about the place and neighbourhood: we knew, in depth, many things. It was all about finding the right experienced people, not those who said they represented something or somebody. The mayors of Newham and Hackney were there because they were impressive Labour leaders in east London who were turning around troubled local authorities.

I was asked to join the OPLC board as a person with deep, long-term roots in both a place—east London—and a neighbourhood, Bromley-by-Bow. I could speak and reflect back to the board not one thing—say, the environment—but also health: we were responsible for 43,000 patients. I had also been a Mental Health Act manager for quite some years locally. I think the noble Baroness chose me because I had deep and wide experience of the people, place and local neighbourhoods, and because of the practical work we had done in east London over quite some time—three decades, actually. It was about practical experience of place and neighbourhood and delivery. It was not about a person who thought he or she was representing one group or another, or a particular topic.

Experienced people bring many things to the board with them. I worry about the disabled person on a board who thinks they can talk only about disability issues—this is very condescending—or the young person who can talk only about young people’s issues. They can talk and have views on everything; it is about finding the right-quality person. However, they must have in-depth knowledge of what is actually going on locally and a deep understanding of the practical issues surrounding delivery. This is absolutely crucial.

There is a wider problem with some representatives on committees and structures, because they represent other agendas and they have mixed loyalties. They cannot focus on the task of the board because they have mixed loyalties elsewhere. They do not therefore prioritise the needs of the organisation they are sitting on. There is a lack of clarity about this, and I suspect we will all have experienced this on boards we have sat on. We need to get very clear about these democracy and delivery issues—what I call “the two Ds”. I have listened to a lack of clarity around these issues from successive Governments in recent years. We must get this clear if the new NHS structure is to really deliver the transformation we all now want to see and to deal with the health inequalities we rightly all discussed this morning.

[Baroness Harding of Winscombe (Con)]

My Lords, I too spoke on Tuesday about my concerns about listing the specific membership for the NHS England board. I have similar concerns to those that the right reverend Prelate and the noble Lord, Lord Mawson, have just set out. However, there is a slight difference with this issue, in that the core purpose of an integrated care board is to integrate. So I recognise the very real concerns that noble Lords across the Committee have mentioned about the importance of being able to hear the voices of all the different elements of our health and care system, to hear patients’ needs loud and clear and to make it a board that genuinely works, as the noble Lord, Lord Mawson, has just set out.

Health and Care Bill

Lord Mawson Excerpts

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

[Baroness Harding of Winscombe (Con)]

My Lords, I too stress the importance of digital transformation in our health and care services. I thank the noble Lords, Lord Clement-Jones and Lord Hunt, and my noble friend Lady Cumberlege for their contributions and for enabling us to have this debate.

The way that the noble Lord, Lord Hunt, has characterised this as three different issues interwoven is an extremely good way to think about this. I completely agree that the integrity and confidentiality of patient data, and having the resources to lead transformation, are essential components. I would just like to add a contribution on the third element, the prioritisation of digital and data. I too am going to cite the Wade-Gery review. It is really important that those of us who have worked in digital transformations in other sectors also encourage our health system to look outside. All health systems are probably 10, perhaps 20, years behind other sectors—financial services, retail and, dare I say, even politics—in their digital journey.

This is not just an NHS issue: it is a health sector issue. One reason why that is the case is that we have tended in health to think that digital is “other”, something separate from healthcare itself; whereas, actually, healthcare is that most human of services and digital is an enabler. It is the means, not the end, and it is hugely important that we think of prioritising digital and data as prioritising the overall transformation of care, rather than the digital transformation. This is not just semantics: it is important that everyone owns that transformation, most importantly our front-line clinicians, and that it is not something that is parked separately.

When I was growing up, my parents’ generation abdicated responsibility for the family VCR to the children. Certain business leaders, 10 or 15 years ago, abdicated responsibility for their technology transformation to their chief technology officer. If we really want to see the benefits of digital transform our health and care system, we must not abdicate that transformation to a digital transformation team. It needs to be the business of everyone—most importantly, our leaders. I hugely support the spirit of these amendments and particularly the amendments looking specifically at funding and a duty to lead transformation, but I caution against creating a post of digital transformation because that needs to begin with the chair, the chief executive and the medical and nursing directors, not just an individual with digital in their name.

[Lord Mawson (CB)]

My Lords, my colleagues and I built the first online facility for the voluntary and social enterprise sector in this country in 1997, called CAN Online. We learned rather a lot from doing that, and I actually came to many of the conclusions that the noble Baroness, Lady Harding, is telling us about. When we started this, we naively thought that this online environment was going to solve all our problems, as if it sat “out there” somewhere. We bought 12 computers: they came in very big boxes at that point, as noble Lords might remember. We put them in a room in a conference centre—we were in the Cotswolds—and I invited 12 entrepreneurial people working in the social sector to come and share a few days with them. We connected them all up. We thought it was about technology, but we actually we discovered that it was all about people and relationships; that this technology was simply a tool—an enabler—to facilitate a marketplace that we needed to build between us.

We began to understand that this was not about large systems up there that you plonk in the middle of things in some separate way. It is actually organic: they are very connected, and you need to co-create it and invent it together around the real needs and opportunities that are presenting themselves. I think this technology is telling us something about what needs to happen to the health service. It is organic; it is entrepreneurial; it is about creating a learning-by-doing culture. My colleagues and I have seen examples in the NHS and other parts of the public sector where millions of pounds have been spent on systems that have landed from Mars and have not worked.

First, we must understand the detail of this technology, and the opportunity that it brings. Later on, as we go through the amendments, I will share with noble Lords some technology platforms that we are working with across the country that have absolutely understood this. When they are engaged with the NHS, instead of the system getting behind them and building on their success and knowledge, it never follows up on the conversation with them. They never heard from the NHS again. There is a disconnect going on, and a fatal misunderstanding of how this new world now needs to work.

I welcome these amendments and this conversation, but we must understand—from those of us who built some of this stuff, even in the clunky old days of 1997 —that it is all about the relationship between people and technology and a learning-by-doing entrepreneurial environment.

[Lord Bethell (Con)]

My Lords, I, too, praise the noble Lord, Lord Clement-Jones, for his analysis and for rightly identifying the important connection between trust and confidentiality, and the noble Lord, Lord Hunt, for his diagnosis. In particular, I double up on the praise for Laura Wade-Gery and her report, which provides a huge amount of insight for this debate, and praise also my noble friend Lady Cumberlege, who has been a pioneer and remorseless champion of safety. She is entirely right that we are talking here not just about productivity but safety. Data saves lives, and her report made that point extremely well.

Basically, I just want to repeat absolutely everything that my noble friend Lady Harding said about ambition. My concern about this debate is not the analysis, which I think is spot-on; it is the level of ambition. I have lived through digital transformations. I lived through one in the music industry, and it did not just come from digital transformation officers—although I know that that is not the point of these amendments—but required the commitment of everyone from the superstars down to the roadies. Everyone in the industry was affected; it was a massive revolution; it led to an incredible improvement in the industry; but it was hard fought and a difficult thing to go through.

I have also lived through a revolution in digital in healthcare. Over the past two years, we saw amazing breakthroughs in individual areas, the vaccine rollout being a really good example to which my noble friend Lady Cumberlege referred, but also in non-present appointments with GPs and in other areas. But it took a pandemic to drive that progress as quickly as it did, and I never again want to see such a horrible emergency be required to create change.

The message to the Minister is that the Bill is a remarkable enabling document that helps the healthcare system in the UK make important progress across the board on many different areas, but the big challenge of our generation is digital transformation. It does not require a lot of legislative change. These amendments are not what will make a difference. My noble friend needs to have the energy, passion and determination to see through that transformation when he gets back to the department, and I hope that the Bill gives him the tools to do that.

--- Later in debate ---

Moved by

[Lord Mawson]

41A: Schedule 2, page 137, line 30, at end insert—
“(d) one voting member nominated by place-based partnerships to represent their collective views in delivering their strategy.”

[Lord Mawson (CB)]

My Lords, the noble Lord, Lord Young of Cookham, reminded us last Thursday that we have been talking about the social determinants of health and health inequalities for 40 years. It is now time to act. I want to get practical, and my three amendments are all about the practical detail—the “how” questions—about the transformation of the health culture and about new ways of thinking and working. My focus is on the first small, necessary steps on this journey.

Following my speech at Second Reading, I begin by thanking the noble Lord, Lord Kamall, for agreeing to meet with me and the chairman and CEO of Ashford and St Peter’s Hospitals NHS Foundation Trust in north-west Surrey and allowing us to share with him and his colleagues, in more detail, the work that we have been doing there in recent years. This is set out in Hansard. This work builds on 37 years of work that my colleagues and I have been doing at the Bromley by Bow Centre in east London on the integration and place-making agenda.

The principles of the work in Bromley-by-Bow are now well known and are being shared with communities right across this country, and this work is now starting to have a national reach, through the Well North Enterprises programme, which I lead. I declare my interests. The work in north-west Surrey is one further practical example of what happens when you start to take these principles to scale and apply them to the place and neighbourhood agenda, which I suggest needs to be strengthened in this legislation.

The Minister thought that it might be helpful to the House if I first set out the background to my three amendments, which are focused on the importance of place and the local neighbourhood, before dealing specifically with the first amendment on the Order Paper. What does a modern integrated health service actually look like, and how do we take the first faltering steps towards it? I suggest that the clues are in the micro: in the place and the local neighbourhood.

The NHS is in some difficulty, and much of the narrative that underpins it is from the last century and now well out of date. The chairman of Ashford and St Peter’s hospital describes it as a “financially unsustainable illness service”, not a health service. Science and modern understanding of the integrated nature of life and health have, in recent years, taught us a great deal about the social determinants of health. Ironically, the pandemic has forced all of us—the nation, if not the world—to return to the simple question: what is health? Nowadays, we all know that health is no longer simply a biomedical matter for doctors and hospitals—indeed, it never has been. The Peckham experiment on the social determinants of health was telling us all this early in the last century, but the NHS in 1948 thought that it knew better and chose not to continue with this approach.

Health is everybody’s business. It is not just the domain of health professionals, hospitals and just one government department. If 70% of the determinants of health are social, and if our present business model for the health service is unsustainable, we desperately need to return to the central question: what is health? What changes to the narrative on services and provisions does the state now need to make to respond to this modern understanding of what health is all about? We need to get upstream towards prevention and early intervention. For this modern generation, which takes integration for granted, the siloed approach of the state will no longer cut it.

Over the last 37 years, my colleagues and I have built practical working pathfinder projects in real neighbourhoods with local people. Others may well refer to these in this debate, so I will not waste the Committee’s time now. The Bromley by Bow Centre is in London’s East End and is well known nationally and internationally, but we have been involved in other projects. Today, the Bromley by Bow Centre is responsible for 43,000 patients on four sites in Poplar. Working with local partners, we have built the first independent housing company, which is resident controlled and has connected health, housing, education and jobs and business skills. Today, it brings together people from many nations of the world who live there, around practical place-making, health and social projects. This housing company now owns 10,000 properties, owns 34% of the land in Poplar and has in play a regeneration programme worth many millions of pounds.

Today, the Bromley by Bow centre is visited by over 2,000 people from the public sector and across the world, who we find are desperately asking the same questions as us. These are the practical questions—“how” questions—about how we bring together the health services, local authorities and voluntary and business sectors and generate a 360 degree response to people’s health needs and lives and the opportunities in local communities. This is not a simple matter, but I suggest that the place to start is not in the macro but in the micro: in local communities and neighbourhoods, where lots of talent and opportunity lie that are not being tapped and never will be if you do not join them up and develop a very different approach.

In 2015, Duncan Selbie, who at the time was CEO of Public Health England, asked me to take this place-making work and the working principles of the Bromley by Bow Centre into towns and cities in challenging communities across the country. In partnership with the NHS, local authorities and business and voluntary sector partners, we created 10 innovation platforms in Bradford, Rotherham, Skelmersdale, Doncaster et cetera. We did not write policy papers or research documents, which, in my experience, often few read; we created practical learning-by-doing environments. The clues that we have found are local—in people and relationships—and not necessarily national.

My three amendments seek to use this legislation to tap into this local talent to take the first steps on the road to integration, with a necessary focus on the local, the place, the neighbourhood and the community. Health is a social matter: it is not just about private individuals, and we now desperately need to get upstream on the health agenda in this country and move forward.

This legislation, and the integration White Paper that is soon to follow, can help us all take the first steps in this century in the transformation of the NHS. I suggest that the micro is the way into the macro; it is not the other way around. In local neighbourhoods across the country, at a human level, we now need to create innovation platforms in local places and neighbourhoods, with public sector leaders and local people willing to support and generate new integrated approaches to health, and learn from them. Let a thousand flowers bloom.

As we expand our work across the country through practical engagement, we are finding that lots of people already get all of this. Many of them are in the public sector and the NHS and are desperately frustrated with the present state of affairs. They want to be health creators, but the system is not harnessing their creativity and energy—so, often unintentionally, it is pouring treacle into their projects and disempowering them, creating an ill organisation.

--- Later in debate ---

[Baroness Thornton (Lab)]

Might I have some clarification from the noble Lord, Lord Mawson? He and the noble Baroness, Lady Cumberlege, have referred to three amendments and I can see only one. I would be grateful if he could enlighten me on which the other two amendments are that we might be addressing in this debate.

[Lord Mawson (CB)]

My Lords, there is just one amendment in this debate. My other two come further on.

[Lord Clement-Jones (LD)]

My Lords, it is a huge pleasure to follow the noble Lord, Lord Mawson, and the noble Baroness, Lady Cumberlege. I have signed and strongly support all the amendments tabled by the noble Lord to ensure that integrated care boards are closely connected to local communities. We have riches yet to come: the noble Lord’s later amendments ensure that local solutions are prioritised, and that procurement is firmly rooted in local communities, but I will speak only to Amendment 41A.

I will give an example of when the noble Lord and I have been involved in another project, beyond the very important Bromley-by-Bow project that the noble Baroness, Lady Cumberlege, talked about; namely, the St Paul’s Way Transformation Project, the health, education, jobs and skills, and community campus which started in 2006. It is a great example of a response to the local challenges faced in an east London neighbourhood very close to Bromley-by-Bow, with failing health and education services and community relationships. This transformation project was focused on integration from day one and has been a huge success.

The noble Baroness, Lady Cumberlege, talked about the extraordinary track record of the noble Lord, Lord Mawson, as a social entrepreneur. He launched this project in partnership with the NHS and Tower Hamlets Council, and brought together the local authority, the local school, the GP network, the local housing association, Poplar Housing and Regeneration Community Association, and the diocese of London, to bring about transformational change in and around St Paul’s Way, a main street running through Poplar. Together they built a new secondary school, new primary school, new health centre, new mosque, new community centre and restaurant, new park, new street scene and 595 new homes. In parallel with this, the quality of the local leadership, and hence of local service provision, was transformed. The failing secondary school moved to Ofsted outstanding, the failed GP practice was replaced and its successor became CQC outstanding, and the independently monitored residents’ satisfaction level is currently 85%.

The St Paul’s Way project has been a great success story of local partnership with other local actors. For example, near neighbour Queen Mary University of London, the governing body of which I chair, with two campuses in Tower Hamlets, and which is intimately involved in the governance of St Paul’s Way Trust School, helped design and develop the school’s new science labs. They are in the health building, which the school uses and where we have taken space for our school of dentistry and DNA research.

Partners in the local schools, the GP practice and the housing association have played an important role in recent years, as they have shared their work and experience with communities in towns and cities across the north of England and now beyond. However, the project faces major challenges, as outdated NHS procurement systems are now in danger of undermining the good work that it has been doing for over a decade. Amid this project being put together, the PCT procured a primary healthcare provider with no London experience, let alone any local experience. After two years, it surrendered the contract because it had not understood that primary healthcare is very different and costs a lot more to deliver in Poplar than in affluent suburbs. This experience is an illustration of the importance of there being a neighbourhood voice in the making of decisions by the NHS, which, if they are got wrong, can damage the ability of local integrated partnerships to function and develop effectively at the neighbourhood level. There is an opportunity to address this in legislation.

In this light, how can the Government make integration a reality? This is a clear example of disconnects that will be replicated on other streets across the country, and a demonstration of what happens when the NHS procurement systems and policy do not take place and neighbourhood seriously. Health is about bringing people and communities together, not undermining them. The solutions are often local and not in large outdated systems and processes. This local approach must be embraced. It is at the 50,000-person neighbourhood level, not an enormous eight-borough ICS where integration aimed at innovation in prevention and recovery can be most effective. Neighbourhood must be understood, valued, and given leverage in the system and flexible use of budgets. It is at this level that the actual practical interventions can happen. It is here that schools, housing, job opportunities and community action can happen. Neighbourhoods can act with speed and agility.

The noble Baroness, Lady Cumberlege, suggested that the Ministers visit Bromley-by-Bow; equally, I suggest a visit to the St Paul’s Way transformation project. This amendment is as much about creating the right culture as the right representative structure. I hope that the Government accept this important amendment and the other amendments tabled by the noble Lord, Lord Mawson, on this subject.

--- Later in debate ---

With those points in mind and looking forward, as I say, to our further debates on the subject, I hope that this assures noble Lords that the Government have this agenda very firmly in their sights and that NHS England has equally. Therefore, I hope that the noble Lord will be able to withdraw his amendment, in the knowledge that I am sure we shall have further things to say on this important subject.

[Lord Mawson (CB)]

My Lords, I thank the Minister for those thoughts and comments. I also thank noble Lords who have supported this amendment and this very encouraging debate. The purpose of today was to open up a discussion about these issues. They have been very well aired and I think the discussion needs to go further. Certainly, I would like to take further with the Minister and his colleague the discussion around the implications. My concern is to ensure that the significance of place and neighbourhood and that the role of the micro is absolutely clear at an ICB level. Senior colleagues in the NHS where I am working warn me to be very careful about this. The danger is that fine words will be used, but as others have said, this is not about words; this is about understanding the actions that now need to take place to really transform the health service. The micro and the macro need to learn to dance together, and that will not happen unless there is greater clarity on it. It has been a helpful conversation and one that I hope will be taken further.

I have a few final thoughts. It has been good to have colleagues from different parties and very different backgrounds in this discussion, which I have found very helpful. This is not a party-political matter; this is about the next 20 or 30 years of the National Health Service. There are likely to be different Governments and different parties with responsibility, but laying the foundation stones correctly and getting the detail right—it is all about the devil in the detail, in my view—is really important.

It was very interesting to hear bits of the history. It was Lord Michael Young who came to see me, many years ago, in Bromley by Bow, precisely because he got very interested in what we were doing. It was not just that he joined us as a community and became our patron—we have had patrons from different parties; Lord Peyton from the Conservative Party was a patron for many years, as was Lord Ennals from the Labour Party. Lord Young ended up asking me to marry him and his new wife. I had to do the marriage, and eventually the baptism of his child, so there is a long history. Allison Trimble, my former chief executive, was called to work in the King’s Fund precisely to help it understand the devil in the detail of what we were discovering, so this debate brought back many memories for me.

One of the last few things to say is that it is important in this journey that we create a learning-by-doing culture. This culture is very well known to science. In part of my life, I work with Professor Brian Cox, who knows a thing or two about science. I think the reason we get on is that we both understand that science and entrepreneurship are profoundly connected. It is not just the health service, in my view, but the whole public sector that needs now to embrace a learning-by-doing culture that moves beyond strategy and process into learning from the practical things it does and does not do.

Finally, I thank Suzanne Rankin, the chief executive of Ashford and St Peter’s Hospitals, and the chairman, Andy Field—Suzanne is a brilliant chief exec and Andy is a rather excellent chairman—for joining in this conversation with the Minister. I also thank colleagues from the hospital, who I think we would agree have been very brave, and who have now, with four local authorities, set out on a journey to lead the way in Surrey on what this might mean when you start to move it to scale. Having said that, I beg leave to withdraw the amendment.

Amendment 41A withdrawn.

Health and Care Bill

Lord Mawson Excerpts

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

[Baroness Wyld (Con)]

My Lords, I support my noble friend Lord Farmer. I declare my interest as a non-executive member of the board of Ofsted. I apologise for not being able to speak at Second Reading for my own family reasons. I echo everything that the noble Baroness, Lady Tyler, said. It was a real pleasure to serve with her on the Public Services Committee.

I will praise the Government first, which is always wise. They are showing great commitment to family hubs and I believe that they are committed to the rollout. What concerned me when the committee took evidence from certain members of the Government was a sense of a lack of urgency. Everybody agreed that this was a brilliant idea, but different people from different departments had different ideas about how they should work.

We also took evidence from families, in private and in public. The stories we heard over and again were, as others have alluded to, that, “This could have been prevented if it had been addressed in a joined-up way”. We particularly heard from young children, “I had to tell my story over and again.” Imagine the trauma. This could have been prevented under a different model. These situations did not have to happen.

We have the building blocks to make sure that these situations do not happen, but I do not think the legislative framework is in place to help us to address that. For that reason, I am persuaded by my noble friend Lord Farmer and I am happy to support his amendment.

[Lord Mawson (CB)]

My Lords, I am very supportive of what the noble Lord, Lord Farmer, said. My colleagues and I have been in this space for 37 years and we have built rather a lot of things in it. It has been very interesting to watch what happened in east London, when this new scheme from a new Government arrived in the middle of a group of communities that already had well-established relationships with very vulnerable families, with a whole range of opportunities emerging. I am sure it was unintentional—it is part of the danger of being overinfluenced by the idea that local authorities will sort this stuff out in the same old usual way that they have tried to before—but it was very disruptive for the social enterprise sector, which was already doing this stuff very effectively, with all the numbers to show it. I will not go into the detail now, but when you look at the detail of what actually happened, the present facilities cost £100,000 more than those being delivered by the social enterprise sector.

These ideas are really important. I am happy to take the noble Lord into this in a lot more detail. I encourage him to spend more time in the detail in some real places to look at the unintended consequences of what happens when new government programmes arrive in communities, with the best will in the world, with an overconfidence in what they think the state can deliver. I am very happy to have a further conversation with the noble Lord, but the detail of the long-term relationships with these families really matters.

[Lord Warner (CB)]

My Lords, briefly, I support these amendments, partly from my own experience as a director of social services and Children’s Commissioner, but also because of the points that the noble Lord, Lord Mawson, raised.

I have three key points from history. As a director of social services in the 1980s and 1990s, I offloaded my local authority family centres to the voluntary sector because a survey of parents suggested that they would not come to a service run by the organisation that was likely to take away their children. That was a perfectly rational position and we should listen to what people say about that.

Fast forward to 1999 and parenting orders under the Crime and Disorder Act. We find that compulsion brought parents to the party but, when they actually attended, they found—not so much men but women—that they were being treated and given skills that enabled them to manage children, largely teenage children, much better than they had been. It was a great shame that we used the criminal justice system to bring people to a parenting tuition experience that they should have been given many years before.

This is a final point from history. Michael Gove made me—this was madness on my part, as well as his—children’s commissioner for the failing Birmingham City Council children’s services. Ofsted report after Ofsted report had been telling them of their deficiencies. We found that the group they could not handle, for which they had no effective responses, was teenagers. If we are to make any progress in helping people to help the family unit, we need to address the support given to parents during the teenage years, because they are really struggling, particularly mums.

--- Later in debate ---

Moved by

[Lord Mawson]

159A: Clause 22, page 32, line 29, at end insert—
“223CZA Financial duties of NHS England: the principle of subsidiarity(1) NHS England must exercise its functions in accordance with the principle of subsidiarity, and must promote the principle throughout the integrated care system in particular by ensuring that integrated care boards observe the principle.(2) The principle of subsidiarity is that responsibility for deciding how and where to use resources is as far as possible to be delegated to local areas in order to meet local needs and to promote local groups working collaboratively.(3) In doing so, the process and timing of procurement should take account of the benefits of long-term relationships and stable partnerships in delivering sustainable integrated solutions to local health issues.”

[Lord Mawson (CB)]

My Lords, I have listened carefully to the debate taking place in Committee over the last few weeks with great interest and noted the growing consensus that now exists across this Chamber for transformation and change. These debates have shown the House at its best. It is clear that the Government now have before them an opportunity to transform not only the NHS, its culture and its ways of working but the public sector, much of which is not fit for purpose in this century. People inside and outside these systems know this—listen to those who are leaving for early retirement.

As well as listening, I have been talking to colleagues around the country: those inside the NHS systems; those responsible for the development of the ICSs; and those outside who seek to transform the health and care world and who wish to partner with these systems. I will share a few concerns that I have heard, because they relate to my two amendments, Amendment 159A and 210A.

First, colleagues both inside and outside NHS systems have heard fine words from Governments before about change and transformation in health and care, but they are sceptical. They know that the Civil Service and government systems and mindsets are not fully fit for purpose. The Civil Service’s culture and mindset need to transform; it needs to get interested in what is happening among young entrepreneurs in Bradford, for example. The voluntary and social enterprise sectors need the Government to go beyond fine words and deal with, for example, the situation that my colleagues at the Bromley by Bow Centre have to deal with every day as they navigate—as the noble Baroness, Lady Cumberlege, mentioned last week—41 different funding streams coming up the silos from the Treasury, at enormous cost and wastage of time, as they try to deliver integrated services. If we are to build a more integrated health and care programme, these practical issues are going to get worse—not just in east London but across the country—unless we address this now.

Many years ago, we had a secondee from the Treasury in Bromley who told us how all tax revenue was paid into one bank account. How much does it cost to then spread this out across 41 government departments and programmes, only for it all to be brought back together to address the multiple, complex and interlocking issues that somewhere like Bromley by Bow faces? How much cost does all this add? No one knows. Is it 20%, 30% or more? No wonder we have a productivity crises.

The Single Regeneration Budget programme was an early attempt, some years ago now, by the Civil Service and the Government to bring funding streams together. What lessons have been learned in government and the Treasury from it? I suspect there is no memory of this programme in the system.

There is also a danger of the NHS and public sector culture imposing itself on the voluntary and social enterprise sectors, as they try to innovate and generate new ways of working—what I call putting old men in new clothes. I have seen this in the housing association movement, which I was involved with in the very early days, and in what happened to children’s centres, which were launched in Bromley-by-Bow by a Labour Government, which then unwittingly undermined our integrated model and ways of working with local families.

My colleagues in parts of the country can already see the NHS centrally trying to impose its old processes on them as they innovate, at the very moment there needs to be a two-way street and real learning taking place. The centre needs to learn from the micro, from the innovation platforms we have created, not impose its outdated systems on them. Government needs now to show a clear resolve to transform the culture of the NHS or people will become even more cynical. The whole system and culture desperately needs change, and the way into this is via the micro and practical details.

Yes, it will take time, but first we must be clear about why we are taking these initial early steps and where we are trying to get to. There is a real danger of our Civil Service systems unwittingly deepening poor-quality outcomes and a dependency culture. The centre should see these innovation platforms as a place that can teach the centre, not the other way around. I declare my interests here. We need new behaviours from NHS England, not last-minute processes that want everything tomorrow. The macro needs to learn from the micro; the whole system needs to return to first principles and create an environment which encourages healthy communities.

Levelling up is surely about addressing the UK’s productivity gap, especially in marginalised communities, and one way of doing that is via a healthy and thriving population. It is also the only way to stop the NHS taking an ever-greater percentage of the UK’s GDP. I suggest health is now everybody’s business.

My two amendments fit within this mindset and suggest some first steps that could be taken along this road. Let me now deal with my first amendment, Amendment 159A. True subsidiarity cannot be achieved without delegation of resources and the authority to allocate in a way which will achieve the intended and agreed objectives. For example, systems may wish to ensure that discretionary local services such as community centres, community transport, struggling family support and meals on wheels should be prioritised and sustained ahead of further spend on health capacity, given their key role in supporting ongoing independence and social cohesion and preventing the need for health services.

Place systems may choose to pool delegated resources in order to commission collaborative services at scale, where they jointly agree that they are not best placed to provide such services, and such discussions are already taking place in mature systems. For example, in north-west Surrey we have agreed to jointly commission dermatology services across two place systems. The point is that delegation to place does not work against the development of services at a wider scale where that is appropriate, but the recognition of this needs to come from the place level.

True transformation—true to the spirit of the Bill and the long-term plan and to achieving the intended benefits of integration—cannot be achieved without the freedom to invest those resources in a way which can unlock long-term benefits. This may require speculative investment in some cases, as well as investment in preventive services which do not offer rapid returns but are essential to maintaining the ongoing sustainability of services. We would not expect any of this to be done without due diligence on the capability of place-based partnerships and appropriate levels of holding to account for achievement of improvements and results. The ICS will have a key role in not only ensuring that funds are delegated appropriately but supporting place-based systems to build the capability to manage delegated funds effectively.

We need to make leaps in how health services are now delivered through integrated services and offers to populations, by thinking radically about who can support people best, and in what way, to keep them healthy, look after them at home where possible and provide services which understand people as individuals and meet their needs holistically.

This degree of change in public health, prevention and provision of services needs innovative and broad-based collaborations and partnerships between organisations—health organisations, local authority organisations, VCSE and business—tailored to fit the needs of the place. These relationships are not quick to build; they take time and effort. The work takes years and the impact can be seen only through long-term relationships and stable partnerships. For this to succeed, the ICS will need to embrace the principle of subsidiarity, delegating meaningful responsibilities and accompanying budgetary responsibility to place level. This may mean that standard procurement cycles and processes do not immediately bring the outcomes that the Bill envisages. More innovative processes and timings may be needed to ensure that the benefits brought through long-term relationships and stable partnerships are given time to be achieved.

Let me now deal with Amendment 210A. In general, NHS bodies do not currently make best use of their local voluntary community, social enterprise and faith sectors when procuring services to achieve key health outcomes, especially in prevention and early intervention services. This is all well understood but, somehow, we never seem to get beyond one-off experiments or short-term, time-limited initiatives. By contrast, the best local authorities have been procuring and partnering with their VCFS for many years, though this has become more difficult with recent funding pressures. There is an opportunity, therefore, for health colleagues to learn from their local authority colleagues in the ICS on best practice in this regard.

With NHS vacancy rates at their highest levels, together with waiting lists for treatment, now is the time to take a whole-system approach and look more collaboratively across the local community. There is also a strong value-for-money argument. Simply waiting for people to become seriously ill, which is what is happening in practice at the moment with regard to many mental health services—but not by design—and could equally be applied to services for struggling families, leads to very poor outcomes and is very expensive. Using VCFS organisations and others, with a combination of staff and local volunteers to create a coherent health-oriented rather than illness-oriented approach, will pay dividends, but only if there is real intention and focus over a sustained period of time. This is a long-term play, not a quick win, but vital none the less.

Traditional models are not working for the groups which can offer most value. Local charities and social enterprises tend to be funded on a hand-to-mouth basis using grants, so most cannot permanently invest in their services. This is despite a huge growth in charitable giving from the public, directed in the main at the NHS.

In north-west Surrey, we are looking at how we can give similar prominence to local charities supporting areas of deprivation and communities in need, but more needs to be done to enable charities and voluntary sector groups to be assured of ongoing funding to provide core services. Keeping such VCS groups active is essential to achieve insight into the needs of communities. There are innovative approaches such as Tribe, a platform developed by a technology business- person, Richard Howells, simply because he had become so frustrated by the inabilities of the NHS and care services to deal with his own mother’s care needs. Richard did not write a research paper; he created a practical solution, which is pretty impressive. When he shared this practical solution with the NHS centrally, there was a lot of interest and fine words but, in actual detail, no follow through.

We now need to allow these insights at the most granular level to inform the commissioning and targeting of services. Without this, we will not be able effectively to respond to specific areas of inequality or health risks, leading to ill health and pressure on services. The existing models of voluntary sector support need to be developed to enable and promote micro- enterprise creation on a far greater scale. This both protects the quality of services and enables individuals to gain training, support and income. It has the potential to open up a currently untapped resource of care support, which is critical in places such as north-west Surrey, where community care staff vacancies run at around 40%.

Employment and volunteering are themselves key determinants of well-being. Place-based systems will wish to use their spending power to leverage this benefit and invest directly in local employment, where it can be demonstrated to be the most effective use of resources. In north-west Surrey, we have achieved a virtuous cycle of supporting furloughed airline workers during lockdown through recruiting them into the hospital workforce, supporting the delivery of services and well-being of clinical staff, and reducing the risk of those individuals developing physical or mental health problems through inactivity and stress.

--- Later in debate ---

This has been a helpful debate on an important matter. I hope I have been able to reassure noble Lords that we are already taking a sensible approach in the provisions in the Bill and that making amendments to it is not necessary. I therefore hope the noble Lord, Lord Mawson, will feel able to withdraw his Amendment 159A and not to move Amendment 210A when it is reached.

[Lord Mawson (CB)]

My Lords, I thank the Minister for those helpful thoughts and reflections. First, on NHS England, we need to be very sure that a two-way street is established, because I worry that systems such as this are not learning organisations—we know this from experience—and they now need to become such if they are really to embrace an environment that is about innovation and more entrepreneurial activity. I put that on the record. We will watch what happens; I am sharing with noble Lords what is actually happening now, live, in some of these services around the country as they try to establish new ways of working.

I pass on apologies from the noble Baroness, Lady Andrews, and the noble Lord, Lord Clement-Jones. They have supported these amendments but, because of the change in the timetable, were not able to be with us today. This debate is being watched around the country, and I am aware of a very interesting dialogue going on with people both inside and outside the system. We should all be encouraged by that and should build on it.

With regard to the Report stage and to these two amendments and my earlier amendment, my colleagues and I, with others in the system, will reflect on these discussions. We will, I hope, talk further with the Minister and other colleagues and think about what the next steps might be. For now, I beg leave to withdraw my amendment.

Amendment 159A withdrawn.

Health and Care Bill

Lord Mawson Excerpts

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

[Baroness Merron (Lab)]

My Lords, this group of amendments concerns the licensing of non-surgical cosmetic procedures and other important considerations, such as hospital rehabilitation accommodation and the doctors’ register of interests. They all relate to the interests of patients.

I shall address particularly the issue of cosmetic procedures and I start by thanking the Minister and his Bill team for giving so much support, showing such interest and bringing this into being today. I know we all welcome it; it is much appreciated. I am glad to have taken part in the meetings and to have tabled an amendment in Committee relating to cosmetic regulation. The amendments before us today have been very much welcomed by medical associations, because we all know that lack of regulation has been a ballooning problem. For example, the Save Face organisation received more than 2,000 complaints of botched procedures in 2020 alone and the true number, as we know, is likely to be higher.

The other point to make is that this is a fast-moving industry and I am glad that these amendments will be able to keep pace with an ever-changing landscape. We have seen a significant rise in recent years in the number and type of non-surgical aesthetic procedures performed in the UK. Practitioners, both medically and non-medically trained, are performing procedures without even being able to evidence appropriate training and the required standards of oversight and supervision of procedures that can be described only as high- risk. When they go wrong—and we have all heard the stories of intense and lasting damage from untrained practitioners carrying out procedures in unlicensed premises—we all know that it will then fall to the NHS to pick up the pieces. This, today, is a meaningful step in protecting more people from rogue operators.

I close by thanking noble Lords for their contributions not only to this debate but to shaping the legislation. Once again, I thank the Minister and his team for all their efforts. I hope we will come to see a much safer set of non-surgical cosmetic procedures than we have at present.

[Lord Mawson (CB)]

My Lords, just before the Minister stands, I rise to support Amendment 184ZA in the name of the noble Baroness, Lady Cumberlege.

Over the last 28 years, it has been my privilege to work with a fantastic team of GPs in the East End of London who are now responsible for 43,000 patients. I know what great GPs and doctors are like. If I am honest, however, I have also had to deal with a number of dodgy doctors, which is a very difficult matter to deal with. One doctor undertook female circumcision in his practice, unbeknown to the health authority for quite a period of time. He ended up marrying his practice manager and, some years later, he murdered her. Another practice, when I dug under the carpet, had bought a cheap fridge from B&Q and, over a period of three years, kept 10,000 injections at the wrong temperature and injected 10,000 patients with dead, illegal injections. Another doctor, as we learned when we took over his list, had countless ghost patients. As a result, I started to discover what ghost patients are. It took our team two years to sort out the realities of who were and were not real patients.

For the sake of GPs and patients, we need to protect them in the way the noble Baroness is suggesting. Doctors are flawed human beings like the rest of us, and we need to protect them from themselves and from us. It is really important that these things are taken seriously. This amendment puts its finger on a very important matter.

[Baroness Wyld (Con)]

My Lords, this morning, I told my three daughters that they needed to be more assertive at school, but I have completely failed to intervene tonight. I will be very quick in paying tribute to the noble Baroness, Lady Merron, and my noble friend Lord Lansley, who is not here tonight, and in thanking the Government for the amendments on cosmetic interventions. I sponsored the Botulinum Toxin and Cosmetic Fillers (Children) Bill in this House, which assisted with the regulation of non-surgical interventions for children. At the time, we said that this was only the start and that there was a lot more to do. We acknowledged that others had done a lot of spade work, and I pay tribute to all those who have done yet more spade work. I want to put on record my appreciation to the Government for listening and reacting.