Health and Care Bill

Lord Patel Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Lord Patel (CB)]

My Lords, it is a pleasure, on behalf of the whole House, to welcome the noble Lord, Lord Stevens of Birmingham, and to congratulate him on his thoughtful, inspirational and brilliant speech. There ends the good news.

The noble Lord did not say much about himself, so I am going to fill in the gaps. He has been a household name for many years. Coming from a council estate and a comprehensive school, he went on to win a scholarship to Oxford to read PPE, received an MBA from Strathclyde University, and attended Columbia University on a Harkness Fellowship, followed by management training in health. He worked as a porter in a hospital and as a mortuary clerk—those clients could not complain about him. He served on several management boards in England, was CEO and president of UnitedHealth Group in the United States and, finally, was CEO of NHS England—and he is still quite young.

The noble Lord is regarded as the second most important person in the history of the NHS—the first being Nye Bevan—and the fourth most important person in the United Kingdom. My first contact with him, which he might remember, was when he was very young, hardly 30, and was a health policy adviser to Prime Minister Tony Blair and subsequently to Secretaries of State for Health Frank Dobson and Alan Milburn. His efforts resulted in the NHS getting the biggest rise in funding in its history. He played a major part in the reforms that followed. One light-hearted anecdote of the time is—and he may well remember—that he persuaded Frank Dobson to make Viagra available on the NHS. More importantly, he has been a central and respected figure in health policy for most of his career. Simon Stevens makes the weather in all his dealings. He knows health, he knows policy and he knows politics, which he is deft at exploring, always in the best interests of the people.

There is another side to the noble Lord apart from health. At Oxford, as president of the Union, he was drawn into controversy following an invitation to a visiting speaker. He also took part in a debate defending the proposition that patriotism is the last refuge of the scoundrel. I do not know whether Boris Johnson opposed him, but he credits the noble Lord with his own election as president of the Oxford Union. They both toured the United States in a debating society and it is said that Boris won the hearts of the audience and Simon won their heads. Once when asked if Boris Johnson could have led the NHS instead of him, the noble Lord evaded answering and sought refuge in a book entitled Napoleon’s Hemorrhoids.

For fun, the noble Lord indulges in competitive offshore sailing and cooking. I am told that he likes cooking without recipes: I wonder if there might be an analogy to health policies. Today, however, I thank him on behalf of us all for a brilliant, thoughtful and thought-provoking speech.

I now turn to my meagre contribution, which will be short because the time is limited. The Bill contains more than 150 clauses and 16 schedules; it proposes changes to several existing Acts. The policy objectives are equally broad: there are approximately 138 delegated powers and at least seven Henry VIII powers.

While I welcome the emphasis on increasing collaboration between and with different parts of the health and care system, the possible benefits are not clear; nor is it clear, with myriads of smaller organisations and sub-committees, who is in overall charge, or who will be responsible for improving standards of care.

The Bill has no clear plan for how workforce shortages, tackling inequalities in healthcare and the variation in care that exists will be addressed. Workforce shortages are the greatest threat to NHS and social care, as the House of Lords report alluded to. Covid-19 has exacerbated the pressures that staff have been under. They are exhausted. I know that from three of my family members. Without an adequate workforce, none of the reforms will come to full fruition.

Proposals in the Bill fall way short of what is needed and Health Education England’s framework 15 will not solve the problem. The Bill includes very limited measures in Clause 35. It fails to address whether the system is training, educating and retaining enough people in the workforce to meet the needs of the service in future. There needs to be a fundamental change to workforce strategy and planning on a much firmer footing than the Bill can provide. I will strongly support amendments to Clause 35, to which the noble Lord, Lord Stevens of Birmingham, referred.

Covid-19 has exposed and exacerbated existing health inequalities. Progress on reducing inequalities is slow. The Bill has no new ideas; it merely transposes the current duties of CCGs to ICBs. One area where there is scope for improvement relates to strengthening reporting on health inequalities. NHS England should publish national guidance on performance data and indicators, which should be collected and reported on by NHS bodies.

The new triple aim is another area where the scope of the Bill can be amended to go further. It should explicitly reference the need for all NHS organisations to report on the impact that their decisions will have on reducing inequalities. The first part of the triple aim of the health and well-being of the population does not suffice. I will support amendments to address that.

There are also issues about the wide-ranging new powers of the Secretary of State, not least on reconfiguration, which I have no doubt other noble Lords will address, but also his involvement in professional regulation and regulators. I will have comments to make about safety, as I chaired the National Patient Safety Agency for five years and know much about what learning is all about. What is important is how the learning is implemented, but the Bill is very short about how that will be done. I look forward to Committee.

Health and Care Bill

Lord Patel Excerpts

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

[Lord Patel (CB)]

My Lords, I support the amendment in the name of the noble Baronesses, Lady Merron and Lady Walmsley. I speak in support of the principles behind the amendment, which were well articulated by both noble Baronesses. Is it wrong in principle to have board members who have experience of NHS England’s areas of work, which I agree includes finance? No, but that cannot be totally exclusive of one side of the experience and expertise required. One of the board members suggested in the amendment should be from a public health background; let me take that as an example. That could be a public health director; I do not mind whether it is a public health director or somebody with public health expertise.

The reforms in the Bill are far reaching, but they are underpinned by the integration of health services to deliver on population health. The Government’s ambition is to extend healthy life by five years by 2035 and to have a greater focus on health prevention. Public Health England has been abolished and replaced by the Office for Health Improvement and Disparities. It is interesting that the name has changed, but I do not mind that. The word “inequalities” has been used hitherto but, if you use the WHO definition, “disparities” has the same meaning. The aim is to address inequity. The UK Health Security Agency has now been brought into being. It is right that there is strong public health involvement at local and regional level, as defined in the Bill, although it is not clear to me at this stage how this will work at regional level—no doubt we will spend some hours debating that.

Public health directors should be involved in developing strategies for population health at the local and regional level. There is a strong argument for public health representation on all integrated care boards—again, we will discuss these in amendments to come. At national level, the Government need to be much more joined up. The Department of Health and Social Care and the triumvirate of NHS England, the UK Health Security Agency and the Office for Health Improvement and Disparities needs to demonstrate an integrated model that the rest of the service is expected to deliver on. The ICBs will be in a clear accountability relationship with NHS England and NHS Improvement for delivering on all aspects of population health, yet neither will be accountable for public health, except in a limited case where NHS England will have responsibility. NHS England needs strong representation from and involvement of public health expertise, including at board level, to be able to develop indicators that assess the performance of ICBs, including for population health.

Turning to the part of the amendment that relates to public involvement, while there may be a difficulty in identifying an individual who can focus on the needs of patients, there are ways of doing this. The principle is that a board member chosen as a representative of patients’ voices knows that it is that individual’s responsibility to speak on their behalf. Of course, I am biased; I would say that the chief executive or, more appropriately, the chairman of Healthwatch England should be represented on the NHS England board. I fought the battle and lost—the noble Earl, Lord Howe, well remembers the point about Healthwatch being an important aspect, but we will come to that debate at a later stage. This time, I hope I do not lose.

I strongly support this amendment and the principle that representation on the NHS England board needs to reflect its work.

[Baroness Harding of Winscombe (Con)]

My Lords, I begin by declaring my interest, having very recently stepped down as the chair of NHS Improvement, which included both the NHS Trust Development Authority and Monitor. I am very supportive of the spirit of these amendments, and I could not agree more with the way in which the noble Baroness, Lady Merron, set out the importance of propriety in the appointment process and the skills, attitude and culture that the directors on the board of the new NHS England need to have. It is essential, as she said, to have a spirit of collaboration, integration and patient focus.

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[Lord Brooke of Alverthorpe (Lab)]

We have a Green intervention.

I support particularly the amendment tabled by the noble Baronesses, Lady Merron and Lady Walmsley, and the noble Lord, Lord Patel, and I pick up the points made so strongly by the noble Lord, Lord Patel, about Public Health England. The major issue where we are still lacking as we move forward is the recognition that we have to go beyond the clinical and be as inclusive and wide-ranging as we can in involving people in the health service. If we go way back, in the early days of the Labour Government, we even talked about people having shares in the National Health Service to try to get more people involved. We are not yet there.

At the other end of the scale, I take a contrary view to that of the noble Baroness, Lady Harding. I have spent a lifetime while I have been in this Chamber working on issues of addiction and with voluntary organisations that offer help free of charge. Often they make no progress, but quite often they produce remarkable results. I believe that Public Health England has not given big enough recognition to those organisations. It endeavours to work with them, but we need greater collaboration between the two. We need not just the public health element present on the board but the suggestion from the noble Lord, Lord Howarth, of wider involvement with what I would describe generally as the third sector. The development of the National Academy for Social Prescribing is a great movement, and it should be expanded at a faster pace. It would produce great benefits in relieving pressures in other parts of the health service.

As somebody who works on the other side—as distinct from being a director and running the organisation—I see the difficulties of trying to get influence at that end. From the noble Baroness’s viewpoint, not too many people are involved and the chair makes the decisions, but I beg to differ. I think we need wider representation there. The amendment in the name of the noble Baroness, Lady Merron, provides that, and I most certainly give strong support to Amendment 3 in the name of my noble friend Lord Howarth of Newport.

[Lord Patel (CB)]

My Lords, I would like to ask a question of the noble Baroness, Lady Harding, who has what is accepted as huge experience at board level, on boards of different sizes. If it is right, no matter the size of the board, to have representation selected on the basis of experience, can it be wrong, no matter the size of the board, to have as board members people with experience in, let us say, public health or local authorities—because they have experience specifically in that area—as opposed to people who might have wider experience, including in finance or whatever?

[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.

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[Baroness Cumberlege (Con)]

My Lords, I will make a rather simple point. I listened very carefully to what the noble Lord, Lord Lansley, said, and a lot of it makes an awful lot of sense—of course it does. He is a very experienced politician and he led the NHS in an outstanding way. I have to say that some of us very much supported what was in the 2012 Act and we are finding it quite difficult now to try to discard that—although throughout the Bill points are made that bring it back in, which is to be welcomed.

Outcomes are extremely difficult. In the National Health Service, we have two sorts of outcomes: PROMs and PREMs. PROMs are patient-reported outcome measures, and we work hard to try to achieve that. At one time we used to take soundings from people on hospital wards on how they were getting on, and it did not quite work. Now we are trying to ensure that the patient-reported outcome measures are set out quite clearly, so that people can relate to them, and they have to be patient driven—it must be the patients who say what is important to them as outcomes. PREMs—patient-reported experience measures—are equally important, and are also extremely difficult to collect.

At the moment we are trying still to implement the report First Do No Harm; I chaired the group that led it. We spent two and a half years listening to patients—that is virtually all we did. Out of that report we have set up centres to address the issue of mesh that was inserted into women, which has proved very unsatisfactory, certainly in the majority of cases that we listened to. We have said what has to happen in these centres before they are fully functioning. We now have sites and staff and are going forward on them, but they will not be any use until we have these outcome measures. This is how we will have to judge things in the NHS in the future.

Of course we have clinicians who are extremely well trained and are very good and well-motivated people. But sometimes they can miss the obvious which is transparent to patients. They are the people we should listen to, because they are the people who receive the service and who, like all of us, pay for it. It is important that these outcome measures are taken much more seriously and that we put a lot more work into ensuring that they will work for patients and for clinicians. It is important that the staff in the NHS also understand that what they are doing is valued—or not. On the whole, of course it is valued, but on occasions it is not, as we heard in our report First Do No Harm. I just wanted to make that quite simple point.

[Lord Patel (CB)]

My Lords, my knee-jerk reaction was going to be, “I don’t agree with what Lord Lansley says”. However, I have put my knee hammer back in my pocket, because I do agree with him about the importance of using outcomes indicators as a measure of the performance of health in patients. In that respect the outcomes framework has always been a good development. Although Clause 4 focuses on cancer—and I hope we do not change that—it is an example of how it can be used for other conditions to improve healthcare.

The noble Lord has also identified one key omission in this Bill, which I hope we can find a way to fill: who will be responsible for making sure that there is continuous improvement and development in healthcare that measures the outcomes? That is not in the Bill. I hope we might find a way to do that, whether through the mandate or other ways. That is all I have to say.

[Baroness Finlay of Llandaff (CB)]

My Lords, I must declare an interest, because a lot of the outcome measures that are now used are in place at Cardiff University. I will expand a little on and support what my noble friend Lord Patel said about outcome measures, particularly for something such as cancer. That is in part because the disease process itself is marching on all the time. It is different from many other diseases, where there might be a chronic condition and other things happen as a result of it. If you do not intervene rapidly with some cancers, you miss the boat and go from being able to cure it to a situation where you certainly will not be able to.

The other group of outcome measures that I do not think we should forget has just now been developed: family-reported outcome measures. That is the impact on the family. We know about the number of carers that there are. There are child carers and many unpaid carers. Having somebody in the family with a disease process, waiting for something to happen and seeing that disease process getting worse and worse in front of their eyes, has a major impact on the health of others and stacks up problems for the future in the health service.

That is why, when I was on the All-Party Parliamentary Group on Cancer, I strongly supported John Baron in all his efforts to look at the one-year survival times in cancer. Looking at outcomes can be far more informative than looking simply at process targets, which is what we have been looking at too much to date rather than looking at the overall impact of disease.

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[Baroness Tyler of Enfield (LD)]

My Lords, I rise to speak to the rather large list of amendments in this group—15 at the last count—to which my name is attached. I declare my interests as laid out in the register, particularly my new registered interest as a non-executive director of the Royal Free London NHS Foundation Trust.

Before turning to specific amendments, I have a couple of general points which apply across the board. The first concerns the scale of demand. Despite welcome investment and greater focus in recent years on mental health, there are now an estimated 1.6 million people waiting to access mental health services and so on a waiting list, and prevalence data suggests that some 8 million people with emerging mental health issues would benefit from services if they were able to meet the thresholds to access them.

Frankly, there are still too many instances of mental health services not being prioritised, such as the lack of investment in the mental health estate, which has a real impact on the trust’s ability to ensure both a safe and, particularly, a therapeutic environment. Also, the Prime Minister’s announcement on investment in new hospitals almost entirely overlooked the needs of mental health trusts.

The second general point is that the need to replicate the parity of esteem duty in the 2012 Bill throughout this Bill is more important than ever at a time when there is growing unmet need across multiple areas of health and care. Local health systems therefore face difficult choices around the allocation of resources. The full mental health impact of the pandemic is still emerging but mental health trust leaders report extraordinary pressures; in particular, a high proportion of children and young people not previously known to services are coming forward for treatment, often more unwell and with more complex problems.

The various amendments in the names of the noble Baroness, Lady Hollins, and my noble friend Lady Walmsley to which I have attached my name, and which I strongly support, recognise the important role that NHS England, ICBs, NHS trusts and foundation trusts will each have in advancing parity of esteem between mental and physical health. It will be important that amendments to the Bill that explicitly require the prioritisation of both physical and mental health are made at each level of the system. Simply put, trusts’ ability to prioritise both physical and mental health is crucially dependent on the extent to which integrated care boards and NHS England do the same. Ultimately, of course, each level in the system’s ability to meet this requirement is reliant on the Government prioritising both physical and mental health.

I will turn briefly to various sets of amendments. As I have said, a lot of these amendments are about explicitly including mental health on the face of the Bill, at each level and relating specifically to the NHS triple aim. I want to explain why that is important. As I said, Section 1 of the Health and Social Care Act 2012 enshrined in law a duty for the Secretary of State to secure parity of esteem between mental and physical health services. While the new Bill does not remove the duty from the Secretary of State, it fails to replicate it in the triple aim, and this sends out an unhelpful message. I fully accept that culture change needs far more than legislation but legislation can and does send an important signal, which is why we need parity of esteem strengthened throughout the Bill.

We know that the burden of mental illness in the UK far outstrips spend and that referrals to mental health services were at a peak during the pandemic. Thus, I strongly support the amendments tabled by the noble Baroness, Lady Hollins, and my noble friend Lady Walmsley which explicitly reference mental health in parts of the Bill setting out how the triple aim applies to trusts, foundation trusts, integrated care boards, NHS England and the licensing of healthcare providers. This would ensure that the whole of the NHS is aware of its duties around parity of esteem.

I turn briefly now to what is happening at the local level. A recent survey by the Royal College of Psychiatrists found that almost two-thirds of responding psychiatrists considered that their local area had been ineffective in working towards parity of esteem, and fewer than one in 10 said that their local area was effectively promoting parity. That is why each ICB should be required to promote parity; it should be included in their forward plans and they should be required to report on it as part of their annual reports. This would help transparency and help to hold the system to account; that is why I have added my name to the amendments from the noble Baroness, Lady McIntosh, and strongly support a separate amendment from the noble Baroness, Lady Hollins, which calls for a duty on ICBs to promote and seek parity of esteem between physical and mental health and, critically, to annually report on their efforts to do so.

I come now to the Secretary of State’s responsibilities in all this. Having the parity of esteem in the 2012 Act has helped to secure welcome and important initiatives, such as the five-year forward view for mental health and the review of the Mental Health Act. Amendment 263 in the name of the noble Baroness, Lady McIntosh, to which my name is attached, builds on this duty and requires the Secretary of State to outline to Parliament how the resourcing of mental health services and prevention efforts have ultimately improved care for people with mental illness and those at risk of developing poor mental health. This will bring further and much needed parliamentary scrutiny to this issue, and help us understand how we can build on current efforts to improve care and, most importantly, improve outcomes.

I turn finally to Amendments 5, 12 and 136, in the name of the noble Lord, Lord Stevens, regarding the funding of mental health. Of course, financing is one of the most important indicators of parity of esteem—if it is real—and legal teeth to ensure clarity on it are absolutely critical. As I highlighted earlier, even with recent efforts, spending on mental health is not commensurate with the burden of mental illness in this country. Indeed, a King’s Fund analysis recently found that mental health outcomes accounted for 23% of the burden of ill health in the UK but received only 11% of spend for both prevention and treatment.

The Government’s recent spending review did not specifically allocate any additional funding for mental health services, despite over £44 billion being pumped into the NHS over the course of the spending review and services facing increased and sustained pressure. The mental health sector has made it clear that it will need to cut services from April 2022 if additional funding is not received. The noble Lord, Lord Stevens, is very well placed to know the right mechanisms and levers to pull to ensure improvements in how we fund mental health services, and how different parts of the system are held accountable for their efforts to do so.

These three amendments, which build on the mental health investment standard—something I very much welcomed at the time—at a local level for ICBs, adding an additional legislative lever and helping to increase overall transparency on how local areas fund mental health services, are extremely important. Finally, at national level, I strongly support the need for greater transparency for both the Government’s intentions on mental health spending and NHS England’s response to, and meeting of, these intentions.

While we often hear encouraging and warm words of support on mental health from the Government—and they are welcome—these amendments would make clear where those words have been put into action. As the old saying goes, what gets measured gets done.

[Lord Patel (CB)]

My Lords, I will speak to the amendments in the name of my noble friend Lady Hollins. I have put my name to several of her amendments and I will speak to them all but, before I do so, I pay a very special tribute to her. For decades now, she has fought hard to improve the care of people with mental health and learning disabilities. Any progress that has been made has been to her credit, and any progress that we may help to make will not be ours but hers. We should try to help her.

On 8 February 2012, this House voted to put into legislation that mental health should be given parity of esteem with physical health. It was the only amendment of the 2012 Act that was carried, by a very narrow margin, as the then coalition Government had a big enough majority in both Houses. I remember apologising to the noble Earl, Lord Howe, who was the Minister taking the Bill through the House, for moving the amendment—I do not know why. He looked pretty confident, as he should have been because I was not confident; but I had moved the amendment on behalf of my noble friend Lady Hollins because it was her amendment. It just so happened that she was not able to be here; she was advising the Vatican at the time. Despite that, and to give credit to initiatives by NHS England and other NHS bodies, progress has been made—but it has been slow.

I declare an interest. I hold an honorary fellowship of the Royal College of Psychiatrists, which I am very proud of. In my time as a high-risk obstetrician, unfortunately, I had to look after women who suffered from severe puerperal depression and I can testify to how serious a mental condition it is.

Health and Care Bill

Lord Patel Excerpts

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

[Lord Howarth of Newport (Lab) [V]]

My Lords, Professor Sir Michael Marmot’s work, to which my noble friend just alluded, has shown that health inequalities have widened across England in the last 10 years. The impact of these inequalities has been both exemplified and amplified by Covid-19. I support Amendments 11, 14 and others that address this massively important problem and I fully agree with my noble friend’s analysis.

Health is powerfully influenced by the social, economic and environmental conditions in which people live and work. Place-based and whole systems are therefore vital to improving health and reducing inequalities. This is recognised in the NHS Long Term Plan and the move towards integrated care.

Sir Michael endorsed the findings of the Creative Health report of the All-Party Parliamentary Group on Arts, Health and Well-being, which in 2017 documented over 100 studies on how the arts and creative activities have supported health. In 2019, the World Health Organization’s scoping review of the role of the arts in improving health and well-being provided evidence that creative activities could mitigate the detrimental impact of stressful environments and the negative health impacts of growing up in disadvantaged conditions. Engaging with the arts, the evidence shows, can improve social cohesion and lead to a reduction in social inequalities in deprived areas. It can build skills and mutual support, which can improve social mobility. The positive effects of the arts can make a particular impact on early years development, as is demonstrated in the evidence provided to DCMS by Dr Daisy Fancourt et al in 2020.

Social prescribing, through bringing people together in shared creative activity and voluntary work, helps to build social capital and better health and well-being in deprived communities.

Research by the MARCH network, a UKRI-funded research programme, has shown that the health benefits of engaging with cultural and other community activities are felt by all, regardless of socioeconomic status. We know that there is a social gradient in participation in cultural and community activities and that those living in areas of higher deprivation are less likely to engage in them. However, the MARCH research indicates that when individuals in areas of high deprivation do engage, the mental health and well-being benefits may be particularly great for them, even greater than for those who live in more affluent areas. Therefore, targeted investment in cultural and community opportunities in areas where people are likely to benefit most can help to reduce health inequalities.

For instance, in Manchester, the Natural Cultural Health Service of the Whitworth art gallery is encouraging activities by local residents from diverse backgrounds that promote physical and mental well-being. Contact, a theatre company, supported by the Wellcome Trust, offers a health and well-being space for use by local community groups. Manchester Camerata has moved its base to Pugin’s wonderful Gorton abbey, in a deprived part of the city. Its musicians are working to support people with dementia and the Camerata is providing a resident composer and musician for local schools. Evaluation has shown that encouraging children to express themselves through music-making has raised their confidence and self-esteem, with a positive impact on their schoolwork and all the implications for them and their community that can follow from that.

The Big Noise project, run by Sistema Scotland in Govanhill since 2008, provides free orchestral training to young people. Evaluation has shown positive health outcomes as a result of improved confidence, social and other skills and emotional well-being. Similarly, the Royal Liverpool Philharmonic has run its In Harmony project to improve the life chances of children through music, and since 2009 has benefited 2,500 children in the Everton and Anfield areas of Liverpool.

The cultural and VCSE sectors have a key role to play in reducing health inequalities and should be fully embedded at systems level and in the health decision-making process. Integrated care partnerships provide the gateway to making this happen.

The National Centre for Creative Health, a charity of which I am chair, is currently working in partnership with NHS England in pilot programmes with four ICSs with a specific focus on mitigating health inequalities. We are looking to establish how best to embed creative health into healthcare strategies. We are also hosting a further AHRC-funded research project called Mobilising Cultural and Natural Assets to Combat Health Inequalities. The outputs will support ICSs to maximise the potential of the arts and natural assets in improving health and reducing inequalities.

I hope the Minister will assure us that the Government recognise the indispensable role of the arts and culture, as well as engagement with nature, in mitigating health inequalities, and that the system created by the Bill—designed, I hope, with an unambiguous purpose to reduce health inequalities—will fully embrace such non- clinical approaches.

[Lord Patel (CB)]

My Lords, I thank the noble Baroness, Lady Thornton, for introducing this group of amendments. My name is attached to her amendments, and I have some amendments in my name; I thank noble Lords who have added their names. I will speak in particular to Amendments 11 and 14 but what the noble Baroness, Lady Thornton, said applies to other amendments, and I agree with them and have added my name to them.

Covid-19 has exposed and exacerbated existing health inequalities in England, and the Government have committed to “levelling up” the country. Progress on national NHS commitments related to reducing health inequalities has been slow in recent years, and NHS England has urged local systems to accelerate action to tackle health inequalities after the pandemic. A step change is clearly needed, yet the Bill’s current provisions on health inequalities amount to no more than the same: transposing existing inequality duties from CCGs to the new NHS ICBs.

One area where there is clearly scope for improvement is strengthening reporting on health inequalities. There is currently no explicit requirement for NHS England to publish national guidance about which performance data and indicators relevant to health inequalities should be collected, analysed and reported on by NHS bodies. The NHS’s current system oversight framework, as a means to define national priorities and monitor the overall performance of local systems, also includes little in the way of concrete measures on health inequalities, with those that are included being focused primarily on shorter-term Covid-19-related equity impacts.

The amendment in the name of the noble Baroness, Lady Thornton, addresses this. It would require NHS England to publish guidance on collecting, analysing, reporting and publishing data on all factors or indicators relevant to health inequalities. I hope the Government will commit to considering this amendment in order to drive more action on inequalities and enable better tracking of progress across different areas.

The only thing I would add to this is the NHS Priorities and Operational Planning Guidance that was published by NHS England just before Christmas—in fact, on 24 December; it could not be much nearer to Christmas. On page 6 of this, as one of the priorities for 2022-23, NHS England asks local health systems to:

“Continue to develop our approach to population health management, prevent ill-health and address health inequalities—using data and analytics to redesign care pathways and measure outcomes with a focus on improving access and health equity for underserved communities.”


It also states that in delivering all the NHS’s priorities, it intends to maintain the

“focus on … tackling health inequalities by redoubling our efforts on the five priority areas”—

already mentioned by the noble Baroness—

“set out in guidance in March 2021.”

It reiterates that ICSs will take a lead role in tackling health inequalities and notes:

“Improved data collection and reporting will drive a better understanding of local health inequalities in access to, experience of and outcomes from healthcare services, by informing the development of action plans to narrow the health inequalities gap. ICBs, once established, and trust board performance packs are therefore expected to be disaggregated by deprivation and ethnicity.”


On page 29 onwards there are further details about this.

Health and Care Bill

Lord Patel Excerpts

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

[Baroness Meacher (CB)]

My Lords, I support Amendment 37. In so doing, I add my strong support to the comments of the noble Baronesses, Lady Bakewell and Lady Bennett.

Of course, the ICBs will be central to ensuring adequate funding and support, not only for the powerful acute health trusts and primary care but for the services that are historically underfunded. It is for these services that this amendment is particularly important. Before discussing these specific gaps in the Government’s vision for the new system, I want to stress that I am very concerned that we should not lose vital clinical leadership along with patient representation, which were the hallmarks of the CCG system. Of course, we want worker and carer representation but, in my experience, top medics are actually rather good at deciding how money should be allocated across services.

In my view, the absence of a public health representative from the shortlist of necessary ICB members in the Bill is an extraordinary oversight. This amendment seeks to put that right. ICSs are already in the process of developing their draft constitutions, which, while dependent on the final content of the Bill, provide a clear indication of their intent regarding clinical membership. It is particularly concerning that several ICSs have failed to include any role on their ICB for public health experts in their draft constitutions, with some failing to make any reference to public health at all. As the BMA points out in its briefing, this poses a significant risk to the role and prominence of public health within the work of those ICBs.

In relation to the importance of public health representation on ICBs, noble Lords should be aware of the impact of this on the vexed issue of drug addiction. Police services up and down the country are recognising that criminalisation and imprisonment are entirely counterproductive in this field. These responses only limit the young person’s education and employment options and tie them into a life of drugs and crime, with appalling consequences for them but also for their communities. Police services are increasingly adopting diversion to treatment as a preferable response when an individual is found in possession of drugs, but drug treatment services have been cut over the past 10 years. ICBs will need to tackle this situation as a matter of urgency if the police are to be able to stem the tide of county lines and other highly damaging consequences of our counterproductive and, in my view, idiotic drug policies and failure to treat addiction as a mental health problem, which, of course, it is. These urgent issues will not be confronted unless public health is strongly represented on ICBs and other boards and committees in the new structure.

Another cri de coeur is for mental health, as others have said. Having chaired a mental health trust for many years, I am acutely conscious of the impact of bed shortages on very sick people and their families and of the very high threshold for child mental health services. There is no doubt that if we do not treat children with mental health problems, we will have adults with these kinds of problems throughout their lives. The country cannot afford to continue neglecting this important field. I support the other amendments in this group. The NHS has major long-term workforce shortages and other problems. If they are to be addressed adequately, the staff need representation, along with patients and carers.

I end with a plea to ensure, through membership of ICBs, ICSs and ICPs, that clinical leadership is retained within the NHS. On ICBs, this must include at least two primary care members, at least one clinical representative of secondary care, acute care and mental health and at least one qualified and registered public health consultant. I hope the Minister will tell the Committee whether he agrees with this approach to ICB membership.

[Lord Patel (CB)]

My Lord, I rise very briefly to support Amendment 37 in the name of the noble Baroness, Lady Thornton, to which I have added my name. She and the noble Baroness, Lady Meacher, have identified in detail why this is a key amendment that identifies the core representation that is required for ICB boards to function satisfactorily and develop strategies for population health in their area, and I strongly support it.

[Baroness Tyler of Enfield (LD)]

My Lords, I shall speak very briefly to Amendment 38 in the name of the noble Lord, Lord Bradley. I have huge sympathy with the intention behind this amendment. Everything that we have talked about so far on mental health has pointed to the fact that unless there is a strong mental health voice on ICBs, the whole issue of mental health funding and the priority it has will not get as strong a voice as it should. I recognise that some argue that we should not overspecify the membership of new bodies but should allow each integrated care system the flexibility to develop based on its own set of local relationships, and I do not overlook that point. However, my natural sympathy is that it is only too possible for mental health concerns to be ignored when decisions are made about resource allocation and prioritisation without a strong mental health voice around the table.

However, I think I may have a way through this. We need to look back to the discussions we had on Tuesday about the overriding importance of mental health being explicitly mentioned in the triple aims. If such an aim were in place, I think we would be hard pushed to form an ICS or an ICB without mental health representation and we might be able to argue that it is not necessary, in those circumstances, to have it in the Bill. However, if that aim is not explicit, then the argument put forward by the noble Lord, Lord Bradley, is very strong indeed.

Health and Care Bill

Lord Patel Excerpts

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

[Lord Patel (CB)]

My Lords, I am glad to see the noble Lord, Lord Hunt, in his place. I welcome him back and am pleased to hear that things are good with his family. As he mentioned, in 2012 I led on the amendment arguing for Healthwatch to be made independent. I did not succeed—it was defeated by 22 votes—but we had a coalition Government at the time, so I did not stand much chance anyway. I will try again today.

My name is attached to all the amendments in this group. They are the key amendments relating to local and national Healthwatch, and they address public and patient involvement in the Bill. The Bill says a lot about how patients will be centre stage in the whole reorganisation, so it is important that the patient voice be heard. How will we do that?

Amendment 220 is about the independence of Healthwatch England in statute and its ability to get the information about health services it will need to do its job. The Government’s genuine aspiration to establish an effective system of public involvement requires that Healthwatch England be strengthened by making it truly independent. In fact it deserves it; it has grown into its role and proved its worth. Healthwatch England should provide a national vehicle to drive standards of health and social care and identify areas of poor practice. It has a very special mission that is quite different from that of the regulator, the CQC, of which the Government want Healthwatch England to be a committee. Healthwatch England should be the voice of the people, the voice to which the Secretary of State listens, working in close collaboration with the CQC but also able to hold it to account.

Healthwatch England should be the voice of the abused patient—of the forgotten person with dementia on the second floor of a nursing home, of the child with a learning disability who is getting poor care on a children’s ward, of the people waiting for excessive periods for emergency care in an A&E department. When a local Healthwatch or member of the public raises their voice because of a persistent local problem, as occurred in Mid Staffordshire, Healthwatch England must hear it and respond immediately. To do so, it needs to be independent.

Embedding Healthwatch England in the CQC is a fundamental error, as the noble Lord, Lord Hunt of Kings Heath, said. Calling it “a committee” is a fundamental error: it diminishes its power and influence. The only people who think a committee is important are the people who sit on it. Having sat on so many of them, I might agree. It has been argued that locating Healthwatch England within the CQC puts it at the centre of regulation, where it can have real power and influence. However, it cannot have power and influence if it is a committee of the regulator. To have power and influence it needs independence and the ability to challenge the regulator, and to have influence with every local authority in England. It must be seen to be independent, not just called independent. Being independent and being seen to be so requires Healthwatch England to be run by a board that has public trust and confidence, meets in public and speaks to the public, not the board of the CQC.

With the development of the ICS, it is even more important that Healthwatch England is an independent voice of patients and the public. I agree with the noble Lord, Lord Hunt of Kings Heath.

Health and Care Bill

Lord Patel Excerpts

Lords Hansard - Part 3 & Committee stage
Tuesday 18th January 2022 Lords Chamber

[Lord Howarth of Newport (Lab) [V]]

My Lords, while we all treasure the hospice movement and revere Cicely Saunders and her disciples, the grim fact is that there are all too many parts of the country where hospices are lacking and, as the noble Baroness, Lady Finlay, explained, palliative care is limited and inadequate, or perhaps even non-existent. Of course, palliative care, available in every setting, must become a core responsibility of the NHS. We should not displace the hospices and the charitable ethos, but where hospices do not exist—mainly in poorer communities where fund-raising capacity is small—default provision should be made by the NHS. These amendments would secure universal availability of high-quality palliative care.

High-quality palliative care is, of course, not just a matter of technical skills in pain relief and so on. Dr Iona Heath, a past chair of the Royal College of General Practitioners, has written:

“The whole discipline of medicine has colluded in the wider … project of seeking technical solutions to the existential problems posed by distress, suffering and the finitude of life and the inevitability of ageing, loss and death. Sickness and death have gradually come to be regarded as failures of medicine, even by doctors themselves, rather than inevitable constituents of what it is to be human.”


At a round table on the arts and palliative care, dying and bereavement convened by the All-Party Parliamentary Group on Arts, Health and Wellbeing and chaired by the noble Baroness, Lady Finlay, Dr Viv Lucas—medical director of the Garden House Hospice, Letchworth—said that the role of doctors in this context is not to cure disease but to heal their patients. She said that this implies

“addressing the subjective experience of human suffering and facilitating a process of inner change—not about the technological doing to of the disease-orientated model but of being with, bearing witness.”

The hospice movement acknowledges creative work to be a vital human activity. Through the arts, we can transcend suffering, come to terms with our own mortality and enable our own healing. Artist Virginia Hearth has said:

“The arts offer us a way of making sense of the world and help us to define who we are and who we have been.”


There is an abundance of evidence cited in the World Health Organization scoping review of the benefits of the arts in end-of-life care, through opportunities for communication and emotional expression, reframing of the illness experience, and enhanced human connection.

Equally, the arts can help families watching their loved ones approach death and afterwards. At another APPG round table, the director of Grampian Hospitals Art Trust, Sally Thomson, read out a letter from a woman whose husband had been diagnosed with terminal cancer:

“To be given a terminal prognosis is devastating for both the patient and family. To take away your future, the opportunity to grow old and grey with your spouse and to watch your children grow and thrive. You lose your independence and your sense of self, your purpose and role in life. Yet in the midst of this suffering lies the Artroom. An oasis of positivity and fulfilment providing a different purpose. One of creativity and self-expression. It is a place where the self is rediscovered and allowed to flourish … It’s medicine for the soul and every bit as vital as drugs and chemotherapy. A life-fulfilling experience that has changed both our lives for the better.”


As Dr Rachel Clarke, a palliative care doctor, writes in her beautiful book, Dear Life:

“What I witness, over and over, in the hospice … is that there is nothing more powerful than another human presence … reaching out with love and tenderness towards one of our own.”

[Lord Patel (CB)]

My Lords, I support Amendment 47, to which I have attached my name. I thank the noble Baroness, Lady Finlay, for her brilliant introduction to these amendments, and the other three speakers who spoke so passionately. We have debated this issue several times, and the time has now come that we should be angry about it. The time has come that we should have palliative care and hospice care being made a part of the NHS as a commitment on the face of the Bill.

I shall read the words of a government Minister in Our Commitment to You for End of Life Care—The Government Response to the Review of Choice in End of Life Care. The Minister, Ben Gummer, then Parliamentary Under-Secretary of Health, said this:

“A universal provision of good care will make possible what we should expect from our health and care system - a universal expectation of a good death.”


He went on to say:

“Cicely Saunders was articulating an ancient truth when she described her mission: that ‘we should see the last stages of life not as a defeat but as life’s fulfilment’. A good death - peaceful, dignified, reflective, compassionate, in the loving embrace of those closest to the dying person - is already a happy end for hundreds of thousands of people across our nation.”


The next line is important:

“In making this commitment, we make that promise universal, so that every dying person in England can live in anticipation of a good death.”


I ask the Minister: when that was written in 2016, was it an empty promise or is it likely to become a reality now?

We do not sufficiently value care for those for whom there is no cure. We do not value the short lives of children and young people who die prematurely and who will never be parents, let alone grandparents. Some Members here may have attended the annual reception held downstairs for parliamentarians by Together for Short Lives and other charities. They are attended by children and young people from the ages of three to 16, some using crutches, some using wheelchairs, some with tubes in their noses to supply oxygen, some undergoing IV treatment and some with IV pumps to relieve the pain. It brings tears to your eyes when you see them, but they all come with smiles on their faces, grateful for the care that they get—professional and dedicated care from professionals and volunteers.

So why do we rely for three-quarters of the funding for palliative and hospice care on the charity sector? Why is it that the Government fund only one-third of the care? Why, as the noble Baroness, Lady Finlay, said, do these charities have to sell cakes at village fêtes and second-hand books, toys and clothes for the money that they so fervently raise? Why can we not find the money?

Sue Ryder commissioned research into the total costs required to fund palliative and hospice care for every patient that needs it. They come to about £987 million a year. I should imagine that the transaction costs of the reforms that we are debating in the Health and Care Bill will probably cost several billion pounds. So it is possible for us to reorganise the health service at a cost of billions of pounds, but we cannot fund end-of-life care for those who are dying—children, young people and older people. We should be ashamed of that.

[The Lord Bishop of Carlisle]

My Lords, it is always a pleasure to follow the noble Lord, Lord Patel. I am pleased to give my wholehearted support to Amendment 47 and to Amendment 52, to which I have added my name, which compellingly requires the commissioning of specialist palliative care services in every part of England. Throughout my life and work I have often had the privilege of being present with families and communities, supporting people of all ages through the final chapter of their life, so I have seen at first hand the enormous difference that high-quality palliative care can make to their experience of dying, death and bereavement.

However, as the noble Baronesses, Lady Brinton and Lady Masham, pointed out, 90% of people might need such care, but as things stand at present only about half of them will receive it. What is more, it is all too often those in our most deprived communities who are dying without the help and dignity they deserve.

Health and Care Bill

Lord Patel Excerpts

Lords Hansard - Part 1 & Committee stage
Monday 24th January 2022 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I agree with the thrust of all these amendments. Most of the discussion has been about research—encouraging research in clinical trials within NHS trusts and foundation trusts—but I want to speak in support of Amendment 78, in the name of the noble Baroness, Lady McIntosh, which looks at the issue of commissioning and the role of integrated care boards, because I believe that it is just as important to ensure that integrated care boards have in mind the need, through their commissioning policies, to encourage innovation. In our last debate on NICE, last week, we discussed the same issue, which is the fact that the reason NICE exists is that there are many innovative new medicines and treatments coming on stream, many of them developed in the UK, which the health service has found difficulty in adopting more generally.

The noble Baroness’s Amendment 78, about ICBs, is designed to encourage the ICB boards to consider that they have a responsibility in relation to innovations. It also proposes that integrated care boards must appoint a dedicated innovation officer to the board. I do not want to open up the issue raised by my noble friend Lady Thornton as we went into Committee, but we come back to the issue of the composition of ICB boards. She referred to guidance issued by NHS England a few days ago, which is not obtainable in the public domain. It is obtainable through something called “NHS Net”, but the Library has not been able to get hold of it. It is a bit much that advice on the contents of the Bill has been given out which we cannot even see. I hope that, as part of his response to my noble friend Lady Thornton, the Minister will look into that.

On the question, “Why add another postholder to the board of an ICB?”, I point to the Nuffield Trust report, which says that no organisation in the health service at the moment—or very few places—has someone with a direct responsibility for encouraging innovation. The Nuffield Trust thinks that having chief innovation officers with broad oversight could make what it calls a fundamental difference. I refer the noble Lord to research by the ABHI, which is essentially the trade association for medical devices. It showed that fewer than 20 NHS trusts across the UK have a member of their board with explicit responsibility for the uptake of innovative technologies.

Sometimes one must be wary of having a board appointment that may seem to be a token appointment. However, when it comes to commissioning, having someone around the table who is constantly reminding the board that through commissioning we must encourage and invest in innovation, would be very helpful. The slew of amendments tabled by the noble Baroness, Lady McIntosh, is valuable in getting that message across.

[Lord Patel (CB)]

My Lords, I am seriously concerned, for my sake, that I am invisible to the noble Baroness, Lady Harding—which I regret, but I will tease her about it.

[Baroness Harding of Winscombe (Con)]

My Lords, I fear that is my blindness and my problem, not his. I am very sorry.

[Lord Patel (CB)]

My Lords, I am only teasing.

I declare an interest as a fellow of the Royal Society of Edinburgh and of the Academy of Medical Sciences, and as a professor emeritus at the University of Dundee, where I have spent all my life bar the first 18 years. I say this because we have lost something in the United Kingdom. A key strength of our academic clinical departments was a worldwide reputation for conducting health service-related research. We were second to none, and I mean that. We have lost that because we have changed the environment. People who work in clinical academic institutions—our so-called teaching hospitals—no longer have the environment to promote that. It was the duty of those of us who worked in clinical academic departments to grow the next generation of academics. It was important that we were all involved in conducting clinical research that produced innovation, better care for patients and a first-rate, first-class, internationally renowned next generation of academics. We do not have that any more, and anything we can do through this Bill to bring that back would be a major plus.

I will speak to the amendments tabled by the noble Baroness, Lady McIntosh of Pickering, and the noble Lord, Lord Sharkey. Much has been said, excellently, and I will try not to repeat it, but a strengthened research mandate through this Bill could support patients, clinicians, NHS organisations and research. The patient benefits from increased research activity have already been mentioned, but there is a significant variability across the UK in the opportunity for patients to engage in research. A strengthened mandate could support ensuring that all patients can access clinical trials and their associated benefits. Therefore, wider changes are needed to increase the competitiveness of the UK as a destination for research, particularly through the proposed changes to clinical trials legislation, and through increases in Department of Health and Social Care and NIHR funding.

This could include measures to support faster approval timelines and closer multiagency collaborations. Clinical research has clear benefits to patients, as has already been mentioned. NHS trusts with higher levels of research have a higher rating from the CQC and better outcomes, as have already been said. During Covid, the UK has demonstrated its potential with the success of Covid-19 research, with 68 commercial Covid trials launched in the UK in 2020—the third-highest globally, beating the United States and the rest of Europe.

How did we manage to do that? It is because, during the emergency, we set up methodologies that allow patients to be involved in trials more quickly by creating a voluntary registry, where patients themselves volunteer to take part in research. I also note the clinical recovery trials that we set up—some noble Lords might have seen the article in the Times, with Sir Martin Landray suggesting that we follow that process in the future to try to find treatments for other common diseases. If we do that, we will lead globally. The NHS has the capacity to do that, but it now requires the will and the leadership from the centre to drive that. The clinical academics will be up to it—they just want to be given a chance. Let us do that, because we have demonstrated that we can.

--- Later in debate ---

[Lord Stevens of Birmingham (CB)]

My Lords, in theory these amendments should not be needed, but in practice they clearly are, as the noble Baroness, Lady Cumberlege, has just so forensically set out. It is a statement of the blindingly obvious, particularly coming out of the pandemic, to say that we need better workforce planning at a time when staff are exhausted from having dealt with Covid for several years and the NHS is confronting the need to deal with the backlog of care.

But, frankly, it would be a statement of the blindingly obvious at any time, because the lead times for decisions on training for health professionals are such that they go beyond any individual term of Parliament or government manifesto. Universities need a strong signal as to what future demand will look like. The interconnectedness between health and social care means that we are actually thinking about a workforce of 3 million plus, and the materiality of getting it wrong over a five or 10-year period is bigger in this sector of the workforce than any other part of the economy. As we heard earlier—I think from the noble Baroness, Lady Walmsley—estimates from the Health Foundation, for example, suggest that on the current trajectory the gap could be more than a third of a million staff in the health service by 2030-31; and in respect of the social care workforce, Skills for Care talks about perhaps 490,000 additional posts being required over the period to 2035. Those figures may be right or they may be wrong, but there is not a forensic forum in which those debates are scrutinised and choices made. This is not just about more; this is about different.

It is not all doom and gloom. Over the last two years, during the most intense challenge the health service has faced since its creation, nearly 160,000 people have signed up to join the health and care staff and professions. We have seen applications for undergraduate nursing up by more than a quarter and a huge increase in applications for and interest in studying medicine, yet we have an acceptance rate of only about 52% for undergraduate nursing, according to figures from UCAS, and we are turning away bright and brilliant young people with fantastic A-level grades who would like to study medicine. That is a paradox which stems from the fact that, unlike the day-to-day running costs of the health service, those items which have the longest planning horizon—workforce and capital investment—are the areas with the shortest financial horizon.

Of course, it may well be argued by the Government that we are about to turn a corner and that although there has been a degree of short-termism hitherto, things are about to improve. But I am afraid that I think we are entitled to treat that proposition with a degree of scepticism, because although what has been said up until now may be blindingly obvious, in fact what we have been confronted with is wilful blindness. Health Education England, which should be looking at 10 years, does not yet have its running budget for 10 weeks’ time. If we look back over the history of recent years, we can see a series of missed opportunities. The Minister may assure us that we will be presented with this 15-year further vision from Health Education England this coming summer, which will, of course, be welcome. But if we remind ourselves of the history since 2014 or 2015, as I say, we can perhaps be a tad sceptical. Obviously, I draw attention to my prior NHS interest, and everything I am about to say only draws on the public record, just to clarify that point.

It was back in 2014 that the NHS Five Year Forward View talked about the service changes that were required, but it was not permitted to talk about future capital investment, social care or workforce training, since they were being kept separate. So, in summer 2016, the Department of Health and Social Care was going to produce this detailed quantified workforce plan instead. Twenty-sixteen came and went and instead, in December 2017—three years after the Five Year Forward View—Health Education England launched a consultation document which said: “Your responses will be used to inform the full strategy to be published in July 2018 to coincide with the NHS’s 70th birthday.”

Twenty-eighteen came and went, and answers saw we none. Then in June 2019, we got another, in this case interim people plan, with lots of excellent content but unfortunately no actual numbers and no new pound notes. Despite the fact that it promised:

“We will aim to publish a full, costed five-year Plan later this year”


quantifying

“the full range of additional staff needed”.

But again, “later this year” came and went, and no such documents saw the light of day, until in July 2020 we had a one-year people plan which, at that point, was covering just the next eight months. Fear not, though, because it said:

“Further action for 2021/22 and beyond is expected to be set out later in the year”—


in 2020—

“once funding arrangements have been confirmed by the Government.”

That did not happen.

Instead, in July 2021, last summer, the Department of Health and Social Care again commissioned Health Education England to start from scratch. Last November, HEE published a short PowerPoint—commissioned from a firm of accountants—with the discouraging disclaimer on the first page that:

“We do not warrant or represent that the report is appropriate for your purposes”


and “no warranty is made as to the accuracy of any data”. As it happens, that does not really matter because there were no real data in the document anyway, which came to startling conclusions such as “workforce demand will be affected by demography and disease”.

I think we are entitled to say that this litany tells us that what, to everybody else, is blindingly obvious has instead been confronted with wilful blindness. What explains this? Is it a lack of interest on the part of the committed people to getting this right? No, it is not—some excellent work has been done. Your Lordships may take a clue from a statement that Jeremy Hunt, the former Secretary of State and now Chair of the Commons Health and Social Care Committee, made last Tuesday, when he said that “the Health and Social Care Committee has recommended on numerous occasions that we should have independently verified forecasts of the number of doctors, nurses and other staff that we should be training for the future. But that has been blocked consistently by the Treasury”.

Without in any way commenting on or editorialising that, the Minister may want to take the opportunity to confirm whether that is indeed the case. But just on the off chance that he does not refute the statement Jeremy Hunt has made, then that, I think, tells us that unfortunately, these amendments are necessary and will strengthen the hand of Health and Social Care Ministers in the future. I cannot help thinking that, in their heart of hearts, past Health Ministers know that they would have benefited enormously, were these amendments on the statute book. I am afraid that, if the Government choose not to support these amendments—as I hope will not be the case—that will be proof positive that they are very necessary. Therefore, I hope they will recognise that ignorance is not bliss and if we do find ourselves in that situation, this House will take the opportunity at Report to give the Commons another go.

[Lord Patel (CB)]

My Lords, listening to my noble friend Lord Stevens of Birmingham, I am beginning to feel the pain of his frustration at being chief executive of the NHS and not being listened to in order to fix such an important issue as workforce planning. Also, there is a bit of déjà vu that he may remember, along with some of my colleagues who were took part in the Lords committee inquiry into the long-term sustainability of the NHS and adult social care.

Let me argue the same issues that he just presented. The report on the long-term sustainability of the NHS and adult social care, published in April 2017, looked at data on demographic and disease burden projections of the population over the next 15 to 20 years. It identified a lack of long-term workforce planning as a key threat to the long-term sustainability of the NHS. The Committee heard from the then Secretary of State, the right honourable Jeremy Hunt, who had this to say:

“workforce planning is an area where we have failed… Brexit will be a catalyst to get this right… That is an area where we need to be much more strategic”.

That was nearly five years ago and yet, there is no strategic healthcare workforce plan from the Department of Health and Social Care, as we just heard.

The solution is not going to come from an outside body, no matter how influential. It has to come from the centre, from the leadership of the NHS and social care, and not one in the isolation from the other. What we have heard from the centre and NHS organisations is many publications identifying the problem, but not the solution with a long-term plan. We are told that this may be coming in April 2022—or perhaps later.

On the other hand, there are several detailed authoritative documents on the NHS workforce from think tanks, NHS providers, the BMA, the nursing councils and many others, who have been grappling with this issue and trying to find a solution for a long time and advising the Government on how to do this. There is no lack of authoritative reports based on data related to long-term projections of population, its demography, health needs and the workforce needed to deliver them. For example, an extensive, well-researched report by Dr Latifa Patel, a respiratory paediatrician, and Dr Wrigley, a GP of medical staff in England, projected to 2045—based on population and disease data—the number of doctors needed in each speciality and possible models of plans to deliver on this by 2032. A document extending to 60 pages is not only highly informative and well-researched but identifies a way forward.

Since the Health and Social Care Act 2012, there has been inadequate workforce planning, fuelled by inadequate regional and national workforce data and a lack of accountability for it at government level. We are not training enough doctors, despite record numbers of people applying. The latest figures, as the noble Lord, Lord Stevens of Birmingham, mentioned, show a 21% increase on previous years in applications to medical schools of highly talented young people. This means the NHS is ill-equipped to tackle the backlog of care, is not prepared for future public health crises and cannot meet patient needs, either now or in the future.

If we compare England with EU nations within the OECD, which have an average of 3.7 doctors per 1,000 people, the medical workforce in England is currently short of around 49,000 full-time equivalent doctors. Without significant intervention regarding the current rate of growth, the estimate is that the future medical workforce shortage will be between 26,889 and 83,779 full-time doctors by 2043. Such precise numbers show how well-researched this document is. Each full-time doctor in NHS England is doing an average of 1.3 full-time equivalent roles. I have three of them in the NHS and I can see what they do—although I tell them they are lazy compared to me.

Health and Care Bill

Lord Patel Excerpts

Lords Hansard - Part 2 & Committee stage
Wednesday 26th January 2022 Lords Chamber

[Baroness Fraser of Craigmaddie (Con)]

My Lords, in this rather large group of amendments, I shall take us from catering to my Amendment 242 on professional regulation. I thank the noble Baroness, Lady Finlay, for adding her name. I draw your Lordships’ attention to my registered interests, in particular as chief executive of Cerebral Palsy Scotland. I am involved with the employment of regulated allied health professionals.

Clause 142 gives the Secretary of State far-ranging powers to alter the professional regulatory landscape, with the potential to make significant changes to how certain health and care professions may be regulated, including the power to remove professions from, or bring professions into, statutory regulation.

The UK model of regulation for healthcare is rigid, complex and needs to change to better protect patients, to support our health services and to help the future workforce meet future challenges. The case for reform has been acknowledged.

Whether a health and care profession falls under regulation is a major decision affecting not only the professions themselves but employers, patients and service users who place their trust in those professionals. My Amendment 242 is a probing one. I want to explore some of the issues that will be particularly important for the Government to consider as and when they might seek to use these extended powers.

I want first to thank my noble friend the Minister and the Bill team for the time they have taken so far to discuss the issues around my amendment. We are all agreed on the importance of encouraging greater collaboration between regulators, with the ability to share data and intelligence, but I remain to be convinced that the legislation is being used to reduce regulatory silos, which is crucial to reducing regulatory failures in the future.

I want to be clear that I am not advocating for a single super regulator, which would be a step in the wrong direction, not to mention complicated, disruptive and expensive. I would rather harness the best elements of professional regulation and give the regulators the tools to work more closely together and share best practice more consistently.

I accept that work is being done in the department on various regulatory reform initiatives. These are all important, but it strikes me that they are all focused on individual regulators and amend specific operational issues, rather than looking at the landscape as a whole and what could be achieved.

We have sadly seen all too many reviews and inquiries which have identified regulatory silos as a key factor in why something went terribly wrong. My noble friend Lady Cumberlege’s First Do No Harm report highlights the issue starkly, but the Paterson inquiry, the Sir Robert Francis report on Mid Staffs, the Shipman inquiry and others have all underscored the value of greater collaboration between regulatory bodies, sharing data and intelligence as well as adopting shared professional standards. Reducing and removing silos is also good for professionals and employers, with benefits in terms of intra-professional learning and for professional and patient safety.

I am grateful to the Health and Care Professions Council for its briefing, but I was concerned to note something which regulators have stressed to me: that due to their tightly defined duties, they have often been forced to resort to informal memorandums of understanding to try to make the system work better. That is piecemeal and inefficient— frankly, I would be extremely disappointed if the Minister in his response was to rely on such MoUs to fix the issue.

Do not the powers in this Bill offer a chance to look at things differently: a whole system regulatory approach rather than a set of silos? Amendment 242 identifies some principles and considerations that I believe the Government would find beneficial in developing this more collaborative landscape.

Maintaining regulatory independence is crucial. The Government have rightly recognised this in other legislation recently, but I would welcome confirmation from the Minister that this remains a cornerstone of any future regulatory reform proposals. I would be grateful for reassurance that no regulatory reform would be undertaken by the UK Government without working with the devolved Administrations to ensure that it worked for all parts of the UK.

I particularly want to highlight the benefits of multi-profession regulation, which, as the CEO of an organisation that relies on a range of expert allied health and care professionals registered with the HCPC, I see at first hand, supporting improvements across professions that are increasingly interconnected. As the Minister is aware, the HCPC regulates 15 professions, so is able to utilise common frameworks and outcome-based standards. This approach could, and should, be spread among all the professional regulators.

This is particularly important as the Government, NHS England and NHS Improvement seek to create a more flexible workforce with an ability to move between professions, work as multidisciplinary teams and support career progression. From my own experience, I know that this is positive, but we need our regulatory system to keep up with innovations in delivery. Can my noble friend the Minister therefore tell us about how we can harness the benefits of multi-profession regulation and how he anticipates this will influence the Government’s thinking in terms of reform? Collaboration and the development of a system-wide approach to overcome fragmentation and silos is critical to the future success of regulation. It is an enabler of better care, and a collaborative structure would generate considerably higher and richer levels of data.

Finally, this holistic approach would offer an opportunity to create consistent criteria for making decisions about which professions may be brought into or taken out of regulation. Could the Minister put it on record today that the issues in the amendment are principles that would govern the future use of the powers within Clause 142, that they are all principles that the Government are actively considering and that no decisions on regulatory change would be taken if the criteria set out in this amendment were not met? Once again, I thank him and his team for his engagement so far, and I look forward to his response today. I hope we can continue discussions between now and Report.

[Lord Patel (CB)]

My Lords, I rise to speak to Amendment 243 in the name of the noble Baroness, Lady Merron, and Amendment 264 in the name of the noble Lord, Lord Hunt of Kings Heath.

Yesterday I was chastised—wrongly, in my view—for speaking at length. Such boldness requires training in speaking up, confidence in being right and using authority. The comments came from a government Whip, who happens to be a registered nurse. As a doctor, I am used to that. When a nurse speaks up, patient safety improves, health equity improves, collegial relationships are stronger—again, as a doctor I can vouch for that—and healthcare systems improve. This is because of their training. Not recognising legally the status that the title of “nurse” brings to those that are highly trained and qualified and on a nursing council register is wrong.

We all know what a nurse is; a nurse is highly trained, highly competent, can do the job well and is on a nursing register. Anybody else is not a nurse. It is right, therefore, that we recognise this and give it a legal status. Furthermore, the NHS and health providers should not employ anyone as a nurse who does not meet the above criteria. I understand that last year there were 195 advertisements for nurses in the NHS which did not say that the qualification of being registered was necessary. In my view, that is wrong. I strongly back this amendment, and I look forward to the contribution of my noble friend Lady Watkins.

Turning to Amendment 264 on the appointment of consultants in surgery, I am a fellow of the Royal College of Surgeons of England, the Royal College of Surgeons of Edinburgh and the Royal College of Physicians and Surgeons of Glasgow, so I speak on behalf of all surgical colleges. Let me give your Lordships an example: there is a surgical post empty in Birmingham. A highly qualified person, who was well-trained in Scotland and holds a fellowship of the Royal College of Surgeons of Edinburgh, is a key candidate for application but cannot be appointed because the Royal College of Surgeons of England cannot provide an assessor. On the other hand, there is a surgical vacancy in Glasgow, and the top candidate is a fellow of the Royal College of Surgeons of England but can be appointed without a Royal College of Surgeons of England assessor being there. That is a total anomaly.

A person can be appointed who is fully trained in Scotland, is a fellow of the Royal College of Surgeons of Edinburgh, works in Cambridge, applies in Cambridge, but you cannot have an assessor from the Royal College of Surgeons of Edinburgh. In all other specialties—the Royal Colleges of Obstetricians and Gynaecologists, of Ophthalmologists, of Radiologists, of Psychiatrists, of Anaesthetists, and in public health—the assessor can come from any part of the United Kingdom. This anomaly can be stopped very easily. I agree with the noble Lord, Lord Hunt of Kings Heath, that it is not a big deal; just change it in legislation. I do not know who opposes it.

[Baroness Watkins of Tavistock (CB)]

My Lords, it is a pleasure to follow the noble Lord, Lord Patel, on the term “nurse”, which is protected in law at the moment only for those who are a “registered nurse”. This means that anyone can describe themselves as a nurse, as the noble Baroness, Lady Wheeler, outlined. They can even describe themselves as a nurse if they have no qualifications or experience—or, perhaps more seriously, have just been struck off the register. As somebody who was a member of the forerunner to the Nursing and Midwifery Council, I can say that we do not strike people off the register lightly, so the risks of such people being at large and describing themselves as nurses are serious. For this reason, a petition was created calling for the title “nurse” to be protected further in UK law.

In the initial response by the Government to the petition, recognition was given that the protection of professional titles

“provides assurance to the public that someone using that title is competent and safe to practise.”

The response references a consultation by the Department of Health and Social Care on professional regulation, Regulating Healthcare Professionals, Protecting the Public. In the Nursing and Midwifery Council response to this consultation, the nursing regulator recognised issues around the limitations of “nurse” not being a protected title and said it did not think that its current powers are sufficient,

“given that they are primarily based around titles that are not widely understood by the public or used by the professions.”

This amendment is designed to ensure that there are sufficient regulatory levers to be able to protect the public in the future.

Nurses on the NMC register find it difficult to understand why the Government are reluctant to protect the title. As part of the statutory regulations of the Health and Social Care Act 2012, it was mandated that registered nurses would be part of the clinical commissioning group governing body. In Regulation 11 of the National Health Service (Clinical Commissioning Groups) Regulations 2012, the CCG governing body is required to include at least one registered nurse within its membership. This created a statutory commissioning role for nursing leaders in England that will be lost should this not be required within integrated care boards’ executive membership. Please can the Minister explain whether guidance will include a recommendation that there should be a registered nurse as part of the executive team on integrated care boards?

--- Later in debate ---

Given all that, and given the public consultation and other issues, I ask noble Lords to withdraw and not press their amendments.

[Lord Patel (CB)]

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

[Lord Kamall (Con)]

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

Health and Care Bill

Lord Patel Excerpts

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

[Lord Patel (CB)]

My Lords, I support all the amendments in the name of the noble Baroness, Lady Cumberlege. She introduced them very comprehensively and I agree with what she said. My noble friend Lord Stevens of Birmingham added to it, so much has already been said and I need to be extremely brief.

I concur with my noble friend Lord Stevens of Birmingham that outside bodies, including professional organisations in medicine, oppose these powers and that they will lead to more chaos rather than solving problems. As a clinician, I find the unchecked powers for Secretaries of State over local service reconfigurations that the Bill proposes astounding. Local service reconfigurations should be driven by clinical advice and expert assessment of what services are needed to meet the health needs of a local community with patient safety at the heart, as well as considerations about what resources are available in terms of workforce, infrastructure and the proximity of alternative services.

The powers in the Bill would allow the Secretary of State to initiate service changes without any consultation. How can any Secretary of State feel sufficiently qualified to be making unilateral judgments about what constitutes “safe”? The existing, largely successful, processes, which have already been mentioned, take account of clinical advice and the views of local communities in the final decision have been effective. The noble Baroness gave the example of Kent and Medway stroke services, which were held up by the Secretary of State, not by the consultation. I strongly support these amendments and I hope that the Minister will think about removing the provisions from the Bill.

[Lord Lansley (Con)]

My Lords, I shall be brief. I put my name to Clause 40 stand part, and I think that is the best way to go. I shall add one or two things. First, as Secretary of State, I asked the now noble Lord, Lord Ribeiro, to lead the independent reconfiguration panel, and I never had cause to regret doing so. Secondly, I can say something which other noble Lords cannot, because I am on this side, and I am hoping that we continue to have Conservative Secretaries of State for many years hence. They will be much better off if they do not do this. If the Government take Clause 40 out, they will equally not regret doing so.

Health and Care Bill

Lord Patel Excerpts

Lords Hansard - Part 1 & Committee stage
Wednesday 9th February 2022 Lords Chamber

[Lord Patel (CB)]

My Lords, I shall try to be brief, otherwise we will be here until 3 am, and I am sure none of us want that. I join the noble Baroness, Lady Cumberlege, in the comments she has made, and I support her amendment and the government amendments. I also agree that the system should be mandatory— not “may” but “shall”— and aligned with the similar system in the United States which I was used to many years ago.

To try to explore this further with the industry, I have been in correspondence with the ABPI to test how committed it is to agreeing to this being mandatory and that they “shall report” in all aspects. I will read what it sent me:

“ABPI are supportive of the intention to move to a mandatory model of disclosure for payments made between industry and relevant individuals including Health Professionals, and”


all healthcare organisations and research institutions. It continues:

“We believe proposals to introduce a legislative mandate are an opportunity to further strengthen the pharmaceutical sector’s existing transparency mechanism for branded medicines”—


that was the point I made to it, that its system needs to be transparent, mandatory and easily accessible by patients and the public. It goes on:

“Our briefing outlines a number of considerations and learnings based on ABPI’s experience running Disclosure UK, which since 2016 has supported transparency around transfers of value made by the innovative pharmaceutical industry to relevant individuals including Health Professionals … and Healthcare Organisations”.


I asked for a similar comment from industries that market medical devices, and I understand that a similar commitment is made by those companies too.

I therefore support the noble Baroness, Lady Cumberlege, and support the Government’s amendment. However, I hope that the Minister can confirm that the loose word “may” is not intentional and they intend to make this mandatory.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I rise very briefly, rather enjoying this reunion from our debates during the passage of the Medicines and Medical Devices Bill of a group of people who taught me a great deal about dealing with legislation. We also looked at an amendment that was very like this. There is a phrase I use often: “Campaigning works”. I should make that “Campaigning by the noble Baroness, Lady Cumberlege, works particularly well”. We are seeing real progress here, although, as many noble Lords have already said, we need to make sure that this is mandatory and not some kind of voluntary extra.

When I was working on the then Medicines and Medical Devices Bill, I spoke to a number of people from the industry. They were very much concerned about the fact that they wanted tight rules that apply to everybody, otherwise those who cut corners and push the envelope have a competitive advantage against people who doing the right thing, being absolutely open and not flinging money around. Many parts of the sector are keen on tight rules.

It is interesting that it has taken us so long to get to this point when the noble Baroness, Lady Cumberlege, presented ways of doing this back in the Medicines and Medical Devices Bill. We have not heard the Government using their favourite phrasing “world-leading” or “world-beating” very often in this area. As the noble Baroness, Lady Brinton, said, we are very much trailing behind other countries in our transparency here.

I will make one final comment. We have a huge problem with public trust—we see this on the street outside your Lordships’ House quite often. Absolute transparency and openness is crucial and, as we heard in Oral Questions earlier, the fact that some companies have been able to profiteer hugely from the pandemic causes more damage to public trust. We need to tackle that with as much of the sunlight of transparency and openness as possible.

--- Later in debate ---

[Lord Kamall (Con)]

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

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

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

To improve transparency, the review recommended that

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

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

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

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

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

[Lord Patel (CB)]

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

[Baroness Bennett of Manor Castle (GP)]

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

Health and Care Bill

Lord Patel Excerpts

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

[Lord Hunt of Kings Heath (Lab)]

My Lords, I have put my name to the amendments tabled by the noble and learned Lord and have tabled amendments of my own. As the noble and learned Lord said, his amendments simply take out the HSSIB provisions from the Bill, whereas mine take out the reference to senior coroners.

I think we are all united in supporting the concept of HSSIB improving safety in the health service. A stand-alone Bill in 2019 had a Second Reading in which we were beginning to get to grips with some of the issues around the construct of HSSIB and, particularly, the safe spaces concept. This is very important in the health service because of the traditional reluctance of staff to come forward with information about where things have gone wrong because experience has shown that whistleblowers have often been treated very poorly indeed.

I fully support the concept of HSSIB and safe spaces and believe that if it is implemented properly it will lead to improved safety. However, as the noble and learned Lord has so eloquently pointed out, the problem is that the inclusion in the Bill of the coroner’s ability to access this information would render the whole safe space concept unworkable. Staff will simply not trust it if these provisions are left in the Bill.

We are faced with two options. One is to take out the whole of the HSSIB provisions. Ideally, I would support that because it would benefit from a stand-alone Bill, where we could give it the scrutiny it clearly deserves. On the other hand, our job here is to be constructive as a revising Chamber. On that basis, we would be much safer removing the coroner elements and giving the Government a little more time to discuss this further before the Bill goes on to Third Reading and back to the other place.

I think there are ways through. I have been attracted, for instance, to one solution put forward by the noble Baroness, Lady Brinton, in relation to a memorandum of understanding between the noble Earl’s department and the MoJ. We need to discuss that; in order to do so now, I believe we should remove the coroner provisions from the Bill.

[Lord Patel (CB)]

My Lords, I apologise for rising because I know we need to move on but before I speak to this amendment perhaps I may take the opportunity, as I was not here on the first day of Report, to thank the Ministers for listening—and taking action after doing so on many aspects. I thank them all for that. I also thank all those who sent me good wishes. It helped, and I did not realise I had so many friends.

I shall not speak at length on this group. I have my name on both sets of amendments. The reason I supported removing the whole clause was that there are a lot of issues arising, not just the invasion of the safe space. However, I agree with the noble Lord, Lord Hunt of Kings Heath, that it gives the Government another chance if it is confined to removing the coroner provisions. I agree with what has been said: the medical profession particularly, but even other health professionals, will find it difficult if the safe space of what they say confidentially can be invaded, so I support that proposal.

[Baroness Walmsley (LD)]

My Lords, I well recall hearing Jeremy Hunt announce that we would have this organisation and thinking at the time how important it would be in turning the NHS into a learning organisation, in the interests of patient safety. I would prefer not to take the whole clause out but to amend it.

The predecessor non-statutory organisation’s chief inspector has written to us, pointing out that when his organisation was set up it was made clear that full statutory independence, along with the fully enclosed prohibition on disclosure, would be essential to its success. I am concerned that if this power to disclose information to coroners is left in then this organisation, which we all so much support, will be set up to fail. That would be a very bad thing for patients and the whole NHS.

Quite honestly, the number of cases that the HSSIB is going to investigate—only 30—is highly unlikely to cut across anything that the coroner wants to do. In fact, the Joint Committee which scrutinised the previous Bill in 2018, which got only as far as Second Reading, concluded that the safe space would in no way impede the ability of coroners, regulators, the PHSO or the police in undertaking their own investigations or speaking to witnesses. That is not what we heard in the meetings which the Ministers have been kind enough to set up on Zoom, or from the Ministry of Justice. They obviously disagreed with the Joint Committee that scrutinised this carefully.

I hope the Minister is not going to rely on paragraph 6(7) of Schedule 14 because, as it stands, the so-called protections in that part of the Bill are completely unknowable. How can the High Court know whether a disclosure to the coroner will deter future witnesses from giving full disclosure? It simply cannot know that but there is a big danger. Nor can it know whether it will have an

“impact on securing the improvement of the safety”

of the health service. This is an empty protection and I hope the Government will not rely on it when arguing against the amendment of the noble Lord, Lord Hunt.