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.