Health and Care Bill

Lord Young of Cookham Excerpts

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

The Government so far have argued that addressing inequalities is already implicit in the first aspect of the triple aim—the requirement to consider the effects of decisions on the health and well-being of the population. It has clearly not been obvious to many experts and charities scrutinising the Bill. However, if it is the Government’s intention to ensure that the reduction of inequalities is prioritised, they should make this explicit in the Bill.

[Lord Young of Cookham (Con)]

My Lords, this is my first contribution to the debate on the Bill and, listening to earlier exchanges, it struck me how many were being made by those who had either run the NHS as administrators or, indeed, as Ministers. I can join that happy band. I was a Health Minister in 1979 and put on the statute book the Health Services Act 1980, abolishing area health authorities. Nostalgia has overcome me, as phrases I used 40 years ago about streamlining the structure and making it more efficient have been recycled in debates on this Bill.

My first piece of health legislation followed the appointment of commissioners to run the Lambeth, Southwark and Lewisham Area Health Authority which was breaking its cash limits and behaving illegally. Unfortunately, our suspension was also illegal, and I had to pilot through the other place the National Health Service (Invalid Direction) Bill, with much hilarity at my expense from the Opposition. So, more than 40 years later, it is good to join in another debate about NHS reorganisation. Today’s debate about inequality was actually raised 40 years ago: noble Lords may remember the Black report on inequalities in health. I was rereading it last night and it struck me how many of the 37 recommendations made 40 years ago are still relevant today.

Mine is the lead name on four amendments, but I plan to say very little on Amendment 66 and leave it to the noble Lords, Lord Rennard and Lord Faulkner, to make the case for a specific reference to smoking as a key factor in reducing health inequalities.

As we have heard, the Bill gives integrated care boards a responsibility to reduce inequalities in access to health services and in health service outcomes. The biggest cause of inequalities are factors such as smoking, obesity and alcohol, particularly smoking, which is responsible for half the difference in life expectancy between the richest and poorest in society—an issue that was raised an hour ago during Oral Questions. Others will say more about the imperatives of tackling these hazards to health.

I will focus instead on Amendment 152 in my name and will also speak briefly to Amendments 156 and 157. These amendments are supported by the noble Lord, Lord Shipley, who will focus on housing and why legislation is necessary, and by the noble Baronesses, Lady Neuberger and Lady Watkins. I am grateful to Crisis, the homeless charity, for its briefing.

I commend the Government’s welcome commitment to tackle health inequalities and hope the forthcoming White Paper on levelling up will have a strong section on this, following the recent report of the Public Services Select Committee, chaired by the noble Baroness, Lady Armstrong. I hope that will put flesh on the bone of what risks becoming more of a slogan rather than a policy, meaning different things to different people. I hope the levelling up White Paper will directly address inequalities in health.

As the Secretary of State for Health has said recently, we must tackle the “disease of disparity”, and these amendments highlight the experiences of those groups who are undoubtedly at the worst end of that disease. In current NHS policy and documents, these groups are referred to as “inclusion health populations”—a term used to highlight the need for health services to overcome the social exclusion and marginalisation that many people face, resulting in dire consequences for their health. That group includes rough sleepers, Gypsy, Roma and Traveller communities, vulnerable non-UK nationals and people with substance misuse issues.

These people develop health conditions usually seen in people in their 70s and 80s up to 40 years earlier, and often die from them. Tragically, the average age of death among people experiencing homelessness is 46 for men and 42 for women. Clearly, these are not health outcomes we should accept for anyone. The solutions exist, and chime very well with what the Health and Care Bill seeks to do. However, it currently does not go far enough.

The Bill places a welcome emphasis on integrated services. To tackle the health injustices for people who are socially excluded, we need holistic, integrated health services to meet their needs, and we need them everywhere. They do exist in some places; they are also referred to as “inclusion health services” and they have a significantly positive impact. For example, Pathway, the leading health charity for inclusion health, has helped 11 hospitals in the UK create multidisciplinary teams of doctors, nurses, social care professionals and housing workers. These teams support over 4,000 patients every year who are homeless, with very positive outcomes. An audit of Pathway’s services in 2017 showed a 37% reduction in A&E attendances, a 66% reduction in hospital admissions and an 11% reduction in bed days. However, despite these successful services, inclusion health services are not currently commissioned at the scale required, and access to them is a postcode lottery. King’s College London found that 56.5% of homelessness projects in England do not have a specialist GP inclusion health service in their area—hence the amendments on best practice.

During my time as a Housing Minister, I saw the impact of social exclusion on people, including how not having a stable home to live in is devastating for people’s physical and mental health. Therefore, working closely with expert organisations across these sectors including Crisis, Pathway, St Mungo’s and many others, we want to amend the Bill to ensure a strategic focus in the new systems being set up to help the most socially excluded in our society.

The amendments introduce two important and necessary changes. The first would place a duty on integrated care partnerships to have due regard to the need to improve health outcomes for inclusion health populations when they create their healthcare strategies. Placing a duty on partnerships will make it clear that inclusion health is a strategic focus, and that should follow through and be reflected in the resourcing and commissioning decisions of integrated care boards. I do not regard the requirement to “have regard to” as an onerous imposition.

The second change would make clear the importance on health outcomes of having a stable home. It would mean that, in addition to the partnership having to consider health and social care in its strategic integration arrangements, it would also need to consider housing. This possible change would make clear that housing is on a par with health and social care services. The noble Lord, Lord Shipley, will say more about this.

With the advent of the Everyone In scheme in March last year, which sought to provide safe accommodation for those who without it would have continued to sleep rough, we saw how critical it is for people to have a place of their own. We need to build on that success and prevent rough sleepers drifting back on to our streets. My amendment legislates to ensure that health, social care and housing services continue to work more closely together to consistently support people who too often fall through the gaps between these services.

These amendments are firmly within the scope of the Bill. They will complement and strengthen its welcome aims to integrate health services across the whole system and tackle health inequalities. The amendments are neither overly prescriptive nor bureaucratic; their aims are simple. I look forward to my noble friend the Minister’s reply.