Public Health

Debate between Philippa Whitford and Alex Norris

Tuesday 30th November 2021 Commons Chamber

[Alex Norris]

I cannot cast my mind back to that debate—I believe I had just started secondary school when it took place—but I can foresee the issues that were raised. I would not do down the idea of opening windows; that would be a good thing to do in and of itself, and I would support that. What I am saying is that there are certain places where that will work less effectively, and we ought to have some sense, certainly building by building, of what might be an effective measure. As I said, I do not think this is something that we can just click our fingers and do easily, but I would like to get a sense that we have tried to do any of it at all, and I have yet to get that. I hope the Minister will disabuse me of that.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I raised the issue of ventilation last summer—we have known for a long time that covid is airborne—and I wrote to the Chancellor on two occasions asking him at least to remove VAT, to help businesses and public bodies that pay VAT to afford ventilation. Sticking 20% extra on the cost of a ventilation system seems quite weird in the middle of a pandemic.

[Alex Norris]

I am grateful to the hon. Member for that intervention, which gets to the root of the matter. We have been talking about ventilation for a long time. What I would really like to hear from the Minister is whether any progress whatsoever has been made in this area.

I turn to statutory instrument No. 1338 regarding self-isolation. The regulations introduce new rules for self-isolation after contact with a person who is suspected to have contracted the omicron variant of the virus, removing the exemptions to self-isolation. As we saw in the summer, this will be frustrating for those who would otherwise have been able to avoid self-isolation requirements by being vaccinated and who will now have to stay at home for the full period. However, as we wait to see how our vaccines and antivirals respond to the new variant, it is right that we prioritise caution and seek to limit community transmission as much as humanly possible. The Minister may have sensed colleagues’ eagerness to know more about this requirement. I hope that she will tell us when she thinks she is likely to have enough information about the variant to return to Parliament and say whether the Government feel that the regulations ought to remain.

There is, of course, a significant gap in the fence of these regulations. The gap has existed throughout the pandemic, and it is bewildering that we in the Opposition are still having to raise it. It relates, of course, to fixing sick pay. We have learned during the pandemic that the overwhelming majority of the British people want to do the right thing to protect themselves, their family and each other, but that falls short when they are forced to pit it against their need to feed their families. In both rate and availability, sick pay has proven insufficient to protect families against that horrendous choice.

These regulations will be weakened. They will be weakened when people ignore their symptoms and go to work, weakened when people say they are self-isolating and they are not, and weakened when people turn the app off to avoid being a close contact. Surely Ministers have learned this lesson over the last month. I am surprised that we did not hear more from the Minister about that.

The hon. Member for South Dorset (Richard Drax) raised the regulations relating to red list travel. My understanding is that we are not discussing those today because they were laid via the negative procedure, but the elements relating to testing will have an impact on SI No. 1338. Last week, we suggested that the Secretary of State should begin PCR testing for those entering the country, so I am pleased the Government have listened and included day-two PCR tests in the measures announced yesterday, but there are still holes in our defences on international travel.

I am keen to hear from the Minister how she and her colleagues reached the decision to introduce only day-two testing, and not to reintroduce pre-departure tests. I am keen to know the scientific basis behind that. We have heard many reports of private tests not being followed up, especially, perhaps, by those offering the cheapest prices. What are the Government doing to enforce this and to ensure that bringing back day-two PCR tests, which we support, is effective?

I will bring my remarks to a conclusion, because I am conscious of how many colleagues wish to speak in the debate. This is a concerning moment in the pandemic. We have learned over the last 18 months that it is vital that we act decisively at such moments. We are pleased to see these regulations come forward—indeed, in the case of mask wearing, it was premature to stop at all—but there is much more to do if we are to avoid being back here in the coming days and weeks, including working from home where possible, fixing sick pay and improving ventilation. The actions we need to take are clear. It is time for the Government to meet the moment.

Health and Care Bill (Twenty Second sitting)

Debate between Philippa Whitford and Alex Norris

Committee stage
Tuesday 2nd November 2021 Public Bill Committees

[Dr Whitford]

I accept the Minister’s reassurance that they will finally look at correcting this anomaly; I hope that he will take that forward. It is something that we will be looking for. I beg to ask leave to withdraw the clause.

Clause, by leave, withdrawn.

New Clause 66

Support provided by the NHS to populations at risk of malnutrition

“(1) Each integrated care board must—

(a) assess, or make arrangements for the assessment of, the need for support for patients and/or populations at risk of malnutrition, including social and clinical/disease related malnutrition, using their services;

(b) prepare and publish a strategy for the provision of such support in its area;

(c) monitor and evaluate the effectiveness of the strategy; and

(d) designate a malnutrition lead.

(2) An integrated care board that publishes a strategy under this section must, in carrying out its functions, give effect to the strategy.

(3) Before publishing a strategy under this section, an integrated care board must consult—

(a) any local authority for an area within the relevant Integrated care board’s area; and

(b) such other persons as the relevant local authority considers appropriate.

(4) For the purposes of subsection (3), ‘local authority’ means—

(a) a county council or district council in England; or

(b) a London borough council.

(5) An integrated care board that publishes a strategy under this section—

(a) must keep the strategy under review;

(b) may alter or replace the strategy; and

(c) must publish any altered or replacement strategy.

(6) The Secretary of State may by regulations make provision about the preparation and publication of strategies under this section.

(7) The power to make regulations under subsection (6) may, in particular, be exercised to make provision about—

(a) the procedure to be followed by an integrated care board in preparing a strategy;

(b) matters to which an integrated care board must have regard in preparing a strategy;

(c) how an integrated care board must publish a strategy;

(d) the date by which an integrated care board must first publish a strategy; and

(e) the frequency with which an integrated care board must review its strategy or any effect of the strategy on the provision of other provision in its area.

(8) Before making regulations under this section, the Secretary of State must consult—

(a) all integrated care boards; and

(b) such other persons as the Secretary of State considers appropriate.” —(Alex Norris.)

This new clause would require integrated care boards to publish a strategy for the provision of support for patients and/or populations at particular risk of malnutrition using their services, and designate a malnutrition lead.

Brought up, and read the First time.

[Alex Norris]

I beg to move, That the clause be read a Second time.

This new clause would put responsibility on integrated care boards to take the lead on tackling malnutrition in their community. We spoke about malnutrition in the context of hospital food standards, and we were not able to move the Minister to extend those hospital food standards to other care settings. I thought that was a shame, and I hope the Government will continue to look at the issue. I want to broaden the conversation on malnutrition to try, via another way, to improve the standing of our communities.

Malnutrition is a serious condition that occurs when a person does not get the energy or vitamins that their body requires to function properly. It affects at least 3 million people every year, and it costs the health and social care system £23.5 billion each year. The condition is particularly common amongst certain groups. Those groups are: older people; hospital patients; people in mental health units and care homes; people living in sheltered housing; and those living with chronic diseases, such as cancer. Malnutrition can seriously threaten patients’ health. Hospitalised malnourished patients are three times more at risk of infection than the well-nourished, while hospital patients at high risk of malnutrition are 12 times more likely to die early than those at no risk. It is a very significant issue. Unfortunately, the figures are not moving in the right direction. The number of adults being admitted to hospital with malnutrition has more than doubled in the last decade—that is the bill for austerity. The evidence is clear that malnutrition impacts a wide range of people in different health settings; again, those are hospitals, mental health units, care homes and sheltered housing. It has a knock-on effect on other conditions.

Earlier this year, the media reported the death of a young disabled woman after a routine operation. Her death was partially caused by malnutrition, and the coroner said there had been a gross failure of care in managing her nutrition. A July 2021 report on malnutrition called it a widespread yet historically overlooked and undertreated issue in the NHS and social care, and attributed that to two factors that block progress—a lack of understanding, and a lack of systematic leadership. The new clause seeks to address that at a local level, which is why we think it is a good one.

The tragic case that I have mentioned shows how important it is to have a clear strategy to tackle malnutrition, to have designated leads and to have targets and co-ordinated policy. The Government say that integrated care boards are about ensuring proper integration between health staff and community services, and this is a really good example of a way in which that could be done. I am keen to hear the Minister’s assessment of the new clause, which should be included in the Bill. We have a significant issue that we are not addressing and that is getting worse, so what are we going to do differently?

--- Later in debate ---

[Alex Norris]

I am grateful for that intervention. It is sobering to hear that 55% was what we started with; we know that it will be less than that now. That rather picks away at the idea of a universal healthcare service.

To finish where I was going with my previous point, if I am wrong about where recovery funding for the NHS is going, and there is to be investment in dentistry, I hope that the Minister will correct me. I would be delighted if that was the case, because the BDA is warning—again, this is something that we will have picked up on in our constituencies—that morale among NHS dentists is at an all-time low. Almost 1,000 dentists in England have stopped providing NHS services in the last financial year. There was the failed contract—I know there is enthusiasm for contract reform in the Department and we will support the Department on that, but we are running out of time to have anything ready for April. In fact, we are probably already too late in that regard. The shambles of the negotiations before Christmas last year that led to the breakdown and the imposition of targets really whittled away at good will and caused a lot of upset.

Almost half of NHS dentists are saying that, unless things change, they intend to hand back their contracts or reduce their NHS commitment. This exodus of dentists from the NHS will have a disastrous and lasting impact on our ability to access NHS dentistry. If 55% is the summit of our ambition, goodness me, where will we go from there? The British Dental Association talks about the last-chance saloon; it is not hyperbole to say that we will not have NHS dentistry in the medium term if we do not have a course change.

More and more people are being pushed into the private sector. That creates market forces that mean that it is almost a self-fulfilling prophecy that dentists—both new ones entering the profession and those who have come to the end of their tether with their NHS contract—go into the private sector. We are seeing significant growth in that space as people living in pain seek drastic action. We will see more pushed on to dental insurance if people do not want to be worried about their finances. That is what privatisation looks like. We will not have NHS dentistry in the medium term unless we do something about this issue—that is the wrong way forward.

New clause 68 makes a very modest ask; it asks the Secretary of State to do what any Secretary of State should want to do: commit to universal access to NHS dentistry and say how it will practically be achieved. At the moment, we have a yawning gap. In that lack of leadership, we will see the drip, drip, drip of the loss of NHS dentistry, until we no longer have it.

[Dr Whitford]

I rise to support new clause 68, which is linked to new clause 67. We are aware of the impact of the pandemic, particularly on dentistry. Using a drill on someone’s teeth generates aerosols in their mouth, and that would vastly increase the risk of spreading covid to the dental staff, or to any patient who entered the space soon afterwards. Despite that impact, there has not been significant funding from the UK Government for the dental industry in England to fund the establishment of ventilation and air purification systems. The Scottish Government have committed £5 million specifically for this. As the hon. Member for Nottingham North highlighted, the pandemic impact comes on top of an underlying issue, the core of which is the 2006 dental contract in England and Wales, which breaks provision down into units of dental activity. It does not reward preventive dentistry. It does not reward any practice for taking on someone who already has dental issues, because it will not be properly funded for that.

Out of that comes the failure to focus on child dental health and making sure that this generation of young children grow up with good dental health. Scotland set up Childsmile in 2007, and Wales set up Designed to Smile in 2011. There is plenty of data from both of these programmes to show that providing free dental treatment to children—along with supported tooth brushing at school, fluoride coating and so on—can decrease caries found in children in primary school and at the beginning of secondary school.

Poor dental health has a big impact on general health and self-confidence, yet we hear repeated reports of families and children struggling to access an NHS practice. In the last five years, NHS practice numbers in England have dropped by over 1,250. BDA surveys suggest that almost half of remaining NHS practices are planning to reduce their NHS commitment over the next 12 to 24 months. There was a promise that the contract would be changed by next April, and 100 practices have been trialling a new method of contract. According to the BDA, it has been warned of a return to using units of dental activity from next April. This would be an enormous missed opportunity to improve NHS dental access for everyone, and particularly to take the further step of ensuring that every child in England does not just have access to a dental practice, but is involved, as they grow up, in a programme promoting good dental health.

Health and Care Bill (Twenty First sitting)

Debate between Philippa Whitford and Alex Norris

Committee stage
Thursday 28th October 2021 Public Bill Committees

[Dr Whitford]

I wonder whether the hon. Gentleman shares my concerns after leaving the European Union about access for clinicians, and indeed their patients, to the European reference network, which helps to provide advice and treatment and has co-ordinated research, through the European Medicines Agency, into these rare, often childhood, diseases? They can be studied much more easily in a population of 500 million than one of 60 million.

[Alex Norris]

I am grateful for that contribution. It is axiomatic that, if we are talking about diseases that affect small populations in this country, growing the field of people who are affected so that we can undertake better research, trials and treatment can only be a good thing. I hope that the Minister might touch on how he is ensuring that we are not disadvantaged in that way. When we add up the nearly 8,000 diseases, we are talking about 3.5 million people—one in 17, so one person on the Committee, basically—who will in their lifetime be affected by a rare disease. So actually they are not so rare at all. It is really important that we are meeting that group of people’s needs, but access to medicines and medical devices remains a problem, which is why such reporting for rare conditions is so important.

At the moment, approved medicines are available for only 5% of rare diseases and, even where licensed treatments exist, patients can face an uphill battle in accessing them on the NHS. I am sure that most of us will have at least one case of a young constituent who desperately needs medicinal cannabis to treat epilepsy. There is a political consensus that this is the right thing to do, and we ought to do it. That has been a settled matter for at least three years now, but frustratingly it is still not getting through, and that is a pattern across rare diseases. Perhaps that points us to the conclusion that the current assessment process is not quite accounting for the unique challenges presented by rare and ultra-rare diseases.

I do not think that the Minister will want to be drawn on the National Institute for Health and Care Excellence methods review, because we are in that process. I have spoken in multiple debates about my enthusiasm for NICE, and its processes and expertise, but clearly something is missing. My working theory is around evaluation. Again, if we have a small patient population, the data is noisy and there are higher degrees of uncertainty due to the small sample sizes. That leads us nicely to the point that the hon. Member for Central Ayrshire made about trying to grow those pools. At the moment, we are unable to get first-in-class treatments in many cases, which we should want to do something about.

Herein lies the squeeze, as the medicines for rare and ultra-rare diseases are often assessed by processes that were designed for drugs with larger target populations. The statistics are a bit of an apples-to-oranges comparison, which creates a severe disadvantage. The purpose of the new clause is to get the Secretary of State to report generally on how we are ensuring that we are world leading and meeting population need, and then to drill down within that on how we are ensuring that the system for rarer conditions is fit for purpose. As I say, I am conscious that the methods review is ongoing, but I hope that the Minister might at least give us a sense of the general policy direction in this area, and what we might look to do differently in the future.

--- Later in debate ---

[Alex Norris]

I beg to move, That the clause be read a Second time.

I cannot quite remember on what day this new clause was submitted; it is towards the end of the new clauses but not at the very end, so that probably carbon dates it by 10 days or so. Nevertheless, we had some news in this space from yesterday’s Budget. We are in the strange situation of having seen effective early intervention services, such as Sure Start, take a clobbering for a decade, and then getting paid back pennies on the pound and being supposed to feel grateful for it. We are not. Nevertheless, there needs to be a commitment at all levels of Government and local government—and, in this case, integrated care boards—to have a real focus on early years.

The first 1,001 days of a child’s life, from conception to age two, are crucial. Getting things right in this period can determine what kind of life a child has and their health, wellbeing, cognitive function and psychological make-up. During those early years, a baby’s brain grows rapidly, and it doubles in size within the first year of life. As is so well established, child development is influenced by early experiences and environment, which means that it is so important to ensure that little ones in our communities get what they need—care, nurture and support—while ensuring that they are protected from neglect, harm and stress.

As the Government’s strategy in this space recognises, getting things right impacts not just on the lives of our children, but on our entire society. By ensuring that children get what they need at an early age, we can target some of the big issues that we have talked about for the last two months in this Committee: physical and mental health issues, pressures on the NHS, crime and antisocial behaviour, and drug and substance abuse. So much of that leads back to the early stages in life, and this is a matter of established science. There is no doubt that in this country, we are not very good at doing something about that. Six months or maybe even a year ago—time flies—we had a fantastic Westminster Hall debate, led by the right hon. Member for South Northamptonshire (Dame Andrea Leadsom), who chaired a very good review in this space.

There is barely a leaf’s width of disagreement on this issue between right hon. and hon. Members of all political persuasions. The common diagnosis for why we have not made more progress is that we know that such things save public services money in a generation’s time, but we cannot demonstrate that in a cashable savings way that passes Treasury processes. I am afraid that I did not see anything yesterday to suggest that that fight is yet being won, and I hope the Minister and his colleagues are doing everything in their power to argue for early interventions. Frankly, I would argue that for pretty much all Members present, the bulk of the returns will come when someone else is sitting in our seats and our roles are somebody else’s dreams, but that should not stop us acting, because it is so significantly in the national interest and in the interests of our communities.

There are huge inequalities. The most basic health statistic is that a child born in my city will live for seven fewer years than one born in the City of Westminster—never mind the yawning chasm of almost twice that in healthy life expectancy. That is the result of smaller inequalities that all add up to different life paths: family income, financial stress, smoking and alcohol use, and access to care and services. We know that the 1,001 critical days from conception are the moment to offer really good-quality support. Families receive support from a wide range of services, including maternity, health visiting and early years, and perhaps children’s social care, mental health and paediatrics.

As well as the inequalities, there is complexity. I have mentioned five different organisations with five different uniforms, five different organisational plans and five different organisational cultures. Someone has to pull that together. We have been told throughout proceedings on the Bill that that is exactly what integrated care partnerships are here to do, so let us put a responsibility on them to do so, and to have a plan. I dare say—the Minister might say this himself—that they are more than likely to want to do that themselves, and that would be a very good thing, but I do not think we can allow variance. This should be important for everybody and all footprints should be doing it, so that the first 1,001 days are given priority in new health systems. That would have a significant impact on the long-term health and wellbeing of our country.

[Dr Whitford]

I rise in support of the new clause. It is important to shift the narrative from what is often a structural focus on the NHS, and catching people when they fall, to looking at wellbeing and population to allow people to be healthier and live higher-quality lives for longer.

The hon. Member for Nottingham North mentioned the slowing down of improvement in life expectancy and the variation in life expectancy, but the bigger issue is the failure to improve healthy life expectancy. The 20 years of unhealthy life expectancy faced by many across the UK, particularly in more deprived areas, put pressure on the NHS, and we have seen that come home to roost over the last decade.

A lot of those health issues, or unhealth issues, are laid down in childhood. I am vice-chair of the all-party parliamentary group for health in all policies, which conducted an inquiry into the impact of child poverty. A figure from the Faculty of Public Health that has stayed with me is that the UK loses 1,400 children a year as a direct result of poverty, including by immature birth, small birth weight, foetal alcohol syndrome, fires, road traffic accidents, alcohol and drugs, violence and suicide. That is the number of students in a large secondary school, and if the roof of a large secondary school were collapsing every single year, we would do something about it.

Often, the time to do something about that is in the 1,001 days from conception forward, as the hon. Gentleman said. That means looking at maternal health and nutrition, which is why the early years collaborative in Scotland led to the Best Start grants to mothers and children at birth, on entering nursery and on entering school.

One internationally used measure on the health of our youngest children is infant mortality—death perinatally or in the first year. In 2014, England and Scotland had the same rate of 3.6 per 1,000 live births. In Scotland, we have managed to drive the rate down to 3.2, but in England, it is currently at 3.8. In some poorer areas of the UK, the rate is worse than in parts of the global south and the developing world. That is a brutal statistic.

We talked yesterday about maternal and infant deaths, but this also relates to the attainment gap and other issues faced throughout life by those who struggle in childhood. Investing in early years saves money in the long term. That might be the pitch to the Treasury: if we gave more children a decent start in life, fewer would struggle in the education system, fewer would struggle to get jobs, and fewer would be trapped by addiction or caught in the criminal services system. Instead of picking up the pieces later through the NHS or other public services, surely we should be investing in the best start in life for all our children.

--- Later in debate ---

[Alex Norris]

I beg to move, That the clause be read a Second time.

In February 2018, the noble Baroness Cumberlege was asked to carry out the independent medicines and medical devices review into the experiences of people—generally women—who had been treated with Primodos, sodium valproate or pelvic mesh implants. In very many cases, they had to battle for decades to be heard. They were gaslit, belittled and ignored at every turn. Some of the ways in which they were treated were just astonishing, and so upsetting. However, through that report they got their deliverance. They were vindicated: what they said had happened to them had happened to them—even though they had not been believed—and it should not have done. Acknowledging the pain that had been caused to these families was a big start in helping them come to terms with what they had experienced.

The excellent review team set out nine ways in which things would be made better, or at least a little bit easier, for those people now, and to try to prevent future incidents. Those nine recommendations should have been accepted in full. Instead, we have seen from the Government a pattern of accepting things that I suspect they were already keen to do, but otherwise taking the families for a long walk when it comes to the harder and more significant things that the Government clearly do not want to do. In aggregate, it has become a refusal to do right by these families, and that is a really poor decision.

This new clause seeks to attend to that by saying that within six months, the Secretary of State must publish a report containing a plan for the implementation of the recommendations in full. Of the nine, only four are being implemented in full and, frankly, that is not good enough. I am pleased that there has been an apology, and the families were too. I was also pleased to see legislation for a patient safety commissioner. We were lucky that the Medicines and Medical Devices Act 2021 was in front of us at that time, because it gave us a moment to introduce that and a devices database, which the hon. Member for Central Ayrshire and I pursued during proceedings on that Bill. Those things have a bit further to go, but they were significant, as were the promises of cultural reforms at the Medicines and Healthcare products Regulatory Agency. We will wait to see meaningful change there. With the remaining five recommendations, there has been a mixture of in-principle acceptance, partial acceptance and, in some cases, outright denial. I do not think that is good enough, and the new clause seeks to change that.

These are the bits that we are still missing. Recommendation 3 calls for:

“A new independent Redress Agency for those harmed by medicines and medical devices”.

The Government responded that they did not accept that. The problem is that families are therefore left to rely on conventional civil and legal routes. Those are expensive and long, and who do the families sit against in the courtroom? Very big companies with very big legal teams, so there is a significant imbalance. The whole point is that, as recommendation 3 goes on to state:

“The Redress Agency will administer decisions using a non-adversarial process with determinations based on avoidable harm looking at systemic failings, rather than blaming individuals.”

That would have been really significant, but we do not have that. Instead, families are left stuck in the court system for as long as they can stick at it.

Recommendation 4 states:

“Separate schemes should be set up for each intervention—HPTs, valproate and pelvic mesh—to meet the cost of providing additional care and support to those who have experienced avoidable harm and are eligible to claim.”

Again, the Government do not accept that. These families meet exceptionally challenging needs day after day. Some have lost their house; some have had failed relationships; and all struggle with mental health, or certainly distress, as a result of what has happened, and we are not doing enough to help them. This should have been done, if not on day one, at the very first possible moment for support, rather than us expecting them to fall back on the conventional system, as they did. What have they gained by their vindication?

Recommendation 5 states:

“Networks of specialist centres should be set up to provide comprehensive treatment, care and advice for those affected by implanted mesh; and separately for those adversely affected by medications taken during pregnancy.”

The Government accept that only in part; it is particularly with regard to valproate that those affected will not get those centres. I will listen carefully to the Minister’s justification for that. I understand that valproate is different, in the sense that its use is ongoing in certain situations where that remains medically appropriate. However, the lack of specialised knowledge is a real issue. If there is not specialisation, we need a real sense that there is a universal step change in knowledge and experience in this area to give us greater comfort.

Recommendation 8 states:

“Transparency of payments made to clinicians needs to improve. The register of the General Medical Council (GMC) should be expanded to include a list of financial and non-pecuniary interests for all doctors”.

That is very basic. There were relationships between clinicians and big drug companies that were unknown to the families when certain treatments were suggested. The Government accept the recommendation in principle, but will not use the General Medical Council model, preferring to go practice by practice. That is big mistake. Our constituents can go to one easy, obvious place—our website—to find out our exact financial interests if they have concerns or just want to know them. We ought to be able to do the same, through the GMC, when it comes to doctors. Again, there is an unwillingness to move quickly enough to resolve these issues.

Finally, it remains surprising that the Government have not availed themselves of recommendation 9. I will listen carefully to the Minister’s response on this point. It states:

“The Government should immediately set up a task force to implement this Review’s recommendations. Its first task should be to set out a timeline for their implementation.”

Of course there should be a taskforce, including families and the broader aspects of the state, to do that. Again, the Government say they accept the recommendation in part, but the reality is that they have no plans to establish an independent taskforce. There is a patient reference group, and we of course support its work, but it is not in control; it is not at the table. The problem is that these things were done to families; they had no agency and no say. The solutions that come out of this cannot follow that same model. Once again, families are having things done to them, rather than being worked with.

I meet representatives of these groups frequently, as I know colleagues do. I like meeting them. These are good people who have been through incredible things and have extraordinary dignity and courage, not to mention that they are brilliant campaigners. They are probably sick of seeing me, and I would rather see them in happier circumstances. When I ask them what is next, they say that they are campaigning again. They campaigned over many years to be listened to, and were proven right in the most absolute terms, but they feel they have to campaign again to get the justice that should flow from that report and from their vindication. What an extraordinary demonstration of how we have let them down. They fought for too long. It is time that we stood up for them and did right by them by implementing the recommendations in full; otherwise we fail them again. I hope to hear of significant progress from the Minister.

[Dr Whitford]

I support the new clause. For a surgeon, knowing that an operation that they were trained to carry out, and performed in good faith, has caused harm is one of the worst things that can happen. I remember how I felt in the mid-1980s when we began to realise the impact of contaminated blood. It had a huge impact on how I operated. I used special diathermy techniques to avoid blood transfusion in all elective circumstances, and that is something I carried on throughout my time doing breast cancer surgery.

In this case, there may well have been doctors who were dealing with device companies and so on—that regulatory declaration is absolutely needed—but there will be a much greater number of surgeons who were using a device that was licensed and was given to them as the correct, safe device to use.

I find it shocking that although the report was commissioned by the Government, they have accepted fewer than half of its recommendations. The others directly relate to patients who have suffered harm, whether that is the women who had vaginal meshes inserted, or the mothers of children who were harmed by the use of Primodos or sodium valproate.

Sodium valproate is still an excellent anti-epileptic and will not disappear, but it is not a matter for specialist centres. It is so widely used that it is critical that within primary care and on product boxes it is made clear that women who are looking to conceive or who are of child-bearing age should not be left on Epilim; that should be discussed with them right from when they are young teenagers, so they can think about the impact later on.

The recommendations that have not been accepted are not to do with reorganising licensing, or a yellow card system; they are all recommendations that relate to women. That is really disappointing. The redress for them—the setting up of specialist centres to try to repair the damage as far as possible—is what is not being provided. The Government should look at the fact that those are the recommendations they have skirted around and not accepted. These women and the children affected have gone through enough.

--- Later in debate ---

[Alex Norris]

I beg to move, that the clause be read a Second time.

I keep going, Ms Elliott. Again, you can perhaps file this under gluttony for punishment. I do not intend to talk for very long about this new clause. I am sure that the Minister will be able to give us comfort easily on the point of new clause 54. It is just to develop the point about data one last time before our carriages turn into pumpkins.

A specific part of the Bill deals with data, and we had some very good conversations at that point. I will not repeat any of that. I will explain what I am chancing my arm at in new clause 54. I talked previously about systems and the problems with systems talking to one another. Here, we are asking integrated care boards to develop

“single whole-system IT systems”.

That is perhaps at the top end in terms of what should be aspirational and what is in fact achievable, but I do want to pursue the point a little.

Data is critical, as we have said before, in driving improvements. NHS England’s own website talks about the need to use it to improve services and decision making, to identify trends and patterns, to draw comparisons, to predict future events and outcomes and to evaluate services. But to do that, we have to have some sense of consistency. I will not repeat the arguments around the General Data Protection Regulation—we had those at length—but that shows the challenges if we do not get it right.

Going down to ICS level, if we are going to have a system that really does harness all the information, we need systems that talk to one another. Therefore, the prescription in proposed new subsection (a) is that it is a single system. As I have said, that is the stretch target. What I am hoping to get from the Minister is a sense of where he thinks this will land. Is it the same organisations using the same systems but trying to find a new way to do them, or will there be some new, novel approach to how we support footprints to do that? It is an established fact that data is going to be really important to local systems, so we want to give them the fairest wind to make the best use of it that they can.

[Dr Whitford]

On new clause 54, I just want to speak to proposed new subsection (d)—the use of data to assess performance against outcomes. Between 2009 and 2019, there was really no significant national audit of quality of breast cancer services in England, even though some of that audit had been carried out in previous years. Part of that was due to the fracturing of the system from the social care Act. There might be only one breast unit within an area, and quality was left to commissioners. How can commissioners measure whether a local breast unit is treating people properly or achieving the aspired-to targets?

In Scotland, 19 of the commonest cancers are audited; I was involved in developing the breast cancer standards in 2000, and they have been updated many times since. They are assessed annually with an annual peer review conference, where clinicians will openly discuss the challenges they face and therefore will share the solutions many of them have come up with. The clinical things that we know will affect the survival and outcomes of our women in the future are all set as national benchmarks. It is important that, while data would be collected locally, it is benchmarked against national standards.

The Getting It Right First Time project was restarted in England a few years ago but, to my knowledge, although the Getting It Right First Time for breast cancer report was completed at the end of 2019, I have not seen it published. That appeared to be due to the election in December 2019; perhaps the Minister can clarify whether the breast cancer GIRFT report has now been published, when it might be published and what other GIRFT reports have come out.

The problem is that, even if that report were published now, two years after its completion, it would largely be based on data from 2018, and therefore clinicians would shrug their shoulders and say, “Out of date.” It is important that data is used in a timeous manner to audit as quickly as possible, so that the audit loop can be closed and services improved. Having led on this process in Scotland, I saw the change in standards between 2001, when we began the first assessment, and 2005, and it is an incredibly satisfying, not frightening, thing for clinicians to see year on year the quality of care delivered by their unit driven up. There must be national standards, but local audit.

Health and Care Bill (Twentieth sitting)

Debate between Philippa Whitford and Alex Norris

Committee stage
Thursday 28th October 2021 Public Bill Committees

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Obviously, smoking has increased during covid, particularly during the lockdowns, which is quite depressing after some of the progress made in recent decades. This array of new clauses tries to tackle the issue from different angles. New clauses 32 and 38 relate to the age at which someone can purchase, along with other point-of-sale policies. Those issues are all under devolved control, so I have not got involved in those. However, the policy decisions around manufacturing, flavourings, packaging and so on are all reserved, and all four nations of the UK would agree that the biggest single favour anyone can do for their own health is to give up smoking.

As older people and people who have smoked for many years sadly succumb to the diseases we know are caused by smoking, such as heart disease, stroke and cancer, it is incumbent on tobacco companies to recruit a new generation. That is what ornate packaging and childish flavourings are clearly aimed at doing, and they are therefore completely counter to the policies of the UK Government and the devolved Governments.

This is an opportunity to stake the point, move forward and take action to prevent the recruitment of young smokers into cigarette smoking, which will inevitably cost the NHS—indeed the four NHSs—more, as they deal with the health issues over a number of decades, than is raised by tobacco duty. The Government need to stop looking at what they earn from cigarettes and focus on minimising their use. That is the Government’s stated policy, and these new clauses would take that forward.

[Alex Norris (Nottingham North) (Lab/Co-op)]

It is a pleasure to resume proceedings with you in the Chair, Mr Bone. I commend my hon. Friend the Member for City of Durham for her new clauses and the powerful case she made for them, but also for her leadership in the all-party parliamentary group on smoking and health, alongside the hon. Member for Harrow East (Bob Blackman). I know it is a truly impactful APPG and I have always been grateful for my opportunities to go to its sessions to contribute or to listen, as I know Ministers have as well. Reducing smoking and being smoke free by 2030 is a major public health prize. It was a bit disappointing and surprising that there were no tobacco control elements on the face of the Bill, so it is right that we spend a little time trying to change that.

Successive Governments have rightly taken real pride in the reductions in smoking over the past 20 to 25 years. Those reductions have not happened by accident, but through concrete interventions that were sometimes controversial and often challenging at the time, such as the smoking ban, plain packaging and packet warnings—things that we soon afterwards realised were very impactful, and very much the right thing to do. Of course, as the hon. Member for Central Ayrshire says, we have to view this in the context of covid, and there has perhaps been a bit of backsliding on that progress, but that should drive us not to despair, but to redouble our efforts. I hope we can move things forward in the spirit that my hon. Friend the Member for City of Durham suggested.

We have to understand that the gains we have made in recent years come with a caveat. Most of the quitting has been done by people from better-off communities, and the benefits have largely accrued to those communities. We are now at the point where smoking accounts for 50% of health inequalities between the poorest and the best-off communities. If we really are serious about levelling up or whatever we want to call it, health is surely a crucial part of that. We know that smoking accounts for half of that difference, so we really ought to be focusing on it.

Reducing smoking ought to be a major project for any Government, because poorer smokers are just as likely to want to quit as their better-off counterparts, and just as able to do so if they have access to good services. However, we have spent a decade cutting those services in general, but particularly in the poorest communities, so high-quality smoking cessation services—which are so effective—have withered on the vine in many of the places that need them the most.

I will now turn to the new clauses tabled by my hon. Friend the Member for City of Durham, beginning with new clause 29. About one in seven adults smokes. That is about 7 million people, and while health warnings have been displayed on smoking packages for well over a decade, there is evidence that the impact of warnings such as those wane over time. However, the dangers of smoking remain high—between 2016 and 2018, there were 1,167 deaths attributable to smoking in my city of Nottingham alone—so we need to build on the techniques that have worked, with new ones to refresh our under-standing of the dangers of cigarettes to smokers.

There is evidence that dissuasive cigarettes can make smoking less attractive to younger people and non-smokers, and the inclusion of warnings on individual cigarettes, as proposed by new clause 29, is one key way of doing that. Such warnings are already being considered around the world: an in-depth study from France found that warnings on cigarettes increased negative health perceptions, reduced positive smoker image and the perceived pleasure of smoking, decreased the desire to start smoking, and increased the desire to quit. There are therefore signs that such a policy would be impactful.

New clause 30 deals with cigarette pack inserts. Inserting leaflets that contain health information and information about quitting is an effective and cheap way to target existing smokers and help them get support to quit. Those inserts are easy and cheap to implement and, moreover, while the reading of cigarette pack warnings decreases over time, the reading of inserts increases. In Canada, package inserts have been a legal requirement since 2000, and a survey of smokers in Canada found that between one quarter and one third of respondents had read pack inserts at least once in the prior month, and those intending to quit or having recently tried to do so were significantly more likely to have read them. Pack inserts will support and reinforce the impact of other measures that will require more significant investment campaigns to go with them, such as behaviour change campaigns and stop smoking services. They are a really good evidence-based, low-cost addition to such campaigns.

New clause 31 relates to the packaging and labelling of nicotine products. Over the decades, regulation has transformed traditional cigarette packaging, plastering it with warnings and preventing tobacco companies from selling a desirable image of smoking. However, regulations have not kept pace with the less traditional nicotine products, such as e-cigarettes and nicotine pouches. Tobacco companies are still able to sell e-cigarettes adorned with bright colours, cartoon characters and attractive images, as we have heard from my hon. Friend the Member for City of Durham and the hon. Member for Central Ayrshire, and I know that e-cigarette shops in my constituency offer vape liquids branded as vanilla ice cream, slushies and cookie dough, all of which appear targeted at young people, and children in particular.

I am enthusiastic about vaping—it still feels like that is an unfashionable thing to say, but I stand by it. I think vaping is a really good way to help people quit smoking and stay quit, and it is a really important part of a smoke-free 2030. However, it should be regulated properly to help make being smoke free a reality. Data shows that restrictions on the branding of e-cigarettes and refills reduce the appeal of vaping to young people, particularly children, while having little impact on adult smokers’ interest in using these products to quit smoking, so, again, it is cost-free.

[Dr Whitford]

I assume from the hon. Gentleman’s comments that he shares my concern that although vaping is considerably safer than traditional tobacco, as Public Health England reports on vaping show, vaping products still contain nicotine, which is a vascularly active substance. Therefore, we should still be concerned about non-smoking children being recruited on to vaping. We have no idea what decades of nicotine vaping will do to someone.

[Alex Norris]

I do share that view, particularly around children. Our preference would be for them to never start. There should not be packages with cartoons and child-friendly descriptors to develop a market among children. I think there would be a high level of consensus on that.

In that spirit, new clause 32 addresses an incredible loophole, which I cannot believe anybody thinks is a good idea. If the Minister is not going to accept new clause 32, I hope he will say when the issue will be resolved. The idea that you cannot sell e-cigarettes to children but that you can give them out as free samples to under-18s is quite hard to understand. It is time for us to get hold of this simple loophole, which goes against the spirit of the legislation, which is designed to protect children against nicotine addiction. I hope we can get some clarity, either because the Minister accepts the new clause or gives us a clear picture that we will see action very soon.

On new clause 33, about flavoured tobacco products, it again feels like the market is not acting in the spirit of the laws that have been passed. Flavoured tobacco is designed to make products more appealing, especially to younger people. In May 2020, we banned the sale of tobacco with a characterising flavour such as vanilla, spices and menthol. However, companies have adapted to this legal change with new innovations that skirt the law and provide smoking experiences that replicate flavoured tobacco. I can go to supermarket websites and find “green” branded cigarettes being sold, with many reviews stating how similar the flavour is to menthol cigarettes. I do not think that is in the spirit of the law.

In the year from May 2020, Japan Tobacco made over £91 million in profits from menthol brands. Clearly, the law has not worked as we want it to. Moreover, between January 2020 and 2021, a survey of smokers showed that the smoking of menthol cigarettes has not declined, despite the apparent ban, so I do not think the law is working. This new clause would do a good job of closing that legal loophole. If the Minister is not minded to accept it, I would be keen to know what the Government intend to do instead, because I cannot believe that they want laws that they passed, in possession of full facts, to be worked around in that way.

I will take new clauses 34 to 37 as a group, because they create the same thing: a tobacco control fund, paid for by manufacturers, combined with the regulation of tobacco companies’ profits. As my hon. Friend the Member for City of Durham said, when the Government announced their smoke-free 2030 ambition, they promised to consider a US-style “polluter pays” levy on the manufacturers, and included an ultimatum for industry to make smoked tobacco obsolete by 2030. My hon. Friend’s APPG has published a very strong option for how to do that. Ministers could lift and shift that very happily and get on with this. There are real benefits to that.

Action on Smoking and Health do some wonderful work, and I am grateful for its support in my work. It estimates that a comprehensive national, regional and local tobacco control programme—in many ways, we have lost that in recent years—to deliver a smoke-free 2030 would cost the UK about £315 million. That would involve adding back lost services. ASH’s estimate for a levy, based on the model the APPG talks about, is £700 million. This could be a “polluter pays” model, and we would have plenty left over to overturn all those poor public health budget cut decisions taken over the last decade. If the spirit of yesterday’s Budget was to try to rewind and erase the lost decade that we have had in this country, this would be a really good place to do that, and I think that is a good deal.

Of course, the EU tobacco tax directive is no longer a blocking factor, so we have complete agency to act in this area and it is in the gift of the Government, so I am very interested to know how far along the Minister or his colleagues are in the consideration, as they said, of this matter, and when we will see some proposals. Similarly, when will we see another tobacco control plan? That is something that everybody, from local government, public services, the private sector, community and voluntary services and all of us in this place, can organise around. The 2030 goal is a common goal. Pretty much everything that we have said in the new clauses are things that we are of one mind on. We can do something really good for the health of the nation, and I hope to find the Minister in action mode on that.

I will finish by referencing new clause 38, also tabled by my hon. Friend the Member for City of Durham, because I do not want it to look like I have ducked the question. It is important that we actively look at that and consider the evidence. I am perhaps not ready to say that it should be in the Bill, but it should be part of an active conversation in this area and part of a tobacco control plan. I think the Minister may be in a similar place on that, because we know that it is an effective part of the armoury. There are loads of really great things to go at in this set of new clauses, and I hope that he feels the same way.

--- Later in debate ---

[Dr Whitford]

Many of the labels simply say, “Drink responsibly” or, “Drink aware”, but, as the hon. Gentleman is highlighting, the lack of information on labels introduces quite a complex step of that person having to go and look up the risk of harm or the unit measures. Yet we have just been debating the need to have warnings on cigarettes. Alcohol introduces harm both to the individual and, if they are heavy drinkers, to those around them, and therefore we should be taking this seriously. We have tried to do so in Scotland with measures such as minimum unit pricing, but information to the consumer is the first step.

[Alex Norris]

I am grateful for that intervention. I would certainly not talk down including the very broad messages that the hon. Lady mentions; I know that in an overwhelming number of cases that is available, but, as she says, that is not enough. People are conscious of that message and we should keep reinforcing it, but the jump-off point is, “So what? What am I going to do differently, or what do I need to understand differently?” At the moment, we are not helping them in that process.

This new clause, mirroring clause 127, asks the Secretary of State to introduce secondary legislation to compel the inclusion of this sort of information on products. It is a relatively modest ask, but it promotes informed choice, which in this area would be a very good thing. I do not think we should miss the opportunity to put it in the Bill.

Health and Care Bill (Nineteeth sitting)

Debate between Philippa Whitford and Alex Norris

Committee stage
Wednesday 27th October 2021 Public Bill Committees

[Alex Norris (Nottingham North) (Lab/Co-op)]

It is a pleasure to resume with you in the Chair, Mr McCabe. I commend the right hon. Member for Kingswood for his new clause and for the persuasive case that he made for it. I will cover much of what he said in my contribution, but I highlight his point about long-term certainty, because I was not going to cover that. Those points were very well made. If we want to embed a culture of research in this country and to be world-leading, as surely we do, we must give our researchers that long-term certainty.

I am going to start with the National Institute for Health Research, which was, of course, established by the previous Labour Government in 2006. We are very proud of that, and since then, in partnership with NICE and other organisations, it has delivered on its mission to improve on the health and wealth of the nation through research. I refer any colleagues who have not had a chance to look at it to the 2016 RAND report, which identifies 100 examples of positive change resulting from the institute’s research. You may be pleased, Mr McCabe, to hear me say that I do not intend to read out all 100, but I do want to highlight the role that it has played since in fighting covid-19 by funding, enabling and delivering lifesaving research throughout the pandemic and now in this current phase. I will not list all the ways in which that has been done, but I will highlight the recovery trial that discovered dexamethasone. That was the first drug to reduce covid-19 mortality in hospitalised patients, cutting deaths by one third, and it was funded and supported by the NIHR. It is a great organisation, which we should be backing and should be very proud of.

On research more generally, there is a shared vision and a shared ambition across this place: the UK should be at the very forefront in science more generally, and particularly in research on health and care. We have all the assets to do that, if we link everything up and invest in it, and to make the UK the destination of choice for clinical research. The new clause offers the Government the chance to put that on a statutory footing, and to make good that commitment, ringfencing funding and mandating the Secretary of State’s support and interest in leadership. As the right hon. Member for Kingswood said, we would expect the Secretary of State to make many things a personal priority. We would argue that this is one of those things.

As in many of our proceedings, we are tidying up on the Health and Social Care Act 2012, and this is a good opportunity to do so again. The Minister smiles; I am always here to offer those opportunities. My hon. Friend and I have been ever so accommodating in that regard. The 2012 Act only included the duty for clinical commissioning groups to promote research. I would direct colleagues to the cross-sector written evidence headed up by the Academy of Medical Sciences, which said that the NHS’s lack of ability

“to prioritise the resourcing and delivery of research has been a major impediment to improving the UK’s clinical research environment over the last decade.”

According to that submission, that has subsequently been a contributing factor to wide-ranging disparities in opportunities for patients to engage in research. When it talks about that, we should listen. As with so many things, we have chance to right that wrong in the 2012 Act and to show in the Bill that we want an active research culture in the NHS, building on the last 18 months.

Evidence shows that a strengthened research mandate would bring many benefits. First, patients treated in research-active NHS organisations have improved outcomes. They have lower mortality rates and higher confidence in the care they receive, which really is a big prize. Secondly, at a time when the NHS is dealing with many work force issues, this increases job satisfaction, with most doctors surveyed by the Royal College of Physicians wanting to be more involved in research and two thirds more likely to apply for a role with dedicated research time. We know it is what our excellent clinicians want too. Thirdly, it brings economic investment into this country; £2.7 billion was generated by NIHR clinical research network-supported activity in 2018-19, making the NHS around £350 million from life science companies. So we win here both coming and going; it is better for our patients, better for clinicians and better for our economy.

There really is a lot in this very good new clause with regard to both the NIHR itself and research more generally. I hope that the Minister will look favourably on the new clause. If he does not, I hope that he will give the Committee comfort on how this will be not just a broad priority for the entire system, where it is not quite clear who is responsible, but something that he as a Minister, and the Secretary of State, will be driving personally and taking as a personal responsibility. As I say, the prizes are very great indeed.

[Dr Whitford]

Although this would obviously apply in England and not Scotland, and the NIHR does not generally fund a lot of clinical research that comes from Scotland, I absolutely support the principle. When I was lead clinician in the west of Scotland, we put trial support staff into all 13 breast cancer units around the west of Scotland. That drove up participation in trials, which, as the hon. Gentleman just said, is what generates confidence among patients and results in better outcomes. Most trials come with a lot of bureaucracy, and people working in very busy clinical jobs in district generals often do not engage because of that. Putting trial staff out in district generals can actually mean that, instead of research being within academic units, it is suddenly available to all patients. That is really important.

Having a questioning mind should be part of being any doctor. All junior doctors are encouraged to develop auditing and clinical ideas as an approach. The hon. Gentleman—I have forgotten the constituency, I am afraid.

[Alex Norris]

Nottingham North.

[Dr Whitford]

I was going to guess some other city and get it wrong, but it is somewhere north. The hon. Member said that having access to research time as a clinician, which the right hon. Member for Kingswood mentioned is a way of retaining staff, is quite important. My local health board now employs younger, as opposed to older, doctors as clinical fellows, and they have a day a week as part of their contract. It is not just one or two doctors; the board are doing it as a standard approach. It has become really popular and has certainly helped with our workforce issues in Ayrshire and on Arran. It is important to see laboratory and trials research and frontline outcome audit and clinical ideas research from all young clinicians, and we should encourage that. The money is great, but we then have to work out how the money feeds into the health service to generate the biggest impact.

Health and Care Bill (Eighteenth sitting)

Debate between Philippa Whitford and Alex Norris

Committee stage
Wednesday 27th October 2021 Public Bill Committees

[Alex Norris (Nottingham North) (Lab/Co-op)]

It is a pleasure to serve again with you in the Chair, Mrs Murray. As I said yesterday, we are grateful for the Minister writing with his explanation of this and the other new clauses ahead of time. That was helpful.

As the Minister explained in his letter, the new clause will simplify and safeguard the process of remuneration where the Government centrally procures vaccines, immunisations or products used to treat a pandemic, as well as other listed products, replacing “special medicinal products” under the previous legislation, in particular when there is significant international demand. That is very topical and we have a rich understanding of it given the events of the past 18 months, so it makes sense to the Opposition and we will not dwell on it long, nor will we press the new clause to a division. However, I seek clarity from the Minister on a couple of issues.

In the Minister’s letter, he cited the risk of wholesalers exporting the products or selling them at a much higher price if they were fed into the conventional supply chain. He characterised that as market failure. Community pharmacies would then be claiming reimbursement from the NHS based on the drug tariff determinations. I do not doubt the risk of that, and it is a foreseeable one, but am keen to hear from the Minister whether he is able to quantify the risk or demonstrate examples in either case. For example, during this pandemic, did that happen at the beginning? What was the cost if that took place? Have there been examples of profiteering preventing necessary products from reaching the patients for which they were intended?

In a second point, I am curious about the arrangements put in place to transition back to normal payment arrangements, once the disease in question is no longer pandemic or at risk of becoming pandemic. Again, I think we would always want restoration of normal circumstances at the first appropriate moment. In his letter, the Minister describes the arrangements as “appropriate”, while the new clause reads:

“Where…the Secretary of State considers that the disease to which it relates is no longer a pandemic disease or at risk of becoming a pandemic disease, the Secretary of State must revoke that provision within such period as the Secretary of State considers reasonable”.

Given that section 164 of the National Health Service Act 2006 also allows the Secretary of State to determine remuneration, that feels a little like the Secretary of State being allowed to mark their own homework. It could leave such measures in place for as long as suits them, rather than for as long as necessary, because the only determination of their need sits with that person. Will the Minister offer some reassurance that the power is for an emergency and is exceptionally limited, and give the Committee some comfort about the oversight and how Parliament perhaps will be given the chance to challenge the Secretary of State, so that the measures are not kept in place for any longer than necessary?

[Dr Whitford]

I have a small comment following on from the hon. Gentleman, who was asking for evidence of profiteering on specials. I was on the Committee considering the Health Service Medical Supplies (Costs) Act 2017 and brought the issue of specials before the Committee. These are often personalised medicines. In Scotland, they are produced centrally by the NHS, but there is certainly huge evidence of profiteering on them within NHS England, with hundreds of pounds being charged for simple ointments. While we may not have evidence on vaccines, evidence of profiteering on specials is long standing.

--- Later in debate ---

[Alex Norris]

I beg to move, That the clause be read a Second time.

For Opposition Members in Committees of this type, as we assemble the issues that we prioritise in proceedings, we have to be a bit of a magpie and pinch things along the way, so I want to recognise that this new clause is pinched from the hon. Member for Newton Abbot. I am grateful to her for tabling this and for the level of thought that she put into the amendment, which is a very good one.

Earlier in the proceedings, we discussed integrated care board plans and their responsibility to engage with the Domestic Abuse Commissioner. I was grateful for the commitments that the Minister made. There was a common understanding that the health and social care system has a crucial role in both preventing and tackling domestic abuse and in supporting victims and survivors. That sounds self-evident, but we are not in that position in this country yet, and we could do much better. I hope we can build on that consensus with the new clause, which requires integrated care boards to publish a strategy for the provision of support for victims of domestic abuse using their services and to designate a domestic abuse and sexual violence lead.

I will not repeat the arguments that I made earlier regarding the scale of domestic abuse, but it is worth reiterating top lines, particularly the global statistics from the World Health Organisation, which show that 30% of women have experienced some form of physical and/or sexual violence by an intimate partner in their lifetime. In this country it is one in four, so it is of a similar order of magnitude. The Government’s own estimate is that it costs health services £2.3 billion annually. A common refrain from the sector, with which I meet a lot, as I did before coming to this place, concerns the impact it could make with a fraction of that money if it was put into statutory services or the services that it provides. We should think about that investment model.

In discussing the new clause, I want to take the opportunity to cover something that we have not previously considered, namely domestic abuse, which tends to be against women but also concerns people with disabilities. According to Stay Safe East, disabled people and, most specifically again, disabled women, experience higher rates of domestic abuse than those who do not have disabilities. Abuse against women with disabilities is likely to be more violent and to happen over a longer period before the victim discloses it or can access help. The really sad thing is that if the victim––who is living with a disability––is not heard, there is a significant risk that they will then be sent home by the system to be cared for, in the very loosest sense, by their abuser. None of us would want that but it is the sort of thing that happens at the moment because we do not have a strong enough grip. I hope that we can use the new clause and the Bill generally to take more active steps to address that problem.

There is clearly a significant need for specialist domestic abuse services, which are crucial to enable women’s recovery in particular. Often, such services take on the work of statutory services and provide vital advocacy for women facing health exclusion, particularly in respect of services supporting black and minoritised women. It came out strongly in the debate on what is now the Domestic Abuse Act 2021 that we need specific and specialised services for those who are at greatest risk of being excluded. We did not quite get there in those provisions. I confess to using every legislative and parliamentary opportunity to keep pushing at this because it is really important and we can do much better.

We know that medical staff receive some training in adult safeguarding and, in a few hospitals, even on domestic abuse and sexual violence. But the skills and time to communicate with people with, say, learning disabilities or cognitive issues, with deaf survivors or with very elderly people who might be less likely to disclose personal information are not always available, and certainly not universally. The new clause seeks to put the onus on the integrated care system to get organised around this, to specialise and to prioritise it. It should be a priority across the system.

[Dr Whitford]

Does the hon. Gentleman think that we also have a job to do socially in reducing the stigma? I have worked in casualty departments and as a surgeon facing women who had clearly been abused but were standing or lying there making excuses for their abuser and saying why it was their own fault. As well as women with disability, there are women with insecure immigration status or insecure financial status who have no money of their own and feel that they have nowhere to go. I support the principle here, but we have a much bigger job to do around domestic abuse, which is endemic across the UK.

[Alex Norris]

I am very grateful to the hon. Lady for that intervention and completely agree with everything she said. For my part, and that of many of our colleagues, our way to tackle all those different barriers is to seek to put this in every bit of legislation. Most domestic legislation touches on these issues.

What is pertinent to this debate is thinking about the barriers to reporting. One barrier is the fear of not being believed. Of course, there is a bigger fear around prosecutions, which the Minister took a personal interest in when he was a Justice Minister, but it is clear from the evidence that we are not making enough progress. We have heard lots of positive sounds from the Government but no concrete proposals for change. We could do much better there.

On the barrier of not being believed, one way to create a better environment for a survivor to disclose what has happened to them is by their knowing that the person they are talking to in that healthcare setting has had training and works in a system that prioritises the safe disclosure of abuse. That would do a lot to build confidence. On the hon. Lady’s point about migration status, it is important that we talk about that. It was a key theme in the Domestic Abuse Act. There must be safeguards in place so that the disclosure of abuse trumps immigration status. The practitioner that they work with must be someone whose role is to help them address those issues, not someone who will be speaking to the Home Office. That first knock on the door will be someone trying to help them deal with the abuse and its impact on their life; it will not be from someone trying to resolve their migration status. That is an important principle.

Returning to the new clause, meeting with a professional social worker who ought be trained in assessing risks, including domestic abuse, might be the significant moment that an older or disabled person discloses domestic or other abuse. If given time and asked skilful questions in a safe environment, the person may disclose or express their fears, knowing they can do so in a protect manner. But across the country, such interventions are not falling into place on their own.

Women’s Aid’s data shows that in 2019-20, no refuge services responding to its survey were commissioned by their CCG, and just 10% of community-based services were. This is a multi-agency issue. I fought very hard to persuade the hon. Member for South Derbyshire (Mrs Wheeler) when she was Housing Minister that there ought to be investment and support going into the services through local government. She took that on, which was a good thing. Local authorities alone cannot tackle this issue. The picture that emerges from the evidence is that health agencies are not delivering as they ought to.

To be clear on what our modest ask is, subsection (1) states that each board must

“assess, or make arrangements for the assessment of, the need for support for victims of domestic abuse using their services”.

That is pretty basic. Following that, it must prepare a strategy, monitor that strategy and have an annual report on it, but particularly, under paragraph (d), it must

“designate a domestic abuse and sexual violence lead”,

because we know that in organisations such as the police or health organisations, where they have designated such a person, that person has been impactful. Those are pretty basic requirements. On many occasions the Minister has said that the point of the system is to be a permissive one and to let local areas shape services in the interests of their population, depending on the challenges they face; but the reality is that this problem is in every community, and we ought to be clear to ICBs that we expect this kind of activity. Subsection (3) includes a modest ask for consultation, which is reasonable and desirable.

Women in particular, and all our communities, desperately need this issue to be given deliberate focused attention. There is a high degree of consensus on it, but that does not lead to action frequently enough. The appointment of a Domestic Abuse Commissioner, which we have discussed, was a welcome step, but from a health and social care perspective we need to do more in the system. At the moment, that is not happening. That is not because I think that commissioners, leaders and decision makers do not think it is important, but they have an awful lot on. This can be a hidden crime that goes on behind closed doors, and as such drops down the list of priorities because of the urgent pressures on them; but we cannot let it go. As well as the leadership that we try to display on a national scale, we must do more to encourage this on a local scale. In this case, that is in the strategies and plans of the ICBs. We should make sure that happens.

To conclude—this is in the same vein as what I said when we debated new clauses 1 and 2—we should in our remaining time seek to put in the Bill things that will change people’s health outcomes, and outcomes in life more generally. New clause 5 is one of those things, so I hope the Government are in listening mode.

Health and Care Bill (Seventeenth sitting)

Debate between Philippa Whitford and Alex Norris

Committee stage
Tuesday 26th October 2021 Public Bill Committees

[Alex Norris]

We have been at this now for the best part of a couple of months. This is our 16th session. Some of the faces have changed but largely it is the same group of people. We have reached clause 121 of the Health and Care Bill and we have finally found the bit that is about care. It is amazing—you had to not blink or you might have missed it. But I would not get too excited; it is only two clauses, and neither comes anywhere near addressing the problems we face in our nation’s social care.

The national Government’s cuts to local authorities over the past decade have had a devastating impact, particularly around social care. They have led to rationed care and poor quality care. They have led to care being devalued as a profession and to providers being unable to retain their staff. As a result, we see short visits and a constant changing cast of carers, and we know that is bad for all those individuals receiving support. That is the story across all our communities, and it is worsening as we go.

Clause 121 proposes that the Care Quality Commission will now make a general assessment of the quality of a local authority’s offering for those needing care. Once those reports start coming back, I have no doubt they will make very difficult reading for many parts of the country, if not all, because they will lay bare the issues that I talk about. I do not have any problem with inspection and public assessment of the quality of care services. I do not have any problem understanding this at a local authority level rather than provider by provider. My constituents, and people across the country, deserve excellent services, and I can see how these things work in support of that goal. What I do worry about is that this will be just another way for the Government to passport blame to hard-pressed local authorities that are doing their best but are simply not adequately funded to do their job. That is the reality in this country today.

Amendment 145 seeks to improve clause 121 a little, in line with our broader efforts throughout the Bill, because we want to see service users at the heart of the health and care system as genuine shapers of what happens to them in their lives and their community. We want to make sure that those with the greatest stake and the greatest expertise by experience have the chance to be part of the process, as set out in clause 121, and to talk about their experiences in their community and about how things might be done better, because they hold so many of the answers to the challenges we face. That is a moderate but important ask and I hope the Minister will support it in the Bill or make a commitment that it will follow in the guidance that will be issued to the Care Quality Commission.

Similarly, we should seek the voice of providers, for a couple of reasons. First, they know what the successes and challenges are in their local system, and they know about the hard conversations they have with commissioners, which ought to be conversations about an individual’s needs but are, inevitably, rationing decisions. Secondly, and this them gives a special insight, many if not most—probably the vast majority—of these providers work across multiple local authorities, giving them a rich picture of the differences in approach, availability of care and similar. That is a rich contribution. We strongly think that those two voices should be heard, and the amendment is a good way of doing that.

Turning to Government new clauses 60 and 61, I express my gratitude to the Minister for his correspondence on them to give the Committee a sense of where the Government seek to go, but he was not quite able to provide comfort. New clause 60 is a mess constitutionally. It allows the Secretary of State for Health and Social Care greater powers over local authority social care functions, including giving him powers to talk about failures and directions. First, local authority accountability is to its public. We know that, every four years, we have elections. Beyond that, exceptionally and rarely, the Secretary of State who leads for local government—I know they have taken “local government” out of the name, but there is still one in whatever the Department is calling itself now—can take action in instances where the local authority is deemed to be failing in its duties to its population. The Secretary of State can put in directions, support and, as we have seen, even commissioners. That is a well-established process, but the clause inserts the Secretary of State for Health and Social and Care into this arrangement, which is a considerable overreach. It gives the Secretary of State a power to impose themselves on local authorities in a way that I do not think is welcome. At the bare minimum, it ought to be something that is exercised by the colleague of the Secretary of State who leads on local government in ways that are already well established, rather than creating another actor in the piece.

That leads us to the continued pattern that we have seen throughout the Bill. I am afraid that integration is a bit of a myth, but where there is any, it is largely that the health service ought to have more power and, more importantly, that the Secretary of State ought to have more power over telling local government what to do. There is no equivalent or supporting ability for local authorities to impact on the decisions taken by the Secretary of State. That creates a mismatch, which is really undesirable. I am keen to hear from the Minister why it was decided that the Secretary of State needed direct access to do that, when they could perhaps have worked better through their colleague, who does it more conventionally on a day-by-day basis.

New clause 61 dispenses with the Care Quality Commission’s ability to issue a notice of failure to a local authority in England. Again, when taken with new clause 60, my suspicion is that that is because the Secretary of State is in charge now. The commissioners and inspectors may be there to give some helpful evidence but, in reality, it is the Secretary of State who will command and control the system. That might be deemed adequate by the Government with regards to the health service, but I do not think it is adequate in local government, given the mandate that our councillors get from their population.

We cannot support the new clauses. We will not oppose clause 121, because there needs to be some oversight in the new environment that the Government are seeking to create, but I have no doubt that we will have to find a better way to do that in years to come. In the meantime, I hope that we can at least enhance that with amendment 145.

[Dr Whitford]

I rise to support amendment 145 but also to echo the comments of the Labour Front Bench about how far we have to go into the Bill, which is called a Health and Care Bill, before we hear anything about care. I think that all of us with any interest in social care have recognised the challenges within the sector over the past 18 months, which have been laid bare by the pandemic. What needs to come out is a much more radical approach to social care, including closing what is thought to be between a £6 billion and £8 billion funding gap in England every year.

In Scotland, we spend over 43% more per head on social care than in England, and that provides free personal care to people who are resident in Scotland. We fund the real living wage, which helps to begin to tackle the workforce issues, but the deeper issue facing all four nations is that we need a different approach to social care. The Feeley review, which the Scottish Government commissioned last autumn, highlighted the fact that we constantly talk about social care as a burden, and about how much it costs, instead of realising that almost half of those receiving care are people of working age. We must recognise the importance of social care for both younger and older people, recognise it as a human rights issue, and recognise it as funding to allow people to participate in the society in which they live. We need to turn that around, which means that we need to change the approach to the staff who deliver it.

Workforce is the biggest single problem. It is unfortunately much worse since we left the EU—certainly in parts of rural Scotland, where up to 30% of care workers were European citizens. We need to develop care as a profession. It is a registered profession in Scotland, but the staff need to be treated as professionals with career development, so that people come into social care for a lifetime, not just until they get a job on the checkout in Tesco. I appreciate clause 121, but it is not remotely radical enough. In something called the Health and Care Bill it is very small considering the mountain that has to be climbed.

--- Later in debate ---

[Dr Whitford]

Basically, clause 125 is just schedule 16 —there is nothing very much in clause 125. I sat on the Health and Social Care Committee when we talked about trying to tackle obesity, which is a growing harm across the UK, giving rise to heart disease, diabetes and so on, and the difficulties of trying to regulate the advertising of unhealthy foods, particularly foods with high fat, salt and sugar. I welcome the fact that there is an attempt to tackle that issue in broadcasting, streaming and particularly online.

I have concerns that the exemption for small and medium-sized enterprises could be worked into a loophole at a later date by large companies simply employing multiple small advertisers or restructuring themselves to get away with still advertising. I would be grateful if the Minister could explain that exemption, because unhealthy food is just as unhealthy whether made by a small or a big company.

Broadcasting and online regulation are clearly reserved matters, and I totally respect that, but public health is devolved, so I would welcome clarification from the Minister on exactly how the devolved Ministers will be involved, how their public health policies will be respected, and how they will be consulted.

Proposed new section 368Z20(3) of the Communications Act 2003 gives power to amend by regulation Acts of the devolved Parliaments, and proposed new subsection (4) states that the Secretary of State can consult who they think appropriate. I am surprised that at that point there is no mention of consulting the devolved Governments. I totally accept that it would not be a matter of consent, but yet again there is absolutely no mention of consultation with or involvement of the Public Health Ministers in the devolved nations.

[Alex Norris]

It is a pleasure to speak to this important clause, which sets out restrictions on advertising less healthy food and drink. I echo what the hon. Member for Central Ayrshire said about its importance and the general commitment to it across the House. Importantly, it also gives me an opportunity to put on the record a message of thanks to the hon. Member for Bury St Edmunds (Jo Churchill) for all the work she did in this area while a Health Minister. She has moved to a new post during the Bill’s consideration, but she championed this provision for a long time and fought very hard for it, so I have no doubt that she will be glad to see it included in the Bill.

These measures form part of the Government’s obesity strategy, which is coming through the system bit by bit. The strategy has largely come through in secondary measures, so I welcome the fact that this provision has been included in the Bill, because it gives us an opportunity to propose improving amendments. Is the Minister able to explain why other provisions in the strategy have not been brought forward in this way? For example, we have considered a statutory instrument on showing calories on menus, which I dare say all Members will have received something about in their mailbags, because it is a contentious and emotive topic, with many shades of grey. That provision would have been improved if we had had a chance to amend it, so I am sad that we instead got a “take it or leave it” measure. I do wonder why the entire obesity strategy was not put through in this way.

Turning to what is before us, ensuring that we do not see the aggressive promotion of products high in fat, sugar and salt, particularly to our nation’s children, is an important step in reducing the obesogenic environment we live in. We know that one in three of our children leave primary school overweight and one in five are obese, and we know the lifelong impact that that has on physical and mental health, such as the links to diabetes, musculoskeletal ailments and depression. We also know the impact on children’s education, as they go to secondary school and beyond, and on their prospects in the world of work.

It is a well-established and long-standing precedent in this country that we try to protect children from exposure via the television by using a watershed, so it makes sense to consider these products within that scope. Of course, the nature of the content we all consume—children are no exception—has changed beyond all recognition in my lifetime. The explosion of the internet and its pre-eminence in our lives has provided new advertising space for traditional means—banner ads, pop-up ads and similar—but there is also a much broader platform. Today is probably not the day, certainly not in the witching hour of this Committee, to get into the influence of culture and how the entertainment landscape is changing—not least because I feel woefully underqualified to talk about it—but the point is that there are extraordinarily novel ways of connecting with people, especially young people. It is therefore right that we in Parliament enter this space to try to create the safest possible environment.

I will say, alongside this, that I am surprised that we have not yet seen the online harms legislation—it seems to have been coming through the system for a very long time indeed—because it would sit very neatly with this. I hope there will be a sense of trying to weave this in with that in due course.

The Government’s answer here goes beyond a watershed and into full prohibition. I hope that the Minister will take us through how that decision was reached. I understand from my conversations with industry, particularly those working in digital media, that they have offered a solution that would act as a de facto ban for children without being an outright ban. Given that we genuinely lay claim to being world leading in advertising in general, and in digital media in particular, we ought to listen if there are more elegant ways of doing that. I hope the Minister can cover the conversations being had with the sector and why this approach was chosen, not a slightly more nuanced one. Perhaps it was considered too complicated, but we need to know that.

As the hon. Member for Central Ayrshire says, clause 125 inserts schedule 16 into the Bill. As that is where the meat is, I want to probe the Minister on a couple of points. First, on the fines regime, what are the sanctions in the Government’s mind? Secondly, the schedule provides for regulations to follow. I suspect we will see a full regime, but when are we likely to see it? How far along are we, and what sort of consultation will there be? Thirdly—again, this will be a matter for regulations, but I hope the Minister might be drawn on it now as a concept—who does the burden fall on? Is it the advertiser or the platform? It might be both, and obviously it could not be neither. That will be a very important point going forwards.

Adding to the case the hon. Member made about small and medium-sized enterprises, we supported that conceptually in the statutory instrument on calories on menus because there was agreement that it was reasonable to say that these things would be a significant burden for a small operator, which might have only one or two members of staff. I do not think that applies in the advertising space. Again, we would be keen to understand how the Minister and his colleagues reached the conclusion they did.

Amendments 139 and 141 deal with alcohol. One of the few parts of the obesity strategy where we have departed from the Government’s view is the curious decision to remove alcohol, particularly with regard to calories and labels. We all know that alcohol is a less healthy product—I may well be the billboard for that, certainly when it comes to weight—so why has it been left out? Our amendments are more probing than an attempt to actually change the Bill, because I hope that alcohol has already been covered. However, in the obesity strategy in general, it seems to have disappeared, which seems very odd. I hope that the Minister can explain his thinking on that.

New clause 55 seeks to protect the nutrient profiling model. According to gov.uk, the NPM

“was developed by the Food Standards Agency in 2004-2005 as a tool to help Ofcom differentiate foods and improve the balance of television advertising to children. Ofcom introduced controls which restricted the advertising of HFSS foods in order to encourage the promotion of healthier alternatives.”

So far, so good. We would say that that principle is sound today and will be sound going forward; that is why we are keen to see it in the Bill. It is crucial that we continue to uphold those standards, but we know that foods change. We know that our understanding of what different nutrients mean for us or our children changes over time. We know that the biggest prize in this space is about reformulation, as much as it is about anything else, which would put more stresses on the NPM. I am keen to hear a full commitment from the Minister today that before meaningful changes are made to the NPM, they will be put out to proper consultation and that industry and consumer groups will be properly engaged, along with anyone else who may have an interest.

I will finish with amendment 113, in the name of the hon. Member for Central Ayrshire. I have made the arguments around engagement through consent, mutual good faith and co-operation from Ministers multiple times, and I hope to hear that in closing.

Clause 125 is very important, and we would like to know a bit more about schedule 16. I would be keen to hear that the issues raised in our amendments are covered elsewhere or at least to have a commitment to that. Finally, I would like to hear a bit about the nutrient profiling model.

--- Later in debate ---

[Dr Whitford]

I do not plan to press my amendment to a Division, but I encourage the Minister to put in the Bill the consultation that is required. I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 125 ordered to stand part of the Bill.

Schedule 16 agreed to.

Clause 126

Hospital food standards

[Alex Norris]

I beg to move amendment 137, in clause 126, page 107, line 18, leave out “hospital”.

This amendment would make the power to impose food standards applicable to all premises within the remit of the Care Quality Commission, rather than just hospitals.

--- Later in debate ---

[Alex Norris]

I am really pleased that we have reached clauses 128 and 129, on fluoridation of water supplies. This is something that I am personally very enthusiastic about, so I want to make a few points on it. Fluoridation is a very important venture. Oral ill health can be a hidden and very personal but insidious ailment. It is the single biggest reason for hospital admission among our children. A 2015 review of children’s dental health found that a quarter of five-year-olds have decayed teeth, with an average of 3.4 per child.

[Dr Whitford]

I wonder whether the hon. Member, like me, is surprised that the opportunity offered by this Bill has not been used to introduce a child dental health programme in England similar to Childsmile, which has existed in Scotland since 2007, or the scheme that Wales has had since 2011. Although there was agreement a couple of years ago to establish pilot sites across England, data on the impact in Scotland, where many areas had significantly poor dental health, has been available for four years. I am just surprised that something like that has not been included in this Bill, when we are talking improving the dental health of children and addressing the fact that, as the hon. Member mentioned, dental clearance—the removal of significant numbers of teeth—is the commonest reason to administer a general anaesthetic to a child. That is quite a shocking indictment.

[Alex Norris]

I am grateful for that intervention; I was going to turn to that issue next. Not only have opportunities been missed over the last decade to invest in oral health, but we are actually going backwards. Supervised tooth brushing and other high-quality evidence-based interventions, such as the models that the hon. Member mentioned, have disappeared because of this Government’s cuts to the public health budget. Of course, the savings from those cuts are hoovered up very quickly by the costs that they generate elsewhere in the system. It is very sad, it results in a lot of pain and lost potential for the individual, and it is bad for the collective.

Fluoridation is one element in trying to put that right. Putting fluoride in our water is a really good, evidence-based intervention that is proven to work. For every pound spent in deprived communities, there are savings of nearly £13 within just five years, and of course every independent review of fluoridation has affirmed its safety. As a nation, we ought to be creating new fluoridation schemes targeted at the communities that would benefit the most. The current system does not work, as I remember well from my time in Nottingham. Currently, a local authority has to decide to enter into this space, build support, and then, with support from Public Health England and the Secretary of State, move to implementation. However, that generally fails for two reasons.

First, our political boundaries do not match up very accurately with our water boundaries, so where we would physically tip in the bag of fluoride does not fit with our political geographies. That creates issues between authorities such as mine, where the case would be very strong because of our oral health outcomes, and bordering authorities that would have less interest because they have better oral health outcomes. Secondly, this issue is contentious. Local authorities have an awful lot on, and it is very hard for a local council to make this the one totemic fight in its four-year term. There are only so many big things that a council can take on at once, and fluoridation gets beyond the bandwidth of local authorities.

We support the principle behind clause 128; bringing the Secretary of State into this is a very good idea. The position of the Secretary of State, once removed from the entire country, can make different geographic decisions sensibly align with water boundaries. He is perhaps also in a stronger position to help with some of the political issues, so in concept we support that.

Amendments 149 and 150 are a pair. Why are the Government keen to swap the current local system for one that is nationally driven, when we could have both? As I have said, we support adding the heft of the Secretary of State to the local expertise of our councils, but why remove councils from the process? Although clause 128 gives new powers to the Secretary of State, our argument is that local authorities should be able to retain their powers in the event that they might want to use them. This is a cost-free proposal. It merely expands the range of possible approaches and paths towards fluoridation, and it promotes local decision making.

Clause 128(2)(d), which inserts new subsection (6B) into section 87 of the Water Industry Act 1991, is a little bit naughty, and amendment 150 seeks to address it. According to page 43 of the Government’s community water fluoridation toolkit, if a local community can successfully get itself together to get a scheme going, Public Health England is required to meet the reasonable capital and operating costs. I presume that that responsibility ported to the new Office for Health Improvement and Disparities when it came into force at the beginning of this month. However, subsection (6B) removes that provision and instead allows the Secretary of State to direct another body—I presume it will be the local authority—to pay for the scheme. Therefore, instead of being paid for nationally, the scheme will be paid for by a body chosen by the Secretary of State. That will be a barrier to the creation of a scheme.

I think that local authorities will be less keen to engage with the Secretary of State in implementing a scheme if they feel that they will have to pay for it. Their budgets are exceptionally stretched—I suspect they will not get much support tomorrow—and the benefits do not generally go back to local authorities. Of course, the benefit goes to the community in general, but in terms of organisations and cashable benefits, they would be health service benefits rather than local authority benefits. I do not think that the proposal promotes integrated thinking. The amendment seeks to address that, and I hope that the Minister will reflect on it. As I have said, I think that, broadly speaking, the clauses do the right thing, but their current effect will be to replace a locally led system with a nationally led one, when actually we could just have both.

To conclude, over the past year we have stood shoulder to shoulder with the Government in expressing to communities up and down the country that vaccines are not only safe but necessary. The objections that we receive come from those who argue in the face of evidence or who rely on conspiracy theories. The same is true of arguments against fluoridation. It is an evidence-based, safe and highly effective intervention. That is not to say that it is easy to do. It does not require behaviour change but it has a remarkable impact, so I am keen to hear from the Minister not only that the Government want to put this in the Bill, but that they want to get on with doing it in communities such as mine, which will benefit. If they do that, we will stand shoulder to shoulder with them again, and I think it will be an exceptionally important breakthrough in oral health in this country.

Health and Care Bill (Fourteenth sitting)

Debate between Philippa Whitford and Alex Norris

Committee stage
Tuesday 19th October 2021 Public Bill Committees

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

A lot of this covers the issues that we discussed in relation to data, consultation and consent. I respect that these are UK-wide bodies, whereas data is within the devolved systems, so that was an even bigger issue, but there must be recognition that although health is devolved, the regulation, licensing and registration of staff for bodies of this sort affect the devolved health services. There should at the very least be proper, genuine consultation, rather than changes simply being made.

As we discussed this morning, we saw how NHS Digital—in essence, an England-only service within NHS England—is now being turned into the Health and Social Care Information Centre, which is UK-wide. We already have the information and statistics division in Scotland, so changing the ability of the Secretary of State to change arm’s length bodies may indeed affect what happens in the devolved health systems. Reference is made to the Human Fertilisation and Embryology Authority and the Human Tissue Authority simply to respect that those health services are under the control of the Welsh and Scottish Parliaments and the Northern Ireland Executive, but decisions made here will have an impact on them.

I welcome the Minister saying that NICE would not be forced on Scotland—we have the Scottish Medicines Consortium, and the Care Inspectorate rather than the Care Quality Commission. However, that is people’s fear because it is not explicit here—either through consultation or consent—that bodies that have been set up for almost two decades, that are integrated with our health system and functioning well, could suddenly be rolled over. It is important that the Minister points out that clause 89(6) is merely consequential. It increases anxiety that the Minister here can, simply through regulations, revoke, repeal and amend Acts of the Scottish and Welsh Parliaments without consent or even consultation.

I do not see an issue with a name change, but there is an issue with a Bill of this size and complexity being published and Ministers in the devolved Administrations seeing it only the day before. That does not show respect between the Governments. That is something that I hope, as the provision is taken into regulations, will change. I do not plan to push the amendment to a vote because the Minister said that he is consulting the Scottish and Welsh Cabinet Secretaries, but it should not have come to this. Respect for devolution should have been implicit in the Bill from the start.

[Alex Norris (Nottingham North) (Lab/Co-op)]

It is a pleasure to resume with you in the Chair, Ms Elliott, and to move on to part 3. Of the various parts, it has possibly had the least impact on my mailbag, but it is important. I am a little troubled by some of the provisions and want to probe them a bit.

The Minister gave a good and characteristically cogent explanation of what is in the Bill, but not of why it is there. That explanation was much shorter, so I want to come back to that because I do not think it is clear what problem the Government are seeking to solve. Has a significant risk to the health and wellbeing of the nation been caused by the Secretary of Secretary’s inability to remove functions from one organisation to another more quickly? I do not think that is the case. The Minister made the point about a rather fractured service and the need to be able to act more swiftly. I will revisit those points shortly.

Clause 86 specifies the organisations that the Secretary of State can delegate or transfer functions to: Health Education England, the Health and Social Care Information Centre, the Health Research Authority, the Human Fertilisation and Embryology Authority, the Human Tissue Authority and NHS England. I was surprised not to see the UK Health Security Agency in that list and I hope the Minister will come back to that.

Clause 87 allows the Secretary of State to move functions between the organisations, and clause 88 provides for the Secretary of State to permit them to exercise functions on the Secretary of State’s behalf. Are we really saying that there are not decent, appropriate and effective ways to do that already? For example, the UK Health Security Agency is a relatively new body and it will take time for it to settle in and find its level. Do we really believe that there are no mechanisms to ensure that it can exercise functions on the Department’s behalf, or that there might be a public health information function currently exercised by NHS England that the agency might be better able to deliver in the future, but cannot because it is not covered by this legislation? I find that hard to believe. Are we saying that there will be an alternative route for that? I cannot understand why there would be a different way of doing that.

If that is really necessary, why is the Government’s instinct to do it by regulation? If there are problems today that perhaps the past challenging 18 months have revealed, we have got primary legislation here, so we could make whatever changes the Secretary of State wishes to make to the organisations on the face of the Bill. Obviously, that would not help with new and emerging problems, but what are they? What examples have happened recently? It feels as though we have a solution in search of a problem to solve.

Clause 87(3) basically prevents the Secretary of State from abolishing NHS England. Well, we would hope so—that seems wise—but what of the other agencies? The Health and Social Care Information Centre was formed by the Health and Social Care Act 2012; the Health Research Authority and Health Education England were created by the Care Act 2014; the Human Fertilisation and Embryology Authority was formed by its own Act in 1990; and the Human Tissue Authority was created by the Human Tissue Act 2004. Are we really saying that we need a more direct ministerial route to dissolve or amend these bodies?

We have recent precedent for this: over the course of the past couple of weeks, or certainly over the past few months, the Government have taken Public Health England apart, taking some functions for themselves and creating a new organisation with the remaining ones. They were perfectly able to do it in that case, which would seem to me to be a very drastic case. Now, we think that was a very bad thing to do—I will continue to make that argument—but what I cannot understand is why, if the Government were able to do that then, they would not pursue the same routes in the future.

I would not argue the case against clauses 88 to 91, which form the blueprint for these powers, but I would argue against the rationale for them existing at all. Amendments 68 to 72 again seek to protect the devolved settlement: as the Minister has said, clause 92 provides for devolved nations to be consulted on changes that are within their legislative competence, but I am concerned that that consultation might not go far enough. If we consider a policy area as a devolved matter, that surely requires consent. I have heard some response to that point from the Minister, but we may well hear a little bit more.

Clause 92 lists who the Secretary of State “must consult”. As well as devolved nations, it includes the organisation in question and then anyone else the Secretary of State wishes to consult. That list does not expressly include the public or experts in the relevant discipline, for example, and I do not think that is sufficient. In reality, the decision over Public Health England was a rash one, made in its early stages by individuals who are not really involved anymore. In all honesty, nobody would have made the decision that was made: it was a situation in which, despite our desperate attempts to give the Government room to do so, they never quite managed to climb down. However, talking to the public and to experts would have helped the Government make a much better decision in that case, and I am surprised not to see those groups included on the face of the Bill. I hope that we will get an assurance that at least in the Minister’s mind, “anyone else the Secretary of State wishes to consult” would involve some experts, if not the public. I very much hope it would.

To conclude, we have gone back and forth on this topic in recent days, and we cannot support the provisions in this part of the Bill. They are Executive overreach, and there are recent examples of why these powers are unnecessary, because the Government can already do these things. During the proceedings on the Bill, the Minister has frequently told us that our amendments are not necessary because they are already covered elsewhere. I am going to gently turn the tables and suggest that these powers exist elsewhere, and therefore these provisions are not necessary.

Health and Care Bill (Sixth sitting)

Debate between Philippa Whitford and Alex Norris

Committee stage
Tuesday 14th September 2021 Public Bill Committees

[Alex Norris]

I am grateful for that intervention—I am going to stop at 10. That evidence actually supports the point the I am making. When we heard that evidence, the witness said that it was automatic to them, but of course we would want someone from a mental health background and someone from a social care background. I completely agree. What I am saying is that if that is so clear and obvious, which I believe it is, why on earth would we not put it in the Bill? It was clear and obvious enough that we wanted to have someone on behalf of local authorities, and that we wanted someone on behalf of primary care. If it is clear and obvious in those cases, it is clear and obvious in these, too. That was my reasoning, and it was obviously echoed in the evidence submitted by the Royal College of Psychiatrists and the Mental Health Foundation. That is the first thing I want to say about the amendment.

The second relates to a director of public health drawn from that patch. Goodness me—as my hon. Friend the Member for Ellesmere Port and Neston said this morning, if anyone has proven themselves under fire over the last 18 months, it is our incredible DPHs. With a unique combination of knowledge, training, local insight and cross-system relationships, they have done an extraordinary job for us in pulling together our approach to the pandemic. We should be using that to pull together our approach to all sorts of big issues that we face in our local communities.

The DPHs are the human embodiment of our communities’ joint strategic needs assessment. They bring that to life, and they could bring that to the table. If we want our system leaders to go beyond their organisational concerns when they go into their integrated care board meeting, who better than the person who develops the insight into system need? The DPH is exactly the right person. They also provide an invaluable director-level connection to all the departments of the local authority that have such a profound impact on the wider determinants of health—housing, leisure and planning. What a wealth of knowledge, and what connections, they would bring to the table.

Thirdly, the amendment provides for a designated social care representative. The stated aim of the Bill is to drive integration and to foster collaboration between health and care partners. I really want that to be the case, rather than this being just a reorganisation Bill. It is a 135-clause Bill, and two of the clauses are about social care, so it is not unreasonable to say that perhaps there is an imbalance. Rather like the much-hyped social care reform and funding plan that the Government are discussing downstairs at the moment, the clauses in the Bill neither reform nor, in the main part, fund social care. Again, social care is left trailing behind. It has been battered for 11 years and, as a result, we see rationed care, dreadful terms and conditions for staff, and services that are just not fit for what they were supposed do. If the Bill really is about fostering collaboration, social care ought to be explicitly represented.

I am conscious that there is a nominated local authority representative under paragraph 7(2)(c) of schedule 2, but that person will already have quite a lot on their plate. They will have to represent the broader views of the entire local government family. Nottingham and Nottinghamshire is probably one of the simpler planning footprints in the country, but it is still 11 counties, and representing all those views at once is very difficult. It is too much—and not credible—to represent not only 11 council chief executives, but 11 directors of adult social care and children’s social care, as well as all the other functions of the local authority. A social care lead, who convenes the social care leads in the given geography, would give the ICBs the specialist knowledge and insight to create and foster the environment for a true partnership between health and care.

Fourthly and penultimately, amendment 32 would replace the staff voice through recognised trade unions. As has already been mentioned, our health and social care services are well served with amazing staff. They are our experts. They are the people who feel things on the frontline and who know, when they go, “Here we go—here’s a new initiative”, whether it is practical and rooted in real-world experience. They have that very direct experience of population health and how it is changing over time.

The staff are the ones telling us about the fractures in the health and care system that make their jobs harder—the fractures we are supposed to be dealing with. They were the ones—boy, should we have listened to them then!—who told the Government very clearly what the impact of the 2012 reforms would be on the system and about the greater fracturing of the system. They were not listened to then, but they should have been and they should be now.

Prior to coming here, I was a union organiser. I know one thing for sure: senior management always think they can speak for the staff, but I am afraid they generally cannot. That is not a criticism; their lives at work are very different. The health and care family is better served when all aspects are covered, rather than some speaking for others. If we are going to develop really significant plans at these boards, the discussion would be incredibly enriched if the voice of the frontline was there, to sense-check things, to highlight things that are working already and the workarounds that staff develop as time goes on, and to assist on planning as well. There is an awful lot they could contribute.

Finally, and crucially, let us have a representative of the patient voice. The whole reason why any of us come to this place is that we want to give communities a voice. We think that is important. The key way we do that is to listen to people. If we do not, we do not do very well for very long.

We want our communities to have brilliant health and care services, but sometimes we make it harder for them to tell us what they want. We have tremendous mechanisms for finding out. The evidence of Sir Robert Francis from Healthwatch was particularly pertinent on not just using numbers, but the wealth of qualitative information. Let us have someone who is an expert by experience and who can draw on and bring that with them, and speak for thousands of other experts by experience. We must believe that they have as much to contribute as senior leaders. Not only would they bring insight, but it would give legitimacy to decision making, which is something that we have real concerns about, as we have said on discussion on multiple groups of amendments.

Those are the extra five members we are suggesting. If anyone listening at home is keeping score, that means five members—the chair, the chief executive, the acute lead, the primary care lead and the mental health lead—who owe their employment fundamentally to the NHS, and five—the local authority lead, the DPH, the social care representative, the staff representative and the patient representative—who do not.

If the Bill is about integrating and not about a restructure and reorganisation that involves the big acutes taking on the rest of the system, that might be quite an elegant balance. Of course, local systems could seek to augment that, which would be a matter for them, but this would be a very solid foundation, which I think enriches the board. I look forward to the Minister’s response.

[Dr Whitford]

I, too, rise to support the amendment. This is probably one of the most important amendments so far. In the witness discussion, we came back time and again to which voices would be on the ICB and would be able to influence. I agree that, with all the talk of parity of esteem, it seems incredible that there would not be a voice representing the importance of mental health on the board. Similarly, with the talk of moving to population health and wellbeing, there is a need for directors of public health to agree policy and to feed in information about the underlying health inequalities, life expectancy and so on in the local population. Not to have a social care voice when what the Government say is that they are trying to integrate the NHS with social care seems quite bizarre.

The NHS and social care are both services delivered by people for people and having both the workforce and staff voice, and the patient voice, is therefore important. On the staff voice, the “Learning from Scotland’s NHS” report from the Nuffield Trust highlights that the success of both the Scottish patient safety programme and the Scottish quality improvement standards was driven by the fact that frontline staff were involved as drivers, champions and developers from the word go. These programmes have been able to run over years, building on experience that is then shared with other sectors and specialities. It is important to get this part of the Bill right, or else priority will not be given to integration, population health or wellbeing. Of all the things that have been discussed so far in Committee, and through the witness statements, this amendment is one of the most important.

Health and Care Bill (Fourth sitting)

Debate between Philippa Whitford and Alex Norris

Committee stage
Thursday 9th September 2021 Public Bill Committees

[Dr Whitford]

Q In the morning sitting we heard from Professor Marshall, who was talking about your own ICS. I asked about the problem of the power imbalance between the partnership and the board, and he mentioned that you have a primary care sub-group. We have had a lot of discussion about how we gather the voices and ensure everyone is there. What led Gloucestershire to develop that? How do you feel it is working? Do you think that is a good model? How do you ensure the board listen to what the partnership come up with?

Dame Gill Morgan: It is about multi-layering of advice. We will have a primary care sub-committee partly because managing primary care, and all the things that come through GMS and the opportunities, is expert; we do not want it to be subsumed by a generalist groups. We want it to have proper focus, because if our vision of the future is right, we need better and more engaged primary care at local level that can link its services more effectively with support in the hospital and the community. That is the objective, so we will have that.

We will also have an ICB. GPs will have different views. That is one view, which is about me as a jobbing GP. I go in in the morning, and I do my work and all of those things. I need to be supported to do that, but I also need GPs in the system who are engaged in management. We are very proud of our primary care networks, which are beginning to pull together around our localities, because we are smaller and it is not a big place.

There are models where they are working with second tier local government, where they are beginning to think about housing, and they are working with the voluntary sector, so when they are talking about frailty, it is not a GP or a hospital conversation; it is a system conversation in this place. All of a sudden there are things that can be unlocked. If we leave it in any one box, as we have always done in the past—there is a box for acute, for this and for that—we do not get this. Our task is to make those boundaries semi-permeable, with the expectation that we look at the patient flowing through all those boundaries, rather than pretending that patients sit in an individual box, because they do not.

Louise Patten: Frankly, stakeholders who are anxious about whether they have a place on the partnership board or the integrated care board need support in being helped to co-ordinate their response, so they have a collective voice. The variations for ICSs are huge, from a population of 600,000 right the way through to just upwards of 3 million. Supporting those stakeholders to have a united voice and providing assistance will be really helpful.

[Alex Norris (Nottingham North) (Lab/Co-op)]

Q Thank you both for coming this afternoon. Dame Gill or Ms Patten—it is fairer to ask the question more generally—suppose the integrated care partnership itself put forward plans for the footprint. The integrated care board, under this draft legislation, has to pay due regard to that. If you disagreed with that as a board, how would you manage that? How would that be resolved? How would that manifest locally?

Dame Gill Morgan: The first thing is that you would try to make sure that you have developed a mechanism for engagement and trust, so that you do not get into those sorts of disagreements. If you get into those disagreements while you are sat around the board, you have failed to do the task of integration and partnership. That is what happens in the conversations about how we solve it. If we ever got into that sort of difficulty, it would have to be resolved at the integrated care board, and we will have local government, public health and social care on our board as full and equal partners.

Health and Care Bill (Second sitting)

Debate between Philippa Whitford and Alex Norris

Committee stage
Tuesday 7th September 2021 Public Bill Committees

[Dr Whitford]

Q And that would apply also to things like sharing patient information of a certain type, and whether it was anonymised or pseudo-anonymised and so on? That would be a concern for you?

Eluned Morgan: Absolutely, and we are developing our own systems in relation to those things, of course. It is our patient information, and we should be deciding who has access to it and when.

[Alex Norris]

Q I thank you, Minister, and your officials for your time this afternoon. You mentioned correspondence with Ministers in the UK Government. Is that correspondence publicly available, or is it something you are willing to make publicly available?

Eluned Morgan: I am more than happy to send the correspondence that I have sent to Minister Argar to the Committee, so you can see it. It sets out all the issues that we are concerned with in relation to the Bill.