House of Lords
Thursday 20 January 2022
Prayers—read by the Lord Bishop of Birmingham.
Ukraine and Russia: Ceasefire
To ask Her Majesty’s Government what assessment they have made of (1) reports that on 21 December 2021 Jens Stoltenberg, NATO Secretary General, expressed his intention to call for a meeting of the NATO-Russia Council early in 2022, and (2) that on 22 December 2021 negotiators from the Organisation of Security and Cooperation in Europe and the governments of Ukraine and Russia agreed to restore a full ceasefire between the Ukrainian government forces and separatists in eastern Ukraine.
My Lords, the Government welcomed the 12 January NATO-Russia Council as an opportunity to discuss ways in which to build transparency and address mutual concerns. The only way forward is for Russia to de-escalate and engage in meaningful discussions. We welcome the strong determination by participants in the Trilateral Contact Group to fully adhere to the July 2020 strengthened ceasefire. We hope that this will reduce violence in eastern Ukraine and contribute to improved conditions for efforts towards de-escalating regional tensions.
My Lords, I thank the Minister for his reply. The NATO-Russia Council has met and, more generally, we have had Ministerial Statements on the diplomacy to prevent future conflict. I regret, however, that the Government continue to be studiedly silent in respect of the seven-year continuing conflict in eastern Ukraine. The agreed restoration of a full ceasefire has made little difference. Yesterday, there were 58 ceasefire violations, including four explosions. Enhanced monitoring and verification capability for the OSCE special monitoring mission and military- to-military crisis management dialogue through the OSCE Trilateral Contact Group are essential to restore, consolidate and strengthen the ceasefire, to reduce casualties and to provide, perhaps, a foundation for progress in other areas. What steps are we taking to support such objectives?
The noble Lord is quite right. The OSCE special monitoring missions are essential and the UK is one of the leading contributors to those. They report on the security situation on the ground in eastern Ukraine and obviously we continue to call on all sides to uphold the strengthened ceasefire.
My Lords, Russia is isolated and lacks any meaningful international alliances. If there has been one misstep by President Putin in recent weeks, it is probably blaming, or seeking to blame, NATO aggression. It has unified NATO members. However, NATO is not the only western alliance. There is also the informal military alliance of the Northern Group, which includes non-NATO members such as Sweden and Finland, which I see the Secretary of State for Defence has visited in recent weeks. Can my noble friend update me on what conversations there have been with those countries in trying to deter the Russian threat?
I am afraid that I cannot update my noble friend on that specific question but he is right to point out that NATO is a defensive alliance. Its purpose is to protect member states and every country that joins undertakes to uphold its principles and policies. That includes the commitment that the alliance does not seek confrontation and poses no threat to Russia, as reaffirmed at the Brussels summit.
My Lords, the Minister has said that the only way forward is for Russia to de-escalate. It may be the best way forward but is certainly not the only way forward, particularly according to President Biden. Does the Minister agree that should Russia intervene militarily in Ukraine it would not be a quarrel in a faraway country between people of whom we know nothing but something that would cast a long shadow over wider European security, that Russia responds only to strength and determination, and that the best way for us to express that is through NATO, a revivification of NATO and, in particular, a strengthening of the transatlantic links within NATO?
My Lords, what assessment have Her Majesty’s Government made of the statement by Sergey Lavrov two days ago that the OSCE used to convene parties on an equal basis but it is now simply a defender of western interests? What impact does that have on our conversations with the Russians?
My Lords, I was the first chairman of the NATO-Russia Council. I am delighted that it is now back in session and that there are now opportunities to both disagree and agree in that forum. I hope it is kept alive and that the United Kingdom does so. However, is it not a matter of some regret that this country, our country, was not involved in the original Normandy process, which led to the Minsk agreement? Is it not now time for Her Majesty’s Government to consider getting back into the Normandy process and being part of the exercise that perhaps will produce a diplomatic solution?
My Lords, what practical steps are Her Majesty’s Government taking to work with our European and NATO partners to try to persuade Russia to de-escalate? There is no point in simply saying that Russia must de-escalate. There need to be provisions to make that something that Russia sees as desirable.
The noble Baroness is quite right. We are co-ordinating with allies and partners to maximise the impact of all this. The Prime Minister spoke to the French, German, Italian and US leaders in December. In December, the G7 Foreign Ministers and the High Representative of the EU issued a joint statement calling on Russia to de-escalate. The Foreign Secretary raised concerns on the situation at the NATO Foreign Ministers’ meeting at the end of last year and at the OSCE Ministerial Council in December. She has engaged bilaterally with NATO and EU allies, including the US, Canada, Germany, Poland, Slovakia and Turkey. NATO Foreign Ministers spoke on 7 January. I am sorry that it is a long list but there is an awful lot of engagement.
My Lords, I want to pick up the last point. Last week, I made it clear that this Parliament had a clear and unified message on Ukraine and the threat from Russia. I welcome the initiatives from the Government, but can the Minister tell us a bit more about not only the diplomatic initiatives, which are vital to ensuring de-escalation, but the efforts to work in concert with our allies in terms of any sanctions that might be needed? It is important that we are prepared to act immediately with our allies, including the United States, if that is necessary.
I thank the noble Lord for his question. A Russian incursion into Ukraine would be a major strategic mistake. There should be no doubt that Russian military aggression will be met with strength, including massive economic consequences through co-ordinated—I stress that word—economic sanctions by allies and partners, targeting Russian financial transactions, assets and individuals.
Obviously, it would be inappropriate to speculate on future sanctions designations, but I refer the noble Lord back to the sanctions that were imposed in response to Russia’s actions in Crimea. The UK took action against Russia for its illegal annexation of Crimea; that was in co-ordination with our international partners. We worked closely with the EU, the US, Australia and Canada to impose costs on those facilitating Russia’s illegal annexation of Crimea and Sevastopol through sanctions. I imagine that this template will be deployed again in future.
My Lords, if the only way forward is for Russia to de-escalate but Russia will not do so, clearly other ways forward of a non-conventional kind will have to be found. Can we be assured that we are fully engaged with these and with other democracies—not just in NATO and the European zone but the powerful nations of Asia, since this is a global issue? If war were to break out, it would affect not just Europe and the West but the entire planet.
My Lords, is it not obvious that, as long as Russia maintains its position of wanting a guarantee that NATO will not allow Ukraine to join, NATO maintains its position that that is a non-starter, and their discussions are confined to those two propositions, there is no diplomatic solution? We all know, although we may not want to admit it, that there is no military solution to this problem either. That is why, as my noble friend said, it is a tragedy that we were not involved in the Normandy talks. What consideration have the Government given to other alternatives? One example is that of Austria in the 1950s, which, through negotiation, was guaranteed an independent, neutral status. There is also the position of Finland, which has had a relatively open border with Russia for many years. What consideration has been given to these other alternatives?
I thank the noble Lord for his question and defer to his extensive knowledge of defence matters. I repeat what I said earlier: NATO is very much a defensive alliance. However, we have not really talked about Ukraine in this. I note that, in a debate on Tuesday, my noble friend Lady Goldie said:
“In terms of the agreements it has reached in its own right, and legitimately so, with the international community and NATO, it has positions which should be respected.”—[Official Report, 18/1/22; col. 1617.]
Food and Farming: Supply Issues
To ask Her Majesty’s Government what assessment they have made of the supply chain issues in the food and farming sector identified by the National Farmers’ Union and the British Retail Consortium at the Food Security Summit on 14 December 2021; and what plans they have to prepare a long-term solution to these issues.
My Lords, I declare my farming interests as set out in the register. The UK’s food industry sectors operate highly resilient supply chains, as demonstrated throughout the Covid-19 response. The Government have well-established ways of working with the industry on preparedness for, and in response to, issues with the potential to cause disruption to food supply chains. Our production-to-supply ratio remains high in comparison with historical levels: we produce 60% of all the food we need. These figures have changed little over the past 20 years.
My Lords, I thank the Minister for that reply. We are facing a serious supply chain crisis, with an estimated 500,000 labour shortages and rising costs. There is a shortage of seasonal workers to pick our fruit and veg and of lorry drivers to deliver them. There is a lack of produce on supermarket shelves and a rise in imports as a result. We are seeing a mass cull of pigs because we have no butchers, while the import of pork products from the EU is rising. Does the Minister accept that short-term fixes and three-month temporary visas will not solve the labour shortage? We need a long-term plan for this. Does he also accept that we should have a target of at least 60% food self-sufficiency in the UK, and that this should be underpinned by specific support to put British farmers and businesses first?
The noble Baroness is of course right that we should not be concerned just with short-term fixes. However, if she will forgive me, I think that she is a little out of date. We have agreed, through to 2024, to allow 30,000 people to come from outside the UK into this country under the seasonal workers scheme. In addition, we have people under the EU settled status. We are also trying to encourage more domestic employment and innovation through automation. All these things will ease the pressures that existed last year—and still exist, to an extent—but the situation is better. We are not complacent and it will continue to improve.
My Lords, can the Minister tell us what action is being taken to improve the facilities available to long-distance and other delivery drivers on the motorway network? Together with the long hours that these drivers spend waiting, the lack of facilities is a main concern in the recruitment process. It is not about pay and, in some ways, it is not about quotas for foreigners to come in. The concern is about the facilities.
The noble Lord is absolutely right. We have worked with other departments, including the Department for Transport and the Home Office, in the development of our scheme to encourage more drivers, to ease the difficulties caused mainly by the pandemic but also by our withdrawal from the EU, which have resulted in a shortage of drivers. The noble Lord is right: it is the quality of their lives that we need to look at, alongside all the generous incentives that we are giving to encourage people to come here and fill this gap.
My noble friend raises an important point. Vegetable producers will always try to produce slightly more than the demand because that is better than being short of supply to the next stage of the food chain. Every year, some vegetables are ploughed in, but it has increased recently, for reasons that we are all aware of. We are very mindful of encouraging a much more stable supply chain. That is why we have increased the number of drivers and brought in a variety of different skill sets through the seasonal workers scheme. We hope that this problem will ease in the coming months.
We are taking a number of measures to tackle this pernicious greenhouse gas. It operates very differently from other greenhouse gases; it has a much more damaging short-term effect but is a short-term problem. There is enormous progress in technologies around what we feed cattle and in husbandry. We can offset the effects of methane through other measures we are taking through our environmental land management schemes.
My Lords, I speak as the chair of Feeding Britain. All the problems that noble Lords have referred to are impacting on the price of food. One measure we have is the Healthy Start vouchers, and I congratulate the Government on increasing this; it really helps poor families. However, we have just learned that the uptake is only just over 51%. What are the Government doing to extend the reach of these things? Will they consider making an opt-in scheme the de facto way of becoming a member of this important scheme which helps low-income families?
I will relay the suggestion to colleagues in the Government. The Healthy Start food vouchers scheme, which has been raised from £3.10 to £4.25, should be seen as part of a wider array of measures that we are providing to target families on lower incomes. The £500 million household support fund is another example, but the noble Baroness makes a very important point which I will relay.
My Lords, I refer to my horticultural interests. What success has the department had in negotiations with the Home Office on extending temporary worker schemes to non-edible horticultural products—for example, nursery trees, nursery products, flowers, and other such things?
This is an incredibly important part of our economy, particularly our rural economy. I am delighted that we have managed to get the addition of ornamental and other non-food-related measures as part of the seasonal worker scheme, and it is quite right that we do so. But we are reliant on the industry telling us in advance, as much as it can, about where it thinks the pressures will come from in the future. We have the ability to increase the £30,000 by another £10,000, and we want to encourage much more training in the sector.
My Lords, the national food strategy has met with criticism from ITV, which is keen to continue advertising fast, unhealthy food. Given the rise in obesity and diabetes, why are the Government not promoting local, healthily grown fruit and vegetables which can then go into the free school meals system, to both improve the health of our children and support our farmers?
My Lords, we are. We want to encourage local food chains to operate more effectively; it is of course much healthier for the environment and the quality of the food is better. We want to disrupt highly centralised food chains where we can. We also want to make sure that we are encouraging as stable a food chain system as we can, because we rely on the just-in-time measures to get food from the field to the plate.
The best pressure on supermarkets does not necessarily come from finger-wagging of the Government or measures from Ministers but from the customer. We must encourage people to shop locally; for example, if they are concerned about the effects of their diet on climate change, eating grass-fed, locally produced meat means they are probably doing more to help the environment than when buying products that have been brought from the other side of the world, under circumstances that are much below our standards in this country.
My Lords, how do the new trade deals with Australia and New Zealand help with the aims of maintaining Britain’s food production self-sufficiency level at 60% and creating an environment for farm and food businesses to thrive and compete in the coming years?
There is good news on a variety of different measures in trade deals, not least on the point of the noble Lord’s question. We are about to see the end of the ban on UK lamb being sold to the United States. Free trade is important; it benefits us all. We have incorporated into the two trade deals that the noble Lord talked about the absolute determination to protect our standards of animal welfare and environmental protection. That is the best protection that we can give to the high-quality produce that our farmers produce in this country.
Devolved Governments: Public Expenditure
My Lords, the Chief Secretary to the Treasury is responsible for the Treasury’s relationship with the devolved Administrations and last met their Finance Ministers a week ago, on 12 January. The devolved Administrations provide the Treasury with information on their spending every month to support the management of the public finances. It is for the devolved Administrations to allocate their Barnett-based funding across their devolved responsibilities. They are accountable to their respective legislatures for their decisions.
My Lords, the Minister is aware, as he says, of the billions of pounds that are transferred to the Scottish Government under what is known as the Barnett consequentials, but does he know where it is spent? The Scottish Government seem remarkably reluctant to tell the Scottish Parliament and the Scottish people how that money is spent. What does he think of the fact that, at the moment, the Scottish Government are starving Scottish local authorities of money, thereby forcing them either to put up council taxes or cut services?
My Lords, as I said in my opening Answer, the Scottish Government are accountable to their electorate and to the Treasury here for how they spend their money. They have had a very generous settlement in the SR—an additional £8.7 billion went to the devolved Administrations, of which £4.6 billion per year has gone to Scotland. I encourage the noble Lord to keep his scrutiny up.
My Lords, does my noble friend realise that there has been a series of major financial scandals in Scotland, such as two ferries for the price of five? There is a whole series of examples of complete mismanagement of public money, and there seems to be no consequence. Following on from the point made by the noble Lord, Lord Robertson, about the Barnett formula, the Scottish Government have the gall to blame Westminster for cuts in the health service where they fail to spend the Barnett consequentials on health that they have been given. There is no transparency. Surely the Treasury has a responsibility to ensure that transparency is given.
I agree with my noble friend that any wastage in government is extremely distressing, certainly to me. In October of last year, we reached an agreement with the Scottish Government to jointly commission an independent report covering the block grant adjustment arrangements. The independent report will inform a broader review of the Scottish Government’s fiscal framework later this year.
My Lords, the Scottish Government have a Minister for consular affairs. Does the Minister believe that this is consistent with the delivery of devolution? Following up on the intervention by the noble Lord, Lord Forsyth, would the Scottish Government not better serve the people of Scotland if they concentrated on protecting and delivering public services and developing a strong economy, instead of fiddling in a way that has had a disastrous effect on the economy and job losses?
My Lords, in 2005, the then Labour Government agreed to allow the Scottish Government to have international development involvement. To my knowledge, they are involved in three countries—Rwanda, Malawi and Zambia. I can only come back to my earlier point that it is for the Scottish electorate to decide whether that is a good use of public funds.
My Lords, my noble friend mentioned the discussions which are happening and the report that will come later this year. Will it be clear that there will be more transparency on how the money is spent? It is not the money going from here but how the money is spent in Scotland that is so opaque.
My Lords, the Scottish Government have a unit committed to making the case—or more correctly, preparing the case—for independence. Does the Minister think that that is a proper expenditure for the people of the United Kingdom to have to bear?
My Lords, as someone who is very against the independence movement in Scotland, I would agree. We have also to accept that an increasing amount of revenue is raised in Scotland for the Scottish Government. For example, from 2017-18 Scottish income tax rates were entirely devolved, and all revenues from Scottish income tax are retained. Likewise, in 2015, stamp duty was devolved to the Scottish Government. So there is a rising percentage that is in their own gift and I can only assume that some of that is being used for what is, in my view, a mistaken approach.
My Lords, perhaps I might take a moment to remind the House that, as well as Scotland, Wales has a devolved Government. I believe transparency there is of an order of which we could all be proud. I want to pick up on a point made yesterday by the noble Lord, Lord Forsyth, during a Question about the Barnett formula. In his opinion—and in the opinion of many of us—it needs to be looked at in a radically new way for a new age. The Answer from the Dispatch Box yesterday was, quite simply, that there was no prospect of such a review. Is the Minister today, who is refreshingly different from the Minister yesterday, of the same mind?
My Lords, I think we all know that the Barnett formula was something of a fudge, put together many years ago. It is an extremely complicated thing to try to unravel. We know that the amount of funding that goes to individual citizens is favourable to the devolved regions, but the formula is not necessarily satisfactory—so I would encourage the noble Lord to keep up his campaign to push for a review.
My Lords, given the Minister’s dislike of waste in government, could he comment on the article earlier this month by the Comptroller of the National Audit Office, Gareth Davies? He criticised the lack of any formal process for evaluating both the efficiency and delivery of cross-government projects. He said that there was very little information on
“what difference is made by the billions”
spent by government. What does the Minister think of that?
My Lords, building on that point, is not the problem that the UK Government are in no position to lecture others—whether it is the National Audit Office, influential think tanks or others? We regularly hear of cases where Ministers have exercised poor judgment when spending public funds. The most recent example was the quiet announcement that the Treasury does not intend to chase down an estimated £4.3 billion fraudulently claimed from coronavirus support schemes. Why did the Government not listen to Labour’s warning about potential fraud earlier in the pandemic, and why will family units have to pay the price for the actions of fraudsters through upcoming tax increases?
The noble Lord raises a very good point. I believe that I will be coming back on Monday to deal with an Urgent Question on this specific subject. I would remind noble Lords that these schemes were stood up at an incredibly fast pace to protect the productive capacity of this country. Yes, the fraud losses are extremely frustrating but, if we had not got that money to the business community as quickly as we did, we would have seen a lot more damage to our economy.
My noble and learned friend is right that we need to remind Scottish citizens that a great deal of the funding that goes into Scotland comes from here. We now have a Minister for the Union, Michael Gove, and his job is to keep reminding all the devolved Administrations that we are one union. A very senior civil servant, Sue Gray—of whom some of you may have heard—is the Permanent Secretary for the Union, and we are encouraging engagement at, for example, local authority level on a much more frequent basis.
My Lords, we are talking about the spending of government money, and I congratulate the Government on the fact that, on 26 December 2021, although it did not get a lot of press, they decided to spend £360 million—for which I and others had been asking—on homeless prevention grants, so that people were not put out because they had lost their job due to Covid-19.
To ask Her Majesty’s Government what assessment they have made of the potential negative impacts of their decision to permit the use of the pesticide thiamethoxam for sugar beet cultivation on (1) bee health, and (2) the spread of antimicrobial resistance; and what steps they will take to mitigate the concerns raised by their scientific advisors about the use of this pesticide.
My Lords, the Government have given emergency authorisation for the use of thiamethoxam in 2022 to protect sugar beet from viruses. The environmental assessment identified potential risks to bees and the authorisation imposes strict restrictions to minimise these risks. In particular, the pesticide will be used only if, according to independent modelling, the predicted level of virus is at or above 19% of the national crop. No flowering crop may be planted within 32 months of sugar beet having been treated.
My Lords, I thank the Minister for his Answer. I have no doubt that other Peers will address the absolutely crucial issue of bees. This relates also to our second Question on food security.
In the light of the Lancet article yesterday which showed that, in 2019, 1.3 million people around the world died as a result of antimicrobial resistance, I will focus on the second part of my Question. It is, perhaps, the first time this has been mentioned in the House. Increasing numbers of studies, and increasing understanding, show that cross-resistance can develop. Bacteria exposed to pesticides can end up being resistant to drugs they have never even experienced. Will the Minister commit to going back to his department and speaking to officials to ensure that sufficient account is being taken of this when all pesticides are considered?
I, my department and others mind desperately about antimicrobial resistance. When I saw the wording of the Question, I looked into the matter in some detail. The neonicotinoid we are talking about is an insecticide that is not found to be causally related to antimicrobial resistance. I will look at the Lancet article about which the noble Baroness spoke and I will take her points back. The Government take AMR extremely seriously and we are coming forward with a number of different ideas to tackle this problem.
Excellent work is being done and I do not think we will be having this conversation in future years. I very much hope we will not. Enormous amounts are being done through integrated pest management. There is a variety of different breeding techniques and husbandry for sugar beet. So I very much hope that there will be no need for derogations in future.
The Government have a pollinator strategy and work closely with the bee sector to make sure that our policies reflect the needs of pollinators right across the piece. The sustainable farming incentive, the key part of our ELMS announcement, has an integrated pest management part. These are the sorts of policy products that have come out of work that we are doing to enhance bee health across the country.
My Lords, does the Minister accept that this policy is making a mockery of the promise in the Environment Act to replace the use of toxic pesticides with integrated pest management techniques and low-toxicity solutions? How does the decision comply with the current need under law for pesticide products to have no unacceptable effects on the environment, when this clearly does?
I do not take that view, because we have massively increased the condition that we have applied this year. Last year, the derogation was not used because it did not reach of the already high 9%; we have raised that to 19% this year. There is a wider factor. If there is a catastrophic loss of yield, that sugar will have to come from other countries. Spain, France, Belgium and other EU countries have derogations with very few of the conditions that we have applied. We could damage our sugar infrastructure in this country—the factories that we need to produce sugar for our own population—and export the problem to countries that do not have our conditions and our determination to move towards integrated pest management.
My Lords, Countryside Online tells us that the sugar beet industry supports 9,500 jobs, produces half of the UK’s sugar and is environmentally friendly because of the low number of miles beet travels from farm to processing plant to consumer. Mr Gove supported a total ban on neonicotinoids when he was Environment Secretary because they harm populations of bees and other pollinators. By allowing their use now, why are the Government breaking their promise to maintain high environmental standards?
My Lords, we are not. We are in exceptional circumstances, responding to an exceptional problem. We are imposing very high standards. I repeat that no flowering crop may be planted on land where this seed dressing is used within 32 months of treated sugar beet. There is a minimal effect on pollinators because sugar beet is not harvested after it has flowered. The other conditions that we have applied might well mean that it will not be used this year.
My Lords, my noble friend is absolutely right. The key thing is getting the balance between risk and benefit right. Can he confirm that this will be taken on sound scientific grounds and not on emotional grounds? The decision obviously has to be taken at the last possible moment. Does he foresee any logistical problems, as raised in the second Question today, with getting the chemical to the seed producers in time so that the decision can be made at the last possible moment?
I have not heard of any logistical problems. If the weather continues to be cold, it is unlikely that the threshold will be reached and that this will be required at all. If there is a large increase in aphids, which are the vector of this yellows virus disease, measures are already in place, but there is a very good chance that it will not be required to be used at all.
We provide advice to beekeepers and work with trade bodies and organisations across the country, whether urban or rural. I take this opportunity to applaud the work of the London Pollinator Project, which, as the noble Baroness identified, is of enormous benefit to pollinators in urban areas. It is not just urban gardens; it can be in quite highly built-up urban areas.
The noble Lord is absolutely right. A lot of work is being done in organisations across the country—Rothamsted has been mentioned, but also the Roslin Institute and others in Scotland and England—where we are seeing the possibility of great advances, not through GMOs but through using and perhaps accelerating existing plant breeding techniques that will make these kinds of conversations seem very out of date.
My Lords, in answer to my noble friend Lady Whitaker, the noble Lord talked about the benefits of urban gardens for pollinators. Of course, he is absolutely right. One of the reasons why pollinators are very well served by urban gardens is that there is the great diversity of plant life there compared with, say, mass agricultural areas. However, there is a problem with people concreting over urban garden space. Could he say what the Government are doing in conjunction with local authorities to discourage this practice? It is a problem not only for pollinators but for flood management.
The noble Baroness’s last point is the one where the Government can be most effective, particularly with building regulations and planning policy. It is hard to say to a householder, “You cannot get rid of a 10 by 10 lawn outside your house”, but we can design in green infrastructure. An enormous amount of work is going on across government to try to make sure that we are greening our planning policies and urban infrastructure to address precisely the point that she raises.
Building Safety Bill
The Bill was brought from the Commons, read a first time and ordered to be printed.
Migrant Crossings: Role of the Military
Commons Urgent Question
The following Answer to an Urgent Question was given in the House of Commons on Tuesday 18 January.
“Unacceptable numbers of people continue to make these dangerous channel crossings, and last November’s tragic deaths serve as the strongest reminder of the need to stop them. The Government have been exploring every avenue to prevent further crossings and have now appointed the Ministry of Defence to take operational primacy for cross-channel countermigration operations. That will mean a much larger and more visible role for the Royal Navy in operational planning, asset co-ordination and operational delivery.
As the Home Secretary explained during Home Office Questions yesterday, the Home Office and the Ministry of Defence have worked closely on countering the small boats challenge through the military aid to civilian authorities process. Throughout the last 12 months Defence has provided a range of support, including the provision of surveillance aircraft, additional accommodation and planning expertise, and has assisted in the delivery of trials for novel tactics to help Border Force and the Home Office better interdict and deter migrant vessels.
Details of how Defence will deliver and maintain the primacy of cross-channel countermigration operations are currently being worked through. The Government’s objective is that no one should arrive illegally in the United Kingdom on their own terms, and all vessels transporting illegal migrants across the channel must therefore be intercepted before or as they land. Defence is committed to delivering that step change. Details of how it will be achieved will be made known in due course, but the House can be reassured that the MoD is working hand in hand with the Home Secretary and her department to achieve this goal while ensuring the safety of all individuals involved and protecting other Defence priority output.”
My Lords, following the failure of the Government to deal with record numbers of migrants crossing the channel and, rightly, the abandonment of policies such as wave machines and sonic booms, the Navy has been called in. What is the plan? Where are the ships that the Navy will use coming from? Can the Minister also clarify whether the awful policy of pushback is still government policy? The Minister in the other place said only on Monday that pushback remains an option, as has the Home Secretary, but the MoD apparently says that it is not. Who is in control? What is the policy? Although a naval ship might not be used, what about a Border Force vessel? This is a real crisis involving real people, with only a confused policy coming from the Government. It is time that they got a grip.
I am very proud to stand at this Dispatch Box once again on behalf of the MoD to say that, once again, the MoD is going to contribute to dealing with a crisis that has perplexed not just the Government and the Opposition but the public: the danger being encountered by migrants who seek to come to this country and have been enduring appalling experiences while trying to cross the channel. That is why the MoD’s primary role will be to ensure that all vessels transporting illegal migrants across the channel are intercepted before or as they land, preventing the uncontrolled arrival of migrants on UK shores. The Armed Forces will not be engaged in turnaround tactics.
My Lords, the Minister was asked if she could say where the ships were coming from. Could she answer that question and say whether the MoD will be funding this new activity or whether the Home Office will pick up the tab, and whether there are not also diplomatic routes to try to ensure that, instead of stopping boats landing, the boats never leave the departing shores?
The noble Baroness makes an important series of points. She is right, for example, that the Home Office and the FCDO will continue the primary discussion with France on the diplomatic front. I reassure her that Defence has a very strong relationship with France, and we regularly speak to our counterparts on matters of mutual interest. Funding will be required for this, and the Ministry of Defence is currently computing costs with a view to informing discussions with the Treasury. On the assets, we are dealing with a domestic situation in largely indigenous waters, and therefore the capabilities that Defence makes available for this task will be assets already permanently assigned and committed to operations in home waters, including offshore patrol vessels, P2000s and RHIBs.
My Lords, it is very unlikely that the migration effort by people wanting to come to this country will cease. I must therefore ask the Minister how long the Ministry of Defence expects to be committed to this task. Is it indefinite or for a set period?
I say to the noble and gallant Lord that the overall responsibility for dealing with immigration is cross-government. In so far as the MoD’s operational role is concerned, it will retain primacy of operational control until public confidence is restored and the number of individuals attempting to enter the UK through this route is brought under manageable levels.
Forgive me, my Lords, I am not clear from my noble friend’s Answer as to whether or not this task will be subject to MACA rules. If it is, can she reassure me that for once the MoD will remember to send the bill, as it does not always do so? Could she clarify exactly where this task sits in the order of priority of defence tasks?
I reassure my noble friend that a keen eye will be kept on funding. As I said to the noble Baroness, Lady Smith, the MoD is currently computing costs to inform discussions with the Treasury—and, yes, we will certainly make sure that bills presented are paid. We are satisfied that this deployment does not in any way impinge on or prejudice our ability to carry out our broader MoD responsibilities on behalf of the nation.
My Lords, the Answer suggests to me that the Government have not thought this through. It makes all sorts of vague comments like
“are currently being worked through”
“will be made known in due course”.
Has this even been discussed with the French authorities? Without co-operation with the French, we are not going to get anywhere. Lastly, the Answer keeps talking about “illegal” people. If they are refugees or claiming to be so then they are not illegal; they are people who have an entitlement to claim asylum status.
I thank the noble Lord. I have endeavoured to refer to them as “migrants” because that is what they are. The MoD’s role is to assist the Government’s broader objectives in approaching immigration policy by dealing with this particular aspect in the channel, which has caused such concern and has been such a source of heart-breaking tragedy and worry to the migrants themselves. The noble Lord asked whether this plan had been thought through. Obviously, the detail has to be worked out but it is very positive that the MoD is gladly taking on this role, and Defence Ministers have committed to providing a Statement to both Houses once the plans for implementing defence primacy have been thoroughly worked through and refined.
My Lords, has the Minister had a chance to look at the implications for her department’s actions under UNCLOS, the law of the sea, and will she assure us that we will always conform to it? Will she return to the debate that was held in your Lordships’ House two weeks ago today on behalf of Cross-Bench Peers that drew attention to the over 80 million refugees and displaced people in the world today, and to the calls from throughout the House to look not just at the pull factors but at the push factors and to co-ordinate cross-department activity and international activity in getting to the root cause?
I reassure the noble Lord that, whatever the MoD does in its primacy of operational control, discharge of that duty will absolutely be done in compliance with international laws and the United Nations Convention on the Law of the Sea. The noble Lord is quite right that there is a much broader picture here that is shared by countries across the world, and he is correct to identify it as a need to be addressed in the hope that we can stop migrants setting off on perilous journeys in the first place.
My Lords, I can understand the impact on Daily Mail readers of the news that the Navy has taken charge, but I am not sure how many refugees seeking asylum in the UK read the Daily Mail. So what practical difference will we see—or, more importantly, will they see—in deterring refugees from crossing the channel in small boats?
The involvement of the Navy is primarily to ensure that the dangers that have confronted migrants setting out on this hazardous course can be assuaged or even prevented from arising altogether. That is why the modus operandi will be one of interception and escort; the Navy will be responsible for bringing migrants to UK shores in a safe and controlled manner. That will prevent uncontrolled or undocumented arrivals.
My Lords, Tobias Ellwood, the well-respected chair of the Defence Committee in the other place, has called these proposals “rushed” and a “massive distraction” for the military, but of course it is a massive distraction for the electorate as well. Does the Minister understand the fear that proposals to deploy the military against desperate refugees causes in refugee and migrant communities who are already here? This smacks not of the dog whistle but of the foghorn.
My Lords, just before Christmas the French Government closed their borders to British citizens, seeming to be able to do so legally. Can the Minister explain to the British public how they can do that, yet we seem not to be able to stop migrants illegally coming into our country?
As I said earlier, the broader issues of immigration policy are a matter for the Home Office and the FCDO, and the issues that the noble Baroness mentions are something that they are actively pursuing. The role of the MoD in respect of this immediate requirement, which I think is a positive participation and involvement, is to try to ensure that migrants who set out on these hazardous journeys are supported to safety in a controlled manner.
Commercial Rent (Coronavirus) Bill
Motion to Refer to Grand Committee
The following Statement was made in the House of Commons on Wednesday 19 January.
“Within hours of learning from scientists in South Africa about the emergence of a new Covid variant last November, this Government acted to introduce balanced and proportionate restrictions at our borders to slow the seeding of omicron in our country. As we learned more about this highly transmissible new variant, we implemented the plan B measures that we had prepared precisely in case our situation deteriorated, encouraging people to change their behaviour to slow the spread of the virus and buying crucial time to get boosters into arms.
We made the big call to refocus our National Health Service, necessarily requiring the difficult postponement of many other appointments, so that we could double the speed of the booster programme. Thanks to the extraordinary efforts of our NHS and its volunteers, we delivered the fastest booster programme in Europe, reaching half our population before any other European country. There are more than 36 million boosters now in arms across the UK, including more than 90% of all over-60s in England.
Taking a balanced approach, we resisted calls from others to shut down our country all over again. Many nations across Europe have endured further winter lockdowns, and many have seen hospitality curfews and nightclubs closed, capacity limits at sports stadiums, the return of social distancing and, in some places, Christmas and new year as good as cancelled. But this Government took a different path. We kept England open and we supported those businesses that faced reduced demand because of the response to plan B measures. Although we must continue to remain cautious, the data are showing that, time and again, this Government got the toughest decisions right.
Today’s latest Office for National Statistics data show clearly that infection levels are falling in England and, although there are some places where cases are likely to continue rising, including in primary schools, our scientists believe it is likely that the omicron wave has now peaked nationally. There remain, of course, significant pressures on the NHS across our country, especially in the north-east and north-west, but hospital admissions, which were doubling every nine days just two weeks ago, have now stabilised, with admissions in London even falling, and the number of people in intensive care not only remains low but is actually falling.
This morning the Cabinet concluded that because of the extraordinary booster campaign, together with the way the public have responded to the plan B measures, we can return to plan A in England and allow plan B regulations to expire. As a result, from the start of Thursday next week, mandatory certification will end. Organisations can of course choose to use the NHS Covid Pass voluntarily, but we will end the compulsory use of Covid status certification in England.
From now on, the Government are no longer asking people to work from home. People should now speak to their employer about arrangements for returning to the office. Having looked at the data carefully, the Cabinet concluded that once regulations lapse, the Government will no longer mandate the wearing of face masks anywhere. From tomorrow, we will no longer require face masks in classrooms, and the Department for Education will shortly remove national guidance on their use in communal areas.
In the country at large, we will continue to suggest the use of face coverings in enclosed or crowded spaces, particularly where people come into contact with people they do not usually meet, but we will trust the judgment of the British people and no longer criminalise anyone who chooses not to wear one. The Government will also ease restrictions further on visits to care homes, and my right honourable friend the Secretary of State for Health and Social Care will set out plans in the coming days.
As we return to plan A, the House will know that some measures remain, including those on self-isolation. In particular, it is still a legal requirement for those who have tested positive for Covid to self-isolate. On Monday, we reduced the isolation period to five full days with two negative tests, and there will soon come a time when we can remove the legal requirement to self-isolate altogether—just as we do not place legal obligations on people to isolate if they have flu. As Covid becomes endemic, we will need to replace legal requirements with advice and guidance urging people with the virus to be careful and considerate of others.
The self-isolation regulations expire on 24 March, at which point I very much expect not to renew them. Indeed, were the data to allow, I would like to seek a vote in this House to bring that date forward. In advance of that, we will set out our long-term strategy for living with Covid-19, explaining how we hope and intend to protect our liberty and avoid restrictions in future by relying instead on medical advances, especially the vaccines which have already saved so many lives.
But to make that possible, we must all remain cautious during these last weeks of winter. When there are still over 16,000 people in hospital in England alone, the pandemic is not over—and make no mistake, omicron is not a mild disease for everyone, especially if you are not vaccinated. Just look at the numbers in intensive care in other countries where vaccination rates are far lower. Indeed, from our NHS data, we know that around 90% of people in intensive care are not boosted. So I urge Members across the House to do everything possible to encourage any remaining constituents who have not done so to get boosted now. For the next few weeks, I encourage everyone across the country to continue with the behaviours that we know help to keep everybody safe—washing hands, letting fresh air in, getting tested and self-isolating if positive, and, as I say, thinking about wearing a face covering in crowded and enclosed settings.
Omicron tested us, just as alpha and delta did before, but let us remember some of what we have achieved. We were the first nation in the world to administer a vaccine. We were the fastest in Europe to roll it out, because, outside the European Medicines Agency, this Government made the big call to pursue our own British procurement strategy rather than opting back into the EU scheme, as some people urged. We created a world-beating testing programme, the largest in Europe, and procured the most antivirals of any country in Europe too, because this Government made the big call to invest early in lateral flow tests and in cutting-edge drugs to protect the most vulnerable. We have delivered the fastest booster campaign in Europe, and we are the first to emerge from the omicron wave, because the Government made the big call to focus on our NHS and to refocus our activity by leading the Get Boosted Now campaign.
That is why we have retained the most open economy and society anywhere across the European continent, and the fastest-growing economy in the G7—because we made that tough decision to open up last summer when others said that we should not, and to keep things open in the winter when others wanted them shut. This week the World Health Organization said that while the global situation remains challenging, the United Kingdom can start to see the
“light at the end of the tunnel”.
That is no accident of history. Confronted by the nation’s biggest challenge since the Second World War and the worst pandemic since 1918, any Government would get some things wrong, but this Government got the big things right. I commend this Statement to the House.”
My Lords, this pandemic has taken a huge toll on the physical and mental health of the nation, on businesses, on leisure and on our economy. Across the UK, people have made heroic efforts to care for, serve and protect others, from the staff and volunteers who have delivered an amazing vaccination programme to the NHS and to those who have kept schools, shops, hospitality and public services running, as well as all those who have stayed at home—and have not had parties—in order to protect others, and have missed out on special times with friends and family.
So we are all keen to get back to living and working as normal as quickly as possible. We welcome the overall fall in cases, hospitalisations and the death rate. This follows the success of the vaccine and the care that so many have taken in testing and in following the rules.
Yesterday, the Prime Minister announced that plan B measures will lapse throughout the UK. We do not want to see restrictions in place any longer than necessary. In response to a question yesterday from Keir Starmer, Mr Johnson agreed that he would publish the scientific evidence behind the decision. Can the noble Baroness today confirm that this has now been published and is publicly available and will she commit to ensuring that it is available in the Library of the House of Lords as soon as possible? I think she will understand, given the recent scandalous events in Downing Street with varying accounts from the Prime Minister, that public confidence can now be assured only when back-up evidence is available.
Although there are fewer cases and deaths across the country than there were last week and scientists are optimistic that omicron has peaked, does the noble Baroness accept that we still need to be cautious? In some parts of the country, cases are still rising though we hope they will start to fall. The health service, underresourced even before the pandemic, is facing enormous pressures with huge delays. Many appointments for surgery and treatment have been cancelled. The WHO and many scientists predict that there may be further variants into the summer and daily deaths are still over 350. The British Medical Association, representing those in the NHS front line, is concerned that given these factors the Prime Minister
“risks creating a false sense of security”.
I would be grateful if the noble Baroness could respond to this: what advice is now available for those shielding or people who are clinically more vulnerable regarding the move from plan B back to plan A, including on working from home and using public transport?
What is clear with all these factors is that we need a credible plan on how we can live with Covid, including any new variants that may emerge. The Government have to look past the current maelstrom they are experiencing and the focus must be on resilience to any future pandemics or future variants.
I do not know what the Government’s plan is—I hope the noble Baroness does—but we can offer some advice on the way forward that I hope she can respond to. The vaccination programme has proved its worth. We would retain an army of trained volunteers to always be available to support the National Health Service. We also have to work with other countries and international organisations to provide vaccines across the world, if we are to end the cycle of another new variant emerging just as we think we have dealt with the last one.
We know testing works. There has to be a national supply of test kits to avoid shortages so tests can be available when and where they are needed. Ideally, it would be good if the Government could look at the UK manufacturers, which are so keen to provide these.
I do not know how many times we have to say this, but the Government really must increase sick pay and extend it to all workers. It should never be a choice between keeping others safe by staying home or being able to pay the rent and the energy bills.
We cannot just keep talking about ventilation in classrooms, or indeed workplaces. I know the schools’ ventilation programme has eventually started—and that is welcome—but the Government have to move more quickly to ensure that all children can stay in school. Can the noble Baroness say when this programme will be completed and what percentage of classrooms or schools have now been included and seen their ventilation improved?
There are also a number of common-sense measures that, while not ideal or enjoyable, do not impinge too much on our daily lives—such as mask wearing in busy crowded spaces and basic hygiene measures to protect from infection transmission—that we should not be too quick to discard. Will the Government continue with public health messaging to enable this?
Finally, the death toll in the UK from this virus is devastating. It is over 150,000, which is one of the worst rates in the world. Despite the shocking errors in test and trace, the lack of NHS readiness at the start of the pandemic, and the problems that we saw with PPE supplies and contracts—which may be subject to ongoing legal proceedings—the vaccination programme and the adherence of the public, though not Downing Street, to public safety measures have been real game changers. Those two things—the public’s response and having a vaccine—have really made a difference.
At this point all our decisions must be based on moving forward with care, using sensible proportionate measures to learn to live with Covid. We need to do all we can to ensure that we do not again end up playing Covid hokey-cokey in lifting and then reimposing restrictions that none of us wants to see. I would be grateful if the noble Baroness can address some of these points. The key thing is that we welcome this but urge caution as well.
My Lords, we obviously share the relief being felt across the whole country that the peak of the omicron wave seems now to have passed. However, Covid is not over. Yesterday, the ONS reported that one in 20 people in England caught Covid last week and government-reported cases still number over 100,000. The NHS remains pressured, with around 2,000 admissions per day, and last week there were 1,900 deaths.
We clearly need to learn to live with Covid, but that is not necessarily the same as going back to life exactly as it was before Covid. We need to remember that continuing levels of Covid, even at reduced numbers, will continue to fill some hospital beds. This delays treatment of everybody else, which is particularly significant given the 6 million people on the NHS waiting list.
This is the backdrop against which we have to judge yesterday’s announcement. The exact timing clearly has more to do with Conservative Party management and saving the Prime Minister’s premiership than concerns about public health or boosting the economy. While ending some of the restrictions, such as Covid passports, is to be welcomed, we have some reservations elsewhere, particularly on masks.
As everybody knows, masks are a cost-effective precaution that help reduce transmission of the virus and consequently reduce the pressure on the NHS and its staff. People have been asked to make tough sacrifices throughout the pandemic but, in our view, requiring people to wear a mask on public transport and in the shops a little longer to protect others is a small price worth paying. There are many, especially the clinically extremely vulnerable, who are concerned about travelling on crowded public transport or using the shops. Keeping masks in those crowded places will allow them to get on with their day-to-day lives with confidence in a way that they have not been able to do for virtually two years.
The Prime Minister said that
“we will trust the judgment of the British people”
on whether to wear masks. Given his own complete lack of judgment and moral authority, I suspect the consequence will be that mask wearing on the Tube and on trains will collapse. Before the latest restrictions, mask wearing on the Tube was under 50%. Today it is about 90%. Next week, I bet it will be back to 50% or less. In our view, to have permitted this at this point is a mistake.
As for masks in schools, we all want to keep schools open but with huge numbers of pupils still out of school, it remains hard to do so in some cases. As long as the evidence shows that masks are helping reduce these absences, we support heads who want to retain masks in their schools. If individual heads decide to do this beyond the end of this week, will the Government support them?
The real issue in schools is, of course, the Government’s failure to provide air purifiers in classrooms. I echo the noble Baroness’s question: how far have the Government got in their admittedly inadequate plans to improve the number of classrooms that have such air purifiers?
On ending the requirement to work from home, while going back to the office will be good and right for many, we would encourage employers to consider the wishes of their employees—as many of them are already doing. Can the noble Baroness say what policy the Government are adopting towards their own employees? Will they require all civil servants to return to their former work patterns or will they, like many private sector employers, show more flexibility?
More generally, this Statement—which unfortunately we did not have the benefit of hearing—is suffused with the kind of hyperbole and exceptionalism that we have come to expect from this Prime Minister. Given his abject failure to stick to the rules himself or to ensure that his own staff behave responsibly, to many ears this tone sounds more than usually ill-judged. It is too much to expect sincere humility from this Prime Minister. He should go.
I thank the noble Lord and the noble Baroness for their comments on the positive news in this Statement that we have been able to move forward. I will attempt to address some of their questions.
I will ensure that the scientific evidence is placed in the Library. I am afraid I am not sure whether it has been published yet; it was said that this would happen this week, but I will check and make sure that it is available for noble Lords. I can say that we considered a range of data in making this decision, including data on infections, the effectiveness of vaccination, Covid pressures on the NHS, workforce absences, public behaviours and international comparisons, alongside the views from the scientific community. As the noble Baroness rightly said, the data is showing that Covid cases are falling and that the high levels of vaccination and booster uptake have helped reduce the risk of severe disease and hospitalisation, which, in turn, has helped reduce the pressure.
However, I completely accept what the noble Baroness and the noble Lord said and we continue to urge caution, because there are still around 1,600 Covid patients in England. They are both absolutely right: while we are very pleased to have been able to take this step forward, we all have to be cautious. I think we can all accept that the British people have shown that they can make judgments about what they are doing and how they can feel safe, and will continue to do so. It is thanks to their willingness to get vaccinated and the way they have thought of others as much as themselves that we have been able to get to this position. I would also say that hospital admissions have stabilised and the number of patients in ICU is falling, so the data is showing that we are moving in the right direction.
The noble Baroness asked about advice for people who have previously been shielding. There is now no specific advice and, as the noble Lord said, people will need to make their own judgments about how they feel and what they want to do.
The noble Lord asked about public transport. Operators of public transport can still require passengers to wear face coverings as a condition of carriage. I might be wrong, but I thought the Mayor of London, for instance, said that about the Tube yesterday, notwithstanding some of his comments. That option is still available; I believe the mayor has introduced it and obviously he did previously.
Masks will no longer be required, but the guidance suggests that individuals continue to wear a face covering in crowded and enclosed spaces where they may come into contact with people they do not usually meet. Again, it will be up to individual businesses and organisations whether they wish to ask their customers to wear face coverings. We think that, as we move towards an endemic scenario—we hope that this is becoming endemic, rather than a pandemic—we need to move towards guidance rather than mandated rules.
The noble Baroness rightly asked about our international efforts. She will know that we have been a world leader in ensuring that developing countries can access vaccines. Last month, we pledged £105 million of emergency aid to help support vulnerable countries and we met our goal of sharing 30 million doses by the end of last year. That benefited over 30 countries as part of our G7 pledge to donate 100 million doses by June.
In relation to support for individuals, we have committed over £344 million to ensure there are no financial barriers to isolating in England. The noble Baroness asked about statutory sick pay. We have made Covid-related statutory sick pay payable from day 1, meaning that it can be up to 75% more generous for full-time employees who need to self-isolate. We have also reintroduced the statutory sick pay rebate scheme which reimburses eligible businesses for the cost of statutory sick pay for Covid-related absences. Sick pay is one part of the support available, but people may also be eligible for the £500 support payment as well.
Both the noble Lord and the noble Baroness asked about schools. We have removed the requirement for face masks in the classroom, but directors of public health will be able to propose temporary recommendations for face coverings in communal areas across their area, or parts of it, in the event of a Covid outbreak and if the public health situation justifies it. On ventilation in schools, I can say that over 350,000 CO2 monitors have been rolled out across the school estate and the country to help in identifying poorly ventilated areas, backed by a £25 million investment. I am happy to say—I hope this provides some reassurance—that feedback following this shows that, in most settings, existing ventilation measures were sufficient. For the cases where maintaining good ventilation is not possible, 8,000 air-cleaning units are being rolled out across schools. That figure has gone up quite significantly and I am sure it will continue to do so if needed.
The noble Lord also asked about working from home. It will be up to departments to decide their own arrangements with their staff, but we are encouraging people to return to the office as a cross-government message, not least because I think quite a lot of people would like to come back and see friends and colleagues who they perhaps have not seen for a very long time.
My Lords, the Leader of the House just said that there is no advice for people who were formerly shielding, the clinically extremely vulnerable, but there is; the noble Lord, Lord Kamall, confirmed this to me last night. It says that this group should still consider meeting people only 14 days after they have been fully vaccinated, social distancing, asking friends and family to have rapid lateral flow antigen tests, asking any visitors to their homes to wear face coverings and not going into enclosed crowded spaces. Putting this guidance on a website is not the same as telling this group of people, or the wider public, especially their employers, directly that this group still need to take care. Will the Leader take this back and ensure that communications go to this vulnerable group of just under 4 million people?
My Lords, there does not seem to be anything about future plans for boosters. We all acknowledge that the vaccination campaign has been a triumph, but we still do not know for how long the vaccine is efficacious. Are there plans for booster doses to be given annually or at other intervals?
My noble friend puts his finger on it when he says that at this stage we do not know. However, I can reassure him that this will continue to be monitored. If it becomes necessary to deliver further boosters, we will of course do so. We will also need to be alive to the potential for different variants, which may involve other actions. I can assure him that we now have a wealth of evidence and experience and know, as in this very announcement today, how important vaccines and boosters are. That will certainly be at the forefront of our mind as we continue moving forward.
My Lords, I thank the noble Baroness for her update. I believe that NHS staff who have not received two doses of the vaccine face dismissal from 1 April onwards. It is estimated that this will result in London losing something like 12.5% of its midwives, putting at risk the lives of pregnant women and their babies. Such a loss of staff may be thought to be justified were it not for the case that two doses of the vaccine are not understood to protect against the omicron variant of Covid-19. We shall lose precious midwives to implement a policy that has been superseded by the evolution of the virus. Will Her Majesty’s Government put the implementation of existing legislation on hold, given that it may now lead only to harm and not the good that it was designed to promote?
I am sure the right reverend Prelate would also accept that unvaccinated healthcare workers increase the risk to themselves, their colleagues and the very vulnerable people in their care. It is our responsibility to help give everyone the best possible protection. I can say that the vast majority of NHS staff have been vaccinated: nine in 10 have already had their second jabs. The NHS will continue to support and encourage staff who have not yet been vaccinated to take up the offer. Since we first consulted on this proposal, the proportion of NHS trust healthcare workers who have been vaccinated with a first dose has increased from 92% to 94%, an increase of 75,000.
My Lords, in the period since the pandemic began, we have learned that the protections we have all been routinely using, such as the wearing of masks, handwashing and so forth, protect not only against Covid but against a number of other common infections which themselves have an impact on workforces and absentee rates, and therefore economic outcomes. I want to take the Minister back to my noble friend Lady Smith’s point about public messaging. Rather than encourage people to see this as a moment of freedom from restrictions, is it the Government’s intention to remind them that, in certain respects—which as the noble Lord, Lord Newby, said, are not particularly onerous—if they continue to observe certain precautions, they will be protecting not only against Covid but against other diseases and infections that cause pressure on the NHS?
I entirely agree with the noble Baroness. We will of course continue to do that and make sure we are getting the message out. As she rightly says, people can wash their hands and have better ventilation. We will absolutely continue to pass those messages on, nationally and, I am sure, within schools and other settings and in individual businesses. We are all used to the signs now, as we go around various places, and I am sure that will continue.
My Lords, the Health Secretary claimed in the media this morning that the Government are actively considering removing the mandatory isolation period at some point in the near future. Presumably, if that goes ahead, it will place greater responsibility on lateral flow testing to show that you are negative, and so that would be an even more difficult moment to introduce charges for those tests, as the Government are also apparently considering.
The noble Lord is right. As he says, the self-isolation regulations expire on 24 March. In the other place, the Prime Minister said yesterday that he expects them not to be renewed. Obviously, a final decision will be made nearer the time, but that is the intention. We will continue to provide free lateral flow tests for as long as is necessary. As the noble Lord rightly said, testing has been one of our most important lines of defence, and we continue to issue record numbers. At a later stage in our response, free tests will end, but there will have to be a balance; it is not something that will be happening imminently. We completely understand the value of lateral flow tests—all of us have seen it—but, as I said, as we start to move towards treating this as an endemic, things will need to change. That is something we will have to consider further down the line.
My Lords, ventilation remains a distinct problem in very many schools up and down the country. So concerned have some teacher friends of mine been that they have bought their own air purifiers, given that the Government have not filled the gap. The Minister said that 8,000 cleaning units will be rolled out—that seems to me to be an extremely small number—but can she also say over what period these will be rolled out?
They are being rolled out currently and will continue to be so. As I said in response to a previous question, 350,000 CO2 monitors have been rolled out. Notwithstanding the comments the noble Baroness made, feedback has shown that, in most settings, existing ventilation measures are sufficient.
My Lords, if we accept that we are going to be living with this virus for many years to come, we have to start being proactive rather than reactive. Ventilation affects more than schools; it affects public buildings and business buildings, where many people congregate. What is the Government’s view on changing building regulations, so that new builds start to deal with the endemic, rather than cause problems by not keeping people safe, and so help the economy to keep going?
My Lords, I thank the noble Baroness the Leader of the House for repeating the Statement. Could she confirm that we will still continue with the vaccination of 12 to 15 year-olds? The JCVI recommends that the over-5s are also vaccinated. Now that the MHRA has approved the drug Paxlovid, which has been found to be highly effective in trials at reducing serious illness by 89%, do the Government have plans to purchase such drugs for those who might catch Covid in future?
As the noble Lord will be aware, we have already purchased more antivirals than anywhere else in Europe, so we are on the front foot on this and will continue to be so. As new drugs become available, I am sure we will continue to do that. The noble Lord is absolutely right: we will be continuing to vaccinate those aged between 12 and 15. In England alone, we have already delivered over 1.7 million doses to that age group, and we are continuing to work on increasing take-up—for example, through repeat offers, ensuring information is translated into appropriate languages, and collaborating with leading social media platforms to direct young people and their parents to trusted sources of information.
My Lords, one of the interesting things about the Statement is the complete absence of any reference to advice from the Government’s Chief Scientific Adviser, Chief Medical Officer or the Scientific Advisory Group for Emergencies, which is the Government’s chief advisory committee in the pandemic. Although the Minister says that the advice will be put in the Library of the House, can she assure us now that the advice received from the scientists accords with and supports the decision that the Government have taken?
My Lords, I congratulate the Government on their brave decision to relax the restrictions. I think many people who have been suffering severe mental health impacts from the pandemic will be relieved that perhaps we can start on a road to recovery and, as the noble Lord said, living with this virus. I go back to the question of the right reverend Prelate regarding mandatory vaccinations for NHS health staff. We are perhaps in danger of shooting ourselves in the foot if we get rid of loyal staff, and indeed many staff who are not even patient-facing, at a time when we face such a crisis in the NHS. There has already been a significant impact, as I understand it, in care homes and the social care sector.
Health and Care Bill
Committee (4th Day)
Relevant documents: 15th and 16th Reports from the Delegated Powers Committee, 9th Report from the Constitution Committee
Clause 16: Commissioning hospital and other health services
50: Clause 16, page 14, line 4, at end insert—
“(j) fracture liaison services to identify people at increased risk of fragility fractures and prevent future fractures.”Member’s explanatory statement
This amendment ensures equity of access to Fracture Liaison Services for people with osteoporosis.
My Lords, Amendment 50 is supported by the noble Lords, Lord Hunt of Kings Heath and Lord Rennard, and the noble Baroness, Lady Masham, underlining the cross-party interest in and support for this vital issue. I am grateful to them. I note my interest as co-chairman of the APPG on Osteoporosis and Bone Health. I also support Amendment 101B in this group, on mental health, and much look forward to the debate on the other amendments.
Amendment 50 is, at heart, about equality of access to services for people with osteoporosis. If accepted, it would end the current appalling postcode lottery which means that so many people are suffering unnecessarily from the pain and distress of avoidable broken bones. It will do this by making the provision of fracture liaison services—FLS—one of the core services that an integrated care board must consider for the people for whom it has responsibility, alongside dental and ophthalmic services and others.
I will give noble Lords a little background. We are fortunate to live in a country where each generation has lived longer than the last, but that brings with it many issues about how people can achieve a good quality of life in their later years. One of the biggest issues is broken bones. The uneven patchwork of fracture liaison services across England and Wales means that every year around 90,000 people with a new fracture who should have treatment are not being treated with the bone strengthening medication they need, so problems which need not become acute are routinely left to escalate, with numerous missed opportunities for prevention.
The lack of equitable access to fracture prevention services has led to entrenched health inequalities. People who live just the wrong side of a catchment line are being left to suffer life-changing spinal and hip fractures that with modest investment and better planning could have been avoided. These people are falling through the cracks in the system every day, and they are at the heart of the amendment.
Some 3.5 million people in the UK have osteoporosis and a fracture is, sadly, often the first sign of their condition. If the fracture is picked up and the underlying osteoporosis treated, further fractures can be prevented. Fracture prevention is therefore clearly beneficial to the patient, but also cost effective to the NHS. Fragility fractures caused by osteoporosis currently cost the NHS a staggering £4.5 billion each year, yet for every £1 spent on FLS the taxpayer can expect £3.28 back. Currently, however, access to an FLS to identify people at increased risk of fragility fractures and prevent future fractures is a postcode lottery in England and Wales. People will often have several fractures and no treatment before underlying osteoporosis is identified. There can be no excuse for that.
Secondary prevention is a well-established concept in clinical practice and should be at the heart of the work of the integrated care boards. After a heart attack, for instance, emergency treatment can be life-saving but it is the package of rehabilitation and treatment that supports a full recovery and reduces the chances of a further heart attack. Similarly, orthopaedic treatment to fix the fracture is essential for the 1,300 people who break a bone every day in the UK.
For people with underlying osteoporosis, a seamless package of identification, assessment and treatment is critical to support a full recovery and reduce the chance of further fractures. Without this, their risk of fracture remains high. This is exactly what a fracture liaison service is designed to provide and why this amendment is so important. An FLS identifies and treats people aged 50 or over who have had a fragility fracture, to reduce their risk of further fractures. The FLS model is an evidence-based, cost-effective, preventive intervention that can help to improve the health of the population and reduce health and care service demand.
The APPG on Osteoporosis and Bone Health launched an inquiry into FLS provision in March 2021 to understand the scale of the problem, the factors behind it, and what is required to ensure that everyone who breaks a bone due to osteoporosis receives the best care. The inquiry learned how in England only 51% of NHS trusts provide a fracture liaison service, while both Scotland and Northern Ireland provide 100% coverage. The inquiry’s report made a number of recommendations for government and policymakers on how to drive up both quality and access to FLS, the key one being a government commitment to ensure that all patients have equitable access to a quality-assured FLS, thereby delivering on the mantra that the first fracture should be the last fracture. Amendment 50 would achieve that aspiration.
The impact of osteoporosis on individuals can be devastating. Fragility fractures can lead to the loss of independence, mobility and the capacity to carry out everyday tasks. The Royal Osteoporosis Society conducted a survey last year of over 3,000 people living with the condition. Three in five respondents said that their osteoporosis affected them physically; 55% had suffered height loss or change in body shape; 22% had digestive difficulties; 19% experienced breathlessness; and 10% experienced incontinence. Many people expressed anger, frustration, resentment and sadness about the activities that they could no longer do. Fragility fractures can cause pain, both acute at the time of fracture and in the longer term. The survey found that more than one in four people experienced long-term pain; of these, one in three said that their pain was either severe or unbearable.
A fragility fracture is a red flag that predicts further fractures. This is particularly the case with vertebral fractures, which are powerful predictors of future vertebral, hip and other fractures. Without identification and treatment, a person with a vertebral fracture is nearly three times more likely to have a hip fracture, and five times more likely to have another vertebral fracture.
Hip fractures are the costliest fractures to treat. The average length of stay in hospital is 20 days. Hip fractures account for about £2 billion of the £4.5 billion cost of fragility fractures per annum to the NHS. When we consider that 50% of people with a hip fracture have broken a bone in the past, it is clear that investment in secondary fracture prevention makes both clinical and financial sense. I also point out that, tragically, around one in four of those who fracture their hip will die within a year of doing so.
The current variation in services and outcomes for those with osteoporosis is sobering but the amendment underlines how straightforward the process of change can be. There is no need for any discovery phase for new solutions: the British-born fracture liaison service model has been shown the world over to be a game-changer for dramatically reducing the risk of further fractures. But a repeated theme has been the doggedness among a few individuals it takes to get an FLS set up. This is where the leadership role of government—I say to my noble friend—can transform the picture through clear strategic direction. This amendment would drive 100% population coverage of FLS, ending the postcode lottery. This is what this Bill should be all about.
If we get this right, we can disrupt the pathway from first fracture through to devastating hip fracture, preserving people’s independence and making Britain a safer place in which to grow old. I hope that this amendment will find support on all sides of the Committee and, indeed, from the Government. I beg to move.
My Lords, the noble Baroness, Lady Masham of Ilton, is taking part remotely. I invite her to speak now.
My Lords, I have put my name to Amendment 50 and will speak also to Amendment 57. I am a member of the All-Party Parliamentary Group on Osteoporosis and Bone Health. I thank the noble Lord, Lord Black of Brentwood, for leading on this cross-party amendment.
Osteoporosis is a condition which can cause much pain and debilitation to many people, mainly women. Prevention is important and this is a condition which needs treating by a fracture liaison service. This service should be available to and in easy reach of patients who can be frail and elderly and whose bones can be easily fractured.
I would like to bring to your Lordships’ attention the case of the local hospital which serves the north part of North Yorkshire, a very rural area: the Friarage Hospital, Northallerton, which, sadly, over the years has been downgraded. It used to have an excellent orthopaedic unit; the senior consultant was a brilliant surgeon who unfortunately had to go back to South Africa. He was the brightest and the best. The health service needs leaders, and both staff and patients need up-to-date equipment for satisfactory outcomes. Now there is a visiting consultant, who wanted a DEXA scanner to save his patients the long journey to James Cook University Hospital in Middlesbrough. Many of the patients are elderly and frail. Transport can be a problem. The consultant did not get his DEXA scanner, which diagnoses osteoporosis. I thank the Minister for looking into this case after I tabled a Parliamentary Question.
The problem is upgrading with new equipment. This generally goes to the large hospitals. Women’s orthopaedic wards always seem to have to fight for what they need. A good fracture liaison service, which patients can reach, helps prevention of ill health and without doubt has benefits for everyone, especially the frail and elderly. If they are to be treated in an accessible clinic, near their homes, it must have the correct equipment and well-trained staff. I think it was Winston Churchill who said, “Give them the tools and they will do the job.” The big need at the moment is finding and retaining trained, dedicated, enthusiastic staff. They are the National Health Service’s biggest asset; without them, the job will not be done.
Amendment 57, in the name of the noble Lord, Lord Farmer, follows on well from Amendment 50, and I would like to say a few words on that amendment. It requires that
“health services are available in a community setting where possible, in order to improve access.”
At the moment, weekends are becoming very difficult in rural areas, such as the one where I live. From Friday afternoon to Monday, there is no GP service. On a Sunday, a young woman I know went with an eye infection to the nearest A&E department only to be told that it was not an emergency and she should wait and go to her GP. She did so and was given some eye drops, which were not the answer. When the eye infection worsened, she rang 111. They sent an email to the GP, as the infection had spread to both eyes. She was then sent to the eye clinic at the same hospital that had sent her away from A&E. She was off work for two weeks. Only if the correct treatments are available quickly can infections be treated and days off work saved.
The correct antibiotics for infections are so important to stop resistance to drugs. We also need a first-class pathology service, with test results coming back quickly. I do not think the public always realise what an important job these services do. I hope the failing health service in rural areas can be revived, where it is desirable to have a service in the community near where people live. We need the specialist health services as well—which may be miles away from rare diseases, serious accidents and illness. Wherever the best treatment is, the relief of being treated by experts who know what they are doing is unbeatable.
Will the Minister agree that there is a lot to do to get the health service back on the road post Covid-19? We all want to see it thrive. Thank you.
My Lords, my Amendment 57, which the noble Baroness, Lady Masham, has mentioned, is also supported by the noble Baroness, Lady Walmsley. I declare my interest as a director and controlling shareholder of the Family Hubs Network Ltd, which advocates for family hubs and advises local authorities on how to establish them. I am also a vice-president of the LGA.
In speaking to my Amendment 57, I would point out that in Chinese medicine you traditionally saw the doctor when in health. They were paid a retainer to keep you that way and, if you became sick, they would not be paid until health was regained. This speaks volumes about alternative health paradigms to our own. Even if we never go that far, the prevention of disease and the maintenance of health should be an overriding priority for the health service.
In placing the duty to prevent the development of poor physical and mental health directly under the duty to promote the NHS constitution, it is my intention to make it a similarly fundamental duty. Prevention is always better than cure. Yes, prevention is already mentioned in the Bill, for example in Clauses 5 and 16, and elsewhere in Clauses 20 and 59. However I do not consider that it is given sufficient weight, particularly given concerns shared with me by members of the Family Hubs Network.
Family Hubs Network members work with existing integrated care systems and note that the main issue faced by these ICSs is the management and throughput of the frail, elderly population to address bed-blocking and the onward delays to elective surgery. Hence they can lean towards an acute hospital reactive care model. Family Hubs Network members are already seeing the consequence of this with, for example, few if any ICS strategies focusing on population health through prevention and early help, especially for children and families.
Indeed, more and more ICSs are seeing community-based contracts swallowed up by the acute hospital conglomerates. They rarely, if ever, hold the necessary cultural understanding of community care, prevention and early help, and their interests do not lie in these. Children’s health services, which would ideally be delivered in the community, can be drawn into acute hospital structures which are more reactive than preventive in nature. Yet in some cases these very same services, such as continence, speech and language, allergies and others, are being delivered in community settings, close to families, through integrated family service hubs. Given that many of these health needs are also psychosocial and practical, accessing them from such settings enables families also to receive local authority-commissioned early help. This surely is integration in action.
My amendment also specifies that health services should be available in the community where possible, to improve access and help prevent conditions from worsening. A local-by-default approach would cut down the number of patients required to make prohibitively long journeys when a service could instead be delivered in a primary care or local authority setting. We need a reverse Beeching for healthcare, where we reopen community hospitals. Out-of-area specialist mental health hospitals, which remove people from the social networks which help them get better more quickly, were in the news again this week. Local units have closed and there is a lack of care in the community, even though this is a far less expensive option and the setting in which many prefer to be treated.
Returning to the issue of our ageing population, a reactive care model is completely unsustainable. Unless we focus on preventing big-ticket items such as diabetes, depression, anxiety and dementia—the list is endless—the cost of providing healthcare will keep going up year on year, by even more than it already does. A preventive paradigm would ensure greater ruthlessness about educating parents and healthcare workers about the psychotic effects of high-strength cannabis, for instance.
The eminent professor, Sir Robin Murray, recently said:
“I think we’re now 100 per cent sure that cannabis is one of the causes of a schizophrenia-like psychosis. If we could abolish the consumption of skunk we would have 30 per cent less patients”—
this was in south London—
“and we might make a better job of looking after the patients we have.”
In 2019, Murray’s research team reported in the Lancet Psychiatry their finding that south London had the highest incidence of psychosis in Europe and singled out cannabis as the largest contributing factor. He expressed concern that some liberal-minded parents would rather see their children smoking pot than drinking, without appreciating the potential associated dangers and the social and economic costs. These multiply with skunk, which is several times more potent than the drug they might have been used to in their day.
It is not just parents who need educating, including about higher-strength forms: experts say that cannabis addiction is treated by health professionals as a low-risk soft drug, yet, since 2005, there has been a 777% increase in the number of those aged 55 and over who need treatment for it. When cigarettes’ contribution to the development of lung cancer was firmly established, action to prevent smoking was taken despite it being fashionable and popular—more than 60% of adult males smoked; now that number is approaching 15%.
When there is incontrovertible evidence that something harms mental or physical health, a duty to prevent would mean that such damaging ignorance was no longer allowed to prevail. Ditto foot-dragging on access: mental health care in the community has been talked about since we began to close asylums in the early 1960s, yet it is still in the NHS long-term plan. I am keen to hear from my noble friend the Minister why prevention should not be given prominence as a duty in the Bill.
My Lords, it is a pleasure to follow the noble Lord, Lord Farmer. I really appreciate his remarks about Professor Murray’s work and his interpretation of it.
This is a Bill about integration, but how much integration will it actually achieve? We have spoken many times about wanting health and social care to work better together, but there is a difference between collaboration and integration. The former achieves two separate systems that, while better aligned in, for example, their information sharing, still operate without particular reference to the other. Those who use both systems continue to straddle a divide between the two and, too often, fall between those gaps.
Integration, on the other hand, speaks of synergy and of systems that enable one another and close the divide between the two, so that people can move between them without the terrifying leap of faith that currently exists. This is what will truly make a difference for those who use these services.
Unfortunately, the Bill in its current form will struggle to bring about this true integration. It requires the production of only a health outcomes framework, which will simply entrench the divide between health and social care, as both will continue to pull in different directions with different objectives, which are often conflicting.
Currently, health and social care sectors work towards two different sets of aims: social care is led by the well-being objectives of the Care Act 2014, whereas the NHS is led by various objectives set out in documents such as the NHS constitution, the NHS Oversight Framework and the NHS Long Term Plan.
An integrated service would mark a major shift in how the two systems view their role in supporting those who use their services. For example, it could see the NHS adopting an approach that was informed by ensuring the independence of its patients in a similar way to the principles that lead the provision of care and support. The greatest problems have been caused when health and social care start to gatekeep their domains: I have had to speak too often about the abhorrent placement of people with complex needs in in-patient units far from home, as a result of catastrophically poor alignment of health and social care support to meet their needs locally. I declare an interest as chair of the Department of Health and Social Care-appointed panel to oversee the discharge of people with learning disabilities and autistic people who are detained in long-term segregation.
I want to thank Mencap and Skills for Care for briefings on my amendments in this group. My Amendments 85 and 88 would place greater emphasis on the provision and quality of social care services and on the integration of health and social care services. I also declare an interest as president of the Royal College of Occupational Therapists. This is relevant because occupational therapy is a health profession that is equally at home in the NHS and in social care, and because occupational therapists have a role in tackling long-standing health inequalities through community rehabilitation and in prevention.
The history of health and care integration is littered with a natural reflex towards health and the pressing political priorities of the day. The ICB is primarily NHS focused and will hold responsibility for strategic planning and monitoring of services against the needs of an ICS population, but the answers cannot all come from health alone. We are in danger of missing an opportunity.
A duty to promote integration must include adequate provision for both health and care by taking a holistic approach. The outcomes from one will impact significantly on the other. Viewing the duty to promote integration through a health lens alone limits our understanding of what social care has to offer—think back to the debate on my noble friend Lord Mawson’s amendment on Tuesday. In some areas, integrated care system planning seems to focus mostly on integration within healthcare and not on integration between and across health-led provision and social care. At present, provider alliances are largely acute trust led.
Let us take discharge co-ordination as an example. It is currently suboptimal, with too few care co-ordinators, a lack of social care representation and feedback in assessment decisions, and a neglect of the resources and expertise of voluntary and independent providers.
The staffing context is complex. According to Skills for Care, there are 17,700 organisations providing or organising care, delivered through 39,000 establishments. Some 41% of those are residential, 59% are non- residential and 68% are CQC regulated. More than 6,000 organisations have fewer than four employees. That is a very broad church of employers. Not only does it make it much more difficult to communicate but social care lacks the infrastructure of the NHS to disseminate and co-ordinate.
My amendments propose strengthened provisions for ICBs to consider how integration benefits and can benefit from social care. My Amendment 89 would require ICBs to develop and publish a health and social care outcomes framework at least every two years to ensure that health and social care services are properly integrated.
ICSs present an opportunity to co-ordinate services, improve population health and plan on a system-wide basis to attract and retain staff with the right mix of skills. The ICS role should therefore ensure that the right staff skill mix is available to deliver this singular vision, a vision of person-centred and outcome-based care through multidisciplinary teams operating with and around each individual. Integrated care would mean that people would only have to tell their story once to receive high-quality, joined-up and seamless care. The approach each system takes to workforce planning will rightly vary to meet local needs and requirements, but that does not mean that their workforce plans cannot be measured against a joint outcomes framework. In collaboration with partners, Skills for Care has developed principles of workforce integration which address the above points.
The aim of this amendment is to ensure that health and social care do not pursue two different sets of objectives but work to a common aim to underpin transformation. I ask the Minister to reassure the Committee on these points. I believe these amendments will be helpful.
My Lords, I am delighted to follow the noble Baroness, who speaks with such knowledge and authority on these issues. I will speak to Amendment 110, but first I will make some comments on the amendments spoken to by the noble Baroness, Lady Masham, and my noble friend Lord Black.
The noble Baroness, Lady Masham, highlights the difficulties that those of us living in rural areas have. I regret to see the downgrading, in particular, of the Friarage Hospital in Northallerton, where my father, for one, was treated to great effect. I associate myself with the comments of the noble Baroness, Lady Masham. I know that the Minister is familiar with these arguments now, because he very kindly spent an hour with his team listening to me on these issues. Whereas before, national health policy used to recognise and measure rural health policy, particularly as regards rurality and sparsity of population, those markers have now gone.
The House will be familiar with my work with the Dispensing Doctors’ Association. I regret the fact that, whereas my father and my brother in their time would have been rewarded by the number of patients that they had on their list, and by the distance they had to travel from the surgery to visit patients in their own homes or when called out to an emergency, that has now gone. Much of the bread-and-butter income, as I understand it, for dispensing doctors and pharmacists in rural areas is made up from dispensing. So a separate argument to be had on another day is how, from the beginning of April, I understand, those reimbursements are going to come under the cosh. I will just leave that with my noble friend; I will ask for a separate meeting with him on that. I pay tribute to the work that dispensing doctors do in rural areas under these pressures and I am delighted to be working with them in this regard.
My noble friend Lord Black spoke eloquently on osteopenia. There is a cohort of people—mainly women—who, like myself, are diagnosed with osteopenia. I had not been in the House very long when, having broken one bone six months previously, I broke another. I was sent to the fall clinic where, unsurprisingly, we were mostly women being tested to see how likely we were to have a fall and break a bone. When my noble friend said that many women could die within a year of breaking a hip, I recalled that I was told that I had an 11% chance of breaking a hip. The good news, I suppose, is that I have an 89% chance of not breaking a hip, and that is something I cling on to.
I was put on a course—as I am sure others have been as well—of very strong vitamin D tablets. Since I completed that course, I have had no further treatment, but also no recommendations as to how to prevent the condition—in my case, and I am sure in the cases of other women—deteriorating into osteoporosis. I will just leave the Minister with the thought that, given the seriousness of the condition, those who are on the cusp of descending into osteoporosis itself should perhaps be given greater guidance.
Amendment 110 is intended as a probing amendment, and I am delighted to see that the noble Baroness, Lady Bennett of Manor Castle, has lent her support to it. I am very grateful to her for that. We had many debates on domestic abuse in the context of that Bill, now an Act, but domestic abuse remains a scourge in our society. While it is recognised as a crime, it is most often manifested initially in a GP’s surgery, not at a police station. In the context of the noble Baroness, Lady Hollins, describing the Bill as essentially an integration exercise, I believe it is important to see and recognise a victim of domestic abuse in a safe place or a safe haven—in a setting with trusted professionals, such as a GP’s surgery.
I am sure that the Minister will share my concern that there is currently no training for GPs or other health professionals enabling them, or expecting them to be able, to spot or treat an individual suffering from mental or physical abuse or to instruct them on how to engage with the police. Does he share my concern that that is indeed the case? I understand from Anne Marie Morris, my honourable friend in the other place who moved this amendment at that time, that Devon is the only health system to have a dedicated individual on the CCG board and a health and care strategy for victims of abuse. That strategy has improved health and care outcomes through training and other interventions. Surely, this should be rolled out nationally for other local health services to benefit from.
While it is welcome that the Government have agreed to take this issue into account—and I understand that the amendment was agreed in the Commons—I urge the Minister and the department to go further. ICBs should be mandated to have a strategy to deal with domestic abuse. I am sure that the Minister would agree that, if it is not mandated, it probably simply will not be done. Additionally, the role of the domestic abuse and sexual violence lead on the ICB is essential to spearhead the work in this area and to provide essential expertise. As there is only such a lead at the moment in Devon—who does fantastic work which can be seen first hand, and has been seen to help a number of related pilots roll out in that area—I would like to see this work rolled out throughout the country.
Amendment 110 therefore sets out a duty to prepare a strategy to support victims of domestic abuse using the services set out in that amendment. It asks for various consultations to take place not only with the local authority for the area within the integrated care board but with the domestic abuse local partnership board and other persons whom the integrated care board considers appropriate. I humbly submit that this is a gap in the Bill at the moment that Amendment 110 would fill.
My Lords, I will speak to my Amendment 297J in this group, but I will preface my remarks by returning to the purpose of this Bill. The stated purpose of this Bill is to promote integration of health and care services in order to reduce health inequalities and to promote better outcomes. I have chosen, in this amendment, to speak on the issue of HIV and AIDS services. I have spoken in previous debates about access to sexual and reproductive health services such as contraception and abortion. They are two services which we would do well to look at in considerable detail, because they are services addressing issues that cannot alone be solved by the National Health Service. They are services which will only be solved by not only integration but collaboration between health and social care. Having, like many Members of this House, discussed these issues for many, many years, I come back to the point made by the noble Baroness, Lady Thornton, the other day, that we are trying to seek integration and collaboration between two fundamentally different services. One is organised as a national and essentially top-down system, and the other is organised on a local and democratically accountable basis, with a completely different ethos.
At this point it is worth us taking advantage of the presence of the noble Lord, Lord Stevens of Birmingham, and noting what he said the other day about the National Health Service. He said—and I paraphrase—that one of the best ways to ensure that the National Health Service does what we expect it to do is to ensure that it has resources, and he is absolutely right. Would that people took the same attitude to social care—but they do not, and in the matters of both sexual health services and HIV services, we see in graphic and demonstrable terms the failure to do just that.
Turning to HIV services, it is important to note that although, overall, we have a very good story to tell on HIV in this country, and a reasonably good story to tell in the last few years as we are on a path towards the complete ending of transmission by 2030, we do have some problems. Last year, the number of people living with HIV in the UK rose to 106,000. In 2020, the number of people being tested at clinics decreased by 30%, and more so in black and minority communities, where late diagnosis, with all its complications, remains stubbornly high. However, there was a very great increase in online testing. HIV is an area in which there have been and will be, over the next few years, huge technological changes in diagnosis and treatment, which the NHS and social care should be up to speed with if we are to get to the stated aim of ending transmission by 2030—which we can do. The problem is that, at the moment, we have an increase in the rate of late HIV diagnosis—it was up to 42% in 2019—and we know the concomitant costs that that presents for the health service.
Anyone who has spoken to anybody involved in HIV services, be it in social care, local authorities or the NHS, will have heard exactly the same story since 2012. Just look at commissioning. HIV testing in sexual health clinics and community settings is commissioned by local authorities; HIV testing in GP settings, where it is clinically indicated, is commissioned by NHS England; HIV testing in GP settings as a public health intervention is commissioned by local authorities; HIV testing in secondary care, where it is clinically indicated, is commissioned by CCGs; HIV testing in secondary care as a public health intervention is commissioned by local authorities—keep with me, my Lords. Home testing, which is increasingly popular, is commissioned by local authorities and by Public Health England, for some periods, at some times in the year. Is it any wonder that it is a mess? We are not taking advantage of any of this and we are letting people down. The fragmentation in this area—even for people who have HIV, who are some of the savviest patients the NHS comes across and who are up to speed, sometimes in advance of their clinicians—is really difficult and does not make sense on any level; it does not make sense on a public health level or an individual level. I do not need to go into great detail, as noble Lords can work out for themselves all the consequences of that.
It is quite interesting to talk about one piece of work that the All-Party Parliamentary Group on HIV/Aids did. We did some in-depth research in south-east London, where there are some of the most advanced integrated care services for HIV. Even there, where there is very high prevalence and they know, largely, what they are dealing with and the populations where this is the biggest problem, they struggled to make sense of this fragmented commissioning picture.
I am not asking that all this funding be put into the NHS—most definitely not, because we all know that once money goes into the NHS, it never comes out again. I think there is a case to be made for increasing budgets, not least the budgets of local authorities, which have been slashed, in order for them to carry on doing what is important, which is getting to people long before they are anywhere near being any kind of medical priority.
What I am asking for in this amendment is a formal duty to collaborate. I have no doubt that the Minister will say that that is not necessary, but we cannot carry on as at present: we are badly wasting resources when we should not be. We have enough knowledge in this Committee of the levers that make decision-makers and commissioners change what they are doing, not least when they understand that there are new and more efficient ways to meet the needs of the population. I propose this amendment with no great sense of hope, but, if he does not accept it, I hope the noble Lord will at least understand that we cannot continue with this inefficient way of dealing with known issues. We must stop failing people when we could be sorting out the issues.
My Lords, Amendment 101B, in my name and those of the noble Baroness, Lady Watkins, and the noble Lord, Lord Alderdice, is a fundamental amendment to remedy the shocking imbalance between the provision of mental and physical healthcare. As was said in the debate last week, people with mental disorders who receive treatment are a minority—35% of children and 40% of adults—while for people with physical illnesses, the vast majority get treated. This is not parity of esteem; in fact, I think it is one of the greatest cases of discrimination in our public life. There is only one way to remedy it, which is that the funding of mental healthcare has to rise faster than the funding of physical healthcare. In other words, the fraction of NHS funding devoted to mental healthcare has to rise—it is a matter of simple logic. This is such a fundamental point of principle that it should be put into law.
The increase does not of course have to go on for ever, but only until the inequality has been eliminated and mental health is treated like physical health. In the words of the amendment, the rise should continue until
“people coming forward with mental health problems are as likely to be offered treatment as people with physical health problems”,
and, of course, to receive it within a period of time appropriate to their problem. Only then will we have achieved parity of esteem.
The amendment is a statement of principle. As we know, there are always problems of definition and interpretation with statements of principle, but such statements are common in our statute law. This is a sector, in financial terms, as big as the police service, and it is right that there should be legal principles governing it. If we want to secure justice for the sector, it needs a statement of principle. This is a stronger statement than any of those discussed last week, but if this is what we believe, it is what we should say.
The main argument for the amendment, as I have said, is one based on simple equity, but there is also a strong economic argument. Mental illness is mainly a disease of working age, while physical illness is mainly a disease of retirement. Half of all working-age disability and absenteeism is due to mental illness, so when we successfully treat mental illness, the savings to the economy and to the Exchequer are massive, especially when compared with the economic savings from the majority of physical healthcare. These economic savings were a key argument that led to the establishment of IAPT, Improving Access to Psychological Therapies, from 2008 onwards, and they have been verified in what has happened since in that service.
There is also another very important source of savings: savings to NHS physical healthcare. Psychological therapy has been shown to reduce the cost of physical healthcare for people with comorbid physical conditions. This can be seen in a major nationwide controlled trial done recently, which provided IAPT treatments to people with long-term physical conditions such as diabetes, CVD and COPD. This trial found that, within a year, the savings on physical healthcare covered the total cost of the psychological therapy—so the mental health service is saving money for the physical healthcare service. As a result, this approach is now being rolled out nationally.
So mental health is a classic case of spend to save, and extra spending is desperately needed. Some of it would fill the massive gaps in existing services, including for severe mental illness, and some of it would provide services to key groups of people who are barely helped at present, many of whom were referred to earlier in this debate.
First come the tragic children who fall below the CAMHS threshold, who are sometimes assessed and sent back home as not sick enough, but who desperately need help. For these young people, the Government are developing mental health support teams in schools, but the rollout is incredibly slow and the services also need to include a much higher level of expertise.
Then there are millions of people whose lives are wrecked by addiction to drugs, alcohol and gambling and who need psychological therapy. There are the victims and perpetrators of domestic violence, who have already been mentioned, and other forms of violence. So many of our social problems have a strong mental health component. There are good, evidence-based psychological treatments which NICE recommends for these problems, but they are not provided. They should be provided. Extra spending on mental health could massively improve our society.
There is one further point in the amendment. If we spend the money, we need to know what it is achieving. In IAPT we know the progress of 100% of those treated, but in most parts of adult and child mental health services we currently have very little quantitative data on what is being achieved. That has to change, so universal routine outcome measurement should be a reasonable quid pro quo for extra funding, but the extra funding is crucial. It is not enough to talk about parity of esteem. We must have a clear statement of how to recognise it and the funding principles to achieve it.
My Lords, I rise to speak to this group of amendments with an emphasis on Amendment 101B, in the name of the noble Lord, Lord Layard, whom it is a pleasure to follow.
Last night, I went to the ballet and saw “Raymonda”, which has been placed in the context of the Crimea. It reminded me that Florence Nightingale took a hammer to a store-cupboard to get food and blankets for some of her patients because nobody knew what was inside it. She went on to be a leader in sound data for health- care, recognising that without data we could not plan for the future. This amendment emphasises measuring the outcomes of mental health nursing and other mental health interventions in order to ensure that we learn from practice and develop best practice cost-effectively. That is why I have put my name to Amendment 101B.
We need to look at similar patterns for care to those for physical illness. For example, the onset of paranoia and delusions which threaten the safety of an individual or those close to them could perhaps be equated with a suspected cancer where you wait for two weeks for an initial diagnosis. How many people are sectioned under the Mental Health Act for assessment because they have not managed to get an out-patient appointment for assessment earlier? I believe that is an example of discrimination against people with severe mental health problems. If we could get parity of access for assessment, it would be an extremely good beginning. I recognise that there are other physical and mental health problems that are less urgent, but I use that as a comparison.
Yesterday at a meeting concerning mental health reform after the pandemic, the Minister for Care and Mental Health Gillian Keegan and the chief executive of Mind were panellists. At that meeting, it was noted that investment in NHS mental health services currently increases year on year, largely due, I think, to action under the leadership of the noble Lord, Lord Stevens of Birmingham. It was £11 billion in 2015-16 and is £14.3 billion today and it will continue to increase, including an additional £2.3 billion by 2023-24. It was said yesterday that the Government will ensure ICBs will increase spending on mental health in their area in line with growth in their overall funding allocations to meet the mental health investment standard. To address backlogs, the Government have published their mental health recovery action plan backed by an additional £5 million to ensure that the right support is in place. This illustrates that the Government are committed to the improvement of mental health services. The amendment would place a duty to monitor this investment and evaluate its effectiveness. I hope that the Minister feels able to support the principle behind the amendment and will meet those of us interested in this area to try to find a summary solution to the issues we are raising on parity not only for mental health care but for the care sector that has been outlined so comprehensively by my noble friend Lady Hollins.
All the points that were made by the noble Lord, Lord Black of Brentwood, concerning osteoporosis could be made for drug-induced psychosis, schizophrenia and other severe mental illness problems. I hope that this Committee will be able to influence an amendment to the Bill that will ensure that the monitoring outlined in the amendment introduced by the noble Lord, Lord Layard, will be taken forward.
My Lords, I have added my name to Amendment 50 tabled by the noble Lord, Lord Black, but I want to say how much I agree with Amendment 297J, tabled by the noble Baroness, Lady Barker, about the mess we have between local government and the NHS on sexual health services in general and the HIV services that she mentioned.
My view is that local government has a choice. It either accepts that it is part of a national service here and agrees to earmark funding allocations, or the service will have to go back to the NHS. The current situation is not working. Some local authorities are having to take on the responsibilities of others because some local authorities are not spending sufficiently. There is a movement of people, largely into the big cities, and it is an unfair system. We have to do something about it.
I also support the noble Baroness, Lady McIntosh, in her Amendment 110. Anyone listening to the debates during the recent passage of the domestic abuse legislation would have noted that one of the big challenges is the lack of integration among local agencies. I am afraid the NHS is a part of that and the noble Baroness’s amendment would give a very clear indication to the NHS that we expect more of it.
I have no doubt that, in winding, the Minister will say that Amendment 50 is not necessary because there is already a general duty on the NHS to provide fracture liaison services and the department is doing all it can to encourage the NHS to implement them. However, the dilemma for us is that the positive outcomes from those services have been known about for many years, yet progress in moving to the standard adoption of them through the country is very slow indeed.
As far back as 2010, the Royal College of Physicians produced an audit of the quality of clinical care of patients who had fallen, had a fracture and had been seen in a hospital emergency department. It reckoned then that only 32% of patients with a non-hip fracture received an adequate fracture risk assessment. Just 28% were established on anti-osteoporosis medication within 12 weeks. As a result, the Department of Health incentivised primary care services to initiate these treatments for relevant patients, but, by the end of the first year of that scheme, fewer than one in five patients were receiving the treatments.
Moving forward to 2018, the Royal College of Physicians came back to the issue. It found that there had been some improvements, but there was still very marked variability in access and quality of care provided by those services. So, less than a quarter of fracture liaison services were able to assess over 95% of patients within 90 days, and 28% of fracture liaison services saw less than half of patients in the recommended time- frame. Only 41% of patients who were prescribed anti- osteoporosis medication were monitored in the 12 to 16 weeks post fracture. My question to the Minister is this: after years of reports showing the effectiveness of these services in terms of outcomes, during which time Ministers have said this is something they agree with, and when it is clearly cost-effective for the health service to invest in these services, why has so little progress been made?
If we could forecast the next NHS restructuring Bill in a year of two, do we think much will have changed? I am afraid that it will not have, and this is why legislating is about the only way we can go forward, and why I support the noble Lord, Lord Black.
My Lords, this has been a really interesting debate and it made me think of Aneurin Bevan’s original vision, which incorporated the concept of dealing with the problem and then secondary prevention in rehabilitation and concepts of convalescence. After this debate, I am tempted to go back and read again In Place of Fear, because it is a very short book but it is worth reading.
There seems to be a theme coming through here really strongly. If we do not integrate these services and pull them together, we will never get not only the primary prevention but the secondary prevention which, as the noble Lord, Lord Black, highlighted, is so important. You do not just fix the problem; you prevent the next set of problems coming along.
I was slightly alarmed to note that in 2018 alone, there were over 6,000 deaths attributed to falls. A lot of those were on stairs. They were just simple trips on steps, yet they resulted in deaths. It took me back to when I worked at the Westminster Hospital, which, of course, is no longer across the road. Somebody tripped on the steps of the Tate and subsequently died from a head injury after hitting the concrete. One sees that at stations and so on, too, and we now see it with these scooters, where people scoot into trees and lampposts.
Anyway, to return to the subject of the amendments, the reason for my Amendment 100 is precisely to promote that rehabilitation and remind everybody that rehabilitation is not just a medical and nursing issue. It involves many different professionals, and volunteers quite often, at different levels. A rehabilitation plan at the ICS level could provide the co-ordination required, across different settings and services, to properly support early discharge from hospital, provide access to multidisciplinary teams and incorporate the psychological support that is needed. At the moment, things are organised in condition-specific medical silos, and we have already heard about the fragmentation of provision.
We need to respond more effectively to the needs of people with long-term conditions. When we come to measure outcomes, it is much easier to immediately measure the outcomes of an intervention. The outcomes from long-term secondary prevention are much more difficult to measure and quantify, particularly in a population that has multiple pathologies. So there has been poor data collection in part because it has been very difficult.
A simple example is that NICE guidelines suggested that over 1 million people with COPD every year should be referred for pulmonary rehabilitation, but only 15% are referred. We need to understand why. These are people who are breathless. They are getting chest infections and becoming oxygen dependent—so the consumption of NHS resources goes up. After a stroke, people have very marked rehabilitation needs in many different areas. That may be physiotherapy, occupational therapy, speech and language therapy and so on, going much more widely.
We also have a problem with our housing, because many people are not in accommodation that is suitable for them to go to when they are discharged from hospital. It has been estimated that there are 10,000 people in hospital at the moment who do not have a suitable home to go back to—hence the problem of where they go after hospital. So it is not only about providing a social care workforce to go in. We have already debated last week the problem of housing.
I do want to speak specifically to Amendment 51A in my name and the name of the noble Baroness, Lady Jolly. That is about having responsibility for every person present in an area. If we take the south-west, which is dependent on tourism, it goes from relatively low populations to absolutely bursting at the seams with holidaymakers. We have all seen it. These areas have an additional problem: when people are on holiday, their guard is down, they are less vigilant about what they do and they are less risk averse. Going back to falls, they are much more likely to have a fall or an accident. People fall off cliffs, fall down surfaces and so on. All of a sudden, in the tourist season, these people are at higher risk of something going wrong. They often go away and forget to take their medication, or they take something that interferes with it and end up with different side-effects and so on. They put a huge pressure on the emergency services in the area, so I am quite concerned at the way the funding might flow, in the way this Bill is written. We could inadvertently find that some areas are incredibly pushed at certain times of the year because of the way the population moves. I hope that will be taken into consideration.
My Lords, following the impressive, high-calibre tour d’horizon from the noble Baroness, Lady Finlay of Llandaff, I rise to support the importance of proper and full rehabilitation as in Amendment 100, again supported by the Royal College of Speech and Language Therapists. Perhaps I should have declared, at my last intervention in Committee, that I speak as a vice chair of the All-Party Parliamentary Group on Speech and Language Difficulties—I apologise.
Very briefly, an annual plan, as in Amendment 100, would ensure that rehabilitation is explicitly integrated. Rehabilitation spans many disciplines, as the noble Baroness, Lady Finlay, said. It is what enables those who have degenerative diseases, strokes, cancer, autism and learning difficulties, to name only a few, to communicate—how essential is that for even minimal well-being?—as well as helping people to, for instance, swallow without choking and stay alive. As ever, it is the vulnerable who suffer when these structural underpinnings to ensure joined-up, consistent care are not there. I hope the Government will adopt these amendments.
My Lords, first, I apologise for arriving a little late for this debate. I hope that your Lordships will allow me to add my voice of support to this group of amendments.
We all come to this Bill with the same intentions and belief that collaboration and integration are the future for a health and care system. This group of amendments tackles the uncomfortable reality that, despite everyone’s best intentions—both in our NHS and in local government social care and even in the private sector—to collaborate and deliver integrated care, we are not doing that. A number of these amendments practically point at ways in which we can move from the rhetoric to practical change.
I particularly support Amendment 101B, in the name of the noble Lord, Lord Layard. As a great economist, he is pointing us in the direction of an economic structure and nudge that will force us on to a path to do what we have all talked about for a long time, which is to create parity of esteem between mental and physical health. We debated the importance of mental health in great detail last week, so I do not wish to repeat that, but I want to add my voice to that of the noble Lord in supporting his amendment because it is very practical.
By creating a ratchet that gets us on to a path whereby inch by inch—week by week, month by month and year by year—we start to close the gap between physical and mental health provision, we would start practically on the path that we want to go on without creating a funding hole. This would allow the NHS and our overall health and care system to go step by step at an achievable pace, while recognising that we come out of the Covid pandemic with such enormous physical health waiting lists that achieving parity of esteem will be even harder than it was two years ago, so it is even more important that we force a mechanism in. The second element of this amendment would also force outcome measurement.
This is a very smart and simple amendment. I know that my noble friend the Minister cares deeply about this agenda, as does the Secretary of State, and I urge them to adopt it.
My Lords, I draw the Committee’s attention to my registered interests in healthcare equipment. I have added my name to Amendment 50, moved by the noble Lord, Lord Black of Brentwood. The noble Lord, Lord Hunt of Kings Heath, demonstrated clearly, as have others, that it simply cannot be said that the amendment is unnecessary.
The recent report on fracture liaison services from the APPG on Osteoporosis and Bone Health makes important reading. It shows clearly that the health and independence of tens of thousands of older people who suffer from osteoporosis are threatened by great inconsistencies in accessing vital services and treatment. Far too many people are suffering multiple fractures before their condition is properly diagnosed. Much unnecessary pain is caused and more permanent disability results from failures to diagnose osteoporosis in thousands of cases. Those failures add significantly to the future costs of the NHS and care system than would have been the case with early diagnosis.
The Committee has already heard from the noble Lord, Lord Black, of the significant cost savings to the NHS where a fracture liaison service is in place. The Royal Osteoporosis Society estimates that extending fracture liaison service provision to cover the whole population would require a modest initial investment of about £27 million in England and £2 million in Wales. There should be much more long-term cost-benefit analysis of provision such as this, and it would more than justify those sums of expenditure.
There are many examples in preventive healthcare where focused interventions dramatically improve outcomes for patients and cut long-term costs. We need to raise awareness of conditions such as osteoporosis, provide more education and training for healthcare providers about diagnosing it and increase support for people who suffer from it. Osteoporosis is a long-term condition. It is more prevalent than many people realise and we should all recognise that a spinal or hip fracture is equivalent to a heart attack or stroke in terms of its clinical implications. Fractures are often preventable through use of pharmacological treatments supported by lifestyle modifications, which include appropriate exercise and smoking cessation as well as nutritional supplements such as calcium and vitamin D.
There needs to be much greater public awareness of how to maintain or improve bone health, particularly for the most at-risk populations. The introduction of integrated care boards will provide an opportunity to better co-ordinate and integrate fracture prevention and osteoporosis care. It is currently too dispersed across different parts of the system, as so often our short debate on this group of amendments has shown is the case. For fracture liaison services we need universal access. We need a clear mandate from government that the new boards have a specific responsibility to provide fracture liaison services for the whole population.
My Lords, it is clear from the number of noble Lords wishing to speak in this debate that this group of amendments is extremely important. I want to speak particularly in favour of the amendments from the noble Baroness, Lady Hollins, about integration, which she put before us so eloquently.
In the 40-odd years that I have been working on these issues, I have never heard anyone say anything other than that collaboration would be a lot better than the current situation and that collaboration between health and social care is absolutely vital. Everyone always says that, and in recent years we even have had the hope that, when the Department of Health changed its name to the Department of Health and Social Care, we would begin to see more movements towards integration. Sadly, little progress has been made.
If one asks any patient about integration between health and social care, they think that it already exists. Most patients have absolutely no idea about different jurisdictions, how one sorts out a medical bath from a social bath or how different pots of funding ensure different points of view. That is, of course, until the patients start to find their way around the system in the way in which the noble Baroness, Lady Barker, brought so amusingly to mind. The lack of incentives to integration in the Bill are disappointing. I have not seen anything in it that will stop 15-minute visits by overworked and underpaid care staff or any ideas about integrating services and having much better integrated budgets—still less about data sharing. Those are all the things that we need if we are truly going to move to proper integration.
As the noble Baroness, Lady Barker, reminded us, at a time when waiting lists for the NHS are growing longer by the minute, should it not be a priority to ensure that no one stays in hospital longer than they have to by having discharge procedures that provide a seamless transition and making sure that the all-too-frequent readmission because of inadequate co-operation between the NHS and local authorities does not happen? We hear that care jobs are unfulfilled and that requests for care are turned down because of staff shortages. Local authorities struggle to recruit enough workers to meet increasing demands. No wonder that that is the case when one can earn more by filling shelves at Sainsbury’s.
A truly integrated service would mean that, the minute that someone is admitted to hospital, plans should be being made between health services, social care and the often-ignored but often significant voluntary services about what is going to happen on discharge. Sadly, the usual pattern is for a conflict to emerge, usually on a Friday afternoon, between a hospital ward desperate to empty beds and social care services inadequately prepared or even informed. What happens? The person goes home, the care services are not adequate and so the person is readmitted to hospital. I know someone in my local area in Herefordshire, an elderly lady who has been admitted 14 separate times since last July, and still care services to keep her adequately at home are not provided.
The Bill is a failed opportunity because we are seeing social care once again as the poor relation, the tail-end Charlie, that is considered after everything else is settled. Social care could be at the heart of a levelling-up agenda if we had a vision for its workforce and the impact that it has on the health of a community in the broadest sense. Care providers could be encouraged to diversify their businesses to reach out creatively into the community by providing tax incentives, for example, or reductions on business rates. If we want a high-skill, high-wage economy, what better place to start than social care, with its huge workforce badly paid but certainly not unskilled? Those skills could be developed by providing training, and retention could be dealt with by better career progression and recognition of qualifications. It is sad that we are not looking at practical ways in which to develop that integration in the Bill.
Fixing social care requires two things: money and better integration. We will come on to money later in the Bill. For the moment, I hope that the Government will give proper recognition of and acceptance to the amendment on integration in the name of the noble Baroness, Lady Hollins.
My Lords, I will speak briefly in support of the amendments in the name of the noble Baroness, Lady Hollins. I had intended to put my name to them; I apologise to the noble Baroness for being so slow off the mark. I also strongly support the amendment in the name of the noble Lord, Lord Layard.
Both these amendments, in their different ways, go some way to righting what I consider to be two big wrongs inflicted on local government in the past, where responsibilities have been transferred to it but have not had their funding sustained into the future. The first was the closure of long-stay hospitals in the 1980s and 1990s. When I was a director of social services, I was the NHS’s favourite person when building provision and making available services for people coming out of long-stay hospitals. After a few years, I and my many colleagues became forgotten men and women because the money that was transferred was never maintained in real terms over a couple of decades.
Fast-forward to the 1990s and the setting up, with much enthusiasm, of the Roy Griffiths community care changes. These enabled the Government to get off the hook of an expanding social security budget. It was another repeat performance: the money was not maintained in real terms in the longer term. What we saw in both cases was local government having to pick up the tab without support from the Government—successive Governments, that is; I am not making a party-political point—to ensure that those services could be maintained for the people who became the responsibility of local government.
The amendments in the name of the noble Baroness, Lady Hollins, remind people that there is an obligation to make sure that both health and social care produce good outcomes for the people who are now primarily the responsibility of local government, which, as the noble Baroness, Lady Pitkeathley, gently reminded us, has been underfunded over a long time in terms of maintaining these services. The amendment in the name of the noble Lord, Lord Layard, is another righting of a wrong and we should all get behind it.
My Lords, I support Amendments 85 and 88 in the name of the noble Baroness, Lady Hollins.
We must be clear. The previous two speeches highlighted the elephant in the room: you cannot have integration on a sustainable basis unless you reform health and social care together. We have to be honest with ourselves that this Bill is predominantly about the reform of healthcare.
That was highlighted eloquently in the speech by the noble Lord, Lord Hunt, in response to my noble friend Lady Barker, about who should commission sexual health services. These have been lobbed to the side of the commissioning silo but it should be about how to break down this silo so that we have joint and sustainable commissioning around outcomes, rather than around which silo or which part of the health and social care framework should deal with it. It is the elephant in the room, but we are where we are so we must make this Bill better knowing that that is the real issue.
This is about three little words: social care services. It is clear to those who understand health and social care that the Bill has been written predominantly through the lens of healthcare. I do not blame anybody for that but clearly this is a healthcare commissioning reform Bill, with a little tinkering with the structure, and does not deal predominantly with those people who do not understand social care—unless they are asking for an NHS long-term care package, when the argument tends to be about not the care provided but the funding, including who is going to fund what part. That is when it affects people’s outcomes. Those three little words are really important, which is why the noble Baroness’s amendments are important. If they were accepted, the Bill would actually say that social care service and health outcomes are jointly important.
It is important that this is about integration. The noble Baronesses, Lady Pitkeathley and Lady Hollins, said that there is a significant difference between collaboration and integration. You can have two people collaborate but, if their silos send them in different directions, the outcomes will not be joint. The real issue is how we bring about integration. It will not solve all the problems but it will help to bring about the first stage of integration if you have a joint framework on outcomes for which both healthcare and social care are held accountable. That is why Amendment 88 is so important.
The Bill’s intention goes in the right direction but the three amendments in the name of the noble Baroness, Lady Hollins, will significantly help in that journey. They will not solve the problems fully but they are an important way to say to people who work in health and social care that they will be held responsible for the outcomes of individuals, whether their needs come under healthcare or social care. That is why I support these amendments.
My Lords, I support Amendment 101B in the name of the noble Lord, Lord Layard. Before I speak to it, I want to say how much I agree with the sentiment expressed by noble Lords on all Benches that true integration will be achieved only if the Bill is as much about social care as it is about health. It is such a fundamental point that I wanted to underline it.
I see Amendment 101B as an important continuation of our deliberations last week on parity of esteem because “parity of esteem” are simply meaningless words unless they are reflected in the provision of funding. First, like the noble Baroness, Lady Watkins, I acknowledge the welcome fact that NHS England has met its commitment to ensure that the increase in local funding for mental health is at least in line with the overall increase in the money available to CCGs through the mental health investment standard. It is also welcome that, from 2019-20 onwards, as part of the NHS long-term plan, that standard also includes a further commitment that local funding for mental health will grow by an additional percentage increment to reflect the additional mental health funding being made available to CCGs. I recognise all of that.
But—and it is a big but—the investment standard relates only to CCGs, and that total spending had already declined in 2019-20 compared with 2018-19 as a percentage of total NHSE revenue spend. Also, given the urgent need for healthcare, which, as other noble Lords have said, has been much exacerbated by the pandemic, this amendment would help strengthen the consideration of mental health services when large amounts of money are announced for Covid recovery—this is welcome—but it all falls outside the remit of the mental health investment standard.
We need to know how much of the money is currently going to preventive and community services—prevention is the overarching theme of this group of amendments—as opposed to acute services. We also need to know whether the spending increases we are seeing are simply because crisis services are so in demand; indeed, they are overwhelmed in some cases. We know from a recent survey by the Royal College of Psychiatrists that two-fifths of patients awaiting mental health treatment contact emergency or crisis services, with one in nine ending up in A&E. That is not a sustainable position.
As I think we all know, the burden of mental illness in the UK far outstrips NHS spend. In our debate last week, I quoted from the King’s Fund. I highlighted the fact that mental ill-health makes up around 23% of the burden of ill health in the UK but receives roughly only 11% of the spend. With that burden outstripping demand, we also know that referrals have been at a peak during the pandemic. Indeed, modelling from the Centre for Mental Health estimates that 10 million people—a very large number—will need either new or additional mental health care as a result of Covid-19.
I am also very concerned about the very great regional variation we see at the moment. I will not quote all the figures, although I have them, but there is huge variation in access to CAMHS services depending on which part of the country you live in. That is also the case for access to IAPT services, which the noble Lord, Lord Layard, talked about, and other mental health services.
Given the chronic underfunding of mental health and the frankly egregiously low historical baseline, there is still far to go for mental health to reach parity with physical health services. The foundations provided by the £500 million Covid-19 recovery funding need to be built on in the coming years to ensure that the long-term planned trajectory is restored, the demand arising from the pandemic can begin to be addressed, the Mental Health Act reforms, which we have not heard very much about recently, are successfully implemented, and the waiting time targets arising from the clinical review of standards can be introduced effectively.
My Lords, this has been an extremely rich and informative debate on a diverse set of amendments. My contribution will be fairly brief, but I want first to reflect on the comments of the noble Lord, Lord Scriven, about the elephant in the room. He reflected on many other contributions about the lack of real integration of health and social care in the Bill, and the way the Bill is essentially written for health. I do not disagree with that identification of that elephant, but a second giant creature in the room is being ignored—let us call it a mammoth—which is the lack of adequate funding and numbers of people for health and social care. That means that those silos are seeking to defend their funding and resources, and reserve it for what they see as their core functions. They therefore find it very difficult to reach out and stretch into new areas even where that would have huge net positive impact overall.
To reflect on a couple of other things, I heartily endorse the call from the noble Lord, Lord Farmer, for a reverse Beeching for the NHS with the reopening of community hospitals. I am not sure whether he coined that phrase; I might borrow it, if he does not mind.
I will also comment on Amendment 51A in the names of the noble Baronesses, Lady Finlay and Lady Jolly, about emergency services going to everyone in the area. I see that the noble Lord, Lord Davies of Brixton, is in his place. This very much ties in with an amendment that he spoke to on Tuesday. He told a tale, which I will not repeat, about a case in which someone was denied a treatment in a neighbouring area that they desperately needed because of arguments about which area they were in. This is potentially a huge problem with the structure we are creating that has to be taken on board. Amendment 51A deals with the responsibility, but of course there also have to be funds to go with that responsibility.
It has not got a lot of attention, but I also commend Amendment 100 in the name of the noble Baroness, Lady Finlay, on the duty to promote rehabilitation. When we talk about dramatic medical interventions—the high-profile stuff—it is generally acknowledged, but always as an afterthought, that the person who has had that big dramatic intervention will not suddenly be cured tomorrow, in most cases. There is a long process of recovery. Indeed, I have put on my reading list Recovery: The Lost Art of Convalescence by Dr Gavin Francis, which has been glowingly reviewed in many places. That is something we all should be thinking about a lot more.
Finally, I come to Amendment 110, in the name of the noble Baroness, Lady McIntosh of Pickering, to which I attached my name because, as the noble Baroness said in her introduction, this is something that we have addressed again and again in the police Bill and the Domestic Abuse Act, but it is very acutely an NHS problem. I draw on an article from the Nursing Times on 24 December. It is an account of a nurse, who was called Claire in the article. When she was going through a checklist with a patient that had been provided by a charity—this was something extra added in from the outside, not core NHS—she realised that she herself was a victim of domestic abuse. She had said yes to more of the questions than the patient had. That is a demonstration of what the noble Baroness, Lady McIntosh, said: training is not given to medical professionals to see what is happening to themselves and to their patients. Maybe it is added in because a charity has managed to get something into the system, but it will certainly not be across the system.
We hope we are doing this Bill for the long term—although perhaps we are not so certain, as the noble Lord, Lord Hunt, said—but we have to note that this is happening in the context of the Covid-19 pandemic. I note that the NHS sexual assault referral figures for the first half of 2020 dropped significantly. That also picks up a great deal of domestic abuse, yet online searches for domestic abuse were up by 350% in the same period. We have an NHS that has been forced to focus on the Covid-19 pandemic, often drawing away resources that might have started to deal with domestic abuse anyway. We have a huge rise in the problem. Considering the moment we are at now, it is crucial that domestic abuse is in the Bill.
My Lords, this is an enormously important debate because it deals with my favourite word in health and care: prevention. Prevention is so important because it is cost effective. Although successive Governments give more and more to health services, no Government will ever be able to give enough to the NHS, because we have an ageing population and innovative medical interventions are getting more and more expensive, unless we do things differently and more cost effectively.
The noble Lord, Lord Black of Brentwood, outlined one very good, cost-effective intervention. It is an excellent example of something that has absolutely powerful evidence of its cost effectiveness but which is not being undertaken everywhere. I would like to know what evidence those areas that are not using fracture liaison services have that their way of doing it is better and more cost effective. I do not think they have that evidence. It is an example of where if you do not mandate it they will not all do it, and then they will not be spending their money effectively. I support the noble Lord’s amendment.
It is also very important that we prevent not just the second fall but the first, because, as the noble Baroness, Lady Finlay, said in her very important intervention, including what she said about tourist areas, which is very significant, people do die from falls. I had a very old friend who recently did. It was the first fall. I am afraid that person died because he had internal bleeding that nobody spotted. It is really important.
My noble friend Lord Rennard mentioned something really important that is pre-primary intervention: health education. If you know that you are likely to have good, strong, healthy bones from weight-bearing exercise and a diet that has enough calcium and vitamin D, you are much less likely to have the first fall. Fortunately for the Minister, that is beyond his remit. I am sure he is pleased about that, because he has quite enough to do. The Department for Education should listen to that.
My noble friends on these Benches have highlighted some other areas where effective prevention services are not being done properly. I think we were all struck by the chaotic situation that my noble friend Lady Barker highlighted; something really has to be done about that. A lot of good has been done but a lot more could be done, and, again, it would be cost-effective.
The noble Lord, Lord Layard, has suggested a very cost-effective intervention. If we diagnose and intervene on mental health issues early then we can prevent all kinds of more severe mental and physical health problems. I support the ratchet method that the noble Baroness, Lady Harding, referred to of increasing the amount of funding that goes there. Although the noble Baroness, Lady Watkins, rightly listed the number of times that the Government have put more money into mental health services, the question is: have they kept up with the demand and the backlog? I do not think they have.
We have an opportunity in the Bill to improve our measures to prevent ill health, as well as treat it, which is of course more cost-effective, especially when services are delivered by small social enterprises working at community level. I have added my name to the amendment from the noble Lord, Lord Farmer, because I believe these prevention services should be available as close as possible to those who need them most. If that does not happen then the people who need them will not access them, and health inequality will continue.
That is particularly important for those communities where health inequality is at its worst and where preventable diseases are most prevalent. For example, the services might include healthy weight management services, therapies to address less severe mental health conditions, and alcohol and drug addiction services, in addition to the usual GP services. The population groups are not just those in poverty but marginalised groups such as homeless people, those in temporary accommodation, refugees, Gypsy and Traveller communities, and others who may not be plugged into regular services, and that includes those in rural areas.
Many of these services are delivered very effectively by social enterprises or charities, where any surpluses are ploughed straight back into more services. Many of them also provide weekend services, which were mentioned as lacking by the noble Baroness, Lady Masham. Boards that do not ensure the survival of such services are really missing a trick that would help them to deliver their duty to level up health inequalities, because these organisations are usually very close to their communities and know exactly what is needed and where. They are not constrained by the regulations or the culture of large organisations, and are therefore more flexible and fleet of foot, and therefore very cost-effective.
On rural areas, I shall give your Lordships a brief example from my noble friend Lady Jolly, who lives in a very remote part of Cornwall. She says:
“We have a satellite surgery in our local village, it is in the ground floor of an old cottage. The pharmacist visits once a week, and a practice nurse visits once a week. When she is seeing a patient they have to switch the radio on so that no one can hear the conversation”—
because of patient confidentiality. In that village you have to drive 20 miles to reach a GP. That is the sort of place where we really need community access to health services of all kinds. It would be nice to think that the ICB would be aware of that and act accordingly, and it might perhaps be worth putting a duty in the Bill.
My Lords, this is an assortment of amendments that are all linked to the core of the Bill, which is about integration. The issues, as ever, are about whether it is appropriate to place such a detailed level of specification in the Bill, and where.
Amendment 50 seeks equity of access for fracture liaison services. In many ways the amendment by the noble Lord, Lord Black, supported by my noble friend Lord Hunt and others, is about the balance between a national mandate and local delivery in order to ensure that there is equity of access—in this case, for fracture liaison services. I would be interested to learn how the Minister believes such a thing could be implemented and assured, and in how we can best express that in the Bill.
Amendment 51A briefly touches on the well-trodden ground of the 2012 Act and the differences in the famous Sections 1 and 3 of the National Health Service Act 2006, which varied the wording around the duties of the Secretary of State. Some saw that as a device to try to exclude patients or treatment as a cost-cutting measure; others saw it as simply tidying up the wording to meet reality. In fact, experience since 2012 indicates that fears were indeed overstated at that time. However, as the noble Baroness, Lady McIntosh of Pickering, said:
“Surely, this should be rolled out nationally”,
and that is the aspect that we are discussing here.
The amendment seeks to ensure that emergency care cannot be refused when it is needed just because a patient is not resident in the ICB area. We touched on that last week—or perhaps it was earlier this week; I cannot remember—but, frankly, if you break your leg in Blackpool but live in Bolton, the ambulance will still come for you. As far as I know, there is no mechanism for checking where you live or even whether you are ordinarily resident in an area in the case of non-emergency hospital in-patients. We all know that infectious diseases and emergency care can and should be properly protected.
Amendment 57 from the noble Lord, Lord Farmer, is very much in line with Labour’s policy of promoting care close to home, with a focus on prevention, but achieving that probably goes beyond what the Bill says it will do. It will take a change of attitude and culture throughout government. For example, in Wales, the focus on well-being and adequate funding getting to the right places in the NHS and beyond is about tackling the determinants of poor health. That policy was put in place at least five years ago and is now beginning to have effects, so this is a long-term change of culture and attitude.
Amendment 100 in the name of the noble Baroness, Lady Finlay, is about rehabilitation and patient support. I fully support the aim that this serves and how it highlights, as have other amendments, the fragmentation of sources of support.
Amendment 110 would require ICBs to publish a strategy on support for victims of domestic abuse. Again, I agree with that, but we have to work out how best to deal with it, because such a strategy would require agreement across a much wider range of stakeholders, which is exactly as it should be.
Amendment 101B, in the name of my noble friend Lord Layard, addresses parity of esteem, an issue that many noble Lords have addressed. We know that two things appear to work in the NHS, and the Minister, as a distinguished economist, knows this: money and targets. So we hope that the amendment in the name of the noble Lord, Lord Stevens, and that of my noble friend Lord Layard, could, as it were, work together across the House to produce an amendment that addressed those issues: the targets, progress and resourcing to deliver parity of esteem. We on these Benches are certainly very keen to see that happen and to be part of the process that will take us there.
Through the important discussion that we have had today, perhaps we can see that something needs to be done and will, I hope, work towards those things. I was struck by the remarks of the noble Baroness, Lady Barker, about HIV, which highlighted three matters: inequalities, innovation and fragmentation. It is unacceptable that we are having to look at an area where there is great innovation and scope for great improvement but where there are huge inequalities and huge fragmentation. That underlines the issue of the lack of integration and the case for public health to be at the core of prevention and integration. I look forward to the Minister’s response to this debate, because I hope we are on the cusp of making some improvements to the Bill that will actually take us forward.
My Lords, this has been a fascinating debate, covering issues around prevention, as the noble Baroness, Lady Walmsley, said, and talking about what we mean by integration and how we make sure that it is more than just a word. I remind noble Lords that we have a forthcoming paper on integration as part of the overall package of the Bill, and a social care paper as well.
The noble Baroness, Lady Thornton, mentioned culture and attitude. I think it is very important to recognise that you can change structures and have legislation but you have to make sure that the culture and attitude are right across the system. I say to noble Lords that we fully sympathise with the intentions and I hope I can offer some reassurance.
In my departmental job as Minister for Technology, Innovation and Life Sciences, I feel very strongly that one way to drive integration is through better use of data across the system. Even before we look at integrating with social care, the NHS as it is at the moment is not sharing data well across the system. There are still a number of inefficiencies. I really believe in the digital transformation agenda and will give a quick example of that.
Just before Christmas, at a time when the NHS was under extreme pressure, I had my annual check-up in two parts. One part was an ECG at a local community centre; the second was supposed to be a telephone conversation with a consultant a week later. When the phone call came from the consultant, he started talking and I had to stop him. I said, “Have you seen my ECG results?” and he said, “No. What ECG? When was that?” I said, “This is all part of the same appointment. Can I now give you the date and time when I had it so you can look at the results?” “Don’t worry about that,” he said, “we’ll just have to make a new appointment”.
This was at a time when the NHS was under extreme pressure, as it is every winter. That shows the challenge. Even though we have been talking about the integration of health services since 1948, we still have these problems. That is why I believe so strongly in the digitisation and data-sharing challenge. It is not just because I am a geek and love technology; it really can make a difference, save money and lives and mean a more effective service all around.
I start by addressing Amendment 50 on fracture liaison services. Fracture liaison services and fragility fracture prevention are recognised by NHS England as critical to both healthy ageing and elective recovery. Within its high-impact restoration strategy, NHS England recommends that all systems optimise the secondary prevention of fragility fractures. NHS England is working closely with stakeholders to support the implementation of secondary fracture prevention services where they do not exist already and to support sustainability and quality improvement where services exist. Once again, this will rely on good data being shared across the system.
There are already duties in the Bill to require ICBs to commission such services. As fracture liaison services aim to identify people at risk and therefore prevent future fractures, their provision would already be covered in Clause 16 under new Section 3(1)(h), which places a duty on ICBs to commission such services or facilities for prevention, care and aftercare as the ICB considers appropriate. As I hope noble Lords will agree, it would be inappropriate to be overly specific in setting out the services to be commissioned as part of the new Section 3 that would be inserted by Clause 16, given the wide range of services the NHS needs to commission. However, I hope I can give assurances to noble Lords that NHS England will continue to monitor this and ensure that ICBs are commissioning effective fracture services. I hope we continue to drive this data being shared appropriately.
I turn to Amendment 51A. It makes sense that people should be able to receive emergency treatment wherever they are, as the noble Baroness, Lady Thornton, alluded to. We believe that is already the case. Once again, data would make a huge difference. If I am in Newcastle and fall off my bike and am taken to hospital, and if I have an existing condition, would it not be great if the clinicians when they triage me could know about it? I have asked my local GP practice to share my data on the app and it still has not done it. The mechanisms are there but the culture and attitudes are a huge challenge for whichever Government are in power.
The Bill confers a power on NHS England to publish rules that determine the people for whom each ICB is responsible. Those rules must make sure that everyone registered in the area, or everyone who may have need of services, is looked after. The Secretary of State may make regulations expanding that responsibility or creating exceptions where necessary. This was the case with existing CCGs and will continue under the ICBs. I hope I can reassure your Lordships that these regulations will be replaced to ensure continuity in this between CCGs and ICBs,
I now turn to the noble Lord, Lord Farmer, and his amendment. I also thank him for sharing his wisdom and his experience of family hubs. It is incredibly important. We agree with the spirit behind Amendment 57. We fully agree that, generally speaking, as the noble Baroness, Lady Walmsley, said, prevention is better than cure. One of the things that I have been reassured by in my early conversations in my role as a Minister for Health is the number of people in meetings who have said that they want to move towards a focus on prevention. That is not avoiding cure. We have to tackle cure, of course, but we can avoid a lot of that and save resources and time and promote better health and healthy living if we focus on prevention.
There are also duties in relation to the improvement of services for the prevention of illnesses as well as a duty to obtain appropriate advice, which expressly includes a requirement to seek advice from people with expertise in the prevention of illness. The NHS is already working hard to prevent ill health but, once again, we have to make sure that, in this prevention, people are all talking to each other, we are learning from best practice, and ICBs and trusts are learning from each other. As a number of noble Lords have made clear in their contributions in Committee, the issue is wider and social prescribing, for example, and other issues are really important.
Commissioners have also developed good practice, including funding alcohol care teams and tobacco treatment teams in hospitals, and expanding the diabetes prevention programme. This was re-emphasised in the NHS Long Term Plan, which contained commitments for the NHS to focus on major causes of ill health such as smoking, poor diet, high blood pressure, obesity and alcohol and drug use.
I remind noble Lords that prevention is not simply also a matter for ICBs. It involves local authorities and sometimes law enforcement authorities. It is a multiagency approach, led by local authorities but with ICBs, the NHS and other agencies playing their role.
I acknowledge the point that my noble friend made about cannabis and young people and I will write in more detail about that rather than take up time now. But we also have to look at such issues in the round. For example, in the United States Michael Cannon of the Cato Institute wrote that a lot of drug enforcement or anti-drug policy disproportionately affects young black men who then get thrown into the criminal justice system. How do we tackle that? One of the interesting conversations I have had with the noble Lord, Lord Paddick, was about his experience as borough commander in south London, an area that my noble friend mentioned. He gave the example that young black men in possession of drugs were far more likely to be picked up than a white middle-class male or female.
We have to make sure that we look at this as a whole. When we look at the tackling inequalities strand that we all feel so strongly about, we have to make sure we get the right balance. It is, of course, very difficult on a case-by-case basis but we have to be aware of unintended consequences.
On the integration duty, we are sympathetic to the intent behind the amendment from the noble Baroness, Lady Hollins, and support greater integration between health and social care. We hope that we can make sure that stakeholders work together and that, with all the papers, we are able to push through this integration.
I hesitate to take the words of the noble Baroness, Lady Hollins, away from her, but she is talking about putting a duty for this integration in the Bill. That is the way forward. Assurance is not the point here. I think we have gone past the point of needing assurance. We have been assured about this for years. This is about the duty.
The duty to promote quality social care services rests with local authorities. The Care Act 2014 already requires local authorities to integrate services where they consider that this will improve the quality of care or support in the local authority area, including the outcomes that are achieved for local people. However, I sense the strength of feeling on the duty from the Committee and given some of the conversations—
I do not think that the Minister really understands. Yes, there may be a duty on local authorities. The amendment tabled by the noble Baroness is basically a duty to promote integration. At the moment, the Bill says that:
“Each integrated care board must exercise its functions with a view to securing that”
health services are provided in an integrated way. The amendment says “and social care”. It then justifies at what point that integration must be done. Why does the Minister feel that not putting this in the Bill somehow strengthens the main aim of the Bill, which is to look at the integration of health and social care for individuals who are going through a health and social care episode?
The Bill complements these existing duties by placing an equivalent duty on ICBs to integrate the provision of health services with the provision of health-related services and social care services, where this will lead to improvements in quality or reductions in inequalities. Taken together with the wider introduction of integrated care boards and integrated care partnerships, this gives the NHS and local authorities the best platform on which to build new ways of working. New provisions in the Bill will also complement and reinvigorate existing place-based structures for integration between the NHS and social care, such as health and well-being boards, the better care fund and pooled budget arrangements. We will, of course, be listening throughout the passage of this Bill to other ways in which we can facilitate the NHS, local authorities and others to work together to deliver integrated care for patients and the public.
I am sorry and will not delay the House much longer, but this is a really important point: the heart of the Bill.
As the Bill is written at the moment, the only integration that the integrated care board is responsible for is to ensure that health services are integrated. That means integrating primary, mental health and acute. It does not say that it is for the integration of social care. That is exactly what the noble Baroness is trying to achieve. As this is written, is it not the case that the duty in the Bill is for the ICB to secure that only health services are integrated?
One of the reasons for the introduction of integrated care boards and integrated care partnerships is to give local systems, both NHS and local authorities, a platform on which to build new ways of working. That includes social care. If the noble Lord feels that this duty is not explicit enough or that we should bring it out, we should have further conversations.
The architecture is very curious regarding why we must have an integrated care board and integrated care partnerships. It has never been clear to me why the Government have not attempted to set up a health and care board to bring those services together. We know that the funding systems will be different and that there is a clear difference between free at the point of use and means-tested social care, but surely that is what an integrated board, jointly owned by the NHS and local government, with councillors at the table not officers, is trying to sort out. Why have we ended up with this nonsense of a structure? We are carrying on with health and well-being boards as well. That is the great puzzle here.
If the Government are not willing to move on that, we must come back to the point made by the noble Lord, Lord Scriven. By splitting it, you then must say to the integrated care board, “Ah, but in your duties, you must ensure that you integrate with social care as well.” It really is a mess. The Minister said earlier that this is what the NHS wanted. Yes, this is an NHS Bill designed by NHS managers with a focus on the NHS. I do not know why it is called a care Bill, because it has nothing to do with care.
Before the Minister responds to that, can I amplify what is being refused here by the Government? As I understand it, he is trying to rely on the Care Act to get local government to co-operate and integrate care with the great elephant, the NHS. This is asking a minor player to take on a major player with far more resources. Amendment 89, tabled by the noble Baroness, Lady Hollins, makes the NHS come back every two years about the outcomes. That is a fairly modest challenge to the NHS and I fail to understand why the Government cannot simply accept that in principle and then negotiate the drafting.
I am so sorry to delay the Minister again, but briefly. After we have pushed this Bill through Parliament, we will have an integration Bill and a White Paper and legislation on social care. When we have had this, those and those, can we come back to this?
These are all building blocks. I thought that might get a laugh.
In response to the noble Lord, Lord Hunt, ICPs were the idea of the Local Government Association, and we want to ensure that they work with the ICBs. Also, we must recognise that local authorities are accountable to their local electorates and fund many of the services for which they are responsible from local taxation. While we encourage local authorities and the NHS to work together as much as possible and pool their budgets where it is beneficial for local people, we are not mandating this, as this would probably require significant shift in how local authorities are held accountable for managing their money. One of the reasons why we have this strange ICB-ICP partnership is to ensure that it is at the right level and, beneath that, to have the health and well-being boards at place level. I sense the strength of feeling in the Committee, and I see the noble Baroness, Lady Hollins, giving a wry smile.
I love this debate—it is brilliant—but it makes the point that this is an ideal opportunity to pre-empt a later Bill and get on with the job now where it belongs. Given the strength of feeling in the Committee, if we cannot reach a solution to this, I will bring it back on Report.
My Lords, I feel for the Minister in his position. He is right: people observing our proceedings will see us laughing, but in practice this is really serious. I talk to colleagues in local government who receive endless requests from the NHS to turn up to meetings and they do not go, and why? It is not because they do not think that it is important, but because local government has been hollowed out over the last 10 years to the point where it has very senior management and front-line staff, and does not have large numbers of people in the middle doing middle-management planning jobs that exist in the NHS. That was the reality before Covid and is the reality now. Each of those building blocks that the Minister is putting in may be some great stepping-stone to a nirvana for the NHS, but they are just another obstacle for local government. It is so important that we in this House are not tied to constituencies or particular areas of importance. Speak truth to power—to the Government. We are building something unsustainable that will not work.
I thank the noble Baroness for her sympathy for my role. Debates like this are important. They give the Government a measure of the strength of feeling on particular issues. It would be blind for me not to acknowledge the strength of feeling and the support for the noble Baroness, Lady Hollins. As I have done with some of the other issues discussed in this debate, I will take this back to the department and call a meeting of those who are interested, as we did for mental health, and hopefully we can have a discussion to find a way forward. I thank noble Lords for expressing the strength of their feeling. It is very helpful to know where we can focus time and resources as we try to get this Bill through and ensure that it is workable and leads to the integration that we all want to see.
I will also add that NHS England intends to assess ICBs, as I does CCGs. This may not be reassuring, given some of the strength of feeling about NHS England’s drive behind the Bill. The CQC will also make assessments of ICSs and systems, and part of that will be to consider how health and social care are working together.
I will now talk about rehabilitation—not of my career but of health. Our intention with this legislation is to establish overarching principles and requirements, while allowing ICBs space and discretion. This means avoiding being prescriptive, wherever possible. I am sure that noble Lords acknowledge that. Looking at the duties on ICBs that are relevant here, the first—in Clause 16—requires an ICB to arrange for the provision of the listed services it considers necessary to meet the needs of those for whom it is responsible. This includes aftercare which, in turn, includes rehabilitation. The ICB is also required to develop a joint forward plan, setting out how it will meet the health needs of its population—which should consider rehabilitation. ICBs are also under a duty to seek continuous improvement in the quality of care. That of course has to include rehabilitation. We hope that, without legislating for the production of a separate annual plan, ICBs will be required to provide, and improve provision of, community rehabilitation services.
I turn to Amendment 101B. I can assure noble Lords that the Government fully support the increased focus on mental health spending. I thank noble Lords who met with me earlier this week to discuss some of the issues around mental health and how we make sure that it gets the profile it deserves. We are trying to move towards parity between mental and physical health, and indeed all other types of health service. If I may, I will leave that there for now. If we have to continue the conversations about mental health, those who were not invited to this week’s meeting might like to drop me an email to let me know if they are interested in joining the meetings, and I will make sure that the Bill team invites them.
I am trying to get through this as quickly as possible. Turning to Amendment 110, I thank my noble friend Lady McIntosh of Pickering for the conversations we have had on inequalities, particularly in rural areas. A number of noble Lords alluded to this. I should also like to record my thanks to noble Lords in the Committee and in the other place who have campaigned so strongly on this issue. We have listened. The amendments already accepted in Clause 20 have directly addressed the need to consider victims of abuse, including victims of domestic and sexual abuse.
Clause 20 ensures that integrated care boards and their partner NHS trusts and foundation trusts set out a joint forward plan for any steps that the ICB proposes to take forward. As the noble Baroness, Lady Barker, said, we also have to make sure that this is not seen as just an NHS issue. We want to make sure that we work more widely with all agencies in the area to tackle these issues. For these reasons, we do not feel that a separate strategy is necessary in the Bill. Also, the accepted amendment is more comprehensive. It covers all forms of abuse. There are also duties on CCGs to consider the needs of victims of violence, including a joint strategic needs assessment. CCGs must respond to these, and this will be transferred to the ICBs.
Under the Government’s new Domestic Abuse Act, local healthcare systems will be required to contribute to domestic abuse local partnership boards. It is also worth noting that the Government are undertaking wider work to protect and support victims of domestic violence. Clearly, further action is needed beyond the NHS. In particular, the Police, Crime, Sentencing and Courts Bill will require action from across government, and we will ensure that this work is aligned as much as possible.
The proposed amendment would place a requirement on ICBs to have a domestic abuse and sexual violence lead. We agree with the principle, but we think we can do this effectively through existing legislation and guidance, as set out in the Government’s recent violence against women and girls strategy. My department will engage with ICBs and partnerships to make sure that we have appropriate guidance.
Beyond ICBs, there is a huge opportunity for ICPs to support improved services for victims of domestic abuse, sexual violence and other forms of harm through better partnerships. I hope that I have given noble Lords some assurance about this.
Once again, I am grateful to the noble Baroness, Lady Barker, for tabling Amendment 297J. Good sexual and reproductive health and healthy relationships make a significant contribution to our health and well-being. We believe that access to appropriate and high-quality interventions is much needed. As the noble Baroness once again said, this is not just for the NHS. We are currently developing a new sexual and reproductive health strategy, which will be published this year. In the HIV action plan, published last year, we set out our plans to end new HIV transmissions in England by 2030. This amendment would require us to report to Parliament within six months of the passage of the Bill—also subject to the findings of the report.
We accept that there are concerns about fragmentation in commissioning and delivery of SRH services across England, which were so eloquently laid out in the contribution from the noble Baroness. In her words, we cannot continue in this inefficient way. The Government are determined to address this, given the shared agenda on sexual and reproductive health between local government and the NHS, as well as having stronger commissioning and leadership responsibilities. We want to see stronger collaboration and co-operation right across government to ensure more efficient and effective services.
Subject to the successful passage of this Bill, we will update the existing duty on ICBs and local authorities to co-operate with each other. Clause 66 will give us the power to issue statutory guidance on the duty of local government and the NHS to co-operate. We will consider using this power in relation to sexual and reproductive health services to support the implementation of our new strategy and our ambitions for both our sexual and reproductive health and HIV programmes.
I regret that the Government cannot accept these amendments. I hope I have given noble Lords some assurance on the issues where I have sensed the strength of the House’s feeling. I hope we can continue these conversations. In that spirit, I hope that noble Lords will not press their amendments.
My Lords, even by the standards of your Lordships’ House, this has been an exceptional debate. The noble Baroness, Lady Pitkeathley, said that this is a really important set of amendments which go right to the heart of the Bill. They cover a remarkable range of issues. I, for one, am profoundly grateful to all the speakers who have taken part.
I think we all have some sympathy for my noble friend the Minister. He will have heard a number of messages loud and clear. I would like to mention the powerful contribution from the noble Baroness, Lady Masham, with her very important personal insights on the issue of fractures and the problems in rural communities. The noble Baroness, Lady Hollins, gave us a comprehensive view of the integration of services. It certainly struck a chord with me, as I am currently grappling with the problems faced by an elderly friend who is seriously ill and for whom these issues are very real and distressing. My noble friend Lady McIntosh told her own story of osteopenia, which underlined how vital early diagnosis and treatment are.
I thank the Minister for his comprehensive response. I think we all welcome his comments on data and digitisation. These are obviously good, but it is not just about data or monitoring, nor about building blocks, however important they are. It is about structures and obligations, and about effective integration being written into the Bill.
I am afraid that the elephant in the room, identified by the noble Lord, Lord Scriven, is still sitting out there. The Minister will have seen the strength of feeling of the House. As he said, there should be further conversations, which I think everybody would welcome. Otherwise, these issues will come back on Report.
It is essential that we tackle the issue of bone health and, as the noble Lord, Lord Rennard, said, this Bill is the right place to do it. The noble Lord, Lord Hunt of Kings Heath, summed it up superbly. We have known the benefits of proper prevention for a very long time, but progress has been at a snail’s pace. There was no answer to that point. In purely economic terms, as well as for the care of individuals, this is—in the vernacular—a no-brainer. If we do not make progress, we are letting down patients, taxpayers and the NHS.
I hope we can make further progress on all the points that have been raised by noble Lords in this extraordinary debate. In the meantime, I beg leave to withdraw my amendment.
Amendment 50 withdrawn.
Amendments 51 to 53 not moved.
54: Clause 16, page 14, line 47, at end insert—
“3AA Duty of integrated care boards to commission approved treatments(1) This section applies where—(a) a treatment has been approved by the National Institute for Health and Care Excellence,(b) an integrated care board has not arranged for the provision of that treatment under section 3 or 3A, and(c) a clinician has recommended that treatment for a person for whom that integrated care board has responsibility.(2) The integrated care board must arrange for the provision of that treatment to the person for whom it has responsibility.(3) In subsection (1) “clinician” means a medical professional employed by or acting on behalf of an NHS Trust, NHS Foundation Trust or primary care service from whom the integrated care board has arranged for the provision of services.”Member’s explanatory statement
This amendment would require an integrated care board to arrange for the provision of a NICE-approved treatment to any patient whose NHS clinician has recommended it, even if that treatment is not otherwise available to patients in that ICB area.
My Lords, I will speak particularly to Amendments 54, 74 and 97 in this group. I warmly thank the noble Lords, Lord Patel and Lord Hunt, for lending their support to all three amendments, and the noble Lord, Lord Warner, for supporting Amendment 74. I pay particular tribute to the noble Lord, Lord Patel, and his historic work prior to the setting up of NICE; it was a great contribution that deserves to be recognised.
We are all aware of the procedure that, when a medicine is approved, it goes through two processes. First, it goes to the Medicines and Healthcare products Regulatory Agency, known as the MHRA, a body which checks whether a drug is safe and effectively does what it says on the tin. It then goes through a separate process run by the National Institute for Health and Care Excellence, known as NICE, which looks at cost-effectiveness and value for money. After those two hurdles have been passed, the medicines should, theoretically, be accessible to anyone. That is very clear in the NHS constitution, which explains that there is a legal right for people to have access to NHS NICE-approved drugs if it is right in their particular circumstances that they should. Indeed, the NICE guidelines say very clearly that there should be automatic adoption within 90 days of approval, if clinically appropriate and relevant.
For a drug then to be prescribed, it must not only have been approved by NICE but go on to the approved list of drugs in the local health authorities, called a formulary. The problem is that somebody must put the drug on the formulary and, currently, while in theory there is a system under the NHS NICE guidelines, this does not actually happen. Sadly, this results in a postcode lottery where some areas have the product on their formulary and others do not. Sometimes this is a process failure, but sometimes it is to avoid budget overspends. Therefore, I would say that it is at the patient’s expense that they are deprived of the drug.
To give an example of the problem, there is currently a drug for multiple sclerosis that patients are still waiting after 150 days to see go on to the formularies in around 25% of the local health systems across the country. There is a state-of-the-art flash monitor for type 1 diabetes, but the uptake across the country varies between 16% and 65%. What is most worrying is that those parts of the country with the greatest levels of deprivation have the lowest level of uptake.
I make a plea to the Minister: in my view, ICBs should be required to ensure that all NICE-approved medicines and devices are available and promoted to their population, because the cost of these drugs is covered by the VPAS reimbursement scheme agreed between the NHS and the pharmaceutical industry. If a treatment is unavailable in one ICB footprint, they should be required to commission the required treatment from another ICB. The Government should also promote uptake through the ICBs of NICE-approved medicines and report uptake of new medicines annually.
Amendment 54 would require an ICB to arrange for provision of a NICE-approved treatment to any patient whose NHS clinician has recommended it, even if that treatment is not otherwise available to patients in that ICB area. Amendment 74 would require ICBs to ensure that all NICE approvals are available and promoted to their population via a publicly accessible format, normally online, and to report on their uptake annually. Amendment 97 would mandate integrated care boards and healthcare providers, notably hospital trusts, to update their formularies to include all NICE-approved medicines or devices within 28 days of market authorisation, to ensure they are available for healthcare practitioners, through either their physician, for example, or prescribing pharmacist, to make available for suitable patients.
I thank those who submitted briefings to me while I was preparing for today, notably JDRF, which makes a number of recommendations on this issue, particularly in regard to type 1 diabetes. These aim to reduce inequalities, remove the postcode lotteries to which I referred and make sure that treatments, such as those for type 1 diabetes, are uniformly available across the piece. I also thank EMIG, a pharmaceutical trade association for small and medium-sized companies, for its briefing. It says that the uptake of NICE-approved medicines is critical for NHS patients to benefit from the latest and most promising innovations. Finally, I am grateful to Vertex Pharmaceuticals, which submitted a briefing that again supports the conclusions reached. Among the proposals it highlights is the introduction of a modifier to take account of the severity of a disease and efforts to more fairly consider uncertainty in the evidence for highly innovative and complex treatments for rare and severe diseases, including through greater use of real-world evidence.
On this small group of amendments, I look forward to hearing what the noble Baroness, Lady Finlay, has to say in connection with her neat, simple amendment, which would strengthen what we are proposing to do here. I urge the Minister and the department to address these postcode lotteries and make sure that NICE does not just make the guidelines but ensures that treatments reach the formularies and ultimately the patient in question. I beg to move.
My Lords, the noble Baroness, Lady Brinton, is taking part remotely. I invite her to speak now.
My Lords, I wish to speak in support of Amendments 54, 74 and 97, tabled by the noble Baroness, Lady McIntosh, and Amendment 163, tabled by the noble Baroness, Lady Finlay. I too pay tribute to the historic work of the noble Lord, Lord Patel, prior to the setting up of NICE.
While it is not an interest in the formal sense, I declare that I have autoimmune disease and have experience of being on the NICE rheumatoid arthritis care and treatment pathway for 19 years, which has been regularly updated by NICE over that time. Where it has been applied in full and from diagnosis, patients have found it very beneficial and, with new and more effective drugs being approved every few years, many are now in remission. I pay tribute to the consultants trying to do their best for their patients and the National Rheumatoid Arthritis Society and Versus Arthritis helplines which support RA patients in navigating their way through access to their NICE treatments when these have been blocked.
I thank the noble Baroness, Lady McIntosh, for her introduction to this group and for explaining the problem with the formulary list. She is right that this should be addressed formally. However, I want to focus on some of the commissioning practices on NICE-recommended treatments, including those on the formulary, in the current CCGs, because I believe these explain the need for the amendments in this group.
In May 2014, the High Court ruled that Thanet CCG could not disagree with NICE guidance merely because it disagreed with it, even when there is no statutory duty to provide that treatment. This specific case was about access to fertility treatments for a woman who was about to undergo bone marrow transplantation to put her severe form of Crohn’s disease into remission. NICE’s 2013 clinical guidance recommended that
“oocyte or embryo cryopreservation as appropriate”
should be offered
“to women of reproductive age … who are preparing for medical treatment for cancer that is likely to make them infertile”.
This was not cancer, and the CCG’s own policy was to not grant funding unless there were exceptional circumstances.
One might think that, after the High Court ruling, CCGs would follow the High Court judgment, but many have found ways to delay the implementation of NICE treatment pathways recommended by consultants for their patients. A particularly unhelpful practice is that many CCGs have developed a committee for considering the initially more expensive NICE pathways. A nasty delaying tactic employed by some sub-committees, reported to me by consultants, is to meet only a limited number of times a year, meaning that there is an automatic minimum delay of some months before any request for a biologic drug can be approved for autoimmune disease. Worse still, one consultant told me that, when budgets are tight, some CCGs use bureaucracy to wait until the committee is due to meet, and at that point write back to the consultant to say that their proposal does not exactly meet the NICE pathway as they understand it and, like a game of snakes and ladders, the consultant must apply all over again. I am sure that this is because of budgetary means, but it makes a mockery of the principles behind the NICE pathway.
Some CCGs are interested only in the medication side—the noble Baroness, Lady McIntosh, talked principally about medication—and ignore the other elements of a NICE treatment pathway. In the RA pathway one key recommendation is that all newly diagnosed patients have access to specialist physiotherapy and occupational therapy, hand exercises, podiatry and psychological interventions, among others. Far too many patients are not offered any of these. The importance of this at diagnosis is that it helps to reduce symptoms, reduce bone damage and reduce future costs to the NHS.
My local CCG, among others, used to have specialist provision, but it now refers new patients to cheaper, non-specialist physios and occupational therapists, wasting valuable time to prevent damage to patients’ joints. I am horrified when talking to recently diagnosed patients to discover they have not been referred to any of the wider multidisciplinary teams, despite the clarity of the NICE guidelines.
NICE uses experts to develop the most effective and cost-effective treatment pathways. In the case of RA, this includes a ladder of medications that consultants and patients progress up, ensuring value for money as well as value for treatment. Providing a consultant uses the NICE guidelines and pathways, it should not be within the gift of any commissioning body to change or delay that.
These amendments place in the Bill the duty of ICBs to approve and deliver treatments as set out by NICE in full. We delude ourselves if we think that ICBs will not try to behave in a similar way to CCGs, not least because many of the staff who deal with the commissioning will have been TUPE-ed straight across from CCGs.
Amendment 54 tackles the problem of the patient in the High Court case I referred to, by proposing that if a clinician recommends a NICE-approved treatment, even if the treatment is not available to other patients in their area, the patient should receive that treatment. I agree.
Amendment 74 deals with the problems of poor practice in some of the CCGs, which I have outlined, and ensures that if NICE has an approved treatment pathway, ICBs should not be able to refuse it. The reporting mechanisms in Amendment 97 would hold ICBs to account publicly. I like the way that Amendment 163 links all this back to the NHS mandate, because of course the NHS is going to be providing the funding for CCGs.
To do anything less than accept these amendments is to demean the work and statutory role of NICE and its experts, to frustrate consultants trying to do their best under those guidelines for their patients, and to deny patients their fundamental right to access to treatment as approved by NICE. I look forward to hearing the Minister’s response and hope that it will be helpful.
My noble friend Lord Patel has had to leave because of pre-booked travel, but he has given me the honour—and it is an honour—of having his brief speaking notes, from which I would like to start, and then move on.
Before I get on to that, I think it is important for us to remember that NICE was set up to establish the evidence base behind what we do. Before NICE was established—and I have worked with Deirdre Hine, who was very involved in setting it up when she was Chief Medical Officer for Wales—people were doing things because they had always done them and because they liked doing them that way, with no evidence base, and often they were doing things that made situations worse, not better.
As Lord Patel wanted to stress, clinicians have a strong belief now in evidence-based healthcare, and guidelines are critical to ensure high and consistent levels of evidence-based clinical practice across the NHS. The guidelines developed by NICE can be adapted to the local situation, and they are also under review. I should declare that I have served for three years as vice-chair of the group looking at ME/CFS guidelines, and it was very instructive to see the depth to which everything was explored and the rigour of the processes; to the point that, when we were asked to review again some papers, we went back to the beginning and reviewed them all over again. Interestingly, in doing that, we slightly downgraded their scoring, rather than upgrading it, which is what had been expected. I was really impressed at the rigour of the process, including the health economics impact.
That experience has been behind the push to make sure that there is compliance. My proposed amendment would be a way of assessing compliance with the guidelines as predetermined and set out in the NHS mandate. The mandate could select a few that would act as proxy markers across the piece and include a date line, so that their implementation across the country could be benchmarked. It would not increase the workload, because it could draw on existing sources of data in the NHS. As the Minister has said, data is our key to understanding and unlocking things.
The noble Baroness, Lady McIntosh, in her comprehensive introduction to this group of amendments, spoke about type 1 diabetes and highlighted that, in some areas, the adoption of continuous glucose monitoring is as low as 0%, whereas in other areas it is up to 20%. There are a couple of other emerging areas; one is in atrial fibrillation, where direct oral anticoagulants have made warfarin a drug of the past. Yet the variation between clinical commissioning groups’ adoption of the guidance is quite horrifying. There is a threefold variation in prescribing, so there are areas of the country where a lot of patients are being denied an intervention that has been shown to be beneficial compared to what was done before.
We have already alluded to another emerging area: the new biologics. On the face of it, they are very expensive, but they are often remarkably effective—they can revolutionise the management of some diseases. We have a budgetary problem here, because the NHS budgets are year-on-year, and the face-value cost of the new biologics is very high; but if you look at the whole lifetime cost of healthcare interventions then they come out much lower. Take the example alluded to, of Crohn’s disease, and consider the cost of someone having their bowel removed, who might then end up on total parenteral nutrition; it is not only the cost of that nutrition but the costs in all other domains in their life, and the lives of their family. In comparison, the new biologics can rapidly get this disease’s process under control and revolutionise things.
The proposal is to give the CQC the powers routinely to address the adherence to guidelines—that would be specified by the NHS mandate, so a national standard could be set—and introduce a reporting metric using current data sources as a starting point to establish a benchmark. I want to stress, as I know does my noble friend Lord Patel, that we are not advocating for guidelines to be mandatory—that would not be right, because each patient is different and individual—but we are asking for a system to be introduced that gives powers so that there can be scrutiny of whether the guidelines are being adopted, because their adoption would narrow the gap in inequalities. We both feel that we need to commit to address this in this important legislation, because it is a way of achieving tangible action to ensure equity in access to quality in healthcare.
My Lords, I have added my name to the three amendments that the noble Baroness, Lady McIntosh of Pickering, has referred to. I was the first Minister for NICE, going back to 1999. At that time, we were confronted with a paradox which continues to this day, which is that, although the NHS is full of innovation and we have an incredibly strong life sciences sector and industry, the NHS is also very slow to adopt those innovations. NICE was developed to speed up the introduction of effective new medicines and devices. Right from the start, we had a problem with the NHS being reluctant to implement its recommendations and, within a few months of it starting, a regulation had to be put through which required it to implement them within 90 days. That has been slightly modified since, but none the less, it is still in being. The NHS has become very adept at finding ways to get round this through the various blocks that have been put in at CCG level—the noble Baroness, Lady Brinton, explained clearly the kind of blocks, devices and bureaucratic machinations that are put into place.
The result is that we continue to be very slow to introduce proven new technologies and medicines. NHS patients are very disadvantaged compared to patients in most countries. It then impacts on pharma and the devices industry—I think that pharma is more reluctant now to introduce medicines and develop R&D in this country as a result.
The Minister knows that there is an agreement—it is called VPAS at the moment—whereby NHS expenditure on drugs is capped and industry pays rebates if the cost goes over that cap. Given what I have always thought to be an imaginative agreement and given that industry is essentially underwriting some of those additional costs, surely there must be a better way to approach this which would allow the NHS to implement NICE recommendations enthusiastically, rather than essentially putting into place blocks.
I doubt that we are going to spend two and a half hours on this group of amendments, but these are just as important as the last group, because they go to the heart of whether NHS patients get access to the drugs, devices and technologies that they should. At the moment, they do not. I hope that the Minister might be prepared to take the amendment away. Legislation is the only way that we can see of leveraging the kind of change we need.
My Lords, I support Amendment 163 in the name of the noble Baroness, Lady Finlay, to which I was delighted to add my name.
Perhaps I may remind the Minister of his very first session at the Dispatch Box. He confirmed to your Lordships that the Government had full confidence in the processes at NICE. In a follow-up letter to me he wrote:
“The National Institute for Health and Care Excellence (NICE) is the independent body that develops authoritative, evidence-based guidance for the health and care system to drive best practice. NICE is one of the few organisations with a remit spanning the NHS, public health and social care, meaning it is well placed to provide a system-wide perspective and support Government priorities for the health and care system.”
As noble Lords have outlined, and the Government have acknowledged, the process for publishing guidelines is authoritative, evidence-based and drives best practice. Why then would the Government not want to include a review of compliance with NICE guidelines to be stipulated in the mandate, which is all that Amendment 163 seeks?
I declare my interest as chief executive of Cerebral Palsy Scotland. I want to highlight the challenges faced by people with long-term conditions, particularly adults with cerebral palsy, who struggle to find co-ordinated, specialist services. The guidelines for adults with CP were published in January 2019. I can confirm that the process was indeed thorough and collaborative; Cerebral Palsy Scotland contributed as a registered stakeholder, even though NICE does not necessarily apply in Scotland. The process had wide cross-sector and specialty support. However, the guidelines are yet to be implemented.
In addition to the guideline, a year later, in January 2020, NICE published a quality standard on care and support for adults with cerebral palsy. This included a recommendation that adults with cerebral palsy be referred to a specialist multidisciplinary team. Adults with CP feel that they are second-class citizens. Their daily experience is of struggle to access any specialist services, in contrast to other lifelong conditions. For some reason, health services for people with CP are concentrated in paediatric services, and despite the fact that having CP does not in itself give you a reduced life expectancy, the NHS seems to believe that once you reach the magical age of 18, your cerebral palsy suddenly is not a problem any more.
The NICE guideline and quality standard both recognise the challenges that adults with CP face and that some people require access to specialist multidisciplinary teams, experienced in the management of neurological impairments, who can work to identify their needs, understand how they may change over time and refer on to specialist and local services as appropriate. Unfortunately, not enough of these services exist. The policy framework might be there, but we are doing absolutely nothing to ensure that it is implemented. People with cerebral palsy are asking, “What is the point of NICE?”
Since the Government clearly value the work of NICE, I urge the Minister to take the opportunity of these amendments to ensure that NICE guidelines are put into practice. Therefore, I look forward to the Government’s support for the amendments.
My Lords, I support all the amendments in this group, particularly Amendment 74, to which I have added my name. I was one of the successors to the noble Lord, Lord Hunt, as a Health Minister responsible for NICE. I pay tribute to his sterling work in establishing it. However, I encountered the same difficulties as he encountered with the NHS speedily taking up NICE recommendations and had to wrestle with this same problem.
I had a long and slightly exhausting chat with the chief executive and the chairman of NICE about what they could do to help the NHS implement their recommendations. We arrived at a concordat, and the NICE people went away and developed a rather helpful system for enabling the NHS to prepare for a NICE recommendation and to implement it. As far as I am aware, looking at the NICE website, it still has that system in place, so it is not as though NICE is simply putting its recommendations in the public arena and leaving the NHS to get on with it; it has done its level best to produce a way of helping the NHS to prepare to implement those recommendations.
What I do not understand is why we have not moved faster over time to recognise that more action needs to be taken with the laggards within the NHS to make this happen. I think that one method is captured in the amendment from the noble Baroness, Lady Finlay.
If NICE is so important and it is so important that the NHS implements its recommendations, that ought to figure in the regulator’s assessment of the performance of those NHS bodies. I can see no reason it should not, and I wonder whether the Minister could tell us a little more than I know—and more, I suspect, than the Committee knows—about the current position on the failures of NHS bodies to pursue NICE recommendations. Do the Government accept that the regulator of these bodies should take account of their ability and willingness to implement NICE recommendations? Perhaps the Minister could clarify some of those issues. If he cannot clarify them today, perhaps he could write to us.
My Lords, I had not intended to speak but, animated by the contributions of colleagues who, like me, were there at the conception of NICE, I thought I would offer a couple of contextual remarks to this group of amendments, supporting their underlying motivation, which is to ensure the spread of best practice as fast as possible across the National Health Service.
I was also motivated by the noble Baroness, Lady Watkins, who spoke earlier about the Crimean War, to recall that this is not a new problem. The world’s first controlled clinical trial took place in 1754 on board HMS “Salisbury”, when the Royal Navy was trying out the use of citric fruit—in lemons and limes—to combat scurvy. That experiment showed that scurvy could be tackled with lime juice, and it took the Navy 41 years to mandate its introduction more widely—fortunately, just in time for the Napoleonic Wars, which is why some argue that, contrary to Winston Churchill’s dictum that it was “rum, sodomy and the lash” that contributed to the Navy’s success, it was in fact lemon and lime juice.
The point is that this is not a new problem. We have been grappling with this but, despite that, we have seen the remarkably quick adoption of new clinical practices over the last two years during Covid, as new randomised control trials, following in the wake of the 1754 example, have shown the benefits of treatments such as dexamethasone. My point of context is that we need to be clear, if this group of amendments is to advance, about the terminology incorporated in the amendments. These will inevitably be, if they find their way into the Act, litigated against in the High Court and Court of Appeal.
In the drafting, there is reference to the marketing authorisations given by NICE, although I think it is the MHRA that provides marketing authorisations. There is a clear distinction to be made between the technology appraisals NICE undertakes and the development of guidelines. Although a number of noble Lords have referenced the importance of the guidelines, it is worth saying that a quick look at the NICE website reveals there are 1,591 guidelines, pieces of advice, quality standards and all the rest of it—most of which have not been subject to the full cost-effectiveness and affordability assessments that the gold standard technology appraisal performs. Before there could be a legal mandate for those guidelines, there would be some very significant methodological considerations for NICE. Without those, the risk is that mandating those guidelines would take resources away from other parts of needed care, such as mental health and community nursing—Cinderella services that have not been subject to those same processes.
We should also recognise that, vital though NICE is, the bigger contribution to the diffusion of best practice will probably be made in other ways. Certainly, reporting could help. Although one amendment makes the perfectly reasonable proposition of an annual report from integrated care boards on their adoption and uptake, that still feels a slightly 20th-century solution. If you go to Oxford University’s superb www.openprescribing.net, you can see your own GP practice and your own CCG’s prescribing patterns against the national norm, including, as the noble Baroness, Lady Finlay, said, for the DOACs, the anticoagulating medicines. Those technologies are already available, and the role that clinical pharmacists are now playing, including the thousands of new clinical pharmacists hired to work alongside GPs to improve their prescribing habits, is also likely to have an important influence.
Finally, there is this question of whether, just occasionally, conflicts of interest might arise on the part of prescribers or clinicians over the medicines or devices being used. The noble Baroness, Lady Cumberlege, has drawn attention to this in her important work, and that is perhaps something the House might return to at a later date.