Report (1st Day)
Relevant documents: 15th, 16th and 19th Reports from the Delegated Powers Committee, 9th Report from the Constitution Committee
Schedule 1: Renaming of NHS Commissioning Board
1: Schedule 1, page 139, line 29, at end insert—
“the Armed Forces Act 2006, section 343AA (as inserted by section 8(3) of the Armed Forces Act 2021);”Member’s explanatory statement
This amendment is consequential on Clause 1 of the Bill which renames the National Health Service Commissioning Board “NHS England”.
My Lords, in moving Amendment 1, tabled in the name of my noble friend Lord Kamall, I will speak to the other government amendments in this group in his name.
Amendments 1, 76 and 77 are consequential amendments to two pieces of legislation that have been before Parliament during this Session. These amendments relate to the Police, Crime, Sentencing and Courts Bill and the Armed Forces Act 2021, and replace references to clinical commissioning groups with references to integrated care boards, and references to the NHS Commissioning Board with references to NHS England. Amendments 110 and 126 are purely minor and technical in nature to correct small drafting points in Clause 79 and Schedule 16.
I turn now to capital expenditure. The Government have listened carefully to the debate on Clause 54, and Amendments 88 to 91 will ensure that the powers in Clause 54, alongside our commitments to publish further operational guidance, are in line with the agreement between NHS Providers and NHS England in 2019. These amendments limit the powers to set capital expenditure limits for NHS foundation trusts, so that they cannot apply for periods longer than a financial year.
NHS England will continue to work with NHS trusts and foundation trusts to ensure sustainable use of capital expenditure, and it is our intention that a capital limit would be imposed only if other ways of resolution have been unsuccessful. A limit would be set only where usual financial reporting returns identify a likely breach of system expenditure limits. We therefore expect that the vast majority of capital limits will be set either in-year or shortly before the beginning of a financial year.
I reaffirm the Government’s commitment to ensuring that these powers are used only as a last resort, as NHS England agreed with NHS Providers. I am grateful to both NHS Providers and the noble Lord, Lord Crisp, for their constructive work in ensuring that these powers reflect that intention.
I hope noble Lords will therefore be supportive of these amendments. I beg to move Amendment 1.
My Lords, I thank the Minister for explaining the government amendments. I particularly welcome Amendments 88 to 91, because the Bill will now reflect the agreement made with the NHS foundation trusts in a much closer manner than in its original drafting. They are very welcome.
Amendment 1 agreed.
2: After Clause 2, insert the following new Clause—
“Spending on mental health
(1) The National Health Service Act 2006 is amended as follows.(2) After section 12E insert—“12F Expected mental health spending(1) The Secretary of State must, in respect of each financial year, publish and lay before Parliament a document—(a) stating, by comparison with the previous financial year—(i) whether the Secretary of State expects there to be an increase in the amount of expenditure incurred by NHS England and integrated care boards (taken together) in relation to mental health, and (ii) whether the Secretary of State expects there to be an increase in the proportion of the expenditure incurred by NHS England and integrated care boards (taken together) that relates to mental health, and(b) explaining why.(2) The Secretary of State must publish and lay the document before the financial year to which it relates.”(3) In section 13U (annual report), after subsection (2A) (inserted by section 29 of this Act) insert—“(2B) The annual report must include—(a) a statement of the amount of expenditure incurred by NHS England and integrated care boards during the year (taken together) in relation to mental health,(b) a calculation of the proportion of the expenditure incurred by NHS England and integrated care boards during the year (taken together) that relates to mental health, and(c) an explanation of the statement and calculation.””Member’s explanatory statement
This amendment requires the Secretary of State to publish any governmental expectations as to increases in mental health spending by NHS England and integrated care boards, and requires NHS England to include in its annual report information about such spending.
My Lords, in moving Amendment 2, I will speak to Amendments 57, 78 and 109 in my name. We have heard impassioned and compelling arguments here and in the other place for the need for greater emphasis on mental health in the Bill. We have listened and, as a result, have taken action. The result is the package of amendments brought before the House today. I take this opportunity to pay tribute to the many noble Lords across the House who have contributed to the development of these amendments and the advice we have received.
Let us first turn to defining health. I assure your Lordships’ House that this Government remain fully committed to delivering parity of esteem between physical and mental health. We want to support everyone’s mental health and well-being. We are very aware of the impact that the pandemic has had on a number of individuals and communities, particularly the impact on mental health and mental health services.
Amendment 109 removes any potential confusion as to whether references to health within the NHS Act 2006 include mental health. We have made it absolutely clear with our amendment that references to health includes mental health as well as physical health. I know noble Lords will acknowledge that it was our view that the current references to health in the Act would have included mental health, but this amendment is important because it sends a strong signal that health must not just be associated with physical health. Mental and physical health are equally important, and our legislation reflects that fully.
On the transparency and accountability of mental health funding, the Government remain committed to our ambitions in the NHS Long Term Plan to transform mental health services in England. The NHS Long Term Plan committed to increase spending on mental health services in real terms by at least £2.3 billion a year by 2023-24. For each year of the current spending review period, the spend on mental health will increase as a share of the NHS budget. This is in line with the Government’s ongoing commitment to grow investment in mental health services faster than the overall NHS budget. Our amendment seeks to bring added transparency to this commitment and will better enable Parliament, stakeholders and the public to hold the Government to account for meeting this commitment.
The Secretary of State will be required to publish and lay before Parliament, before the start of each financial year, a document setting out the Government’s expectation on mental health spending for the year ahead. This document, a Written Ministerial Statement, will set out whether the Secretary of State expects there to be an increase in the amount and proportion of expenditure incurred by NHS England and integrated care boards, taken together, in relation to mental health, with a supporting explanation. There will also be requirements for NHS England and ICBs to include in their respective annual reports information about such spending to clearly demonstrate performance against expectation.
I am very grateful to the noble Lord, Lord Stevens, as well as the noble Baronesses, Lady Hollins, Lady Merron and Lady Tyler of Enfield, for supporting amendments related to transparency and accountability of mental health funding in Committee, and for their constructive engagement since. I hope I have reassured noble Lords that this Government are committed to delivering parity of esteem between physical and mental health. I hope that our amendments address the issues and concerns previously raised and that the House will pass them today. I beg to move Amendment 2.
My Lords, continuing the outbreak of consensus, a large number of mental health stakeholders welcome the fact that the Government have accepted these amendments, which draw heavily on amendments a number of noble Lords brought forward in Committee. I think I said at that point that they would represent a spine-stiffener for the Government in their commitment to ensure that mental health sees a growing share of the growing NHS budget and an accountability booster for the NHS. I think they do that.
However, before the Minister concludes on this item, will he say whether, when setting the mandate for NHS England for the financial year ahead—the mandate that will therefore be laid at some point within the next 30 days—the Government might set the mental health waiting time standards, the very welcome consultation on which concluded last week, in a way that other amendments in this group would look to advance? None of that should detract from the fact that these amendments have wide support outside this place and will make a real difference to mental health in the years to come.
My Lords, I rise to speak to Amendment 184, tabled in my name. I shall first respond briefly to the government amendment introduced as a result of the discussions in Committee, which set the context for my amendment. I welcome the government amendment requiring the Secretary of State to publish his expectations about increases in the amount and proportion of mental health spending by NHS England and ICBs. I also welcome amendments requiring NHS England and ICBs to include information about spending relating to mental health in their annual reports.
However, it is stating the obvious to point out that their ability to do so is ultimately reliant on the Government—that includes the Treasury—prioritising sustained growth and investment in mental health. This is critical to avoid a widening care deficit in mental health and inequity between physical and mental health care standards. When I say “a care deficit” I want to explain briefly that the healthcare system is still operating in the context of a mental healthcare deficit, where not all those who need help and treatment will seek it or be able to access it and it is estimated that 1.7 million people are waiting to access mental health services.
That is the context of my Amendment 148. It is designed to build on the welcome government amendments and to provide what I call the critical third pillar of reform, which is service access standards. I welcome the measures that the Government have already taken in relation to access standards as part of the NHS long-term plan, but I believe we need to go a bit further and give them more teeth. Waiting time standards can play a critical role in making progress towards our shared ambition of achieving parity of esteem, particularly in service response times. Standards are a driver to secure the resources needed for services to be able to meet demand in an effective and timely way.
Key to the successful implementation of the service access standards will be two things: first, the funding to develop services in a way that means they can meet these standards without leading to unintended consequences, such as transfer of delays from accessing the system to further down the care pathway; and secondly, a clear expectation that these standards must be matched with a sufficient workforce so that the standards are delivering better care and not shifting problems further down the line.
Having these service access and waiting time standards underpinned by legislation would be a very effective lever for improvement by helping to identify where additional resources are needed. I have looked very carefully at the two points in the response published last week to the consultation on NHS access standards. I think the key points were clear: new targets cannot be introduced without additional funding to support them; respondents were generally strongly supportive of new targets in mental health; quality as well as speed of response is important; and expanding the range of the targets to include preventive and early intervention services would be beneficial.
I took heart from the news release that accompanied the publication of that response. I saw that the Minister for Mental Health, Gillian Keegan MP, said:
“Improving access to mental health services is a top priority. These new standards would help patients get support faster—including having a face-to-face assessment within one hour of being referred from A&E. I know there is more to do and that’s why we’re transforming mental health services in England with an extra £2.3 billion a year and will soon be launching a national conversation to inform a new long term Mental Health Strategy later this year”.
That is all very welcome. With such an endorsement from the Minister in the other place, I hope that the Minister will feel able to support my amendment, which provides that critical third pillar of funding, workforce and waiting time standards to ensure that all those aspirations become a reality.
My Lords, I welcome all the amendments in this group. The importance of parity between mental and physical health is key, and I am grateful to the Minister for confirming that that is the intention behind the Government’s amendments. The explanatory component of the amendment is important, but a question remains over what precisely constitutes mental health spending. I would be grateful if the noble Lord could clarify this. For example, will the report on the expected change and expenditure by NHS England and the ICBs, and the comparison with the previous year, include other aspects of mental health investment not covered by the mental health investment standard, including dementia and learning disabilities? Will the Minister consider identifying in the report whether each ICB has increased the proportion of spending on children and young persons’ mental health, with details of any failure to increase spend?
Turning to Amendment 184, tabled by the noble Baroness, Lady Tyler, to which I also added my name, Dr Adrian James, president of the Royal College of Psychiatrists, said:
“These new standards will help patients get the treatment they need when they need it by setting more rigorous standards and generating vital data, helping to put mental health on a more equal footing with physical health. The standards will only have this impact if matched with similarly ambitious investment and action on the workforce crisis to ensure that no-one has to wait too long for the treatment they need. It’s vital the government provides further clarity on how it will support the implementation of these standards as part of the broader recovery from COVID-19.”
I would add that the range of treatments available in all localities needs to be thought about very carefully by ICBs, just as in surgical teams the right specialist expertise is required for each condition, with reasonable adjustments being made for people who have difficulties in accessing specialist services. I include here, of course, people with learning disabilities. It would be unfortunate if waiting times simply led to an increase in medication clinics, rather than the development of a gold standard treatment in mental health, which would include appropriate skills and psychotherapeutic help alongside appropriate social prescribing.
I want to reiterate a couple of points on this issue that I made at earlier stages of the Bill. I welcome all these amendments, and I am glad about the movement from the Government and that they have recognised the issues raised. Obviously, the key issue here is funding, and a move to better funding for mental health services within the health service is clearly important. It is also important that mental health is referred to in the legislation, and good that the standards have some statutory backing.
I have to express one concern: waiting times and access are important in and of themselves, but they are not a direct reflection of the standard of care. We need to do more work to understand how we can measure the standard of care being delivered by our mental health services. I have mentioned the issue of the differential mortality. I am sure that there are other issues, but mortality is something that I know a little bit about; those other issues could be brought in so that we directly assess the output as well as the input.
These amendments are important and will address the way in which mental health services suffer because of a lack of esteem. However, they are only treating the symptoms of this lack of esteem. We need to understand a lot more about why mental health, in all sorts of subjective ways, has not achieved a parity of esteem within medical culture as a whole. It is a deep-seated problem which needs to be addressed. The money and standards are important, but we need to understand a lot more about this differential level of esteem and how it can be addressed at its heart—not just by addressing the symptoms.
My Lords, I support these amendments and all that has been said already.
I will put a slight tone of reality on the size of the mountain which has to be climbed to get to the point we want to reach. I do not know how many people last night watched the Channel 4 documentary, “Emergency”, about four trauma centres. It is well worth watching if noble Lords want to see what the NHS is like now under pressure. I happen to know that, on one day last week in one of those major trauma centres, there were seven mental health acute patients in the emergency department but only one mental health nurse was present for all of them. One-to-one care should have been provided. There was nowhere for these patients to go; a further 20 acute patients also needed admission and there were no beds available in the hospital.
This illustrates that the intention behind all this is excellent and laudable—we are finally getting there. However, we have not got to the end of the road; we are just at the beginning. I hope that no one in the public, or in the service, has unrealistic expectations, because it will take a lot of work on everyone’s part to reach the goals we want to reach.
My Lords, I thank the Minister for listening very carefully to what noble Lords from across the House have been saying about the need to recognise the parity of esteem between physical and mental health, and for giving us some reassurance that the funding for mental health will increase in the future. A lot of mental distress has been caused by the fact that many patients suffering from mental ill health have not been able to reach the threshold for access to services. The reason for that has been a shortage of resources and a properly trained workforce which can deliver the therapies required. At the end of the debate, I hope that the Minister will be able to assure us that those resources will be made available.
My noble friend commented that she hoped that the new standards would not have the unintended consequences of transferring delays from the initial diagnosis to further down the treatment pathway. That is a very important consideration. We will talk about the importance of increasing the NHS workforce later in our debates. However, will the Minister consider how focusing increased resources on early intervention and prevention will save both money in the end and a lot of distress, as dealing with it early will save patients having to go into more intensive therapies further down the track? It is very important that any increased resources—or, at least, much of them—are focused on early intervention and prevention. I hope the Minister can reassure us of this.
My Lords, if the role of your Lordships’ House is to improve the Bill, I feel that this set of amendments will achieve this. I am grateful to the Minister and his officials for responding to the points which were made so powerfully in Committee and in meetings outside this Chamber. The range of amendments will take us further.
The Minister talked about the introduction of transparency and accountability, which are key in the efforts to improve the provision of mental health services. However, of course, improving transparency and accountability is not an end in itself; it is purely a way of getting us to the right place. What will be important is what this delivers. A step along the way to improving mental health services is definitely being made, but there is an awful lot more to do. For example, the Centre for Mental Health estimates that some 10 million additional people, and that includes 1.5 million children and young people, will need mental health care as a result of the pandemic. It would of interest to understand a little more about how the Government intend to make progress on this once the Bill receives Royal Assent. Will we see a recovery plan in the area of mental health services, backed by a long-term workforce plan, something which we will return to later?
On the policy to bring practice into line with aspiration, and on the funding for and redoubling of effort towards achieving parity, while we are talking about this on a national level, it would also be helpful for the Minister to clarify that it applies to all areas of the Bill’s implementation and that the new bodies set up by the Bill will be expected to treat mental health equally from the outset. For example, it would mean ensuring that the decisions about resource allocation, capital spending, waiting times and priorities were all taken on the basis that mental health must be valued equally with physical health.
The noble Baroness, Lady Tyler, was right to point out that we do not start in a neutral position, because we know that waiting times are considerable, standards of services need massively to be improved and the workforce needs to be strengthened in order to deliver those services. It is therefore extremely important that the Minister in putting forward these amendments undertakes to see the job through, so that we do not just have transparency and accountability for their own sake but we deliver for the many millions who will rely on those services.
My Lords, I once again thank not only noble Lords who spoke in this debate but those who engaged with us throughout the process. As the noble Baroness, Lady Merron, said, if the role of this House is to improve the Bill, we have learned much. As a relatively new Health Minister, I have learned so much from the various meetings that I have had with noble Lords, not only on this issue but on many others across the health and care spectrum.
I thank noble Lords who have engaged with me personally but also with my officials to make sure that we closed the gaps as much as we could. I am pleased to hear support from your Lordships for the package of amendments that I have brought forward, and I am grateful.
I stress that this package of amendments should be considered alongside the amendment placing a duty on ICBs to have an appropriate skill mix and experience necessary to deliver all their functions—I hope that noble Lords will look at those in that context—as we expect skills pertaining to the delivery of mental health services to be considered when meeting this duty at the ICB level as well as below that at place level. Many noble Lords have discussed the importance of place.
Amendment 184 would require the Government to report on our plans to improve mental health standards. Access to services is at the heart of the mental health commitments in the NHS long-term plan. The department, NHS England and NHS Improvement regularly report performance against existing waiting time standards in mental health, including improving access to psychological therapies services, children and young people’s eating disorder services and people experiencing a first episode of psychosis.
As noble Lords have acknowledged, last week NHS England and NHS Improvement took another step to strengthen mental health standards, publishing a consultation response following the mental health clinically led review of standards consultation. As noble Lords will know, this sought views on the proposed introduction of new measures, including five new waiting time standards, to support our ambitions to ensure that patients have timely access to community mental health care.
I will now turn to some other points on this and other issues. At this stage, we do not believe that a legislative amendment in this space is needed because of the work under way to move forward on mental health waiting time standards. As I have said, the department, NHS England and NHS Improvement have been looking at this. With the consultation, we hope we will be able to add more.
We acknowledge that no measure is perfect, but the use of first appointments is consistent; they are something that all patients will go through. There are challenges in using measures around ongoing treatment, given that length of treatment varies from case to case, based on different individuals. For example, there might be a good clinical reason for a person to receive periodic support over a number of months or years.
We agree with noble Lords who said that early prevention and intervention are important. For parents and younger children, the Chancellor announced £500 million for early years intervention, which includes £100 million to roll out bespoke parent-infant mental health support. For children and young people, we are making some progress on rolling out mental health support teams to schools; in fact, we have accelerated rollout to cover about 35% of schools and colleges in England by 2023. We are also introducing new models of care which will give 370,000 adults with serious mental ill health greater choice and control over their care and support them to live well in their communities.
I think a noble Lord asked about spending commitments. The Government are committed via the NHS long-term plan to increase spending on mental health services in real terms by at least £2.3 billion a year by 2023-24. For each year of the current spending review period, spend on mental health will increase as a share of the NHS budget. This is in line with our commitment. We are also ensuring that every CCG and ICB—once they are operational, subject to the Bill—meets the mental health investment standard, so that the spending will increase.
We have also committed to investing £300 million over this spending review to eradicate mental health dormitories by 2024-25. In addition, we are investing £150 million in significant improvements in the mental health estate over the course of the spending review. This will include investing in NHS mental health facilities linked to A&E departments, and enhancing patient safety in mental health units.
The Government will continue to work with NHS England and NHS Improvement on the next steps for the proposed mental health access and waiting time standards. I hope that, with the Secretary of State publishing the reports I have outlined, we will be held to account for this. This will include possible initiatives ahead of any formal performance thresholds being set in future.
I hope noble Lords will agree that, given the amount of comprehensive work already under way and the reports my right honourable friend the Secretary of State has committed to publish, a report such as the one outlined in the amendment is unnecessary. So I beg to move the amendment in my name and hope that the noble Baroness will consider not pressing hers.
My Lords, I thank the Minister for that very detailed and comprehensive response to my amendment. While in an ideal world I would like to see an amendment or measure in the Bill on waiting time standards to complement the other work, I accept that there is an awful lot going on that the Government are committed to. I think we will need to monitor very carefully how effective that is, but I will not press my amendment when the time comes.
Amendment 2 agreed.
3: After Clause 4, insert the following new Clause—
“Duties as to reducing inequalities
In section 13G of the National Health Service Act 2006 (NHS England’s duties in relation to the reduction of inequalities)—(a) in paragraph (a), for “patients” substitute “persons”;(b) in paragraph (b), after “services” insert “(including the outcomes described in section 13E(3))”.” Member’s explanatory statement
The amendment extends NHS England’s duty in relation to the reduction of inequalities in access to health services to cover people before they are patients. It also makes it explicit that the duty to have regard to the need to reduce inequalities in outcomes for patients covers outcomes such as the quality of experience undergone by patients.
My Lords, in moving Amendment 3 I will speak also to the other government amendments in this group, in the name of my noble friend Lord Kamall. Of the many critical topics we discussed in Committee, our debate on health inequalities stands out as one that prompted unanimous and emphatic agreement from all Benches on the need for us to recognise in the Bill the centrality of the inequalities issue. My noble friend Lord Kamall and I took it as our mission to respond to the compelling points raised by noble Lords by bringing forward government amendments on Report, which I now do. These are issues and points of principle about which the Government—not least my noble friend the Minister—feel very strongly.
As the House will know, we think it important to empower local health and care leaders to pursue new and innovative ways to tackle disparities in the most appropriate way for their area. However, we should not miss the opportunity to ensure that this Bill reinforces those intentions in other ways. The amendments are designed to ensure that the Bill fully reflects the strength of the Government’s ambition to address disparities by levelling up every area of the country.
First, we will put beyond doubt that tackling disparities should be an integral factor when making decisions across the NHS. This was something that NHS England’s four purposes for ICSs made clear. The triple aim duty was always intended to support achieving those purposes, and these amendments strengthen the duty on NHS England, NHS trusts and ICBs so that, when decisions are made by NHS bodies, consideration will always be given to the effect of those decisions on disparities. What does that mean? It means that NHS bodies should consider the wider effects of their decisions on the inequalities that exist between the people of England with respect to their health and well-being and the quality of the services that they receive.
We are also going further by strengthening the more specific duties that complement the triple aim. Disparities are not limited just to health outcomes or access; they relate also to the experience of the care that is received. For example, the independent Commission on Race and Ethnic Disparities reported that Asian patients are more likely to report being less satisfied with GP services than their white, black African and black Caribbean counterparts. These amendments seek to strengthen existing duties as to reducing health inequalities on NHS England and ICBs by explicitly including patients’ experience of care, the safety of services and the effectiveness of services to create a more holistic duty that addresses how disparities manifest themselves in health and care.
When it comes to inequalities in access to health services, we can go further. The duties currently focus only on people who are already using or accessing health services. This fails to address those who do not or cannot access health services—and, as we powerfully heard in Committee, these include many socially excluded and marginalised persons, who are more likely to have preventable health conditions. The point is fully taken, and we have therefore tabled an amendment to ensure that the duties placed on NHS England and integrated care boards as regards reducing health inequalities require the consideration of inequalities in access for “persons”, rather than simply “patients”. The intention here is to improve outreach, as well as access by socially excluded and marginalised groups.
Lastly, we recognise the crucial importance of information on which to base targeted action. The Covid vaccination campaign was unprecedented in the way that it focused activity on every community across the nation, especially where there were disparities in the uptake of the vaccine. Fundamental to that success was the ability to collect and analyse data from across the system so as to target resources in the most effective way.
Our amendment will require NHS England to publish a statement describing certain NHS bodies’ powers to collect, analyse and publish information relating to disparities in health, together with NHS England’s view on how these powers should be exercised. Those bodies will be required annually to review and publish the extent of their compliance with that view. We hope and believe that this will power the evidence-based drive to reduce disparities in health across the country.
I hope that, together, these amendments provide the reassurances that noble Lords sought from their various amendments tabled in Committee. In conjunction, these changes will strengthen the ability and the resolve of the health and care system to take meaningful and impactful action. I commend them to the House and beg to move.
My Lords, in thanking the Minister for having introduced so thoughtfully and elegantly this important suite of government amendments that address the question of inequalities, I would like to pass to the Minister and the Front-Bench team the thanks of my noble friend Lord Patel, who regrettably is unwell, recovering from Covid-19, but who of course spoke with great insight and passion in Committee on this matter, and indeed has engaged actively with the Front-Bench team subsequently in ongoing discussions.
The noble Earl has done something quite remarkable and absolutely essential. There is no need to rehearse the very strong arguments that were made in Committee around the necessity at this particular time to ensure that every element of the National Health Service is able not only to focus its resource and thought quite clearly at the elements of the triple aim but to ensure that, in a tension with those important pan-NHS objectives, the system is never allowed to forget the importance of addressing the inequalities and disparities that regrettably continue to be an abject failure of the delivery of the healthcare system.
Her Majesty’s Government, in proposing these amendments, deal not only with questions of access and outcomes but ensure that data is appropriately collected and all NHS organisations are obliged to pay attention to those data and to act accordingly; that is a very powerful statement and a powerful act of leadership. But beyond that, in ensuring that the patient’s voice and the public’s voice is heard in these matters, this will set a new tone and new direction for the delivery of healthcare in our country, and Her Majesty’s Government are to be strongly congratulated.
My Lords, I apologise; when there are so many amendments in one group I can never work out just when people who are moving subsequent ones further down the line, as it were, ought to rise.
I will speak to Amendments 63, 65 and 67, and begin with an apology that I was not able to be here to speak to those in Committee. I too had a positive test, although I have to say that I had no symptoms. None the less, I was self-isolating, and therefore was not able to be present in the Chamber.
I welcome the amendments tabled by the Government. I chair the Public Services Committee in this House. In our first report, we looked at public services through the mirror of Covid. We noted and reported, and indeed debated in this Chamber, the significant uncovering or rediscovery of the extent to which inequalities in our society affect people’s health. I am pleased that the Government are responding with some of their own amendments.
My amendments, which are supported by other noble Lords around the Chamber, relate specifically to what I understand the National Health Service calls “inclusion health communities”. For me, these are people living with complex needs in different sorts of communities. I have spent much of my working life involved with such communities and have tried to concentrate on that work in this House. The amendments seek to ensure that the NHS has a much more systematic approach to the health needs of people with complex needs and marginalised communities.
This of course involves people who have been rough sleeping—I know the Minister talked about that in Committee—but it concerns more than just that group. Those who have been rough sleeping do not have access to primary care because they do not have a settled address, but other groups are affected, such as those who have been trafficked, women who are being sexually exploited and the Gypsy, Roma and Traveller communities. The Public Services Select Committee recently held a very short inquiry into Gypsy, Roma and Traveller access to public services, which again exposed a real challenge with health and access to health services. All the data shows, and the stories from these communities tell of, very poor health outcomes, with average life expectancy being 10 to 12 years less than that of the settled community. There are some estimates which put that much higher.
As I said, I welcome the Government’s concern to address health inequalities, but having read very carefully what the Minister said in the earlier debates and in letters, it seems to me quite clear that the Government and the NHS remain behind the curve on this, I am sorry to say. I thank the sector for its briefings, which have been both moving and very useful in painting the picture of just how we are letting these communities down. As long as we do that, we will have significant inequalities and therefore significant pressures both on and from those communities. They not only end up with poorer health outcomes but are driven to the most expensive end of healthcare. They end up in A&E because they do not know how else to access anything and normally go there far too late in whatever is going wrong with them.
I want to illustrate what I am trying to say with two different stories. I hope this will help the Minister and Members understand where we are coming from. Professor Aidan Halligan was an incredible, innovative leader in the NHS. I got to know him when I was in government and he was working in the Department of Health. He was always interested in what I was doing in tackling rough sleeping, both in the early part of my ministerial career and then when I was Minister for Social Exclusion at the end of it.
Aidan became interested in, among other things, how to get better healthcare for homeless people. He was shocked by what he encountered when he started to look at it. I agreed to chair a meeting in the House of Commons for him to bring together people to address the issue. More than 200 people turned up. That meeting and discussion inspired him to work initially with University College Hospital on developing a responsive survey. He soon set up a charity, which he appropriately called Pathway, which has flourished, to work with the NHS to ensure more responsive healthcare for the homeless. Tragically, Aidan died in 2015, but his legacy of compassionate leadership and response to the homeless lives on. Pathway teams now work throughout the country, although not, unfortunately, in every area or trust area.
The second story comes around Changing Lives, which was known as the Tyneside Cyrenians when I introduced some pilot projects from the Cabinet Office to look at a more holistic service for people with complex needs. The Tyneside group had a new model for outreach work for rough sleepers that employed people with lived experience as outreach workers. They negotiated with the local National Health Service to have a community matron attached to the team so that appropriate referral and treatment could take place.
This was the most successful pilot in the country, and when I left government I kept in contact with it. I went on its board and eventually became chair. We developed the whole organisation and did a lot more work with women. Appropriately, we changed the name to Changing Lives. We developed the principles of working with people with complex needs so that they too were involved, and getting health and other services involved at a more appropriate level than the emergency services. That initial pilot scheme demonstrated to Newcastle how much money it saved, because the “frequent flyers”, as it called them, did not end up in A&E. That is why I say that it has more to recommend it than the very important aspect of making sure that health outcomes are better for people.
Some of the subsequent work we developed through Changing Lives, particularly with those who were exploited sexually, groomed and so on, and those with addictions, has been innovative and transformative. I recommend that the Government look at how they can establish such programmes, but then make sure that they are normal. That is the problem that these amendments address. There are some really good examples around the country where innovative charities work with the NHS to develop good practice, but by no means is that universal or automatic.
Also, Pathway and Changing Lives include people with lived experience—these days they call them “experts by experience”—in the design and delivery of the service. That makes a huge difference. I know that the Government have said that in general they are in favour of this, but they need to get hold of it to demonstrate that that can be done to a much greater extent.
I understand that the Government and the Minister are concerned about this issue, but the reality is that the Minister sought to reassure the House with measures such as Core20PLUS5. How the NHS keeps coming up with such peculiar and strange hidden titles is beyond me; it is not a phrase I use when I talk to people who have been living on the streets. Anyway, I am told that Core20PLUS5 is one programme that can be used. Then there are JSNAs. They are good and important but not sufficient to get the outcomes we need for both the NHS and the people I am talking about.
I hope that the Government will think again and see how they can systematically ensure that proper attention is paid to how we can enable these communities to access decent services. It is possible—I have tried to be positive and show that—but it must be done throughout the NHS and systematically in partnership with those people who know what it is like to have difficulty in accessing services because they have been excluded for so long. We really must make sure that we make a massive difference on tackling these health inequalities.
As gently as I can, I must point out to the noble Baroness that this not the occasion to move her amendments; we will come to that later. She has correctly spoken to her amendments in this group but we will come to them sequentially later.
My Lords, now that we are on Report, I must remind the House that I am a vice-president of the Local Government Association.
I rise to speak to Amendments 63, 65 and 67 in this group, to which I am a signatory along with the noble Baroness, Lady Armstrong of Hill Top. I will not repeat the points made in Committee and this afternoon unnecessarily because I am confident that the Government are listening to what has been said and wish to see progress towards levelling up health outcomes and tackling health inequalities. It is the right thing to do.
I lend my support to three policy solutions in particular. The first is the significant opportunity presented by the forthcoming health disparities White Paper. The Government should not miss the opportunity that this presents because it can clearly set out how exactly they propose to lead on tackling the poor health outcomes of inclusion health populations. I hope that the Minister will work closely with the voluntary and inclusion health sectors to shape what the White Paper will say. Secondly, I support the idea of creating a task force from the Department of Health and Social Care and NHS England to help drive forward the Government’s work to reduce health inequalities for the most marginalised. Thirdly, I urge the Government to take this opportunity to update guidance to specify explicitly that the NHS does not exist in a vacuum and that secure, safe housing is critical to an individual’s health and well-being. I hope that the Minister will be able to confirm that statutory guidance and the White Paper will reflect all these matters.
Having said that, these three amendments—Amendments 63, 65 and 67—are still important. I welcome yesterday’s letter from the Minister, the noble Lord, Lord Kamall, explaining the package of government amendments now also proposed. I am pleased that that letter confirmed the Government’s commitment to tackling health inequalities. It is very positive to see the reference to “persons”, not just “patients”, in Amendment 3 as an important statement of principle both for inclusion health and to improve outreach, as the noble Earl, Lord Howe, said earlier.
Progress has been made following Committee but I still seek reassurance from the Minister that the Government will dedicate the necessary time and resource to tackling the poor health outcomes of inclusion health populations, who can all too easily fall through the gaps in provision.
My Lords, it is a pleasure to speak to this group of amendments. I declare my interest as chair of Look Ahead, a housing association that specialises in working with people with complex needs. I am delighted by the Government’s new amendments in this area—I believe that they go a long way—but I am disappointed that housing appears to have been omitted from the government amendments.
Amendment 65, which adds housing to this section, is one that I would particularly want to support. I want to take a phrase from my noble friend Lord Crisp: health—and here I would add, “including mental health”—is made at home. However, if you do not have a home, you cannot make physical or mental health. Driving in this morning because of the Tube strike, listening to “Woman’s Hour”, which I do not always manage to do, I heard a dramatic example of somebody who has fled domestic abuse and been temporarily rehoused by the council, but has no white goods. She is diabetic, so her insulin is out of control because she cannot keep it cold. What a straightforward example of how housing and simple equipment can facilitate good health.
Another example is where we discharge people to safe accommodation, where they have the opportunity for rehabilitation or to cope with a long-term disability that may have occurred as a result of an accident. This requires sheltered and semi-independent living accommodation to be built. If those issues are carefully considered by our new boards, together with housing locally, we will find a way forward, to reduce the distress of significant illness and domestic violence, to enable young people in family breakdown to move to bedsits rather than to the streets, and to make care leavers feel safe—as well as older people then knowing that there is somewhere that they can move to. We know that those with significant incomes are increasingly moving, because they can fund themselves, to sheltered accommodation, which reduces loneliness and gives all sorts of advantages in later life.
I again thank the Government and remind them that, tragically, the average age of death of people experiencing homelessness remains at 46 years for a man and 43 years for a woman.
My Lords, I do not want to detain the House for too long, as there is an awful lot of business to think about on Report. However, as I put my name to Amendments 63, 65 and 67, tabled by the noble Baroness, I want to press the Minister on the question of data.
I am advised, as I am sure others are, by really experienced charities, which say that one of the real challenges here, which will be a challenge for the ICSs when they are trying to do a great job in terms of compliance on disparities, is that the data on inclusion health populations is very incomplete. While there have been efforts to collect data on housing status, for example, that has been relatively incomplete and unsuccessful. So what I want to hear from the Minister is how we can be sure that through the development of this commitment to tackling health inequalities with an evidence-based approach, populations such as the inclusion health population are not invisible because the data is so difficult to collect. Is this something that the forthcoming White Paper could pick up? Will it focus on how the health system leaders will get the tools that they need to do a really great job for these populations, who have such complex needs and who really draw on the health service, A&E, et cetera, in a very intense way? There is such potential to make real progress, whether it is in the interests of people coming out of care, sex workers who are really challenged, or homeless people. We are all only a few steps away from that, are we not? So I would be interested to hear from the Minister whether that drive to collect comprehensive data to inform this work can be channelled in some way through a forthcoming policy initiative.
My Lords, from these Benches I thank the Minister and the whole Front-Bench team for the way they have engaged with the House on the issue of doing something really serious about addressing health inequalities.
Many of us put down amendments in Committee: dealing with inequalities was dotted all over the Bill. We even suggested that perhaps we needed a quadruple aim—an additional aim. The Government have taken a different but none the less effective approach, and I really welcome the fact that dealing with health inequalities has been made integral to the first two aims of the triple aim.
The Government have done two things that I particularly welcome. The noble Lord, Lord Kakkar, mentioned the engagement of the noble Lord, Lord Patel, with the Bill team on making sure that data can be collected. Without collecting the data, you cannot analyse or take action on addressing health inequalities.
The second thing, which the Minister mentioned in his introduction, is government Amendment 21, which is about the experience of people in the health service. He mentioned that the experience of people from an Asian background can sometimes be poor. I can give him an example of where that has been the case. My daughter has a friend, an Asian gentleman, who had a very painful physical injury. Very unusually, although his physical problems have now healed, he has been left with a mental scar because of his experience with the health service. This is very unusual, but he was not treated with compassion or respect. Indeed, it was more like discrimination—so I really welcomed what the Minister said about the importance of the experience of people from all demographics and ethnic backgrounds in the health service. It is vital.
I turn to the amendments from the noble Baroness, Lady Armstrong. Like all noble Lords, I have been watching the television recently, looking at the pain that the poor people of Ukraine are going through and seeing children, mothers and whole families huddled in cold, damp cellars. Some of them are taking several days to drive to the border to go to a country that will welcome them, perhaps with even more open arms than we do. It occurred to me that those people, when all this is over—and let us hope it will be over very soon—will probably be suffering from mental and physical illness. It also then occurred to me that there are people in this country who have poor-quality housing, insecure housing or no housing at all. When you put those things together, it is not surprising to realise that such people will be suffering from more serious and more frequent physical and mental ill-health than the rest of us who are in good-quality, secure housing. So the noble Baroness has hit on some very important issues about health inclusion communities and about the importance of housing to making health, and we support what she has to say.
I end by sincerely thanking all three Ministers and the Bill team for the way they have addressed this issue of health inequalities, and I really look forward to it making a real difference in future.
My Lords, the noble Baroness, Lady Walmsley, expressed that very well indeed. From these Benches, I say how much we welcome these amendments and thank the Minister for introducing them. I also join the noble Lord, Lord Kakkar, in regretting the fact that our friend Naren Patel—the noble Lord, Lord Patel—is not with us today. His speech on this in Committee was outstanding, as his speeches always are. In fact, the whole debate was the House at its very best in expressing its view.
We welcome these amendments, and I was very pleased to add my name to Amendment 3 on behalf of these Benches. I was not as energetic as the noble Lord, Lord Kakkar, who put his name to all of them, but that was a symbol of the fact that we supported all these amendments.
We support them because, as people have mentioned, they recognise the importance of addressing inequalities from the top to the bottom of the National Health Service, and of monitoring, counting and research—not a tick-box exercise to say that you are tackling inequalities. As I have mentioned before, I am a non-executive member of a hospital in London. In fact, I have just completed three days of its workforce race equality training. That was three days out of my life during the course of this Bill, but it was definitely worth while. It absolutely was not always comfortable, and nor should it have been. It did indeed raise issues, many of which were raised in research published on 14 February by the NHS Race & Health Observatory. It basically says that the NHS has a very large mountain to climb in tackling race inequalities and inequalities across the board. It is a worthwhile report, which I am sure the noble Earl will be paying attention to in due course.
I also want to say how much I support my noble friend in bringing forward her amendments on the homeless. Coming from Bradford, I am particularly fond of a GP surgery called Bevan Healthcare, named after the founder of the National Health Service. It was started by my local doctor in Bradford, who spent his spare time providing GP services on the street to the homeless. From that, the NHS was commissioned to provide a GP surgery specifically directed to the needs of people who are itinerant and homeless, working girls and so on. It is still there, and it is a brilliant example of how to deliver the service, and of the money it saves the NHS at the end of the day. As I think my noble friend Lady Armstrong said, if you get this right then people do not end up in emergency care or worse.
We hope that the Minister will respond positively to these amendments. I thank him, his team and the Bill team, who addressed this issue thoroughly and with a great deal of success.
My Lords, this has been a very fruitful discussion and I am most grateful to all noble Lords who have spoken. I especially thank my noble friend Lord Young of Cookham, the noble Baronesses, Lady Walmsley, Lady Thornton and Lady Hollins, the noble Lord, Lord Kakkar, and the noble Lord, Lord Patel, in his absence, the King’s Fund and the Health Foundation for their contributions, both inside and outside this Chamber, in shaping this debate and the amendments before us.
Without wishing to repeat what I said earlier, I commend the government amendments to the House as they will strengthen the ability and resolve of the health and care system to take meaningful action on tackling health disparities. I next thank the noble Baronesses, Lady Armstrong of Hill Top and Lady Morgan of Drefelin, and the noble Lord, Lord Shipley, for tabling their three amendments and for the focus they bring to the issues of housing and homelessness. I found the account of the experience in government of the noble Baroness, Lady Armstrong, and the work of Professor Aidan Halligan, whom I too remember with great respect, compelling. I agreed with so much of what she said.
Let me say straight away that the Government are committed to improving the health outcomes of inclusion health groups, as they are known. That is precisely why we tabled the amendment to expand the inequalities duty placed on NHS England and ICBs beyond simply patients to incorporate people who struggle to access health services such as inclusion health groups, but there is much more to say on this.
We have been clear throughout our engagement on integrated care partnerships that housing and homelessness services are essential in improving poor health for many. As my noble friend mentioned in Committee, the Bill already provides that ICPs may include the integration of those services in their integrated care strategy. We will continue to encourage the inclusion of housing and consideration of inclusion health groups in our guidance for ICPs. I hope that that is reassuring and will convince noble Lords that Amendment 65 is unnecessary.
I was very interested to hear what the noble Baroness, Lady Thornton, had to say about Bevan Healthcare. My noble friend Lord Kamall tells me that he has been a long-term supporter of a charity called Vision Care for Homeless People. It is not surprising that, with my noble friend in the Department of Health and Social Care, he and the department have been driving forward a wider agenda aimed at improving the lot of homeless people.
The noble Lord, Lord Shipley, referred to the health disparities White Paper which we will be publishing later this year. That will take a broad look at the factors that affect people’s health and will focus on the people and places facing the worst health outcomes. It will mean looking at the biggest preventable killers, such as tobacco and obesity, as well as the wider causes of ill health and access to the services needed to diagnose and treat it in a timely and accessible way. It is important to emphasise that that endeavour will not be confined to the Department of Health and Social Care; it will be a cross-system endeavour, relying on close working among the NHS, wider health and care services and across central and local government.
It is also important to mention the Levelling Up White Paper. The Government’s focus on preventing homelessness will be renewed by working across government and with local partners to tackle the root causes of homelessness, in order to make sure that the flagship rough sleeping initiative continues to provide support tailored to local areas.
The pandemic highlighted in further stark contrast the importance of integrated care and the need for key services to work closely together to support those experiencing homelessness. Integrated care partnerships will bring together the NHS, local authorities and the voluntary sector, and it will be their job to develop strategies to address the public health and social care needs of people living in their areas, including people experiencing homelessness.
Legislating for new structures is one thing, but what are the Government actually doing to improve health outcomes for people experiencing homelessness or rough sleeping? Work is going on as we speak. We recently announced in the spending review £640 million, to be spent by 2024-25, to tackle homelessness and rough sleeping. This fund will build on progress already made in this area, including support for substance misuse through the rough sleeping initiative. Through the NHS long-term plan, the NHS has committed £30 million for specialist mental health services for people sleeping rough—that is £10 million a year by 2023-24. This year, we are delivering £52 million for substance misuse treatment services for people sleeping rough, and that will fund evidence-based treatment and wraparound support, including for those with co-occurring mental health needs.
The noble Baroness, Lady Morgan of Drefelin, aptly referred to the need for comprehensive and accurate data. I quite agreed with everything she said. We initially looked very carefully at whether there was a statutory basis on which to issue guidance in this area and, in the end, we concluded that there was not. But the amendment that we have proposed requires practical steps which we believe will achieve similar policy aims.
In practice, NHS England must produce a document that sets out NHS bodies’ powers in relation to health inequalities information, together with its view of how those powers should be exercised, as I mentioned earlier. That is bolstered by a requirement for those bodies, in their annual reports, to review the extent to which they have complied with NHS England’s view. In our opinion that essentially squares the circle of the need for this crucial area not to fall between the gaps. I will of course supply the noble Baroness with any further information that I can on how those plans look like they are shaping up.
Finally, defining inclusion health groups in law is very difficult. We have therefore committed to putting a more in-depth explanation of the term in guidance, as well as advice on identifying these groups and their health needs. We recognise that the populations most at risk from health disparities may vary between localities and may change over time; that is an obvious truth. By not defining the term in legislation, we allow bodies to react to their own local and system population’s needs, as seems appropriate to them. We feel that statutory guidance is a better vehicle for helping to set out how health and care services can better identify and address the needs of these groups when drawing up the integrated care strategy.
I ask the noble Baroness, Lady Armstrong, not to move her amendments when they are reached and I beg to move Amendment 3.
Amendment 3 agreed.
4: After Clause 4, insert the following new Clause—
“Duties in respect of research: business plan and annual report etc
(1) The National Health Service Act 2006 is amended as follows.(2) In section 13L (duty in respect of research), after “functions,” insert “facilitate or otherwise”.(3) In section 13T (business plan), in subsection (2)(a), after “13G” insert “, 13L”.(4) In section 13U (annual report), in subsection (2)(c) (as amended by section 69(4) of this Act), at the appropriate place insert—“section 13L;”.”Member’s explanatory statement
This Clause provides that NHS England’s duty to promote research etc includes doing so by facilitating research. NHS England is also required to explain in its business plan and annual report how it proposes to discharge or has discharged its duty to facilitate or otherwise promote research etc.
My Lords, in moving Amendments 4, I shall also speak to Amendments 23, 58 and 79 in my name. Before I start, I really should acknowledge the contribution and engagement of a few noble Lords, in particular the noble Lords, Lord Sharkey and Lord Patel, and my noble friends Lady McIntosh and Lady Blackwood for their constructive engagement with me and my officials.
We have seen the power of research as we have made our way through the pandemic, and research will continue to be essential. I agree that research needs to be embedded in the very DNA of the NHS. Earlier this week, I chaired a round table with a number of research charities and other stakeholders, and we all talked about the importance of embedding research into the NHS. A bit like the challenge I had when I was in academia, when you wanted more time for research but at the same time were told to get on with your day job of teaching students, likewise many clinicians are under the same pressures in terms of the day-to-day delivery of healthcare while wanting time for research.
We know that informed research helps to improve healthcare and health outcomes. It brings benefits to patients, staff, the NHS and the wider economy. We believe that integrated care boards will play a leading role facilitating and enabling research and fostering a culture and environment for research to flourish. To this end, the Bill currently places a duty on each ICB that it
“must, in the exercise of its functions, promote … research on matters relevant to the health service, and … the use in the health service of evidence obtained from research.”
I have, however, heard clearly from noble Lords that they want to see a step change in research. That is a request, or a plea, that I agree with, so rather than directly funding or conducting research, ICBs will primarily facilitate and enable it. However, ICBs will also have the power to conduct, commission or assist the conduct of research. This could include hosting or being a collaborating partner in research infrastructure.
I also heard from noble Lords, particularly the noble Lord, Lord Sharkey, that it is not clear what a duty to promote research should involve. To that end, I have tabled Amendments 4, 23 and 79 to clarify that the meaning of “promote” includes “facilitate”. I once again thank the noble Lord, Lord Sharkey, for his engagement. This highlights that facilitation is a subset of the range of activities meant by promoting research while retaining the breadth of a duty to promote research.
The duty is broad and could be met in a number of ways. For example, when exercising its commissioning functions, an ICB may select providers which have a proven track record of being research-active or can demonstrate the intention and capability to participate in research. The provision is also flexible so that bodies can develop the processes and structures that work most effectively, but we anticipate that ICBs would have dedicated research offices or teams to support their role in research and to encourage the conduct of research.
To ensure that research is fully embedded in local systems, we expect ICBs to consider research when preparing, with the responsible local authority, a joint strategic needs assessment articulating local research needs where they identify them. We would also expect ICBs to ensure that the joint local health and well-being strategy sets out how research needs can be met by the ICB. We have tabled Amendment 35, which is to be debated in the next group, to ensure that the research duty, along with other duties, is given particular consideration during ICBs’ planning of their strategies. We have also tabled a package of amendments to provide increased transparency, accountability and oversight of the research duties.
During the debate in Committee, my noble friend Lady Harding remarked that
“what gets measured gets done”.—[Official Report, 24/1/22; col. 47.]
We agree. Amendment 4 requires NHS England’s business plan to explain how it proposes to discharge its research duty and requires its annual report to contain an assessment of how effectively it discharged this duty. We have tabled similar amendments for ICBs. Amendment 55, also to be debated in the next group, would require that ICB annual reports must explain how the ICB has discharged its research duty. Amendment 58 would require that the NHS England’s performance assessment of each ICB includes an assessment of how well it discharged its research duty. I beg to move.
My Lords, I take this opportunity to thank my noble friend for listening and acting in the terms set out in the amendments in this group, which I support on research as far as they go. I have to express my disappointment that my noble friend has not seen fit to extend his bonhomie to NICE. I have therefore tabled Amendment 29, and I am delighted to have the support of the noble Lords, Lord Hunt of Kings Heath and Lord Patel. As set out by the noble Lord, Lord Kakkar, our thoughts are with the noble Lord, Lord Patel, who is unable to be with us today, and we wish him the speediest possible recovery. It is a great shame that he cannot be here today because we would all wish to pay tribute to his work historically as the forerunner of NICE. We are grateful to him for it. It is a great disappointment to me that he is not able to be here in person.
I also support Amendments 171 and 178 in the name of the noble Lord, Lord Hunt, but I shall leave the noble Lord to set them out.
My noble friend has set out that the government amendments set a responsibility on integrated care boards to respond annually and to measure the research work that they have done. Quite frankly, I am a little concerned and gobsmacked as to why my noble friend is not insisting that integrated care boards do the same as regards NICE. The key provision of my Amendment 29 is:
“Within 28 days of any medicine or device receiving market authorisation from NICE, an integrated care board must update its formulary to include that medicine or device.”
I have set out other provisions, but the other one to which I draw attention is in proposed new subsection (3), which says that every year an individual ICB must report
“in a publicly accessible format”—
to me that would mean it being accessible on its website—
“all medicines and devices that have been added and removed from their formulary over the previous year and maintain an active list of all medicines and devices available on their formulary.”
I would like to get away from what is an effective postcode lottery, meaning that where you live determines the medicine or device from which you can benefit. In this day and age, in the 21st century, it is unacceptable that, for all the good work that NICE does, we are still living in that capacity, whereby not everyone will be able to benefit, as pharmacists, physicians or patients, from the advice that NICE has given.
I am delighted to say that I am supported in this by a number of bodies, including the JDRF, which makes particular reference to the importance of NICE’s work on type 1 diabetes—and we know how invasive and extensive type 1 diabetes is. I pay tribute to our right honourable friend, the former Prime Minister Theresa May, who went public with the fact that she was a type 1 diabetes sufferer. For a woman in that position to go public about her condition captured the public imagination and made it more acceptable to say that people suffer from type 1 diabetes. EMIG, the ethical medicines association, also supports this provision, as does Vertex Pharmaceuticals.
I have only recently become aware of a project called the Orbis scheme, which aims to deliver faster regulatory approval of innovative cancer treatments. I think that all noble Lords would wish to support the speediest possible diagnosis and delivery of treatment that is in play through this project and scheme.
I end with a plea to my noble friend that the Government, MHRA, NICE and NHSE all work closely together, not just among themselves but with the industry and with all patient organisations and clinicians, to make swifter regulatory approval a reality, in keeping with the ambitious government life sciences vision, which I support.
My Lords, as this is my first contribution on Report, I declare my interests as a member of the GMC board and president of GS1, the British Fluoridation Society, the HCA and HCSA.
I welcome what the Minister said about research and its importance, and some of the tensions between practical work as a clinician and the crucial importance of clinicians engaged in research. The amendments that he introduced are very welcome, but like the noble Baroness, Lady McIntosh, I am disappointed that he has not brought similar amendments forward in relation to NICE. One suspects that it is something to do with money; he thinks that giving away amendments on research is cost-free, whereas there might be a resource implication when it comes to NICE. That is a pity.
The noble Baroness has talked about a postcode lottery in this country on the outcome of NICE judgments, but we also have a European postcode lottery. The fact is that NHS patients have much less access to modern new medicines and devices than those in many other countries. Stats that I have seen on medicines suggest that, for every hundred European patients who can access new medicines in the first year they are available, just 15 UK patients have the same access. We know that even when NICE has given its blessing to new medicines and treatments, take-up in the NHS still lags behind that in other countries.
I think that the noble Baroness, Lady McIntosh, and I were somewhat puzzled by the ministerial response in Committee in this area. We know that the NHS uses all sorts of rationing devices to prevent those new medicines and devices being allocated generally throughout the NHS, notwithstanding what NICE has to say—that is why I support the noble Baroness’s amendments. Essentially, my two amendments seek to build on the principles that she has referred to.
Amendment 171 relates to three issues which I think remain from Committee. The first relates to the links between licensing and reimbursement processes. Happily, the MHRA has established two new licensing pathways, ILAP— the Innovative Licensing and Access Pathway—and Project Orbis, for cancer medicines. This is very welcome; it is designed to speed up access.
However, the challenge with faster licensing decisions is that NHS reimbursement decisions need to speed up too, otherwise medicines can be placed on the market but cannot be made available to patients on the NHS. To its credit, the MHRA has designed this into ILAP, because NICE is directly involved in ILAP, and licensing and reimbursement decisions can be joined up. However, in respect of Project Orbis, there has been no such effort. Late last year, breast cancer patients faced the worrying situation where a drug, Trodelvy, which offered them hope, was licensed through Orbis but was not then available on the NHS. My amendment would therefore ensure that NICE acted to issue guidance on Project Orbis medicines as close to licensing as possible, as it does for ILAP.
Secondly, the amendment would clarify that NICE alone is responsible for determining its methods, as an independent body should be. In its recent methods and processes review, it concluded that
“there is an evidence-based case for changing the reference-case discount rate to 1.5% for costs and health effects. However, because of the wider policy and fiscal implications and interdependencies that are beyond the reach of this review, no change to the reference-case discount rate”
could be made. It further stated:
“Reducing the discount rate will make most technologies appear to be more cost effective.”
We are therefore in a situation where NICE wants to make a change to its methods, which would result in more medicines being made available to patients but is being stopped from doing so. That is not acceptable. NICE should be free to determine its methods, including the discount rate.
The final effect of the amendment would be to clarify the role that the current voluntary scheme, VPAS, and the statutory scheme play in reimbursement decisions. These schemes essentially cap the NHS’s expenditure on drugs, meaning the exposure of the taxpayer to spending on drugs is limited. The problem is that the health service then adds a whole host of other mechanisms to restrict access to medicines as well. My own view is that once we have VPAS and the statutory scheme in place, we do not need those other mechanisms.
Amendment 178 builds on this. I have already referred to the Project Orbis scheme. It has great potential, but unfortunately, as Gilead has pointed out, there is a lack of alignment across the system between government, the MHRA, NICE and NHS England, which has an impact on timelines for approval. This is particularly concerning in light of moves by other countries such as France to legislate to enable early access to innovative therapies prior to a cost-effectiveness assessment, with any difference in the final agreed price rebated by the company. We need an integrated access and funding pathway for medicines licensed by Orbis, prior to NICE approval, modelled on the French system, whereby companies rebate any difference in price following the decision by NICE.
The final point I will make is that we also need to deal with NICE capacity issues. In January 2022, NICE highlighted in its board papers that approximately 20 evaluations were paused in 2021-22 due to capacity constraints because of vacancies. This is despite increased industry fees paid for health technology assessments. While NICE’s vacancy rate has reduced, the same board papers note that:
“Organisational capacity continues to be the key risk for NICE ... strategy, and gaps in hard to fill specialist roles in a competitive global market.”
I would like the Minister to respond to this.
More generally, I hope that the Minister can give us some assurance that he and other Ministers recognise that all these initiatives to speed up access, excellent though they are, will come to very little unless they can sort out the NHS side of things and get rid of some of these rationing mechanisms which have been put in place.
My Lords, like the noble Lords, Lord Patel and Lord Kakkar, I have added my name to the government amendments in this group. These amendments directly address the criticisms which we made in Committee that, as things stood, a duty to promote research lacked any real force. Since we made these criticisms, we have met with the Minister and his officials to try to strengthen this research duty and make it more meaningful and concrete. These amendments, and the others in the next group, are the result of our discussions.
The Minister has explained, and given some examples, how they would help. The importance lies on what new things the amendments put in place. They require the NHS to explain, in its business plans and annual report, how it proposes to discharge, or has discharged, its research obligations. They also require a performance assessment of ICBs, which includes how well they have discharged their research duty and their duty to facilitate and promote the use of evidence in research. I thank the Minister and his team for their extensive engagement on the question of research in the NHS. I am pleased that we have strengthened the research duties of the Secretary of State and the ICBs. I am particularly pleased that progress will now be formally reported and assessed.
I should also mention that, in his letter of yesterday, the Minister listed a number of non-legislative measures either being taken or developed for facilitating or fostering a culture of research within the NHS, and for holding to account the people responsible for delivering this.
Finally, the noble Lord, Lord Patel, has asked me to say how sorry he is that he cannot be here today. He wanted the House to know that he supports the Government’s research amendments and is grateful for their co-operation in generating more research in the NHS. As the noble Lord, Lord Kakkar, has said, he is at home recovering from Covid, and I am sure that the House wishes him a speedy recovery.
My Lords, I remind noble Lords of my own declarations of interests made in Committee: I am chairman of the Office for Strategic Coordination of Health Research, chairman of the King’s Fund and chairman of King’s Health Partners. In so doing, I make particular reference to the King’s Fund, since the Minister, in closing the last group of amendments, indicated the contribution to discussion which the fund has made with regard to the questions of inequalities.
I strongly support the amendments on the question of research that have been put by Her Majesty’s Government, and so ably and thoughtfully presented and introduced to your Lordships’ House by the Minister. The noble Lord, Lord Sharkey, has summarised why this is so very important. Ultimately, a research culture needs to be promoted at the heart of the NHS, and these amendments go a long way to achieving that clear objective.
There is so much by way of other initiatives that Her Majesty’s Government promote on the funding of research and support to bring together different parties to drive the broader life sciences agenda. However, ultimately, this all depends upon an NHS which is strongly supportive of, and facilitated to deliver, that research. Without this commitment, there was a very real risk that, with the other priorities that the NHS is inevitably required to pay attention to, the need to promote and facilitate research would be lost.
In facilitating research, NHS organisations, the Secretary of State, the NHS board and integrated care boards will have to pay attention to not only the facilities provided but the attendant workforce questions, ensuring that a workforce is properly prepared and able to engage in the research agenda, that progress in that regard is properly reported and that the full benefits of a research culture and the output of research are available to patients throughout our country.
My Lords, very briefly, I support Amendments 171 and 178 in this group, spoken to so ably by the noble Baroness, Lady McIntosh, and the noble Lord, Lord Hunt. I do so as a former pharmaceuticals Minister and a former NICE Minister. The rather boring thing about all this is that the postcode lottery issue was alive and well when I stopped being a Minister, 15 years ago. It has continued to flourish throughout that time. The noble Lord, Lord Hunt, does not exaggerate in any way how the NHS is quite creative at finding ways around implementing speedily some of the drugs and medicines recommended by NICE.
For a long time, part of the problem has been—Amendment 178 starts to make a move in the direction that I think has been lacking—that we simply do not monitor enough what has happened to NICE recommendations and the take-up of new medicines. It is not really built into the regulatory system. If we are serious about inequalities—I have listened to many of the debates on inequalities today and previously—and levelling up, access to new medicines is pretty important. I have a terrible suspicion that, if we looked around very carefully, we would find that the same parts of the country, year in and year out, are not taking up the medicines as speedily as others. The reason I say this is that we know from the regulator’s evidence that the financial and clinical underperformers are, much of the time, the same places, year after year. I suspect that these are many of the places we need to look at if we want to tackle the postcode lottery of NICE recommendations.
My Lords, I join the debate briefly to add my thanks to the Government for the amendments on research that they have brought forward in this group. It is extremely helpful, as the noble Lord, Lord Kakkar, said, to entrench the concept of a research culture inside the NHS. In our various ways and guises, we have all encountered some of the difficulties of diffusing innovation and the take-up of new medicines in the NHS.
The point was made very well by the noble Lord, Lord Hunt of Kings Heath, but he did not say why the NHS does not adopt new medicines as rapidly as some other European systems have. I do not think we have more conservative clinicians than other countries, but we do not have a third-party payments system. We do not have a system whereby the patient can ask “What about this?”—these days, increasingly, they do—and the clinician can say yes, and pass the bill to somebody else. Instead, our system centrally determines the extent to which new medicines will be available. We have a particular requirement in the National Health Service for a system which looks for areas where there is value in innovation, disseminates it, takes it up and makes it available to patients.
I make two other points. One is to say thank you, as I am not sure I will get another opportunity to do so. We had substantive discussions about rare diseases; the noble Lord, Lord Sharkey, in particular spoke very well and fully about the needs involved, and the Government published their England Rare Diseases Action Plan yesterday. On orphan drugs, that will give significant additional impetus to the availability of treatments for those with rare diseases. I very much welcome that.
Secondly, Amendment 178 in particular is interesting. I do not necessarily advocate that we adopt it, but it asks the Government do something that they generally have not done and ought to do, which is to come back to the issue of access to medicines and treatments—and, I would add, to medical devices—and ask how well we are doing at the process of bringing that into effect and how well our Accelerated Access Collaborative, which is supposed to look at all these things and make them work together, is making that happen.
The beauty of Amendment 178, on which I will add just a little, is that we ought to have a very clear timetable for how we move the system forward. I hope the Government will adopt this. In January 2024, we will have the next voluntary pharmaceutical pricing and access scheme. The industry will be looking, rightly, to arrive at a position where all the initiatives mentioned give patients access to medicines in this country as soon as in any other healthcare system. On that basis, the industry will be prepared to understand that not just the NHS but the Government will look to get some pretty cost-effective prices out of it.
Now I do not happen to think that it is NICE’s job to make that relationship happen. I happen to think that NHS England is increasingly equipped to be a central player in this process. It should sit alongside NICE when it carries out health technology assessments in what is effectively a trialogue with the industry and say, “Well, how can we ensure that the patient has access to this medicine, and at what price? Can NICE act as the referee to establish whether the price and the incremental benefit are reconciled to be cost effective for the NHS?”
We should build that into the system over the next 18 months so that, when we start the new scheme in January 2024, the system is understood to work. It should not depend on large-scale transfers of money, with overpriced new branded medicines on the one hand being recycled back to the NHS to go into the innovative medicines fund on the other. This tracking of money around the system is not the best way to make it happen. We should aim for the industry to be paid what the health technology assessments and the NHS budget requirements mean is a fair price for the medicines it is providing—and that is what the industry should expect.
Everybody should be working to arrive at a position where, when a medicine obtains authorisation—in other words, when it is deemed safe, clinically effective and of good quality—and a clinician recommends it for a patient, the patient should have access to that medicine through the NHS. That is what we are aiming for. It has not always been true, but it ought to be in the future. We need a system that people, including clinicians in the NHS, understand and that supports their ability to prescribe medicines in that way.
My Lords, I do not intend to speak about this for very long, because I feel that I am the least well-equipped person in the whole Chamber to do so—possibly with the exception of the Minister, which is often the way and is how I felt when I was a Minister; I would stand up to speak about research and other huge subjects and everybody else in the Chamber who had spoken certainly knew a lot more than I did, and that is the case here.
Noble Lords may recall that the starting point at Second Reading and in Committee was that there was no place for research in the Bill at all—so I congratulate noble Lords who picked this up and ran with it, and, indeed, the Minister and the Bill team on taking it on board and producing these amendments. That is helpful; as the noble Lord, Lord Kakkar, said, it is about the future and it is exactly the right thing to do.
I also agree with the noble Baroness, Lady McIntosh, and my noble friend Lord Hunt in their disappointment on the issue of NICE. They are quite right about the access and availability of medicine and devices to healthcare practitioners and that the system is still uneven; also, of course, nobody is asking how we are doing and whether it is working. It is a shame that these aspects have not been included in the Bill, but I suspect that the noble Baroness and my noble friend will probably live to fight another day.
My Lords, I am grateful to all noble Lords who have spoken thus far in this debate. I also thank the noble Baroness, Lady Thornton, for expressing her confidence in my ability to understand these issues; I fear that she may be right.
Turning first to Amendment 29, it is firstly important to note that it is the MHRA, not NICE, that licenses these medicines in the UK. NICE makes recommendations on whether the price that the NHS pays for treatments represents value for money. Access to effective new treatments for NHS patients is a priority for the Government. That is why we have committed to maintain the funding requirement for NICE appraisal of recommended treatments.
The standard contract also stipulates that providers must ensure that formularies include all NICE appraisal-recommended treatments. NICE’s guidance on developing and updating local formularies also clearly states:
“When a NICE technology appraisal recommends a medicine, adopt the medicine into the local formulary automatically, if clinically appropriate and relevant to the services provided by the organisation. This process should take place within 3 months.”
I believe that this represents a robust legal framework for ensuring compliance with NICE’s appraisal decisions. A stronger legislative requirement to include all NICE-recommended treatments on formularies within 28 days of a NICE decision would remove any flexibility both to vary the timescale where there are barriers to implementation, or where a product was not relevant to a particular organisation.
Turning to Amendment 171, NICE rightly operates independently from the Government, and key to this is setting its own procedures for developing guidance and recommendations. This includes setting its own discount rate, taking into account the wider policy and fiscal implications. NICE recently carried out a comprehensive review of its methods and processes for making appraisal recommendations, and the changes that NICE is introducing will ensure that its processes are fairer, faster and more consistent. I assure noble Lords that NICE already aims, wherever possible, to make timely recommendations on new medicines with draft guidance around the time of licensing, and final guidance within three months of licensing. However, NICE’s ability to issue guidance depends on an evidence submission from the manufacturer. It would not therefore be appropriate to place a requirement in legislation for a specified timeframe when that is dependent on other organisations.
This amendment would also require NICE to take account of a company’s membership of the Voluntary Scheme for Branded Medicines Pricing and Access, or the statutory scheme, in making its recommendations on medicines. These schemes have a very different purpose from NICE appraisals, which ensure that new medicines are clinically and cost effective, and they are time-limited, so would create significant disparities between medicines launched at different times.
I turn now to Amendment 178. I hope I can assure the noble Lord that arrangements are already in place to regularly review and monitor delivery against priorities and objectives, including through accountability meetings, engagement with external partners and public board meetings. The Government believe that regular monitoring through existing arrangements is the right approach and do not consider that a requirement to carry out a review is necessary. I assure the noble Lord that the changes recently introduced by NICE will make its methods and processes fairer, faster and more consistent, will ensure that they are suited to new and emerging types of technology, and will provide more equitable access for those with severe diseases. The vast majority of cancer medicines covered by the previous end of life flexibilities would also be covered by the severity modifier.
Placing requirements on NICE through primary legislation to use specified processes would fetter its independence to determine its own methods and processes, and it would be unfair to operate two different approaches at the same time. The amendment proposed by the noble Lord could also impact negatively on cancer medicines that were not eligible for the end-of-life flexibilities in their first appraisal but may be eligible for the severity modifier.
I will now turn to a couple of specific questions, one of which was about the uptake of medicines in the UK. The NHS is legally required to fund NICE-recommended treatments, normally within three months, and this requirement will apply to ICBs once established. Differences in healthcare systems between different countries—in commissioning, disease prevalence and population demographics—make any direct comparison of uptake difficult, and the speed at which innovation is taken up is not the only effective measure of quality of care.
However, we are committed to making the UK one of the most pro-innovation healthcare systems in the world, and we have made some real progress in recent years. Noble Lords have mentioned the Accelerated Access Collaborative, which was established to support the appropriate uptake of NICE-recommended medicines and devices, as my noble friend Lord Lansley said. In 2019-20 alone, the AAC helped more than 2,500 innovators to develop their cutting-edge products and launch them in the NHS. Nearly 750,000 patients have benefited from access to these products, and they spent around 125,000 fewer days in hospital as a result.
I should add that NICE is the independent body responsible for methods and processes. NICE’s consultation stated that there is an evidence-based case for changing the discount rate to 1.5%, but it acknowledged the wider policy and fiscal implications and proposed to maintain the existing reference case discount rate while further data is collected on the likely effects of a change to the discount rate. NICE’s changes are in line with the department’s expectations for the review as set out in the VPAS agreed with industry. It is important to recognise that any changes to NICE’s methods could have financial impacts beyond the duration of the current VPAS.
On the postcode lottery, we have reporting tools at our disposal to monitor the use of innovative medicines and products. NHS Digital publishes a biannual report on the use of innovative medicines by the NHS in England, known as the innovation scorecard. The latest publication, from June 2021, shows that uptake of more than 70% of NICE-approved medicines reported in the scorecard has increased over the past 12 months. We are committed to further strengthening these innovation metrics and to improving our understanding of the use of innovative medicines and medicinal products within the NHS.
It is for these reasons that I ask noble Lords not to press their amendments when they are reached.
Amendment 4 agreed.
Clause 5: NHS England: wider effect of decisions
Amendments 5 and 6
5: Clause 5, page 3, line 15, leave out “The reference in subsection (1)” and insert “In subsection (1)—
(a) the reference”Member’s explanatory statement
This amendment is consequential on another amendment which provides that references in new section 13NA of the NHS Act 2006 to effects of a decision in relation to certain matters include its effects in relation to inequalities with respect to those matters.
6: Clause 5, page 3, line 18, at end insert—
“(b) the reference to effects of a decision in relation to the health and well-being of the people of England includes a reference to its effects in relation to inequalities between the people of England with respect to their health and well-being;(c) the reference to effects of a decision in relation to the quality of services provided to individuals includes a reference to its effects in relation to inequalities between individuals with respect to the benefits that they can obtain from those services.”Member’s explanatory statement
This amendment provides that references in new section 13NA of the NHS Act 2006 to effects of a decision in relation to certain matters include its effects in relation to inequalities with respect to those matters.
Amendments 5 and 6 agreed.
7: After Clause 5, insert the following new Clause—
“NHS England: duties in relation to climate change etc
After section 13NB of the National Health Service Act 2006 (inserted by section 5 of this Act) insert—“13NC Duties as to climate change etc(1) NHS England must, in the exercise of its functions, have regard to the need to—(a) contribute towards compliance with—(i) section 1 of the Climate Change Act 2008 (UK net zero emissions target), and(ii) section 5 of the Environment Act 2021 (environmental targets), and(b) adapt to any current or predicted impacts of climate change identified in the most recent report under section 56 of the Climate Change Act 2008. (2) In discharging the duty under this section, NHS England must have regard to guidance published by it under section 13ND. 13ND Guidance about discharge of duty under section 13NC etcNHS England may publish guidance about the discharge of—(a) the duty imposed on it by section 13NC;(b) the duty imposed on integrated care boards by section 14Z43A;(c) the duty imposed on NHS trusts by section 26B;(d) the duty imposed on NHS foundation trusts by section 63B.””Member’s explanatory statement
The new Clause would require NHS England, in exercising its functions, to have regard to certain matters relating to the environment, including climate change.
My Lords, in moving Amendment 7 in the name of my noble friend Lord Kamall, I will speak to the other government amendments in his name.
We had a passionate debate on climate change in Committee. There is no doubting the profound relevance of environmental issues to the NHS; indeed, it is already leading the way as a health system in tackling climate change. These amendments will ensure that the NHS can continue in that vital work with the confidence needed to deliver. They place a duty on NHS trusts, foundation trusts, ICBs and NHS England to have regard to the Government’s key ambitions on climate change and the natural environment in everything they do. This could mean preparing thousands of NHS buildings to adapt to climate impacts, protecting and enhancing biodiversity across 25 million square metres of trust estate, or decarbonising the millions of kilowatts of energy used by trusts every year. I must emphasise to noble Lords that this includes decisions about the NHS’s procurement of goods and services. The noble Lord, Lord Stevens, was quite right to underline in Committee that, according to NHS England’s data, the NHS supply chain accounts for some 62% of its emissions footprint. It is clear that the NHS will need to take urgent action to decarbonise procurement.
These clauses will give vital legislative grounding and confidence to the Greener NHS programme and further strengthen the commitments made by the UK through the COP26 Health Programme: namely, to develop climate-resilient, low-carbon health systems. Importantly, Amendment 7 includes a power for NHS England to issue statutory guidance on environmental issues to the system. As discussed in Committee, NHS England already has some targeted net-zero guidance in place for current ICSs, but the system currently lacks that critical statutory guidance that sets the direction for the whole NHS. We expect this guidance, in the first instance, to be issued within 12 months of the Bill receiving Royal Assent.
In developing these amendments, we have had to consider the excellent work NHS England has already undertaken on these issues and gain clarity over what value a legislative solution could add. This has included working across government with BEIS and Defra, while also looking closely at the individual amendments proposed by noble Lords in Committee. I believe the amendments tabled in my noble friend’s name achieve these aims, adding the right value in the right way, to the benefit of our natural environment, the NHS and the people who depend on it. I pay tribute to the work of noble Lords in helping us reach this position. I beg to move.
My Lords, I thank the Government for supporting these amendments, which reflect the substance of amendments that my noble friend Lady Hayman, I and others brought forward in Committee. That debate rehearsed the health case for action very clearly, as we have just heard, so I will not detain the House by repeating that.
However, I think the events of the last 24 hours have underlined two other reasons why these amendments are so important. In addition to the health case, there is clearly a financial case and we also now clearly see the security and humanitarian case for action. The financial case was underlined by yesterday’s IPCC report:
“The financial value of health benefits from improved air quality alone is projected to be greater than the costs of meeting the goals of the Paris Agreement.”
In respect of the security and humanitarian consequences, yesterday, the Government welcomed Shell’s decision to sever its relationship with Gazprom, yet Ministers may have seen an important story in the Health Service Journal suggesting that, over the last two years, at least 17 NHS trusts have continued to rely on gas sourced from Gazprom, which has confirmed today that it continues to get its gas supplies through Ukraine. Decarbonising the health sector will take pound notes out of the hands of dictatorial regimes that are engaged in acts of aggression. For all these reasons, the clarity that these government amendments provide, putting on a sound statutory basis the ability to take fundamental action across the NHS, is most welcome.
My Lords, I declare my interest as co-chair of Peers for the Planet and apologise to the House that I did not declare that interest in my enthusiasm to get involved in a Question earlier today. I added my name to Amendments 7, 28, 87 and 94 and obviously welcome the way in which the Government Front Bench has responded to the debate we had and the amendments we proposed in Committee. As my noble friend Lord Stevens said, there is no point in all of us going through the arguments, although I think he added a new dimension in his remarks today; that interplay between health and climate is an important one that we should not neglect.
The Government have done very well in providing a comprehensive suite of amendments that make sure that the considerations of not just the net-zero targets but the targets in the Environment Act and the needs for adaptation, which will be extremely significant in the healthcare field, will be considered at all the correct levels within the new infrastructure that the Bill brings into place. The assurances that the Minister gave on the guidance that will be published and on making sure that procurement, which is such a large spend by the NHS, will also be governed by these considerations are extremely important.
I welcome these amendments across the board. They weave considerations of climate and the environment throughout the ecology of the NHS, and it is an excellent result. The next challenge is to persuade the Government to take the initiative on these issues and to embed these considerations throughout their policies and legislation, which would save a lot of time in the House. But I do not wish to be churlish, and I end by simply reiterating my thanks for the way in which the Government have responded to these amendments.
My Lords, the noble Baroness may wish not to be churlish, but I would regret it if I could not be a little churlish. I declare an interest as chairman of the Woodland Trust and vice-president of a range of environmental and conservation organisations. I thank the Government and the Minister for the assurances given. I also thank the noble Lord, Lord Stevens of Birmingham, for his shuttle diplomacy between the churlish and the less churlish in achieving these very welcome amendments.
I will press the Minister a little further on what she said, just to make sure that we are completely clear. The guidance will be crucial, and I am glad to see that it will be issued initially within 12 months of Royal Assent. I just want the Minister to clarify that the guidance on procurement will cover the need not just to reduce emissions through the NHS supply chain but to secure the other environmental targets, such as those set by the Environment Act. The preamble says that, but I want to make sure there is clarity in Hansard that the guidance will ask for procurement to do not just the climate change job but the other job.
Although the duties on the trusts, ICBs and NHS England include climate change, adaptation to climate change and improving the natural environment, most of the examples the Minister gave revert back just to climate change. The proposed new section in the amendment is headed up:
“Duties as to climate change etc”.
It is the “etc” that I am rather interested in. I think we should spell out more clearly what that is.
Can the Minister assure the House that the guidance will include performance in all three areas—climate change, adaptation and the wider environmental objectives set by the Environment Act and in other places? Because of the massive threat that climate change represents, it is very easy—we all fall into this trap—to squeeze out focus on the other, equally vital environmental areas. We have to remember that if we want to defeat climate change, we also have to defeat biodiversity decline and a range of other environmental factors. I hope the Minister can give these assurances to the more churlish among us.
My Lords, my speech follows rather neatly from that of the noble Baroness, Lady Young of Old Scone. I will begin not by being churlish but by turning this around the other way and declaring my position as a member of Peers for the Planet and paying great tribute to the noble Baroness, Lady Hayman, who has so led the Government in the right direction on this Bill—as on the Financial Services Act, to think of a recent one before this. I would like to think that maybe it has got a little easier this time than it was on the Financial Services Act, so maybe we are progressing to the point where a Bill will arrive in your Lordships’ House with climate and environment already there, and we can just focus on trying to strengthen and improve it.
The noble Lord, Lord Stevens, has obviously been hugely important in the progress we have made. He referred to the IPCC report yesterday, which relates to an earlier group we were discussing. The IPCC—I think it is the first time I have seen this—is really explicit about the impact of the climate emergency, and all the events associated with it, on people’s mental health. If we look around the globe at this moment, we see that southern Paraguay is enveloped in a giant ash cloud from fires in Argentina. Queensland and northern New South Wales have record floods, and the city of Brisbane has its second enormous flood in 11 years. That has massive impacts—understandably, through the stress, worry and suffering—on physical and mental health.
I want to particularly pick up the point from the noble Baroness, Lady Young of Old Scone. I noticed, like her, that the Minister said climate and then added environment as an afterthought. Anyone who looks at the Hansard from Committee will see that I very much majored on environment and a couple of aspects of it. Biodiversity is obviously huge, but there is also the issue of antibiotic resistance. The debates between the Minister and me on the Government’s inadequate approach to antibiotic resistance go back to the passage of the Medicines and Medical Devices Act. I also raised in Committee the issue of PFAS—the forever chemicals —and these are huge issues for the NHS.
One final area I raised in Committee was plastics. Before the pandemic I chaired an excellent event seeing some really good progress in the NHS on seeking to reduce the use of single-use plastics. Understandably, that has stalled in the light of the Covid pandemic—for reasons we can all understand. It is really important that that goes back as a focus. There is so much plastic use in the NHS that is easily avoidable, and I would like to ask a very simple question: why is anyone anywhere in the NHS having drinks in plastic bottles? It is the kind of thing that is very easy to get rid of.
I focus on that because I spoke a little in Committee about microplastics. I am going to cite three studies that have come out since then. Microplastics have been found in the placenta and the bodies of newborn babies. Chemicals from microplastics have been linked to obesity; there are studies with mouse fat cells where chemicals from microplastics are promoting the growth of fat cells. Some studies out of China show relative gut health being very closely related to the level of microplastic in people’s bodies. These are studies in the last month.
We have a world choked with plastic. We have a world wildly overheating. We have a world—as the noble Baroness, Lady Young of Old Scone, said—where biodiversity is in collapse. I think the NHS is starting to focus on these things, but we need to see, as the IPCC said, that health and environment are not two separate issues. We live in the environment, and we have to look after it in every part of our activities.
My Lords, I rise for the first time on Report and declare my interests as laid out in the register, particularly as a non-executive director of Chesterfield Royal Hospital NHS Trust and as a vice-president of the Local Government Association. We on these Benches welcome this suite of amendments, with a caveat of clarification that the noble Baroness, Lady Young of Old Scone, raised, to do with not just the climate but the implications for the environment.
The reason we welcome this suite of amendments is that it is vital that there is mandatory guidance from the centre to all parts of the system in the NHS. The only thing I seek to push the Minister on is that she said the guidance would be out within 12 months. I ask that, as we are in a crisis and this is important, it is done as soon as possible. The reason for this—I have experience of it from Chesterfield—is that some of the procurement or building decisions made today will not come around for maybe three or four years, but the design and implications that start today have life cycle implications for both the climate and environment over a long period. So, I strongly push the Minister to ask that the guidance is out as fast as possible, and we do not wait for the whole 12 months.
My Lords, I, too, am a member of Peers for the Planet and I congratulate the noble Baroness, Lady Hayman, and the noble Lord, Lord Stevens, on their engagement with the Government and thank them for taking their concerns on board.
I have previously raised the fact that a big way in which the NHS can reduce its emissions is by having energy-efficient buildings, and I should like reassurance that any new buildings and refurbishment of the NHS estate will involve highly insulated and low-energy buildings. There are so many things that the NHS can do by using low-energy lighting, reducing microplastics, using compostable single-use plastic or not using plastic at all and using microwaves to deal with clinical waste, because they are much more energy efficient. How will all this be reviewed after the Bill has passed? Will there be any reporting back on how well the NHS has been able to respond to this challenge?
My Lords, I thank the Minister and welcome these government amendments in response to the key concerns raised in Committee about the crucial importance of including the NHS’s duties on climate change and working towards net-zero emissions in the Bill, and the excellent supportive speeches today.
The amendments take on particular significance in the light of the stark warning in today’s UN report that climate breakdown is accelerating rapidly and there is only a brief and closing window of opportunity to minimise its catastrophic impacts. The duties rightly go across the roles of NHS England, integrated care boards, NHS trusts and NHS foundation trusts in relation to the Climate Change Act 2008 and the Environment Act 2021, and address the need for those bodies to have regard to the need to contribute towards compliance with government climate change and environment targets. Of particular importance is the duty of each body to adapt to current or predicted impacts of climate change and, in Amendment 7, recognition of the importance of NHS England guidance on how the climate change responsibilities are to be discharged within the promised 12 months of Royal Assent.
My noble friend Lady Young sought reassurance that the guidance on procurement will cover not just the need for the NHS supply chain to reduce emissions but also include the key environmental targets. I hope the Minister will be able to reassure her on that.
Strengthening the law to integrate an active response to climate change through every layer of the NHS has been welcomed by the UK Health Alliance on Climate Change, representing more than 900,000 healthcare professionals. Noble Lords made clear in Committee that omitting sustainability requirements from the Bill would have been a missed opportunity to enshrine and enforce the NHS’s historic commitment to reaching net-zero targets by 2040, and we are pleased the Government have recognised that.
As we heard from all speakers, the NHS has made huge progress, but this is just the start and there is much more to do. The amendments reinforce the importance of action in those areas, particularly for the new bodies and processes the Bill creates, and that progress will need to be managed, delivered, tracked and reported at every level.
My noble friend Lady Young’s point, reinforcing that guidance on duties across NHS bodies must include not just climate change but also the improvement of the natural environment, is well made. I look forward to the Minister’s response on that.
In relation to reporting, raised by the noble Baroness, Lady Walmsley, I understand from the contributions of the noble Lord, Lord Kamall, in Committee that progress is being made. He referred to NHS England’s green plans, and we are told that every NHS trust and interim care system is expected to have prepared a green plan and had it endorsed by its governing body. For trusts, the deadline for submission to ICSs was 14 January, so it would be good to know how they have done so far and how many trusts have submitted such plans. The next stage is for ICSs to develop “consolidated system-wide plans” by the end of the month, which will be
“peer reviewed regionally and published”.
Are we confident that ICSs will meet that deadline, and what is the expected assessment and timescale for ICSs to report back to NHS England and, subsequently, more widely on this vital issue?
My Lords, I thank all noble Lords for their welcome for the government amendments, and for setting the challenge for the Government that there is always more to do.
I agree with the noble Lord, Lord Stevens, on the additional points that he set out about the importance of decarbonisation, not just for the climate but for health, security and humanitarian reasons. I reassure the noble Baroness, Lady Young, and others, that I did not say that decarbonisation was there to exclude other issues; it is just that that particular point related to that.
I say to the noble Baroness, Lady Hayman, that it is a pleasure to work with her on these issues when we look at Bills, including the Financial Services Bill as it went through, but I have noted her and other Peers’ points about the reactive or proactive nature of the Government’s approach to these issues in legislation.
I can provide the noble Baroness, Lady Young, and others, with the reassurance that they seek that the NHS will have to have regard to wider environmental objectives in developing the guidance, and this includes, for example, biodiversity. That applies to procurement and any other guidance NHS England issues to the system using the new power. In my examples, I mentioned enhancing biodiversity and adapting to climate impacts, so I hope I was not inadvertently too narrow in how I spoke to the amendments.
The noble Lord, Lord Scriven, is right that decisions are being made all the time that will have a longer-term impact, so although I cannot go further than the 12-month commitment, I am sure that the NHS will want to work as fast as it can to bring out the guidance within that.
The noble Baronesses, Lady Walmsley and Lady Wheeler, asked about reporting, both on how the NHS will fulfil its obligations under these duties, and specifically under the green plan. NHS England will report on carbon emissions and progress against its wider objectives. The noble Baroness, Lady Wheeler, asked me a number of more specific questions; if I have not addressed them, and those asked by other noble Lords, I will seek to write after today.
Amendment 7 agreed.
8: After Clause 6, insert the following new Clause—
“Information about inequalities
(1) The National Health Service Act 2006 is amended as follows.(2) After section 13S insert—“13SA Information about inequalities(1) NHS England must publish a statement setting out—(a) a description of the powers available to relevant NHS bodies to collect, analyse and publish information relating to—(i) inequalities between persons with respect to their ability to access health services;(ii) inequalities between persons with respect to the outcomes achieved for them by the provision of health services (including the outcomes described in section 13E(3)); and(b) the views of NHS England about how those powers should be exercised in connection with such information.(2) NHS England may from time to time publish a revised statement under subsection (1).(3) In this section “relevant NHS bodies” means—(a) integrated care boards,(b) NHS trusts established under section 25, and(c) NHS foundation trusts.”(3) In Schedule 4 (NHS trusts: constitution etc), in paragraph 12, after sub-paragraph (1A) (inserted by Schedule 4 to this Act) insert—“(1B) The annual report must, in particular, review the extent to which the NHS trust has exercised its functions consistently with NHS England’s views set out in the latest statement published under section 13SA(1) (views about how functions relating to inequalities information should be exercised).” (4) In Schedule 7 (constitution of public benefit corporations), in paragraph 26, after sub-paragraph (1A) (inserted by Schedule 4 to this Act) insert—“(1B) The reports must, in particular, review the extent to which the public benefit corporation has exercised its functions consistently with NHS England’s views set out in the latest statement published under section 13SA(1) (views about how functions relating to inequalities information should be exercised).””Member’s explanatory statement
This Clause requires NHS England to describe the powers of certain NHS bodies to process information relating to inequalities and to express its view on how those powers should be exercised. The annual reports for the bodies will need to state how far the functions have been exercised consistently with those views.
Amendment 8 agreed.
Clause 14: Establishment of integrated care boards
9: Clause 14, page 12, leave out lines 3 to 6 and insert—
“(4) Each integrated care board must set out in its constitution—(a) the arrangements for managing conflicts and potential conflicts of interest in such a way as to ensure that they do not, and do not appear to, affect the integrity of the board’s decision-making processes,(b) the process by which any appointment of a member to the integrated care board or any appointment to any committee or sub-committee of the integrated care board that has a commissioning function must be made so as to avoid the appointment of anyone who would be perceived to have a conflict or potential conflict of interest, and(c) the arrangements for ensuring that no member of any committee or sub-committee of the integrated care board who has a conflict or potential conflict of interest obtains access to information that might be perceived to favour the interest or potential interest.”Member’s explanatory statement
This intends to ensure conflict of interest rules that apply to an ICB also apply to commissioning sub-committees.
My Lords, we now come to the group of amendments where the wonderful harmony that has so far filled the House, with all the fantastic concessions and discussions, comes to a bit of an end. It concerns the make-up of the ICBs. I am very grateful to the Minister and the officials for the range of discussions that we have had and, it has to be said, for the consensus that there was and the brilliant initiative by the noble Baroness, Lady Walmsley, which led to Amendment 31. I commend the noble Baroness and the Minister for that amendment, which very successfully looks to the future of how ICBs might work in terms of an audit of the qualities, skills and so on that you need on an ICB. This group, however, reflects the fact that the House is concerned about who serves on ICBs now; they are being formulated and appointments made right now, and the Bill is the only opportunity we shall get to influence who serves on them and how that works.
This group of amendments addresses that issue in various different ways. I feel particularly strongly in my support of the amendment in the name of my noble friend Lord Bradley, for example. We have had a suite of amendments that have addressed the issue of mental health, but his particularly addresses the issue of ICBs. However, I will allow him to speak to that in due course.
This amendment addresses the fact that in the Commons there was significant discussion and debate about who should and who should not be a member of an ICB—and indeed, agreement was reached about who should not be eligible. Part of the solution came with the amendment which the Minister brought forward then to ensure that private organisations, other than charities, social enterprises and genuine not-for-profit organisations, will be unacceptable as members of the ICB. Employees of a private organisation, lobbyists and those very recently employed would also be barred from being members of an ICB.
That is in the Bill because it was recognised that it was not enough to rely on the governance around declaring conflicts of interest. The Bill is explicit in its exclusion. The current wording of new Section 14Z30(4) says:
“Each integrated care board must make arrangements for managing conflicts and potential conflicts of interest in such a way as to ensure that they do not, and do not appear to, affect the integrity of the board’s decision-making processes.”
Paragraph 4 of new Schedule 1B says:
“The constitution must prohibit a person from appointing someone as a member … if they consider that the appointment could reasonably be regarded as undermining the independence of the health service because of the candidate’s involvement with the private healthcare sector or otherwise.”
There was agreement across the Commons and indeed across your Lordships’ House that that was the right way to move forward.
However, we believe that there is a loophole here. We have discussed this and I have exchanged emails with officials in the department about it, and we believe that the loophole still exists. ICBs will of course be able to set up sub-committees to do some of their work, and those sub-committees can and should be mandated to commission NHS contracts. We believe that the same restriction that the ICB board has on it should be placed on those sub-committees. That is what this amendment centrally concerns.
One of the letters that I received said:
“We anticipate it may be beneficial for a wider range of people to be able to sit on some committees or some sub-committees and NHS England have explicitly asked for this flexibility.”
That reasoning provided made little sense, because it could apply in the same way to the ICB itself. The letter also said:
“We in NHS England think it reasonable to allow private providers to sit on sub-committees of the ICB as barring them risks blocking sensible integration and joint working. For example, if community services in the locality were primarily provided by a private provider it would be unhelpful and damaging to patients to bar an important provider from the committee discussing discharge pathways in that area.”
In fact, the original amendment that was agreed in the Commons was because Virgin Care, as was, got its place on the ICS in its area—which, as we know, was the forerunner of the ICBs—because it was a community provider in that area. So the very thing that caused the anxiety in the first place and which Ministers claim to have addressed—which they have—is in our view still a loophole. We believe that applying the same restrictions to commissioning at that level is unacceptable and flies in the face of flexibility.
One of the reasons for that is that ISPs will set policy and have the discussion about integration. We have accepted that, given the right kind of governance, of course they should have a range of people on them, including people representing the private sector in that area, because those bodies will not be commissioning NHS services. They will be discussing the appropriate commissioning for the ICB to do for that area. We think that is exactly the right place for the flexibility that NHS England seems to be so concerned about to take place.
I regret having to table this amendment but, after many exchanges—this is not an academic argument—we have been told that much of the ICB’s commissioning role will be delegated to, for example, place-based committees. Those place-based committees will be commissioning NHS services. We suggest that the rules that apply to the ICB should apply also to those place-based committees. So at the moment, unless the Minister has something very different from the letters that his officials have sent me about this matter, we will seek the opinion of the House. I think that is a shame. But ICBs are powerful bodies allocating many billions of NHS funding and influencing many millions as more integrated commissioning takes place. We think that the role of allocating funds in the best interests of patients, carers, service users, the public and the staff should be properly governed and governed by the same rules at local level as they are at ICB level.
The amendments in this group seek to express in different ways the fact that we are still unhappy with the way the ICBs are representing themselves. In Committee, the Minister said to us on several occasions, “This is what the NHS wants”. I think one noble Lord—I do not think it was me—said it was not really the point that NHS England wants this. We are talking about what is best for the locality, the patients and the people in it, and how we best invest and use our NHS money. So what we see in this group is that we are not quite there yet. I beg to move.
My Lords, it is a pleasure to follow the introduction from the noble Baroness, Lady Thornton, of her Amendment 9, which I signed. It is the first of a group on the structure and membership of integrated care boards—including the Commons amendments to which she referred. We agree with the noble Baroness and have concerns about the possible loophole of sub-committees. Before I go into that, I will add my thanks and congratulations to my noble friend Lady Walmsley on her excellent proposals for a skills audit and thank Ministers for agreeing to them. I hope that the Minister will reflect on some of the other amendments in this group that seek to ensure core representation from certain key groups within the NHS.
In Committee we had a lengthy debate on the roles and responsibilities of those who may have current or past connections with private sector providers. A key element of that debate revolved around the duties of board members and sub-committee members of the ICB to have its duties at the heart of all they do as they commission using public money. In his response to that debate, the Minister said that
“each ICB must make arrangements on managing the conflicts of interest and potential conflicts of interest, such that they do not and do not appear to affect the integrity of the board’s decision-making processes. Furthermore, each appointee to the ICB is expected to act in the interests of the ICB.”—[Official Report, 13/1/22; col. 1308.]
Amendment 9 seeks to clarify exactly what is meant by “each ICB” by looking at the structures for those that make decisions—which includes sub-committees. The noble Baroness, Lady Thornton, described the difficulties in the example of Virgin Care that demonstrate the loophole she spoke of.
I want to go back a step to the principles behind conflicts of interest. In 1995, the then Conservative Government adopted the seven Nolan principles of public life, which are applied to all who hold public office. Members will know very well that these key principles of personal and corporate behaviour are a golden thread running through the public service that any officeholder delivers, and health bodies are specifically included in the rubric of Nolan. All seven principles are absolutely intrinsic to how an ICB and its members will operate, whether at board or sub-committee level. To pick just two, they must have integrity, including not to
“act or take decisions in order to gain financial or other material benefits”,
and they must
“act and take decisions in an open and transparent manner”.
Amendment 9 expresses exactly the type of arrangement that a public-facing body, even a sub-committee that commissions public services, should have in place. I ask the Minister: would any Government not want conflicts of interest in respect of sub-committees of ICBs to be clear, unambiguous and strong? Is he really arguing that each board should not have that wall of protection in ensuring the integrity of its decision-making processes, as set out in proposed new subsection (4)(a)? Does he think that it is appropriate not to have an appointment process that avoids the appointment of anyone who would be perceived to have a conflict of interest, as in proposed new subsection (4)(b)? Does he also not agree that anyone who has a conflict of interest or potential conflict of interest should not have information that
“might be perceived to favour the interest or the potential interest”,
as set out in proposed new subsection (4)(c)? If the Minister cannot answer those questions, I fear that some noble Lords might be concerned that the Government have abandoned the Nolan principles for some people on sub-committees who will make decisions on commissioning many millions of pounds of public funds. I look forward to his response.
My Lords, with the leave of the House, I hope that noble Lords will find it helpful for me to speak early in this debate, since we believe that government Amendment 31 addresses some of the concerns raised by noble Lords. I shall, of course, listen carefully to the rest of the debate and respond in full at the end.
In speaking to Amendment 31, I thank noble Lords from across the House for the wide-ranging discussions in the Chamber on membership of ICBs. We are grateful for the discussions. Many noble Lords have offered their gratitude to the noble Baroness, Lady Walmsley, for the suggestion on the skills mix. We accept the spirit of these amendments and agree that it is important that ICBs are populated by members with the appropriate range of skills and expertise. I know that noble Lords have heard this many times, but it is also important that we do not over-prescribe, as ICBs should have the flexibility to design their boards to meet their needs, while also ensuring they have the skills and experience necessary to properly discharge their functions.
We have listened, and I hope that the amendments we have brought forward, which require ICBs to consider these skills, knowledge and experience, address those concerns while also ensuring balanced, workable boards. When the amendments refer to the necessary skills, knowledge and experience, that is in relation to the discharge of all the ICBs’ functions, including those related to mental health, children’s health, public health, public and patient involvement, engagement with the voluntary, charity and social enterprise sector, and digital innovation and integration. Therefore, these amendments would help to ensure confidence that ICBs have the necessary skills and expertise to discharge these functions, while allowing them to retain discretion in how they deliver this. This approach has been welcomed by stakeholders, including the Allied Health Professionals Federation, which represents 12 professional bodies representing allied health professionals.
The second, connected amendment would ensure that an ICB reports on how it has discharged this new duty in its publicly available annual report. This will allow public scrutiny of ICBs and create confidence that they are drawing on an appropriate range of skills, expertise and knowledge. This is in addition to governance of ICBs being clearly set out in their constitutions, which will also be published and signed off by NHS England. As I have said, I shall listen carefully to the rest of the debate, but at this stage, for these reasons, I commend these amendments to the House.
My Lords, I rise to speak to this group of amendments, but particularly to move at the appropriate time my Amendment 12. Again, I declare my health interests in the register, especially as a trustee of the Centre for Mental Health and an honorary fellow of the Royal College of Speech and Language Therapists.
As we have heard, we had considerable discussion about membership of ICBs in Committee. I argued in an amendment that membership of ICBs should include a representative of a mental health trust. I also supported amendments stating that allied health professionals—who make up about a third of the health and social care workforce, within which speech and language therapists are a crucial service—should also have membership on the board. However, as we heard, the Government rejected the arguments, principally on the grounds that they made membership too prescriptive and inflexible.
The Minister, with strong support from the noble Baroness, Lady Walmsley, which I welcome, has instead brought forward Amendment 31, which addresses, among other things, the need for an ICB to
“review the skills, knowledge and experience”
of board members and to
“take such steps as it considers necessary to address or mitigate that shortcoming.”
This is clearly very important, and I do not oppose Amendment 31. I certainly hope that, as the Minister indicated, allied health professionals such as speech and language therapists will be part of that review and of the board. But the amendment does not ensure that critical areas of healthcare, particularly mental health, are at the table when the ICBs are established.
Government Amendment 31 is retrospective, looking backward at a possible lack of knowledge and expertise after the event, while ICBs are the crucial forum where decisions will be made about millions of pounds of NHS funding, as well as choices about priorities and system changes. Membership of ICBs really matters from day one. It cannot be left to chance or adjusted inconsistently over subsequent years. Further, I remain concerned that if the voice of mental health is not in the room from the inception of ICBs, there is a danger that the very powerful interests of acute trusts will dominate the agenda, which could lead to undermining the not inconsiderable progress towards parity of esteem between mental and physical health, as we have already heard.
My amendment, on mental health representation, tries to overcome the Government’s criticism of overprescription and inflexibility by proposing that at least one member of the ICB should have expertise and knowledge of mental health in each ICB area. The Centre for Mental Health and the Mental Health Foundation support the view that this has the advantage of not being prescriptive and of not specifying that mental health representation should have a clinical focus or involve the nominee of a particular mental health trust. This could help to contribute to a more rounded conception of mental health, including public mental health representation, user-led representation or community organisation being placed on the board as the advocates for mental health services in their local area. This would help to ensure that integrated care systems do not become remote from their local communities and that the issues that really matter to the people are addressed from day one as the ICB plans its services.
Amendment 31, which would require ICBs to have a balance of skills and knowledge, is certainly a huge step in the right direction. I again commend the noble Baroness, Lady Walmsley, for the work she undertook on this amendment, but it should go one step further and guarantee that none of the 42 ICBs can leave mental health out of the room when crucial decisions are made. My amendment would not constrain ICBs by specifying who can or cannot bring mental health on to the board, but it would ensure that that voice is there and in the room. In doing so, it would benefit everyone’s health and well-being, helping to create a more balanced and effective health and care system in every area, and for all of us.
As the Minister said he would listen to the arguments, I hope he will accept this and, if not, clearly explain why. I will not move my amendment now but certainly will at some point.
My Lords, I support Amendments 9, 10, 14 and 32 and will speak to my Amendment 11, which follows on quite nicely from the contribution of the noble Lord, Lord Bradley. It refers to mental health, public health and secondary care services as vital to be represented on ICBs.
As drafted, the Bill leaves the membership of ICBs very much up to local decision-making. The Minister’s Amendment 31 does not change that; it leaves it up to the ICB to decide what it should look like. My concern is that ICBs may be dominated by managers from a range of organisations, perhaps including private sector health bodies. If such ICBs are established—they are being created as we speak—the Minister’s amendment simply enables them to reproduce themselves over time. There will be a degree of transparency over time, but the amendment ignores key sectors and the need for significant clinical inputs to these boards.
Amendment 31 usefully provides an opportunity for statutory guidance to achieve important objectives. In his letter, the Minister made it clear that statutory guidance will clarify that the ICB’s annual report will cover ICB duties in relation to child safeguarding. I very strongly welcome that. Can he include mental health and public health alongside child safeguarding as very particular services that are too often neglected and really need to be represented on ICBs? If he can agree to include those key services in the statutory guidance, as he has included child safeguarding, I would be very content.
Why are these services so important? As I said in Committee, having chaired a mental health trust for nine years, I am acutely conscious of the importance of high-quality and available child mental health services in particular. Across the country at present, the scarcity of such services means that vast numbers of children with quite severe mental health problems simply never get a psychiatric service at all while they are children. These untreated children will have severe problems for the rest of their lives because of that lack of treatment. It is therefore crucial to have a psychiatrist, who will be very conscious of this, on these ICBs—any psychiatrist will be aware that you have to intervene early if children display mental health problems. That is why I feel so strongly about that; I have watched it happen over years.
Another highly significant field being neglected as ICBs are being formed is public health. As many noble Lords know, I am conscious of the huge impact that effective public health responses could have on drug addiction. Police services are increasingly aware of this and are diverting addicted young people to treatment and away from the criminal justice system. However, this approach assumes that treatment services are available in every urban area, but they are not—they have been dropped or cut. Having a public health consultant on every ICB is crucial if these difficult matters are to be properly dealt with and treatment centres are not just closed because they are inconvenient, or whatever the case may be.
The Government hope to control the growth in knife crime through punitive, serious violence reduction orders. We know from all the research in the field that they simply will not work. The Durham, West Midlands and other police services are way ahead of the game, and more and more police services are following them in showing how best to ensure that violent young people caught up in county lines gangs can be diverted into education and work and away from the criminal justice system. However, that assumes that there are treatment facilities available; otherwise it simply cannot happen. Again, please can the Minister include a public health professional consultant on the ICBs as a recommendation in the statutory guidance, as he has done for child safeguarding. I beg to move.
My Lords, I will speak to Amendments 14 and 32 in my name and that of my noble friend Lady Watkins. I want to give an example from my experience; I declare an interest here as independent chair of an oversight panel, reviewing for the Department of Health and Social Care the use of long-term segregation for children and adults with learning disability and/or autism detained under the Mental Health Act. I have seen the impact of very poor and unaccountable commissioning for this group, with very costly mistakes—costly in money and in terms of lives lost and lives destroyed—because of a failure of commissioning appropriate health and social care in the community.
Some commissioners, frankly, do not have the competencies to do their commissioning job safely. I make this point because—while I appreciate the value of Amendment 31 and its requirement that ICBs would have skills, knowledge and experience, keep them under review and take action if they consider that members are failing in some way—as the noble Lord, Lord Bradley, put it, it is rather looking backwards, or marking their own homework, as I might put it, when they do not know what they do not know. This is the problem and why these amendments propose going a little further.
I welcome the Minister’s statement that ICBs will be required or expected to have the appropriate skill mix and experience necessary to deliver all their functions. I understand that the Government will issue regulations regarding fit and proper person tests, which will apply to ICBs when established, including adherence to the Nolan principles, Without the inclusion of the specific skills and expertise required, however, there will be little oversight or accountability of commissioning competence.
I would like the Minister to think again, and to commit to regulations and guidance that set out the criteria and standards that members of ICBs must possess, recognising the responsibilities that they will have and the impact of their decisions on the health and well-being of some of the most vulnerable people in our society. Commissioners take decisions of extraordinary influence; they spend large sums of public money. Civil service appointments are made in accordance with a competency framework. There is no reason why commissioners should be exempt from meeting specific eligibility criteria—and not just in the clinical sphere but in the commissioning sphere, for which there is currently no professional competency laid out.
To give another example, later this month I will be sponsoring the Second Reading of the Down Syndrome Bill, the Private Member’s Bill from the other place that will require relevant authorities, including the NHS, to take account of the specific needs of people with Down syndrome. During the Committee stage of the Down Syndrome Bill, the Minister committed to
“having a named lead on integrated care boards who will be responsible for the implementation of the guidance in practice.”—[Official Report, Commons, 2/2/22; col. 642.]
Thus, representation of learning disabilities and autism interests on ICBs would be within the context of the duty of ICBs to ensure that they have the necessary skills, knowledge and experience. Much will depend on the guidance issued by the Secretary of State under that Bill, which would fulfil similar obligations, I hope, to those of the autism strategy and the Autism Act 2009.
I reassure the Minister that I and other noble Lords recognise the challenge that the Government have in seeking to ensure that the new ICBs comprise people with the correct skills to enable the board to carry out its functions, but these amendments ask for a slightly stronger approach. I ask the Minister to assure the Chamber that guidance and regulations will address the requirement for criteria to be specified.
My Lords, I am delighted to contribute to this rich and important debate, and particularly to speak to Amendments 10 and 13 in my name.
Commenting on the words of the noble Baroness, Lady Meacher, about the importance of public health, I would stretch that much more broadly than the examples that she gave. It really ties to the previous group, where we were talking about how climate change and the nature of the environment are related to health. A public health approach really is talking about ensuring that we have a healthy environment, that we prevent illness and malfunction. If we do not have that approach in the ICBs, that is a real problem.
I agree with the noble Lord, Lord Bradley, that government Amendment 31 is useful but not sufficient to deal with the issues that are raised by this group of amendments. The Green group very much agrees with Amendments 9 and 12 and will support them should we get to that point.
I declare my interest as a vice-president of the LGA and the NALC, which may be relevant here. In speaking to Amendments 10 and 13, I declare exactly where I come from. It was the Royal College of Nursing that persuaded me that these amendments should be here. It is very much the college’s case that I now present.
To begin with a little bit of history, as part of the statutory regulations of the Health and Social Care Act 2012, it was mandated that registered nurses would be part of the governing body of clinical commissioning groups. If we look at Regulation 11 of the National Health Service (Clinical Commissioning Groups) Regulations 2012, we see that a CCG governing body must have at least one registered nurse within its membership. This will be lost if it is not required within the leadership of the integrated care boards.
This ties to a point made by the noble Lord, Lord Bradley, that sometimes there are very powerful forces in medicine. It also relates to the points made by the noble Baronesses, Lady Thornton and Lady Brinton, about the powerful force of private interests in medicine. Other truly important voices often get swept aside. It is worth noting that in the NHS in England, registered nurses are more than 49% of all professionally qualified clinical staff. They have a unique relationship with patients and clients which gives them a different insight to other professionals on how the service works, and in ensuring that measurement of performance reflects the interests of patients and clients.
In representative volume terms alone, the case here is very clear. Registered nurses lead, innovate, and deliver the largest proportion of care, and their leadership brings critical expertise, advice and challenge into boards. Without this clinical leadership, there is a risk that service design and delivery become a matter of financial accounting, without proper attention being given to quality and outcomes for patients and clients, or that there is a focus on the heroic interventions rather than on day-to-day care or on the importance of rehabilitation, on which we heard a lot of debate in Committee and which is an area to which our registered nurses bring particular skills.
It is not my intention to move these amendments, but I hope that the Government will listen to the case being put by what is a hugely important professional body and a hugely important body of professionals, and that we see action taken after this debate to make sure that registered nurses are represented.
My Lords, I rise to speak to the amendments in my name and to support those of the noble Baroness, Lady Hollins, who earlier described the need to standardise the knowledge and experience of commissioners, given the potential significance of their decisions.
The Government rightly suggest that there must be some flexibility so that integrated care board membership best reflects the competences needed to commission for local populations. However, unless regulations stipulate essential criteria for members’ collective skills, knowledge and experience, we risk falling into old habits of medical paternalism. That will undermine efforts towards more integrated, holistic care and mental health needs may be given cursory regard. The voices of nurses—as so ably outlined by the noble Baroness, Lady Bennett of Manor Castle—and other professionals will not be heard.
I would like to share with the House a well-known quote in organisational management: “Every system is perfectly designed to get the result it gets”. We now have the opportunity to safeguard the diversity of experience in each integrated care board by establishing a minimum standard, imposed either by regulation or by statutory guidance, to ensure the system gets the result that best meets commissioners’ needs for local patients and populations across the country.
My Lords, as well as supporting Amendments 9 and 12 and the rest of the group, I would like briefly to add my support for Amendment 31 in my capacity as patron of the British Stammering Association. This amendment is very much welcomed by the Royal College of Speech and Language Therapists, for all the reasons that we set out in Committee. It would do much to improve the expertise available for these damaging difficulties with the basic human need to communicate and the capacity to swallow, so I hope the Government adopt it—I am sure they will, because it is a government amendment. I am very grateful.
My Lords, before the noble Baroness, Lady Walmsley, speaks, I congratulate her and the Minister on Amendment 31. I also want to ask a question. It very much looks as if the integrated care board is marking its own homework, because the duty to keep the experience of members under review is placed on an integrated care board. It is then for the integrated care board itself to make a judgment as to whether it
“lacks the necessary skills, knowledge and experience”.
Quite clearly, any board that has already appointed a group of members is almost certain, in undertaking its review, to come to the conclusion that it was altogether wise in appointing the members with the balance it did. Who is going to monitor this? Who is going to check?
What if you are a local nursing body concerned that nursing issues are not being debated and reflected enough within an integrated care board? What do you do? Who do you go to? As far as I can see, apart from judicial review proceedings there is absolutely no way you can get any change. That is why—and I pay tribute to the noble Baroness, Lady Walmsley, for her work on this—you need amendments like my noble friend Lord Bradley’s to make some specification in relation to those critical areas where it is essential that the board has members with the relevant experience.
My second point for the Minister is this. In introducing her Amendment 9, my noble friend Lady Thornton essentially said that the Bill already lays out constraints on integrated care boards in relation to potential conflicts of interest. All she seeks to do is to extend that to sub-committees of the integrated care board, including place-based committees, which will commission a huge amount of health service provision in future. For the life of me, I cannot see how those sub-committees can be constituted under any different principle from that of the integrated care board itself. Unless the Minister really comes up with a convincing answer on this, I think the House should make its views clear.
My Lords, as this is my first contribution on Report, I begin by declaring my interest as the recently stepped-down chair of NHS Improvement and NHS Test and Trace.
I commend the noble Baroness, Lady Walmsley, and my noble friend the Minister and support Amendment 31. In Committee, we debated in considerable detail the constituent elements of the ICBs. I think it hugely important that integrated care boards have a loud, strong, forceful voice for mental health, public health and prevention in all its forms, but I also think it really important that we enable a board to be a proper board.
The noble Lord, Lord Hunt, questions whether a board would ever assess its own competence and members. Any really good, functioning board in the public and private sector views that as one of its primary obligations. The first line of defence to ensure that a board is performing well is whether it is actually doing an assessment every year of whether it has the appropriate skills. Yes, you should have second and third-line assessments through the CQC and NHS England, but it is the role of a board, and we should let them do that. I believe that Amendment 31 holds these boards to account to do that.
The amendments we have already debated today, enshrining the obligations around public health, health inequalities and mental health, ensure that that is the clear objective of those integrated care boards. I encourage my noble friend the Minister to hold firm and support his amendments and not the others.
My Lords, I thank noble Lords who have expressed their support for Amendment 31 and my role in it; it is very kind.
I go back to how this arose. It is to some extent influenced by what the noble Baroness, Lady Harding, said in Committee. It was quite clear that many noble Lords were very concerned that appropriate levels of skills, knowledge and experience were on an ICB so that it would be able to carry out all the functions that the Bill puts upon it; not perhaps just the list that the noble Lord, Lord Kamall, mentioned, because it was not intended to be an exclusive list. The amendment actually says:
“in order for the board effectively to carry out its functions”.
I think there it means all of its functions.
It was quite clear in Committee that the Government had set their face against prescribing all the different people who should be on a board. But there had to be a way of making sure that the board had all the necessary commissioning skills, and the knowledge and experience of all the areas of health services which that board had to deliver. The board had to have the duty to make sure it could do all of those things—perhaps without prescribing everything, which the Government are determined not to accept.
The solution came to me not just because of what the noble Baroness, Lady Harding, said but because of what my noble friend Lord Thurso said to me in private—not on the Floor of the House. He is a very experienced board chair. He called my attention to the National Audit Office advice on best practice in this respect and a paper on NHS leadership, which recommends something very similar: that the board must have the duty to make sure it has all the skills, knowledge and experience to carry out all its functions, keep that under constant review and report on what it has done and how.
It is inconceivable to me that, if ICBs had this duty, there would not be somebody who knew everything that needed to be known about mental health and public health to effectively commission those services. The duty to report is very important, to keep this in constant review every year and to report in its annual report on how it makes sure that it has got all those skills and that experience. I think the CQC would look very carefully at whether the board had actually carried out the duty put upon it by Amendment 31. If there were any gaps in a service which the board had to carry out, and it did not have the right skills, knowledge and experience to do that, the CQC would be very critical. I commend this amendment to your Lordships.
I will also say in concluding that on these Benches we also support Amendment 9. The noble Lord, Lord Bradley, had a very good point. The amendment in the name of the noble Lord, Lord Kamall, which I am supporting, is retrospective because it requires that, by the end of when an annual report comes around, the board has to show what it has done in respect of providing the right people to make the right decisions. From day one, what this House has done on mental health and how important it is, with the Government’s co-operation, is right.
My Lords, one has to start with the definition of the functions of the integrated care board in the Bill. It says:
“An integrated care board … has the function of arranging for the provision of services for the purposes of the health service in England in accordance with this Act”—
that is, in accordance with all the provisions of the Act. The idea that you must identify some of them in order that the thing should be perfect strikes me as damaging to the nature of the definition. For example, we had today at Question Time a Question about experts in eating disorders. Ought it be said that we must have an expert with clinical experience of dealing with eating disorders? Is it perfect without that? This is the nature of the board that is being set up: it has a generalised responsibility for all that the Act provides in relation to its area.
So far as Amendment 9 is concerned, it seems to me that the requirement in respect of conflicts of interest is part of the construction of the board itself. Therefore, it must be a restriction, if you like, on every committee and sub-committee of the board, because they are all part of the board and therefore subject to that definition.
My Lords, despite what the noble Baroness, Lady Thornton, said at the beginning about this perhaps being the end of the harmonious start to our debates so far, I feel that this has been a helpful and constructive debate. I am grateful to noble Lords for bringing these issues before the House.
Let me start with Amendment 9, as I understand the wide interest in the membership of the committees of the board and potential conflicts of interest. We firmly agree that conflicts of interest must be handled carefully, and have included multiple references to that in the Bill. We also recognise the concern that ICBs should not allow private providers to control commissioning decisions, which is why we added the amendment relating to private providers in the other place, in paragraph 4 of Schedule 2.
Furthermore, in the helpful discussions we have had with noble Lords since then, there has been mutual recognition that we need to balance the importance of protecting the core values and public nature of the NHS while not overly restricting the membership of ICBs. I am pleased that the amendment to Schedule 2 balances on that tightrope and gives appropriate reassurance. We think that it is reasonable to allow private providers and social enterprises to sit on some committees and sub-committees of the ICB, as barring them risks blocking sensible integration and joint working.
I am also aware of the mixed reactions to this amendment from stakeholders. Many noble Lords will have seen the NHS Providers Report stage briefing, which states that
“there could be circumstances where a local private or voluntary sector provider would be well placed to join a joint committee with a focus on integrated service delivery whereby the usual arrangements to identify and manage conflicts of interest would, and should, apply.”
It goes on to say:
“It does not seem reasonable … therefore to further restrict the membership of those committees in a way which is prescriptive in law.”
Further, the NHS Confederation stated in its Report stage briefing that this amendment
“risks critically undermining integration by reinforcing a rigid, out-dated purchaser-provider split and derailing the fundamental purpose of these reforms.”
As it so eloquently put it:
“The current reforms aim to facilitate collaborative working by bringing all partners in local areas around the table to plan the most effective and the most efficient way to deliver care. This, by its nature, involves bringing providers of services, alongside commissioners, into committees and sub-committees of the ICB to plan how care is delivered”.
Potential conflicts of interest are inevitable in commissioning, especially when we are looking to increase integration and bring multiple bodies together. The ICBs will be required to manage conflicts of interest as part of their day-to-day activities. That is set out in the Bill and will be part of their constitution as well.
For all committees, the board of the ICB will have to determine what functions they exercise, their membership, and the level of oversight of their decisions. The board of the ICB cannot delegate a function and claim to be no longer responsible for how it is discharged, and will be held to account for this by NHS England.
Also, ICBs will be clear and transparent about interests, and how they are being managed. We think that transparency will prevent poor decision-making. New Section 14Z30 makes it clear that an ICB must maintain and give public access to a register of interests for members of its committees or sub-committees. There must be arrangements in place to ensure that conflicts are managed not just for ICB members but within committees. The constitution of the ICB must also include the arrangements to be made to discharge the functions under new Section 14Z30 and a statement of principles to be followed by the board in this regard. This will all be supported by guidance from NHS England. We are quite determined to tackle conflicts head on and not shy away from this issue.
My Lords, if NHS England is determined to tackle conflicts of interest head on, why is it building them into the whole structure of integrated care boards? Let us think about an integrated care board discussing future strategy: it would inevitably discuss where the priorities will be. That inevitably means that money will follow the priorities. At what point in those discussions do the major providers, who will be sitting round the table, have to withdraw from because of a conflict of interest? At heart, this ambiguity is built in, so it is not surprising that my noble friend wants to see consistency right through the system, including the sub-committees.
I thank the noble Lord for that intervention because I was just about to come to it. I should add that new Section 14Z30 very clearly requires ICBs to manage conflicts of interest at sub-committee level.
We think that the approach we have outlined will be more appropriate and possibly more effective than simply barring individuals with a conflict of interest—which, I encourage noble Lords to note, would also include NHS Providers and local authorities— from all committees with a commissioning function. First, this approach is broader than what the noble Baronesses might have intended. Secondly, many committees will have a range of functions, and commissioning may be only a small part of their activity. This approach risks creating a series of duplicated committees with similar interests to enable commissioning decisions to be taken in line with the amendment. This risks undermining one of the very purposes of this reform: to reduce bureaucracy and increase integration.
On Amendment 10A, we are clear that chief executive pay should be value for money. The pay framework is based on our ability to attract the highest-quality candidates. ICB roles, such as the chief executive, are some of the more complex in the health system. Experienced chief executives of trusts already exceed the suggested £150,000 per annum remuneration. Therefore, we do not believe it would be realistic to expect them to take a pay cut to take up a role with such a portfolio.
I remind noble Lords that putting the salary of an ICB chief executive into the Bill would be inappropriate. Such a lack of flexibility would be extremely unusual for a senior position and risks salaries declining in value over time, precisely as ICBs take on more responsibility as they become more established. This would fundamentally weaken ICBs’ ability to recruit and retain senior management. I also warn that directly tying pay to performance is likely to make it significantly harder to recruit chief executives to more challenging ICBs—precisely the organisations that we would want to recruit the very best leaders.
I hope I can reassure noble Lords that the recruitment process will ensure that only the most qualified people can take up these roles. All ICB chief executive appointees across England need to demonstrate how they meet—
I wish my noble friend had stood up the moment I mentioned Amendment 10A. I can only apologise. I have received advice to agree with what my noble friend said. I shall very quickly move on and I thank him for his vast experience of this.
Let me move on to a couple of issues raised about mental health. We expect mental health trusts to play a critical role in ICBs and ICPs. The Bill sets out a minimum requirement. It does not specify what sort of care NHS trusts or NHS foundation trusts deliver. As we said earlier in the debate, we hope that ICBs by local agreement go beyond the minimum requirements. We clearly want to see parity of esteem between mental health and physical health.
Noble Lords mentioned public health. The department and NHS Improvement publications have stated an expectation of an official role for directors of public health in ICBs and ICPs. This recognises the vital advisory and leadership roles of directors of public health in the system-wide effort across all domains of public health, which is amplified by the shift to a more preventive, collaborative and integrated systems focus on improving population health. We are working very closely with stakeholders to shape this official role in relation to ICBs.
Can I just check that we talked about Amendments 14 and 32? Yes, we did. This is a more interactive session than many noble Lords would have expected. Perhaps it will do as a sort of novelty. I believe that Amendments 14 and 32 are aligned closely with the skills mix amendment, and I hope that will go some way to satisfying concerns.
On guidance, I am able to reassure your Lordship’s House that NHS England’s regional teams are having ongoing discussions with CCGs and will deal with ICB leaders about the potential membership of the ICB board on establishment. These discussions are focused on ensuring that the board will be effective in discharging the statutory duties of the ICB. Looking beyond this, NHS England is able to issue guidance to ICBs and will engage with them—to understand what issues are emerging during the initial period of operation —and their committees and how they are working with stakeholders. In some areas, NHS England is already developing draft guidance. For example, the proposal is that each ICB will be expected to have a named lead with responsibility for commissioning for learning disability and autism.
On regulations, we think the rules as currently set out in the Bill, and with the addition of the new skills mix amendment, are sufficient and will give ICBs the space they need to develop effective systems in their area. The Bill already includes a regulation-making power that covers any provision related to ICBs’ constitutions, including ICB membership. Therefore, if we deem it necessary in future to be more specific about ICBs’ membership requirements, we retain the ability to do so through regulations. I hope I have been able to provide some assurance—sufficient assurance—to noble Lords and that they will not move their amendments when they are reached.
I congratulate the noble Baroness, Lady Bennett, on that suggestion.
I shall be very brief. This was an excellent debate, which proved that the House still has some reservations about ICBs and, if nothing else, it should tell NHS England and the 42 existing ICBs that we want them to do extremely well and to be powerful. Amendment 31 will help ensure their future prosperity and the diversity they need to do their job.
However, I am not content with the Minister’s explanation about my Amendment 9. I regret that NHS Providers and the NHS Confederation never bothered to speak to me about this amendment. They seem to have spoken to the Minister and a few other people and have been on Twitter about it. I think that is rude and it makes me wonder where their panic has come from. I do not think they need to panic about something which just adds consistency to the rules that govern commissioning and the spending of our money. I say with great respect to the noble and learned Lord, Lord Mackay of Clashfern, who I did not see at the beginning of this debate, that if sub-committees are commissioning and spending public money, they should have the same rules as the ICBs. That is the crux of this. I wish to test the opinion of the House.
Schedule 2: Integrated care boards: constitution etc
Amendments 10 to 11 not moved.
12: Schedule 2, page 145, line 30, at end insert—
“(d) at least one member with expertise and knowledge of mental health in the integrated care board’s area.”
Amendments 13 and 14 not moved.
Consideration on Report adjourned until not before 8.55 pm.