Report (1st Day) (Continued)
Clause 16: Commissioning hospital and other health services
Amendment 15 not moved.
16: Clause 16, page 13, line 42, at end insert—
“(ga) such other services or facilities for palliative care as the board considers are appropriate as part of the health service,” Member’s explanatory statement
This amendment would specifically require integrated care boards to commission such services or facilities for palliative care (including specialist palliative care) as they consider appropriate for meeting the reasonable requirements of the people for whom they have responsibility.
My Lords, on behalf of my noble friend Lord Kamall, I beg to move Amendment 16 in his name.
The passionate and emotive speeches made on palliative care in Committee left a deep impression on me, as I am sure they did on all noble Lords. Since that debate, the Government have carefully considered the compelling points made by noble Lords from across the House, which we seek to address through this amendment. In moving it, it is right for me to pay particular tribute to the work of the noble Baroness, Lady Finlay, who has done so much to drive this issue forwards.
We recognise that there are variations in access to palliative care services across England. Although we are clear that clinical commissioning groups have always been required to commission appropriate palliative and end-of-life care services as part of the comprehensive health service, we recognise the value of making that clear in the Bill in relation to integrated care boards. We know how important it is that people receive high-quality, personalised palliative care that is built around their individual needs and takes account of what matters to them and those important to them.
These services often include the support of a range of health professionals. For those with more complex needs, this will include access to multi-professional specialist palliative care. These teams provide the essential education and training in the field, supporting research and rapidly disseminating what works. Advice and support need to be available at all hours, wherever patients are, working in an integrated way with other services to ensure that patients can access the support they need early to avoid unnecessary distress.
To make this clear, Amendment 16 would add palliative care services to the list of services that an integrated care board must commission. The amendment clarifies that the commissioning of palliative care is integral to the duty of integrated care boards to commission their part of the comprehensive health service. I am especially grateful for the helpful and constructive way in which the noble Baroness, Lady Finlay, has worked with Ministers and officials to develop this amendment. Without wishing to anticipate her remarks in relation to her Amendment 17, may I just say that, in our view, the kind of detailed provision contained in it would be better covered in statutory guidance, where it can be more fully explained and described? I beg to move.
My Lords, I shall speak to Amendment 17, to which I have added my name, but first I thank the Ministers for listening to the noble Baroness, Lady Finlay, and others, and for tabling Amendment 16. I also thank Together for Short Lives for its helpful briefing.
Your Lordships’ House had a moving debate in Committee that captured the practical and economic need for the wider range of provision of palliative care, and how ICBs can properly fund and plan for it. In Committee, the Minister, the noble Lord, Lord Kamall, said that
“ICBs will be required to have regard to the National Institute for Health and Care Excellence guidelines in their provision of services, as CCGs currently are … NHS England will continue to support commissioners of palliative and end-of-life care services through their palliative and end-of-life care strategic clinical networks. These networks support the delivery of outstanding clinical care by ensuring palliative and end-of-life care is personalised for all.”—[Official Report, 18/1/22; col. 1637.]
The noble Lord’s Amendment 16 provides the specialist services we sought, but it says only
“as the board considers … appropriate as part of the health service”.
Although I join other noble Lords in thanking the Ministers for the amendment, please can the noble Earl confirm that, although the wording of the amendment requires ICBs to commission palliative care “where appropriate”, it is his intention that all ICBs should deem it appropriate, and therefore all of them should commission palliative care services, including for seriously ill children and their families? We know that the provision of palliative care services is very patchy. Will he provide statutory guidance to supplement the amendment and support ICBs to interpret their responsibilities, including for children? When will this be available? What action will Ministers take to ensure that ICBs have the financial resources needed to fulfil the new duty? Finally, what action will the Minister take to ensure that there are enough professionals with the skills and experience needed to provide the palliative care for children that ICBs will have a duty to commission?
We covered all this in very moving stories in Committee. Can the noble Earl confirm that all I have outlined will be covered in regulations and statutory guidance?
My Lords, I am embarrassed to be called to speak ahead of the noble Baroness, Lady Finlay. I understand that the Deputy Speaker does not have discretion to make their own judgment about the sequence of speakers, but I hope this rule can be looked at. As it is, I add my thanks to the Minister, the noble Lord, Lord Kamall, for tabling Amendment 16. He and the noble Earl have graciously paid tribute to the noble Baroness, Lady Finlay of Llandaff. I am sure I speak on behalf of everyone by saying: so should we all. Her vision and persistence have beaten a path towards the progress we can now make.
Although the noble Lord, Lord Kamall, observed in his letter to us that it has always been a duty of the NHS to commission appropriate palliative and end-of-life care services, and that commissioning palliative care is a core function of integrated care boards, these obligations have hitherto been honoured perhaps as much in the breach as in reality. Provision has been patchy, shall we say? I think the noble Earl said that there had been “variations”; indeed there have.
I also acknowledge that the NHS does sometimes provide exemplary palliative and end-of-life care. Many noble Lords will know that my partner Patricia, Lady Hollis, died of cancer in 2018. I express my deep appreciation of the quality of palliative and end-of-life care she received at the hands of the NHS. I particularly express my profound gratitude to her NHS consultant at the Norfolk and Norwich University hospital, Nicola Holtom, and her team, and to others providing community services, because it eased Patricia’s path and made a huge difference to all of us who cared for her.
Sadly, for all too many, including cancer patients, this quality of service has not been available. Indeed, for some there has been no relevant palliative care and end-of-life service. This could therefore be a historic moment, but it is far from certain that it will be. I of course accept that Ministers are acting in good faith, but the indeterminate drafting of Amendment 16 leaves rather a lot of wriggle room. For an NHS which is always short of the resources that it needs and that is struggling to cope with its existing workload, it remains a danger that the provision of palliative care will be sparse. The language of Amendment 16,
“such other services or facilities for palliative care as the board considers are appropriate”,
does not make it clear that it will be an inescapable duty of ICBs to ensure that palliative and end-of-life care is a universal service and that there will be a duty on ICBs to provide high-quality palliative care.
The Minister indicated that he does not expect to agree to write into the legislation Amendment 17, in the name of the noble Baroness, Lady Finlay, which specifies in very useful detail what the nature of an exemplary service would be. He said that it would be better to do this by way of guidance. I am encouraged at least to know that it is the department’s intention to provide guidance and to set out models of how ICBs should set about fulfilling this duty. But what measures will be in place to ensure that this happens? What monitoring does he envisage? What reporting requirements will there be?
I have another question which I think is very important: how will the system enable patients and families to know what palliative care is available for them and how to access it? As things are, so often patients and their families are bewildered. They just do not know where to turn amid the complexities of the system, and they often feel discouraged by the responses they receive. They seem to observe the buck being passed between the NHS and social services and between different entities within those services.
I know that Ministers want to do the right thing, but it is important that we do not miss this opportunity to bring about the real thing. If we can be assured that the quality of provision will be as high as that envisaged in the noble Baroness’s Amendment 17, and that the department and NHS England will have systems to ensure that that is so, this could indeed be a transformative moment—a moment after which there will be the prospect that, instead of experiencing a bleak death, as so many people do, they will have a good death, and that will be an enormous consolation to their families, for whom, in their bereavement, the passing of a loved one is the greatest suffering.
My Lords, I must declare that I am a vice-president of Marie Curie and of Hospice UK. I am most grateful for the kind and generous words that have already been said about me and the work on this amendment. I must thank both Ministers, the team and the officials for all the work they have done on this subject. I also thank the charities Marie Curie, Sue Ryder, Hospice UK, Alzheimer’s Society and Together for Short Lives, and particularly those people who have generously shared their experiences of supporting someone they love who is living with a terminal illness.
Palliative care is not an add-on or aftercare, but must be integrated as an essential part of NHS provision. As we move forward, I want to pick up the point that the provision of services for people who need palliative care must include specialist palliative care as core. Specialist care is provided by multiprofessional teams. These doctors and nurses have specialist training, usually working with allied health professionals who also have become specialised in their way. Hospice care assistants in health and social care have also been specially trained, and others, including multidenominational services and counselling and bereavement support for children and adults, are all part of the wider provision.
People need support in every setting, whether at home or in a care home, hospital, hospice or some other community setting, which includes places such as prisons. In all these settings, the specialist palliative care team works with local clinicians to provide expert advice at all times of the day, every day, supporting health and social care professionals who are providing care to the person and their family. Sadly, as has been said, palliative care is currently patchy, and it must be available wherever people are, as the noble Lord, Lord Howarth, said in his remarks. It must be available for all ages, to reflect on the comments of the noble Baroness, Lady Brinton.
My Amendment 17 sets out the criteria for specialist multiprofessional palliative care services, based on the World Health Organization commissioning guidance. I hope it will act as a guide to all integrated care boards in determining what they will now commission and from whom. In many areas, their local hospice services will be able to have a better contract, spelling out what is expected of them and what is available to them by better integration. In some other areas, services will need to be grown and developed over time.
The charitable hospice world is committed to working with the NHS in an integrated way, leaving the charity free to fundraise for whatever additional, non-core services should be provided to improve the quality of life of patients and their families in their area. Where there are specialist beds, usually in a local hospice, they need to be able to take patients on an urgent basis, as disease does not respect the clock or the calendar.
Specialist palliative care has an important role in supporting the education and training of the health and social care workforce in the area at all levels, as has been said, as well as supporting and participating in relevant research and disseminating evidence-based innovations for rapid rollout. As services develop and move forward, being linked to a What Works centre initiative will help ensure that there is rapid dissemination of new knowledge and skills. Integrated palliative care services can provide support to ensure the right skilled workforce, equipment and medication are available, with a point of contact for people with palliative care needs if their usual source of support is not accessible.
This is all in place in some areas already, with appropriate systems to share information with the person’s consent, to ensure that all professionals involved know about that person’s needs and what matters to them and their family. As services develop, that will be of great benefit in ensuring that the core team members, if provided through a hospice, have honorary contracts so that they can go into NHS hospitals and provide support as needed, as we saw during the peak of the pandemic. At that time, it was said that palliative care had come into its own, providing support in intensive care units, high dependency units and emergency departments, as well as in the community and on wards.
May I share with the House the fact that I have had correspondence of jubilation from colleagues in palliative care, because this recognition means that they feel they finally have equal status with other NHS services and can integrate better, whether with oncology, neurology, cardiology, surgery, anaesthetics and many other services? Such integration can ensure that patients get what they need when they need it, whether it is radiotherapy to relieve bone pain or halt a spinal cord compression or an urgent nerve block or a surgical opinion.
We are at a milestone moment, and I sincerely hope that this amendment really will be game-changing. It is the start of a new journey, and this is the first step for the Department of Health and the NHS to guide integrated care boards as they look to develop over time the services that their local population need. Now delivery plans need to be communicated to integrated care boards and providers as they work together on the journey to integration and ensure fair access for all to the palliative care that people desperately need, often at the most vulnerable time in their life.
My Lords, I pay tribute to the noble Baroness, Lady Finlay, for her outstanding work in this area. I was very moved by the remarks of my noble friend Lord Howarth in tribute to the care given to Baroness Hollis, who was such a tremendous force for good in your Lordships’ Chamber over many years.
Can the noble Earl clarify the point that has already been raised? In the letter from Ministers of 26 February it was said that the amendment would add palliative care services to the list of services that an ICB must commission. On the face of it, the amendment seems rather more permissive. Proposed new subsection 3(1) in Clause 16 states:
“An integrated care board must arrange for the provision of the following to such extent as it considers necessary to meet the reasonable requirements of the people for whom it has responsibility”.
There is then a list, which starts with “hospital accommodation”, which the ICB must arrange for—then on page 17 are a couple of provisions that seem rather more permissive.
The nub of the issue is this: we have fantastic palliative care in the mainly voluntary sector as well as in the National Health Service itself, but it is very patchy. The health service has been very reluctant to give long-term certainty to hospices and other providers of palliative care services, insisting on short-term contracts. The real question to the noble Earl is this: will this change as a result of this amendment? Where is the beef that will actually get the message across that we expect the health service to do a lot better than it has been doing in support of palliative care services?
My Lords, I declare my interests in the register. I join in thanking the Government for having listened in Committee. I hope that this will make a difference not just to the lives of those whose lives are shorter but also their families, so it is very welcome. I pay tribute to the noble Baroness, Lady Finlay, but also to my friend, the right reverend Prelate the Bishop of Carlisle, who put his name to Amendment 17.
As I say, I welcome this amendment. As the chair of the UK Commission on Bereavement, I have been reminded recently of the inconsistency of palliative care, which other noble Lords have spoken of this evening. It affects not only those who require palliative care but also their family and friends, and it leaves a legacy into bereavement, which we should not underestimate. I too was reassured to hear the Minister say that palliative care must be commissioned, but I share again the concern of the noble Lord, Lord Hunt. In Amendment 16, the word “appropriate” is used, and it is not quite the same thing. Could the Minister reassure the House about the Government’s expectations regarding the nature of palliative care services that the ICBs will commission? How will they ensure that that is delivered in a way that creates consistency? It is care that is rightly deserved by people in our communities, which also reflects the skill and hard work of our palliative care practitioners
My Lords, I too congratulate the Minister and his officials on listening to the House and the strong representations he received in Committee on this issue.
I welcome the Government’s amendment. I add my tribute to the work of the noble Baroness, Lady Finlay, as well as the many Members of this House and the campaigns of organisations such as Marie Curie in getting us to this point. It is wonderful that the symbol of Marie Curie is a daffodil, and we are here today on St David’s Day being led by the noble Baroness, Lady Finlay of Llandaff. That is very appropriate.
I disagree with the noble Lord, Lord Howarth of Newport—this is an historic moment and a huge step forward. It is the first time in the history of the NHS that there will be an explicit requirement to commission palliative care. I declare my interests as chair of the Scottish Government’s National Advisory Committee for Neurological Conditions and a trustee of the Neurological Alliance of Scotland. Many people with long-term, progressive conditions have not been able to access palliative care at an early enough point. Not only would this ensure better outcomes for patients, but it would also be a better use of NHS resources. I hope that the result of the Government’s amendment will ensure that these people get better care, including the palliative care they need. I also hope that ICBs will recognise the difference that they could make.
I welcome the opening remarks of my noble friend Lord Howe about taking the criteria set out in Amendment 17 in the name of the noble Baroness, Lady Finlay, and to which I was happy to add my name. It provides a helpful set of guidance for ICBs to follow, based on standards. I echo the question of the noble Lord, Lord Howarth, on ensuring that we have the right reporting requirements. I am grateful to hear that the Government will be developing statutory guidance to ensure that we put the necessary tools in place. However, I have been concerned to learn, in my meetings with NHS England, how—as far as I have been able to ascertain—it reports on services, rather than medicines or specific procedures. When reporting on NICE guidelines for services, NHS England seems to rely on “noise in the system” to ensure whether they know that something is happening or not. I share some noble Lords’ worry about the word “appropriate”. If we develop statutory guidance based on the criteria set out in Amendment 17, I hope that the risks that the word “appropriate” might continue to see a postcode lottery will somehow be allayed.
Finally, given that ICBs are at different stages of their development, can the Minister and the department give careful consideration to the ongoing and direct communication to ICBs regarding this duty? Will they consider writing to all ICB chairs to ensure that they are fully aware of the duty and their responsibilities?
The Government have made a very important step forward today in giving people who are facing the end of their life the reassurance they and their families need. The focus now must be on ensuring that this amendment is used to its fullest by the ICBs, so that everyone who needs palliative care will benefit.
My Lords, I shall speak briefly to add my very strong support for Amendment 17, promoting the provision of specialist multiprofessional palliative care services. I also welcome, and will comment on, the Government’s Amendment 16 on the same topic. Alongside all other noble Lords, I pay tribute to my noble friend Lady Finlay for her tireless work to improve palliative care services.
It is of course most welcome that the Government have tabled an amendment in this field, but their amendment leaves it to the ICB to decide what standard and extent of palliative care services are “appropriate” to meet what they deem to be the “reasonable” requirements of their populations—the Government’s words. What do these terms mean? Does the Minister accept that the amendment does not ensure that adequate specialist palliative care services will be available across the country? That is what we all desperately want to see. I hope that, in his response, the Minister can define these terms. What do the Government mean by “appropriate” palliative care services and a “reasonable” level of such services?
As I said in Committee, it is unbelievable that the NHS provides services according to need throughout our lives, until we are dying, when of course our health needs are at their greatest. At that stage, precious hospices have to raise their own money, as others have said in the past, to finance their doctors and nurses to care for the dying. Inevitably, hospital beds lie empty. Some 50% of beds in a hospice I visited recently were empty, because it simply did not have the staff to deal with patients in those beds. Can the Minister confirm that the Government will provide statutory guidance to supplement Amendment 16 and clarify what they mean by the terms “appropriate” and “reasonable”?
As things stand, I strongly support the amendment tabled by my noble friend Lady Finlay. As we die, we should all have high-quality palliative care services. We can then expect that, when assisted dying is legalised, a reasonably small percentage of dying people will suffer unbearably, despite benefiting from top-quality services, because of course there are situations when the best possible palliative care services have done everything they possibly can and yet certain patients suffer unbearably. We need a change in the law to ensure that those patients have control over the suffering that they can reasonably tolerate.
I look forward to the Minister’s response and, as I say, hope that he will clarify the definitions of the terms used in the amendment.
My Lords, this amendment adds a new paragraph to the new Section 3(1) set out in Clause 16 and it seems clear that what Section 3(1) says refers to all that follows it:
“An integrated care board must arrange for the provision of the following to such extent as it considers necessary to meet the reasonable requirements of the people for whom it has responsibility”.
One has to look at reasonable requirements in relation to everything in that list, with the first being “hospital accommodation”. The idea that there might be some areas with no hospital access at all is absolutely ridiculous. So this is a qualification, to be fitted in as paragraph (ga).
Immediately before it is another provision, which refers to services considered
“appropriate as part of the health service”.
That seems to suggest that it is absolutely essential that the needs and reasonable requirements of people who need palliative care are met. ICBs do not need to provide palliative care for the whole community, but are required to provide it for the proportion of people expected to require it, namely those getting near the gates of death. That is a reasonable interpretation of this clause.
I believe it goes quite a long distance in the way that the noble Baroness, Lady Finlay, and others for some years have asked for. I do not think it feasible to say that nobody in an area will require palliative care—unless its inhabitants are people who live for ever, of which there are only very few. It looks to me as though this is well constructed to ensure that palliative care must be provided where people die, in the area of the integrated care board.
I entirely welcome Amendment 17 from the noble Baroness, Lady Finlay, but the crucial amendment is provided by the Government and is written in a way that will be very difficult for any care board to try to escape, because it is very clear.
I also join the noble Lord’s tribute to Lady Hollis, who was such a tremendous source of value in this House, including, as many of your Lordships will remember, the time when she was able to get the House to set aside the order about capital provision for poorer people.
My Lords, I will be very brief. Having spoken on this in Committee, I simply thank my noble friend the Minister for bringing forward Amendment 16 to include palliative care services in the list of things required by ICBs to commission. We all agree that the end of life is one of those times when care is needed most, and I too congratulate the noble Baroness, Lady Finlay, on all her work on this, and all those who spoke in support in Committee.
This is an example of where the Government have truly listened and responded to concerns voiced on all sides of the House. They have made the most of the Bill’s unique opportunity to ensure that nobody with a terminal illness misses out on the care and support they need, both now and in the future.
My Lords, I congratulate the noble Baroness, Lady Finlay, without whom this amendment would not have been laid by the Government —although I pay tribute to the Government for listening to her. As she said, it could be game-changing—I say “could be” because unless the resources are made available for these services and for training enough of the health professionals needed to carry them out and make them available everywhere, it will not be game-changing. I would like a reassurance from the Minister that adequate resources will be made available so that, as appropriate, ICBs can carry out the duty that will be put on them.
I was horrified to hear the noble Baroness, Lady Meacher, mention a hospice with half its beds empty. I hope additional resources will be provided for hospices. I clearly remember somebody saying in Committee that you would not expect to have a coffee morning or a cake bake to treat a broken leg; you should not have to do the same sort of thing for services at the end of life. I hope the Minister will bear in mind the possibility that additional resources should go there.
We have heard that services are patchy across the country, and I suggest that the worst patchiness is in services for people dying at home. I know it is not easy to provide 24-hour services and advice to a family doing their best to try to care for somebody dying at home, but it must be done. I am afraid I know friends who have had a very bad experience of that. The person at the end of life had a bad experience, and the family have never forgotten it. As the noble Baroness, Lady Finlay, has often told us, it is possible for everybody to have a good death if the right services are provided to them. That means a good experience too for the family, who simply want to know that they have done the best and that that has been enough.
My Lords, from these Benches I am very glad to continue our support for palliative care being part of a comprehensive health service—literally from the cradle to the grave—no matter who you are, your age or where you live. I join other noble Lords in paying tribute and giving appreciation to the noble Baroness, Lady Finlay, for her assistance and professionalism over many years. I hope that the real tribute to the efforts of the noble Baroness will be in the delivery of real change to the quality of people’s lives—and their deaths. I add my appreciation to all the charities and hospices that have also been a force for good in seeking this change.
I welcome the government amendment in this area and, in so doing, I simply say to the Minister that I hope the Government have heard the number of questions asked today. Clearly, there is concern about the words “appropriate” and “reasonable”, and I will add a few questions to those already put to explore that further. I am sure the Minister understands that noble Lords are simply trying to ensure that what is intended will actually be delivered.
Can the Minister confirm how the Government’s expectations will be conveyed to ICBs, and how they will understand what is expected of them in terms of the nature of palliative care services that they would be required to commission? It would also be helpful if he could commit to providing a definition of “specialist palliative care” services, referring to the amendment tabled by the noble Baroness, Lady Finlay, so that we can see a consistent standard in provision of services across the country. My final question is: can the Minister confirm that it is the Government’s intention to communicate to all ICBs that they should fulfil the true requirements of this amendment, and can he tell your Lordships’ House how this will be monitored?
The right reverend Prelate the Bishop of London and other noble Lords have made it clear that we would like the matter settled by the amendment, but it is not entirely. I hope that the Government will not lose the opportunity to really make the transformation so that we can all expect, and have, a good death, as we would want to have a good life.
My Lords, I am very grateful to all noble Lords who have spoken in this important short debate, but, in particular, I express my thanks to the noble Baroness, Lady Finlay, for the illumination that she shed on the reality of well-functioning palliative care services from her personal perspective.
Without repeating what I said earlier, the Government recognise and understand the strength of feeling on the issue of variation among access to palliative care services. I understand the line of questioning posed by a number of noble Lords on the strength of the imperative implicit in the government amendment. The noble Baronesses, Lady Brinton, Lady Meacher and Lady Walmsley, and the noble Lord, Lord Hunt, all had questions on that theme.
The first thing for me to say is that I agree with the noble Baroness, Lady Finlay: this is a game-changing amendment because it would specifically require—that is the word—integrated care boards to commission such services or facilities for palliative care, including specialist palliative care, as they consider appropriate for meeting the reasonable requirements of the people for whom they have responsibility.
Questions have been asked about the word “appropriate”. I do not think any other word could be fitted into this context; you have to talk about what is appropriate when the extent of need and the requirements of the local population inevitably vary according to the locality. It is for the board to judge what is appropriate to meet that need in the local area and what is appropriate to the nature of the palliative care provision that may exist in an area: for example, whether it is a hospital, a hospice, social care hospices or hospices at home—all the panoply of palliative care provision that noble Lords will be familiar with. My noble and learned friend Lord Mackay of Clashfern made a very helpful intervention on that issue, for which I thank him.
We therefore expect palliative care to be commissioned by every ICB. It will be for them to allocate resources to meet the needs of their population that they identify but, on funding more broadly, the House will know that there is a multifaceted funding pattern in the palliative care field. Palliative and end-of-life care services are delivered by services and staff across the NHS, social care, the voluntary and community sector and independent hospices.
We recognise the vital role that hospices and other voluntary organisations play in the delivery and funding of palliative and end-of-life care and continue to engage proactively with our stakeholders on an ongoing basis to understand the issues they face. Those are not bald words; as part of the NHS Covid response, over £400 million has been made available to hospices since the start of the pandemic to secure and increase additional NHS capacity and enable hospital discharge.
The noble Baroness, Lady Brinton, asked me about statutory guidance. A range of guidance is already available to commissioners about the provision of palliative and end-of-life care, including detailed, evidence-based guidance from the National Institute for Health and Care Excellence. We will continue to keep the guidance under review. NHS England and NHS Improvement have also made funding available to seven palliative and end-of-life care strategic clinical networks, which will support commissioners in the delivery of outstanding clinical care, with sustainability of commissioning as a guiding principle.
The noble Lord, Lord Howarth, and my noble friend Lady Fraser touched on transparency and reporting. I point to our later amendments requiring ICBs to set out how they intend to commission services and report on that in their annual reports. That will of course include palliative care. I can also give an assurance that we are not only looking at the guidance currently but will continue to keep the range of guidance available to commissioners under review.
In answer to the noble Baroness, Lady Merron, on the Government’s expectations in this area, I can say only that our expectations as of now are set out in this amendment and in the guidance we will issue, and the assurance that we will engage with in our dealings with NHS England.
I hope I have been able to reassure the House that the Government are absolutely committed to ensuring that people receive high-quality palliative care if and when they need it. I invite the House to support Amendment 16.
Amendment 16 agreed.
Amendment 17 not moved.
Schedule 3: Conferral of primary care functions on integrated care boards etc
18: Schedule 3, page 159, line 16, at end insert—
“116C Primary ophthalmic services for people with learning disabilitiesNHS England must make arrangements for the assessment of the need for primary ophthalmic services by people with learning disabilities, including access to sight tests, and ensure primary ophthalmic services are commissioned to meet those needs, including in special schools.”Member’s explanatory statement
Under Schedule 3 of the Bill, NHS England retains its powers to make arrangements for the provision of primary ophthalmic services itself or direct Integrated Care Boards for such provision. This amendment seeks to improve eye care for people with learning disabilities including in special schools.
My Lords, I rise to speak to this amendment on behalf of my noble friend Lord Low, who is unable to move it because of a failure of his technology. I commend my noble friend’s sustained advocacy of the issues raised by the amendment. I declare my interest as founder and chair of the charity Books Beyond Words, which has published a word-free book called Looking After My Eyes jointly with the charity SeeAbility, which briefed my noble friend and me on this amendment.
The amendment seeks to improve primary ophthalmic services for people with learning disabilities, including pupils in special schools. There is no system of national monitoring of the number of people with learning disabilities who have visual impairments. Some research has estimated that people with learning disabilities are 10 times more likely to have serious eye problems than the general population, and six in 10 people with learning disabilities need glasses but may not recognise that they have sight problems. They may not be able to communicate this effectively, and they certainly need reasonable adjustments to access ophthalmic services.
The prevalence of visual impairment increases with the severity of someone’s learning disability. We know that some conditions associated with a learning disability, such as Down’s Syndrome, are associated with specific causes of visual impairment such as cataracts. My noble friend commented in Committee that the charity SeeAbility had identified that “four in 10 children” in special schools
“had never had a sight test”
“half of adults with learning disabilities had not had a sight test” —[Official Report, 20/1/22; col.1837.]
within the recommended period. In short, those most in need of high-quality eyecare are arguably those least likely to get it. We need targeted improvements in primary eyecare for all people with learning disabilities. I am therefore very pleased to support my noble friend’s amendment and, in his absence, I beg to move.
My Lords, I am very grateful to the noble Baroness, Lady Hollins, for introducing this debate on behalf of the noble Lord, Lord Low. I am the first to agree that the provision of primary ophthalmic services for people with learning disabilities is important. This is indeed why the majority of people with more severe learning disabilities are already likely to be eligible for free NHS sight tests.
However, we recognise that more needs to be done in this area to improve access to services. For that reason, the NHS Long Term Plan made a commitment to ensure that children and young people with a learning disability, autism or both in special residential schools have access to eyesight checks. NHS England commenced a proof of concept programme in 2021-22 to further pilot access to sight tests in special schools. Any future national commissioning model will be informed by an evaluation of this pilot, and I ask the noble Baroness to accept that we need to wait for its learning before pushing too far ahead. NHS England will continue to engage providers in the development of any future programme of work beyond the existing proof of concept, and I am sure that the Minister for Primary Care and my noble friend Lord Kamall would be happy to meet the noble Baroness and the noble Lord to discuss the programme further.
Finally, I remind the House that the imperative to improve access to these services is part and parcel of the duties placed on ICBs and NHS England to reduce inequalities in accessing health services and inequalities in health outcomes. The work NHS England has undertaken in this space demonstrates how seriously it takes these duties. I hope that, on the basis of the answer I have been able to give and the Government’s commitment to update noble Lords on the future development of this service, the noble Baroness will be content to withdraw this amendment on behalf of her noble friend.
I thank the Minister for her sympathetic response to the amendment. I appreciate the importance of waiting for proof of concept, as was spelled out.
One of the remaining issues, of course, is that training in how to adapt services for people with learning disabilities is also important. However, I hope that the proposed mandatory training in learning disability and autism will help to address that further. On that basis, I am content to withdraw the amendment.
Amendment 18 withdrawn.
Clause 20: General functions
19: Clause 20, page 16, line 12, at end insert—
“14Z32A Duty to prevent illnessEach integrated care board must exercise its functions with a view to preventing the development of poor physical and mental health, including by ensuring health services are available in a community setting where possible, in order to improve access.”Member’s explanatory statement
This amendment would ensure the prevention of ill-health was prioritised including by making health services available closer to patients’ homes to lower barriers to access.
My Lords, in reintroducing this amendment, I want to pick up on comments made by my noble friend Lord Kamall in Committee. He said that he agreed with “the spirit” of my amendment and had been reassured since becoming a Health Minister by
“the number of people in meetings who have said that they want to move towards a focus on prevention.”—[Official Report, 20/1/22; col. 1811.]
Although the duty to improve continuously the quality of services and obtain appropriate advice includes those in connection with prevention, this in no way guarantees that it will be raised up from the current low bar relative to treatment.
I do not think it misuses the important concept of levelling up to apply it in this context. The thrust of my amendment is to level up the emphasis on addressing the precursors of illness with delivering care while it runs its course, as well as with what comes after, whether that is its sequelae, rehabilitation or palliative care. After all, the NHS is the National Health Service. Keeping people healthy and preventing ill health should be the first duty of integrated care boards, thereby fulfilling the purpose of the NHS. The chronic waiting lists and ever-increasing costs, which seem never to end, both flow from a culture that is reactive rather than proactive.
As my amendment states, a duty to prevent could mean, in many contexts, community health provision. A reverse Beeching for healthcare would help to nip in the bud any developing conditions and, when health needs have family implications, enable them to be treated alongside and integrated with early family help. Prohibitively long journeys to hospitals, in respect of which ICBs might choose to integrate health and health-related services to reduce inequality of access, will work against this prevention imperative, hence the need to give it primacy. A couple of examples will be helpful here. I will touch on how preventing, for example, childhood obesity and mental ill health will in no small part require improving family relationships, which is best done in the community.
The Leeds child healthy weight plan, established and led by Public Health England but multiagency in approach, focuses on prevention as it can be more difficult to engage families and see improvement once problems arise. Families on the plan took healthier steps in both the consumption of fruit, vegetables and sugary drinks, and physical activity, but they also reported a reduction in screen time and increased parenting confidence. Leeds has seen child obesity rates among reception-age children decline significantly as a result, particularly among the most disadvantaged children, over a period when similar cities and England have seen no change in this key area.
Secondly, in a recent major study of more than 43,000 children in children and young people’s mental health services, over half cited family difficulties, which were the biggest presenting problem. Again, community-based family support is vital for preventing mental ill-health.
In concluding—as noble Lords can see, I have not spoken for long—I want to stand back from this. The tragic events in eastern Europe indicate the need to spend more money on defence. Where will it come from if we do not cut our cloth differently? The prevention of ill health has to be a part of that. I beg to move.
My Lords, I will speak to Amendments 33, and 37 to 54. I thank the noble Lords who have added their names to those amendments.
There is a very simple point here. The purpose of these amendments is to make sure that primary care is as highly influential in the new system as, and not the poor relation of, NHS trusts and NHS foundation trusts. It is vital for the whole success of the entire Bill moving forward that primary care is able to play its proper part in the future. It is therefore very good indeed that the Bill includes having a representative for primary care on the board of ICBs—the integrated care boards. However, I will turn to the problem, which is exemplified by the first of these amendments.
Amendment 33 refers to a passage in the Bill which says:
“Before the start of each financial year, an integrated care board and its partner NHS trusts and NHS foundation trusts must prepare a plan setting out how they propose to exercise their functions in the next five years.”
There is no mention of primary care in that, which is where the amendment comes in, adding the words “and primary care”. It is worth just noting that this is an entire reversal of what is in a sense the current situation, where primary care has a big role within planning and the acute and NHS trusts more generally have a much lesser one. So this is a very big change. My first question to the Minister is that it would be helpful if he would explain why NHS trusts and foundation trusts are being treated differently from primary care. Alongside that, why and how will he make sure that primary care will be able to function as it should do in being equally influential with the other sectors?
I have already outlined the reasons for this in very broad terms, but I will pick out three or four points. First, it is so that their contribution can be made. Primary care is not just about what is happening in the out-of-hospital sector; it also has a significant role in what should be happening in the hospital sector and, of course, to pick up the point made by the noble Lord, Lord Farmer, it has a major role in prevention as well. Secondly, this is about morale. Primary care has very poor morale at the moment, and anything that seems to downgrade its role is important.
Thirdly, it is about messaging and the priority that is being given to the different parts of the system. Fourthly, there is another point here. Over the last—I guess—25 years, a number of GPs in particular have become quite adept at planning, thinking about the future and commissioning and so on. There is a great wealth of experience there, and that is experience of planning not just for primary care but for health services, and indeed prevention more generally. Then, of course, as I said at the beginning, this is about the direction of travel.
I am pleased to say that I have had some good discussions with the Minister, and indeed with officials, and I look forward to hearing what the Minister will be able to say in response to this. My request, and that of the noble Lords who have added their names to the amendment, could not be simpler. Why is it intended to treat NHS trusts and NHS foundation trusts differently, giving them apparently a more central role, and how will the Minister give the same level of influence to primary care as the Bill does to these other bodies?
My Lords, I have an amendment in this group, but I support the thrust of the debate so far. I should declare that I am a fellow of the Royal College of General Practitioners, having previously worked as a GP.
The noble Lord, Lord Farmer, stressed the importance of trying to prevent ill health later on and to bring a population up to be less unwell than the current population is. We have to have a very strong primary care workforce to manage people in the community. There has been a great move to try to move people out of hospital and back into the community, but primary care is currently creaking under the load and social care services are not there to provide much of the support these people need. So primary care has to be factored in as a major contributor, the more we expect people to be looked after at home, nearer home and in the community. That can be particularly difficult in rural areas, where GPs are expected to take on much broader responsibilities. They might even be managing some of the accident services in the area, working with the ambulance services.
The amendment I have tabled is about rehabilitation. Part of the reason for it being in this group—I think it is appropriate that it is—is that recovery from any episode will require a period of rehabilitation. That must be factored in. People will need physiotherapy expertise, occupational therapy, and speech and language therapists. They might need podiatry. They might need to have technology supplied to them to manage their condition at home, and to learn about managing it. The patient and the family themselves might need education in how to manage their rehabilitation and recovery.
When a person is clearly through the critical phase of whether they are going to survive a major accident, they then have a very long haul of rehabilitation, which might take years and might require ongoing support if they are ever to realise their true potential within the limitations. There have been some astounding examples of catastrophic injury where people have gone on to contribute enormously to their own families and in life, but they have needed intensive rehabilitation services over a long time.
So my amendment is there to ensure that this does not get forgotten in the way that services are commissioned and planned for, and so that rehabilitation is viewed as an integral part of the follow-on after the acute phase, as people get home, transition from hospital into the community and look towards resuming their life. It might well be very different from the life they had before, but this would enable them to fulfil their potential.
My Lords, I support the amendments in the name of the noble Lord, Lord Crisp, to which I have added my name. I think the noble Lord had to table these amendments because the Minister said when we discussed this in Committee that his challenge was to ensure that
“primary care is better represented and not dominated by acute trusts.”—[Official Report, 20/1/22; col. 1854.]
We expected something to come back that did exactly that, because the very fact the Minister said that suggested that the Government had accepted that there was a potential imbalance with the role of primary care.
I come back to the purpose of the Bill, which I did a number of times in Committee. The purpose of the Bill is to bring about effective integration, improve health outcomes and reduce health inequalities. That is underpinned by making primary care central to healthcare planning and ideas about healthcare, following through on those plans and having primary care as an equal partner in the ICB. So we moved away from who we want on the board to asking very simply for primary care to be treated as an equal in the planning, implementation and monitoring of what will happen in health and social care in the area. It is disappointing that, despite the Minister’s suggestion that he would go away and look at this, nothing new has come back since Committee to deal with that.
What new has come back on Report which makes sure that primary care can be better represented and not dominated by acute trusts in this new system? My worry is that the Bill giving this to NHS acute trusts and foundation trusts signals which are most important within the system. If primary care does not have that equity, there will be unrealistic expectations and uninformed decisions made in planning for final decisions and tactical, not transformational, systems and services, which will not represent the full view of primary care. It is for those reasons that I support the amendments of the noble Lord, Lord Crisp, and look forward to the Minister bringing to the House’s attention what new proposals are in here on Report to do with the challenge that he set himself: to ensure that primary care has a bigger voice and is not dominated by the acute sector.
My Lords, I added my name to the amendments of the noble Lord, Lord Crisp, and echo the remarks of the noble Lord, Lord Scriven, on the Minister’s offer in Committee to go back to see how the potential dominance of acute trusts could be mitigated by ensuring that the voice of primary care was heard loud and clear in the various decision-making bodies.
It is a pity that it is a very late hour, because primary care warrants a much wider debate, given the challenges it undoubtedly faces. We are all aware of the workforce issues, such as the reluctance of many GPs to take on partnerships and that so many GPs will do only part-time work, partly because of the pressures. It is because of those challenges and because primary care is so valued in this country that we need some assurances that the people running the new system being introduced through this legislation will be concerned with and listen to primary care.
It is somewhat ironic. The noble Lord, Lord Lansley, is not here any more, but in a sense, we are seeing a transformation from what he hoped would be a GP-led system through clinical commissioning groups to one which looks very strongly acute care-led in the integrated care boards. As someone who was spent quite a lot of my time in the health service around acute trusts, I do not particularly worry about acute trusts being listened to, because we depend on them so much. We really need assurance that integrated care boards will take primary care seriously.
Finally, whatever concerns and reservations we on this side of the House had about clinical commissioning groups, some GPs undoubtedly rose to the challenge of leadership within them. I should be very concerned if they were lost from the new arrangements. It would be good to know that the Government recognise that and will ensure that a place is found for them in the new system.
My Lords, I rise to support Amendments 30 and 34. On Amendment 30, I echo the widespread concern of the professional bodies and expressed by the noble Baroness, Lady Finlay, that rehabilitation should be a core service in the NHS. It is inseparable from healing, and healing is often impaired if rehabilitation is not there.
On Amendment 34, it will be important to know whether the proposed integrated health boards will be in contact with services outside the NHS where health can be a critical factor, such as education and criminal justice. As we said in Committee, many speech and language professionals are not NHS employees. How will they be brought into the integrated system?
My Lords, I shall speak to Amendment 62 in my name and those of the noble Baronesses, Lady Hollins and Lady Walmsley, and the noble Lord, Lord Jones of Cheltenham. I thank them, and the Alzheimer’s Society and Alzheimer’s Research UK, for their support of this amendment.
People with dementia will be one of the largest groups of people to see the benefits of the integration of health and social care services and, therefore, the benefits from the Bill. Currently, there are 900,000 people living with dementia in the UK and, without a disease-modifying treatment available after diagnosis through the NHS, they get the majority of their support through the social care system.
This amendment relates to Clause 21, which ensures that integrated care partnerships prepare an integrated care strategy. These new strategies will be a powerful way to bring together various currently disparate bodies to work towards the same aims. Topics discussed within these strategies will be given consideration across the health and social care systems, consideration that too often people living with dementia have lacked, leaving them falling through the cracks between the various systems. This amendment therefore suggests that each strategy should explicitly consider the needs of people living with dementia. There are two areas where integration could provide particular benefits, which I will touch on briefly.
The first is diagnosis. A diagnosis is incredibly important for people living with dementia, as it allows them to plan for the future, arranging their housing and care needs, putting themselves forward for clinical trials and ensuring that they have first access to the most innovative treatments, while also unlocking access to vital extra support in the short term. This does not just help the individual. By providing the right support at the right time, we can reduce pressure on the NHS. That is why NHS England rightly has a target that two-thirds of all people living with dementia will have received a diagnosis. This was consistently met from 2015 until the pandemic. As people visited their GPs less frequently, clinicians were diverted to other areas and individuals had little access to memory clinics. The rate dramatically fell from 67.6% in January 2020 to just 61% in January 2022. This has meant that, according to NHS data, an extra 35,000 people are now living in the dark about their dementia status. As we address the backlogs in elective treatment and cancer care, it is vital that we also tackle the backlog in diagnosis of dementia. To do so, we must have clear strategies in place, at local and national level.
I am proud that the UK is seen as a world leader in dementia research, as many noble Lords know very well. However, there are still barriers to us reaching our potential, including a lack of participants for research. This is not because there is low interest in participating in research among the public. According to Alzheimer’s Research UK, 69% of the public would be willing to take part in dementia research. However, 81% did not know how to volunteer. The NHS, as a single health system, has many advantages which give it great potential for data sharing between research and clinical practice, connecting those who want to take part in studies with those conducting the studies.
A valuable report recently released by the All-Party Dementia Group, Fuelling the Moonshot, recommended that all newly diagnosed patients receive a letter from the NHS within three months of diagnosis, explaining how they can take part in dementia research. Integrating dementia research with integrated care partnerships will provide other benefits. The benefits should, and would, flow in both directions. While research can benefit from better access to participants, it should also ensure that innovation, whether in treatments or models of care, can reach people living with dementia.
With no treatments available, we cannot ignore the vital role of encouraging dementia prevention and ensuring that individuals look after their brain health. In discussing the possible causes of dementia, obesity raises its ugly head once again. Researchers at University College Hospital studied a group of participants from the English Longitudinal Study of Ageing. Each participant was at least 50 years old when they were enrolled in the study. Their measurements, including BMI and waist circumference, were collected, and the participants were studied on average 11 years later to determine whether they had developed dementia. The researchers found that participants who had a BMI corresponding with overweight or obese were more likely to develop dementia. Obesity has also been found as a risk factor in several previous studies.
Research has also shown that the number of dementia cases worldwide could potentially be reduced by a staggering 40% if the 12 modifiable risk factors for the condition could be completely eliminated. The Lancet identified that the three modifiable risk factors with the largest potential impact were hearing loss, low education in early life and smoking. Not everyone who smokes will get dementia, but stopping smoking is thought to reduce the risk down to the level of non-smokers. While there is no sure-fire way of preventing dementia, advances in dementia research have shown that there are steps that we can all take to keep our brains healthy and reduce our risk of developing dementia. The dementia research sector can continue to build on this work with the right support from various sources. However, efforts to improve both dementia research participation and diagnosis rates will amount to little without action taken at national level as well.
The Department of Health and Social Care is currently preparing its updated national dementia strategy, which has been much delayed by the pandemic. At its heart, it must have two main focuses, much like local strategies: diagnosis rates and dementia research. On boosting research, it would be remiss of me not to mention the need to deliver urgently on the promise of the 2019 Conservative manifesto to provide a “dementia moonshot”; that is, a doubling of government funding provided to dementia research. If we are to improve the lives of people living with dementia, we need not only determination from local and national government but strategies for how to deliver these ambitions. Whether it is delivered through this amendment or through other means such as the strategy, dementia care should get the co-ordinated planning that it deserves.
My Lords, it is a pleasure to add my name to the amendment tabled by the noble Lord, Lord McColl. I am not going to say very much in support, because the background has already been explained. Without a diagnosis, people living with dementia cannot access the community support they need.
I will add one specific group who experience dementia, which is people with Down’s syndrome. Some 60% of people with Down’s syndrome will develop Alzheimer’s by the age of 60. A lot of research on Alzheimer’s has been developed from an understanding of Down’s syndrome and the changes that take place in people’s brains. The manifesto pledged to double the funding for dementia research. The amount is interesting. It was a commitment of £800 million over 10 years for dementia research. To put that figure into context, the co-chair of the APPG on dementia, Debbie Abrahams, has stated that dementia currently costs our economy £34.7 billion each year. I therefore support this amendment requiring integrated care partnerships to include a strategy to improve both the diagnosis of dementia and dementia research, which has the potential to improve the lives of so many people in the UK.
I also added my name to the amendment in the name of my noble friend Lady Finlay. I, too, began my medical career as a GP. I therefore support my noble friend Lord Crisp’s amendments. It also has some relevance to my later practice in psychiatry. Having worked as a general practitioner in south London, I began to understand the importance of social factors in the development of mental illness and in the ability of my patients to live with whatever long-term condition they might have. As a community psychiatrist I have extensive experience of practicing medicine that addresses people’s biological, psychological and social needs, and I have been a prominent advocate of the least restrictive practices. Best practice includes facilitating robust, multidisciplinary mental health care in the community where it is a feasible alternative to treatment in hospital and, when admission is needed, helping people to be discharged back into the community at the earliest point so that their recovery can continue in the community, close to family and friends. As a mother, I advocated for effective community rehabilitation for my daughter after she become quadriplegic, which was a much better option than the nursing home care that she was initially offered.
Robust integration between multiple disciplines within health and social care is essential to ensure the high-quality, coherent, consistent and readily accessible community rehabilitation that can promote physical and mental health and help people to thrive to their full potential within communities. I am very pleased to support my noble friend’s amendment. I should declare an interest as president of the Royal College of Occupational Therapists, a profession which has a particular contribution to make in community rehabilitation.
My Lords, before I speak to my amendment I would like to put on record that I particularly support my noble friend Lord McColl’s Amendment 62, which considers the needs of those with dementia. I also support the thrust of the amendment tabled by the noble Baroness, Lady Finlay, on better rehabilitation. Perhaps the concept of convalescence, as it used to be called, would help free acute beds and thus save money. I also support the amendments tabled by the noble Lord, Lord Crisp, to ensure that integrated care boards work with primary care and, I hope, with community nursing as well.
Amendment 177 is in my name. Much of the Bill is about the architecture of the NHS, and it is important that we get it right. However, the success of the Bill will be whether it delivers for patients. As we have discussed before, healthcare needs to be patient focused. At the moment we sadly have a system where the traditional idea of a family doctor who knows their patients is too often disappearing. Why has this been allowed to happen when we know it worked so well? We need somehow to get an element of that back. I understand that today many doctors in general practice find their role far less satisfactory, with fewer people wanting to go into general practice. I am given to understand that a large element of this has to do with the fact that fewer doctors know their patients, whereas in years gone by they would know and look after the whole family and be part of the community.
With people living ever longer, looking after older people so that they can stay healthier for longer is critical, as is ensuring that they receive the care they need and have a dignified and secure old age. This amendment would introduce a new clause that lowers from 75 to 65 the age at which every patient is assigned a named GP, which would help with prevention, an issue raised by my noble friend Lord Farmer in his amendment. The amendment would also ensure that named GPs actually have to meet and have some knowledge of each patient they are responsible for, and to communicate directly with them and their family.
I will not reiterate all the facts and figures I gave in Committee. I merely remind your Lordships that studies have shown that, quite simply, being treated by a doctor who really knows you can be life-saving. Quality care by a named GP benefits patients by delivering continuity of care and therefore better healthcare, and by keeping more people out of hospital, relieving some of the burden on the NHS.
Following the debate in Committee, I have added proposed subsection (2) to enable the role of the named GP to be “delegated” to another doctor in the practice who might be chosen and preferred by the patient. But this amendment ensures that patients will have someone who actually has some knowledge of them and whom they or their relatives can turn to for help, care and advice.
I was very disappointed that, in Committee, my noble friend the Minister failed to grasp the significant difference between current regulations, guidance and what happens in practice. I have personal proof that, as things stand, some named GPs are able to choose not to know the patients they are responsible for. This amendment seeks to positively address that.
I urge the Minister to reconsider and accept these proposed changes to the Bill. I absolutely agree with the noble Lord, Lord Hunt, that primary healthcare is incredibly important. This whole area really needs an in-depth debate because it is breaking down in some places.
My Lords, I will make just a few comments. I put my name to the amendment of the noble Lord, Lord McColl, which I will not say much about because he and the noble Baroness, Lady Hollins, have said it all.
However, I will make one point about the importance of early diagnosis. As most noble Lords will know, Alzheimer’s is a complex range of diseases, and it is very important for the patient that their doctor is able to know what sort of Alzheimer’s they have so that an appropriate set of support can be prescribed. The other very important reason is that we do not yet have a disease-modifying cure. Unless more suitable patients go forward for clinical trials, the researchers will not be able to do their research, no matter how much money the Government put forward. We know that 80% of people who put themselves forward for a dementia clinical trial have to be rejected because their disease has progressed too far. So, we really need early diagnosis so that the researchers have some chance of finding the cure that we all want.
Secondly, I will say two things about primary care. The noble Baroness, Lady Hodgson, talked about patients having to see a doctor they have never seen before within their practice. Well, now—and I would like the Minister’s answer to this—not only are people ringing up and going to a doctor in the practice whom they have never seen before; in London, they are now being referred to a completely different practice, because something like five practices share patients. I understand that that is a temporary measure during the pandemic, but could the noble Lord confirm that that is the case? Could he also confirm that it is going to end once we believe the pandemic is over, which of course it is not yet?
I shall say a few words about the amendment proposed by the noble Lord, Lord Crisp. It is vital, as he rightly said, that primary care has a role in planning the commissioning of services. As the noble Lord, Lord Hunt, said, a lot of expertise has been developed, and it must not be lost. It is vital because primary care services are the gateway for a patient to everything else in the health service; it is the first port of call for a patient and, without a referral from a GP, on the whole you cannot get to anything else.
I very much support what the noble Lord, Lord Crisp, is doing and look forward to hearing what the Minister has to say about the reasons why primary care services do not appear to be treated equally with NHS trusts and foundation trusts.
My Lords, this is an important group, so it is a shame that we are discussing it so late in the evening. It is important because it contains essential broad things that people need to stay well in their community. It is about the bread and butter of people’s health—their GPs, dentists, the physios and pharmacists, getting podiatry services and getting the proper social care that you need to be able to stay in your home. It is literally about helping people to stay local and stay well. In many ways, that is why I enjoyed the three years that I spent on a CCG so much, because I knew that it was local and that every month I was going to be visiting a GP surgery. I knew all those things, and I felt that that was an important contribution to healthcare in my area.
The amendment in the name of the noble Lord, Lord Crisp, is particularly important. If primary healthcare and these local services do not work, the rest of the NHS falls over.
My Lords, I am grateful to all noble Lords who have spoken on these amendments in this debate and in Committee, but I am also grateful for the discussions that we have had between the various stages and the conversations that noble Lords have continued to have with my officials—indeed, right up to the dinner break this evening. I shall speak to Amendments 34, 35 and 55 in my name, which I hope will go far in addressing many of the concerns raised in the debate.
We have heard the calls for greater clarity about what will be expected of ICBs in their forward planning. We also understand the importance of ICBs being transparent in discharging their functions to allow for public scrutiny and accountability. We have therefore brought forward these amendments to further clarify what ICBs must include in their forward plans and annual reports. These amendments provide that the forward plan must describe what services the ICB proposes to make arrangements for in the exercise of its functions. It must also explain how the ICB proposes to discharge each of its duties under new Sections 14Z34 to 14Z44. These duties include improving the quality of services, reducing inequalities, promoting the involvement of patients and carers in decisions about treatment and promoting the integration of health and social care services.
Amendment 55 requires an ICB’s annual report to explain how it has discharged each of its duties under new Sections 14Z34 to 14Z44. This would additionally include new Section 14Z47A, which is the new duty we discussed earlier requiring the ICB to keep under review the skills, knowledge and experience that it needs to discharge its functions and, when there are gaps, to consider what steps it can take to address or mitigate them. I hope that noble Lords will agree that these amendments represent a significant step forward in making sure ICBs are held accountable by ensuring that they are transparent in how they intend to discharge their numerous duties and functions.
I turn to the amendments proposed by noble Lords, and I shall address each of them as briefly as I can. On Amendment 19, I assure my noble friend Lord Farmer that the Bill already includes the power for ICBs to commission services or facilities for the prevention of illness under new Section 3A in Clause 16. The provisions in Clause 16 also require ICBs to act consistently with the Secretary of State’s duty for the promotion of a comprehensive health service, including in the prevention of illness. Further, new Section 14Z34 places a duty on ICBs to improve the quality of services including preventive services, and new Sections 14Z36 and 14Z38 place duties on ICBs to ensure that patients and carers are fully involved in these decisions, including about prevention.
I now turn briefly to Amendment 62, spoken to so ably by my noble friend Lord McColl and the noble Baroness, Lady Hollins. I also pay tribute to the noble Baroness, Lady Greengross, who in my brief time in this House thus far has really educated me about dementia and the fact that, as we are living longer physically, this will become more of an issue.
The department is currently developing a new national dementia strategy for England, which will be published later this year. This will include objectives focused on restoring the dementia diagnosis rates and improving the diagnostic experience for people living with dementia, as well as increasing the number and diversity of people participating in dementia research. I take on board the concern of the noble Baroness, Lady Walmsley, about getting the many volunteers for clinical trials at the right time.
There is already work under way to help restore dementia diagnosis rates back to the target of 66.7% following the pandemic, supported by an additional £17 million to address dementia waiting lists and increase the number of diagnoses. Increasing participation in all types of research is a top priority and is in fact part of my portfolio. The UK has invested in a range of digital platforms, including Join Dementia Research, and we are now working to increase the scale of and interoperability between systems, improve diverse recruitment and reduce the burden and costs of clinical research delivery.
On Amendments 22 and 24, I reassure noble Lords that the Bill already contains requirements on NHS commissioning bodies to tackle health inequalities. Commissioners are also required to promote the right of patients to make choices with respect to services or treatment. This includes allowing patients to choose to be treated outside their ICB area. To support this, we expect ICBs to actively co-operate with each other. Furthermore, we have amended the duty on ICBs to have regard to the need to reduce inequalities between patients, proposing by government amendment to extend this to “persons”, in respect of accessing services. This means we are capturing everyone, not just people accessing services. This duty would encompass the need to reduce inequalities with respect to geography as well.
I now turn to Amendment 30. I thank the noble Baroness, Lady Finlay. First, I should thank her for the daffodil I am wearing to celebrate St David’s Day. She assures me that it is not a listening device to eavesdrop on my conversations with officials. If she had eavesdropped, she probably would have been embarrassed by the amount of praise heaped on her. We acknowledge her desire to see strong provision of community rehabilitation and it is important that this is pushed up the agenda.
Under the existing Bill provisions, every ICB will be required to provide and improve rehabilitation services as part of its duty to provide a comprehensive health service. As an added layer of scrutiny, ICBs must publish an annual review detailing how they have discharged this function. Also, NHS England is currently working on a national intermediate care framework, digital and virtual pathways and models of care, improved data recording and reports, and interventions using a wide range of community assets and levers.
I now turn to Amendments 33 and 37 to 54. I thank the noble Lord, Lord Crisp, for his engagement on this issue—indeed, including right up to the dinner break this evening. We would like to put on record our gratitude to the noble Lord and the Royal College of General Practitioners for pushing us on this and reminding us that, as we move to ICBs, we should make sure that primary care is not the poor relation. In moving to ICBs from CCGs, where GPs and primary medical services have played a huge role, we have to ensure that these are not dominated by a few large trusts.
We understand and continue to recognise the importance of primary care. Indeed, primary care is taking on more of the functions of what would traditionally be considered secondary care, especially with some of the primary care services and community centres appearing in our local communities. Only this week, we have seen stories and press reports of pharmacists calling for more of the functions of GPs to be delegated to them. They have helpfully suggested that they could save the NHS money and also provide better primary care services by taking on some of those functions. There is clearly a demand out there and that has to be encouraged.
Before I turn to this, I note that we hold primary care in equal esteem to any other sector—acute, community or mental health. Right from the outset, we have said that primary care must not be lost and must be at the heart of the ICB. As the Integrated Care Systems: Design Framework said:
“Through a combination of their membership, and the ways in which members engage partners, the board and its committees should ensure they take into account the perspectives and expertise of all relevant partners”,
including primary care.
I know the noble Lord is especially concerned about why primary care is not explicitly referenced in new Clause 14Z50(1). I hope I can offer him some explanation. First, we are conscious that there are 43,000 primary care providers, and it is impractical to require each to be a partner in developing the ICB forward plan. Secondly, new Clause 14Z50 ties NHS providers to the plan, and a failure to play their part could trigger NHS England’s intervention. It will also guide the financial requirements imposed under Clause 24. In contrast, primary care providers, as private contractors, are bound to the plan in a different way, primarily through contracts. Thirdly, new Clauses 14Z50 and 14Z54, on the joint capital resource plan, are intimately connected and primary care capital is provided through other routes.
However, ensuring that the primary care voice is sufficiently involved in joint forward planning in integrated care boards is our common ambition. The law requires the involvement of a primary care representative drawn from primary medical services on ICBs, just as it does for acute providers. ICBs will have to consider how they can best access skills and knowledge across primary care.
In addition, there is a duty in new Clause 14Z52 to consult
“any other persons they consider it appropriate to consult”
about forward plans. We expect that, in publishing its plan, an ICB should set out how it has met this duty and consulted primary care and other partners. I am able to inform the House that NHS England has confirmed that its guidance will be explicit in its expectation that primary care will be a crucial partner in that process. We are happy to engage with the noble Lord further as that guidance develops to ensure that we stick to that commitment to make sure that primary care is at the heart of this.
More broadly, ICBs have the discretion to appoint additional members to the ICB or exercise functions through committees. Commissioning at a local level requires the expertise of primary care, and we expect it to play a significant role as many decisions will be taken at that level under the principle of subsidiarity. Further guidance will be published on the development of place- level arrangements, including the role of primary care.
I also note the Fuller review. NHS England chief executive Amanda Pritchard has announced that Dr Claire Fuller, senior responsible officer of the Surrey Heartlands Integrated Care System, will lead a review on how primary care networks can be supported in integrated systems. NHS England has announced that the review will set out how ICSs and primary care networks should go about improving out-of-hospital care. The findings of the review will then be applied to ICBs, subject to the passage of this Bill. We hope this work will help all ICBs to make progress on developing general practice in this area.
I hope I have been able to assure noble Lords that we hold primary care in great esteem, and have given the noble Lord some reassurance that primary care will be involved in every level of the ICB, its functions and planning.
I now turn to Amendment 177 from my noble friend Lady Hodgson. I thank her for continuing to remind us of its importance and speaking movingly about her own experience. I remind noble Lords that all practices are already required to assign all their registered patients—including those aged 65 and over—a named, accountable GP. The GP must lead in ensuring that any GP services that they are contracted to provide, and that are necessary to meet the patient’s needs, are co-ordinated and delivered to that patient. Practices must take reasonable steps to accommodate the requests of patients to be assigned a particular GP and to see them for an appointment.
However, it is vital that practices retain clinical discretion to provide appointments, as is necessary and appropriate to meet the reasonable needs of patients—something that this amendment would remove. Through primary care networks and initiatives such as enhanced health in care homes and anticipatory care, we are supporting GP practices to improve continuity of care on the ground, including for older patients. We are committed to growing the general practice workforce and increasing access to appointments, in line with our manifesto commitments.
Let me finally very briefly touch on the point made by the noble Baroness, Lady Whitaker, about non-NHS services. We very much see them as part of the wider integrated care partnerships, in terms of making sure we deliver joined-up health and care.
This has been a wide-ranging debate and hope I have been able to provide some reassurances regarding noble Lords’ concerns.
I have just realised I did not directly answer the question from the noble Baroness, Lady Walmsley, about the experience in London and patients being sent elsewhere. I hope the noble Baroness will allow me to investigate further and write to her. On the other issues I hope I have been able to provide some reassurance regarding noble Lords’ concerns. I hope that noble Lords will feel able not to press their amendments when they are reached.
My Lords, I thank the Minister for his fairly comprehensive reply. I also thank many noble Lords for their contributions. I think the Minister’s description of the debate being wide-ranging was correct. It was noticeable also that there was a degree of sadness and regret that it was the end of the day and that this important subject could not have a longer period for debate. The whole area of prevention and primary care, and of named GPs, which my noble friend Lady Hodgson was talking about, is an area of early activity in the health of people which needs to be more debated. This debate has shown that the Bill has not given it the proper emphasis that one would want; the equality with the acute care that we have heard about.
It is late in the day, and I certainly do not want to detain the House, but I thank all noble Lords for their contributions. I hope that the Ministers can take this away and that if to a certain extent they are behind the curve on this front bit of health need, they will muse on it and improve the Bill, as the Minister said he intends to do. I thank noble Lords again and beg leave to withdraw my amendment.
Amendment 19 withdrawn.
Amendments 20 and 21
20: Clause 20, page 16, line 33, leave out “patients” and insert “persons”
Member’s explanatory statement
An integrated care board has a duty to have regard to the need to reduce inequalities in access to health services for patients. The amendment extends it to cover people before they are patients.
21: Clause 20, page 16, line 36, at end insert “(including the outcomes described in section 14Z34(3))”
Member’s explanatory statement
This amendment makes it explicit that the duty for an integrated care board to have regard to the need to reduce inequalities in outcomes for patients covers outcomes such as the quality of experience undergone by patients.
Amendments 20 and 21 agreed.
Amendment 22 not moved.
23: Clause 20, page 17, line 16, at end insert “facilitate or otherwise”
Member’s explanatory statement
This amendment provides that an integrated care board’s duty to promote research etc includes doing so by facilitating research.
Amendment 23 agreed.
Amendment 24 not moved.
Amendments 25 and 26
25: Clause 20, page 18, line 27, 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 14Z43 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.
26: Clause 20, page 18, line 30, 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 14Z43 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 25 and 26 agreed.
Amendment 27 not moved.
28: Clause 20, page 18, line 38, at end insert—
“14Z43A Duties as to climate change etc(1) Each integrated care board 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, integrated care boards must have regard to guidance published by NHS England under section 13ND.”Member’s explanatory statement
This amendment would require integrated care boards, in exercising their functions, to have regard to certain matters relating to the environment, including climate change.
Amendment 28 agreed.
Amendments 29 and 30 not moved.
31: Clause 20, page 20, line 18, at end insert—
“14Z47A Duty to keep experience of members under review etcAn integrated care board must—(a) keep under review the skills, knowledge and experience that it considers necessary for members of the board to possess (when taken together) in order for the board effectively to carry out its functions, and(b) if it considers that the board as constituted lacks the necessary skills, knowledge and experience, take such steps as it considers necessary to address or mitigate that shortcoming.”Member’s explanatory statement
This amendment requires an integrated care board to keep under review the skills, knowledge and experience that it is necessary to have on the board and take steps to address or mitigate shortcomings.
Amendment 31 agreed.
Amendments 32 and 33 not moved.
Amendments 34 and 35
34: Clause 20, page 21, line 12, at end insert—
“(za) describe the health services for which the integrated care board proposes to make arrangements in the exercise of its functions by virtue of this Act;”Member’s explanatory statement
This amendment requires the joint forward plan for an integrated care board and its partners to describe the health services that the board proposes to commission over the next five years.
35: Clause 20, page 21, leave out lines 15 to 20 and insert—
“(i) sections 14Z34 to 14Z44 (general duties of integrated care boards), and (ii) ”Member’s explanatory statement
This amendment requires the joint forward plan for an integrated care board and its partners, in particular, to explain how the board proposes to discharge its duties under sections 14Z34 to 14Z44 (rather than just some of those sections).
Amendments 34 and 35 agreed.
Consideration on Report adjourned.