Grand Committee
(2 years, 3 months ago)
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Arrangement of Business
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The Deputy Chairman of Committees (Baroness Garden of Frognal) (LD)
My Lords, Members are encouraged to leave some distance between themselves and others and to wear a face covering when not speaking. If there is a Division in the Chamber while we are sitting, this Committee will adjourn as soon as the Division Bells are rung and resume after 10 minutes.
The time limit for the next debate is one hour, and the advisory speaking time is wrong: your Lordships can have as much as four minutes each.
Social Media: Deaths of Children
(2 years, 3 months ago)
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Baroness Kidron
To ask Her Majesty’s Government what assessment they have made of the role played by social media in the deaths of children in the United Kingdom, including by suicide, self-harm and murder.
Baroness Kidron (CB)
I declare my interests, particularly as chair of 5Rights and as a member of the Joint Committee on the Draft Online Safety Bill.
My Lords, many of you will have read reports of how, in 2017, 14 year-old Molly Russell took her own life after being bombarded by self-harm and pro-suicide images. In the days after her death, her father Ian tried to access her phone simply to try to understand what had happened to his daughter. The notes from his diary from that time make for grim reading. The woman at the so-called genius bar in the Apple store “could not help”. The promised follow-up call failed to materialise—despite Ian sitting grief-struck, pen in hand, waiting at the appointed hour. Even after he finally found a person enabled to deal with him, they were only allowed to send a template information request form by email, which required a great deal of information from Ian but did not result in him receiving the information he requested. Apple has never helped Ian to access Molly’s phone, and without the assistance—indeed, the persistence—of the coroner and the police, the data it contained would not be available to Molly’s inquest, which is still investigating the contributory causes to Molly’s death four years later.
Judy and Andy Thomas struggled similarly after the suicide of their 15 year-old daughter Frankie, unable to get anything more than an automated response. Their letters to Instagram’s CEO Adam Mosseri, copied to the European headquarters, went unanswered. It was only after a year of desperate letter writing to anyone who might help that I was able to arrange a call on their behalf, only for them to hear that they were not going to get the information they wanted. During Frankie’s inquest, despite evidence that her suicide was highly influenced by what she had seen online, Wattpad refused to disclose full details of Frankie’s activity on its platform, even while confirming that self-harm and suicide stories on its site should be rated mature and should not have been accessible to a user registered as a child.
Olly Stephens, who was 13 when he was murdered, had repeated problems online. He was groomed by a wannabe county lines gang, extorted by a group who stole his bike and, finally, lured to a park where he was killed, the murder having been organised online. His father Stuart says that in the hours immediately after his murder, Olly’s mother and sister had to trawl through social media sites to get evidence because they were aware that they would never get it from the tech companies.
When a child dies, parents are asked to clear out the school locker: they inherit the artefacts of a child’s life. If the authorities have access to information that may shed light on the circumstances of their death, it is shared as a matter of course—but not if that information is online. The argument made by the tech sector is that it is protecting other users, but that does not account for parents’ need for closure and evidence necessary for police and coroners, and it conveniently obscures the role of the tech companies themselves as they continue to recommend harmful material and facilitate violent abuse to other children.
In the other place two days ago, Ian Paisley MP introduced a 10-minute rule Bill to grant next of kin the right to access a smartphone and other digital devices of a person upon their death or incapacity. He made the important point that much precious material, both sentimental and material to understanding what happened, is withheld from the next of kin simply because people—particularly the young—do not think to leave a password in their will. Indeed, it is unlikely any child would even have a will. He also pointed out that access was eminently possible: in the US some states have brought in legislation, such as the Revised Uniform Fiduciary Access to Digital Assets Act, to retrieve financial assets. Once again, money trumps child safety.
The Joint Committee made two recommendations on this issue: that the Government should consult on how terms and conditions of online services can be reformed, by law, to give bereaved parents access to data; and that Ofcom, the ICO and the Chief Coroner should review the powers of coroners to ensure that they have unfettered access to digital data, including data recommended to children by tech companies, following the death of a child—and that both of those should happen before the Bill reaches Royal Assent.
I ask the Minister to put on record today that the draft Bill will be amended so that other families do not suffer as the Russell, Thomas and Stephens families have done. We cannot bring their children back, but we can create a lasting legacy for their extraordinary courage in speaking out.
The purpose of today’s debate is not only to secure justice for bereaved families, but to highlight steps that should be taken to prevent tragedy. Sitting on the Secretary of State’s desk is a comprehensive set of recommendations from the Joint Committee that would fundamentally change how the sector treats children. They are: mandatory safety by design to scale back harmful algorithms, design features and business practices; a binding child safety code that sets out risks and mitigations in accordance with the Convention on the Rights of the Child; alignment with the age-appropriate design code to make sure the Bill applies to all services likely to be accessed by children, so that there is nowhere to hide; mandatory cross-platform co-operation, so that risks known by one service are routinely shared with others; statutory codes for moderation and complaints, to ensure that swift action is taken before tragedy strikes; and a regulatory focus on risk rather than size. Again and again we see that small is not safe. I refer back to the content Frankie saw on Wattpad, a service that many of you will never have heard of.
There should also, of course, be the immediate introduction of age assurance, without which we will fail to deliver any of the protections that I have set out. This list is neither aspirational nor nice to have: these are essential and interdependent elements of a proportionate and enforceable regime to make our children safe. All other business sectors apply rules of product safety, and it is tragic that it has taken the death of children to give urgency to our calls for regulation.
TikTok, Meta, Apple and Alphabet are among the most valuable and profitable companies in the world, and the tech sector is now alone responsible for 25% of global GDP. But these same companies are algorithmically promoting and spreading material that nudges children into states of despair; priming kids into gambling habits with reward features that induce dopamine hits, which cause addiction; granting unfettered access to age-restricted spaces; fuelling an epidemic of eating disorders, self-harm and radicalisation; and systematically hiding the evidence. Even in a world focused on the balance sheet of loss and profit, children’s lives should not be the collateral damage of the tech sector. It is time to bring that to a halt—and halt it we can.
The Joint Committee recommendations have unprecedented support across the political spectrum, as they do across civil society. All that is required is for the Government to act. I ask the Minister, when he answers, to acknowledge that failure to have these things in place is costing children their lives—and I ask for a commitment to all the Joint Committee’s recommendations that relate to children. This is a time not for cherry-picking headline-grabbing changes, but rather for setting out an enforceable product safety regime that will keep our children safe.
Given the tech companies’ determined efforts to frustrate basic child safety requirements, I ask the Minister again to explain to the Committee how the Government can justify delaying the introduction of age assurance. They have failed to implement Part 3 of the DEA and rejected my Private Member’s Bill for privacy-preserving age assurance, instead putting their faith in a voluntary scheme which their own officials estimate would take a minimum of two years and do nothing to impact on those who do not volunteer. This implicitly goes against statements made last week in the other place by the Minister for Digital that self-regulation has failed. If the Government acted today, Ofcom could set out expectations of age assurance by the end of the year, unleashing an arms race of innovation to meet those expectations. Failing to act means that more families will suffer heartbreak and more children harm.
In spite of my many years on this beat, Olly’s father Stuart shocked me to the core when he said that, since Olly’s death, he has received over 300 taunting and abusive messages via social media—images of people waving knives, celebrating Olly’s death and threatening his wife and daughter with rape, along with pictures identifying where they live. This sector does not have the authority or willingness to police itself. My deepest thanks go to those noble Lords who have chosen to speak; given our sad subject matter, I anticipate their words with trepidation.
Lord Allan of Hallam (LD)
My Lords, I will speak to one particular issue that the noble Baroness has raised, quite rightly in my opinion, in this debate and in the report of the Draft Online Safety Bill Joint Committee, of which I know she was a very active member. This is the question of access to data from the accounts of people who have sadly taken their own lives where there is a view that it may reveal something useful and important for their grieving relatives.
I do this as somebody who used to work for a social media platform and took part in the decision-making process on responding to requests for data in these tragic circumstances. In the internal debate, we had to weigh two potential harms against each other. It was obvious that refusing to disclose data would add to the pain and distress of grieving families, which the noble Baroness eloquently described for us, and, importantly, reduce opportunities for lessons to be learned from these awful situations. But there was also a fear that disclosing data might lead to other harms if it included sensitive information related to the connections of the person who had passed away.
The reluctance to disclose is sometimes described as being for “privacy reasons”. We should be more explicit; the concern in these cases is that, in trying to address one tragedy, we take an action that leads to further tragedy. The nightmare scenario for those discussing these issues within the companies is that another young person becomes so distressed by something that has been disclosed that they go on to harm themselves in turn. This genuine fear means that platforms will likely err on the side of non-disclosure as long as providing data is discretionary for them. If we want to solve this problem, we need to move to a system where disclosure is mandated in some form of legal order. I will briefly describe how this might work.
Families should not have to go directly to companies at a time of serious distress; they should instead be able to turn to a specialist unit within our court system which can assess their request and send disclosure orders to relevant companies. The noble Baroness eloquently described the problem we have with the status quo, where people approach companies directly. The platforms would then be required to provide data to the courts, which would need to be able to carry out two functions before making it available to families and coroners as appropriate.
First, they should be able to go through the data to identify whether there are particular sensitivities that might require them to withhold or effectively anonymise any of the content. To the extent possible, they should notify affected people and seek consent to the disclosure. In many cases, the platforms will have contact details for those individuals. Secondly, they must be able to consider any conflicts of law that might arise from disclosure, especially considering content related to individuals who may be protected by laws outside of the jurisdiction of the UK courts. This would need to include making decisions on content where consent has been withheld. If we could set up a structure such as this, we could have a workable regime that would work for all interested parties.
A few minutes is obviously not long enough to cover all these issues in detail, so I will publish a more comprehensive post on my blog, which is aptly named regulate.tech. I thank the noble Baroness for creating an opportunity to consider this important issue, one I am sure we will return to during the passage of the online safety Bill.
Lord Balfe (Con)
My Lords, I was looking for something original to say in this debate, so I went back to my previous existence as a Member of the European Parliament. One of the things that is still of great regret is that, in leaving Europe, we have left all the structures around it that can be helpful when we face problems like this. In particular, I think of the work of the EU directorate for health. In Europe, most countries face problems similar to ours and are trying to solve them. Overall in Spain, suicide among young people—defined by Spain as those aged 15 to 29, which probably goes a bit further than we would—is the second highest cause of death. Spain has put €100 million into a strategy to combat it, but it is doubtful whether it will do anything because, as mentioned by the noble Lord, Lord Allan, the key is getting access to the information. Italy is setting up an observatory, although it seems to be taking a long time. Even in Finland, which one thinks of as a very enlightened, Nordic country that deals with such issues, something like 25% of all suicides are in the age group from 15 to 24, so it is a problem that that country is also grappling with.
This is one of the great tragedies of leaving the EU. Although the EU has no formal responsibility, everyone will tell you that there are unofficial meetings of Health Ministers, where anything can be put on the agenda by any member state, so it is possible to exchange information. Have the Government gone to any effort to get information from other countries on how they are dealing with the issue, what their plans are, and whether they will publish that?
I have a couple of points from the briefing that I got. Among other things, it says that in a debate in the House of Commons, Chris Philp
“argued that they could ‘edit their algorithms tomorrow […] they should not be waiting for us to legislate; they should do the right thing today’.
Is there any sign of that right thing being done today? If so, it is certainly not recognised here. The briefing also said that
“Instagram said that it would ban graphic images of self-harm as part of a series of changes.”
Has it? Also, the online harms consultation says that the framework should include provisions to address suicide and self-harm. Has that been done?
Finally, can the Minister confirm in relation to suicide that all platforms and people of all ages will be in the scope of the final Bill when it is presented to the House? That is an important point. We need to go beyond just this group to the wider problem.
Baroness Boycott (CB)
My Lords, it is a pleasure to follow the noble Lord, Lord Balfe, and I thoroughly agree with him that we have to go beyond this specific issue to the wider problem. I congratulate my noble friend Lady Kidron on keeping up the pressure on this incredibly important debate. I want to briefly mention two different aspects: one is about young girls and one is about young boys.
I have talked before about the sexual pressures on girls that happens online. I remember so well the anxieties of being a teenager, of trying to set up Spare Rib magazine and feeling immensely conflicted about trying to own your own sexuality and your own rights in the world, to have dignity and control, and to be able to say yes and indeed to be able to say no. Looking back, if I had been able to see the kind of pornography that is now available at a simple click, that would have been extremely hard. You are presented with streams and streams of apparently willing young women who agree to have sex with not so much as a dinner and a nice night out; what they enjoy is a semi-situation of rape, over and over. The women are almost always extremely thin, shaved, hairless, kind of perfect—almost doll-like. They are completely and utterly unreal and bear very little resemblance to what an average teenage girl is. While my noble friend Lady Kidron has spoken so movingly about girls who take their own lives, there are a lot of stages on the road to that which are about misery, dejection, unhappiness and shaming—a consciousness all the time that “I am not good enough.” Indeed, the entire advertising world—you see this hugely online—is predicated on the fact that you could be better. There is no such thing left as normal hair or a normal size. In every case, if you spend money, you will be better.
In my remaining minute and a half I will talk about what happens to young men. In particular, I want to talk about my friend Laura Bates, who wrote Everyday Sexism. She used a fake account to set herself up online as a boy. She said, “I am 15 and I’m having a tough time getting dates” and said that she had acne. To start with, there was advice about acne drugs, then a bit of advice about how to dress. Then the advice started to get a bit creepier: “Are the girls in your school being too uppity? Are they beating you in class?” Quite soon, in the course of a few weeks, Laura found herself on an incel website. The progression was just click by click. It preyed on every sort of suspicion that a young man might have that somehow women are doing better and that somehow their lot in life is not their responsibility but the result of what feminists have done.
It is not a question of arguing this or that; the point is that when you see how the end product of misogyny and incels is now “Kill the women”, that is incredibly dangerous. Right across the internet, young people are being drawn into ever more extreme points of view that bear very little relationship to their reality. It happens across sexuality and with young men. At all points the internet companies could stop this but in many instances they are just making money out of preying on people’s weakness and lack of self-respect. These are all really difficult things to talk about, and if, as has been happening in the pandemic, your online world becomes even more real than your real world, you have very little way to express those feelings and get some help.
The Lord Bishop of St Albans
My Lords, I too thank the noble Baroness, Lady Kidron, for securing this most important debate on the contributory role of social media to the deaths of children, and I pay tribute to her persistent campaigning on this subject. It is a timely debate given that only a month ago we received the legislative scrutiny committee’s report on the draft online harms Bill.
I want to focus on the whole question of the extent to which we understand the numbers and the causes of child deaths, not only where social media plays a significant role but in a whole range of other issues. This is a much broader problem than just this topic, although it is a superb example of why we need better research and better recording of data.
In December, your Lordships’ House debated the Second Reading of my Coroners (Determination of Suicide) Bill. It would require coroners to record any relevant contributory factors once a death by suicide has been officially determined. It would not be a finding in law, the results would be anonymised and published anonymously, and it would be akin to the well-established processes that hospitals have for recording comorbidities of death.
All sorts of groups are campaigning and looking for much better data. Your Lordships will know that the reason why I have brought forward the Coroners (Determination of Suicide) Bill is because we have been trying to get accurate stats on gambling-related suicides—many of them are of younger adults—which, according to the recent evidence from Public Health England, accounts for roughly 8% of all suicides. That is a really significant number of suicides. Regardless of the criticisms of my Bill on feasibility, there is an important principle here about how we record comorbidities and use that evidence. Again and again when campaigning against massively powerful industries, one argument is that we do not really have the statistics. I have to say that Her Majesty’s Government officially come back with the same argument again and again, so for the last five years, my question has been, “Please will you help us to start getting accurate stats?” That is why I turned up with the idea of a coroners Bill. It is absolutely crucial to get the accurate stats because, if we do not, we will never be able to devise strategies to reduce the number of suicides. You do not reduce suicides in general by saying nice and comforting things about it to people; you find out what the causes are and get a strategy to address each one. Particularly when we have something that causes 8% of deaths, we really need to collect that sort of evidence.
Of course the Government are legislating to prevent child exposure to some of the content that Molly Russell and others saw, but it is absolutely crucial that we get ways of trying to understand properly what is going on. The Government say that my Bill will not be an appropriate mechanism to collect the evidence. What it has led us to is discussions with a number of coroners about postvention studies, which may be how we can get hold of that data. However it is, we need it. Will the Minister tell the Committee specifically what Her Majesty’s Government are doing to try to get this data, rather than keeping saying, “Oh dear, we haven’t got it”? It is vital that it is collected, if we are to have an evidence-based approach to preventing suicides in relation to all associated risk factors.
Baroness Prashar (CB)
My Lords, I too thank the noble Baroness, Lady Kidron, for securing this short debate, and pay tribute to the work she has done in this area. Her perseverance and tenacity are admirable.
There are many benefits of social media; it is a source of learning, advice and support for children and young people. But as we know there are many negatives too, as illustrated by the case of Molly Russell and other cases highlighted by the noble Baroness. There is also concern that harm caused by these platforms is exacerbated by the systems and processes of companies which amplify the spread of this dangerous content. Access is made easier by recommendations and algorithmically generated content suggestions. There is another concern that these companies then thwart the efforts of grieving parents to retrieve the data and information relating to their child’s online activity.
While quantifying the link between social media and children’s health is complicated, and it is argued that there is no definitive academic research, I agree with the House of Lords Science and Technology Select Committee that the absence of good academic evidence is not evidence that social media and screens have no effect on young people and children—they do. The Joint Committee on the Draft Online Safety Bill recently reported the evidence it has received linking self-harm and suicide attempts with accessing content online. There is therefore a strong case for taking action now, before the situation gets worse, and acting on the recommendations of the Joint Committee. It would be very short-sighted to lose the opportunity of including these in the online safety Bill.
I urge the Government to accept the Joint Committee’s recommendations to protect children as a comprehensive package. A statutory code on child online safety must be introduced, and the Bill should be extended to ensure that children are offered safety measures on all services likely to be accessed by children. Access to data by grieving parents in case of death should be included in the Bill.
Will the Government adopt in full the recommendations of the Joint Committee report and, if not, can the Minister please explain the reasons why not? Will the Government accept the proposal by the Law Commission to criminalise the encouragement of self-harm, threats of serious harm and stirring up hatred on grounds of sex, gender and disability? Can the Minister also confirm, in relation to suicide and self-harm content, that all platforms and people of all ages will be in scope of the final Bill presented to Parliament, and that age assurance will be part of the Bill? I look forward to the Minister’s response.
Baroness Benjamin (LD)
My Lords, I congratulate the noble Baroness, Lady Kidron, on securing this important debate. We are kindred spirits. Like the noble Baroness, I have long campaigned to try to make the internet safer for children, and I declare an interest as a vice-president of Barnardo’s, which is also deeply concerned about these issues.
Protecting children online must be an urgent priority for this House. The online safety Bill provides hope that the internet will be made safer for everyone, particularly for children and young people, but it will not come into force until 2024, so how are we going to protect children today, especially from violent, illegal sexual pornography? We need interim measures now, because even the DCMS research has shown that too many of our children have already been exposed to harmful content online, including violent pornography. Children themselves believe that they should be protected from harmful content online and on social media, saying that social media content often made them feel negatively about themselves, humiliated, threatened, embarrassed and, in some cases, was cause for self-harm, or even suicide. Research by Facebook found that 13% of teenagers in the UK said feelings of wanting to kill themselves had started on Instagram.
The online safety Bill is a once-in-a-generation chance to help to address these problems and finally make the internet safer for children, but we also need interim measures in place now to protect children online. If we wait for the online safety Bill, a whole generation of children and young people will have been left unprotected. The legislation has already been passed in Part 3 of the Digital Economy Act 2017, which provides some level of protection for children. Why not implement it? We have already wasted almost three years so far by not doing so. Think of the harm that has been done in that time.
Along with Barnardo’s and many other children’s charities, I have been calling for the Bill to include age verification for all dangerous pornography sites, but it needs to go further to make sure that it defines harmful but legal content that depicts self-harm and glorifies suicide, so that this, too, can be put on the virtual top shelf, behind a wall and out of sight of vulnerable children. It is also essential that children can access the support they need when they have been abused, bullied and exploited online, which can lead to suicidal thoughts. They desperately need mental health support teams in their schools, too. Social media platforms need to invest in awareness-raising, as well as signposting children who may be at risk of bullying or abuse to the support they need to recover and stay safe.
What research have the Government undertaken to understand the true impact of social media on vulnerable children’s mental health? Will they agree to meet prior to the publication of the online safety Bill with Barnardo’s and other children’s charities to discuss how to ensure that it protects children from preventable harm? Why will they not implement Part 3 of the Digital Economy Act as an interim measure to show that they truly care about children’s well-being?
Lord Harries of Pentregarth (CB)
My Lords, most deaths are sad and some are tragic, but a death from suicide is particularly devastating. It leaves the survivors with a question that remains on their minds for the rest of their lives: what went wrong, what more could I have done? The death of a young person from suicide is especially gut wrenching. How can anyone, let alone someone so young, find existence so unbearable that they choose to reject the precious gift of life? Self-harm, which sometimes leads to death, belongs in the same category.
I am very glad that the noble Baroness, Lady Kidron, has secured this debate before the online safety Bill comes before the House and has pursued this issue so tenaciously for so long. I support what she said about the need for parents of a deceased child to have access to their child’s digital data, which was reiterated in the 10-minute rule Bill by Ian Paisley. If it is possible to add further pain to parents whose child has committed suicide, it is by them not really knowing, or not knowing fully enough, why their child took their own life. This happens if, for example, they leave no farewell note. The parents whose child has committed suicide, partly as a result of what they have seen and heard on social media, may have some idea of what has happened, but they will want to understand as fully as possible and to have access to their child’s data.
I will not repeat what the noble Baroness and other people have said about the terrible difficulty at the moment of parents getting access to the data and the need to do something about it. As I say, this adds to the distress of the parents, who want to know more and try to understand. As has been mentioned, the failure to allow access means that we cannot learn from it to ensure that the same or similar material is not recommended to other children.
Further than this, I simply add my support to the other measures proposed by the noble Baroness. We know how serious the problem is. We have been told that there is no exact academic data, but the surveys we have indicate that there is a link in about 25% of suicides and cases of self-inflicted harm among young people. It is very difficult to doubt that link if one has seen some of that material.
As the noble Baronesses, Lady Boycott and Lady Benjamin, reiterated from their experience of this, it needs to be set within a wider problem. As they will know better than I do, there is a particular fragility among young people at the moment, partly because of Covid and partly because of the intense pressure of social media.
A voluntary code is not enough, of course, so with other noble Lords I look to the Minister to support the recommendations of the Joint Committee. We need clear, firm, enforceable legislation, which is essential to prevent the circulation of harmful content and to ensure that young people simply cannot have access to it.
Lord Addington (LD)
My Lords, this is one of those debates in which one has a developing feeling of sympathy with the Minister who is going to reply. Unfortunately, that feeling does not always survive the Minister’s speech. We will see what happens today.
It is quite clear that the internet and the online world are something that we have not really wanted to address that fully in the past. The whole system has been a little stand-offish, finding that it is a little frightening and moves very quickly. Most of us are probably happier if somebody younger than us, often our children, explains how the damned thing works.
Having said that, it is quite clear now that, in the greatest traditions of legislation, there are problems that we must deal with. One of those problems is that people feel that they are in a space where they cannot be touched, where they can do what they like and indulge themselves, and where money-making activities and things such as this are not things that the rest of society can get at, and it is none of their business to get in there.
This was brought home to me by a family friend, and this relates directly to the last point made by the noble Baroness, Lady Kidron, in her opening remarks. I live in the village of Lambourn, in the “valley of the racehorse”, and one of my family friends down there is a trainer whose daughter is an up-and-coming jockey. He discovered that after a couple of bad rides his daughter was being threatened with being raped and killed. He was quite appalled when he discovered that this is regarded as fairly normal. The real problem started when he went to the police, who said, “Oh well, we’re not really going to do anything about it”.
We must have a structure where we can intervene on this, as we would on other occasions. That is one of the things that must come out of this. There are technical points—on algorithms, how you follow things through, and how the people running these sites generate interest, money or indulgence—but the fact of the matter is that we must have a very clear guide as to how we will get in and make sure that there is a price if people break any rules, laws or structures. This could be one of the restrictions. It would not stop everything, but it would give us a structure to go down.
We need knowledge from sites that suicide victims have used. We need to be able to get in and use this control, which we regard as normal everywhere else—we have laws, and if you break them, we enforce them. The police, of course, will need help with new structures. If, when the Minister replies, he could give us an idea of what this enforcement structure will be like and the Government’s thinking about it, he would have taken the first step. Not only do we need to have these structures, but people have to know about them and the fact that society has decided that we are not going to put up with this anymore. That is one of the key points here.
I will not try to follow my noble friend’s experience and technical detail on this, because I cannot. But the principle behind this must be that the Government take this seriously, act and state publicly that this happens. If they do not, we will carry on having this problem again and again, and people will not react and do something about it because it is easier just to hope that it goes away.
Lord Bassam of Brighton (Lab)
My Lords, we do indeed owe the noble Baroness, Lady Kidron, a big debt of thanks today for bringing forward this important debate, and particularly for the way in which she addressed the issues, giving us the stories and case histories of those tragedies. Too often, this is a very dry subject: we look at the numbers, for example in the Lords briefing on this, and do not think of the human stories and the impact beyond them. That is really important for us to focus on as legislators.
In part, the online harms agenda has come about because of social media-influenced behaviours, with suicide being principal among those. But despite much fanfare about the DCMS policy work, little has yet been delivered by the Government to make the internet a safer place for children and young people.
The briefing for this debate, which I referred to, sets out very worrying trends in relation to suicide and self-harm by young people. Although correlation does not always imply causation, the evidence gathered by a variety of charities and campaign groups strongly points to a negative role played by social media. Our personal experiences reinforce and tell us that, too. My kids grew up as the internet was expanding and growing, and they often relayed to me horror stories of experiences that they and their friends had had and the impact that it had upon them.
The implementation of the age-appropriate design code was a welcome step forward, but we have a long way to go on this, and I hope we can hear more from the Minister on that. As we know, significant gaps in the regulatory landscape remain, and it is not clear whether the Government will adopt all the recommendations made by the Joint Committee on the Draft Online Safety Bill, so perhaps the Minister could enlighten us a bit more on that. I know he cannot give us a full picture and pre-empt a future Queen’s Speech, but some hints would be very helpful.
Even if the Government choose to close loopholes and go further on statutory requirements, your Lordships’ House is unlikely to consider the Bill until late 2022, or possibly even 2023. As the noble Baroness, Lady Benjamin, said, the entry into force of key measures is unlikely before 2024. That delay is unacceptable, particularly at a time when young people are under great pressures—the impact of Covid, and the sense of delay to their lives and their personal development that the past two years have brought. We urgently need to bring forward more measures. I was encouraged to see that, in the Police, Crime, Sentencing and Courts Bill, the Government have at least adopted a position on online racist harm to footballers. That was a sign of good intent, but they need to build on it.
The noble Baroness, Lady Kidron, has been tireless on this issue, and has raised it many times. We should offer as much support as we can to that campaign. Perhaps the Minister will outline some of the Government’s commitments today. When can we expect some concrete actions—legislative or non-legislative—in the current parliamentary Session? That would be a good way forward.
Debates such as this are important, but what we really need is change. We as a party stand ready to engage with colleagues from all sides, and with the platforms themselves, to make the digital world a safer place for children and young people to be, but we need more than warm words from Ministers.
The Parliamentary Under-Secretary of State, Department for Digital, Culture, Media and Sport (Lord Parkinson of Whitley Bay) (Con)
My Lords, I start by thanking the noble Baroness, Lady Kidron, for tabling this important debate, and for beginning by setting out the personal and often harrowing examples that should be uppermost in our minds as we debate these important issues. I am grateful, too, for her drawing to my attention the 10-minute rule Bill introduced in another place on Tuesday by Ian Paisley MP. I have read the transcript of his remarks, in addition to listening to the contributions of noble Lords today.
Her Majesty’s Government share the concerns raised by noble Lords today about the risks to children of harmful content and activity online, including in social media. Although many children have a positive experience online—it is important to remember that—it is clear that the presence of harmful material, and in particular content promoting suicide or self-harm, can have a serious impact on children’s mental health and well-being. The noble Baroness, Lady Boycott, was right to point to the fragility and vulnerability of young people, including adolescents and people well into their teens.
Sadly, we know from research, from coroners’ reports and from colleagues in the police that harmful online content, including that seen in social media, is playing an increasing role in individual suicides. In addition, figures from 2020 show that 40% of 12 to 15 year-olds who are concerned about and have experienced content promoting self-harm cite social media as the source. There is also evidence that gangs are using social media to promote gang culture, to taunt each other, and to incite violence.
The Government are determined to hold social media and other platforms to account for this harmful content, and to make the UK the safest place to be a child online. A key part of that is the online safety Bill, which, as noble Lords know, we published in draft last May. For the first time, under that Bill platforms will have a clear legal responsibility for keeping their users safe online. Platforms will have to understand the risk of harm to their users, and put systems and processes in place that improve their users’ safety.
All companies within the scope of the Bill will have to remove and limit the spread of illegal content, such as material that encourages or assists suicide, and take steps to prevent similar material from appearing. The largest tech companies will also be held to account for tackling activity and content harmful to adults who use their service. Under the new laws, those companies will have to set out clearly what content is acceptable on their platforms, and enforce their terms and conditions consistently. That will enable us to address many of the questions raised by my noble friend Lord Balfe, and to hold companies to account.
The strongest protections in the legislation will be for children. Services likely to be accessed by children will need to conduct a child safety risk assessment and provide safety measures for their child users against harmful and age-inappropriate content. Platforms likely to be accessed by children must consider the risks that children on their services face from priority harmful content—that will be set out in secondary legislation—and any other content they may identify that could cause harm to children. They will also need to consider the risk of harm from the design and operation of their systems.
We expect priority harms for children to include age-inappropriate material, such as pornography and extreme violence, and harmful material such as that which promotes eating disorders and self-harm, as well as cyberbullying. Ahead of designating the “priority harms”, which will be in scope of the legislation, the Government have commissioned research to build the evidence base on harms to children online. This research will review the prevalence and impact of a wide range of harmful content to ensure that the legislation adequately protects children from content that is harmful to them. Ofcom will have a duty to advise the Government on priority categories of harm to children and will also want to draw on evidence and views from relevant parties. That includes Barnardo’s, as raised by the noble Baroness, Lady Benjamin. I am pleased to say that my honourable friend the Minister for Tech and the Digital Economy has already met Barnardo’s in that regard.
The regulator, Ofcom, will set out the steps that companies can take to comply with their duties through statutory codes of practice. Platforms will then be required to put in place systems and processes to mitigate the risks that they have identified. Ofcom will hold companies to account both on the standard of their risk assessments and on the safety measures that they adopt and can take enforcement measures if either of these fall short of what is expected. The approach that we are taking means that children will be much less likely to encounter harmful content in the first place and platforms will no longer, for example, be able to target harmful material at children through the use of algorithms, as the noble Baroness, Lady Kidron, mentioned.
The noble Baroness, Lady Benjamin, asked why the Government cannot in the meantime bring in Part 3 of the Digital Economy Act. The Government have taken the decision to deliver the objective of protecting children from online pornography through the online safety Bill, which we are confident will provide much greater protection to children than Part 3 of the Digital Economy Act would, as it also covers social media companies, where a considerable quantity of pornographic material is available to children at the moment. It would also not be as quick a solution as I think the noble Baroness imagines to commence Part 3 of the Digital Economy Act as an interim measure. The Government would have to designate a new regulator and that regulator would need to produce and consult on statutory guidance. The Government would then need to lay regulations before Parliament ahead of any new regime coming into force. That is why we are keen, as noble Lords today have said they are as well, to do this through the online safety Bill and to do it swiftly.
We expect companies in the scope of the duties of the online safety Bill to use age-assurance technologies to prevent children from accessing content that poses the highest risk of harm. Standards have an important role to play in delivering that and Ofcom will be able to include standards for age assurance as part of its regulatory codes. Companies will either need to follow the steps in the codes, including using these standards, or demonstrate that they achieved an equivalent outcome.
The noble Baroness, Lady Kidron, asked whether the Bill would make reference to the United Nations Convention on the Rights of the Child. I cannot pre-empt the Government’s response in full to the Joint Committee on which she served, but I note in the meantime that the Bill reflects the three principles of the general comments: for the best interests of the child to be a primary consideration; on children’s right to life, survival and development; and respect for the views of the child. Of course, on that and all the recommendations, the Government will respond in full to the Joint Committee, for whose work we are very grateful.
As the noble Lord, Lord Addington, says, regulation of this nature will require effective enforcement. We have confirmed our decision to appoint Ofcom as the regulator and our intention to give it a range of enforcement powers, which will include substantial fines and, in the most serious cases, blocking. There will also be a criminal offence for senior managers who fail to ensure that their company complies with Ofcom’s information requests, to push strong compliance in this area. Ofcom will also be required to set out in enforcement guidance how it will take into account any impact on children due to a company’s failure to fulfil its duty of care.
The Bill will apply to companies that host user-generated content or enable user-to-user interaction, as well as to search services. We have taken this approach to ensure that the Bill captures the services that pose the greatest risk of harm to users and where there is current limited regulatory oversight, without placing disproportionate regulatory burdens elsewhere.
I know that the noble Baroness and the Joint Committee have recommended aligning the scope of these measures with that of the age-appropriate design code. We are grateful for their consideration of this important issue as well. It is vital that any approach is proportionate and remains workable for businesses and Ofcom to ensure that the framework is as effective as possible. We are carefully considering the Joint Committee’s recommendations and are committed to introducing the Bill as soon as possible in this parliamentary Session. In the meantime, we are working closely with Ofcom to ensure that the implementation of the framework is as swift as possible, following passage of the legislation.
I will say a bit more about the interim measures that we are taking, as noble Lords rightly asked about that. We have a comprehensive programme of work to protect children online until the legislation is in force. Ahead of the Bill, the video-sharing platform and video-on-demand regimes are already in force, with Ofcom as the regulator. They include requirements to protect children from harmful online content such as pornography. In addition, the Government have published an interim code of practice for providers to tackle online child sexual exploitation and abuse.
The noble Baroness, Lady Prashar, mentioned our work in asking the Law Commission to review existing legislation on abusive and harmful communications. The Law Commission has published its final report, putting forward recommendations for reform. These include a recommended new offence to tackle communications that encourage or incite self-harm. The Government are considering the recommendations and will set out our position in due course.
As the noble and right reverend Lord, Lord Harries of Pentregarth, said, every death is sad—many are tragic, but they are incredibly so when they involve a young person. The Government recognise the difficulties that some bereaved parents have experienced when accessing their loved ones’ data. Disclosure of data relating to a deceased person is not prevented by the UK’s data protection legislation. As the noble Lord, Lord Allan of Hallam, noted, some companies operate policies of non-disclosure to third parties, including parents, unless a user has taken active steps to nominate a person who may access his or her account after he or she dies or if there is a legal obligation to disclose the data.
We are discussing this issue with companies directly. Officials met Instagram on 22 December, for instance. We are also in discussion with the Information Commissioner’s Office about digital assets. It is important to recognise, as the Joint Committee did, that an automatic right of access is unlikely to be appropriate in every case. Some people might be concerned about the disclosure of private information or other digital assets to third parties after their death.
The Government are grateful to the Joint Committee for its recommendations in this area. While I cannot make any commitment or pre-empt the Government’s response in full, I am happy to say that we will continue to give careful consideration to this before we respond and outline our proposed next steps.
It is worth noting that coroners already have statutory powers to require evidence to be given or documents to be produced for the purpose of their inquests—this would include relevant digital data following the death of a child—with sanctions where such evidence is not given or documents produced. They are well aware of these powers.
The right reverend Prelate the Bishop of St Albans mentioned his Private Member’s Bill. As he knows, the Coroners and Justice Act 2009 is clear that it is beyond a coroner’s powers to determine why somebody died. Coroners’ investigations are about determining who died, how, when and where, but not why. However, he is right that more can be done to understand some of those circumstances. We recognise that quality information on the circumstances leading to self-harm and suicide can support better interventions to prevent them in the first place. The Department for Health and Social Care is considering including questions on gambling as part of the adult psychiatric morbidity survey this year to help establish the prevalence of suicidal tendencies linked to gambling and to improve its evidence base. As the right reverend Prelate knows, we are taking a close look at the Gambling Commission’s powers as part of our review of the Gambling Act.
The Government are deeply concerned about the impact of harmful content and activity online on children. We are committed to introducing legislation as soon as possible to ensure that platforms are held to account for this content so that future generations can have a healthy relationship with the internet. I look forward to debating that Bill when it comes to this House. In the meantime, I thank noble Lords for their contributions to today’s debate.
Government of Qatar
(2 years, 3 months ago)
Grand CommitteeRead Full debate Read Hansard Text
Lord Moynihan
To ask Her Majesty’s Government what assessment they have made of current relations with the government of Qatar.
Lord Moynihan (Con)
My Lords, recent years have seen the torch of international attention shone into the recesses of the State of Qatar as it prepares to host the 2022 FIFA World Cup. It is a country that, since it won the right to host the world’s leading global sports event, has been more than aware that the spotlight would shine on all aspects of its country, policies, laws and people. The Government of Qatar have turned this opportunity into a national challenge for change—a dynamic for managing the modernisation of a small country into a fast-changing leader in the region with global influence and strategic importance for the UK.
Before I seek to set out the case for this view, I declare a key interest. The background to this debate came from Sir David Amess, a close friend for nearly 40 years, who encouraged me to join the APPG on Qatar as vice-chair of the group with responsibility for sport.
Qatar lies at the strategic epicentre of many of the key issues that dominate international politics today. As we sought to manage the exit strategy from Afghanistan, it was the Qataris who brought stability and support to the lives of thousands of refugees, many of whom were seeking support in the UK. It is a country that has been vital to the UK by ensuring the security and prosperity of the Afghan people, providing safe passage to unaccompanied children heading to new homes here, fighting for the rights of women and minorities through its open dialogue with the Taliban, and evacuating 74,000 people from Afghanistan—and over 210 British citizens—while housing the British embassy to Afghanistan in Doha.
Qatar is a friend and an ally. It supplies 20% of our gas requirements and has directed its resources to co-invest with Rolls-Royce on a net-zero journey to deliver a multibillion-dollar pathway to achieve that goal by 2030, working on small modular reactors to create net-zero carbon energy at scale; to back an educational foundation for innovation in technology outside the nuclear industry, where the promotion of energy transition projects maps the steps towards pioneering climate change technology; to look to support 10,000 climate tech jobs; and to aim to create five UK unicorns by 2030 with the support of the Qatar Foundation.
The UK is offering substantial support in its hosting of the FIFA World Cup. Foster, Zaha Hadid Architects, Turner & Townsend, the FA, football clubs such as Leeds United and Sheffield United, universities such as Leeds Beckett and the University of Liverpool and many others are working on projects to harness the power of football to drive positive change.
As we know, Qatar is a country that has invested heavily in the UK and seeks a further £5 billion of investment in our economy by the end of this year. It hosts the RAF Middle East headquarters at the al-Udeid airbase, where coalition forces are based in the fight against Daesh. It works with the UK on cybersecurity. It has a joint Typhoon squadron and seeks to ensure a combined strong stand against terrorism and the promotion of peace, stability and security in the Middle East. Now, when it will become the first country in the Middle East and the Arab world to host the FIFA World Cup, we should look forward to further collaboration to ensure that football leaves a positive human, economic, social and environmental legacy for the country, the region and the world.
There are rightly matters of significant concern to Members of this House which the torch of international attention has magnified, not least the treatment of migrant workers. In the face of widespread international concern, the Qatar Government were right, from the outset, to extend an invitation to the International Labour Organization to set up a well-staffed office in Doha. Its recent in-depth analysis showed that 50 workers had lost their lives in 2020, but these included work-related deaths across all aspects of society and the economy, including, for example, road traffic accidents.
The ILO must, of course, be free to criticise and publicise its concerns, and it is. It is expected to remain and to protect the interests of the migrant labour workers after the World Cup, and I very much hope that it does. Every human rights issue must be pursued. Everyone deserves the right to work safely and securely, whether that be in Qatar, the UK or elsewhere. Qatar’s national policy on occupational safety and health has had to be transformative, and it has been. The end of the kafala system was a critically important first step and established a direction of travel for many other countries in the Middle East that retain it, either entirely or in some form. The Qataris know that they still have further to go. They will need to ensure media freedom. A minimum wage has been introduced, and the banning of exit visas is an essential and critical step. It is also essential that no action is taken against members of the LGBTQ+ community who arrive to be present for the World Cup finals. Subsequent reform must provide a welcome sign to the world and, indeed, to the world of sport.
We are to host the Commonwealth Games in Birmingham later this year. We must continue to campaign to reverse the position that the majority of Commonwealth countries participating in the Games still criminalise sexual acts between consenting adults of the same sex and other forms of sexual orientation, gender identity and expression. Homosexual activity remains a criminal offence in more than 30 of the 54 sovereign states of the Commonwealth, and legal in only 19. I hope my noble friend will confirm that we will continue to engage with all countries where homosexuality is a criminal offence to seek an end to those laws, for we need to continue working with international partners and civil society to promote and defend universal freedoms throughout the world.
At Oral Questions in the Lords on 30 November, calls, led excellently by the noble Lord, Lord Collins, were made by some to boycott the FIFA World Cup or to adopt the now well-trodden policy of calling for a boycott by government officials and members of the royal family of attending the event. My view is well known, not least to the noble Lord, Lord Collins: that the boycott of any sporting event by Ministers and officials is the worst example of posture politics in the world of sport. It serves little purpose. It always generates a strong response from the host city or country and is forgotten the moment the sporting event starts.
I have long taken an active stance on human rights issues, currently as vice-chair of the All-Party Parliamentary Group on Sport, Modern Slavery and Human Rights. All Governments need to act decisively on human rights abuses wherever they exist by making the strongest representations to the country concerned. I oppose calls for a boycott or the withdrawal of government support. It remains my view that for sports boycotts to be effective, they must have the broad support of the international community and be the product not of posturing or reprisal but of an astute and practical moral calculus including a wide-ranging package of trade, travel and diplomatic measures to lead to action that will best advance the cause of human rights and the well-being of those whose rights are violated, as in apartheid-ridden South Africa.
At the same time, it would be wrong to underestimate the growing international influence of sport and the power of the FIFA World Cup or Olympic movement. The goal of sport is to spread fundamental human values as widely as possible, not to confine them exclusively to the western world, as we tended to do in the 20th century. Sport is about humanity and can contribute to the changes we should all seek by unifying our whole approach in seeking the change that is necessary wherever an event is held.
I would go further and argue that one reason why the FIFA World Cup should be held in Qatar is because sport is in itself a force for good. It is a mass phenomenon that gives enjoyment to hundreds of millions of people every week. We have gone far beyond the principle of the value of sport simply as entertainment. Sport, as a universal language, can help to promote peace, tolerance, reconciliation, change and understanding. It cuts across lines of class, nationhood, ethnicity and culture that might otherwise divide, and it is an exceptional vehicle for bringing people together, bridging differences and promoting communication and understanding. As a result, I firmly believe that by working together we can help Qatar to continue on the remarkable journey that it has embarked upon. I look forward to this debate and the response from the Minister on behalf of the Government.
Lord Vaizey of Didcot (Con)
It is a great pleasure to follow my noble friend and to hear his views on the power of sport, which obviously he has vast experience of, and the impact that the World Cup will have on Qatar, where he also has a great deal of experience. I simply wanted to add, almost tangentially, some thoughts about culture and Qatar.
When I was the Minister for Culture many years ago, I supervised from our end the UK-Qatar year of culture, which I think was 2013, and I spent a great deal of time in that country. In fact, I randomly met Robert De Niro when I went to Qatar, which resulted in a diptel with the title “Ed Vaizey goes to Qatar. Robert De Niro’s waiting.” There is a cultural reference in there which I will leave noble Lords to work out.
I will get serious for a moment. There are two elements to the cultural links between the UK and Qatar that are worth emphasising. First, the Qatari Government have been very supportive of British culture. The emir and his wife supported a project in the British Library to digitise a great deal of records relating to Qatar and the Middle East, and they sponsored an exhibition at the V&A that highlighted Qatari cultural treasures. However, it is also interesting to note—this is where it is relevant to my noble friend’s remarks—that the Qatari Government and the emir have pushed forward the use of culture as a means of progress within the country of Qatar. They have built a state-of-the-art museum to show off cultural artefacts from Qatar and the region but, even more importantly, they have held ground-breaking exhibitions of western contemporary art that, frankly, can be quite challenging to a conservative mindset in the Middle East. That is a brave thing for them to do. I met Robert De Niro in Qatar because they were hosting a film festival, and I was out there when they hosted a fashion festival.
This is a textbook example of how countries and Governments in the Middle East can use culture frankly to push forward change and reform within society and their country. For me, as regards my engagement with Qatar, I was left with an abiding impression that this was a country committed to change and progress as well as being a valuable ally of ours.
Baroness Harris of Richmond (LD) [V]
My Lords, I thank the noble Lord, Lord Moynihan, for bringing forward this timely short debate. I declare my interest as a member of the Qatar APPG as well as my policing interests, which are in the register.
I first visited Doha in 2008 when I was on a parliamentary delegation discussing security matters. It was obvious at that time that the state was developing at an enormous rate, with buildings going up daily and facilities for the residents, and visitors, of the highest standard anywhere in the world. Yet it was still a very small city. I visited again a couple of years later and was astounded at the physical rate of progress of its cultural and built environment. It had doubled and more within those two years. What had not changed was its warm and friendly hospitality, which was demonstrated throughout our visit.
Along with colleagues, we were delighted to see the beginning of the building of its amazing Museum of Islamic Art, which the noble Lord, Lord Vaizey, referred to. This was in a complex of many other cultural buildings, including a newly built opera house, a mirror-image of our own in London. The Cultural Village, as it was known, had not yet been fully completed—I expect it has been now—but it gave us a very good idea of what to expect, with an abundance of areas for poetry, music and art that would satisfy all tastes, as we have heard.
Since then, of course, Qatar has become a much valued and essential provider of around 20% of our gas needs, as the noble Lord, Lord Moynihan, referred to. A few years ago, I was invited to lead a delegation to visit the site at Milford Haven, where tankers transporting the liquefied natural gas from Qatar were being offloaded into state-of-the-art refineries and then distributed to our national grid. With the whole of Europe suffering the huge spike in energy prices, the UK has agreed a deal with Qatar to continue delivering LNG so that we have a safe and secure supply, one very good outcome of our trade deals.
In 2020, Qatar was the UK’s 34th largest trading partner and UK exports to Qatar were worth over £3.8 billion. As we have heard, its investments in the UK exceed £40 billion. Qatar has been a good friend to our country.
In the security industry, we sold Qatar 24 Typhoon aircraft, nine Hawks, Brimstone missiles and the services to go with them. Other investments in the UK include linking Rolls-Royce with their green energy operations. As we have heard, Qatar is one of Rolls-Royce’s biggest customers, especially for its Trent engines that power the aircraft for Qatar Airways, one of the most prestigious airlines in the world. It is also hoping to develop small modular nuclear reactors—SMRs—with Rolls-Royce, which, it is anticipated, will deliver thousands of new jobs. It is equally hoped that these jobs will be in areas of the country most in need of levelling up.
However contentious the venue, Qatar did win the right to put on the prestigious World Cup event, and we can only hope that it is as successful as other World Cups have been. There has been a lot of concern, quite rightly, about how migrant workers have been treated when building stadia for this event. Qatar’s human rights have been questioned and criticised, and I believe that its Government know that these things have to change. Indeed, the noble Lord, Lord Moynihan, referred to this. They have begun that process and are making strenuous efforts to address these international concerns. Qatar has created the National Human Rights Committee, which investigates abuses and is advancing the country’s standards, to take part in research programmes and advise other government bodies on human rights issues.
The Government have also developed a significant labour reform programme, and Human Rights Watch has commended Qatar on its progress and hopes that other Gulf countries might follow its lead, especially as it was the first country in the region to introduce a minimum wage. It is also the first Arab country to allow women the right to vote, although there is still a long way to go for women to have anything like equality with men.
This is a very febrile region. Qatar has its own security concerns, so it is perhaps not for us to criticise our country’s friends when they also have to face security challenges. As a good friend to our nation, we should be thankful that our trading ties with Qatar are close and secure and hope that the future plans for working together come to a happy conclusion for both our nations, especially for that troubled region.
Lord Collins of Highbury (Lab)
My Lords, I start by thanking the noble Lord for initiating this debate; it certainly gives me an opportunity to reiterate some of the points that he has heard me make before. I agree with the sentiments of all the contributions that a strong relationship between the United Kingdom and all the Arab states of the Persian Gulf is in everyone’s interest. However, that relationship, important as it is, must be built on the values that we hold as a country. Qatar is a growing economy with considerable regional interests and influence, and although there are clear areas where co-operation is mutually beneficial, we must use that relationship to encourage modernisation, as the noble Lord said.
I agree with the noble Lord that the spotlight on Qatar, as the Qataris themselves say, in terms of that national challenge for change, will bring strong benefits. I agree that sport can be a force for good—although, as a keen Arsenal supporter, I point out that my neighbours back Spurs, and we sometimes do not get on that well. Whenever there is a derby game one fears for one’s own safety. Nevertheless, sport is a force for good.
I also agree that simply calling for boycotts is not necessarily the appropriate solution. The decision to bid for the World Cup was a big political decision of the Qatari Government, and it was politics that made them support that bid. We have done such things ourselves, as a country, because we know that hosting such events can be a force for good in all our communities. I agree with the noble Lord that calls for boycotts should not be made lightly, and that the circumstances of the South African boycott were absolutely right, in terms of the world community, because sport was not permitted to be played in the way that we would expect. But when it comes to the Winter Olympics, there needs to be some clear political statement about the genocide against the Uighurs. A political and diplomatic boycott shows that Governments do not want to be associated with the Games. But it is not for us to interfere with sport through a general boycott. I agree with the noble Lord about that.
As for the force for good and the power of change, there is still a lot more to be done. It is only a short time now until the World Cup, and a lot of the human rights concerns remain and will overshadow the competition. As I said in November, it is eight years since the International Trade Union Confederation first warned that Qatar was not recording the deaths and injuries of migrant workers during preparations for the tournament. According to the Guardian, more than 6,500 have died since the World Cup was awarded. I accept the noble Lord’s point that there is not necessarily a direct link, but this is about the number of migrant labourers who have gone to Qatar, and the impact of that.
Trade unions are, of course, practically outlawed in Qatar, and it is a scandal that Qatar continues to hide the true picture on migrant workers. The ILO’s report published last October, which I have referred to before, identified clear gaps in the collection of data on work-related deaths and injuries, and called for improvement. Importantly, it stressed the need to move with urgency, because behind each statistic there is a worker and their family. Last November I asked the noble Lord, Lord Ahmad, what representations the Government of the United Kingdom had made to Qatar on the ILO report. I also asked him to come back to the House on the progress made on its implementation, so that further injuries and deaths could be prevented, and the families of those killed or injured could receive proper compensation. I have had no response from the noble Lord, so I hope that the Minister here this afternoon will be able to answer those questions, which remain outstanding.
I agree with the noble Lord, Lord Moynihan, that the ILO presence is important and represents progress. But I also think that the United Kingdom has a responsibility to support the ILO and to back it in every respect.
This is not just about migrant workers; the noble Lord referred in his introduction to general oppression of minorities, particularly LGBT people. As he said, homosexuality is still illegal. The head of Qatar’s World Cup bid team has said publicly—I read it in the papers—that gay men attending the World Cup must not publicly display affection. They will be welcome, but must not display affection. As a gay man, I know what real oppression can be—forcing you to be invisible and not the person you are, unable to acknowledge the people you love. You may spend a fortune on going to the World Cup to be constantly fearful—what does it mean not to display affection? We have had cases in the Middle East where a United Kingdom citizen was charged with putting a hand on someone’s knee, something we perhaps all have done. Even the noble Earl, Lord Courtown, has done it—he has certainly done it to me in the bar a couple of times.
The important thing is how we support and back people. If we are truly saying that gay people will be welcome at the World Cup—why should they not be?—they should be able to be visible. They should certainly be able to acknowledge their sexuality in a public way, through flags, badges and things. I am not suggesting we have a blatant attack on the laws in Qatar, but the Government have a duty to protect and defend those people who go to the World Cup so that they do not have to face oppressive circumstances. The Human Rights Watch reports that we have seen mentioned the increased surveillance that will be installed for the World Cup. This could be used to target LGBT activists. In any sort of guidance the Government give, I hope they make that clear.
As has been acknowledged in this debate, the United Kingdom continues to attract significant investment from Qatar, and ties between our two countries are deepening as universities and other institutions establish a base in the Gulf. I too pay tribute to the late David Amess and I certainly pay tribute to the work of the APPG. As attention turns to the World Cup, it is incumbent on Ministers to hold the Qatari Government to account and push them even further in how they keep to their word on modernisation. I hope the noble Earl will give us a clear indication about the progress that has been made so far and the progress to be made for the future.
The Earl of Courtown (Con)
My Lords, I am grateful to my noble friend Lord Moynihan for securing this debate and to all noble Lords who have contributed. I start by expressing my appreciation for the work of the all-party group and the commitment of its members to a strong UK-Qatar relationship. My noble friend mentioned his visit to Qatar with the parliamentary delegation led by Sir David Amess. I take this opportunity to pay tribute to Sir David for his tireless work for his constituents and others. He was tragically killed just days after his visit to Qatar. I am also deeply grateful to the members of the Qatari royal family and Government who sent their most sincere condolences to Sir David’s family and the UK at the darkest of times.
This debate is timely. It comes at a time when the Government are working to deepen and broaden the already strong UK-Qatar relationship. The Foreign Secretary visited Qatar in October as part of her first official visit to the Gulf. Qatar is one of our closest allies in the region, and she used her time in Doha to advance the key pillars of our bilateral partnership. My right honourable friend the Minister for Middle East, James Cleverly, will visit Qatar later this month to do similar, and we are currently preparing to host the first ever UK-Qatar strategic dialogue between the Foreign Secretary and Qatar’s Foreign Minister.
Our partnership with Qatar is sustained by myriad connections and friendships between our people. They are the golden thread that drives our co-operation and dialogue in a number of areas. As noble Lords may be aware, 20,000 British nationals live and work in Qatar, and the UK is a second home to many Qataris. In 2019, prior to the pandemic, there were a record 175,000 visits from Qatar to the UK, worth more than £0.5 billion to the UK economy.
The noble Baroness, Lady Harris of Richmond, commented on trade and investment. Our strong trade and investment relationship with Qatar provides jobs throughout the UK, supporting the Government’s levelling-up agenda. Our bilateral trade currently stands at just over £4.3 billion, which includes £2.4 billion of UK exports, making Qatar the third-largest export market in the region for British firms. Qatar is also a major investor into the UK, playing a role in a huge variety of developments mentioned by noble Lords, including the Shard, Heathrow Airport and even Chelsea Barracks. Overall, Qatari investment in the UK is currently estimated at £40 billion, and the figure is growing.
The latest example of this, as mentioned by the noble Baroness, Lady Harris, was last month’s announcement by Qatar’s sovereign wealth fund of an £85 million investment in the Rolls-Royce small modular reactor programme, giving a boost to the UK’s net-zero agenda and demonstrating Qatar’s commitment to tackling climate change. Qatar is also an important partner for the UK’s energy security, as one of the world’s largest producers of liquefied natural gas. For example, QatarEnergy recently agreed a long-term contract with the national grid for capacity at the Isle of Grain natural gas import terminal east of London.
We want to grow this trade and investment relationship further, not just in Qatar but across the Gulf. That is why we are about to commence negotiations on an ambitious new free trade agreement with the Gulf Cooperation Council countries. The UK public consultation on this has just completed, and my colleagues in the Department for International Trade are working to agree a timeline for those negotiations to commence with ministries here and with our Gulf partners, including Qatar.
A number of noble Lords raised the subject of human rights. The friendship between our nations extends right to the heart of our respective Governments, as demonstrated by the Foreign Secretary, the Defence Secretary and my noble friends Lord Grimstone and Lord Wolfson, all of whom have either met or spoken to their Qatari counterparts in recent months. These close ties provide meaningful opportunities to engage on difficult topics and influence change. The UK Government do not shy away from raising human rights concerns whenever required, in public or in private.
We also welcome progress when we see it. We welcome the concrete steps that Qatar has taken to improve workers’ rights. The priority now is full implementation and enforcement of these reforms, and there is further to go. We stand ready to further assist and support Qatar’s efforts to improve workers’ rights, including through engagement with the International Labour Organization, as mentioned by the noble Lord, Lord Collins.
Our enduring defence partnership with Qatar is exemplified through our joint Typhoon squadron. During a recent visit to RAF Leeming by the Qatari Minister for Defence, the Defence Secretary also unveiled the UK-Qatar joint Hawk training squadron and the delivery of Qatar’s first Hawk jets by BAE Systems.
In recent years, the upcoming World Cup has been a prominent feature in our engagement. We are working with Qatari authorities to support their delivery of a safe and secure tournament. We will continue to engage on the “everybody is welcome” message so that anyone, of any background, can go and enjoy themselves. A range of British companies is playing a notable role in preparations, from the cutting-edge design of football stadia to the recently launched countdown clock. I hope we will have two of the home nations competing in November, with one of them bringing home the trophy.
Qatar plays an important role in regional and global affairs, and our Governments work closely together on a wide range of important issues. As my noble friend Lord Moynihan, said, we commend Qatar for the role that it played helping to evacuate people out of Afghanistan in the summer, including British nationals. Prior to that, Qatar also played an important role in negotiations with the Taliban. Qatar also remains an important development and humanitarian partner for the UK. For example, we value our joint UK-Qatar programme on girls’ education in Syria, and we are keen to deepen our co-operation further as we look to 2022 and beyond.
Noble Lords raised a number of questions, which I shall go through now. I start with the moving speech from the noble Lord, Lord Collins of Highbury, in relation to LGBT rights. Qatari authorities have committed, as I said, to everybody being welcome at the tournament, including LGBT visitors. We will continue to engage on this between now and the tournament, so that anyone of any background can go and enjoy themselves. Qatar has confirmed that individuals will be able to display the rainbow flag.
My noble friend Lord Vaizey brought up the subject of culture ties with Qatar. The UK works with state ministries and key cultural and educational institutions, such as Qatar Museums, Qatar Foundation and the Katara cultural village. The UK attracts 3,000 students from Qatar annually; the British Council has developed a network of 1,200 Qatari alumni who have studied in the UK and runs a UK alumni awards programme that identifies outstanding achievers and celebrates their positive impact. The British Council stages an annual British festival to maintain and strengthen the UK’s position as Qatar’s cultural partner of choice, and to celebrate UK creativity and innovation across the arts, education, science, engineering, design, culture, entertainment and tourism.
In relation to the points made by the noble Baroness, Lady Harris, and the noble Lord, Lord Collins of Highbury, on human rights, our close ties allow us to engage in these difficult topics, and we continue to raise human rights issues wherever appropriate. This includes migrant workers’ rights. No aspect of our relationship with Qatar prevents us from speaking frankly about human rights in public or in private. The UK has a strong history of protecting human rights and promoting our values globally, and we continue to encourage all states, including Qatar, to uphold international human rights obligations.
I agree with the noble Lord, Lord Collins, on a sporting boycott. The UK Government do not favour a sporting boycott. Along with the participation of national teams in World Cups, it is a matter for the relevant football associations, which operate independently from government, as required by FIFA statutes. The noble Lord also asked what we had been doing to press the Qataris on labour rights concerns. We encourage continued close collaboration between the Government of Qatar and the ILO during the second phase of the technical co-operation programme, which runs until the end of 2023. We also encourage continued co-operation with entities such as the international trade unions.
Having engaged with Qatari authorities, the International Labour Organization has, as the noble Lord, Lord Collins, said, this month released a comprehensive report containing recommendations to improve data collection and analysis on occupational injuries and fatalities. This is a really important step, and we welcome that this is one of the key elements of Qatar’s national policy on occupational health and safety.
In conclusion, Qatar is one of our closest allies in the Gulf. We enjoy a friendly, frank and productive partnership that benefits our mutual security and prosperity. It is a relationship we greatly value, and I am grateful to all Members of this House and the other place for their support in helping to ensure that the UK-Qatar relationship attains new heights.
Oil and Gas: Subsidies and Licensing
(2 years, 3 months ago)
Grand CommitteeRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Baroness Jones of Moulsecoomb
To ask Her Majesty’s Government what steps they have taken to ensure that (1) subsidies, and (2) licensing decisions, related to the oil and gas industry are not subject to undue influence from outside interests.
Baroness Jones of Moulsecoomb (GP)
First, I apologise for speaking seated; it is because I sprained my knee. Secondly, I welcome the noble Lord, Lord Offord, to his first outing as a Minister, and I look forward very much to his maiden speech later.
Between July 2019 and March last year, government Ministers had 63 meetings with fossil fuel and biomass producers. That is nine times the number of meetings they had with renewable energy companies. That strikes me as slightly odd: a Government who chaired COP 26 and are meant to be switching to renewables very fast are meeting fossil fuel and biomass companies nine times more than the companies they are meant to be relying on to deliver the sustainable future they promise.
As well as the small private meetings, Ministers also attended hundreds of other larger group meetings with fossil fuel companies and their representatives. Fossil fuel producers were present at 309 of these, compared with 60 for renewable energy generators. Again, I do not understand why Ministers are focusing on a polluting industry that we need to shut down rather than renewables—with all the new job opportunities —which we need to grow very rapidly. But there is a clue, because the Conservative Party under Boris Johnson has taken almost £1.5 million in donations from the energy industry since 2019.
I mention this slightly disturbing fact because my intention in this debate is to draw attention to the fact that we live in a corrupt country run by autocratic Ministers who facilitate their friends pocketing large amounts of public money either directly, via government contracts, or indirectly, through putting holes in the regulatory system. We have seen this recently with the fast-track scheme for PPE contracts, the second-jobs scandal involving MPs, and all sorts of lobbying, such as David Cameron on behalf of Greensill. Money buys access, and access gives you everything from subsidies to licences.
The point I am making is that corruption has real-world impacts on government policy and the lives of ordinary people. If you are in the development industry, it might give you changes to planning red tape. If you are in the energy business, it might buy you another decade of profitable polluting while the planet burns.
We have a Government who are keen to support a polluting industry that is equally keen to support the Government. That might be excused if the oil and gas industry was filling the coffers of the Treasury as well as the Conservative Party, but surprisingly that is not always the case. In a recent court case brought by some climate campaigners, the judge acknowledged that in some years oil and gas companies had paid less in taxes than they received in tax breaks. The judge wrote:
“The claimants point to clear evidence of negative taxation flows in particular years; specifically negative tax flows overall in 2015-16 and 2016-17 of £2 million and £359 million respectively.”
The judge quite rightly said that focusing on single years ignored the fact that
“the tax position over the life of the concession is at worst neutral”.
We know that the UK is one of the most profitable countries for the oil and gas industry in the world, but we cannot even be sure that it pays its own way in tax.
The Government will claim that there is no subsidy for oil and gas, as they define fossil fuel subsidies as
“measures that reduce the effective price of fossil fuels below world market prices.”
In other words, the Government are giving the industry millions of pounds in tax breaks, but this is not a subsidy because it does not result in lower prices for consumers—well, that is obviously absolutely brilliant. But if the Government do not like “subsidy”, we could just call it “fossil fuel support”. Our Government do not deny the tax breaks; they just make it clear that this does not lower prices—it just enables the companies to make more profit. In fact, it is so profitable that those making money out of this polluting industry have enough spare cash to give it to the Conservative Party. That is obviously something we need to be concerned about.
Of course, if a previous Prime Minister, Cameron, had not cut what he called the “green crap”, our energy bills would be £40 lower each. Imagine how much lower they would be if he had been serious about insulating homes and expanding cheap renewable electricity, reducing our current reliance on foreign gas.
I will not go into all the details of the donations made by the industry, directly and indirectly, as we would need far longer than the hour that we have just to list them. Our self-regulatory system of government does not stop people buying influence. Civil servants are not around to take notes when a Minister attends a party fundraiser where oil executives have paid £12,000 for a seat at the table. Civil servants cannot know what conversations go on when an MP gets a huge donation to the private office a few months before they are appointed as a Minister in charge of projects that the donor wants to push through. It has happened in the past few years and, to be fair, the Minister I am thinking about stepped aside from a major decision—but only after the media contacted them.
The National Audit Office cannot even get access to Ministers’ WhatsApp conversations with party donors about favoured projects, unless the Minister self-declares that they regard the messages as relevant. Even when Ministers have been taken to court to get those messages, suddenly the phone is broken or lost—or they do a Boris, who claimed that messages were lost when he changed his phone number. It is not very nice, is it, quite honestly? It is shameful.
Last year, we chaired COP 26, but the Government are now dishing out a large number of licences for North Sea exploration. I really do not see how that can be compatible with reducing our greenhouse gas emissions. Generic conditions have to be met, but only on new submissions; as I understand it, projects already in the pipeline get a licence without reference to climate change. How is that possible?
Individuals and companies linked to the oil and gas industries have donated more than £400,000 to the Conservative Party in the past year, while the Government mulled over these new licences. There might be parliamentary rules that stop Peers like me from asking Written Questions about the influence that such donations have on the Ministers making the decisions—which I have tried to do, but was stopped—but it is clear and obvious that the influences is there.
We have an acknowledgement that corruption is rife, the negative impacts on our environment are clear, and I really want to hear from the Minister today how we are going to junk the broken system of self-regulation in favour of a more robust legal system that involves either the police or an end to large-scale donations. The days of having a Ministerial Code enforced by someone appointed by the Prime Minister really should be gone. It does not work when Ministers do not play by the rules.
Baroness Sheehan (LD)
My Lords, I start by welcoming the Minister to his post—it may be a baptism by fire—and thanking the noble Baroness, Lady Jones, for introducing this debate. My views will be pretty similar to hers on this topic.
The compelling scientific evidence tells us that we must act now to curb greenhouse gas emissions from fossil fuels, but we seem to have an oil and gas industry which is resisting the science—not in words, because it is too clever for that, but in deeds. It is an industry that seems to have the various arms of government firmly tucked into its elbow and is leading them astray.
The OGA regulates and licenses petroleum exploration and production in the UK. Three of its 13 board members are shareholders in oil companies, and eight members of the board previously worked in the industry. There are no voices on the OGA board to put the view of climate scientists, workers or NGOs; it is not a balanced board. The Government seem to be similarly tainted. According to the Library briefing, £812,000 was donated to the Conservative Party between 2019 and 2020 by climate sceptics and fossil fuel interests.
Against this background, we must look at subsidies enjoyed by the sector. Of course, the Government insist that they do not give subsidies to fossil fuels, yet the UK’s tax regime makes it the most profitable country in the world for oil and gas companies, according to a report by Rystad Energy in January 2021. Since signing the Paris agreement, the UK has given £4 billion to oil and gas companies—and I thank the NGOs UPLIFT and Paid to Pollute for the figures. In the tax years 2015-16 and 2016-17, the Treasury gave more money to oil companies than it took from them in taxes. Here is a mind-boggling figure: in 2019, the UK received $1.72 in taxes for each barrel of oil, while at the same time and under the same conditions, Norway received $21.35 per barrel of oil. Here is another mind-boggling fact: Shell paid $1.8 billion in tax to Norway in 2020 but received from the UK Government £99.1 million, according to the company’s own annual report on payments to Governments. There are other examples, but time is short and the list is long, so I will move on.
I will quickly mention decommissioning. The UK taxpayer, not the polluters, pays the decommissioning costs of abandoned oil structures. The UK Government call this a tax rebate, but this process meets the WTO, International Energy Agency and IMF definitions of a subsidy. HMRC estimates that the cost to the UK taxpayer will be £18.3 billion—I think that is a gross underestimate. No wonder the risks of stranded assets are not a deterrent to the shameless companies pushing for new licences, because they are a licence to print money. The Government subsidise exploration, shareholders pocket dividends, and when the game is up, the company ups sticks and leaves it to the good old British taxpayer to pick up the tab. Shame on the Government for letting this continue. With vested interests whispering in their ear, it stinks of corruption. None of that tax relief is benefiting workers in the industry or you and me. We do not see the impact on our living costs, our energy bills or at the pump. The RMT union estimates that 12,000 jobs were lost in the industry in 2020. Compare that to Shell receiving £99.1 million in tax from the UK in 2020. The company went on to increase its dividend in 2021, just weeks after announcing plans to cut 330 North Sea jobs, and CEO Ben van Beurden took home $7 million in 2020. The system is rotten to the core.
The Minister will say that we have to protect the sector or we will be dependent on imports of Saudi or Russian oil and gas, but that is just not so. Most of our oil and gas imports come from Norway, and even if more was pumped from the ground, it would have to be placed on global markets and would not benefit UK citizens with lower prices. To reduce volatility and energy costs, the only solution is to produce more home-grown renewables. Put a halt to this madness and help our citizens lower their energy bills and reduce greenhouse gas emissions. Invest in the green transition, get job security for oil and gas workers, and get energy security for the country by moving away from dependency on geopolitically unstable areas.
In ending, I want to go back to the science. The Mauna Loa observatory in Hawaii recorded the highest-ever concentration of carbon dioxide in May 2021. At 419 parts per million, this is the highest since records began. We are in uncharted territory, and the rate of increase of carbon dioxide in the atmosphere is accelerating. The time for arguing and prevaricating is over—we have to stop burning fossil fuels.
Baroness Worthington (CB)
My Lords, I congratulate the noble Baroness, Lady Jones, on securing this debate and look forward to the Minister’s maiden speech later.
We can point to donations or meetings, but I would like to spend a couple of minutes focusing on whether the structures of government are perhaps out of kilter with our modern goals for energy. It appears that there are legacy structures and conflicting goals within government that at times are not joined up.
In 2014, the Wood review was published and made a number of recommendations focused squarely on increasing the efficiency of the UK continental shelf in the extraction of hydrocarbons. The review then informed the Energy Act 2016 and ushered in the Oil and Gas Authority, a government-owned company that has taken over a range of responsibilities from government in relation to overseeing developments in the UK continental shelf. This body’s primary objective is maximising the economic recovery of hydrocarbons. It is therefore not necessarily a question of external influence. Rather, we have created a statutory obligation and a body single-mindedly pursuing a very narrow set of goals within our energy policy. It may be occluding the real energy agenda that we should be pursuing.
At the time of the Energy Bill in 2016, we argued that to create a new body with such a narrow remit represented a missed opportunity. It was clear even then that UK plc’s pursuit of barrels of oil and, to a lesser degree, therms of gas from the North Sea was unlikely to be the biggest priority. It is an old, mature field, and the biggest discoveries were all found decades ago. What remain are very risky and expensive fields, which the bigger operators are now finding it is not in their interests to exploit. When we think about energy security and climate considerations in the round, is it correct and right that we should have this body and this statutory obligation that skew our focus, and potentially the focus of Ministers?
The UK is rightly considered a leader on climate change, thanks to both its domestic actions and its role in international negotiations. It does not sit well for a country such as the UK, a very mature economy that has arguably benefited from the exploration of oil and gas over decades, to be seen to be trying to extract the very last drop of oil and gas out of the North Sea without a real economic case for doing so. We have had decades of relatively stable and secure energy provision. We have managed to provide a secure and affordable lowering of our carbon footprint at the same time, which has benefited businesses and consumers. Our oil and gas efforts in the North Sea and the UK continental shelf have not contributed to those goals; other sources in our energy policy do that job far more effectively. We need only look at the sudden spike in gas prices now to see how a policy based on fossil fuels can undermine our ability to deliver affordable energy.
I turn to the international case. The case will always be stated that we need to extract our oil and gas, otherwise we will be importing from other places. But in reality we do not use the majority of the oil production from the North Sea domestically, because our refineries are not fit for the refining of those oils; most of it is traded. On an economic basis, it does not matter where it is extracted—we will all face the global price set in the traded market—so that argument does not really hold water.
Another often-cited advantage to the UK is the jobs. The jobs in the North Sea oil and gas sector are very limited—around 30,000 direct jobs. Just the low-carbon economy today employs 200,000 employees, so clearly there should be a much greater focus on the low-carbon future sources of energy, rather than pursuing this very narrow goal.
We have not really addressed the problem of how a Government can develop a balanced policy fit for UK plc in terms of a large, rather than a narrow, set of interests. The risk is that, given these high prices, there will yet again be a temptation to invite in the fossil fuel experts. We will probably hear, even today, a call for a return to “drill, drill, drill”, and the idea that finding more resources will be the way out.
I argue that that would distort the reality, which is that we have a vast array of opportunities to exploit energy, which go beyond fossil fuels. We have a huge offshore wind industry and, as we have recently seen, we are granting very large licences to that sector. That is where our future lies, and it would be a mistake to invite in a narrow band of experts, yet again, to dictate to us what our energy policy should be in response to the current energy crisis.
I believe that there needs to be another Wood review—an updated opportunity to look again at what our focus should be for our own indigenous energy sources. It is clear that there are huge challenges ahead of us. From my perspective, climate is the largest of them, but equally there is energy security, and there are economic concerns that we have to address. We have huge potential to secure investment in a range of zero-emissions technologies, but we need to focus on that and make it our priority.
We should see the hydrocarbons in the North Sea in that context. They are no longer our greatest asset; if anything, they will be a net drain on the public purse in coming years. We receive very little in taxation. Let us start a review to assess whether the Government have the right bodies and the right powers in place—and if we are to have an energy Bill, let us look again at the OGA and whether the obligation it was given is correct for 2022.
Lord Lilley (Con)
My Lords, I apologise for missing the first few seconds of the debate; foolishly, I was sitting in the Chamber instead of here. I congratulate the noble Baroness, Lady Jones, on securing the debate. I have always longed to agree with her, since I like her so much, and I do agree with her on the two objectives of the debate. I am against subsidies for the oil and gas industry, as I am against subsidies for renewables. I am also against undue influence being brought to bear on government.
The oil and gas resources with which this nation has been endowed by a beneficent providence are, essentially, the property of the people. It is right that the economic rent and value of those resources should be extracted for the benefit of the people and not given away. I first made myself an enemy of the oil industry when I published a document called North Sea Giveaway, advocating that licences should be not allocated but sold to the highest bidder, so as to extract the economic rent. For a while, it actually changed the Government’s policy. That was before I was ever a Member of Parliament; I had more influence then than I do now. Sadly, it did not continue for ever, and eventually Governments and officials went back to allocating, rather than selling, auction blocks.
Instead of extracting the money that way, they tried to do so by imposing a whole range of taxes—the royalty, the petroleum revenue tax and the supplementary corporation tax, all on top of the basic corporation tax that other industries pay. Since 1975, when oil first began to be extracted from the North Sea—I was then an energy analyst in the City—the oil industry has paid over £186 billion in those taxes to the Government.
Beyond the folly of giving away the licences rather than selling them, the idea that the UK subsidises the oil and gas industry is a nonsensical myth. The £4 billion that the noble Baroness mentioned is not a subsidy. Every industry is allowed to offset the costs it incurs to produce revenues against the revenues that those costs generate. The oil industry is no exception, but in that industry some of the costs are incurred after the revenues have been generated—in particular, the decommissioning costs. It is absolutely normal and acceptable for companies to be able to offset those costs against revenues in previous years. They get back tax that they paid on those revenues that were in excess of their costs. That is normal, and to describe it as a subsidy is, frankly, an abuse of language.
Baroness Worthington (CB)
I am enjoying this very much, but can the noble Lord comment on the rules that now underwrite those decommissioning costs with taxpayers’ money? As I understand it, that will cost us in the region of £20 billion over the coming years, because we are now underwriting some of those decommissioning costs. Is that not a subsidy?
Lord Lilley (Con)
It could well be but, as I understand it, that is not the £4 billion to which the noble Baroness referred.
Lord Lilley (Con)
Maybe. It seems unwise to have got into a position in which the oil companies are required to do something that they cannot and have not been financing, and to take it to the taxpayer. I think that the noble Baroness will agree with me that up to now there has not been a subsidy. If we did not allow the costs of decommissioning to be offset against the revenues that the oilfields generate, we would effectively be taxing rather than supporting the most ecological activity that we require of oil companies; namely, the removal of what they have constructed in the North Sea.
The second thing that the noble Baroness is against is undue influence on licensing. One of the arguments in my pamphlet about the North Sea giveaway was that giving away those huge resources means that the civil servants who decide on it will be open to corruption. Amazingly, in the ensuing years, I found no evidence of that micro-corruption; nor is there any evidence of macro-corruption, in the sense of the oil and gas industries exercising undue influence. On the contrary, the offshore fields are not being developed—Cambo and the other one whose name I forget—and, onshore, hugely valuable shale resources are not being exploited. It is clearly not the oil industry that is exercising undue influence; somebody else must be. It is not those who want to reduce carbon emissions who are exercising undue influence because, by and large, particularly in the case of shale, if we import gas instead of producing our own—that is the consequence of not allowing shale exploration—we incur greater emissions, not just in transport but in liquefying and then deliquefying gas, which is an energy-intensive process.
There are two ways in which we can meet the net-zero target. One is to reduce demand, and the other is to reduce supply. The sensible way is to reduce demand. If you reduce supply ahead of reducing demand, the price goes up, as we are seeing now; the oil and gas companies make undue profits, which will upset you all greatly, and I do not particularly want to see them make undue profits either; and it will cause difficulties to households in the short term, which is what we are experiencing. I hope that we will see more realistic analysis than we have heard so far.
Baroness Sheehan (LD)
I want to ask the noble Lord something before he sits down. I bow to his greater understanding of the finances behind pricing of oil. Maybe he can explain why, in 2019, for each barrel of oil the UK received so much less—$1.72 in tax—than Norway’s more than $21 per barrel of oil. On the supply and demand side, would he not say that it is not one or the other? We need to do both if we are to get to net zero in the timeframes that we have set ourselves.
Lord Lilley (Con)
I have not looked at the profitability per barrel and the tax paid per barrel, but I used to do that every day 40 years ago. I assume that it is because our fields are now running down, whereas the Norwegian fields are still far from fully mature. As far as I know, Norway’s tax regime is not hugely different from our own; it was not then. On the question of whether we have to restrict supply as well as restricting demand, no, we do not. If you reduce demand and anyone has supply available and no market for it, they lose money—that is their problem—but if you reduce supply without reducing demand, you raise prices, increase profits to the industry and increase costs to ordinary households.
Baroness Jones of Moulsecoomb (GP)
Before the noble Lord sits down, can I ask him how he thinks demand could be reduced?
Lord Lilley (Con)
You could do all sorts of things to reduce demand for oil and gas—requiring people to spend thousands of pounds on shifting from gas to electric heat pumps, that sort of thing. The noble Baroness knows the answer to her own question.
Viscount Younger of Leckie (Con)
My Lords, can we have a little order? Also, I need to remind future speakers that the Minister needs to be speaking by 3.47 pm.
Lord Oates (LD)
My Lords, I welcome the noble Lord, Lord Offord, to his place and look forward to hearing his—
Baroness Boycott (CB)
Sorry, I thought you were just interrupting the noble Lord, Lord Lilley, to make a point. I, also, welcome the new Minister and look forward to his maiden speech. I much enjoyed the exchange just now. It is worth pointing out that the largest single group at the climate talks was the 503 oil executives, spending the most amount of money to show off their wares.
I shall lay out a few facts. We are, undoubtedly, one of the most profitable countries in the world for oil and gas companies, as the noble Baroness, Lady Sheehan, pointed out. Since the Paris agreement, the UK has granted tax relief of £10 billion. I know that the noble Lord, Lord Lilley, would say that that is just par for the course, but we are trying to aim for a zero-carbon world.
During an exchange last week, the noble Lord, Lord Callanan, posed the question about where we get our oil and gas from, and he asked
“do we use oil and gas products we generate … or do we get them from Russia or Saudi Arabia?”.—[Official Report, 11/1/2022; col. 964.]
The facts are that, in 2020, 54% of the demand for natural gas was met by domestic production, 32% from pipeline flows from Norway and the remainder met mainly by LNG cargoes from Qatar at 12%, the US at 7% and Russia only 3%.
On the climate compatibility checkpoint, according to E3G, the UK continental shelf is a mature, high-cost basin with declining reserves. The basin is oil weighted, with gas making up only 30% of remaining reserves. Even if those reserves could be brought online at speed, the UK would still be exposed to international gas markets and their inherent price volatility. To be clear, we do not need to drill anymore for our domestic consumption. The reason why the gas price is currently so high is because of how the global markets work. Companies that extract it just sell it to the highest bidder, and a lot of the gas extracted from our sites is sold to Europe, rather than being used domestically, even if we have a need for it. The argument that, if we drill more, we will have more, is an oversimplification of the issue. It will mean only that producers sell more and, due to the low domestic tax rates, there will be negligible difference to the Treasury. Our Government would have to directly intervene to ensure that domestically produced gas is used in the UK, and to date we have made no signals that that is something we are willing to do.
On the other part of this question, lobbying and licensing, the Times reported that Kwasi Kwarteng met industry officials in the days after COP to urge them to keep drilling in the North Sea, despite what was actually said in Glasgow. How is that compatible with our goal? Afterwards, on 20 December, the Government published a consultation on a new climate compatibility checkpoint, which will govern our new licensing rounds. Did the Government meet oil and gas executives to discuss this consultation before it went public? Surely, they should see that at the same time, everyone should be allowed to feed into the general discussion. For example, the document states that, for the purpose of licensing, it is not practical to separate oil from gas and that
“we understand that, for many fields, a mix of hydrocarbons (both gas and oil) is usually found, and it can be difficult to predict which reservoir fluids will be encountered at licensing stage. For that reason, we have rejected the idea that oil and gas could be licensed separately”.
However, it is not clear how or why the Government have reached that decision. We know that Cambo, for example, is—or, one hopes, was, in the past tense—going to be drilled for oil. So how have the Government got there?
This is an important point because, although we can expect continued domestic demand for gas during any transition, we already export 80% of our oil, so further extraction is just adding to global supply rather than quenching domestic needs. If that was discussed before the checkpoint was published, there is a clear conflict of interest. Oil and gas companies would obviously be in favour of tying them together, as to separate them would affect their profits. So while it is welcome that we have a consultation proposing consideration of production gaps, other parts of it raise suspicion that this is a tick-box in green-washing. “Consideration” is a really weak word.
Finally, on the current energy costs and the cost-of-living crisis, it is likely to become dire without government intervention, but I challenge the argument that this is because we do not have enough fossil fuels to burn. It is because we do not have enough renewable energy. If there had not been an effective moratorium on onshore wind since 2015, for example, our bills would now be lower. Bills are not high because of the green levies; they have been decreasing, and account for about 3% of gas bills. They are high because, as other noble Lords have mentioned, we have uninsulated homes. If the green homes grant had been better implemented, people would have lower bills. It is easy to see high bills and think that we need more of the product that is causing it but, actually, we need to quicken our transition away from it. Fossil fuels have always been volatile, whereas renewables have consistently become cheaper as well as better.
Lord Oates (LD)
My Lords, I apologise to the noble Baroness, Lady Boycott, for stepping in. I welcome the noble Lord, Lord Offord, to his place and look forward to his maiden speech. I cannot help noting, although I am very pleased we heard his point of view, that the noble Lord, Lord Lilley, was allowed to speak having arrived about three minutes late, when only recently in a debate on the nuclear industry, the noble Baroness, Lady Bennett of Manor Castle, was refused the opportunity to speak despite arriving at almost exactly the same time. There cannot be one rule for members of the governing party and another for members of the Opposition. I hope the Government Whips will take note of that. However, I am glad we heard from the noble Lord.
The urgent need for the North Sea industry is not further subsidies or contradictory policy-making by a Government who on the one hand say that they are in favour of net zero and on the other continue to endorse the maximum economic recovery policy. The urgent need for the North Sea industry is transition. If there are tax breaks and subsidies, they must be directed at transitioning that skilled workforce out of the oil and gas industry, because that fossil fuel industry is coming to an end. That is what will happen. It is the reality, and those who think they are standing up for workers in the industry by backing further drilling are simply sending people down a blind alley.
As I mentioned during debate on the Financial Services Bill, the last part of my title—Lord Oates of Denby Grange—is taken from a colliery in Yorkshire where my grandfather and uncles all worked as coal miners. I have great respect for the people who work in the fossil fuel industry; they powered our industry and heated our homes, often working in very dangerous circumstances. However, we know what happened to the coal industry: it came to a dead stop. There was no proper transition and, as a result, communities were stranded and suffered massive social and economic deprivation that remains to this day.
Let us not pretend we are doing any favours if we go down this maximum economic recovery route and keep going until the dead stop happens. It will happen; as the International Energy Agency has stated, we cannot burn all the reserves we have already identified if we are to have any hope of keeping to 1.5 degrees. We cannot do it. The argument of the noble Lord, Lord Lilley, is that we have this stuff so let us burn it. If everybody else takes the same view, we will get nowhere near even 2 degrees but go far beyond it. That is not a problem for the noble Lord, because these things do not matter to him. He thinks the whole net-zero thing is ridiculous and absurd, and he calls anyone who stands against that an eco-fanatic. But, for those of us who care about it, there must be a logical policy.
The Government have set ambitious targets for net zero which the Liberal Democrats welcome. However, it is no good having those targets if your policy tools contradict them. Maximum economic recovery in the North Sea, and the tax subsidies, absolutely do that. The noble Lord, Lord Lilley, said that the reserves in the North Sea should be used for the benefit of the people. The benefit of the people would be to keep those reserves where they are, not to burn them. It would certainly be to the benefit of future generations.
Lord Lilley (Con)
How long—or how shortly—does the noble Lord think it will be before we cease to use gas, both to heat homes and as the natural source of power to deal with the intermittency from renewables? Most people think we will still be using it in 30 years’ time.
Lord Oates (LD)
We have to transition away from using it by 2050, or at least without abatement of it. Exploiting the North Sea resources when we are trying to lead the world is not going to work. It is rank hypocrisy, and it is deeply damaging.
Let me just pick up on the point that the noble Baroness, Lady Boycott, made about energy costs. It is a complete fallacy that the way to reduce energy costs is by scrapping all the green levies, as the GWPF and other people want to do. If you look at what happened to energy costs between 2010 and 2020, in terms of the bills that people paid, you see that total household expenditure on energy fell. It did not rise. One of the reasons it fell was because the levies funded insulation of properties and measures to reduce consumption. Consumption of gas and electricity fell significantly during that time. In fact, the eco levies save people money.
I understand the position of the noble Lord, Lord Lilley, of not worrying about net zero. I do not understand the Government’s position, because they claim to worry about net zero but take actions that show the exact opposite.
Baroness Blake of Leeds (Lab)
I take this opportunity to welcome the noble Lord, Lord Offord, and to wish him all the best with his maiden speech. As a fairly new Member, a maiden speech being made in these circumstances is a first for me. It feels as though he is jumping in at the deep end here, but I look forward to hearing his contribution. I thank the noble Baroness, Lady Jones, for securing the debate.
Time is extraordinarily limited. We have so much to discuss in this hour and we are not going to do it, so I do not want to cover too many of the points that have already been made, other than to recognise the seriousness of the examples that the noble Baroness, Lady Jones, and others gave of where things are going seriously wrong in the whole debate about what a subsidy is. The Government might have a technical definition of a subsidy, but there are certainly other means of getting money where it needs to be which distort the market, lower the price and make fossil fuels a much more positive option than they need to be.
In the limited time I have, I want to turn first to the very nature of the debate. Running through all this is transparency. We have so many examples of where undue influence is being brought to bear, and that lack of transparency in so many areas of public life now is becoming a real scandal. This debate fits very well into that area.
The other important area I want to dwell on is the whole issue of the plan that we need to get to net zero. It is all very well talking about where we will be in 2050 and what it will look like, but we need to know what it will look like in 2022 or 2025. The year 2030 is obviously recognised as a critical date, but the plan really is missing. For example, I took part in the debate on the Subsidy Control Bill last night. Where is the plan which says that if we are investing and giving subsidies to any range of interests, the recipients have to demonstrate that they are joining the collective effort towards net zero? I am afraid that the absence of this in government policy and the lack of costing of what it is actually going to take gives me deep cause for concern.
This is against the backdrop of the impact not only on the planet but on individual households and families, the cost of living crisis, the choices that people are making on whether they heat their homes or feed their kids, and the crisis we saw with the break in deliveries from the shortage of drivers. It is that lack of resilience and forward planning, and the whole issue of security that is wrapped around it, that I do not believe the Government are really taking seriously enough.
The other issue is the obligations that we came to from COP 26, and there is another dimension to this. Although the outcomes were lauded as some degree of success, there was watering down from other countries across the world. While we must look at local imperatives, we need also to look at the global imperatives. We have some really important discussions about trade deals coming up. Are we making sure that those countries that failed to sign up fully to COP 26 will receive our full influence?
We can talk about government action, but the Government need to empower those out there who can actually make the difference. I draw your Lordships’ attention, if they have not already seen it, to the letter from the CBI, the TUC and different green groups to the Government suggesting a really practical way forward. Until almost a year ago, I was the leader of the second largest local authority in the country, and there is a lack of powers going down to local level, where the differences can be made by reducing energy consumption and through planning and transport powers—all the things that can really make the difference and reduce our dependency on fossil fuels.
I highlight one of the asks from the letter, which is that the Government establish a cross-government initiative to review all those policy areas. Is the Minister aware that such a cross-government initiative has been set up? Do different departments of government talk to each other and say, “If this department does that, the knock-on impact will be something else”? Those are the collective actions that everyone at local level has been charged with taking for many years, but the Government are falling down.
I urge real focus to go to those areas that can assist this agenda. The clock is well and truly ticking. As the noble Baroness said, the debate about corruption is absolutely at the top of the agenda. What is being done to address what we collectively are doing to enable our dependency on fossil fuels, and all the corruption to which it leads? When will we see a real road map to achieving net zero by, at the very latest, 2050?
The Parliamentary Under-Secretary of State, Scotland Office (Lord Offord of Garvel) (Con) (Maiden Speech)
My Lords, it is a great honour to be here to make the final contribution to this short debate today. As a newly appointed Parliamentary Under-Secretary of State for Scotland, here I am making my maiden speech in this House.
Allow me to start by thanking noble Lords for the great welcome you have given me in this place, my supporters—my noble friends Lord Kirkham and Lord Forsyth of Drumlean—Black Rod, the Clerk and, especially, the doorkeepers, who look with great amusement at me as I wander around the place in circles. I should also give special thanks to my mentor and noble friend Lord Leigh of Hurley, and to my Whip and noble friend Lord Younger of Leckie, for sharing their invaluable knowledge of the workings of your Lordships’ House. We have an important debate to discuss this afternoon, but just before I do, I think it is customary on these occasions to spend a little moment on some personal matters, so let me get those out of the way now.
I was born in a modest but homely tenement at 33 Bank Street in Greenock, an industrial town west of Glasgow on the Firth of Clyde. I was educated at my local schools, Ardgowan Primary and Greenock Academy, and I got a first-class education for free. I am not the first alumnus of that school to be associated with this House; my noble friend Lady Goldie of Bishopton was a distinguished head girl of Greenock Academy, as indeed was the wife of my noble friend Lord Leigh of Hurley. I was dismayed when my old school was closed in 2011, having been founded in 1855. It was determined by the local council that, with Inverclyde depopulating post industrialisation, the schools needed to go down from eight to six, and it was decided that it conferred too great an advantage on the students who went to that school to study there, so it was closed. Surely that is an egregious example of levelling down in Scotland, and it was a personal motivator for me in joining this Government to support the levelling-up agenda.
So, why Lord Offord of Garvel? If you walk down Bank Street, where I was born, past the Wellpark to my local parish church, the mighty Mid Kirk, and cross the road past the magnificent Georgian Custom House on the Clyde, and then turn right along the river, you will come to Garvel Point. Garvel has long been a landmark in Greenock because it is where the deep water is located, and it was originally a safe harbour for the fishing fleets before the first industrial revolution transformed the town into a thriving trading port and shipbuilding hub. Greenock’s most famous son is the inventor and engineer James Watt, and the dock which bears his name today remains in use at Garvel Point. In fact, two of the three dry docks on the Clyde were located at Garvel, and a recent renovation project has repurposed one into the award-winning Beacon theatre.
That brings me neatly to the Question before the Committee today. One of my first ministerial duties was to participate in COP 26 in Glasgow—how fitting that the world came back to the Clyde to seek new solutions to this climate emergency. What a tremendous achievement of the UK’s two-year presidency it was to increase the global commitment to net zero from 30% to 90% of world emissions. Some say that the UK has a limited role to play in climate change as we account for only 1% of world emissions. Yet COP 26 proves that our leadership still counts, because we can demonstrate that it is possible simultaneously to grow our economy while cutting our emissions.
This is what I learned at COP 26: we have the capital, the brains and the political will to meet the climate challenge. Participating in the Net Zero Technology Centre forum—funded by the Aberdeen City Region Deal—I was so encouraged to hear technologists from the oil and gas sector in Aberdeen collaborating with Houston, Calgary, Perth and Canberra as they repurposed their assets and people into low-carbon energy sources.
How gratifying it is that Scotland has such a prominent and world-leading role to play in rebalancing the UK’s energy programme to net zero by 2050. We have all the natural resources and the existing infrastructure, plus the scientists, engineers and skilled workforce required to build a balanced scorecard in energy. Scotland contributes 60% of UK wind and 40% of the 160,000 highly skilled jobs already working in energy across the UK. This is called punching above our weight in a UK where we contribute just 8% of the population but 33% of the geography.
However, we must remember that a key word in this climate debate, already mentioned by the noble Lord, Lord Oates, is “transition”, and that it is to net zero, not to zero carbon. Some 35% of our energy needs in 2050 will still come from carbon; today it is 75%, so that will be a massive reduction—more than halved. It would be foolhardy and irresponsible to ditch our world-class oil and gas sector in the North Sea to increase our carbon footprint by importing, whether from Russia—bad—or Qatar: good.
The North Sea Transition Deal is an exemplar in the G7 of a domestic oil and gas industry working in partnership with government to ensure that net zero is met by 2050. The noble Baroness asked what milestones we have along the way. By 2030, the cash flow generated in oil and gas will contribute £15 billion of long-term investment into new energy technologies. On the transition of jobs, by 2030 the UK offshore energy sector in total will increase from 160,000 to 200,000 jobs, of which two-thirds will be in low-carbon energy sources.
One of my new responsibilities is the North Sea Transition Deal, and in the last forum we had there were presentations from oil and gas companies, talking about how their target for 2025 is 50:50 investment of capex and renewables to get a return on capital in the region of 12%. Speaking as a businessman, I asked what percentage return on capital you get on each side of the scorecard. There was a certain amount of silence, because it emerged that renewables on their own do not return on capital at this point. Therefore, it is essential for the cash flow made in oil and gas to be reinvested to produce renewables. We will get transition to renewables only if it is a managed transition, using cash flow from carbon as it reduces to invest in renewables. That is absolutely essential. The two go hand in hand; you cannot have one without the other.
I will directly answer some of the questions posed in this debate, turning first to the noble Baroness, Lady Jones. I must say, this is a baptism of fire. I do not recognise the country she mentioned as corrupt. Maybe if I am here long enough that will emerge for me, but I do not recognise that to be the case where we are today. The financing of parties seems to be a whole new debate and perhaps can be done another time. I am on the record as saying that parties should not be financed by taxpayers. However they are financed, as long as it is transparent and legal I suggest that it is fine, but perhaps we should park that for another debate at another time.
The key thing that has come through here is the use of language and the fact that the word “subsidy” is so misused. My noble friend Lord Lilley made it very clear that as a matter of business practice, whichever industry you are in, it is entirely legitimate to off-set costs against revenues. In this sector, because the lead times are so long there is quite often a mismatch, and therefore money flows back and forwards. Since the oil and gas industry began in this country, total tax revenues of £360 billion have been received, and £33 billion in the last 10 years alone, but along the way you will see ebb and flow: money in, money back.
Tax relief is a normal part of the corporate tax system. Genuine costs and injuries such as the safe removal of infrastructure at the end of a field’s life are not a subsidy but a tax deduction and quite often, in certain cases, money flows back to the Treasury. Therefore, it is just inaccurate—perhaps self-serving—to use an emotive word such as “subsidy” when something is regulated by our own accountancy businesses, as is the case for all sectors. I push back firmly on the idea that we subsidise. We are against subsidies in this country and generally want to have free trade.
As I said before, on the point raised by the noble Baroness, Lady Worthington, it is essential that we transition jobs to renewables if we are to have two-thirds of jobs in low-carbon renewables. We have discovered from a study at Robert Gordon University that the onshore and offshore skills we currently have in carbon are absolutely essential to the new world. For example, when it comes to carbon storage, floating oil fields, et cetera, we currently have very transferable skills in the oil and gas industry and will transition them into renewables.
The noble Lord, Lord Oates, talked about his heritage in coal mining. We know exactly how that feels in Scotland; 40 years ago we closed the mines and started importing coal. What on earth is the point of that? Are we really going to make the same mistake again 40 years later, when we have a vibrant industry with 160,000 workers?
We are talking about a new Britain here, are we not? This is a new global Britain—a high-production, high-wage economy, with highly skilled jobs. This is an exemplar of highly skilled jobs in this country that we should be very proud of. Certainly, from a Scottish perspective, this is our second biggest industry, after fisheries, food and drink. It is one of our five exemplars in the UK, and we need to protect it.
Before I come to the end of my piece, the answer to the Question—for Hansard—is that the Government do not give subsidies to fossil fuel companies. The licences are awarded by an independent regulator, the Oil and Gas Authority, within the framework of achieving net zero. In fact, on Tuesday the High Court dismissed a case brought by climate activists that the regulator was giving unlawful subsidies.
The OGA is an independent regulator. Its staff are classified as public servants and are subject to rigorous standards and codes. Therefore I would say that the oil and gas industry is subject to a robust, multilayered regulatory system, which is independent and transparent, and there is no
“undue influence from outside interests”.
In closing this debate, let me be quite clear that the Government do not believe that decarbonising our economy means shutting the oil and gas industry, as has been said in this Room. We certainly do not believe in demonising a world-leading industry with the sort of intemperate language used by Patrick Harvie, Green Minister in the Scottish Government, who recently said that only those on the “hard right” would support oil and gas extraction. What an insult to the 160,000 workers in this vital sector. A broad range of stakeholders, from entrepreneur Sir Ian Wood to the GMB trade union, have warned politicians against creating an adverse investment environment for this vital sector. There is nothing just or fair about that, and it would set us back on the road to net zero.
Lord Lilley (Con)
May I intervene, on behalf of the Committee, to congratulate the Minister on his maiden speech? It was an eloquent, fascinating account of his background. His is a welcome Scottish voice in this House, and he will bring his experience of developing industries and business to our debates. We look forward eagerly to hearing his future contributions to our debates.
E-scooters
(2 years, 3 months ago)
Grand CommitteeRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Baroness Neville-Rolfe
To ask Her Majesty’s Government what plans they have for further regulating the use of e-scooters given the safety concerns about their use.
The Deputy Chairman of Committees (Baroness Henig) (Lab)
The time limit is one hour.
Baroness Neville-Rolfe (Con)
My Lords, it is a particular pleasure to follow my noble friend Lord Offord of Garvel and to be able to complement him on a powerful and stimulating maiden speech. However, we are here now to ask the Government what plans they have for further regulating the use of e-scooters, given the safety concerns about their use. I feel I have won the jackpot, as this is my first QSD from the Back Benches since 2013.
E-scooters are a recent invention. Like most inventions, they potentially offer some people real advantages. Also like most inventions, they have downsides. The trick, if possible, is to maximise the advantages and minimise the disadvantages.
Unfortunately, developments so far have not been encouraging. There can be no dispute that the law is being widely flouted—never a good place to start. I believe, and the Commons Library note confirms this, that riding e-scooters on public roads is illegal, unless authorised as part of an official experiment. Let us call them Boris scooters so that people listening to the debate can understand that arrangement. I believe that many of the e-scooters that I see on roads are not part of any such experiment. Moreover, unfortunately, it is difficult for the public to identify vehicles that do not qualify—especially on a dark night. In any event, we all know from personal experience that e-scooters are often ridden on pavements, which is illegal in any circumstances. Yet there seem to be limited attempts to enforce the law.
The point, of course, is that heavy objects moving at the equivalent of a fast running speed are potentially dangerous to the public, especially to pedestrians. It is a pity that these problems have been allowed to develop without any attempt by the Government to set appropriate limits and boundaries. Speaking more personally, I live in fear of my life from e-scooters as I walk home from here. If I were disabled, I would be much more worried. The pavements have become a jungle. This has become an urgent matter; something must be done, and done quickly.
I have two possible approaches which I should like us to debate. The first would be radical: namely, to learn from the experience of motorbikes and prohibit the sale of e-scooters in the UK. Arguably, we should have banned motorbikes long ago. They give much pleasure to a small group of people, and my uncle rode one into his 80s. However, they are very dangerous and have been instrumental in the deaths of thousands of young people in the UK. What a waste! If they were invented today, I do not believe we would allow motorbikes to be used on public roads.
For the same reason, although they do not go quite as fast, there is a case for stopping the use of e-scooters on public roads—and doing so now, before more damage is done and more lives lost. There have been 258 collisions in London alone during the first six months of 2021, according to the police, and I am sure this is an underestimate, as many collisions go unreported.
As I said, the risk to the disabled is especially worrying, and I note that organisations representing them, especially the blind, very much agree. I will be particularly interested to see what my noble friends Lord Holmes and Lord Shinkwin have to say on the matter: it is great to see them here today. I add that e-scooters also generate fear for the citizen, both about being injured and being the subject of e-scooter-based mugging.
These are serious disadvantages to e-scooters, and we will hear of others, but we need also to consider the benefits, which might be economic, environmental, or from increased convenience. Taking the economic aspect first, I recognise that new consumer goods can usher in economic growth—think fridges and hoovers in the 1930s, and washing machines and dishwashers in later waves. Bicycles were actually a very early example. So far, the production of e-scooters appears to generate no economic benefit for the UK—they are predominantly manufactured overseas—so benefit must be found, if at all, elsewhere in the economic cycle, and it is difficult to see where it might lie.
We also need to understand what they will replace. There seems very little evidence that they will replace cars. The main users are young people, and they will be substituting for bicycles, including electric bikes, non-electric scooters and public transport. All of these are less dangerous, and cycling is better for your health.
Some have argued that there are environmental advantages. Interestingly, the House of Commons report suggests this may not be the case, at least at present, essentially because there is a high carbon cost in manufacturing, as well as in obtaining the rare minerals increasingly needed in large quantities for batteries. Nor can I see that, overall, there is a net benefit in convenience for society as a whole. Although I am normally free market in my approach, as colleagues will know, I think a ban would be worth considering.
However, there is a second approach, which is to regulate, provide appropriate powers and penalties, and give the police or local and transport authorities the resources needed to enforce the law. The regulations would need to cover the safety and design of the scooters so that they are less dangerous and, in particular, do not catch fire, which has been an issue mentioned in a number of recent media reports. The design might include lights and sounds. The regulations would also need to cover speed limits, mandatory helmet wearing—given their speed—perhaps a simple driving test, and compulsory insurance. We would also need existing laws to be properly enforced. If this approach were chosen, a proper costed impact assessment would be illuminating.
Perhaps my noble friend could advise on what basis current e-scooter provision has been permitted under law and whether we presently have the subordinate powers to make legislation of the sort I have outlined—or something like it—or whether a new Bill would be needed for that purpose.
I have called this debate today because I am very worried by the present situation. We are drifting into a bad place and failing to act as scooter numbers mushroom, making action needed to control them much more difficult. There are various trials going on, of course, and I look forward to an update on the results.
I am grateful to so many fellow Peers for speaking today in last business. It is because we are all looking to the Government for a response and for action on this matter. I very much look forward to the reply from my noble friend, and I hope she will surprise me.
Lord Holmes of Richmond (Con)
My Lords, it is a pleasure to follow my noble friend Lady Neville-Rolfe, and I congratulate her on securing this timely and incredibly important debate. I echo her congratulations to our noble friend Lord Offord on his excellent maiden speech as well.
How can e-scooters be part of a public realm of transport which is inclusive by design? How can they fit within anything which could be seen as safe? Just today, a report mentioned the fire risks and trip hazards when they are abandoned on pavements. The riders themselves, often young men or boys from lower socioeconomic groups, can be injured and sometimes tragically killed. How is this something that any Government would seek to support in any of our key policy areas?
We are told that e-scooters are part of micro-mobility, and I can see some potential use cases there. But I ask my noble friend how e-scooters can help with people’s health? How can they help other pedestrians, who—as is suggested by the word “pedestrian”—are trying to walk on the pavement? For me, that is an impossibility and a clear and present danger, but they would be a trip hazard for anybody. The bays. often sited on pavements, take up crucial pedestrian space as well.
E-scooters are often seen as a piece of fun equipment or something to enjoy. As my noble friend Lady Neville-Rolfe said, there are many analogies to the motorbike when it first emerged. But when we look at the engineering, is it not possible that even at that primary production level, e-scooters are dangerous by design? They are seen as a bit of fun, yet our A&E departments up and down the country tell a very different story. A&E doctors and nurses are having to deal with the consequences of e-scooter accidents at a time when they are already exhausted and under pressure, not least through the pandemic.
When we go to the international comparator, why would we push forward on e-scooters when nations such as Denmark, Spain, France and Israel, and the state of Texas and others, are looking to retreat, if not heavily regulate, control and withdraw from the e-scooter experiment? The law is clear, but it is not being enforced. What advice are police forces being given, and have they the resources to enforce the current legal situation?
I agree with my noble friend Lady Neville-Rolfe that, if not an outright ban, this is certainly time for serious consideration and a pause in what is happening. I say that for myself, as a blind person, but I say it also for all people who could become casualties of this e-scooter free-for-all. At least we need the current law to be fully enforced; we then absolutely need to look at further and closer regulation. If something is not safe, if it is not inclusive design, what part can it possibly have in a society for everybody? If we truly believe in levelling up and building back better, what place the e-scooter?
Baroness McIntosh of Pickering (Con)
My Lords, I am delighted to follow my noble friend, who spoke so eloquently, and I congratulate my noble friend Lady Neville-Rolfe on securing this debate. Can the Minister confirm at the outset that, in fact, e-scooters are banned on public land unless they are part of the control trial? If they are part of the control trial, we are told by the Met Office—sorry, by the Metropolitan Police; the Met Office is for forecasting of a different kind—that e-scooters are classed as a motor vehicle under the Road Traffic Act 1988. Can she tell us how many driving licences for this motorised vehicle have been issued as part of the control trials, since their commencement?
In the Minister’s view, and that of the department, does she consider that perhaps those driving an e-scooter need to realise that they have to be over the age of 16, in possession of a driving licence, and should not be riding one without insurance cover, which would lead to a £100 fine? Can she tell us how many e-scooters have been confiscated that are privately owned but being driven on public land, and how many fines have been imposed? I am sure that my noble friend shares my concern at the statistics on the sheer volume of accidents provided in the Library note. Her own department, in November 2021, records 882 accidents involving e-scooters, with 173 involving other vehicles, and 931 casualties in accidents involving e-scooters, of which there were three deaths, all of whom were e-scooter drivers. In that, 253 were seriously injured, while 675 were slightly injured.
How are the Government going to respond to the recommendations of the Association of British Insurers, which sides with my noble friend Lady Neville-Rolfe? If there is going to be a regulatory framework for e-scooters, it said:
“We strongly oppose the implementation of any regulatory framework that could result in liabilities falling onto the Motor Insurers’ Bureau (MIB) and premium-paying motorists without a corresponding insurance requirement for these vehicles; or some form of contribution towards the MIB’s liabilities from users of”
e-scooters and related devices. Without such a recommendation being implemented, we will all have to pay extra insurance premiums to cover the third-party liability. Do the Government intend to ensure mandatory use of helmets for e-scooter users?
My noble friend told me in reply to a Question last year that the current framework is that a person can be fined up to £300, or get six points on their licence, or their e-scooters could be impounded. I end where I began by asking her to tell us who is responsible for enforcement, how many e-scooters have been seized and how many driving licences have been endorsed and fines have been issued? What expectation can we have of better enforcement in future?
Baroness Sanderson of Welton (Con)
My Lords, I thank my noble friend for calling this debate. I hope noble Lords will forgive me for taking part not as an expert but as someone who lives in London and has become concerned and, to be honest, bemused by the rise of e-scooters on our streets. What a meteoric rise it is; having been properly introduced only in 2018, the companies that make these vehicles are now raising millions of pounds in venture capital, a clear indication that the market for e-scooters is not slowing down any time soon.
Despite their envisaged popularity, I am still unclear whom these scooters are aimed at or what they are for. The argument you hear most is about the environmental benefits—how they will contribute to greener, cleaner spaces in our towns and cities—but is this really the case? As my noble friend just said, and according to the Royal Society of Chemistry, unless e-scooters are used daily for many years and replace a car, their impact on the environment is ultimately damaging, with high carbon costs in manufacture and mining of raw materials.
Is it realistic to suppose that e-scooters can and will replace a private car? According to recent figures by Lime, one of the companies taking part in the Government’s trial, the average journey is two kilometres—a journey that would take about 20 minutes to walk. Is it not more likely that, far from replacing car journeys, e-scooters are in fact replacing walking or cycling, both of which are far more environmentally friendly? The evidence on this is still sketchy, but the Government’s evaluation is looking at usage. If it shows that e-scooters are replacing not car journeys but active travel—a key aim of the Department for Transport—can my noble friend the Minister say whether this will be a consideration in deciding how and whether to regulate further usage? When the House of Commons Transport Committee recommended legalising their use, it also said
“it would be counter-productive if an uptake in e-scooters … primarily replaced people undertaking more active and healthy forms of travel.”
The evaluation report will also look at the user demographic of e-scooters, which will make interesting reading. The 2020 Kantar report into public attitudes revealed that there was no obvious target market for e-scooters. Some people did not feel that they were relevant for their personal transport needs. Others thought that they were not suitable for their age or stage in life—for example, because they had children. In that case, why are there so many of them?
I refer today only to London, as that is my experience. In my area, where e-scooters are supposedly banned, they seem to be the exclusive preserve, as mentioned, of 20-something men, used at all hours of the day and night, often without much care and attention. Invariably, they tend to be illegally ridden private scooters. As one online writer said when test-driving the legally trialled version:
“At a tenner an hour, or a fiver for a 25-minute run, they’re hardly a cheap commute … but restricted to the roads and banned from most parks, they’re not much of a leisure activity either.”
If we are not sure who or what they are for and the green argument is by no means clear, are these scooters really worth all the associated risks—the many rider accidents and the danger to pedestrians? I would say no. However, as I suspect they are here to stay, can my noble friend say whether the Government will take account of the experience of other European cities? Stockholm is now halving its number of e-scooters from 23,000 to 12,000, Copenhagen has banned them in the city centre and Oslo has capped the number at 8,000. Arguably, these cities are all far more suited to their use than London but, having let the genie out of the bottle, even they are having to grapple with the consequences. I fear it will not be long before we have to do the same.
Lord Shinkwin (Con)
My Lords, I, too, thank my noble friend Lady Neville-Rolfe for giving us the opportunity to debate such an important subject. I also thank her for her empathy: something which has been notably lacking from the Government’s approach.
The primary duty of the state is to protect the citizen. I take no pleasure in saying that that fundamental duty has not been honoured by the Government in respect of the introduction of e-scooters, and the scant regard they have shown for the safety of the UK’s 14.1 million disabled people.
Perhaps I could illustrate the point. Just over two hours ago, a wheelchair user was propelling themselves over a zebra crossing not a mile from your Lordships’ House. A cyclist was approaching from a distance, so the wheelchair user stopped to allow time for the cyclist to stop. They did not stop. Instead, they swerved at the last moment, within inches of hitting me, leaving me feeling very unsafe in my wheelchair. I made it to the House in one piece—just. Sadly, that is not a rare incident. Barely a day goes by when I do not feel threatened by e-scooter users, e-cyclists or pedal cyclists, sometimes all three and often as not on the pavement.
I know that the incident I described is not specific to the regulation of e-scooters, but it is symptomatic of the culture of impunity that this Government have allowed to take hold and, sadly, seem to be doing nothing to prevent. About 23,000 pedestrians are killed or injured in police-reported road accidents every year in Britain. Of course, disabled people are at greater risk—as I explained from my experience this afternoon. The problem is that the laws designed to protect us are not being abided by; nor are e-scooter users, cyclists or e-cyclists being required to abide by them.
My noble friend Lord Holmes of Richmond mentioned A&E cases. Just this Tuesday, a pedestrian was struck by an e-scooter in Hackney; she may be left with life-changing injuries. Freedom of information requests have shown that ambulance call-outs to incidents involving e-scooters jumped from 75 in 2019 to 480 in the first eight months of 2021, an increase of 540%. Yet the Metropolitan Police will reportedly now no longer routinely seize e-scooters being ridden illegally on public roads, instead confiscating them only from repeat offenders.
The UK’s disabled citizens need to hear that the Government recognise that their primary duty to protect the citizen applies equally to them. The Government have a duty to ensure that those who break the law by cycling on the pavement, going through red lights, failing to stop at zebra crossings or breaking the speed limit, outside your Lordships’ House, are punished—fined and named and shamed—so that disabled pedestrians can leave their homes without fear of being injured, whether by an e-scooter, e-bike or bicycle.
Baroness Stowell of Beeston (Con)
My Lords, I was rather taken with my noble friend Lady Sanderson’s questions: what are e-scooters for and who are they for? In the absence of answers to those questions, I am even more inspired by my noble friend Lady Neville-Rolfe’s bold desire for a complete ban. But my starting position is that, if the Government want to retain and expand a commercial e-scooter rental scheme, they must ensure that the current rules and regulations are enforced and be prepared to regulate yet further.
Like other noble Lords who have spoken this afternoon, I am very concerned by the evidence of accidents provided in the Library briefing note, and indeed other anecdotal evidence supplied by correspondence to those of us taking part today. Please do not take my pragmatic approach to the continuation of commercial schemes as support for them; I just find it hard to imagine that the Government are going to revoke them. Because of that, my bigger concern is if they are to relax the law and make e-scooters permissible on public roads. As we have already heard from my noble friends this afternoon, I fear that is happening by stealth because of inertia in enforcing the current laws. As my noble friends have said, people are using these e-scooters with impunity and doing so in a reckless and often unsafe way.
I would be grateful if my noble friend the Minister could provide an update today on police enforcement, as my noble friend Lady McIntosh has already requested, around things such as confiscation. I would also be grateful if she were able, after today’s debate, to provide us in writing with what guidance has been provided to the police to inform how they enforce the law. I hope she will forgive my scepticism on the police’s enthusiasm to do what is required of them.
To illustrate my scepticism, the other week I observed a police officer open a gate to the Parliamentary Estate to allow a private e-scooter rider to exit. On seeing this, I said to the police officer, “That’s illegal; why didn’t you stop him?”, and the response I received was, “You’d think I could”. I said, “You’re the police; I think you should”. That was the end of the conversation.
It is bad enough when pedestrians and other road users see e-scooters flouting the law, but it provokes anger when the same e-scooters travel at speeds that exceed the limits or breach traffic lights. So the Government also need to bear in mind the frustrations of road users for whom driving is critical to their job or direct source of income, such as black cab or taxi drivers, delivery drivers and tradesmen such as plumbers, electricians and so on—the people who are struggling to enter cities to provide essential services to the people who live here or to other businesses because of increasing traffic regulations or traffic schemes. Beyond what I have already asked, my question to the Minister is: what is the department doing actively to consult the kind of users I have just described about the current e-scooter pilot schemes and the way in which private users are flouting the law? It is worth bearing in mind that the people I have just described are not the sort of people who respond to consultations, so are the Government in contact with trade bodies and firms—Pimlico Plumbers, or whatever? Can the Minister also provide us with an update on the evidence of the involvement of e-scooters in other crimes?
Lord Young of Cookham (Con)
My Lords, I congratulate my noble friend on introducing this debate, which has been monopolised by seven Conservative Back-Benchers. It is a very timely debate because, as we have discovered, we are trying to identify the correct new regime for e-scooters. I will take a slightly more nuanced view than some of my noble friends—and I do so as a former Secretary of State for Transport.
Where I entirely agree with everything that has been said is that we need to minimise this interregnum where there is widespread illegal use of e-scooters, alongside legal use of rented e-scooters. We have listened to the questions. What do the police do? Do they intervene only if an e-scooter is being driven dangerously? Do they stop somebody and warn them that it is illegal? Do they confiscate the e-bike? Or do they simply turn a blind eye, in which case the law is brought into disrepute? We need clarity on the final regime as soon as possible, and then enforcement.
On 24 December, the Government said they were extending several trial areas to November this year. They then have to evaluate the scheme and legislate, so what is the earliest date by which we can have a final regime, which we can then begin to enforce? What is the target date?
As for what the regime should look like, I have travelled to Westminster on two wheels for the best part of 50 years—although the wheels have a longer circumference than those on an e-scooter—so I am aware of both the benefits and the hazards of two wheels. The benefits are the speed, the certainty of the length of journey, the flexibility, the economy and the scope for replacing car use. Nottingham launched a trial zone for e-scooters in October, which saw 1 million rides in the first 12 months. The latest citizen research by the TIER project showed that 17.3% of rides replaced car journeys.
On the other hand, we have heard about the risks and hazards, not just to the rider, which can be reduced by high-visibility clothing and observing the Highway Code, but, more importantly, to other road users and pedestrians. There is no excuse whatever for riding on pavements or for anti-social behaviour.
Looking ahead, my view is that we should live with the e-scooter. While I understand all the problems outlined by my noble friends, I am not in favour of banning them. If we are to ban activities—something deeply un-Conservative—I would choose smoking before e-scootering. A ban would be an unnecessary barrier to the promotion of an individual and popular mobility scheme, which can complement public and private transport.
Having said that, I agree with my noble friends that we need parameters. I have been overtaken by someone on an e-scooter going twice as fast as the 15 mph that I do on my bike. The Dualtron e-scooter has an advertised top speed of 68 mph. I favour a maximum speed limit, as with e-bikes.
On licensing, at the moment you do not need a driving licence for an e-bike; you just have to be 14. But you do need one, even if provisional, to ride a rented e-scooter legally, as my noble friend Lady McIntosh said. If we have licences for one, we should have them for the other, and on balance I am not in favour of driving licences for either e-scooters or e-bikes. If you need a licence for an e-bike with a top speed of 15 mph, what about bicycles that go twice as fast? If we are to make it compulsory for e-scooter riders, capped at 15 mph, to wear helmets, what is the logic of exempting cyclists, who can go much faster?
Finally, I think you should be able to buy e-scooters and not have to rent them—but why are nearly all of them made in China? I understand why the trials are restricted to rental projects, but I see no reason for subsequent restrictions, which would constrain the beginning and end point of each journey because you have to dock the scooter. Owned scooters are less likely to be left around, and are likely to be ridden more carefully. I hope that these points might be taken on board.
Baroness Randerson (LD)
My Lords, I thank the noble Baroness for giving us this excellent opportunity, and I am surprised to find that I agree with most of the views that have been put forward. In my view, the Department for Transport is treating the 31 pilot projects rather as the Prime Minister is treating the Sue Gray report—as an excuse for lack of action, while the evidence mounts and everyone can see there is a big problem.
I start from a position of positively welcoming e-scooters, as another potential alternative to cars. They are not exactly active travel because they require very little effort, but they are emission-free at the point of use. Evidence shows that they tend to be used by young people for short journeys and are often used just for fun. There is absolutely nothing wrong with that.
One problem is that the Government have set up so many very long-term pilot projects that a large number of people think that all e-scooters are now legal. Another is that there is virtually no police enforcement for illegally used e-scooters outside the pilot areas, while retailers are selling hundreds of thousands of them—mostly with no warning that they are illegal on roads and pavements. It is estimated that there are now at least 1 million privately owned e-scooters across the UK. In addition, there are 23,000 available to rent.
That is a very large experiment from which to draw conclusions, and there is now plenty of evidence of the damage that the current wild west approach is doing. Nine e-scooter riders died last year, and a study in Bristol showed that only 7% of riders were wearing helmets. Indeed, the pilot schemes do not require helmet wearing. There were 951 casualties involving e-scooters, 732 of which were the riders—one as young as four—and 253 seriously injured people.
The Government seem paralysed into inaction while the rest of the world is taking this issue on. To give a snapshot of good ideas, in Germany, for instance, you have to be insured, with an annual insurance sticker; you must have lights, brakes, reflectors and a bell; and there is a 20 kilometre per hour maximum speed. France, Austria, Belgium, Finland, Portugal and Sweden have all based their rules on those that apply to cycling. Spain, the Netherlands, Ireland, Italy and Australia all seem to have rules. There are a host of ways in which sensible regulations can be introduced and technology can come to the rescue—for example, using geo-fencing to exclude them.
Despite all that regulation, however, very serious issues remain. The impact on people with disabilities has been very well outlined. I have lost more than 70% of my hearing, and I am told that they make a swishing sound as they come along, but I cannot hear that. The hire and charging model for e-scooters is not as environmentally friendly as you might think, because the batteries have a very short lifespan, and a time-based hiring system encourages people to speed to get to the end of their journey by the end of their hire time. There is also a serious and major fire risk, which has been revealed only this week, with a house destroyed by a fire due to the combustion of an e-scooter battery. So, I ask the Minister to please address that issue if she does not do anything else.
Lord Rosser (Lab)
My Lords, as has been pointed out, this is one debate where the Minister gets more grief from behind her than from in front of her. I, too, thank the noble Baroness, Lady Neville-Rolfe, for securing and opening this debate.
As has been said, there are concerns about the use of e-scooters and the safety implications. I do not know whether the figures I have are anywhere near accurate, but as I understand it, in London there were 258 reported collisions in the first six months of last year, and no doubt a very much larger number of near-misses, which will have caused distress and fear for other road users—but, more concerningly, for pedestrians and wheelchair users, who do not expect to be mown down while on our pavements.
The Royal National Institute of Blind People has warned that e-scooters could pose dangers for blind people and has asked the Government whether they should each make a recognisable sound to alert pedestrians. E-scooters may be used on public roads in the UK only if they are part of a trial in a select number of areas. As part of these trials, e-scooters may be unlocked using a smartphone app and are limited, as I understand it, to 15 miles per hour and certain geographical locations. As the noble Lord, Lord Young of Cookham, said, it has been reported that these trials are to be extended to late 2022.
Despite being currently illegal to use outside of private land, the Times estimates that there may be 750,000 personally owned e-scooters, which suggests either a lot of illegal use or a lot of suitable private land, or both. Due to reports of fires and the obvious threat to safety, e-scooters have been banned from Transport for London services and premises. Some 3,600 e-scooters were apparently seized by the Met police between January and November of last year, and any owners wanting to retrieve them must pay £150 and a £10 daily storage charge. I am not quite sure what else happens to them.
As I understand it—I am sure I will be corrected if I am wrong—in October 2020, the House of Commons Transport Select Committee recommended the legalisation of e-scooters. We cannot uninvent the technology, but as the question asked by this debate indicates, we need to ensure that there are relevant and appropriate regulations in place to address the safety concerns over the use of e-scooters if their general use is to be given the go-ahead. If they can provide a safe, relatively cheap and environmentally friendly method of transport, e-scooters could have much to offer, particularly if they encourage some people who use their car for shorter journeys in our towns and cities to switch their mode of transport.
I certainly hope that, in their response today, the Government will be able to update us on the progress with the trials and any emerging findings, particularly in relation to safety, and any initial thoughts they have on the scope of regulations that would be required in connection with the use of e-scooters. It would also be helpful to know whether they are or are not contemplating their legal use on pavements, and if they are satisfied that enough is being done—taking into account the cuts in police numbers over the past decade—to enforce the current law in relation to the illegal use of personally owned e-scooters on our public roads and pavements. Finally, what engagement do the Government currently have with the RNIB and other relevant organisations representing disabled people as part of the e-scooter trials?
The Parliamentary Under-Secretary of State, Department for Transport (Baroness Vere of Norbiton) (Con)
My Lords, I thank my noble friend Lady Neville-Rolfe for securing this debate, and I thank all my Conservative colleagues for turning up as well. In my five years as a Minister, I think this is the strongest showing, proportionately, that I have ever had. There were many valuable contributions from all Benches, and I am truly grateful.
Transport is always changing and, as my noble friend Lady Neville-Rolfe noted, battery e-scooters are a relatively recent invention, although there was an internal combustion engine scooter around 100 years ago—there is a fantastic photograph of one—so maybe they will just be a fad. Who knows? But the Government believe that, with the right regulations, there is potential for significant economic, social and environmental benefits from light, zero-emission vehicles such as e-scooters. E-scooters can help to reduce emissions, as noted by a number of noble Lords. They can reduce carbon, of course, and nitrogen oxide emissions and particulates, which both contribute to poor air quality. If users switch from cars, there will be environmental benefits—but if they switch from cycling or walking, I agree that there will not be, although there may be other benefits.
Mode shift will be a key part of our considerations going forward, as was asked about by my noble friend Lady Sanderson. Based on examples from across Europe, in a pre-Covid context, we could expect modal shift to e-scooters to be around one-third from walking, one-third from public transport, 15% to 20% from car, and 10% from cycling, with around 2% for new trips. As with all emerging technologies, however, we must be mindful of the risks, and noble Lords have set out many valid concerns today. We want to ensure a measured and evidence-based approach to our policy decisions, which is of course why we are running controlled trials. They are trials, not experiments.
Let me share a few facts about the trials from the period from July 2020 to the end of November. More than 66,000 e-scooters have been approved in 31 trials across 54 areas. At the end of November, there were 23,141 e-scooters available to rent across all areas. Roughly 13 million trips had been taken, over 18.5 million miles travelled, and roughly 3 million hours ridden in total across the rental trials. To date, around a million individual users have rented an e-scooter as part of the trials.
The current regulations for trials limit e-scooters to a maximum speed of 15 and a half miles an hour and a maximum power of 5 watts. Users must have a full or provisional driving licence, and the licence is confirmed by the trial operator. While helmets are not mandatory, we, local areas and trial operators recommend that people use them. E-scooters are able to use cycle lanes, but I can confirm that it is absolutely illegal to use them on pavements. All trial e-scooters have insurance, provided by the rental operator and confirmed by the department.
The department also sets out minimum vehicle standards, including a requirement to have lights and a horn or bell to warn other road users, plus there are data-sharing requirements. All users in trials are provided with training via apps, and in some cases in person, to instruct them on safe and considerate riding. Most trial areas have dedicated parking bays and/or docking stations to help to reduce the risks caused by additional street clutter, a point made by my noble friend Lord Shinkwin.
Where problems with trials have arisen—and I agree that there have been issues—we have worked very quickly to nip them in the bud. For example, we increased the level of driving-licence checks that trial operators must perform when a new user signs up and put systems in place to ensure that you cannot get multiple sign-ups from a single driving licence.
In October 2021, the trials were extended to the end of this November. This will allow us to continue to fill data gaps and make some small changes; for example, we have introduced uniform ID plates to ensure that we can recognise e-scooters and make sure that the trials are as safe and well run as possible. We have been monitoring and evaluating the trials all the way through. It is a very fast-moving area; substantial additional data has been generated since we received an interim report last June. This has come from direct data feeds from the trial operators and survey data from, and interviews and focus groups with, e-scooter users and residents, including those whose income derives from being able to get out and about—that might be local tradespeople or taxi drivers. The final report for the trials is due relatively soon and will include all this information; we are just figuring out how to compile and present it to provide a comprehensive picture of the evidence. We hope to publish it in spring.
I have heard from many noble Lords—and, to a certain extent, I agree—that enforcement is absolutely essential. We know there are occasions where trial e-scooters are not used as they should be. We also know there are similar offences and penalties we can use for privately owned e-scooters in the public arena. For the avoidance of doubt, for my noble friend Lady McIntosh and all noble Lords, it is absolutely illegal to use a private e-scooter on public land or a public highway. These offences are available to both trial and private e-scooter users and derived from the same offences as for motor vehicles. This means they might include driving on the pavement, which applies to those using a trial e-scooter and those naughtily using a private one; not having insurance or a driving licence—this would mostly apply to people with a private e-scooter; dangerous driving, which applies to everyone; and drink-driving. E-scooter users either illegally using a private scooter in the public domain or committing an offence on a rented e-scooter, such as riding on a pavement, can be fined up to £300 and have six points put on their driving licence, and the e-scooter can be impounded.
My noble friend Lord Holmes asked whether police forces have had advice. We have issued guidelines to the National Police Chiefs’ Council on general safety and rules for trial e-scooter users. We have also made sure that, before local authorities apply to set up for a trial, we need to see evidence that they have engaged with the local police to ensure that they are well aware of what is about to happen in the area. However, the level of enforcement within each local police force is an operational matter for that police force—I suggest, in consultation with the police and crime commissioner. Many noble Lords in London may wish to write to the Mayor of London about that. Local authorities and trial operators are also required to demonstrate that the vehicles used are distinctive so that you can tell they are legal, trial e-scooters that are allowed rather than privately owned e-scooters that are not.
My noble friend Lady McIntosh asked for further information on confiscations and fines and the use of e-scooters in other crimes. I will follow up with whatever I can find in a letter. We are aware that a large number of people have purchased an e-scooter in recent years. That is why we believe it is so important that we conduct these very large trials to gather evidence so that we can inform future policy and any legislative basis for e-scooter users in future.
It is not illegal to sell an e-scooter. However, there are protections for the general public: under the Consumer Protection from Unfair Trading Regulations 2008, retailers need to give sufficient information about goods and services to consumers. These regulations carry criminal penalties, so they can be used against individual retailers. Ministers from my department have written to retailers twice, in December 2018 and again in July 2021, to set out their concerns that retailers were not providing this clear, visible and consistent information that we need.
On the safety of e-scooters themselves—are these things actually safe?—at the moment there is not enough reliable international evidence on e-scooter safety to compare them accurately with other modes. Evidence to date suggests that the rates of injuries are broadly similar when compared with pedal cycles. The overall change in safety risk will depend on the mode shift. If we see a mode shift from cars, that would of course be a positive thing, because cars can be a significantly more dangerous mode, particularly for other road users. We will look at the impact on safety overall and in the context of the sorts of journeys that are carried out on e-scooters.
We are aware that a small number of fire incidents have involved e-scooters in recent months and we are liaising with the trial operators and participating local authorities. We are also co-ordinating with a number of government departments, including the Office for Product Safety & Standards, to ensure that such matters are considered as part of regulations around any electric vehicle entering the UK.
My noble friends Lord Holmes and Lord Shinkwin both eloquently raised the challenge of e-scooters to disabled people, and of course we are well aware that there can be challenges, although to some other disabled people they may be of benefit. We particularly take the point about those who are blind or visually impaired and therefore unable to see the scooters coming. We have had numerous discussions with disability groups and we require that all e-scooters have a horn or bell so that they can make others aware. We will continue to engage with groups that we have good relationships with, including the RNIB. We want e-scooters to be as inclusive by design as possible. Indeed, all transport should be inclusive by design. I was horrified to hear about what happened to my noble friend Lord Shinkwin earlier today.
We have looked at other European countries and we will take heed of the way that they have taken forward e-scooters. For the time being we have a regulatory landscape that we put in in June 2020 following a consultation. What does that look like for the future? I know that noble Lords are looking for certainty from me but I cannot provide that today. We are still gathering and analysing the data. We want a safe, proportionate and flexible regulatory framework if we decide that is our way forward. We have been gathering plenty of evidence: we have responses to the future of transport regulatory review, and there is further stakeholder engagement to do, including state engagement with the insurance industry. No decision has been taken about the future legal status of e-scooters. Much as I would like to give a response to my noble friend Lord Young about timelines, I cannot at this moment in time. However, if they are to be legalised, we would consider removing them from the motor vehicle category and instead creating a new bespoke category of vehicles with the appropriate regulatory regime in place.
I am extremely grateful to all noble Lords—
Baroness Neville-Rolfe (Con)
Before my noble friend sits down, to go back to her answer on the legislative framework, would that require primary legislation to ban or regulate? Would it be necessary to have another Bill? I am very sorry that we cannot have a timeline, but it would be good to know the legislative framework.
Baroness Vere of Norbiton (Con)
Of course, that will depend on what we decide to do. One might assume that there would be a route with a primary framework that would set out this new type of vehicle. We have to remember that this stuff moves quickly, and one could have a system where you would have a framework from which you would then regulate to ensure that things can be adjusted as technology moves on. As I say, that is just one of many options, as I am sure the noble Baroness understands.
House of Lords
Ukraine and Russia: Ceasefire
Lord Browne of Ladyton
To ask Her Majesty’s Government what assessment they have made of (1) reports that on 21 December 2021 Jens Stoltenberg, NATO Secretary General, expressed his intention to call for a meeting of the NATO-Russia Council early in 2022, and (2) that on 22 December 2021 negotiators from the Organisation of Security and Cooperation in Europe and the governments of Ukraine and Russia agreed to restore a full ceasefire between the Ukrainian government forces and separatists in eastern Ukraine.
Lord Sharpe of Epsom (Con)
My Lords, the Government welcomed the 12 January NATO-Russia Council as an opportunity to discuss ways in which to build transparency and address mutual concerns. The only way forward is for Russia to de-escalate and engage in meaningful discussions. We welcome the strong determination by participants in the Trilateral Contact Group to fully adhere to the July 2020 strengthened ceasefire. We hope that this will reduce violence in eastern Ukraine and contribute to improved conditions for efforts towards de-escalating regional tensions.
Lord Browne of Ladyton (Lab)
My Lords, I thank the Minister for his reply. The NATO-Russia Council has met and, more generally, we have had Ministerial Statements on the diplomacy to prevent future conflict. I regret, however, that the Government continue to be studiedly silent in respect of the seven-year continuing conflict in eastern Ukraine. The agreed restoration of a full ceasefire has made little difference. Yesterday, there were 58 ceasefire violations, including four explosions. Enhanced monitoring and verification capability for the OSCE special monitoring mission and military- to-military crisis management dialogue through the OSCE Trilateral Contact Group are essential to restore, consolidate and strengthen the ceasefire, to reduce casualties and to provide, perhaps, a foundation for progress in other areas. What steps are we taking to support such objectives?
Lord Sharpe of Epsom (Con)
The noble Lord is quite right. The OSCE special monitoring missions are essential and the UK is one of the leading contributors to those. They report on the security situation on the ground in eastern Ukraine and obviously we continue to call on all sides to uphold the strengthened ceasefire.
Lord Lancaster of Kimbolton (Con)
My Lords, Russia is isolated and lacks any meaningful international alliances. If there has been one misstep by President Putin in recent weeks, it is probably blaming, or seeking to blame, NATO aggression. It has unified NATO members. However, NATO is not the only western alliance. There is also the informal military alliance of the Northern Group, which includes non-NATO members such as Sweden and Finland, which I see the Secretary of State for Defence has visited in recent weeks. Can my noble friend update me on what conversations there have been with those countries in trying to deter the Russian threat?
Lord Sharpe of Epsom (Con)
I am afraid that I cannot update my noble friend on that specific question but he is right to point out that NATO is a defensive alliance. Its purpose is to protect member states and every country that joins undertakes to uphold its principles and policies. That includes the commitment that the alliance does not seek confrontation and poses no threat to Russia, as reaffirmed at the Brussels summit.
Lord Stirrup (CB)
My Lords, the Minister has said that the only way forward is for Russia to de-escalate. It may be the best way forward but is certainly not the only way forward, particularly according to President Biden. Does the Minister agree that should Russia intervene militarily in Ukraine it would not be a quarrel in a faraway country between people of whom we know nothing but something that would cast a long shadow over wider European security, that Russia responds only to strength and determination, and that the best way for us to express that is through NATO, a revivification of NATO and, in particular, a strengthening of the transatlantic links within NATO?
Lord Sharpe of Epsom (Con)
I thank the noble and gallant Lord for pointing that out. I entirely agree with him. As I said, NATO offers the best opportunity for us to help Russia de-escalate this and he is quite right.
The Lord Bishop of Leeds
My Lords, what assessment have Her Majesty’s Government made of the statement by Sergey Lavrov two days ago that the OSCE used to convene parties on an equal basis but it is now simply a defender of western interests? What impact does that have on our conversations with the Russians?
Lord Sharpe of Epsom (Con)
I am sorry but I shall have to write to the right reverend Prelate on that. I have not seen Sergey Lavrov’s statement.
Lord Robertson of Port Ellen (Lab)
My Lords, I was the first chairman of the NATO-Russia Council. I am delighted that it is now back in session and that there are now opportunities to both disagree and agree in that forum. I hope it is kept alive and that the United Kingdom does so. However, is it not a matter of some regret that this country, our country, was not involved in the original Normandy process, which led to the Minsk agreement? Is it not now time for Her Majesty’s Government to consider getting back into the Normandy process and being part of the exercise that perhaps will produce a diplomatic solution?
Lord Sharpe of Epsom (Con)
I thank the noble Lord for his question. I cannot say whether or not that is a matter of regret. Of course, the UK Government continue to work closely with all allies and that includes the Normandy group.
Baroness Smith of Newnham (LD)
My Lords, what practical steps are Her Majesty’s Government taking to work with our European and NATO partners to try to persuade Russia to de-escalate? There is no point in simply saying that Russia must de-escalate. There need to be provisions to make that something that Russia sees as desirable.
Lord Sharpe of Epsom (Con)
The noble Baroness is quite right. We are co-ordinating with allies and partners to maximise the impact of all this. The Prime Minister spoke to the French, German, Italian and US leaders in December. In December, the G7 Foreign Ministers and the High Representative of the EU issued a joint statement calling on Russia to de-escalate. The Foreign Secretary raised concerns on the situation at the NATO Foreign Ministers’ meeting at the end of last year and at the OSCE Ministerial Council in December. She has engaged bilaterally with NATO and EU allies, including the US, Canada, Germany, Poland, Slovakia and Turkey. NATO Foreign Ministers spoke on 7 January. I am sorry that it is a long list but there is an awful lot of engagement.
Lord Collins of Highbury (Lab)
My Lords, I want to pick up the last point. Last week, I made it clear that this Parliament had a clear and unified message on Ukraine and the threat from Russia. I welcome the initiatives from the Government, but can the Minister tell us a bit more about not only the diplomatic initiatives, which are vital to ensuring de-escalation, but the efforts to work in concert with our allies in terms of any sanctions that might be needed? It is important that we are prepared to act immediately with our allies, including the United States, if that is necessary.
Lord Sharpe of Epsom (Con)
I thank the noble Lord for his question. A Russian incursion into Ukraine would be a major strategic mistake. There should be no doubt that Russian military aggression will be met with strength, including massive economic consequences through co-ordinated—I stress that word—economic sanctions by allies and partners, targeting Russian financial transactions, assets and individuals.
Obviously, it would be inappropriate to speculate on future sanctions designations, but I refer the noble Lord back to the sanctions that were imposed in response to Russia’s actions in Crimea. The UK took action against Russia for its illegal annexation of Crimea; that was in co-ordination with our international partners. We worked closely with the EU, the US, Australia and Canada to impose costs on those facilitating Russia’s illegal annexation of Crimea and Sevastopol through sanctions. I imagine that this template will be deployed again in future.
Lord Howell of Guildford (Con)
My Lords, if the only way forward is for Russia to de-escalate but Russia will not do so, clearly other ways forward of a non-conventional kind will have to be found. Can we be assured that we are fully engaged with these and with other democracies—not just in NATO and the European zone but the powerful nations of Asia, since this is a global issue? If war were to break out, it would affect not just Europe and the West but the entire planet.
Lord Sharpe of Epsom (Con)
The noble Lord is completely right. As I just referred to, when it came to the sanctions regime imposed over the annexation of Crimea, the response was global, including from Australia and so on. We are engaging and listening to the world.
Lord Reid of Cardowan (Lab)
My Lords, is it not obvious that, as long as Russia maintains its position of wanting a guarantee that NATO will not allow Ukraine to join, NATO maintains its position that that is a non-starter, and their discussions are confined to those two propositions, there is no diplomatic solution? We all know, although we may not want to admit it, that there is no military solution to this problem either. That is why, as my noble friend said, it is a tragedy that we were not involved in the Normandy talks. What consideration have the Government given to other alternatives? One example is that of Austria in the 1950s, which, through negotiation, was guaranteed an independent, neutral status. There is also the position of Finland, which has had a relatively open border with Russia for many years. What consideration has been given to these other alternatives?
Lord Sharpe of Epsom (Con)
I thank the noble Lord for his question and defer to his extensive knowledge of defence matters. I repeat what I said earlier: NATO is very much a defensive alliance. However, we have not really talked about Ukraine in this. I note that, in a debate on Tuesday, my noble friend Lady Goldie said:
“In terms of the agreements it has reached in its own right, and legitimately so, with the international community and NATO, it has positions which should be respected.”—[Official Report, 18/1/22; col. 1617.]
Food and Farming: Supply Issues
(2 years, 3 months ago)
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Baroness Jones of Whitchurch
To ask Her Majesty’s Government what assessment they have made of the supply chain issues in the food and farming sector identified by the National Farmers’ Union and the British Retail Consortium at the Food Security Summit on 14 December 2021; and what plans they have to prepare a long-term solution to these issues.
The Parliamentary Under-Secretary of State, Department for Environment, Food and Rural Affairs (Lord Benyon) (Con)
My Lords, I declare my farming interests as set out in the register. The UK’s food industry sectors operate highly resilient supply chains, as demonstrated throughout the Covid-19 response. The Government have well-established ways of working with the industry on preparedness for, and in response to, issues with the potential to cause disruption to food supply chains. Our production-to-supply ratio remains high in comparison with historical levels: we produce 60% of all the food we need. These figures have changed little over the past 20 years.
Baroness Jones of Whitchurch (Lab)
My Lords, I thank the Minister for that reply. We are facing a serious supply chain crisis, with an estimated 500,000 labour shortages and rising costs. There is a shortage of seasonal workers to pick our fruit and veg and of lorry drivers to deliver them. There is a lack of produce on supermarket shelves and a rise in imports as a result. We are seeing a mass cull of pigs because we have no butchers, while the import of pork products from the EU is rising. Does the Minister accept that short-term fixes and three-month temporary visas will not solve the labour shortage? We need a long-term plan for this. Does he also accept that we should have a target of at least 60% food self-sufficiency in the UK, and that this should be underpinned by specific support to put British farmers and businesses first?
Lord Benyon (Con)
The noble Baroness is of course right that we should not be concerned just with short-term fixes. However, if she will forgive me, I think that she is a little out of date. We have agreed, through to 2024, to allow 30,000 people to come from outside the UK into this country under the seasonal workers scheme. In addition, we have people under the EU settled status. We are also trying to encourage more domestic employment and innovation through automation. All these things will ease the pressures that existed last year—and still exist, to an extent—but the situation is better. We are not complacent and it will continue to improve.
Lord Carrington (CB)
My Lords, can the Minister tell us what action is being taken to improve the facilities available to long-distance and other delivery drivers on the motorway network? Together with the long hours that these drivers spend waiting, the lack of facilities is a main concern in the recruitment process. It is not about pay and, in some ways, it is not about quotas for foreigners to come in. The concern is about the facilities.
Lord Benyon (Con)
The noble Lord is absolutely right. We have worked with other departments, including the Department for Transport and the Home Office, in the development of our scheme to encourage more drivers, to ease the difficulties caused mainly by the pandemic but also by our withdrawal from the EU, which have resulted in a shortage of drivers. The noble Lord is right: it is the quality of their lives that we need to look at, alongside all the generous incentives that we are giving to encourage people to come here and fill this gap.
Lord Harlech (Con)
My Lords, what measures are the Government taking to prevent the scene of edible vegetables being ploughed in rather than being harvested and entering the food chain?
Lord Benyon (Con)
My noble friend raises an important point. Vegetable producers will always try to produce slightly more than the demand because that is better than being short of supply to the next stage of the food chain. Every year, some vegetables are ploughed in, but it has increased recently, for reasons that we are all aware of. We are very mindful of encouraging a much more stable supply chain. That is why we have increased the number of drivers and brought in a variety of different skill sets through the seasonal workers scheme. We hope that this problem will ease in the coming months.
Baroness Whitaker (Lab)
My Lords, looking more widely in the farming industry, what are the Government doing to help farmers reduce their methane emissions, which are an extremely large source of carbon emissions?
Lord Benyon (Con)
We are taking a number of measures to tackle this pernicious greenhouse gas. It operates very differently from other greenhouse gases; it has a much more damaging short-term effect but is a short-term problem. There is enormous progress in technologies around what we feed cattle and in husbandry. We can offset the effects of methane through other measures we are taking through our environmental land management schemes.
Baroness Boycott (CB)
My Lords, I speak as the chair of Feeding Britain. All the problems that noble Lords have referred to are impacting on the price of food. One measure we have is the Healthy Start vouchers, and I congratulate the Government on increasing this; it really helps poor families. However, we have just learned that the uptake is only just over 51%. What are the Government doing to extend the reach of these things? Will they consider making an opt-in scheme the de facto way of becoming a member of this important scheme which helps low-income families?
Lord Benyon (Con)
I will relay the suggestion to colleagues in the Government. The Healthy Start food vouchers scheme, which has been raised from £3.10 to £4.25, should be seen as part of a wider array of measures that we are providing to target families on lower incomes. The £500 million household support fund is another example, but the noble Baroness makes a very important point which I will relay.
Lord Taylor of Holbeach (Con)
My Lords, I refer to my horticultural interests. What success has the department had in negotiations with the Home Office on extending temporary worker schemes to non-edible horticultural products—for example, nursery trees, nursery products, flowers, and other such things?
Lord Benyon (Con)
This is an incredibly important part of our economy, particularly our rural economy. I am delighted that we have managed to get the addition of ornamental and other non-food-related measures as part of the seasonal worker scheme, and it is quite right that we do so. But we are reliant on the industry telling us in advance, as much as it can, about where it thinks the pressures will come from in the future. We have the ability to increase the £30,000 by another £10,000, and we want to encourage much more training in the sector.
Baroness Bakewell of Hardington Mandeville (LD)
My Lords, the national food strategy has met with criticism from ITV, which is keen to continue advertising fast, unhealthy food. Given the rise in obesity and diabetes, why are the Government not promoting local, healthily grown fruit and vegetables which can then go into the free school meals system, to both improve the health of our children and support our farmers?
Lord Benyon (Con)
My Lords, we are. We want to encourage local food chains to operate more effectively; it is of course much healthier for the environment and the quality of the food is better. We want to disrupt highly centralised food chains where we can. We also want to make sure that we are encouraging as stable a food chain system as we can, because we rely on the just-in-time measures to get food from the field to the plate.
Lord McLoughlin (Con)
My Lords, we are seeing a rise in the number of farm shops up and down the country, but what is the department doing to ensure that large supermarkets sell British products?
Lord Benyon (Con)
The best pressure on supermarkets does not necessarily come from finger-wagging of the Government or measures from Ministers but from the customer. We must encourage people to shop locally; for example, if they are concerned about the effects of their diet on climate change, eating grass-fed, locally produced meat means they are probably doing more to help the environment than when buying products that have been brought from the other side of the world, under circumstances that are much below our standards in this country.
The Deputy Speaker (Lord Ashton of Hyde) (Con)
My Lords, the noble Lord, Lord Jones of Cheltenham, wishes to speak virtually. I think this would be a convenient moment to hear from him.
Lord Jones of Cheltenham (LD) [V]
My Lords, how do the new trade deals with Australia and New Zealand help with the aims of maintaining Britain’s food production self-sufficiency level at 60% and creating an environment for farm and food businesses to thrive and compete in the coming years?
Lord Benyon (Con)
There is good news on a variety of different measures in trade deals, not least on the point of the noble Lord’s question. We are about to see the end of the ban on UK lamb being sold to the United States. Free trade is important; it benefits us all. We have incorporated into the two trade deals that the noble Lord talked about the absolute determination to protect our standards of animal welfare and environmental protection. That is the best protection that we can give to the high-quality produce that our farmers produce in this country.
Devolved Governments: Public Expenditure
(2 years, 3 months ago)
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Lord Foulkes of Cumnock
To ask Her Majesty’s Government what discussions they have had with the devolved governments regarding monitoring of their public expenditure.
Lord Robertson of Port Ellen (Lab)
My Lords, on behalf of my noble friend Lord Foulkes of Cumnock—who is self-isolating, according to law—and with his permission, I beg leave to ask the Question standing in his name on the Order Paper.
The Minister of State, Cabinet Office and the Treasury (Lord Agnew of Oulton) (Con)
My Lords, the Chief Secretary to the Treasury is responsible for the Treasury’s relationship with the devolved Administrations and last met their Finance Ministers a week ago, on 12 January. The devolved Administrations provide the Treasury with information on their spending every month to support the management of the public finances. It is for the devolved Administrations to allocate their Barnett-based funding across their devolved responsibilities. They are accountable to their respective legislatures for their decisions.
Lord Robertson of Port Ellen (Lab)
My Lords, the Minister is aware, as he says, of the billions of pounds that are transferred to the Scottish Government under what is known as the Barnett consequentials, but does he know where it is spent? The Scottish Government seem remarkably reluctant to tell the Scottish Parliament and the Scottish people how that money is spent. What does he think of the fact that, at the moment, the Scottish Government are starving Scottish local authorities of money, thereby forcing them either to put up council taxes or cut services?
Lord Agnew of Oulton (Con)
My Lords, as I said in my opening Answer, the Scottish Government are accountable to their electorate and to the Treasury here for how they spend their money. They have had a very generous settlement in the SR—an additional £8.7 billion went to the devolved Administrations, of which £4.6 billion per year has gone to Scotland. I encourage the noble Lord to keep his scrutiny up.
Lord Forsyth of Drumlean (Con)
My Lords, does my noble friend realise that there has been a series of major financial scandals in Scotland, such as two ferries for the price of five? There is a whole series of examples of complete mismanagement of public money, and there seems to be no consequence. Following on from the point made by the noble Lord, Lord Robertson, about the Barnett formula, the Scottish Government have the gall to blame Westminster for cuts in the health service where they fail to spend the Barnett consequentials on health that they have been given. There is no transparency. Surely the Treasury has a responsibility to ensure that transparency is given.
Lord Agnew of Oulton (Con)
I agree with my noble friend that any wastage in government is extremely distressing, certainly to me. In October of last year, we reached an agreement with the Scottish Government to jointly commission an independent report covering the block grant adjustment arrangements. The independent report will inform a broader review of the Scottish Government’s fiscal framework later this year.
Lord Bruce of Bennachie (LD)
My Lords, the Scottish Government have a Minister for consular affairs. Does the Minister believe that this is consistent with the delivery of devolution? Following up on the intervention by the noble Lord, Lord Forsyth, would the Scottish Government not better serve the people of Scotland if they concentrated on protecting and delivering public services and developing a strong economy, instead of fiddling in a way that has had a disastrous effect on the economy and job losses?
Lord Agnew of Oulton (Con)
My Lords, in 2005, the then Labour Government agreed to allow the Scottish Government to have international development involvement. To my knowledge, they are involved in three countries—Rwanda, Malawi and Zambia. I can only come back to my earlier point that it is for the Scottish electorate to decide whether that is a good use of public funds.
The Earl of Caithness (Con)
My Lords, my noble friend mentioned the discussions which are happening and the report that will come later this year. Will it be clear that there will be more transparency on how the money is spent? It is not the money going from here but how the money is spent in Scotland that is so opaque.
Lord Agnew of Oulton (Con)
My Lords, we are certainly keen to see more transparency. At the moment, the Treasury receives monthly reports on expenditure—but I accept that more transparency would be useful.
Lord Campbell of Pittenweem (LD)
My Lords, the Scottish Government have a unit committed to making the case—or more correctly, preparing the case—for independence. Does the Minister think that that is a proper expenditure for the people of the United Kingdom to have to bear?
Lord Agnew of Oulton (Con)
My Lords, as someone who is very against the independence movement in Scotland, I would agree. We have also to accept that an increasing amount of revenue is raised in Scotland for the Scottish Government. For example, from 2017-18 Scottish income tax rates were entirely devolved, and all revenues from Scottish income tax are retained. Likewise, in 2015, stamp duty was devolved to the Scottish Government. So there is a rising percentage that is in their own gift and I can only assume that some of that is being used for what is, in my view, a mistaken approach.
Lord Griffiths of Burry Port (Lab)
My Lords, perhaps I might take a moment to remind the House that, as well as Scotland, Wales has a devolved Government. I believe transparency there is of an order of which we could all be proud. I want to pick up on a point made yesterday by the noble Lord, Lord Forsyth, during a Question about the Barnett formula. In his opinion—and in the opinion of many of us—it needs to be looked at in a radically new way for a new age. The Answer from the Dispatch Box yesterday was, quite simply, that there was no prospect of such a review. Is the Minister today, who is refreshingly different from the Minister yesterday, of the same mind?
Lord Agnew of Oulton (Con)
My Lords, I think we all know that the Barnett formula was something of a fudge, put together many years ago. It is an extremely complicated thing to try to unravel. We know that the amount of funding that goes to individual citizens is favourable to the devolved regions, but the formula is not necessarily satisfactory—so I would encourage the noble Lord to keep up his campaign to push for a review.
Baroness Wheatcroft (CB)
My Lords, given the Minister’s dislike of waste in government, could he comment on the article earlier this month by the Comptroller of the National Audit Office, Gareth Davies? He criticised the lack of any formal process for evaluating both the efficiency and delivery of cross-government projects. He said that there was very little information on
“what difference is made by the billions”
spent by government. What does the Minister think of that?
Lord Agnew of Oulton (Con)
I think the noble Baroness makes a very good point. I will suggest to the relevant Ministers that the work on the fiscal framework, announced in October, includes a review of the points raised.
Lord Tunnicliffe (Lab)
My Lords, building on that point, is not the problem that the UK Government are in no position to lecture others—whether it is the National Audit Office, influential think tanks or others? We regularly hear of cases where Ministers have exercised poor judgment when spending public funds. The most recent example was the quiet announcement that the Treasury does not intend to chase down an estimated £4.3 billion fraudulently claimed from coronavirus support schemes. Why did the Government not listen to Labour’s warning about potential fraud earlier in the pandemic, and why will family units have to pay the price for the actions of fraudsters through upcoming tax increases?
Lord Agnew of Oulton (Con)
The noble Lord raises a very good point. I believe that I will be coming back on Monday to deal with an Urgent Question on this specific subject. I would remind noble Lords that these schemes were stood up at an incredibly fast pace to protect the productive capacity of this country. Yes, the fraud losses are extremely frustrating but, if we had not got that money to the business community as quickly as we did, we would have seen a lot more damage to our economy.
Lord Mackay of Clashfern (Con)
My Lords, to what extent do the UK Government make clear in the publicity in the devolved Administrations the amounts of money that come from the UK Government to those Administrations?
Lord Agnew of Oulton (Con)
My noble and learned friend is right that we need to remind Scottish citizens that a great deal of the funding that goes into Scotland comes from here. We now have a Minister for the Union, Michael Gove, and his job is to keep reminding all the devolved Administrations that we are one union. A very senior civil servant, Sue Gray—of whom some of you may have heard—is the Permanent Secretary for the Union, and we are encouraging engagement at, for example, local authority level on a much more frequent basis.
Lord Bird (CB)
My Lords, we are talking about the spending of government money, and I congratulate the Government on the fact that, on 26 December 2021, although it did not get a lot of press, they decided to spend £360 million—for which I and others had been asking—on homeless prevention grants, so that people were not put out because they had lost their job due to Covid-19.
Lord Agnew of Oulton (Con)
I thank the noble Lord for his support. Homelessness is one of society’s most complicated problems and we are very committed to trying to minimise it.
Pesticides: Thiamethoxam
(2 years, 3 months ago)
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Baroness Bennett of Manor Castle
To ask Her Majesty’s Government what assessment they have made of the potential negative impacts of their decision to permit the use of the pesticide thiamethoxam for sugar beet cultivation on (1) bee health, and (2) the spread of antimicrobial resistance; and what steps they will take to mitigate the concerns raised by their scientific advisors about the use of this pesticide.
The Parliamentary Under-Secretary of State, Department for Environment, Food and Rural Affairs (Lord Benyon) (Con)
My Lords, the Government have given emergency authorisation for the use of thiamethoxam in 2022 to protect sugar beet from viruses. The environmental assessment identified potential risks to bees and the authorisation imposes strict restrictions to minimise these risks. In particular, the pesticide will be used only if, according to independent modelling, the predicted level of virus is at or above 19% of the national crop. No flowering crop may be planted within 32 months of sugar beet having been treated.
Baroness Bennett of Manor Castle (GP)
My Lords, I thank the Minister for his Answer. I have no doubt that other Peers will address the absolutely crucial issue of bees. This relates also to our second Question on food security.
In the light of the Lancet article yesterday which showed that, in 2019, 1.3 million people around the world died as a result of antimicrobial resistance, I will focus on the second part of my Question. It is, perhaps, the first time this has been mentioned in the House. Increasing numbers of studies, and increasing understanding, show that cross-resistance can develop. Bacteria exposed to pesticides can end up being resistant to drugs they have never even experienced. Will the Minister commit to going back to his department and speaking to officials to ensure that sufficient account is being taken of this when all pesticides are considered?
Lord Benyon (Con)
I, my department and others mind desperately about antimicrobial resistance. When I saw the wording of the Question, I looked into the matter in some detail. The neonicotinoid we are talking about is an insecticide that is not found to be causally related to antimicrobial resistance. I will look at the Lancet article about which the noble Baroness spoke and I will take her points back. The Government take AMR extremely seriously and we are coming forward with a number of different ideas to tackle this problem.
Baroness McIntosh of Pickering (Con)
My Lords, will my noble friend take this opportunity to update the House on alternative forms of production of sugar beet, such as organic and the work done by LEAF and Rothamsted institute in this regard?
Lord Benyon (Con)
Excellent work is being done and I do not think we will be having this conversation in future years. I very much hope we will not. Enormous amounts are being done through integrated pest management. There is a variety of different breeding techniques and husbandry for sugar beet. So I very much hope that there will be no need for derogations in future.
Lord Stoneham of Droxford (LD)
My Lords, what assessment have the Government made of the health of the bee population in this country, and what contingency plans will they consider if it is deteriorating?
Lord Benyon (Con)
The Government have a pollinator strategy and work closely with the bee sector to make sure that our policies reflect the needs of pollinators right across the piece. The sustainable farming incentive, the key part of our ELMS announcement, has an integrated pest management part. These are the sorts of policy products that have come out of work that we are doing to enhance bee health across the country.
Baroness Jones of Whitchurch (Lab)
My Lords, does the Minister accept that this policy is making a mockery of the promise in the Environment Act to replace the use of toxic pesticides with integrated pest management techniques and low-toxicity solutions? How does the decision comply with the current need under law for pesticide products to have no unacceptable effects on the environment, when this clearly does?
Lord Benyon (Con)
I do not take that view, because we have massively increased the condition that we have applied this year. Last year, the derogation was not used because it did not reach of the already high 9%; we have raised that to 19% this year. There is a wider factor. If there is a catastrophic loss of yield, that sugar will have to come from other countries. Spain, France, Belgium and other EU countries have derogations with very few of the conditions that we have applied. We could damage our sugar infrastructure in this country—the factories that we need to produce sugar for our own population—and export the problem to countries that do not have our conditions and our determination to move towards integrated pest management.
Lord Ashton of Hyde (Con)
My Lords, the noble Lord, Lord Jones of Cheltenham, wishes to speak virtually. It is a good time to call him now.
Lord Jones of Cheltenham (LD) [V]
My Lords, Countryside Online tells us that the sugar beet industry supports 9,500 jobs, produces half of the UK’s sugar and is environmentally friendly because of the low number of miles beet travels from farm to processing plant to consumer. Mr Gove supported a total ban on neonicotinoids when he was Environment Secretary because they harm populations of bees and other pollinators. By allowing their use now, why are the Government breaking their promise to maintain high environmental standards?
Lord Benyon (Con)
My Lords, we are not. We are in exceptional circumstances, responding to an exceptional problem. We are imposing very high standards. I repeat that no flowering crop may be planted on land where this seed dressing is used within 32 months of treated sugar beet. There is a minimal effect on pollinators because sugar beet is not harvested after it has flowered. The other conditions that we have applied might well mean that it will not be used this year.
The Earl of Caithness (Con)
My Lords, my noble friend is absolutely right. The key thing is getting the balance between risk and benefit right. Can he confirm that this will be taken on sound scientific grounds and not on emotional grounds? The decision obviously has to be taken at the last possible moment. Does he foresee any logistical problems, as raised in the second Question today, with getting the chemical to the seed producers in time so that the decision can be made at the last possible moment?
Lord Benyon (Con)
I have not heard of any logistical problems. If the weather continues to be cold, it is unlikely that the threshold will be reached and that this will be required at all. If there is a large increase in aphids, which are the vector of this yellows virus disease, measures are already in place, but there is a very good chance that it will not be required to be used at all.
Baroness Whitaker (Lab)
My Lords, another study published in the Journal of Applied Ecology says that small gardens are at least as important as large ones for conserving bees and other pollinators. Are the Government doing anything to encourage small urban gardens?
Lord Benyon (Con)
We provide advice to beekeepers and work with trade bodies and organisations across the country, whether urban or rural. I take this opportunity to applaud the work of the London Pollinator Project, which, as the noble Baroness identified, is of enormous benefit to pollinators in urban areas. It is not just urban gardens; it can be in quite highly built-up urban areas.
Lord Trees (CB)
Does the noble Lord agree that plant breeding, facilitated by the novel gene editing technologies that are available now, is the progressive way to avoid chemical pesticide use?
Lord Benyon (Con)
The noble Lord is absolutely right. A lot of work is being done in organisations across the country—Rothamsted has been mentioned, but also the Roslin Institute and others in Scotland and England—where we are seeing the possibility of great advances, not through GMOs but through using and perhaps accelerating existing plant breeding techniques that will make these kinds of conversations seem very out of date.
Baroness McIntosh of Hudnall (Lab)
My Lords, in answer to my noble friend Lady Whitaker, the noble Lord talked about the benefits of urban gardens for pollinators. Of course, he is absolutely right. One of the reasons why pollinators are very well served by urban gardens is that there is the great diversity of plant life there compared with, say, mass agricultural areas. However, there is a problem with people concreting over urban garden space. Could he say what the Government are doing in conjunction with local authorities to discourage this practice? It is a problem not only for pollinators but for flood management.
Lord Benyon (Con)
The noble Baroness’s last point is the one where the Government can be most effective, particularly with building regulations and planning policy. It is hard to say to a householder, “You cannot get rid of a 10 by 10 lawn outside your house”, but we can design in green infrastructure. An enormous amount of work is going on across government to try to make sure that we are greening our planning policies and urban infrastructure to address precisely the point that she raises.
Building Safety Bill
Thursday 20th January 2022
(2 years, 3 months ago)
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Migrant Crossings: Role of the Military
(2 years, 3 months ago)
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Lord Coaker (Lab)
My Lords, following the failure of the Government to deal with record numbers of migrants crossing the channel and, rightly, the abandonment of policies such as wave machines and sonic booms, the Navy has been called in. What is the plan? Where are the ships that the Navy will use coming from? Can the Minister also clarify whether the awful policy of pushback is still government policy? The Minister in the other place said only on Monday that pushback remains an option, as has the Home Secretary, but the MoD apparently says that it is not. Who is in control? What is the policy? Although a naval ship might not be used, what about a Border Force vessel? This is a real crisis involving real people, with only a confused policy coming from the Government. It is time that they got a grip.
The Minister of State, Ministry of Defence (Baroness Goldie) (Con)
I am very proud to stand at this Dispatch Box once again on behalf of the MoD to say that, once again, the MoD is going to contribute to dealing with a crisis that has perplexed not just the Government and the Opposition but the public: the danger being encountered by migrants who seek to come to this country and have been enduring appalling experiences while trying to cross the channel. That is why the MoD’s primary role will be to ensure that all vessels transporting illegal migrants across the channel are intercepted before or as they land, preventing the uncontrolled arrival of migrants on UK shores. The Armed Forces will not be engaged in turnaround tactics.
Baroness Smith of Newnham (LD)
My Lords, the Minister was asked if she could say where the ships were coming from. Could she answer that question and say whether the MoD will be funding this new activity or whether the Home Office will pick up the tab, and whether there are not also diplomatic routes to try to ensure that, instead of stopping boats landing, the boats never leave the departing shores?
Baroness Goldie (Con)
The noble Baroness makes an important series of points. She is right, for example, that the Home Office and the FCDO will continue the primary discussion with France on the diplomatic front. I reassure her that Defence has a very strong relationship with France, and we regularly speak to our counterparts on matters of mutual interest. Funding will be required for this, and the Ministry of Defence is currently computing costs with a view to informing discussions with the Treasury. On the assets, we are dealing with a domestic situation in largely indigenous waters, and therefore the capabilities that Defence makes available for this task will be assets already permanently assigned and committed to operations in home waters, including offshore patrol vessels, P2000s and RHIBs.
Lord Craig of Radley (CB)
My Lords, it is very unlikely that the migration effort by people wanting to come to this country will cease. I must therefore ask the Minister how long the Ministry of Defence expects to be committed to this task. Is it indefinite or for a set period?
Baroness Goldie (Con)
I say to the noble and gallant Lord that the overall responsibility for dealing with immigration is cross-government. In so far as the MoD’s operational role is concerned, it will retain primacy of operational control until public confidence is restored and the number of individuals attempting to enter the UK through this route is brought under manageable levels.
Lord Lancaster of Kimbolton (Con)
Forgive me, my Lords, I am not clear from my noble friend’s Answer as to whether or not this task will be subject to MACA rules. If it is, can she reassure me that for once the MoD will remember to send the bill, as it does not always do so? Could she clarify exactly where this task sits in the order of priority of defence tasks?
Baroness Goldie (Con)
I reassure my noble friend that a keen eye will be kept on funding. As I said to the noble Baroness, Lady Smith, the MoD is currently computing costs to inform discussions with the Treasury—and, yes, we will certainly make sure that bills presented are paid. We are satisfied that this deployment does not in any way impinge on or prejudice our ability to carry out our broader MoD responsibilities on behalf of the nation.
Lord Dubs (Lab)
My Lords, the Answer suggests to me that the Government have not thought this through. It makes all sorts of vague comments like
“are currently being worked through”
and
“will be made known in due course”.
Has this even been discussed with the French authorities? Without co-operation with the French, we are not going to get anywhere. Lastly, the Answer keeps talking about “illegal” people. If they are refugees or claiming to be so then they are not illegal; they are people who have an entitlement to claim asylum status.
Baroness Goldie (Con)
I thank the noble Lord. I have endeavoured to refer to them as “migrants” because that is what they are. The MoD’s role is to assist the Government’s broader objectives in approaching immigration policy by dealing with this particular aspect in the channel, which has caused such concern and has been such a source of heart-breaking tragedy and worry to the migrants themselves. The noble Lord asked whether this plan had been thought through. Obviously, the detail has to be worked out but it is very positive that the MoD is gladly taking on this role, and Defence Ministers have committed to providing a Statement to both Houses once the plans for implementing defence primacy have been thoroughly worked through and refined.
Lord Alton of Liverpool (CB)
My Lords, has the Minister had a chance to look at the implications for her department’s actions under UNCLOS, the law of the sea, and will she assure us that we will always conform to it? Will she return to the debate that was held in your Lordships’ House two weeks ago today on behalf of Cross-Bench Peers that drew attention to the over 80 million refugees and displaced people in the world today, and to the calls from throughout the House to look not just at the pull factors but at the push factors and to co-ordinate cross-department activity and international activity in getting to the root cause?
Baroness Goldie (Con)
I reassure the noble Lord that, whatever the MoD does in its primacy of operational control, discharge of that duty will absolutely be done in compliance with international laws and the United Nations Convention on the Law of the Sea. The noble Lord is quite right that there is a much broader picture here that is shared by countries across the world, and he is correct to identify it as a need to be addressed in the hope that we can stop migrants setting off on perilous journeys in the first place.
Lord Hamilton of Epsom (Con)
My Lords, is the noble Lord, Lord Dubs, not right that until agreement is reached with the French to take them back, it does not really matter who picks them out of the water?
Baroness Goldie (Con)
What is important is that we have in place a plan to try to mitigate and prevent the misery that has been enduring, which I think has been upsetting to everyone. That is what this initiative is about.
Lord Paddick (LD)
My Lords, I can understand the impact on Daily Mail readers of the news that the Navy has taken charge, but I am not sure how many refugees seeking asylum in the UK read the Daily Mail. So what practical difference will we see—or, more importantly, will they see—in deterring refugees from crossing the channel in small boats?
Baroness Goldie (Con)
The involvement of the Navy is primarily to ensure that the dangers that have confronted migrants setting out on this hazardous course can be assuaged or even prevented from arising altogether. That is why the modus operandi will be one of interception and escort; the Navy will be responsible for bringing migrants to UK shores in a safe and controlled manner. That will prevent uncontrolled or undocumented arrivals.
Baroness Chakrabarti (Lab)
My Lords, Tobias Ellwood, the well-respected chair of the Defence Committee in the other place, has called these proposals “rushed” and a “massive distraction” for the military, but of course it is a massive distraction for the electorate as well. Does the Minister understand the fear that proposals to deploy the military against desperate refugees causes in refugee and migrant communities who are already here? This smacks not of the dog whistle but of the foghorn.
Baroness Goldie (Con)
I totally disagree. This is a positive intervention to, as I said earlier, assuage and prevent tragedy and make a positive contribution to helping the plight in which the migrants find themselves.
Baroness Hoey (Non-Afl)
My Lords, just before Christmas the French Government closed their borders to British citizens, seeming to be able to do so legally. Can the Minister explain to the British public how they can do that, yet we seem not to be able to stop migrants illegally coming into our country?
Baroness Goldie (Con)
As I said earlier, the broader issues of immigration policy are a matter for the Home Office and the FCDO, and the issues that the noble Baroness mentions are something that they are actively pursuing. The role of the MoD in respect of this immediate requirement, which I think is a positive participation and involvement, is to try to ensure that migrants who set out on these hazardous journeys are supported to safety in a controlled manner.
Commercial Rent (Coronavirus) Bill
(2 years, 3 months ago)
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Baroness Evans of Bowes Park
That the bill be referred to a Grand Committee on Thursday 27 January for debate before Second Reading.
Covid-19
(2 years, 3 months ago)
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Baroness Smith of Basildon (Lab)
My Lords, this pandemic has taken a huge toll on the physical and mental health of the nation, on businesses, on leisure and on our economy. Across the UK, people have made heroic efforts to care for, serve and protect others, from the staff and volunteers who have delivered an amazing vaccination programme to the NHS and to those who have kept schools, shops, hospitality and public services running, as well as all those who have stayed at home—and have not had parties—in order to protect others, and have missed out on special times with friends and family.
So we are all keen to get back to living and working as normal as quickly as possible. We welcome the overall fall in cases, hospitalisations and the death rate. This follows the success of the vaccine and the care that so many have taken in testing and in following the rules.
Yesterday, the Prime Minister announced that plan B measures will lapse throughout the UK. We do not want to see restrictions in place any longer than necessary. In response to a question yesterday from Keir Starmer, Mr Johnson agreed that he would publish the scientific evidence behind the decision. Can the noble Baroness today confirm that this has now been published and is publicly available and will she commit to ensuring that it is available in the Library of the House of Lords as soon as possible? I think she will understand, given the recent scandalous events in Downing Street with varying accounts from the Prime Minister, that public confidence can now be assured only when back-up evidence is available.
Although there are fewer cases and deaths across the country than there were last week and scientists are optimistic that omicron has peaked, does the noble Baroness accept that we still need to be cautious? In some parts of the country, cases are still rising though we hope they will start to fall. The health service, underresourced even before the pandemic, is facing enormous pressures with huge delays. Many appointments for surgery and treatment have been cancelled. The WHO and many scientists predict that there may be further variants into the summer and daily deaths are still over 350. The British Medical Association, representing those in the NHS front line, is concerned that given these factors the Prime Minister
“risks creating a false sense of security”.
I would be grateful if the noble Baroness could respond to this: what advice is now available for those shielding or people who are clinically more vulnerable regarding the move from plan B back to plan A, including on working from home and using public transport?
What is clear with all these factors is that we need a credible plan on how we can live with Covid, including any new variants that may emerge. The Government have to look past the current maelstrom they are experiencing and the focus must be on resilience to any future pandemics or future variants.
I do not know what the Government’s plan is—I hope the noble Baroness does—but we can offer some advice on the way forward that I hope she can respond to. The vaccination programme has proved its worth. We would retain an army of trained volunteers to always be available to support the National Health Service. We also have to work with other countries and international organisations to provide vaccines across the world, if we are to end the cycle of another new variant emerging just as we think we have dealt with the last one.
We know testing works. There has to be a national supply of test kits to avoid shortages so tests can be available when and where they are needed. Ideally, it would be good if the Government could look at the UK manufacturers, which are so keen to provide these.
I do not know how many times we have to say this, but the Government really must increase sick pay and extend it to all workers. It should never be a choice between keeping others safe by staying home or being able to pay the rent and the energy bills.
We cannot just keep talking about ventilation in classrooms, or indeed workplaces. I know the schools’ ventilation programme has eventually started—and that is welcome—but the Government have to move more quickly to ensure that all children can stay in school. Can the noble Baroness say when this programme will be completed and what percentage of classrooms or schools have now been included and seen their ventilation improved?
There are also a number of common-sense measures that, while not ideal or enjoyable, do not impinge too much on our daily lives—such as mask wearing in busy crowded spaces and basic hygiene measures to protect from infection transmission—that we should not be too quick to discard. Will the Government continue with public health messaging to enable this?
Finally, the death toll in the UK from this virus is devastating. It is over 150,000, which is one of the worst rates in the world. Despite the shocking errors in test and trace, the lack of NHS readiness at the start of the pandemic, and the problems that we saw with PPE supplies and contracts—which may be subject to ongoing legal proceedings—the vaccination programme and the adherence of the public, though not Downing Street, to public safety measures have been real game changers. Those two things—the public’s response and having a vaccine—have really made a difference.
At this point all our decisions must be based on moving forward with care, using sensible proportionate measures to learn to live with Covid. We need to do all we can to ensure that we do not again end up playing Covid hokey-cokey in lifting and then reimposing restrictions that none of us wants to see. I would be grateful if the noble Baroness can address some of these points. The key thing is that we welcome this but urge caution as well.
Lord Newby (LD)
My Lords, we obviously share the relief being felt across the whole country that the peak of the omicron wave seems now to have passed. However, Covid is not over. Yesterday, the ONS reported that one in 20 people in England caught Covid last week and government-reported cases still number over 100,000. The NHS remains pressured, with around 2,000 admissions per day, and last week there were 1,900 deaths.
We clearly need to learn to live with Covid, but that is not necessarily the same as going back to life exactly as it was before Covid. We need to remember that continuing levels of Covid, even at reduced numbers, will continue to fill some hospital beds. This delays treatment of everybody else, which is particularly significant given the 6 million people on the NHS waiting list.
This is the backdrop against which we have to judge yesterday’s announcement. The exact timing clearly has more to do with Conservative Party management and saving the Prime Minister’s premiership than concerns about public health or boosting the economy. While ending some of the restrictions, such as Covid passports, is to be welcomed, we have some reservations elsewhere, particularly on masks.
As everybody knows, masks are a cost-effective precaution that help reduce transmission of the virus and consequently reduce the pressure on the NHS and its staff. People have been asked to make tough sacrifices throughout the pandemic but, in our view, requiring people to wear a mask on public transport and in the shops a little longer to protect others is a small price worth paying. There are many, especially the clinically extremely vulnerable, who are concerned about travelling on crowded public transport or using the shops. Keeping masks in those crowded places will allow them to get on with their day-to-day lives with confidence in a way that they have not been able to do for virtually two years.
The Prime Minister said that
“we will trust the judgment of the British people”
on whether to wear masks. Given his own complete lack of judgment and moral authority, I suspect the consequence will be that mask wearing on the Tube and on trains will collapse. Before the latest restrictions, mask wearing on the Tube was under 50%. Today it is about 90%. Next week, I bet it will be back to 50% or less. In our view, to have permitted this at this point is a mistake.
As for masks in schools, we all want to keep schools open but with huge numbers of pupils still out of school, it remains hard to do so in some cases. As long as the evidence shows that masks are helping reduce these absences, we support heads who want to retain masks in their schools. If individual heads decide to do this beyond the end of this week, will the Government support them?
The real issue in schools is, of course, the Government’s failure to provide air purifiers in classrooms. I echo the noble Baroness’s question: how far have the Government got in their admittedly inadequate plans to improve the number of classrooms that have such air purifiers?
On ending the requirement to work from home, while going back to the office will be good and right for many, we would encourage employers to consider the wishes of their employees—as many of them are already doing. Can the noble Baroness say what policy the Government are adopting towards their own employees? Will they require all civil servants to return to their former work patterns or will they, like many private sector employers, show more flexibility?
More generally, this Statement—which unfortunately we did not have the benefit of hearing—is suffused with the kind of hyperbole and exceptionalism that we have come to expect from this Prime Minister. Given his abject failure to stick to the rules himself or to ensure that his own staff behave responsibly, to many ears this tone sounds more than usually ill-judged. It is too much to expect sincere humility from this Prime Minister. He should go.
The Lord Privy Seal (Baroness Evans of Bowes Park) (Con)
I thank the noble Lord and the noble Baroness for their comments on the positive news in this Statement that we have been able to move forward. I will attempt to address some of their questions.
I will ensure that the scientific evidence is placed in the Library. I am afraid I am not sure whether it has been published yet; it was said that this would happen this week, but I will check and make sure that it is available for noble Lords. I can say that we considered a range of data in making this decision, including data on infections, the effectiveness of vaccination, Covid pressures on the NHS, workforce absences, public behaviours and international comparisons, alongside the views from the scientific community. As the noble Baroness rightly said, the data is showing that Covid cases are falling and that the high levels of vaccination and booster uptake have helped reduce the risk of severe disease and hospitalisation, which, in turn, has helped reduce the pressure.
However, I completely accept what the noble Baroness and the noble Lord said and we continue to urge caution, because there are still around 1,600 Covid patients in England. They are both absolutely right: while we are very pleased to have been able to take this step forward, we all have to be cautious. I think we can all accept that the British people have shown that they can make judgments about what they are doing and how they can feel safe, and will continue to do so. It is thanks to their willingness to get vaccinated and the way they have thought of others as much as themselves that we have been able to get to this position. I would also say that hospital admissions have stabilised and the number of patients in ICU is falling, so the data is showing that we are moving in the right direction.
The noble Baroness asked about advice for people who have previously been shielding. There is now no specific advice and, as the noble Lord said, people will need to make their own judgments about how they feel and what they want to do.
The noble Lord asked about public transport. Operators of public transport can still require passengers to wear face coverings as a condition of carriage. I might be wrong, but I thought the Mayor of London, for instance, said that about the Tube yesterday, notwithstanding some of his comments. That option is still available; I believe the mayor has introduced it and obviously he did previously.
Masks will no longer be required, but the guidance suggests that individuals continue to wear a face covering in crowded and enclosed spaces where they may come into contact with people they do not usually meet. Again, it will be up to individual businesses and organisations whether they wish to ask their customers to wear face coverings. We think that, as we move towards an endemic scenario—we hope that this is becoming endemic, rather than a pandemic—we need to move towards guidance rather than mandated rules.
The noble Baroness rightly asked about our international efforts. She will know that we have been a world leader in ensuring that developing countries can access vaccines. Last month, we pledged £105 million of emergency aid to help support vulnerable countries and we met our goal of sharing 30 million doses by the end of last year. That benefited over 30 countries as part of our G7 pledge to donate 100 million doses by June.
In relation to support for individuals, we have committed over £344 million to ensure there are no financial barriers to isolating in England. The noble Baroness asked about statutory sick pay. We have made Covid-related statutory sick pay payable from day 1, meaning that it can be up to 75% more generous for full-time employees who need to self-isolate. We have also reintroduced the statutory sick pay rebate scheme which reimburses eligible businesses for the cost of statutory sick pay for Covid-related absences. Sick pay is one part of the support available, but people may also be eligible for the £500 support payment as well.
Both the noble Lord and the noble Baroness asked about schools. We have removed the requirement for face masks in the classroom, but directors of public health will be able to propose temporary recommendations for face coverings in communal areas across their area, or parts of it, in the event of a Covid outbreak and if the public health situation justifies it. On ventilation in schools, I can say that over 350,000 CO2 monitors have been rolled out across the school estate and the country to help in identifying poorly ventilated areas, backed by a £25 million investment. I am happy to say—I hope this provides some reassurance—that feedback following this shows that, in most settings, existing ventilation measures were sufficient. For the cases where maintaining good ventilation is not possible, 8,000 air-cleaning units are being rolled out across schools. That figure has gone up quite significantly and I am sure it will continue to do so if needed.
The noble Lord also asked about working from home. It will be up to departments to decide their own arrangements with their staff, but we are encouraging people to return to the office as a cross-government message, not least because I think quite a lot of people would like to come back and see friends and colleagues who they perhaps have not seen for a very long time.
The Deputy Speaker (The Earl of Kinnoull) (CB)
The noble Baroness, Lady Brinton, will speak remotely and I invite her to speak now.
Baroness Brinton (LD) [V]
My Lords, the Leader of the House just said that there is no advice for people who were formerly shielding, the clinically extremely vulnerable, but there is; the noble Lord, Lord Kamall, confirmed this to me last night. It says that this group should still consider meeting people only 14 days after they have been fully vaccinated, social distancing, asking friends and family to have rapid lateral flow antigen tests, asking any visitors to their homes to wear face coverings and not going into enclosed crowded spaces. Putting this guidance on a website is not the same as telling this group of people, or the wider public, especially their employers, directly that this group still need to take care. Will the Leader take this back and ensure that communications go to this vulnerable group of just under 4 million people?
Baroness Evans of Bowes Park (Con)
I apologise to the noble Baroness and will certainly take that back to government colleagues. I recognise what she says.
Lord Cormack (Con)
My Lords, there does not seem to be anything about future plans for boosters. We all acknowledge that the vaccination campaign has been a triumph, but we still do not know for how long the vaccine is efficacious. Are there plans for booster doses to be given annually or at other intervals?
Baroness Evans of Bowes Park (Con)
My noble friend puts his finger on it when he says that at this stage we do not know. However, I can reassure him that this will continue to be monitored. If it becomes necessary to deliver further boosters, we will of course do so. We will also need to be alive to the potential for different variants, which may involve other actions. I can assure him that we now have a wealth of evidence and experience and know, as in this very announcement today, how important vaccines and boosters are. That will certainly be at the forefront of our mind as we continue moving forward.
The Lord Bishop of London
My Lords, I thank the noble Baroness for her update. I believe that NHS staff who have not received two doses of the vaccine face dismissal from 1 April onwards. It is estimated that this will result in London losing something like 12.5% of its midwives, putting at risk the lives of pregnant women and their babies. Such a loss of staff may be thought to be justified were it not for the case that two doses of the vaccine are not understood to protect against the omicron variant of Covid-19. We shall lose precious midwives to implement a policy that has been superseded by the evolution of the virus. Will Her Majesty’s Government put the implementation of existing legislation on hold, given that it may now lead only to harm and not the good that it was designed to promote?
Baroness Evans of Bowes Park (Con)
I am sure the right reverend Prelate would also accept that unvaccinated healthcare workers increase the risk to themselves, their colleagues and the very vulnerable people in their care. It is our responsibility to help give everyone the best possible protection. I can say that the vast majority of NHS staff have been vaccinated: nine in 10 have already had their second jabs. The NHS will continue to support and encourage staff who have not yet been vaccinated to take up the offer. Since we first consulted on this proposal, the proportion of NHS trust healthcare workers who have been vaccinated with a first dose has increased from 92% to 94%, an increase of 75,000.
Baroness McIntosh of Hudnall (Lab)
My Lords, in the period since the pandemic began, we have learned that the protections we have all been routinely using, such as the wearing of masks, handwashing and so forth, protect not only against Covid but against a number of other common infections which themselves have an impact on workforces and absentee rates, and therefore economic outcomes. I want to take the Minister back to my noble friend Lady Smith’s point about public messaging. Rather than encourage people to see this as a moment of freedom from restrictions, is it the Government’s intention to remind them that, in certain respects—which as the noble Lord, Lord Newby, said, are not particularly onerous—if they continue to observe certain precautions, they will be protecting not only against Covid but against other diseases and infections that cause pressure on the NHS?
Baroness Evans of Bowes Park (Con)
I entirely agree with the noble Baroness. We will of course continue to do that and make sure we are getting the message out. As she rightly says, people can wash their hands and have better ventilation. We will absolutely continue to pass those messages on, nationally and, I am sure, within schools and other settings and in individual businesses. We are all used to the signs now, as we go around various places, and I am sure that will continue.
Lord Walney (CB)
My Lords, the Health Secretary claimed in the media this morning that the Government are actively considering removing the mandatory isolation period at some point in the near future. Presumably, if that goes ahead, it will place greater responsibility on lateral flow testing to show that you are negative, and so that would be an even more difficult moment to introduce charges for those tests, as the Government are also apparently considering.
Baroness Evans of Bowes Park (Con)
The noble Lord is right. As he says, the self-isolation regulations expire on 24 March. In the other place, the Prime Minister said yesterday that he expects them not to be renewed. Obviously, a final decision will be made nearer the time, but that is the intention. We will continue to provide free lateral flow tests for as long as is necessary. As the noble Lord rightly said, testing has been one of our most important lines of defence, and we continue to issue record numbers. At a later stage in our response, free tests will end, but there will have to be a balance; it is not something that will be happening imminently. We completely understand the value of lateral flow tests—all of us have seen it—but, as I said, as we start to move towards treating this as an endemic, things will need to change. That is something we will have to consider further down the line.
Baroness Blower (Lab)
My Lords, ventilation remains a distinct problem in very many schools up and down the country. So concerned have some teacher friends of mine been that they have bought their own air purifiers, given that the Government have not filled the gap. The Minister said that 8,000 cleaning units will be rolled out—that seems to me to be an extremely small number—but can she also say over what period these will be rolled out?
Baroness Evans of Bowes Park (Con)
They are being rolled out currently and will continue to be so. As I said in response to a previous question, 350,000 CO2 monitors have been rolled out. Notwithstanding the comments the noble Baroness made, feedback has shown that, in most settings, existing ventilation measures are sufficient.
Lord Scriven (LD)
My Lords, if we accept that we are going to be living with this virus for many years to come, we have to start being proactive rather than reactive. Ventilation affects more than schools; it affects public buildings and business buildings, where many people congregate. What is the Government’s view on changing building regulations, so that new builds start to deal with the endemic, rather than cause problems by not keeping people safe, and so help the economy to keep going?
Baroness Evans of Bowes Park (Con)
I am afraid I do not have an answer to that question, so I will go back to the department to try to find out, and will provide that information to the noble Lord.
Lord Patel (CB)
My Lords, I thank the noble Baroness the Leader of the House for repeating the Statement. Could she confirm that we will still continue with the vaccination of 12 to 15 year-olds? The JCVI recommends that the over-5s are also vaccinated. Now that the MHRA has approved the drug Paxlovid, which has been found to be highly effective in trials at reducing serious illness by 89%, do the Government have plans to purchase such drugs for those who might catch Covid in future?
Baroness Evans of Bowes Park (Con)
As the noble Lord will be aware, we have already purchased more antivirals than anywhere else in Europe, so we are on the front foot on this and will continue to be so. As new drugs become available, I am sure we will continue to do that. The noble Lord is absolutely right: we will be continuing to vaccinate those aged between 12 and 15. In England alone, we have already delivered over 1.7 million doses to that age group, and we are continuing to work on increasing take-up—for example, through repeat offers, ensuring information is translated into appropriate languages, and collaborating with leading social media platforms to direct young people and their parents to trusted sources of information.
Viscount Stansgate (Lab)
My Lords, one of the interesting things about the Statement is the complete absence of any reference to advice from the Government’s Chief Scientific Adviser, Chief Medical Officer or the Scientific Advisory Group for Emergencies, which is the Government’s chief advisory committee in the pandemic. Although the Minister says that the advice will be put in the Library of the House, can she assure us now that the advice received from the scientists accords with and supports the decision that the Government have taken?
Baroness Evans of Bowes Park (Con)
As I said in response to the first question from the noble Baroness, we considered a range of data in the decision-making and, of course, the views of the scientific community.
Baroness Altmann (Con)
My Lords, I congratulate the Government on their brave decision to relax the restrictions. I think many people who have been suffering severe mental health impacts from the pandemic will be relieved that perhaps we can start on a road to recovery and, as the noble Lord said, living with this virus. I go back to the question of the right reverend Prelate regarding mandatory vaccinations for NHS health staff. We are perhaps in danger of shooting ourselves in the foot if we get rid of loyal staff, and indeed many staff who are not even patient-facing, at a time when we face such a crisis in the NHS. There has already been a significant impact, as I understand it, in care homes and the social care sector.
Baroness Evans of Bowes Park (Con)
As I said in response to the right reverend Prelate, we are continuing to support and encourage staff who have not yet been vaccinated, and we are seeing more and more staff coming forward to get their jabs.
Health and Care Bill
Thursday 20th January 2022
(2 years, 3 months ago)
Lords ChamberRead Full debate Health and Care Act 2022 View all Health and Care Act 2022 Debates Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: HL Bill 71-V Fifth marshalled list for Committee - (20 Jan 2022)
“(j) fracture liaison services to identify people at increased risk of fragility fractures and prevent future fractures.”Member’s explanatory statement
This amendment ensures equity of access to Fracture Liaison Services for people with osteoporosis.
Lord Black of Brentwood (Con)
My Lords, Amendment 50 is supported by the noble Lords, Lord Hunt of Kings Heath and Lord Rennard, and the noble Baroness, Lady Masham, underlining the cross-party interest in and support for this vital issue. I am grateful to them. I note my interest as co-chairman of the APPG on Osteoporosis and Bone Health. I also support Amendment 101B in this group, on mental health, and much look forward to the debate on the other amendments.
Amendment 50 is, at heart, about equality of access to services for people with osteoporosis. If accepted, it would end the current appalling postcode lottery which means that so many people are suffering unnecessarily from the pain and distress of avoidable broken bones. It will do this by making the provision of fracture liaison services—FLS—one of the core services that an integrated care board must consider for the people for whom it has responsibility, alongside dental and ophthalmic services and others.
The Principal Deputy Chairman of Committees (The Earl of Kinnoull) (CB)
My Lords, the noble Baroness, Lady Masham of Ilton, is taking part remotely. I invite her to speak now.
Baroness Masham of Ilton (CB) [V]
My Lords, I have put my name to Amendment 50 and will speak also to Amendment 57. I am a member of the All-Party Parliamentary Group on Osteoporosis and Bone Health. I thank the noble Lord, Lord Black of Brentwood, for leading on this cross-party amendment.
Osteoporosis is a condition which can cause much pain and debilitation to many people, mainly women. Prevention is important and this is a condition which needs treating by a fracture liaison service. This service should be available to and in easy reach of patients who can be frail and elderly and whose bones can be easily fractured.
I would like to bring to your Lordships’ attention the case of the local hospital which serves the north part of North Yorkshire, a very rural area: the Friarage Hospital, Northallerton, which, sadly, over the years has been downgraded. It used to have an excellent orthopaedic unit; the senior consultant was a brilliant surgeon who unfortunately had to go back to South Africa. He was the brightest and the best. The health service needs leaders, and both staff and patients need up-to-date equipment for satisfactory outcomes. Now there is a visiting consultant, who wanted a DEXA scanner to save his patients the long journey to James Cook University Hospital in Middlesbrough. Many of the patients are elderly and frail. Transport can be a problem. The consultant did not get his DEXA scanner, which diagnoses osteoporosis. I thank the Minister for looking into this case after I tabled a Parliamentary Question.
The problem is upgrading with new equipment. This generally goes to the large hospitals. Women’s orthopaedic wards always seem to have to fight for what they need. A good fracture liaison service, which patients can reach, helps prevention of ill health and without doubt has benefits for everyone, especially the frail and elderly. If they are to be treated in an accessible clinic, near their homes, it must have the correct equipment and well-trained staff. I think it was Winston Churchill who said, “Give them the tools and they will do the job.” The big need at the moment is finding and retaining trained, dedicated, enthusiastic staff. They are the National Health Service’s biggest asset; without them, the job will not be done.
Amendment 57, in the name of the noble Lord, Lord Farmer, follows on well from Amendment 50, and I would like to say a few words on that amendment. It requires that
“health services are available in a community setting where possible, in order to improve access.”
At the moment, weekends are becoming very difficult in rural areas, such as the one where I live. From Friday afternoon to Monday, there is no GP service. On a Sunday, a young woman I know went with an eye infection to the nearest A&E department only to be told that it was not an emergency and she should wait and go to her GP. She did so and was given some eye drops, which were not the answer. When the eye infection worsened, she rang 111. They sent an email to the GP, as the infection had spread to both eyes. She was then sent to the eye clinic at the same hospital that had sent her away from A&E. She was off work for two weeks. Only if the correct treatments are available quickly can infections be treated and days off work saved.
The correct antibiotics for infections are so important to stop resistance to drugs. We also need a first-class pathology service, with test results coming back quickly. I do not think the public always realise what an important job these services do. I hope the failing health service in rural areas can be revived, where it is desirable to have a service in the community near where people live. We need the specialist health services as well—which may be miles away from rare diseases, serious accidents and illness. Wherever the best treatment is, the relief of being treated by experts who know what they are doing is unbeatable.
Will the Minister agree that there is a lot to do to get the health service back on the road post Covid-19? We all want to see it thrive. Thank you.
Lord Farmer (Con)
My Lords, my Amendment 57, which the noble Baroness, Lady Masham, has mentioned, is also supported by the noble Baroness, Lady Walmsley. I declare my interest as a director and controlling shareholder of the Family Hubs Network Ltd, which advocates for family hubs and advises local authorities on how to establish them. I am also a vice-president of the LGA.
In speaking to my Amendment 57, I would point out that in Chinese medicine you traditionally saw the doctor when in health. They were paid a retainer to keep you that way and, if you became sick, they would not be paid until health was regained. This speaks volumes about alternative health paradigms to our own. Even if we never go that far, the prevention of disease and the maintenance of health should be an overriding priority for the health service.
In placing the duty to prevent the development of poor physical and mental health directly under the duty to promote the NHS constitution, it is my intention to make it a similarly fundamental duty. Prevention is always better than cure. Yes, prevention is already mentioned in the Bill, for example in Clauses 5 and 16, and elsewhere in Clauses 20 and 59. However I do not consider that it is given sufficient weight, particularly given concerns shared with me by members of the Family Hubs Network.
Family Hubs Network members work with existing integrated care systems and note that the main issue faced by these ICSs is the management and throughput of the frail, elderly population to address bed-blocking and the onward delays to elective surgery. Hence they can lean towards an acute hospital reactive care model. Family Hubs Network members are already seeing the consequence of this with, for example, few if any ICS strategies focusing on population health through prevention and early help, especially for children and families.
Indeed, more and more ICSs are seeing community-based contracts swallowed up by the acute hospital conglomerates. They rarely, if ever, hold the necessary cultural understanding of community care, prevention and early help, and their interests do not lie in these. Children’s health services, which would ideally be delivered in the community, can be drawn into acute hospital structures which are more reactive than preventive in nature. Yet in some cases these very same services, such as continence, speech and language, allergies and others, are being delivered in community settings, close to families, through integrated family service hubs. Given that many of these health needs are also psychosocial and practical, accessing them from such settings enables families also to receive local authority-commissioned early help. This surely is integration in action.
My amendment also specifies that health services should be available in the community where possible, to improve access and help prevent conditions from worsening. A local-by-default approach would cut down the number of patients required to make prohibitively long journeys when a service could instead be delivered in a primary care or local authority setting. We need a reverse Beeching for healthcare, where we reopen community hospitals. Out-of-area specialist mental health hospitals, which remove people from the social networks which help them get better more quickly, were in the news again this week. Local units have closed and there is a lack of care in the community, even though this is a far less expensive option and the setting in which many prefer to be treated.
Returning to the issue of our ageing population, a reactive care model is completely unsustainable. Unless we focus on preventing big-ticket items such as diabetes, depression, anxiety and dementia—the list is endless—the cost of providing healthcare will keep going up year on year, by even more than it already does. A preventive paradigm would ensure greater ruthlessness about educating parents and healthcare workers about the psychotic effects of high-strength cannabis, for instance.
The eminent professor, Sir Robin Murray, recently said:
“I think we’re now 100 per cent sure that cannabis is one of the causes of a schizophrenia-like psychosis. If we could abolish the consumption of skunk we would have 30 per cent less patients”—
this was in south London—
“and we might make a better job of looking after the patients we have.”
In 2019, Murray’s research team reported in the Lancet Psychiatry their finding that south London had the highest incidence of psychosis in Europe and singled out cannabis as the largest contributing factor. He expressed concern that some liberal-minded parents would rather see their children smoking pot than drinking, without appreciating the potential associated dangers and the social and economic costs. These multiply with skunk, which is several times more potent than the drug they might have been used to in their day.
It is not just parents who need educating, including about higher-strength forms: experts say that cannabis addiction is treated by health professionals as a low-risk soft drug, yet, since 2005, there has been a 777% increase in the number of those aged 55 and over who need treatment for it. When cigarettes’ contribution to the development of lung cancer was firmly established, action to prevent smoking was taken despite it being fashionable and popular—more than 60% of adult males smoked; now that number is approaching 15%.
When there is incontrovertible evidence that something harms mental or physical health, a duty to prevent would mean that such damaging ignorance was no longer allowed to prevail. Ditto foot-dragging on access: mental health care in the community has been talked about since we began to close asylums in the early 1960s, yet it is still in the NHS long-term plan. I am keen to hear from my noble friend the Minister why prevention should not be given prominence as a duty in the Bill.
Baroness Hollins (CB)
My Lords, it is a pleasure to follow the noble Lord, Lord Farmer. I really appreciate his remarks about Professor Murray’s work and his interpretation of it.
This is a Bill about integration, but how much integration will it actually achieve? We have spoken many times about wanting health and social care to work better together, but there is a difference between collaboration and integration. The former achieves two separate systems that, while better aligned in, for example, their information sharing, still operate without particular reference to the other. Those who use both systems continue to straddle a divide between the two and, too often, fall between those gaps.
Integration, on the other hand, speaks of synergy and of systems that enable one another and close the divide between the two, so that people can move between them without the terrifying leap of faith that currently exists. This is what will truly make a difference for those who use these services.
Unfortunately, the Bill in its current form will struggle to bring about this true integration. It requires the production of only a health outcomes framework, which will simply entrench the divide between health and social care, as both will continue to pull in different directions with different objectives, which are often conflicting.
Currently, health and social care sectors work towards two different sets of aims: social care is led by the well-being objectives of the Care Act 2014, whereas the NHS is led by various objectives set out in documents such as the NHS constitution, the NHS Oversight Framework and the NHS Long Term Plan.
An integrated service would mark a major shift in how the two systems view their role in supporting those who use their services. For example, it could see the NHS adopting an approach that was informed by ensuring the independence of its patients in a similar way to the principles that lead the provision of care and support. The greatest problems have been caused when health and social care start to gatekeep their domains: I have had to speak too often about the abhorrent placement of people with complex needs in in-patient units far from home, as a result of catastrophically poor alignment of health and social care support to meet their needs locally. I declare an interest as chair of the Department of Health and Social Care-appointed panel to oversee the discharge of people with learning disabilities and autistic people who are detained in long-term segregation.
I want to thank Mencap and Skills for Care for briefings on my amendments in this group. My Amendments 85 and 88 would place greater emphasis on the provision and quality of social care services and on the integration of health and social care services. I also declare an interest as president of the Royal College of Occupational Therapists. This is relevant because occupational therapy is a health profession that is equally at home in the NHS and in social care, and because occupational therapists have a role in tackling long-standing health inequalities through community rehabilitation and in prevention.
The history of health and care integration is littered with a natural reflex towards health and the pressing political priorities of the day. The ICB is primarily NHS focused and will hold responsibility for strategic planning and monitoring of services against the needs of an ICS population, but the answers cannot all come from health alone. We are in danger of missing an opportunity.
A duty to promote integration must include adequate provision for both health and care by taking a holistic approach. The outcomes from one will impact significantly on the other. Viewing the duty to promote integration through a health lens alone limits our understanding of what social care has to offer—think back to the debate on my noble friend Lord Mawson’s amendment on Tuesday. In some areas, integrated care system planning seems to focus mostly on integration within healthcare and not on integration between and across health-led provision and social care. At present, provider alliances are largely acute trust led.
Let us take discharge co-ordination as an example. It is currently suboptimal, with too few care co-ordinators, a lack of social care representation and feedback in assessment decisions, and a neglect of the resources and expertise of voluntary and independent providers.
The staffing context is complex. According to Skills for Care, there are 17,700 organisations providing or organising care, delivered through 39,000 establishments. Some 41% of those are residential, 59% are non- residential and 68% are CQC regulated. More than 6,000 organisations have fewer than four employees. That is a very broad church of employers. Not only does it make it much more difficult to communicate but social care lacks the infrastructure of the NHS to disseminate and co-ordinate.
My amendments propose strengthened provisions for ICBs to consider how integration benefits and can benefit from social care. My Amendment 89 would require ICBs to develop and publish a health and social care outcomes framework at least every two years to ensure that health and social care services are properly integrated.
ICSs present an opportunity to co-ordinate services, improve population health and plan on a system-wide basis to attract and retain staff with the right mix of skills. The ICS role should therefore ensure that the right staff skill mix is available to deliver this singular vision, a vision of person-centred and outcome-based care through multidisciplinary teams operating with and around each individual. Integrated care would mean that people would only have to tell their story once to receive high-quality, joined-up and seamless care. The approach each system takes to workforce planning will rightly vary to meet local needs and requirements, but that does not mean that their workforce plans cannot be measured against a joint outcomes framework. In collaboration with partners, Skills for Care has developed principles of workforce integration which address the above points.
The aim of this amendment is to ensure that health and social care do not pursue two different sets of objectives but work to a common aim to underpin transformation. I ask the Minister to reassure the Committee on these points. I believe these amendments will be helpful.
Baroness McIntosh of Pickering (Con)
My Lords, I am delighted to follow the noble Baroness, who speaks with such knowledge and authority on these issues. I will speak to Amendment 110, but first I will make some comments on the amendments spoken to by the noble Baroness, Lady Masham, and my noble friend Lord Black.
The noble Baroness, Lady Masham, highlights the difficulties that those of us living in rural areas have. I regret to see the downgrading, in particular, of the Friarage Hospital in Northallerton, where my father, for one, was treated to great effect. I associate myself with the comments of the noble Baroness, Lady Masham. I know that the Minister is familiar with these arguments now, because he very kindly spent an hour with his team listening to me on these issues. Whereas before, national health policy used to recognise and measure rural health policy, particularly as regards rurality and sparsity of population, those markers have now gone.
The House will be familiar with my work with the Dispensing Doctors’ Association. I regret the fact that, whereas my father and my brother in their time would have been rewarded by the number of patients that they had on their list, and by the distance they had to travel from the surgery to visit patients in their own homes or when called out to an emergency, that has now gone. Much of the bread-and-butter income, as I understand it, for dispensing doctors and pharmacists in rural areas is made up from dispensing. So a separate argument to be had on another day is how, from the beginning of April, I understand, those reimbursements are going to come under the cosh. I will just leave that with my noble friend; I will ask for a separate meeting with him on that. I pay tribute to the work that dispensing doctors do in rural areas under these pressures and I am delighted to be working with them in this regard.
My noble friend Lord Black spoke eloquently on osteopenia. There is a cohort of people—mainly women—who, like myself, are diagnosed with osteopenia. I had not been in the House very long when, having broken one bone six months previously, I broke another. I was sent to the fall clinic where, unsurprisingly, we were mostly women being tested to see how likely we were to have a fall and break a bone. When my noble friend said that many women could die within a year of breaking a hip, I recalled that I was told that I had an 11% chance of breaking a hip. The good news, I suppose, is that I have an 89% chance of not breaking a hip, and that is something I cling on to.
I was put on a course—as I am sure others have been as well—of very strong vitamin D tablets. Since I completed that course, I have had no further treatment, but also no recommendations as to how to prevent the condition—in my case, and I am sure in the cases of other women—deteriorating into osteoporosis. I will just leave the Minister with the thought that, given the seriousness of the condition, those who are on the cusp of descending into osteoporosis itself should perhaps be given greater guidance.
Amendment 110 is intended as a probing amendment, and I am delighted to see that the noble Baroness, Lady Bennett of Manor Castle, has lent her support to it. I am very grateful to her for that. We had many debates on domestic abuse in the context of that Bill, now an Act, but domestic abuse remains a scourge in our society. While it is recognised as a crime, it is most often manifested initially in a GP’s surgery, not at a police station. In the context of the noble Baroness, Lady Hollins, describing the Bill as essentially an integration exercise, I believe it is important to see and recognise a victim of domestic abuse in a safe place or a safe haven—in a setting with trusted professionals, such as a GP’s surgery.
I am sure that the Minister will share my concern that there is currently no training for GPs or other health professionals enabling them, or expecting them to be able, to spot or treat an individual suffering from mental or physical abuse or to instruct them on how to engage with the police. Does he share my concern that that is indeed the case? I understand from Anne Marie Morris, my honourable friend in the other place who moved this amendment at that time, that Devon is the only health system to have a dedicated individual on the CCG board and a health and care strategy for victims of abuse. That strategy has improved health and care outcomes through training and other interventions. Surely, this should be rolled out nationally for other local health services to benefit from.
While it is welcome that the Government have agreed to take this issue into account—and I understand that the amendment was agreed in the Commons—I urge the Minister and the department to go further. ICBs should be mandated to have a strategy to deal with domestic abuse. I am sure that the Minister would agree that, if it is not mandated, it probably simply will not be done. Additionally, the role of the domestic abuse and sexual violence lead on the ICB is essential to spearhead the work in this area and to provide essential expertise. As there is only such a lead at the moment in Devon—who does fantastic work which can be seen first hand, and has been seen to help a number of related pilots roll out in that area—I would like to see this work rolled out throughout the country.
Amendment 110 therefore sets out a duty to prepare a strategy to support victims of domestic abuse using the services set out in that amendment. It asks for various consultations to take place not only with the local authority for the area within the integrated care board but with the domestic abuse local partnership board and other persons whom the integrated care board considers appropriate. I humbly submit that this is a gap in the Bill at the moment that Amendment 110 would fill.
Baroness Barker (LD)
My Lords, I will speak to my Amendment 297J in this group, but I will preface my remarks by returning to the purpose of this Bill. The stated purpose of this Bill is to promote integration of health and care services in order to reduce health inequalities and to promote better outcomes. I have chosen, in this amendment, to speak on the issue of HIV and AIDS services. I have spoken in previous debates about access to sexual and reproductive health services such as contraception and abortion. They are two services which we would do well to look at in considerable detail, because they are services addressing issues that cannot alone be solved by the National Health Service. They are services which will only be solved by not only integration but collaboration between health and social care. Having, like many Members of this House, discussed these issues for many, many years, I come back to the point made by the noble Baroness, Lady Thornton, the other day, that we are trying to seek integration and collaboration between two fundamentally different services. One is organised as a national and essentially top-down system, and the other is organised on a local and democratically accountable basis, with a completely different ethos.
At this point it is worth us taking advantage of the presence of the noble Lord, Lord Stevens of Birmingham, and noting what he said the other day about the National Health Service. He said—and I paraphrase—that one of the best ways to ensure that the National Health Service does what we expect it to do is to ensure that it has resources, and he is absolutely right. Would that people took the same attitude to social care—but they do not, and in the matters of both sexual health services and HIV services, we see in graphic and demonstrable terms the failure to do just that.
Turning to HIV services, it is important to note that although, overall, we have a very good story to tell on HIV in this country, and a reasonably good story to tell in the last few years as we are on a path towards the complete ending of transmission by 2030, we do have some problems. Last year, the number of people living with HIV in the UK rose to 106,000. In 2020, the number of people being tested at clinics decreased by 30%, and more so in black and minority communities, where late diagnosis, with all its complications, remains stubbornly high. However, there was a very great increase in online testing. HIV is an area in which there have been and will be, over the next few years, huge technological changes in diagnosis and treatment, which the NHS and social care should be up to speed with if we are to get to the stated aim of ending transmission by 2030—which we can do. The problem is that, at the moment, we have an increase in the rate of late HIV diagnosis—it was up to 42% in 2019—and we know the concomitant costs that that presents for the health service.
Anyone who has spoken to anybody involved in HIV services, be it in social care, local authorities or the NHS, will have heard exactly the same story since 2012. Just look at commissioning. HIV testing in sexual health clinics and community settings is commissioned by local authorities; HIV testing in GP settings, where it is clinically indicated, is commissioned by NHS England; HIV testing in GP settings as a public health intervention is commissioned by local authorities; HIV testing in secondary care, where it is clinically indicated, is commissioned by CCGs; HIV testing in secondary care as a public health intervention is commissioned by local authorities—keep with me, my Lords. Home testing, which is increasingly popular, is commissioned by local authorities and by Public Health England, for some periods, at some times in the year. Is it any wonder that it is a mess? We are not taking advantage of any of this and we are letting people down. The fragmentation in this area—even for people who have HIV, who are some of the savviest patients the NHS comes across and who are up to speed, sometimes in advance of their clinicians—is really difficult and does not make sense on any level; it does not make sense on a public health level or an individual level. I do not need to go into great detail, as noble Lords can work out for themselves all the consequences of that.
It is quite interesting to talk about one piece of work that the All-Party Parliamentary Group on HIV/Aids did. We did some in-depth research in south-east London, where there are some of the most advanced integrated care services for HIV. Even there, where there is very high prevalence and they know, largely, what they are dealing with and the populations where this is the biggest problem, they struggled to make sense of this fragmented commissioning picture.
I am not asking that all this funding be put into the NHS—most definitely not, because we all know that once money goes into the NHS, it never comes out again. I think there is a case to be made for increasing budgets, not least the budgets of local authorities, which have been slashed, in order for them to carry on doing what is important, which is getting to people long before they are anywhere near being any kind of medical priority.
What I am asking for in this amendment is a formal duty to collaborate. I have no doubt that the Minister will say that that is not necessary, but we cannot carry on as at present: we are badly wasting resources when we should not be. We have enough knowledge in this Committee of the levers that make decision-makers and commissioners change what they are doing, not least when they understand that there are new and more efficient ways to meet the needs of the population. I propose this amendment with no great sense of hope, but, if he does not accept it, I hope the noble Lord will at least understand that we cannot continue with this inefficient way of dealing with known issues. We must stop failing people when we could be sorting out the issues.
Lord Layard (Lab)
My Lords, Amendment 101B, in my name and those of the noble Baroness, Lady Watkins, and the noble Lord, Lord Alderdice, is a fundamental amendment to remedy the shocking imbalance between the provision of mental and physical healthcare. As was said in the debate last week, people with mental disorders who receive treatment are a minority—35% of children and 40% of adults—while for people with physical illnesses, the vast majority get treated. This is not parity of esteem; in fact, I think it is one of the greatest cases of discrimination in our public life. There is only one way to remedy it, which is that the funding of mental healthcare has to rise faster than the funding of physical healthcare. In other words, the fraction of NHS funding devoted to mental healthcare has to rise—it is a matter of simple logic. This is such a fundamental point of principle that it should be put into law.
The increase does not of course have to go on for ever, but only until the inequality has been eliminated and mental health is treated like physical health. In the words of the amendment, the rise should continue until
“people coming forward with mental health problems are as likely to be offered treatment as people with physical health problems”,
and, of course, to receive it within a period of time appropriate to their problem. Only then will we have achieved parity of esteem.
The amendment is a statement of principle. As we know, there are always problems of definition and interpretation with statements of principle, but such statements are common in our statute law. This is a sector, in financial terms, as big as the police service, and it is right that there should be legal principles governing it. If we want to secure justice for the sector, it needs a statement of principle. This is a stronger statement than any of those discussed last week, but if this is what we believe, it is what we should say.
The main argument for the amendment, as I have said, is one based on simple equity, but there is also a strong economic argument. Mental illness is mainly a disease of working age, while physical illness is mainly a disease of retirement. Half of all working-age disability and absenteeism is due to mental illness, so when we successfully treat mental illness, the savings to the economy and to the Exchequer are massive, especially when compared with the economic savings from the majority of physical healthcare. These economic savings were a key argument that led to the establishment of IAPT, Improving Access to Psychological Therapies, from 2008 onwards, and they have been verified in what has happened since in that service.
There is also another very important source of savings: savings to NHS physical healthcare. Psychological therapy has been shown to reduce the cost of physical healthcare for people with comorbid physical conditions. This can be seen in a major nationwide controlled trial done recently, which provided IAPT treatments to people with long-term physical conditions such as diabetes, CVD and COPD. This trial found that, within a year, the savings on physical healthcare covered the total cost of the psychological therapy—so the mental health service is saving money for the physical healthcare service. As a result, this approach is now being rolled out nationally.
So mental health is a classic case of spend to save, and extra spending is desperately needed. Some of it would fill the massive gaps in existing services, including for severe mental illness, and some of it would provide services to key groups of people who are barely helped at present, many of whom were referred to earlier in this debate.
First come the tragic children who fall below the CAMHS threshold, who are sometimes assessed and sent back home as not sick enough, but who desperately need help. For these young people, the Government are developing mental health support teams in schools, but the rollout is incredibly slow and the services also need to include a much higher level of expertise.
Then there are millions of people whose lives are wrecked by addiction to drugs, alcohol and gambling and who need psychological therapy. There are the victims and perpetrators of domestic violence, who have already been mentioned, and other forms of violence. So many of our social problems have a strong mental health component. There are good, evidence-based psychological treatments which NICE recommends for these problems, but they are not provided. They should be provided. Extra spending on mental health could massively improve our society.
There is one further point in the amendment. If we spend the money, we need to know what it is achieving. In IAPT we know the progress of 100% of those treated, but in most parts of adult and child mental health services we currently have very little quantitative data on what is being achieved. That has to change, so universal routine outcome measurement should be a reasonable quid pro quo for extra funding, but the extra funding is crucial. It is not enough to talk about parity of esteem. We must have a clear statement of how to recognise it and the funding principles to achieve it.
Baroness Watkins of Tavistock (CB)
My Lords, I rise to speak to this group of amendments with an emphasis on Amendment 101B, in the name of the noble Lord, Lord Layard, whom it is a pleasure to follow.
Last night, I went to the ballet and saw “Raymonda”, which has been placed in the context of the Crimea. It reminded me that Florence Nightingale took a hammer to a store-cupboard to get food and blankets for some of her patients because nobody knew what was inside it. She went on to be a leader in sound data for health- care, recognising that without data we could not plan for the future. This amendment emphasises measuring the outcomes of mental health nursing and other mental health interventions in order to ensure that we learn from practice and develop best practice cost-effectively. That is why I have put my name to Amendment 101B.
We need to look at similar patterns for care to those for physical illness. For example, the onset of paranoia and delusions which threaten the safety of an individual or those close to them could perhaps be equated with a suspected cancer where you wait for two weeks for an initial diagnosis. How many people are sectioned under the Mental Health Act for assessment because they have not managed to get an out-patient appointment for assessment earlier? I believe that is an example of discrimination against people with severe mental health problems. If we could get parity of access for assessment, it would be an extremely good beginning. I recognise that there are other physical and mental health problems that are less urgent, but I use that as a comparison.
Yesterday at a meeting concerning mental health reform after the pandemic, the Minister for Care and Mental Health Gillian Keegan and the chief executive of Mind were panellists. At that meeting, it was noted that investment in NHS mental health services currently increases year on year, largely due, I think, to action under the leadership of the noble Lord, Lord Stevens of Birmingham. It was £11 billion in 2015-16 and is £14.3 billion today and it will continue to increase, including an additional £2.3 billion by 2023-24. It was said yesterday that the Government will ensure ICBs will increase spending on mental health in their area in line with growth in their overall funding allocations to meet the mental health investment standard. To address backlogs, the Government have published their mental health recovery action plan backed by an additional £5 million to ensure that the right support is in place. This illustrates that the Government are committed to the improvement of mental health services. The amendment would place a duty to monitor this investment and evaluate its effectiveness. I hope that the Minister feels able to support the principle behind the amendment and will meet those of us interested in this area to try to find a summary solution to the issues we are raising on parity not only for mental health care but for the care sector that has been outlined so comprehensively by my noble friend Lady Hollins.
All the points that were made by the noble Lord, Lord Black of Brentwood, concerning osteoporosis could be made for drug-induced psychosis, schizophrenia and other severe mental illness problems. I hope that this Committee will be able to influence an amendment to the Bill that will ensure that the monitoring outlined in the amendment introduced by the noble Lord, Lord Layard, will be taken forward.
Lord Hunt of Kings Heath (Lab)
My Lords, I have added my name to Amendment 50 tabled by the noble Lord, Lord Black, but I want to say how much I agree with Amendment 297J, tabled by the noble Baroness, Lady Barker, about the mess we have between local government and the NHS on sexual health services in general and the HIV services that she mentioned.
My view is that local government has a choice. It either accepts that it is part of a national service here and agrees to earmark funding allocations, or the service will have to go back to the NHS. The current situation is not working. Some local authorities are having to take on the responsibilities of others because some local authorities are not spending sufficiently. There is a movement of people, largely into the big cities, and it is an unfair system. We have to do something about it.
I also support the noble Baroness, Lady McIntosh, in her Amendment 110. Anyone listening to the debates during the recent passage of the domestic abuse legislation would have noted that one of the big challenges is the lack of integration among local agencies. I am afraid the NHS is a part of that and the noble Baroness’s amendment would give a very clear indication to the NHS that we expect more of it.
I have no doubt that, in winding, the Minister will say that Amendment 50 is not necessary because there is already a general duty on the NHS to provide fracture liaison services and the department is doing all it can to encourage the NHS to implement them. However, the dilemma for us is that the positive outcomes from those services have been known about for many years, yet progress in moving to the standard adoption of them through the country is very slow indeed.
As far back as 2010, the Royal College of Physicians produced an audit of the quality of clinical care of patients who had fallen, had a fracture and had been seen in a hospital emergency department. It reckoned then that only 32% of patients with a non-hip fracture received an adequate fracture risk assessment. Just 28% were established on anti-osteoporosis medication within 12 weeks. As a result, the Department of Health incentivised primary care services to initiate these treatments for relevant patients, but, by the end of the first year of that scheme, fewer than one in five patients were receiving the treatments.
Baroness Finlay of Llandaff (CB)
My Lords, this has been a really interesting debate and it made me think of Aneurin Bevan’s original vision, which incorporated the concept of dealing with the problem and then secondary prevention in rehabilitation and concepts of convalescence. After this debate, I am tempted to go back and read again In Place of Fear, because it is a very short book but it is worth reading.
There seems to be a theme coming through here really strongly. If we do not integrate these services and pull them together, we will never get not only the primary prevention but the secondary prevention which, as the noble Lord, Lord Black, highlighted, is so important. You do not just fix the problem; you prevent the next set of problems coming along.
I was slightly alarmed to note that in 2018 alone, there were over 6,000 deaths attributed to falls. A lot of those were on stairs. They were just simple trips on steps, yet they resulted in deaths. It took me back to when I worked at the Westminster Hospital, which, of course, is no longer across the road. Somebody tripped on the steps of the Tate and subsequently died from a head injury after hitting the concrete. One sees that at stations and so on, too, and we now see it with these scooters, where people scoot into trees and lampposts.
Anyway, to return to the subject of the amendments, the reason for my Amendment 100 is precisely to promote that rehabilitation and remind everybody that rehabilitation is not just a medical and nursing issue. It involves many different professionals, and volunteers quite often, at different levels. A rehabilitation plan at the ICS level could provide the co-ordination required, across different settings and services, to properly support early discharge from hospital, provide access to multidisciplinary teams and incorporate the psychological support that is needed. At the moment, things are organised in condition-specific medical silos, and we have already heard about the fragmentation of provision.
We need to respond more effectively to the needs of people with long-term conditions. When we come to measure outcomes, it is much easier to immediately measure the outcomes of an intervention. The outcomes from long-term secondary prevention are much more difficult to measure and quantify, particularly in a population that has multiple pathologies. So there has been poor data collection in part because it has been very difficult.
A simple example is that NICE guidelines suggested that over 1 million people with COPD every year should be referred for pulmonary rehabilitation, but only 15% are referred. We need to understand why. These are people who are breathless. They are getting chest infections and becoming oxygen dependent—so the consumption of NHS resources goes up. After a stroke, people have very marked rehabilitation needs in many different areas. That may be physiotherapy, occupational therapy, speech and language therapy and so on, going much more widely.
We also have a problem with our housing, because many people are not in accommodation that is suitable for them to go to when they are discharged from hospital. It has been estimated that there are 10,000 people in hospital at the moment who do not have a suitable home to go back to—hence the problem of where they go after hospital. So it is not only about providing a social care workforce to go in. We have already debated last week the problem of housing.
I do want to speak specifically to Amendment 51A in my name and the name of the noble Baroness, Lady Jolly. That is about having responsibility for every person present in an area. If we take the south-west, which is dependent on tourism, it goes from relatively low populations to absolutely bursting at the seams with holidaymakers. We have all seen it. These areas have an additional problem: when people are on holiday, their guard is down, they are less vigilant about what they do and they are less risk averse. Going back to falls, they are much more likely to have a fall or an accident. People fall off cliffs, fall down surfaces and so on. All of a sudden, in the tourist season, these people are at higher risk of something going wrong. They often go away and forget to take their medication, or they take something that interferes with it and end up with different side-effects and so on. They put a huge pressure on the emergency services in the area, so I am quite concerned at the way the funding might flow, in the way this Bill is written. We could inadvertently find that some areas are incredibly pushed at certain times of the year because of the way the population moves. I hope that will be taken into consideration.
Baroness Whitaker (Lab)
My Lords, following the impressive, high-calibre tour d’horizon from the noble Baroness, Lady Finlay of Llandaff, I rise to support the importance of proper and full rehabilitation as in Amendment 100, again supported by the Royal College of Speech and Language Therapists. Perhaps I should have declared, at my last intervention in Committee, that I speak as a vice chair of the All-Party Parliamentary Group on Speech and Language Difficulties—I apologise.
Very briefly, an annual plan, as in Amendment 100, would ensure that rehabilitation is explicitly integrated. Rehabilitation spans many disciplines, as the noble Baroness, Lady Finlay, said. It is what enables those who have degenerative diseases, strokes, cancer, autism and learning difficulties, to name only a few, to communicate—how essential is that for even minimal well-being?—as well as helping people to, for instance, swallow without choking and stay alive. As ever, it is the vulnerable who suffer when these structural underpinnings to ensure joined-up, consistent care are not there. I hope the Government will adopt these amendments.
Baroness Harding of Winscombe (Con)
My Lords, first, I apologise for arriving a little late for this debate. I hope that your Lordships will allow me to add my voice of support to this group of amendments.
We all come to this Bill with the same intentions and belief that collaboration and integration are the future for a health and care system. This group of amendments tackles the uncomfortable reality that, despite everyone’s best intentions—both in our NHS and in local government social care and even in the private sector—to collaborate and deliver integrated care, we are not doing that. A number of these amendments practically point at ways in which we can move from the rhetoric to practical change.
I particularly support Amendment 101B, in the name of the noble Lord, Lord Layard. As a great economist, he is pointing us in the direction of an economic structure and nudge that will force us on to a path to do what we have all talked about for a long time, which is to create parity of esteem between mental and physical health. We debated the importance of mental health in great detail last week, so I do not wish to repeat that, but I want to add my voice to that of the noble Lord in supporting his amendment because it is very practical.
By creating a ratchet that gets us on to a path whereby inch by inch—week by week, month by month and year by year—we start to close the gap between physical and mental health provision, we would start practically on the path that we want to go on without creating a funding hole. This would allow the NHS and our overall health and care system to go step by step at an achievable pace, while recognising that we come out of the Covid pandemic with such enormous physical health waiting lists that achieving parity of esteem will be even harder than it was two years ago, so it is even more important that we force a mechanism in. The second element of this amendment would also force outcome measurement.
This is a very smart and simple amendment. I know that my noble friend the Minister cares deeply about this agenda, as does the Secretary of State, and I urge them to adopt it.
Lord Rennard (LD)
My Lords, I draw the Committee’s attention to my registered interests in healthcare equipment. I have added my name to Amendment 50, moved by the noble Lord, Lord Black of Brentwood. The noble Lord, Lord Hunt of Kings Heath, demonstrated clearly, as have others, that it simply cannot be said that the amendment is unnecessary.
The recent report on fracture liaison services from the APPG on Osteoporosis and Bone Health makes important reading. It shows clearly that the health and independence of tens of thousands of older people who suffer from osteoporosis are threatened by great inconsistencies in accessing vital services and treatment. Far too many people are suffering multiple fractures before their condition is properly diagnosed. Much unnecessary pain is caused and more permanent disability results from failures to diagnose osteoporosis in thousands of cases. Those failures add significantly to the future costs of the NHS and care system than would have been the case with early diagnosis.
The Committee has already heard from the noble Lord, Lord Black, of the significant cost savings to the NHS where a fracture liaison service is in place. The Royal Osteoporosis Society estimates that extending fracture liaison service provision to cover the whole population would require a modest initial investment of about £27 million in England and £2 million in Wales. There should be much more long-term cost-benefit analysis of provision such as this, and it would more than justify those sums of expenditure.
There are many examples in preventive healthcare where focused interventions dramatically improve outcomes for patients and cut long-term costs. We need to raise awareness of conditions such as osteoporosis, provide more education and training for healthcare providers about diagnosing it and increase support for people who suffer from it. Osteoporosis is a long-term condition. It is more prevalent than many people realise and we should all recognise that a spinal or hip fracture is equivalent to a heart attack or stroke in terms of its clinical implications. Fractures are often preventable through use of pharmacological treatments supported by lifestyle modifications, which include appropriate exercise and smoking cessation as well as nutritional supplements such as calcium and vitamin D.
There needs to be much greater public awareness of how to maintain or improve bone health, particularly for the most at-risk populations. The introduction of integrated care boards will provide an opportunity to better co-ordinate and integrate fracture prevention and osteoporosis care. It is currently too dispersed across different parts of the system, as so often our short debate on this group of amendments has shown is the case. For fracture liaison services we need universal access. We need a clear mandate from government that the new boards have a specific responsibility to provide fracture liaison services for the whole population.
Baroness Pitkeathley (Lab)
My Lords, it is clear from the number of noble Lords wishing to speak in this debate that this group of amendments is extremely important. I want to speak particularly in favour of the amendments from the noble Baroness, Lady Hollins, about integration, which she put before us so eloquently.
In the 40-odd years that I have been working on these issues, I have never heard anyone say anything other than that collaboration would be a lot better than the current situation and that collaboration between health and social care is absolutely vital. Everyone always says that, and in recent years we even have had the hope that, when the Department of Health changed its name to the Department of Health and Social Care, we would begin to see more movements towards integration. Sadly, little progress has been made.
If one asks any patient about integration between health and social care, they think that it already exists. Most patients have absolutely no idea about different jurisdictions, how one sorts out a medical bath from a social bath or how different pots of funding ensure different points of view. That is, of course, until the patients start to find their way around the system in the way in which the noble Baroness, Lady Barker, brought so amusingly to mind. The lack of incentives to integration in the Bill are disappointing. I have not seen anything in it that will stop 15-minute visits by overworked and underpaid care staff or any ideas about integrating services and having much better integrated budgets—still less about data sharing. Those are all the things that we need if we are truly going to move to proper integration.
As the noble Baroness, Lady Barker, reminded us, at a time when waiting lists for the NHS are growing longer by the minute, should it not be a priority to ensure that no one stays in hospital longer than they have to by having discharge procedures that provide a seamless transition and making sure that the all-too-frequent readmission because of inadequate co-operation between the NHS and local authorities does not happen? We hear that care jobs are unfulfilled and that requests for care are turned down because of staff shortages. Local authorities struggle to recruit enough workers to meet increasing demands. No wonder that that is the case when one can earn more by filling shelves at Sainsbury’s.
A truly integrated service would mean that, the minute that someone is admitted to hospital, plans should be being made between health services, social care and the often-ignored but often significant voluntary services about what is going to happen on discharge. Sadly, the usual pattern is for a conflict to emerge, usually on a Friday afternoon, between a hospital ward desperate to empty beds and social care services inadequately prepared or even informed. What happens? The person goes home, the care services are not adequate and so the person is readmitted to hospital. I know someone in my local area in Herefordshire, an elderly lady who has been admitted 14 separate times since last July, and still care services to keep her adequately at home are not provided.
The Bill is a failed opportunity because we are seeing social care once again as the poor relation, the tail-end Charlie, that is considered after everything else is settled. Social care could be at the heart of a levelling-up agenda if we had a vision for its workforce and the impact that it has on the health of a community in the broadest sense. Care providers could be encouraged to diversify their businesses to reach out creatively into the community by providing tax incentives, for example, or reductions on business rates. If we want a high-skill, high-wage economy, what better place to start than social care, with its huge workforce badly paid but certainly not unskilled? Those skills could be developed by providing training, and retention could be dealt with by better career progression and recognition of qualifications. It is sad that we are not looking at practical ways in which to develop that integration in the Bill.
Fixing social care requires two things: money and better integration. We will come on to money later in the Bill. For the moment, I hope that the Government will give proper recognition of and acceptance to the amendment on integration in the name of the noble Baroness, Lady Hollins.
Lord Warner (CB)
My Lords, I will speak briefly in support of the amendments in the name of the noble Baroness, Lady Hollins. I had intended to put my name to them; I apologise to the noble Baroness for being so slow off the mark. I also strongly support the amendment in the name of the noble Lord, Lord Layard.
Both these amendments, in their different ways, go some way to righting what I consider to be two big wrongs inflicted on local government in the past, where responsibilities have been transferred to it but have not had their funding sustained into the future. The first was the closure of long-stay hospitals in the 1980s and 1990s. When I was a director of social services, I was the NHS’s favourite person when building provision and making available services for people coming out of long-stay hospitals. After a few years, I and my many colleagues became forgotten men and women because the money that was transferred was never maintained in real terms over a couple of decades.
Fast-forward to the 1990s and the setting up, with much enthusiasm, of the Roy Griffiths community care changes. These enabled the Government to get off the hook of an expanding social security budget. It was another repeat performance: the money was not maintained in real terms in the longer term. What we saw in both cases was local government having to pick up the tab without support from the Government—successive Governments, that is; I am not making a party-political point—to ensure that those services could be maintained for the people who became the responsibility of local government.
The amendments in the name of the noble Baroness, Lady Hollins, remind people that there is an obligation to make sure that both health and social care produce good outcomes for the people who are now primarily the responsibility of local government, which, as the noble Baroness, Lady Pitkeathley, gently reminded us, has been underfunded over a long time in terms of maintaining these services. The amendment in the name of the noble Lord, Lord Layard, is another righting of a wrong and we should all get behind it.
Lord Scriven (LD)
My Lords, I support Amendments 85 and 88 in the name of the noble Baroness, Lady Hollins.
We must be clear. The previous two speeches highlighted the elephant in the room: you cannot have integration on a sustainable basis unless you reform health and social care together. We have to be honest with ourselves that this Bill is predominantly about the reform of healthcare.
That was highlighted eloquently in the speech by the noble Lord, Lord Hunt, in response to my noble friend Lady Barker, about who should commission sexual health services. These have been lobbed to the side of the commissioning silo but it should be about how to break down this silo so that we have joint and sustainable commissioning around outcomes, rather than around which silo or which part of the health and social care framework should deal with it. It is the elephant in the room, but we are where we are so we must make this Bill better knowing that that is the real issue.
This is about three little words: social care services. It is clear to those who understand health and social care that the Bill has been written predominantly through the lens of healthcare. I do not blame anybody for that but clearly this is a healthcare commissioning reform Bill, with a little tinkering with the structure, and does not deal predominantly with those people who do not understand social care—unless they are asking for an NHS long-term care package, when the argument tends to be about not the care provided but the funding, including who is going to fund what part. That is when it affects people’s outcomes. Those three little words are really important, which is why the noble Baroness’s amendments are important. If they were accepted, the Bill would actually say that social care service and health outcomes are jointly important.
It is important that this is about integration. The noble Baronesses, Lady Pitkeathley and Lady Hollins, said that there is a significant difference between collaboration and integration. You can have two people collaborate but, if their silos send them in different directions, the outcomes will not be joint. The real issue is how we bring about integration. It will not solve all the problems but it will help to bring about the first stage of integration if you have a joint framework on outcomes for which both healthcare and social care are held accountable. That is why Amendment 88 is so important.
The Bill’s intention goes in the right direction but the three amendments in the name of the noble Baroness, Lady Hollins, will significantly help in that journey. They will not solve the problems fully but they are an important way to say to people who work in health and social care that they will be held responsible for the outcomes of individuals, whether their needs come under healthcare or social care. That is why I support these amendments.
Baroness Tyler of Enfield (LD)
My Lords, I support Amendment 101B in the name of the noble Lord, Lord Layard. Before I speak to it, I want to say how much I agree with the sentiment expressed by noble Lords on all Benches that true integration will be achieved only if the Bill is as much about social care as it is about health. It is such a fundamental point that I wanted to underline it.
I see Amendment 101B as an important continuation of our deliberations last week on parity of esteem because “parity of esteem” are simply meaningless words unless they are reflected in the provision of funding. First, like the noble Baroness, Lady Watkins, I acknowledge the welcome fact that NHS England has met its commitment to ensure that the increase in local funding for mental health is at least in line with the overall increase in the money available to CCGs through the mental health investment standard. It is also welcome that, from 2019-20 onwards, as part of the NHS long-term plan, that standard also includes a further commitment that local funding for mental health will grow by an additional percentage increment to reflect the additional mental health funding being made available to CCGs. I recognise all of that.
But—and it is a big but—the investment standard relates only to CCGs, and that total spending had already declined in 2019-20 compared with 2018-19 as a percentage of total NHSE revenue spend. Also, given the urgent need for healthcare, which, as other noble Lords have said, has been much exacerbated by the pandemic, this amendment would help strengthen the consideration of mental health services when large amounts of money are announced for Covid recovery—this is welcome—but it all falls outside the remit of the mental health investment standard.
We need to know how much of the money is currently going to preventive and community services—prevention is the overarching theme of this group of amendments—as opposed to acute services. We also need to know whether the spending increases we are seeing are simply because crisis services are so in demand; indeed, they are overwhelmed in some cases. We know from a recent survey by the Royal College of Psychiatrists that two-fifths of patients awaiting mental health treatment contact emergency or crisis services, with one in nine ending up in A&E. That is not a sustainable position.
Baroness Bennett of Manor Castle (GP)
My Lords, this has been an extremely rich and informative debate on a diverse set of amendments. My contribution will be fairly brief, but I want first to reflect on the comments of the noble Lord, Lord Scriven, about the elephant in the room. He reflected on many other contributions about the lack of real integration of health and social care in the Bill, and the way the Bill is essentially written for health. I do not disagree with that identification of that elephant, but a second giant creature in the room is being ignored—let us call it a mammoth—which is the lack of adequate funding and numbers of people for health and social care. That means that those silos are seeking to defend their funding and resources, and reserve it for what they see as their core functions. They therefore find it very difficult to reach out and stretch into new areas even where that would have huge net positive impact overall.
To reflect on a couple of other things, I heartily endorse the call from the noble Lord, Lord Farmer, for a reverse Beeching for the NHS with the reopening of community hospitals. I am not sure whether he coined that phrase; I might borrow it, if he does not mind.
I will also comment on Amendment 51A in the names of the noble Baronesses, Lady Finlay and Lady Jolly, about emergency services going to everyone in the area. I see that the noble Lord, Lord Davies of Brixton, is in his place. This very much ties in with an amendment that he spoke to on Tuesday. He told a tale, which I will not repeat, about a case in which someone was denied a treatment in a neighbouring area that they desperately needed because of arguments about which area they were in. This is potentially a huge problem with the structure we are creating that has to be taken on board. Amendment 51A deals with the responsibility, but of course there also have to be funds to go with that responsibility.
It has not got a lot of attention, but I also commend Amendment 100 in the name of the noble Baroness, Lady Finlay, on the duty to promote rehabilitation. When we talk about dramatic medical interventions—the high-profile stuff—it is generally acknowledged, but always as an afterthought, that the person who has had that big dramatic intervention will not suddenly be cured tomorrow, in most cases. There is a long process of recovery. Indeed, I have put on my reading list Recovery: The Lost Art of Convalescence by Dr Gavin Francis, which has been glowingly reviewed in many places. That is something we all should be thinking about a lot more.
Finally, I come to Amendment 110, in the name of the noble Baroness, Lady McIntosh of Pickering, to which I attached my name because, as the noble Baroness said in her introduction, this is something that we have addressed again and again in the police Bill and the Domestic Abuse Act, but it is very acutely an NHS problem. I draw on an article from the Nursing Times on 24 December. It is an account of a nurse, who was called Claire in the article. When she was going through a checklist with a patient that had been provided by a charity—this was something extra added in from the outside, not core NHS—she realised that she herself was a victim of domestic abuse. She had said yes to more of the questions than the patient had. That is a demonstration of what the noble Baroness, Lady McIntosh, said: training is not given to medical professionals to see what is happening to themselves and to their patients. Maybe it is added in because a charity has managed to get something into the system, but it will certainly not be across the system.
We hope we are doing this Bill for the long term—although perhaps we are not so certain, as the noble Lord, Lord Hunt, said—but we have to note that this is happening in the context of the Covid-19 pandemic. I note that the NHS sexual assault referral figures for the first half of 2020 dropped significantly. That also picks up a great deal of domestic abuse, yet online searches for domestic abuse were up by 350% in the same period. We have an NHS that has been forced to focus on the Covid-19 pandemic, often drawing away resources that might have started to deal with domestic abuse anyway. We have a huge rise in the problem. Considering the moment we are at now, it is crucial that domestic abuse is in the Bill.
Baroness Walmsley (LD)
My Lords, this is an enormously important debate because it deals with my favourite word in health and care: prevention. Prevention is so important because it is cost effective. Although successive Governments give more and more to health services, no Government will ever be able to give enough to the NHS, because we have an ageing population and innovative medical interventions are getting more and more expensive, unless we do things differently and more cost effectively.
The noble Lord, Lord Black of Brentwood, outlined one very good, cost-effective intervention. It is an excellent example of something that has absolutely powerful evidence of its cost effectiveness but which is not being undertaken everywhere. I would like to know what evidence those areas that are not using fracture liaison services have that their way of doing it is better and more cost effective. I do not think they have that evidence. It is an example of where if you do not mandate it they will not all do it, and then they will not be spending their money effectively. I support the noble Lord’s amendment.
It is also very important that we prevent not just the second fall but the first, because, as the noble Baroness, Lady Finlay, said in her very important intervention, including what she said about tourist areas, which is very significant, people do die from falls. I had a very old friend who recently did. It was the first fall. I am afraid that person died because he had internal bleeding that nobody spotted. It is really important.
My noble friend Lord Rennard mentioned something really important that is pre-primary intervention: health education. If you know that you are likely to have good, strong, healthy bones from weight-bearing exercise and a diet that has enough calcium and vitamin D, you are much less likely to have the first fall. Fortunately for the Minister, that is beyond his remit. I am sure he is pleased about that, because he has quite enough to do. The Department for Education should listen to that.
My noble friends on these Benches have highlighted some other areas where effective prevention services are not being done properly. I think we were all struck by the chaotic situation that my noble friend Lady Barker highlighted; something really has to be done about that. A lot of good has been done but a lot more could be done, and, again, it would be cost-effective.
The noble Lord, Lord Layard, has suggested a very cost-effective intervention. If we diagnose and intervene on mental health issues early then we can prevent all kinds of more severe mental and physical health problems. I support the ratchet method that the noble Baroness, Lady Harding, referred to of increasing the amount of funding that goes there. Although the noble Baroness, Lady Watkins, rightly listed the number of times that the Government have put more money into mental health services, the question is: have they kept up with the demand and the backlog? I do not think they have.
We have an opportunity in the Bill to improve our measures to prevent ill health, as well as treat it, which is of course more cost-effective, especially when services are delivered by small social enterprises working at community level. I have added my name to the amendment from the noble Lord, Lord Farmer, because I believe these prevention services should be available as close as possible to those who need them most. If that does not happen then the people who need them will not access them, and health inequality will continue.
That is particularly important for those communities where health inequality is at its worst and where preventable diseases are most prevalent. For example, the services might include healthy weight management services, therapies to address less severe mental health conditions, and alcohol and drug addiction services, in addition to the usual GP services. The population groups are not just those in poverty but marginalised groups such as homeless people, those in temporary accommodation, refugees, Gypsy and Traveller communities, and others who may not be plugged into regular services, and that includes those in rural areas.
Many of these services are delivered very effectively by social enterprises or charities, where any surpluses are ploughed straight back into more services. Many of them also provide weekend services, which were mentioned as lacking by the noble Baroness, Lady Masham. Boards that do not ensure the survival of such services are really missing a trick that would help them to deliver their duty to level up health inequalities, because these organisations are usually very close to their communities and know exactly what is needed and where. They are not constrained by the regulations or the culture of large organisations, and are therefore more flexible and fleet of foot, and therefore very cost-effective.
On rural areas, I shall give your Lordships a brief example from my noble friend Lady Jolly, who lives in a very remote part of Cornwall. She says:
“We have a satellite surgery in our local village, it is in the ground floor of an old cottage. The pharmacist visits once a week, and a practice nurse visits once a week. When she is seeing a patient they have to switch the radio on so that no one can hear the conversation”—
because of patient confidentiality. In that village you have to drive 20 miles to reach a GP. That is the sort of place where we really need community access to health services of all kinds. It would be nice to think that the ICB would be aware of that and act accordingly, and it might perhaps be worth putting a duty in the Bill.
Baroness Thornton (Lab)
My Lords, this is an assortment of amendments that are all linked to the core of the Bill, which is about integration. The issues, as ever, are about whether it is appropriate to place such a detailed level of specification in the Bill, and where.
Amendment 50 seeks equity of access for fracture liaison services. In many ways the amendment by the noble Lord, Lord Black, supported by my noble friend Lord Hunt and others, is about the balance between a national mandate and local delivery in order to ensure that there is equity of access—in this case, for fracture liaison services. I would be interested to learn how the Minister believes such a thing could be implemented and assured, and in how we can best express that in the Bill.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
My Lords, this has been a fascinating debate, covering issues around prevention, as the noble Baroness, Lady Walmsley, said, and talking about what we mean by integration and how we make sure that it is more than just a word. I remind noble Lords that we have a forthcoming paper on integration as part of the overall package of the Bill, and a social care paper as well.
The noble Baroness, Lady Thornton, mentioned culture and attitude. I think it is very important to recognise that you can change structures and have legislation but you have to make sure that the culture and attitude are right across the system. I say to noble Lords that we fully sympathise with the intentions and I hope I can offer some reassurance.
In my departmental job as Minister for Technology, Innovation and Life Sciences, I feel very strongly that one way to drive integration is through better use of data across the system. Even before we look at integrating with social care, the NHS as it is at the moment is not sharing data well across the system. There are still a number of inefficiencies. I really believe in the digital transformation agenda and will give a quick example of that.
Just before Christmas, at a time when the NHS was under extreme pressure, I had my annual check-up in two parts. One part was an ECG at a local community centre; the second was supposed to be a telephone conversation with a consultant a week later. When the phone call came from the consultant, he started talking and I had to stop him. I said, “Have you seen my ECG results?” and he said, “No. What ECG? When was that?” I said, “This is all part of the same appointment. Can I now give you the date and time when I had it so you can look at the results?” “Don’t worry about that,” he said, “we’ll just have to make a new appointment”.
This was at a time when the NHS was under extreme pressure, as it is every winter. That shows the challenge. Even though we have been talking about the integration of health services since 1948, we still have these problems. That is why I believe so strongly in the digitisation and data-sharing challenge. It is not just because I am a geek and love technology; it really can make a difference, save money and lives and mean a more effective service all around.
I start by addressing Amendment 50 on fracture liaison services. Fracture liaison services and fragility fracture prevention are recognised by NHS England as critical to both healthy ageing and elective recovery. Within its high-impact restoration strategy, NHS England recommends that all systems optimise the secondary prevention of fragility fractures. NHS England is working closely with stakeholders to support the implementation of secondary fracture prevention services where they do not exist already and to support sustainability and quality improvement where services exist. Once again, this will rely on good data being shared across the system.
There are already duties in the Bill to require ICBs to commission such services. As fracture liaison services aim to identify people at risk and therefore prevent future fractures, their provision would already be covered in Clause 16 under new Section 3(1)(h), which places a duty on ICBs to commission such services or facilities for prevention, care and aftercare as the ICB considers appropriate. As I hope noble Lords will agree, it would be inappropriate to be overly specific in setting out the services to be commissioned as part of the new Section 3 that would be inserted by Clause 16, given the wide range of services the NHS needs to commission. However, I hope I can give assurances to noble Lords that NHS England will continue to monitor this and ensure that ICBs are commissioning effective fracture services. I hope we continue to drive this data being shared appropriately.
I turn to Amendment 51A. It makes sense that people should be able to receive emergency treatment wherever they are, as the noble Baroness, Lady Thornton, alluded to. We believe that is already the case. Once again, data would make a huge difference. If I am in Newcastle and fall off my bike and am taken to hospital, and if I have an existing condition, would it not be great if the clinicians when they triage me could know about it? I have asked my local GP practice to share my data on the app and it still has not done it. The mechanisms are there but the culture and attitudes are a huge challenge for whichever Government are in power.
The Bill confers a power on NHS England to publish rules that determine the people for whom each ICB is responsible. Those rules must make sure that everyone registered in the area, or everyone who may have need of services, is looked after. The Secretary of State may make regulations expanding that responsibility or creating exceptions where necessary. This was the case with existing CCGs and will continue under the ICBs. I hope I can reassure your Lordships that these regulations will be replaced to ensure continuity in this between CCGs and ICBs,
I now turn to the noble Lord, Lord Farmer, and his amendment. I also thank him for sharing his wisdom and his experience of family hubs. It is incredibly important. We agree with the spirit behind Amendment 57. We fully agree that, generally speaking, as the noble Baroness, Lady Walmsley, said, prevention is better than cure. One of the things that I have been reassured by in my early conversations in my role as a Minister for Health is the number of people in meetings who have said that they want to move towards a focus on prevention. That is not avoiding cure. We have to tackle cure, of course, but we can avoid a lot of that and save resources and time and promote better health and healthy living if we focus on prevention.
There are also duties in relation to the improvement of services for the prevention of illnesses as well as a duty to obtain appropriate advice, which expressly includes a requirement to seek advice from people with expertise in the prevention of illness. The NHS is already working hard to prevent ill health but, once again, we have to make sure that, in this prevention, people are all talking to each other, we are learning from best practice, and ICBs and trusts are learning from each other. As a number of noble Lords have made clear in their contributions in Committee, the issue is wider and social prescribing, for example, and other issues are really important.
Commissioners have also developed good practice, including funding alcohol care teams and tobacco treatment teams in hospitals, and expanding the diabetes prevention programme. This was re-emphasised in the NHS Long Term Plan, which contained commitments for the NHS to focus on major causes of ill health such as smoking, poor diet, high blood pressure, obesity and alcohol and drug use.
I remind noble Lords that prevention is not simply also a matter for ICBs. It involves local authorities and sometimes law enforcement authorities. It is a multiagency approach, led by local authorities but with ICBs, the NHS and other agencies playing their role.
I acknowledge the point that my noble friend made about cannabis and young people and I will write in more detail about that rather than take up time now. But we also have to look at such issues in the round. For example, in the United States Michael Cannon of the Cato Institute wrote that a lot of drug enforcement or anti-drug policy disproportionately affects young black men who then get thrown into the criminal justice system. How do we tackle that? One of the interesting conversations I have had with the noble Lord, Lord Paddick, was about his experience as borough commander in south London, an area that my noble friend mentioned. He gave the example that young black men in possession of drugs were far more likely to be picked up than a white middle-class male or female.
We have to make sure that we look at this as a whole. When we look at the tackling inequalities strand that we all feel so strongly about, we have to make sure we get the right balance. It is, of course, very difficult on a case-by-case basis but we have to be aware of unintended consequences.
On the integration duty, we are sympathetic to the intent behind the amendment from the noble Baroness, Lady Hollins, and support greater integration between health and social care. We hope that we can make sure that stakeholders work together and that, with all the papers, we are able to push through this integration.
Baroness Thornton (Lab)
I hesitate to take the words of the noble Baroness, Lady Hollins, away from her, but she is talking about putting a duty for this integration in the Bill. That is the way forward. Assurance is not the point here. I think we have gone past the point of needing assurance. We have been assured about this for years. This is about the duty.
Lord Kamall (Con)
I was just about to come to duty, so I thank the noble Baroness for hurrying me along.
Lord Scriven (LD)
I do not think that the Minister really understands. Yes, there may be a duty on local authorities. The amendment tabled by the noble Baroness is basically a duty to promote integration. At the moment, the Bill says that:
“Each integrated care board must exercise its functions with a view to securing that”
health services are provided in an integrated way. The amendment says “and social care”. It then justifies at what point that integration must be done. Why does the Minister feel that not putting this in the Bill somehow strengthens the main aim of the Bill, which is to look at the integration of health and social care for individuals who are going through a health and social care episode?
Lord Kamall (Con)
The Bill complements these existing duties by placing an equivalent duty on ICBs to integrate the provision of health services with the provision of health-related services and social care services, where this will lead to improvements in quality or reductions in inequalities. Taken together with the wider introduction of integrated care boards and integrated care partnerships, this gives the NHS and local authorities the best platform on which to build new ways of working. New provisions in the Bill will also complement and reinvigorate existing place-based structures for integration between the NHS and social care, such as health and well-being boards, the better care fund and pooled budget arrangements. We will, of course, be listening throughout the passage of this Bill to other ways in which we can facilitate the NHS, local authorities and others to work together to deliver integrated care for patients and the public.
Lord Scriven (LD)
I am sorry and will not delay the House much longer, but this is a really important point: the heart of the Bill.
As the Bill is written at the moment, the only integration that the integrated care board is responsible for is to ensure that health services are integrated. That means integrating primary, mental health and acute. It does not say that it is for the integration of social care. That is exactly what the noble Baroness is trying to achieve. As this is written, is it not the case that the duty in the Bill is for the ICB to secure that only health services are integrated?
Lord Kamall (Con)
One of the reasons for the introduction of integrated care boards and integrated care partnerships is to give local systems, both NHS and local authorities, a platform on which to build new ways of working. That includes social care. If the noble Lord feels that this duty is not explicit enough or that we should bring it out, we should have further conversations.
Lord Hunt of Kings Heath (Lab)
The architecture is very curious regarding why we must have an integrated care board and integrated care partnerships. It has never been clear to me why the Government have not attempted to set up a health and care board to bring those services together. We know that the funding systems will be different and that there is a clear difference between free at the point of use and means-tested social care, but surely that is what an integrated board, jointly owned by the NHS and local government, with councillors at the table not officers, is trying to sort out. Why have we ended up with this nonsense of a structure? We are carrying on with health and well-being boards as well. That is the great puzzle here.
If the Government are not willing to move on that, we must come back to the point made by the noble Lord, Lord Scriven. By splitting it, you then must say to the integrated care board, “Ah, but in your duties, you must ensure that you integrate with social care as well.” It really is a mess. The Minister said earlier that this is what the NHS wanted. Yes, this is an NHS Bill designed by NHS managers with a focus on the NHS. I do not know why it is called a care Bill, because it has nothing to do with care.
Lord Warner (CB)
Before the Minister responds to that, can I amplify what is being refused here by the Government? As I understand it, he is trying to rely on the Care Act to get local government to co-operate and integrate care with the great elephant, the NHS. This is asking a minor player to take on a major player with far more resources. Amendment 89, tabled by the noble Baroness, Lady Hollins, makes the NHS come back every two years about the outcomes. That is a fairly modest challenge to the NHS and I fail to understand why the Government cannot simply accept that in principle and then negotiate the drafting.
Baroness Walmsley (LD)
I am so sorry to delay the Minister again, but briefly. After we have pushed this Bill through Parliament, we will have an integration Bill and a White Paper and legislation on social care. When we have had this, those and those, can we come back to this?
Lord Kamall (Con)
These are all building blocks. I thought that might get a laugh.
In response to the noble Lord, Lord Hunt, ICPs were the idea of the Local Government Association, and we want to ensure that they work with the ICBs. Also, we must recognise that local authorities are accountable to their local electorates and fund many of the services for which they are responsible from local taxation. While we encourage local authorities and the NHS to work together as much as possible and pool their budgets where it is beneficial for local people, we are not mandating this, as this would probably require significant shift in how local authorities are held accountable for managing their money. One of the reasons why we have this strange ICB-ICP partnership is to ensure that it is at the right level and, beneath that, to have the health and well-being boards at place level. I sense the strength of feeling in the Committee, and I see the noble Baroness, Lady Hollins, giving a wry smile.
Baroness Hollins (CB)
I love this debate—it is brilliant—but it makes the point that this is an ideal opportunity to pre-empt a later Bill and get on with the job now where it belongs. Given the strength of feeling in the Committee, if we cannot reach a solution to this, I will bring it back on Report.
Baroness Barker (LD)
My Lords, I feel for the Minister in his position. He is right: people observing our proceedings will see us laughing, but in practice this is really serious. I talk to colleagues in local government who receive endless requests from the NHS to turn up to meetings and they do not go, and why? It is not because they do not think that it is important, but because local government has been hollowed out over the last 10 years to the point where it has very senior management and front-line staff, and does not have large numbers of people in the middle doing middle-management planning jobs that exist in the NHS. That was the reality before Covid and is the reality now. Each of those building blocks that the Minister is putting in may be some great stepping-stone to a nirvana for the NHS, but they are just another obstacle for local government. It is so important that we in this House are not tied to constituencies or particular areas of importance. Speak truth to power—to the Government. We are building something unsustainable that will not work.
Lord Kamall (Con)
I thank the noble Baroness for her sympathy for my role. Debates like this are important. They give the Government a measure of the strength of feeling on particular issues. It would be blind for me not to acknowledge the strength of feeling and the support for the noble Baroness, Lady Hollins. As I have done with some of the other issues discussed in this debate, I will take this back to the department and call a meeting of those who are interested, as we did for mental health, and hopefully we can have a discussion to find a way forward. I thank noble Lords for expressing the strength of their feeling. It is very helpful to know where we can focus time and resources as we try to get this Bill through and ensure that it is workable and leads to the integration that we all want to see.
I will also add that NHS England intends to assess ICBs, as I does CCGs. This may not be reassuring, given some of the strength of feeling about NHS England’s drive behind the Bill. The CQC will also make assessments of ICSs and systems, and part of that will be to consider how health and social care are working together.
I will now talk about rehabilitation—not of my career but of health. Our intention with this legislation is to establish overarching principles and requirements, while allowing ICBs space and discretion. This means avoiding being prescriptive, wherever possible. I am sure that noble Lords acknowledge that. Looking at the duties on ICBs that are relevant here, the first—in Clause 16—requires an ICB to arrange for the provision of the listed services it considers necessary to meet the needs of those for whom it is responsible. This includes aftercare which, in turn, includes rehabilitation. The ICB is also required to develop a joint forward plan, setting out how it will meet the health needs of its population—which should consider rehabilitation. ICBs are also under a duty to seek continuous improvement in the quality of care. That of course has to include rehabilitation. We hope that, without legislating for the production of a separate annual plan, ICBs will be required to provide, and improve provision of, community rehabilitation services.
I turn to Amendment 101B. I can assure noble Lords that the Government fully support the increased focus on mental health spending. I thank noble Lords who met with me earlier this week to discuss some of the issues around mental health and how we make sure that it gets the profile it deserves. We are trying to move towards parity between mental and physical health, and indeed all other types of health service. If I may, I will leave that there for now. If we have to continue the conversations about mental health, those who were not invited to this week’s meeting might like to drop me an email to let me know if they are interested in joining the meetings, and I will make sure that the Bill team invites them.
I am trying to get through this as quickly as possible. Turning to Amendment 110, I thank my noble friend Lady McIntosh of Pickering for the conversations we have had on inequalities, particularly in rural areas. A number of noble Lords alluded to this. I should also like to record my thanks to noble Lords in the Committee and in the other place who have campaigned so strongly on this issue. We have listened. The amendments already accepted in Clause 20 have directly addressed the need to consider victims of abuse, including victims of domestic and sexual abuse.
Clause 20 ensures that integrated care boards and their partner NHS trusts and foundation trusts set out a joint forward plan for any steps that the ICB proposes to take forward. As the noble Baroness, Lady Barker, said, we also have to make sure that this is not seen as just an NHS issue. We want to make sure that we work more widely with all agencies in the area to tackle these issues. For these reasons, we do not feel that a separate strategy is necessary in the Bill. Also, the accepted amendment is more comprehensive. It covers all forms of abuse. There are also duties on CCGs to consider the needs of victims of violence, including a joint strategic needs assessment. CCGs must respond to these, and this will be transferred to the ICBs.
Under the Government’s new Domestic Abuse Act, local healthcare systems will be required to contribute to domestic abuse local partnership boards. It is also worth noting that the Government are undertaking wider work to protect and support victims of domestic violence. Clearly, further action is needed beyond the NHS. In particular, the Police, Crime, Sentencing and Courts Bill will require action from across government, and we will ensure that this work is aligned as much as possible.
The proposed amendment would place a requirement on ICBs to have a domestic abuse and sexual violence lead. We agree with the principle, but we think we can do this effectively through existing legislation and guidance, as set out in the Government’s recent violence against women and girls strategy. My department will engage with ICBs and partnerships to make sure that we have appropriate guidance.
Beyond ICBs, there is a huge opportunity for ICPs to support improved services for victims of domestic abuse, sexual violence and other forms of harm through better partnerships. I hope that I have given noble Lords some assurance about this.
Lord Black of Brentwood (Con)
My Lords, even by the standards of your Lordships’ House, this has been an exceptional debate. The noble Baroness, Lady Pitkeathley, said that this is a really important set of amendments which go right to the heart of the Bill. They cover a remarkable range of issues. I, for one, am profoundly grateful to all the speakers who have taken part.
I think we all have some sympathy for my noble friend the Minister. He will have heard a number of messages loud and clear. I would like to mention the powerful contribution from the noble Baroness, Lady Masham, with her very important personal insights on the issue of fractures and the problems in rural communities. The noble Baroness, Lady Hollins, gave us a comprehensive view of the integration of services. It certainly struck a chord with me, as I am currently grappling with the problems faced by an elderly friend who is seriously ill and for whom these issues are very real and distressing. My noble friend Lady McIntosh told her own story of osteopenia, which underlined how vital early diagnosis and treatment are.
I thank the Minister for his comprehensive response. I think we all welcome his comments on data and digitisation. These are obviously good, but it is not just about data or monitoring, nor about building blocks, however important they are. It is about structures and obligations, and about effective integration being written into the Bill.
I am afraid that the elephant in the room, identified by the noble Lord, Lord Scriven, is still sitting out there. The Minister will have seen the strength of feeling of the House. As he said, there should be further conversations, which I think everybody would welcome. Otherwise, these issues will come back on Report.
It is essential that we tackle the issue of bone health and, as the noble Lord, Lord Rennard, said, this Bill is the right place to do it. The noble Lord, Lord Hunt of Kings Heath, summed it up superbly. We have known the benefits of proper prevention for a very long time, but progress has been at a snail’s pace. There was no answer to that point. In purely economic terms, as well as for the care of individuals, this is—in the vernacular—a no-brainer. If we do not make progress, we are letting down patients, taxpayers and the NHS.
I hope we can make further progress on all the points that have been raised by noble Lords in this extraordinary debate. In the meantime, I beg leave to withdraw my amendment.
“3AA Duty of integrated care boards to commission approved treatments(1) This section applies where—(a) a treatment has been approved by the National Institute for Health and Care Excellence,(b) an integrated care board has not arranged for the provision of that treatment under section 3 or 3A, and(c) a clinician has recommended that treatment for a person for whom that integrated care board has responsibility.(2) The integrated care board must arrange for the provision of that treatment to the person for whom it has responsibility.(3) In subsection (1) “clinician” means a medical professional employed by or acting on behalf of an NHS Trust, NHS Foundation Trust or primary care service from whom the integrated care board has arranged for the provision of services.”Member’s explanatory statement
This amendment would require an integrated care board to arrange for the provision of a NICE-approved treatment to any patient whose NHS clinician has recommended it, even if that treatment is not otherwise available to patients in that ICB area.
Baroness McIntosh of Pickering (Con)
My Lords, I will speak particularly to Amendments 54, 74 and 97 in this group. I warmly thank the noble Lords, Lord Patel and Lord Hunt, for lending their support to all three amendments, and the noble Lord, Lord Warner, for supporting Amendment 74. I pay particular tribute to the noble Lord, Lord Patel, and his historic work prior to the setting up of NICE; it was a great contribution that deserves to be recognised.
We are all aware of the procedure that, when a medicine is approved, it goes through two processes. First, it goes to the Medicines and Healthcare products Regulatory Agency, known as the MHRA, a body which checks whether a drug is safe and effectively does what it says on the tin. It then goes through a separate process run by the National Institute for Health and Care Excellence, known as NICE, which looks at cost-effectiveness and value for money. After those two hurdles have been passed, the medicines should, theoretically, be accessible to anyone. That is very clear in the NHS constitution, which explains that there is a legal right for people to have access to NHS NICE-approved drugs if it is right in their particular circumstances that they should. Indeed, the NICE guidelines say very clearly that there should be automatic adoption within 90 days of approval, if clinically appropriate and relevant.
For a drug then to be prescribed, it must not only have been approved by NICE but go on to the approved list of drugs in the local health authorities, called a formulary. The problem is that somebody must put the drug on the formulary and, currently, while in theory there is a system under the NHS NICE guidelines, this does not actually happen. Sadly, this results in a postcode lottery where some areas have the product on their formulary and others do not. Sometimes this is a process failure, but sometimes it is to avoid budget overspends. Therefore, I would say that it is at the patient’s expense that they are deprived of the drug.
To give an example of the problem, there is currently a drug for multiple sclerosis that patients are still waiting after 150 days to see go on to the formularies in around 25% of the local health systems across the country. There is a state-of-the-art flash monitor for type 1 diabetes, but the uptake across the country varies between 16% and 65%. What is most worrying is that those parts of the country with the greatest levels of deprivation have the lowest level of uptake.
I make a plea to the Minister: in my view, ICBs should be required to ensure that all NICE-approved medicines and devices are available and promoted to their population, because the cost of these drugs is covered by the VPAS reimbursement scheme agreed between the NHS and the pharmaceutical industry. If a treatment is unavailable in one ICB footprint, they should be required to commission the required treatment from another ICB. The Government should also promote uptake through the ICBs of NICE-approved medicines and report uptake of new medicines annually.
Amendment 54 would require an ICB to arrange for provision of a NICE-approved treatment to any patient whose NHS clinician has recommended it, even if that treatment is not otherwise available to patients in that ICB area. Amendment 74 would require ICBs to ensure that all NICE approvals are available and promoted to their population via a publicly accessible format, normally online, and to report on their uptake annually. Amendment 97 would mandate integrated care boards and healthcare providers, notably hospital trusts, to update their formularies to include all NICE-approved medicines or devices within 28 days of market authorisation, to ensure they are available for healthcare practitioners, through either their physician, for example, or prescribing pharmacist, to make available for suitable patients.
I thank those who submitted briefings to me while I was preparing for today, notably JDRF, which makes a number of recommendations on this issue, particularly in regard to type 1 diabetes. These aim to reduce inequalities, remove the postcode lotteries to which I referred and make sure that treatments, such as those for type 1 diabetes, are uniformly available across the piece. I also thank EMIG, a pharmaceutical trade association for small and medium-sized companies, for its briefing. It says that the uptake of NICE-approved medicines is critical for NHS patients to benefit from the latest and most promising innovations. Finally, I am grateful to Vertex Pharmaceuticals, which submitted a briefing that again supports the conclusions reached. Among the proposals it highlights is the introduction of a modifier to take account of the severity of a disease and efforts to more fairly consider uncertainty in the evidence for highly innovative and complex treatments for rare and severe diseases, including through greater use of real-world evidence.
On this small group of amendments, I look forward to hearing what the noble Baroness, Lady Finlay, has to say in connection with her neat, simple amendment, which would strengthen what we are proposing to do here. I urge the Minister and the department to address these postcode lotteries and make sure that NICE does not just make the guidelines but ensures that treatments reach the formularies and ultimately the patient in question. I beg to move.
The Deputy Chairman of Committees (Lord Russell of Liverpool) (CB)
My Lords, the noble Baroness, Lady Brinton, is taking part remotely. I invite her to speak now.
Baroness Brinton (LD) [V]
My Lords, I wish to speak in support of Amendments 54, 74 and 97, tabled by the noble Baroness, Lady McIntosh, and Amendment 163, tabled by the noble Baroness, Lady Finlay. I too pay tribute to the historic work of the noble Lord, Lord Patel, prior to the setting up of NICE.
While it is not an interest in the formal sense, I declare that I have autoimmune disease and have experience of being on the NICE rheumatoid arthritis care and treatment pathway for 19 years, which has been regularly updated by NICE over that time. Where it has been applied in full and from diagnosis, patients have found it very beneficial and, with new and more effective drugs being approved every few years, many are now in remission. I pay tribute to the consultants trying to do their best for their patients and the National Rheumatoid Arthritis Society and Versus Arthritis helplines which support RA patients in navigating their way through access to their NICE treatments when these have been blocked.
I thank the noble Baroness, Lady McIntosh, for her introduction to this group and for explaining the problem with the formulary list. She is right that this should be addressed formally. However, I want to focus on some of the commissioning practices on NICE-recommended treatments, including those on the formulary, in the current CCGs, because I believe these explain the need for the amendments in this group.
In May 2014, the High Court ruled that Thanet CCG could not disagree with NICE guidance merely because it disagreed with it, even when there is no statutory duty to provide that treatment. This specific case was about access to fertility treatments for a woman who was about to undergo bone marrow transplantation to put her severe form of Crohn’s disease into remission. NICE’s 2013 clinical guidance recommended that
“oocyte or embryo cryopreservation as appropriate”
should be offered
“to women of reproductive age … who are preparing for medical treatment for cancer that is likely to make them infertile”.
This was not cancer, and the CCG’s own policy was to not grant funding unless there were exceptional circumstances.
Baroness Finlay of Llandaff (CB)
My noble friend Lord Patel has had to leave because of pre-booked travel, but he has given me the honour—and it is an honour—of having his brief speaking notes, from which I would like to start, and then move on.
Before I get on to that, I think it is important for us to remember that NICE was set up to establish the evidence base behind what we do. Before NICE was established—and I have worked with Deirdre Hine, who was very involved in setting it up when she was Chief Medical Officer for Wales—people were doing things because they had always done them and because they liked doing them that way, with no evidence base, and often they were doing things that made situations worse, not better.
As Lord Patel wanted to stress, clinicians have a strong belief now in evidence-based healthcare, and guidelines are critical to ensure high and consistent levels of evidence-based clinical practice across the NHS. The guidelines developed by NICE can be adapted to the local situation, and they are also under review. I should declare that I have served for three years as vice-chair of the group looking at ME/CFS guidelines, and it was very instructive to see the depth to which everything was explored and the rigour of the processes; to the point that, when we were asked to review again some papers, we went back to the beginning and reviewed them all over again. Interestingly, in doing that, we slightly downgraded their scoring, rather than upgrading it, which is what had been expected. I was really impressed at the rigour of the process, including the health economics impact.
That experience has been behind the push to make sure that there is compliance. My proposed amendment would be a way of assessing compliance with the guidelines as predetermined and set out in the NHS mandate. The mandate could select a few that would act as proxy markers across the piece and include a date line, so that their implementation across the country could be benchmarked. It would not increase the workload, because it could draw on existing sources of data in the NHS. As the Minister has said, data is our key to understanding and unlocking things.
The noble Baroness, Lady McIntosh, in her comprehensive introduction to this group of amendments, spoke about type 1 diabetes and highlighted that, in some areas, the adoption of continuous glucose monitoring is as low as 0%, whereas in other areas it is up to 20%. There are a couple of other emerging areas; one is in atrial fibrillation, where direct oral anticoagulants have made warfarin a drug of the past. Yet the variation between clinical commissioning groups’ adoption of the guidance is quite horrifying. There is a threefold variation in prescribing, so there are areas of the country where a lot of patients are being denied an intervention that has been shown to be beneficial compared to what was done before.
We have already alluded to another emerging area: the new biologics. On the face of it, they are very expensive, but they are often remarkably effective—they can revolutionise the management of some diseases. We have a budgetary problem here, because the NHS budgets are year-on-year, and the face-value cost of the new biologics is very high; but if you look at the whole lifetime cost of healthcare interventions then they come out much lower. Take the example alluded to, of Crohn’s disease, and consider the cost of someone having their bowel removed, who might then end up on total parenteral nutrition; it is not only the cost of that nutrition but the costs in all other domains in their life, and the lives of their family. In comparison, the new biologics can rapidly get this disease’s process under control and revolutionise things.
The proposal is to give the CQC the powers routinely to address the adherence to guidelines—that would be specified by the NHS mandate, so a national standard could be set—and introduce a reporting metric using current data sources as a starting point to establish a benchmark. I want to stress, as I know does my noble friend Lord Patel, that we are not advocating for guidelines to be mandatory—that would not be right, because each patient is different and individual—but we are asking for a system to be introduced that gives powers so that there can be scrutiny of whether the guidelines are being adopted, because their adoption would narrow the gap in inequalities. We both feel that we need to commit to address this in this important legislation, because it is a way of achieving tangible action to ensure equity in access to quality in healthcare.
Lord Hunt of Kings Heath (Lab)
My Lords, I have added my name to the three amendments that the noble Baroness, Lady McIntosh of Pickering, has referred to. I was the first Minister for NICE, going back to 1999. At that time, we were confronted with a paradox which continues to this day, which is that, although the NHS is full of innovation and we have an incredibly strong life sciences sector and industry, the NHS is also very slow to adopt those innovations. NICE was developed to speed up the introduction of effective new medicines and devices. Right from the start, we had a problem with the NHS being reluctant to implement its recommendations and, within a few months of it starting, a regulation had to be put through which required it to implement them within 90 days. That has been slightly modified since, but none the less, it is still in being. The NHS has become very adept at finding ways to get round this through the various blocks that have been put in at CCG level—the noble Baroness, Lady Brinton, explained clearly the kind of blocks, devices and bureaucratic machinations that are put into place.
The result is that we continue to be very slow to introduce proven new technologies and medicines. NHS patients are very disadvantaged compared to patients in most countries. It then impacts on pharma and the devices industry—I think that pharma is more reluctant now to introduce medicines and develop R&D in this country as a result.
The Minister knows that there is an agreement—it is called VPAS at the moment—whereby NHS expenditure on drugs is capped and industry pays rebates if the cost goes over that cap. Given what I have always thought to be an imaginative agreement and given that industry is essentially underwriting some of those additional costs, surely there must be a better way to approach this which would allow the NHS to implement NICE recommendations enthusiastically, rather than essentially putting into place blocks.
I doubt that we are going to spend two and a half hours on this group of amendments, but these are just as important as the last group, because they go to the heart of whether NHS patients get access to the drugs, devices and technologies that they should. At the moment, they do not. I hope that the Minister might be prepared to take the amendment away. Legislation is the only way that we can see of leveraging the kind of change we need.
Baroness Fraser of Craigmaddie (Con)
My Lords, I support Amendment 163 in the name of the noble Baroness, Lady Finlay, to which I was delighted to add my name.
Perhaps I may remind the Minister of his very first session at the Dispatch Box. He confirmed to your Lordships that the Government had full confidence in the processes at NICE. In a follow-up letter to me he wrote:
“The National Institute for Health and Care Excellence (NICE) is the independent body that develops authoritative, evidence-based guidance for the health and care system to drive best practice. NICE is one of the few organisations with a remit spanning the NHS, public health and social care, meaning it is well placed to provide a system-wide perspective and support Government priorities for the health and care system.”
Lord Warner (CB)
My Lords, I support all the amendments in this group, particularly Amendment 74, to which I have added my name. I was one of the successors to the noble Lord, Lord Hunt, as a Health Minister responsible for NICE. I pay tribute to his sterling work in establishing it. However, I encountered the same difficulties as he encountered with the NHS speedily taking up NICE recommendations and had to wrestle with this same problem.
I had a long and slightly exhausting chat with the chief executive and the chairman of NICE about what they could do to help the NHS implement their recommendations. We arrived at a concordat, and the NICE people went away and developed a rather helpful system for enabling the NHS to prepare for a NICE recommendation and to implement it. As far as I am aware, looking at the NICE website, it still has that system in place, so it is not as though NICE is simply putting its recommendations in the public arena and leaving the NHS to get on with it; it has done its level best to produce a way of helping the NHS to prepare to implement those recommendations.
What I do not understand is why we have not moved faster over time to recognise that more action needs to be taken with the laggards within the NHS to make this happen. I think that one method is captured in the amendment from the noble Baroness, Lady Finlay.
If NICE is so important and it is so important that the NHS implements its recommendations, that ought to figure in the regulator’s assessment of the performance of those NHS bodies. I can see no reason it should not, and I wonder whether the Minister could tell us a little more than I know—and more, I suspect, than the Committee knows—about the current position on the failures of NHS bodies to pursue NICE recommendations. Do the Government accept that the regulator of these bodies should take account of their ability and willingness to implement NICE recommendations? Perhaps the Minister could clarify some of those issues. If he cannot clarify them today, perhaps he could write to us.
Lord Stevens of Birmingham (CB)
My Lords, I had not intended to speak but, animated by the contributions of colleagues who, like me, were there at the conception of NICE, I thought I would offer a couple of contextual remarks to this group of amendments, supporting their underlying motivation, which is to ensure the spread of best practice as fast as possible across the National Health Service.
I was also motivated by the noble Baroness, Lady Watkins, who spoke earlier about the Crimean War, to recall that this is not a new problem. The world’s first controlled clinical trial took place in 1754 on board HMS “Salisbury”, when the Royal Navy was trying out the use of citric fruit—in lemons and limes—to combat scurvy. That experiment showed that scurvy could be tackled with lime juice, and it took the Navy 41 years to mandate its introduction more widely—fortunately, just in time for the Napoleonic Wars, which is why some argue that, contrary to Winston Churchill’s dictum that it was “rum, sodomy and the lash” that contributed to the Navy’s success, it was in fact lemon and lime juice.
The point is that this is not a new problem. We have been grappling with this but, despite that, we have seen the remarkably quick adoption of new clinical practices over the last two years during Covid, as new randomised control trials, following in the wake of the 1754 example, have shown the benefits of treatments such as dexamethasone. My point of context is that we need to be clear, if this group of amendments is to advance, about the terminology incorporated in the amendments. These will inevitably be, if they find their way into the Act, litigated against in the High Court and Court of Appeal.
In the drafting, there is reference to the marketing authorisations given by NICE, although I think it is the MHRA that provides marketing authorisations. There is a clear distinction to be made between the technology appraisals NICE undertakes and the development of guidelines. Although a number of noble Lords have referenced the importance of the guidelines, it is worth saying that a quick look at the NICE website reveals there are 1,591 guidelines, pieces of advice, quality standards and all the rest of it—most of which have not been subject to the full cost-effectiveness and affordability assessments that the gold standard technology appraisal performs. Before there could be a legal mandate for those guidelines, there would be some very significant methodological considerations for NICE. Without those, the risk is that mandating those guidelines would take resources away from other parts of needed care, such as mental health and community nursing—Cinderella services that have not been subject to those same processes.
We should also recognise that, vital though NICE is, the bigger contribution to the diffusion of best practice will probably be made in other ways. Certainly, reporting could help. Although one amendment makes the perfectly reasonable proposition of an annual report from integrated care boards on their adoption and uptake, that still feels a slightly 20th-century solution. If you go to Oxford University’s superb www.openprescribing.net, you can see your own GP practice and your own CCG’s prescribing patterns against the national norm, including, as the noble Baroness, Lady Finlay, said, for the DOACs, the anticoagulating medicines. Those technologies are already available, and the role that clinical pharmacists are now playing, including the thousands of new clinical pharmacists hired to work alongside GPs to improve their prescribing habits, is also likely to have an important influence.
Finally, there is this question of whether, just occasionally, conflicts of interest might arise on the part of prescribers or clinicians over the medicines or devices being used. The noble Baroness, Lady Cumberlege, has drawn attention to this in her important work, and that is perhaps something the House might return to at a later date.
Lord Lansley (Con)
My Lords, I want to intervene at not too much length. I welcome these amendments and am grateful to my noble friend Lady McIntosh of Pickering for bringing hers forward. It enables us to touch on a subject which those of us involved in the Medicines and Medical Devices Act will recognise. This is a short version of the debates we had then, but it gives us an opportunity to update a little on those and me an opportunity to ask my noble friend on the Front Bench a few questions arising from that. We are all grateful to the noble Lord, Lord Stevens of Birmingham, who clarified some of the terminology, which saves us going wrong. But I want to do a bit of clarification about some of the amendments as well.
The timing of this is terrific. We are discussing this today and NICE published the outcome of its methods review yesterday, so we can respond immediately. My starting point is to applaud NICE for having taken up and accepted the proposition that there should be a modifier in relation to its appraisals and assessments on severe diseases. We can argue about the precise detail, but it has taken that up.
Secondly, randomised control trials are terribly important but they are not the whole story. NICE has rightly accepted it should look at more real-world evidence and that, too, we can welcome, but it leads me directly to a question. Part of that real-world evidence, and one of the reasons it is not going directly to NICE, though NICE can use it, is the innovative medicines fund. NHS England published its proposal for the innovative medicines fund in July and said that it would consult on it, but it has not done so yet. My first question to my noble friend is therefore: when will NICE and NHS England consult on the innovative medicines fund?
The third point on NICE’s methods review is that it will take account of the wider impacts of the treatments it appraises. That is terribly important, especially given the present opportunities for personalised medicines and gene-based treatments, when one looks at how these can impact substantially on people’s lives from a relatively early stage and the contributions they can make to society and the economy. That is all good news.
The press release from NICE, however, did not draw specific attention to where it had proceeded in a way that its stakeholders did not support. It has maintained a reference-case discount rate of 3.5%, although NICE itself admitted that there was evidence that a lower discount rate would give significant benefits. It said that there would be wider implications for policy and fiscal complexities and interdependencies if it were to do this, which I think means “The Treasury said no”. We need to think very hard about whether a discount rate as high as 3.5% is appropriate for NICE’s application of its appraisals. I ask my noble friend, though he will not be able to give me the answer to this: who is telling NICE that it cannot adopt what it regards as the evidence-based discount rate for the appraisals it undertakes?
Lord Hunt of Kings Heath (Lab)
My Lords, on that basis, I have seen it said elsewhere that NICE has referred to its “national stakeholders.” I can only assume that they are Her Majesty’s Government.
Lord Lansley (Con)
Given NICE’s remit, it might be the Welsh Government as well, but the noble Lord may well be correct. We are all surmising, but I think we are probably not too far off the mark. It gave us an opportunity to respond to that.
So far as the amendments are concerned, the proposition that approved treatments should be adopted by the NHS is a proper one. What, of course, has not been brought into the debate is that the world has moved on, even in recent years. NHS England has taken what I think is an appropriately substantial interest in the approval of treatments, the uptake of treatments and their adoption by the NHS. When it started out, people said, “Oh dear, NICE is going to approve a treatment and then NHS England is going to tell people not to use it because it is going to cost them a lot of money.” In fact, we all agreed in the debates on the Medicines and Medical Devices Bill that there was everything to be said for NHS England, NICE and the pharmaceutical industry working together early, proactively, for the planned introduction of new medicines, including taking account of their cost. That is an NHS England role, not a NICE role. NICE does gold standard appraisals, but it does not take responsibility for the fiscal consequences of those appraisals, so all these things need to be put together. The pricing decision should not be something that comes out at the end.
One of the things I have been going on about for a decade or more—actually, 15 years—is that we should not end up in a position where there is an effective medicine that is properly approved by the MHRA and authorised for use; clinicians can use it and they know it is the right thing for their patient; but, because of the absence of an appropriate pricing decision, the answer to the patient is “no”. We should not arrive at that position. With NHS England and NICE working together with the pharmaceutical industry, we stand a better chance of the answer not being “no” in those circumstances as long as the resources are, indeed, available.
I do not think, on the face of it, that we should be legislating to change the medicines mandate from where it is now. My noble friend Lady McIntosh, in introducing her Amendment 54, referred to devices. The amendment does not refer to devices, but it should refer to devices. My further question to my noble friend the Minister is: when are we going to get a proper funding mandate on devices, which I think I was promised during our deliberations on the Medicines and Medical Devices Bill but we have not yet formally had it? Some good work has been done on some devices each year, but I am hoping that we will get a proper funding mandate on devices.
On formularies, my noble friend did not actually refer to the British National Formulary. Of course, NICE has had responsibility for the BNF for about seven or eight years, and even if it is not a legislative method, there is everything to be said for the NHS and clinicians looking to the BNF and NICE’s role in the BNF.
My noble friend and the noble Baroness, Lady Finlay of Llandaff, were quite right about the adoption of NICE guidance and standards on the use of them in clinical circumstances. However, via the regulator—the CQC—we already have a process by which the CQC looks at quality standards produced by NICE and incorporates what NICE itself isolates as the essential aspects of the standards that, in order to provide safe and effective care, must be reflected in the practice of a health provider.
My question to the noble Baroness, Lady Finlay of Llandaff, is: if she thinks that is not sufficient, how much further should the CQC actually go in adopting quality standards? At the moment, it has compromised and said, “We will take the essential steps, because those are a few, generally about five, specific things that we can look at to see whether they are being done, in which case, okay; or are they not being done, in which case it clearly needs improvement, or may not be meeting the standard.”
Baroness Finlay of Llandaff (CB)
The noble Lord asked me a question to which I feel obliged to try to respond, but I really want to answer the question with a question: does the CQC have enough powers to benchmark as it would want to do, and to publish those benchmarks? I hear the concerns of my noble friend Lord Stevens in relation to fear of litigation and how that is an objection to the amendments, but I am also quite worried that that is potentially a way of avoiding adopting the guidelines themselves, thereby inhibiting a change in practice and a move to best practice.
While there are sources of information that those who are very health-literate, IT-literate, and so on, can access to establish their own benchmarks about what is happening, many people, particularly those in the most deprived areas of the UK, do not have any knowledge of even where to begin looking for these things. That was the motivation behind the amendment: to try to make sure that in the poorest and most deprived areas, people would still be able to access this. That would drive up standards gently but would not create a mandated requirement that a NICE guideline is adopted, for the reasons I outlined previously.
Lord Lansley (Con)
I can see that my noble friend is eager to come in but I will conclude by answering the noble Baroness. I am not an expert, but I think the CQC has the powers—since it presently does it—to take account of the NICE quality standards and to incorporate specific indicators from those quality standards as part of its regulatory review. If the CQC was to attempt to introduce large-scale application of the guidance as a question in a regulatory review, I do not think the issue would be whether it had the power to do it, but whether it would make the headline conclusions it reaches in relation to healthcare providers increasingly difficult to interpret. At the moment, they are relatively straightforward to interpret. There is a small number of specific indicators in relation to services provided and they are either doing them or they are not. With guidance, it becomes much more complicated and many more value judgments have to be applied about the circumstances in which they are or are not complying. So, there is a real difficulty in going far beyond where we are now.
I will listen with great care when my noble friend the Minister responds to the questions I have asked.
Lord Mackay of Clashfern (Con)
My Lords, I support these amendments, subject to the economic difficulties. As I listened to the local Baroness, Lady Brinton, I wondered whether the amendments might be strengthened by some reference to the timescale in which they must be implemented. That might have some beneficial effect for many people who are waiting.
Baroness Merron (Lab)
My Lords, I welcome these amendments, which relate to the National Institute for Clinical Excellence—NICE. I thank all noble Lords for tabling these amendments and for their contributions today, which certainly expanded my knowledge of the subject, as I am sure they did across the Committee. The debate has shown that there is a need for change, as I am sure the Minister has heard, to better equip the National Health Service to provide the patient what they need when they need it.
The noble Baroness, Lady McIntosh, spoke clearly about hurdles that must be overcome, whether they are bureaucratic, process, budgetary or administrative. All these hurdles get in the way of the end result: meeting the needs of patients. That, I believe, is what this debate is focused on.
NICE is well recognised as a partner to our NHS. Its objective approach and evidence-based analysis rightly gain respect. However, as my noble friend Lord Hunt said—he can now be called the first Minister for NICE—although the National Health Service is full of innovation, it is also slow to pick up on it; that point was emphasised by the noble Lord, Lord Warner. That begs the question: what kind of partner should NICE be to the NHS? Is it going to be an enabling partner, or will it frustrate at times? Of course, we all want to see NICE in that fully enabling capacity.
However, beyond what NICE approves in terms of treatments, pathways or otherwise, there must be procedures for it to implement and connect effectively to patients’ needs. We know that no system or set of procedures will ever be perfect; we have heard that today. Understandably, therefore, as the Minister has heard, pressure and a will for change—in a positive sense—is contained in these amendments. The noble Baroness, Lady Finlay, spoke about how important it is to have evidence-based healthcare and to have known guidelines and see them complied with, as is right and proper.
There are cautionary considerations to note in this debate; we have heard some of them. One is whether it is wise to put what in some cases appear to be operational requirements in the Bill. I am sure the Minister will address this. The new world is certainly paying a lot of attention to flexibilities. We want to make sure that anything contained in the Bill does not inadvertently work in another direction.
My understanding is that NICE guidance is mandated, in effect, with the guidelines somewhat less so. Amendment 54 contains a proposal to reinforce the intention that, once a treatment has been properly assessed and recommended, all patients should be able to gain the benefit. We know, and we have heard in this debate, that this does not always happen, and that clinical commissioning groups follow different policies. However, in considering the amendment at face value, it is important that we consider what impact this latitude might have. I am sure we are all keen not to accidentally invoke some kind of fallout, such as taking away all leeway from commissioners. At present, they can depart if they can set out an objective case for doing so; for example, with requests for certain drugs and therapies through individual funding requests.
Similarly, it would be unfair if a patient could cross an integrated care board border and receive a treatment that was not available in another ICB area. That would seem inadvertently to achieve what we do not want to achieve: the worst of a postcode lottery. Equally, if we have locally based approaches, the reality is that some localities will differ in their priorities and services. I know that we will return to this topic many times in our consideration of the Bill because the care that patients receive should certainly be equitable and fair and not based on where they live.
Lord Kamall (Con)
I thank all noble Lords who have spoken in this debate, both to the amendments and in making wider points about NICE. I take this opportunity to pay tribute to Gillian Leng, who recently stepped down as chief executive of NICE after a number of years.
I turn to Amendment 54. I am sure noble Lords will appreciate that we all want NHS patients to benefit from proven and cost-effective treatment; no one would want otherwise. That is why we see NICE as playing a vital role in supporting patient access to new treatments. I have heard the criticisms from previous Health Ministers, who were responsible for NICE. I sometimes feel in debates such as this, when I am with former Health Ministers, that it is like a special edition of “Doctor Who”, with previous regenerations. I hope we do not create a fracture in the space-time continuum. NICE recommends the vast majority of new medicines for use by the NHS. In fact, in 2020-21 100% of new medicines were recommended by NICE and many thousands of NHS patients have benefited from access to some of the most cost-effective treatments as the result of its work.
Another interesting thing is that when a decision is made and it is difficult to access medicines, patients will get frustrated—rightly so, given that they know it is available or maybe has been recommended. At the same time, on the global stage NICE has a well-earned reputation. It is one of my three priorities; I have mentioned technology, the second is life sciences and the third is international health diplomacy—how we use our position on health as part of UK soft power. One of the institutions people across the world look to and want to learn from is NICE. NICE is looking to be at the centre of a number of global networks on the issues where it has a reputation.
NHS England and clinical commissioning groups are already under a statutory obligation, under Regulations 7 and 8 of the snappily titled National Institute for Health and Care Excellence (Constitution and Functions) and the Health and Social Care Information Centre (Functions) Regulations 2013, to fund any treatment recommended by NICE through its technology appraisal or highly specialised technologies programmes, usually within three months of guidance being issued. As the noble Lord, Lord Stevens, mentioned, NICE also operates a separate medical technologies programme, which supports faster and more consistent adoption of medical devices, diagnostics and digital products.
I assure noble Lords that these funding requirements will apply to the ICBs once established. Therefore, we do not see the amendment as necessary at this stage for clinicians to prescribe NICE-recommended treatments for their patients. I also thank the noble Baroness, Lady Merron, for pointing out some of the unintended consequences and scope of such amendments. I remind your Lordships that, since April 2021, NHS England’s medtech funding mandate has supported faster access to some of these innovative technologies recommended by NICE.
I know that I am going to try to reassure noble Lords on a number of things but, on Amendment 74, I hope they note that the funding requirement on ICBs for NICE-recommended treatments goes even further than the requirement to promote what the noble Lords propose in the first part of the amendment. This will ensure that clinicians will continue to be able to prescribe NICE-recommended treatments for their patients.
The second part of the amendment would replicate existing arrangements that are in place to measure uptake and use of NICE-recommended medicines. Since 2013, NHS Digital has published an innovation scorecard that reports uptake of medicines that NICE has recommended in the last five years at a national and local level. Data on the uptake of NICE-recommended medical devices is not currently reported in the innovation scorecard as it has been more complicated to collect. However, I assure noble Lords that work is under way, by both NHS Digital and the Accelerated Access Collaborative, to address this gap. The Government consider that it is more appropriate and proportionate that this information is collected and published by a single national body using an agreed methodology, not by multiple organisations that will each have different ways of measuring and presenting the data.
On Amendment 97, I can tell noble Lords that NICE works closely with the MHRA—I thank the noble Lord, Lord Stevens, for pointing out the distinction —which issues marketing authorisations to ensure that licensing and appraisal timescales are aligned wherever possible. The NHS in England usually funds any treatment recommended through NICE’s programmes within three months of positive final guidance. We believe that three months is a realistic framework for providers to prepare for and introduce a new technology, and I hope I can assure the Committee that NICE and NHS England already work closely to facilitate the adoption of recommended technologies as quickly as possible.
As the noble Lord, Lord Stevens, again alluded to, there is a high level of transparency in the operation of local formularies. Formularies have their own public websites, which list the selected medicines and associated guidance, and area prescribing committees publish the minutes of meetings, which identify the medicines added or removed from formularies. We believe that there is therefore no need to publish an annual list.
Although healthcare providers are encouraged to use local formularies when prescribing, they are not restricted to them. The decision as to what to prescribe lies with the prescriber, who will act in the best interests of the patient. Indeed, some of the correspondence I get as a Minister for Health often refers to when people cannot get access to a medicine that is not recommended, but the clinician has the authority to suggest that that medicine can be available to the local area.
Lord Hunt of Kings Heath (Lab)
I am sure the Minister is right about how this system is meant to work, but there are far too many examples of clinicians seeking to prescribe medicines that have gone through the technology appraisal and then finding that CCGs have set up the various devices that the noble Baroness, Lady Brinton, mentioned to delay or stop it. Does he recognise that CCGs are engaged in a process of seeking to delay implementation for as long as possible? Will this be accepted under ICBs or will it be tackled?
Lord Kamall (Con)
I thank the noble Lord, Lord Hunt, and the noble Baroness, Lady Brinton, for raising this issue. I should be honest; I was not aware of the suggestion that CCGs often delay and whether that situation will be transferred to ICBs. I ask noble Lords whether I can look into that situation further to understand it more. I simply say that I was not under that impression.
Lord Warner (CB)
When the Minister is looking into that, will he also look at the issue of the usual suspects? The problem that the noble Lord, Lord Hunt, probably encountered—I certainly encountered it—was that many of these areas that are slow to implement NICE recommendations are the same areas where overall performance is pretty poor. There is an issue here about whether we can clearly identify the laggards and take action with them, rather than have a generalised look at the performance of particular areas.
Lord Kamall (Con)
Perhaps I may suggest, following the interventions of both noble Lords and their experience of being Health Ministers and of NICE, arranging a follow-up meeting with them to discuss this matter in more detail so that I can understand the situation more. As I am sure noble Lords will appreciate, I have been in this job for only four months and am still learning an awful lot. In fact, I am learning far more in this Committee than I have in my first four months. That shows that sometimes there is no substitute for learning on the job.
NICE has a suite of more than 300 guidelines and, as the noble Lord, Lord Stevens, said, more than about 1,900 medicines, spanning the whole of health and social care. It makes dozens of recommendations that can be complicated. We do not think it proportionate or feasible to require compliance with NICE guidelines but, given what I have just mentioned, I should like to consult previous Health Ministers with experience in this area and perhaps have further discussions to see what is relevant in the future.
I shall end with the CQC reviews of ICSs. We will look more broadly at the entire system of how the ICS areas are performing. A requirement for the CQC to specifically consider compliance with NICE guidelines as part of these reviews risks adding a considerable burden to this process. I can, however, assure the Committee that the Government expect the healthcare system to take NICE’s recommendations fully into account, subject to what noble Lords have told me about the performance of some CCGs. I am also aware that NICE works closely with system partners to support implementation where possible. It is probably best henceforth for me to have those conversations with the two noble Lords and any others with experience of this matter. There are more than two former Health Ministers in this House and we should have those conversations.
Let me see if I can answer some of the specific questions. As regards VPS—how do I put this in the most diplomatic way?—I have been asked to look at that issue. The industry has complained, for example, because we also have therapeutic tendering at the same time as expecting this. I am grateful to my right honourable friend the Secretary of State for asking me to look into this issue in further detail. I have asked what would happen, for example, when some of the life sciences companies ask whether it makes the UK less attractive in some ways. I am assured that it does not but I am looking into this issue as part of the life sciences aspect of my portfolio.
I think that I have covered all the questions but all that I ask at the moment is to let me have further conversations. That is probably best. In that spirit, I ask noble Lords to consider withdrawing or not moving their amendments.
Baroness McIntosh of Pickering (Con)
My Lords, I am grateful to all who have contributed to this debate and for the number of issues that have been raised.
At the outset, the noble Baroness, Lady Brinton, highlighted and a number of us focused on the hurdles—as the noble Baroness, Lady Merron, described them—to be overcome. However, there has been a lot of focus on the problems of the budgetary challenge. It would be incumbent on my noble friend the Minister to meet not just with the two noble Lords he highlighted but the drafters of the amendments: myself, the noble Baroness, Lady Finlay, the noble Lords, Lord Hunt and Lord Warner, and the noble Lord, Lord Patel, who sat so patiently through the whole of today’s proceedings and had to leave before this discussion was reached. As he had such success in the mental health meeting, I hope that we replicate that and take up a number of the issues raised here.
The Deputy Chairman of Committees (Baroness Garden of Frognal) (LD)
I call the noble Lord, Lord Low of Dalston, to move Amendment 56A—or the noble Baroness, Lady Hollins. Is the noble Baroness, Lady Finlay, moving Amendment 56A?
Baroness Finlay of Llandaff (CB)
My Lords, perhaps I might put in a slight plea to the Committee on behalf of the noble Lord, Lord Low. He has sat patiently through this debate for a long time. He was expecting that the other amendment would be moved and, on realising that it was not, has made every attempt to return to his place as fast as possible.
Amendment 56A
Lord Low of Dalston
“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.”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 seeks to improve eye care for people with learning disabilities.
Lord Low of Dalston (CB)
Right on cue, my Lords, I am rising to move Amendment 56A, which seeks to improve eye care for people with learning difficulties, as they are much more likely to have a sight problem but much less likely to access primary ophthalmic services, including access to NHS sight tests. The Bill offers an opportunity to seek improvements to an often-overlooked area of primary care: namely, primary eye care or ophthalmic care. Schedule 3 to the Bill contains amendments to the National Health Service Act 2006, regarding primary ophthalmic services: that is to say, commissioning of NHS sight tests and more.
Primary eye care is vital for the health of the nation. We know that half of sight loss could be prevented but is not because people do not go for sight tests as frequently and regularly as they need to. Many people are living with sights problems that could be picked up and treated quickly if people were going for regular sight tests. We also know that our hospital eye clinics are overwhelmed and are one of the busiest outpatient specialities. There were delays to treatment prior to the pandemic, but now these have been greatly exacerbated as a result of the pandemic. Work is under way to look at how primary eye care can add capacity to the system through an NHS England eye care transformation programme. Just like their colleagues in general practice, dentistry and pharmacy, there are optometrists and dispensing opticians working in primary care who have the clinical training to provide early and ongoing support to patients but do not have the chance.
Supporting primary eyecare makes sense in very many ways. However, we know that, as with other areas of healthcare, there are inequalities in primary eyecare. Some parts of the population are not accessing regular sight tests, even if they might be eligible to have them free under the NHS. In 2018, the All Party Parliamentary Group on Eye Health and Visual Impairment explored this issue, particularly for people with learning disabilities and people who are homeless. This work was supported by the APPG on learning disabilities. I know that the noble Baroness, Lady Hollins, supports this amendment, but she has not been able to stay to join in the debate.
The APPGs on eye health and visual impairment and on learning disabilities took evidence from the charity SeeAbility. People with learning disabilities are much more likely to have a sight problem but much less likely to access NHS sight tests. Vision problems in people with severe learning disabilities are so high that researchers have said that this population should be considered visually impaired unless proven otherwise. SeeAbility’s work in special schools found that more than four in 10 children had never had a sight test. In other studies, it was found that half of adults with learning disabilities had not had a sight test in all the recommended period. SeeAbility found that many children were attending hospital eye clinics for routine eye tests.
A recommendation that the APPGs made in 2018 that there should be a sight-testing and glasses-dispensing service in all special schools is now being taken forward by NHS England, which is excellent news. It will reach around 130,000 children and help address and prevent avoidable sight loss, as well as reducing the need to use hospital eye clinics. Once the proof of concept phase is completed in 2023, it is understood that a new special schools scheme will need to be legislated for to provide for an additional service to be added to the National Health Service ophthalmic services contract through an amendment to regulations. It is hoped that at the appropriate time the Secretary of State for Health and Social Care will ensure that the special schools eyecare service has the legislative authority that it needs. The commitment by NHS England to this service is commendable, and it must continue with that commitment as these children deserve an equal right to sight. This is something we will all want to follow closely.
However, the APPGs went further in 2018 and also recommended that there is a continuing need to improve eyecare outside special schools for people with learning disabilities. There are an estimated 1 million people with learning disabilities in England. The APPGs noted that the tariff for primary eyecare acts as a disincentive to carry out sight tests within optical practices when seeing adults or children with more severe or profound learning disabilities, despite this group being at most risk of having a sight problem. This compares poorly with other areas of primary care, such as the GP annual health check for people with learning disabilities, or special needs dentistry. The local optical committee support unit’s learning disability eyecare pathway, which is endorsed by SeeAbility and Mencap, can be commissioned by clinical commissioning groups to provide more targeted, longer and adjusted optical appointments for people with moderate to severe learning disabilities. However, it has been commissioned in only a few areas in England and it really needs to be countrywide.
Eligibility for NHS sight tests under secondary legislation has also missed out people with learning disabilities from the exclusive list of eligible groups—that is, children, older adults, people in receipt of certain means-tested benefits and high-risk groups such as those with a family history of glaucoma or diabetes. This places the burden on the person with a learning disability to work out whether they are eligible in other ways. For that reason, no data is collected on how many people with learning disabilities access NHS sight tests in the community. For the purposes of this debate, this is a straightforward amendment that bolsters NHS England’s existing commitment to the special school eye care service across England’s special schools. It reminds us that all people with learning disabilities are in need of particular attention when it comes to eye care.
Schedule 3 to the Bill amends the section on primary ophthalmic services in the National Health Service Act 2006 by introducing general powers to make arrangements, in Section 116A, and to publish general information, in Section 116B. The amendment would supplement that with a new Section 116C, which would simply oblige NHS England to make an assessment of the needs of those with learning disabilities for primary ophthalmic services, including access to NHS sight tests, and ensure that services were commissioned to meet those needs.
The amendment’s national focus is needed because the local discretionary approach to introducing the aforementioned LOCSU learning disability eye care pathway by clinical commissioning groups has not worked. It exists in only six areas of the country when it really needs to be available across the country as a whole. The amendment would allow for the possibility of extending eligibility for NHS sight tests to all people with learning disabilities once the evidence was reviewed.
The Bill clearly envisages that the Secretary of State and NHS England can work together and both can exercise powers to improve primary ophthalmic services, with NHS England having a clear national oversight role. The amendment is supported by three existing NHS England objectives into the bargain: first, the programme of work to address the health inequalities of people with learning disabilities; secondly, the programme of work to improve community eye care and reduce the unnecessary use of hospital eye clinics; and, thirdly, the commendable work in primary optometry of the special school eye care service.
There may be those who would say that no population needs to be explicitly prescribed for in primary legislation and that matters can be left to the discretion of secondary legislation and directives. However, the health inequalities experienced by people with learning disabilities justify putting them in the Bill. People are dying of avoidable health issues at least two decades before their peers. We cannot have a situation where people are living without good sight and even going avoidably blind because NHS services overlook their needs. I beg to move.
Lord Crisp (CB)
My Lords, I shall speak to Amendment 112 and 17 others that are in my name. I am very grateful to the three noble Lords who have added their names to these amendments. These are terribly straightforward; it is the same point in a number of different contexts. As we put it in the explanatory statement, the amendments
“would require Integrated Care Boards to work with the four primary care services … when preparing and revising their five year plans, in the same way they are required to work with NHS trusts and NHS foundation trusts.”
It is a very simple, straightforward point and a matter of proportion. It is appropriate to give a similar level of influence and respect to primary care as we give to acute services.
I will mention that there are some practical difficulties —obviously, there are many more primary care services than NHS trusts—and come back to that at the end. If it is not obvious enough that we should do this, I want to pull out three points about why this is so important; I expect that others will mention other points. I am talking here about GP surgeries, as opposed to the other three services, although I totally endorse everything that my noble friend Lord Low just said about ophthalmology services.
First, if it is true, as Members across this Committee have argued for however many sessions it has been, that a large part of the future is community-based, then alongside public-health figures and their clinical work, it is primary care—nurses and others, not just doctors—who will be the essential guides and specialists to help all those place-based, arts, non-clinical and inequalities-busting activities that we have talked about for a considerable part of this debate. They have that key role.
Secondly, I was dismayed by the way the Government criticised GPs recently. Primary care is under enormous pressure and I do not understand why the Government chose to do that. A large part of the problem is that there are simply not enough primary care specialists of all kinds, including GPs, and I do not think any progress has been made towards the promised 5,000 extra GPs. Primary care is under enormous pressure throughout the country and, while I greatly welcome the focus in the Bill and in government policy on waiting lists, I believe that it will be here in primary care that we will see the real battle for the future of the NHS. It is really important that we give those who are doing so much in our services the respect, influence and prominence that they deserve.
My third and perhaps, in some ways, biggest point is that primary care is changing very fast in all kinds of ways; it is an area where there is enormous innovation. As the Royal College of GPs itself says about the role of the GP, there is a place for one-off consultations—a place for the GP on the railway station, or wherever, where you can have a very quick consultation—but there is an even bigger place for the sort of continuing role based on the relationships between a GP and their patient that we are familiar with traditionally and which I thought the noble Baroness, Lady Cumberlege, described so well in describing her father as knowing his patients “inside and out”. That relationship, however, is not just with individual patients; it is a relationship with the community. Many GPs have taken that role, but more are taking on the role of a relationship with their community.
Some GPs are rewriting this role so that it is more of a public health role in some ways. There is Sir Sam Everington at Bromley by Bow, whom the noble Lord, Lord Mawson, mentioned in his great, eloquent speech on our last occasion in Committee, and others such as Dr Gillian Orrow, who is bringing together groups in the community and leading Growing Health Together in Horley. Others are taking on wider roles, such as Dr Laura Marshall-Andrews in Brighton. People are thinking about their role in a very different and important way and I apologise for giving three southern examples—they happen to be ones I know very well, but I know that this sort of innovation is going on around the country. More generally, of course, we can think about social prescribing and the way that that is changing primary care.
Here is the really big point: these doctors, nurses and others in primary care are acting as clinicians, of course, but they are also agents of change. They are the animateurs, the facilitators enabling local health-creating activity. For that reason, we need to have people like them fully engaged in the planning and all the mechanisms of the new NHS structures so that they can have the influence needed for the future.
I come back to the practical note I made at the beginning. Of course it will be difficult to engage primary care appropriately in every way and there might not be the same structure and arrangements in every part of the country, but it is really important that we get these primary care inputs into the five-year plans, their monitoring, planning and discussion so that they can really influence what will happen in the future. I understand that the Royal College of GPs is in discussion with the Department of Health. I urge the Minister to encourage his officials to find a way to make this obvious thing, which needs doing, work. It is vital that we do not disfranchise a key and currently quite largely demoralised sector or, as importantly, lose their valuable contribution.
Lord Hunt of Kings Heath (Lab)
My Lords, I have Amendments 117 and 218 in this group. I have also put my name to the series of amendments put forward by the noble Lord, Lord Crisp, but I start by endorsing what the noble Lord, Lord Low, had to say. I hope the Government will come back sympathetically in relation to that.
My Amendment 117 would ensure that primary care professions would have mandated roles within integrated care partnerships, with members appointed by each of the four practitioner committees: the local medical, dental, pharmaceutical and optical committees. Secondly —and this is very consistent with the amendments from the noble Lord, Lord Crisp—this would ensure that, in preparing their annual strategic forward plan, the integrated care board and its partner trusts and NHS foundation trusts would need to consult the relevant primary care local representative committees and publish an explanation of how they took account of those views when publishing their plan.
I have the same arguments as the noble Lord, Lord Crisp, and I will not repeat them because he put them so well. History has shown that, even when clinical commissioning groups were nominally under the control of GPs, they often found it very difficult to get the rest of the system to listen to their issues and concerns. I agree with the noble Lord that there is now so much pressure on primary care that there is a great risk that they will be ignored in the work of the ICBs in particular. That would be a great pity. It is not just GPs, but the other parts of the primary care world. The noble Lord, Lord Low, already referred to ophthalmologists and opticians, but there is also this conundrum about the ability of pharmacists to take some of the load off the system but there is also often the inability of the local NHS to talk to them and embrace them sufficiently.
I hope the Minister will be sympathetic. If he says that he is not willing to tell ICBs that they must embrace representatives of the local committees then there is now a clear conflict. He is saying that it is up to the local ICBs to decide, but it has become abundantly clear that NHS England is giving out very heavy-handed guidance about who should be on ICBs. I would make this point to him: you cannot have it both ways. Either you leave it up to ICBs and withdraw this guidance, or Parliament has a role and a right to determine the governance arrangements. The action of NHS England in being so heavy-handed, such as saying that local councillors cannot serve on ICBs, means that the argument he put forward really does not stand up any more.
I move to my Amendment 218. On this one I must remind the House of my membership of the board of the GMC. The noble Lord, Lord Crisp, talked about the crisis in workforce issues generally, which I am not sure we are going to get on to today now. In relation to GPs, it is very apparent that not only do we have a chronic shortage but there is a grossly inadequate distribution of GPs throughout the country. Recent data, published by NHS England in November, shows that the primary care network covering an area in Gloucestershire described as 4PCC and comprising Cadbury Heath, Close Farm, Hanham and Kingswood had an average list of 1,138 patients per full-time equivalent GP. There are some others with similar figures. At the other end of the scale, Shore Medical primary care network in Dorset had an average list of 7,317 patients per full-time equivalent GP. York Priory Medical Group PCN had an average list of 7,154 patients per full-time GP and the Marsh Group PCN in Kent had an average list of 7,040 per full-time equivalent GP. These are huge disparities and there are many other areas that have average lists of under 1,600 and plenty with averages of more than 6,000.
The situation is really reminiscent of the situation before the start of the NHS. That is why in 1948 the Medical Practice Committee for England and Wales started work. It was charged with ensuring equitable distribution and, to a large extent, I believe it achieved its objectives. It was abolished in 2001 and I had better confess to the House that, I am afraid, I took through the legislation abolishing it. However, we were at the start of a massive expansion in the workforce at that time and felt that at that point the kind of bureaucratic way in which the MPC worked probably was no long fit for purpose.
We have a real problem here and confirmation of the dire situation was provided recently in research by the University of Cambridge’s department of primary care. A team including Dr Rebecca Fisher found that the significant GP workforce inequalities I have talked about are increasing and that workforce shortages disproportionately affect deprived areas. If you look at the situation in deprived areas, practices often have lower CQC scores, lower quality and outcome framework performances and lower patient satisfaction scores. Patients in those areas often have shorter GP consultations despite the fact that they have more complex health needs.
General practice is paid according to how many patients they have, with an adjustment made for the workload associated with those patients. Since 2004, the global sum allocation formula, known as the Carr-Hill formula, has been used to make that adjustment. However, Fisher argues that the consultation length is a flawed proxy for need and that the formula has long been widely acknowledged to be incapable of accurately weighing needs associated with socioeconomic deprivation. In 2020, after accounting for need, practices serving deprived areas received about 7% less funding per patient than those in non-deprived areas.
There is also the targeted enhanced recruitment scheme. This offers trainee GPs a one-off payment of £20,000 when joining a practice in an area that had long-standing difficulty in getting more doctors. However, this has not made a significant difference and clearly is not the answer to this enormous problem.
In the amendment—and I am very glad to have the support of the noble Lord, Lord Warner, and the noble Baroness—I have proposed the creation of
“the General Medical Practitioners Equitable Distribution Board”
as a first step. I envisage the board being invested with discretionary powers of negative direction, as was the MPC. It would consider applications from primary care networks, and they would be expected only from adequately doctored, or more than adequately doctored, PCNs. It would be a way of intervening in the market and making it more difficult to appoint GPs in those areas that are already very well supplied with doctors.
I accept that this is not the only approach, but it is an approach that has worked in the past. Frankly, I do not think that we can carry on without some major intervention to try to spread the load, because it is clear that all the odds are stacked against you if you are in an area of high deprivation where there are many more patients per GP. You get burnout among the professions and things become very difficult indeed. It looks as though financial incentives are not the answer. Clearly, we need to get more GPs into those areas to lessen the load, and then improve the quality and outcomes. I hope the Minister will be prepared to take this back and give it some consideration.
Baroness Uddin (Non-Afl)
My Lords, I hesitate to rise. I had not originally intended to participate in this debate, but I feel obliged to speak and make some general points in support of the noble Lord, Lord Low, and his powerful and compelling arguments for his amendments. I declare an interest: the House will be well aware that my son, who is 43 years old, has a learning disability and is autistic, so I have some experience of the arguments spoken about by the noble Lord. I have also been a member of the All-Party Parliamentary Group for Disability for more than a decade, and I know of the fantastic work that SeeAbility has undertaken for its membership for many years.
I want to say something, because this group of adults has suffered dreadfully over the past two years, particularly during lockdown. They do not have the privilege of being at school or in early college education and being looked after by the system. I hope the Minister and the whole NHS system will agree with the suggestions made by the noble Lord, Lord Low, including the suggestion that these services should be available. I assume that making ophthalmic services available in schools and colleges is one of the easiest things to achieve. However, it is not so for adults with a learning disability and autism who have just left school and are at that age when nobody cares about them anymore. That is where the problem occurs.
I had enormous difficulties. I do not want to speak about myself in any way, because I am more than able to argue my case, find out where services are by ringing people and looking at services on the internet, and challenge when I face difficulty. I challenge more now than I was when my son was younger. I am also well attuned. I speak regularly with organisations on the ground that work with the parents and carers of people with learning disabilities and autism, so I know fully how much they struggle to ascertain and obtain information about ophthalmic care.
I want quickly to share the experience I had with my adult son. All his appointments were cancelled for nearly a year. I could see that his eyesight really suffered. He was not able to co-ordinate his way even around his own home where he is very comfortable. I had to push them hard. It was suggested that I should speak to the nearest ophthalmologist and look for these services. I admire all these services, which are trying hard to work with the NHS in the absence of patients being able to go to hospital for ordinary services, but they are not equipped or trained. They do not have the necessary equipment to produce the best results or give effective services to the people who need them. As the noble Lord, Lord Low, said, it is grossly unfair when there is sight and all someone’s eyes need are a little attention to make a fundamental difference and enrich their life. It is really important that the Government take the noble Lord’s amendments on board with the same passion that he argued with. I hope they also understand the passion of the millions of parents, carers and service users who stand behind him.
I thank noble Lords from all sides of the House for their leniency over this interruption.
Lord Scriven (LD)
My Lords, I have attached my name to a whole raft of amendments in the name of the noble Lords, Lord Crisp and Lord Hunt. I am pleased to follow the noble Baroness, Lady Uddin, who has explained powerfully and passionately why primary care in one area is so important to the health and well-being of people. I also thank the noble Lord, Lord Low, for introducing this suite of amendments with such a graphic and powerful explanation of why primary care, particularly for people with learning disabilities, is also important in relation to ophthalmology.
I wanted to put my name to these amendments, because they go right to heart of the purpose of the Bill. Let us be clear about the purpose of the Bill. Its purpose is to integrate healthcare to improve health outcomes and to reduce health inequality. You cannot do that if your focus is purely on the acute sector. The acute sector is the repair system. It is not the part of the system that can really deal with the prevention and innovation that keeps people out of hospital. I am sure that was never the intention of the drafters of the Bill, and I am sure that it is not the Government’s intention. However, the way the Bill is written, the power emphasis is with the acute sector in monitoring, reviewing and strategic plans.
I am sure the Minister will say that that is not the case, but the way the Bill is written it is the acute sector that will have the power over who sits in the ICB and whose plans they are. So I say to the Minister in a very friendly way that the noble Lords, Lord Crisp and Lord Hunt, and I have been involved in the management and leadership of health in different parts of the system. I was involved in acute and primary care myself. When I came into the health service, the noble Lord, Lord Crisp, was so powerful and mighty that he was the chief executive of NHS England. It was the same with the noble Lord, Lord Hunt. I feel in very esteemed and very grand company.
However, the point we are trying to make is that the real way in which healthcare works and how it is developed is that the acute sector is very powerful, even at place. If you do not give a voice and power to primary care, you will not have the innovation and the change that you require. These amendments are a way of trying to make sure that the purpose of the Bill at least moves faster and is eased by having that primary care voice right at the heart of the ICB, and, being statutorily in the Bill and having been there right at the beginning in the planning, monitoring and evaluating, being able to determine what is happening. That is what these amendments are about, nothing more. They are not amendments that should be deemed difficult or trying to slow things down. They are genuinely helpful amendments.
I say very gently but powerfully to the Minister that he really needs to incorporate these amendments. If he cannot incorporate and accept them now, the Government need to come back with a set of amendments that really crystalise the role of some great primary care people, whether they are in GP surgeries, ophthalmology, pharmacy or dental, who can actually help with the purpose of this Bill, which is to improve health outcomes, integrate healthcare and reduce inequalities. It is vital.
Lord Warner (CB)
My Lords, I will speak in support of Amendment 218, in the name of the noble Lord, Lord Hunt, to which I have added my name. Before I get down to that, perhaps I could make a few remarks about the amendments from the noble Lord, Lord Crisp, and the other remarks that have been made.
When I was sitting in Richmond House as a Minister, we had a description for the chief executives of the acute trusts. They were called “the barons”. When the House of Lords Select Committee, chaired by the noble Lord, Lord Patel, took evidence on the long-term sustainability of the NHS and adult social care, three or four of them—I cannot remember exactly how many—came in to give evidence. Their opening salvo was, “We need 4% a year real-terms increase every year, stretching into the future”. I suspect that culture has not changed that much since I was around in Richmond House, and it has to be changed—forcibly if necessary—if we are actually to deliver the sustainability of the NHS.
Since 1948, the acute hospitals have been magnificent in laying down the law about how much money they need. Even when money was short, they were pretty good at it. My personal experience as a Minister was that, if I wanted the go-to people on change, I would go to the GPs. They were much more flexible and willing to have a go at doing things differently. We need to bear some of that in mind.
About 90% of people’s encounters with the NHS are with primary care, not with acute hospitals. People’s vision of the NHS is those encounters. I just want to mention an encounter my wife and I had over vaccinations which illustrates some of this. Our very efficient, local general practice was fast out of the starting blocks and we had two jabs very quickly. Some months later, we were both individually approached by two NHS acute trusts, which shall remain nameless. They asked us when we were going to get round to having our vaccinations. There was absolutely no contact between these two parts of the NHS. One part had no idea that another had dealt with the patients perfectly satisfactorily. This is what we are up against. The least we can do is accept the amendments suggested by the noble Lord, Lord Crisp.
I turn to Amendment 218. I will not repeat the arguments set out by the noble Lord, Lord Hunt. The numbers speak for themselves. In any service that claims to be national, it cannot be right to have such a wide range in the per capita workloads of GPs. After all, these doctors are the gatekeepers of patient access to specialist diagnosis and treatment. They should not be required to handle case loads that vary from around 1,000 to more than 6,000 patients. Such variations are likely to create significant variations in patient treatment outcomes.
I will make two further brief points in support of the amendment in the name of the noble Lord, Lord Hunt. First, there have been many worthy amendments tabled about the long-standing, serious problem of health inequalities. Many places with the most serious health inequalities are places where the patient load of GPs is very high. So the patients with the most need of clinical attention and help have the doctors with the least time for individual attention. I have to say, that is a brilliant piece of public policy that we have managed to develop.
My second point relates to the Government’s worthy aspiration to level up the quality of life in many neglected areas of this country. We now have a Secretary of State for Levelling Up, and no doubt we eagerly await the game plan he has for living up to his title. A fairer share of the national supply of GPs would be a tangible piece of levelling up in many of those deprived areas. Can the Minister say whether the Government have considered a move in the direction of the amendment tabled by the noble Lord, Lord Hunt, as a useful part of their levelling-up strategy? I hope the Government will give that consideration on those grounds alone.
Baroness Hollins (CB)
My Lords, I have some brief points to add in support of my noble friend Lord Low’s Amendment 56A, which the noble Lord set out so clearly, and also in support of the amendments tabled by the noble Lord, Lord Crisp. It is very clear to me that primary eyecare has lagged well behind other areas of primary care in terms of any commissioned schemes for children and young people who are not in special schools and for adults with learning disabilities.
My experience with my son sound very similar to those described so well by the noble Baroness, Lady Uddin. The similarities are quite extraordinary, and my heart goes out to her. This week my son went to see the optician. He is visually impaired; he has a learning disability and autism. Fortunately for him, the optician responded well to the request for some reasonable adjustments to be made—which are required by law, but perhaps not well understood in local high street opticians.
Some years ago I did some research with SeeAbility, and together we created a visual, word-free resource. I declare an interest here, because this was with the charity I founded and chair: Books Beyond Words. We created a story called Looking After My Eyes and I read this with my son before he went to his optician’s appointment yesterday. It helped him and it helped the optician. But we need targeted improvements in optical care for everybody with a learning disability across the country. For this reason, I thoroughly support my noble friend’s amendment.
Baroness Bennett of Manor Castle (GP)
My Lords, in the wake of such a hugely powerful group of contributions, mine is very much a supporting role and I will be brief. I can only endorse the contributions to the amendment put by the noble Lord, Lord Low, and what we have heard about why it is so urgent. I will speak to Amendments 112 and 218, to which I have attached my name.
I attached my name to Amendment 112 because, as I was looking through the amendments, it struck me as such a crucial one. It was one that, even at this stage, it was really important to have four signatures on to show broad cross-party support. I am afraid I did not go for Amendment 113 and the rest of the list as well, on the grounds that I thought my name was there enough already, but I think the rest are—if not technically, certainly practically—consequential on Amendment 112.
After I had done that, I received a briefing from the Royal College of General Practitioners, writing also on behalf of the Royal Pharmaceutical Society and the Association of Optometrists. I will quote one sentence. The college says:
“We think this is a classic example of where secondary care is at the centre of decision-making, while GPs and primary care are ‘consulted’.”
I think that reflects what the noble Lord, who has a great deal of expertise, said, and this is one amendment that is a total no-brainer.
Moving to Amendment 218, the noble Lord, Lord Hunt of Kings Heath, outlined the technical background to this and the statistics. The only thing I will add is that many think tanks, including the Health Foundation, the King’s Fund and the Nuffield Trust have produced information about how extreme the variation in availability of GP services is and how much effect that has on inequality. As the noble Lord, Lord Warner, said, if the Government have a levelling-up agenda, this also is surely essential.
The reason I was personally attracted to this amendment is that in my days as Green Party leader I travelled around the country a lot and quite often ended up meeting GPs, very often talking about public health issues. I encountered so many desperately hard-working, utterly committed people who were exhausted and felt that they could not retire or cut back their hours. They were wearing themselves to the bone because no one was coming to replace them. I felt that I needed to stand up and speak for those people.
Sometimes people think of this as something that affects rural or remote areas. However, the Norfolk Park health centre in Sheffield nearly closed last year because, after extraordinary efforts, it had been unable to find an extra partner to come in. As the noble Lord, Lord Scriven, knows, this surgery is a fairly modest bus ride from the centre of a major city. It is a purpose-built health centre and only eight years old, but it could not find a GP partner to come in. Eventually, after a great deal of public campaigning, the surgery remained open. That is a demonstration of just how broad this problem is, yet, as the noble Lord, Lord Hunt, said, there are parts of the country—broadly the wealthier parts—that have expansive GP coverage.
Something has to be done, but, like the noble Lord, Lord Hunt, I am not sure that the proposal here is exactly the right way forward. We often say that something needs to be done, but we really need to see something done here. As with so many of the amendments that we discussed this morning, the Bill we have before us is the chance to sort out an urgent problem that must be sorted out.
Baroness Cumberlege (Con)
I would like to say a few words and will start by complimenting the noble Lord, Lord Crisp, on all his amendments. I agree with the noble Lord, Lord Scriven, that these are not contentious. In fact, I do not think it would harm the Government at all to include these amendments in the Bill. They are trying to reinstate the primacy of primary care.
We all know that the glamour is not in primary care but hospitals—you have only to see where politicians like to be photographed; when they produce newsletters, they are always pictured in a hospital with a very sophisticated piece of new machinery that that hospital has bought. It is understandable, because that is so easy to recognise. With a photograph of a GP in a consulting room, you do not know quite where this is, who it is, or what he is doing. One can understand why the media goes for the picture of the hospital, because that is what people recognise.
In this debate and these amendments, we know that the absolute foundation of the NHS is primary care. It is so important and we have to build its primacy. I am a child of primary care; I grew up in it. My father joined the NHS in 1948. He welcomed it and thought it was a marvellous innovation. I had a very happy childhood as Dr Camm’s daughter; I had status in the community. Then I segued into being Mrs Cumberlege and my status plummeted—because I had married a farmer. We celebrated our wedding 61 years ago last week, so have had a diamond wedding. My husband said to me, “Julia, what do you want?”, and I said, “Well, it is a diamond wedding”. He delivered, and I was just delighted.
I will not extol the virtues of my father’s practice, but want to think of the role of the GP in the future and how it has already changed. In our practice, all the GPs are now part-time. They are men and women, and they have other lives to lead. None of them is a full-time GP, and that makes continuity of care quite difficult, because you are never quite sure whether they will be there or not. If you want an urgent appointment, of course you can get one, but it will probably not be with your GP. So that has changed.
There has been another change. My father built a health centre. In fact, it was the county council that built it, but he put all the pressure on to build it, and it was called the “health centre”. Today, it is not called that; it is called the “medical centre”. That is because the doctors are transactional. They just do what is in front of them. Health is not part of their remit, and it is our community that provides the health. It is the church which has the social work and provides a huge amount of the social services for our community. So things really have changed.
A very good paper was produced by the Royal College of General Practitioners, in June of last year, The Power of Relationships: What Is Relationship-based Care and Why Is It Important? It is such a good paper, and I recommend that noble Lords look at it before we have the debate led by noble friend Lady Hodgson on relation- ship care and what it means. The statistics show that people live longer with relationship care. They are happier. We have some really good evidence, but I shall talk about that when we come to that amendment.
I have been working with Sir Cyril Chantler, whom many people in this House will know. We have been talking about community hubs. We think they are a very good way of moving forward and getting together not only doctors but social care, voluntary organisations and all the community facilities to ensure that they are in a hub. We know that, with integrated services and boards and the work that is going on in integrated care, the populations are enormous. We have to break it down a bit to make it more accessible to people. The next time we have a chance to debate this matter, which will be in the context of relationship care, I shall talk about community hubs with populations of about half a million. We are already establishing maternity hubs. I have said to them, “No, not maternity hubs—you’ve got to make them community hubs; you’ve got to bring in all the other resources that are in the community, because they’ve all got something to offer, and we would all benefit.”
I hope that my noble friend the Minister will think seriously and work with his colleagues to try to ensure that these amendments, or very similar ones, are introduced into the Bill, because we need to ensure the primacy of primary care. I am afraid that it is not there now; it is all about hospitals.
Baroness Walmsley (LD)
My Lords, it is a great pleasure to follow the noble Baroness, Lady Cumberlege, and I am delighted that her status has now gone up again because of her ennoblement and all the excellent work that she has done. We really benefit from her knowledge and wisdom in your Lordships’ House.
I support the noble Lords, Lord Low and Lord Crisp, and want to make just one point. Correct me if I am wrong or if I am out of date—I am sure that some noble Lord will if I am—but I think it is the situation that if an acute hospital overspends, the NHS bails it out, whereas social care and primary care cannot overspend because nobody will bail them out. I think that says it all.
Baroness Thornton (Lab)
My Lords, in many ways we are drifting back to 1946, when the NHS started on three legs: hospitals, services such as health visitors and ambulances provided by local authorities, and services that were contracted out, such as GPs, dentistry, ophthalmology, pharmacy and so.
Lord Kamall (Con)
I thank all noble Lords who spoke in this debate for once again increasing my understanding of some of the challenges within the system, in addition to briefings I have had thus far. I thank the noble Lord, Lord Low, for his patience and his just-in-time mode of operation and, more than that, for his contribution to the debate today. We appreciate that people with learning disabilities experience a higher prevalence of visual impairment than the general population, and that this prevalence increases with the severity of the learning disability. Children with learning disabilities are, for example, 28 times more likely to have a serious sight problem, and over 40% require glasses.
NHS England continues to responsible for the contracting of the NHS sight testing service. This will eventually be transferred to ICBs. Sight tests are widely available across the country through our very dedicated primary ophthalmic services workforce. Those eligible for a free NHS sight test include children, those on income-related benefits and those at particular risk of eye disease. We expect that those with severe learning disabilities should meet the eligibility criteria in other ways, and for these reasons we do not believe that, at this moment, extending eligibility further is necessary. Where those with learning difficulties are unable to access NHS sight tests on the high street, hospital eye departments also provide routine eyecare services and ongoing care. Children are usually referred on to hospital eye services via visual assessments delivered by specialists in special schools. Others are referred by GPs, school nurses or high street practices. We have also seen the development of special pathways in some parts of the country that cater specifically for adults with learning disabilities and we want to make sure that, via the NHS England central team, we share best practice on a national level, so that all regional teams and all ICBs can benefit from learning from the local initiatives and pilots.
NHS England also tells me that it recognises that more needs to be done to ensure equality of access. That is why the NHS long-term plan committed to ensuring that children and young people with learning disabilities, autism or both in special residential schools have access to eyesight, hearing and dental checks. In order to fulfil this commitment, there is a proof of concept programme building on the work by SeeAbility in London, which was launched in 2021, to provide sight tests and dispense glasses on school premises. My honourable friend the Minister for Care is due to make a visit to one of the schemes.
I now turn to the amendments on primary care providers. I understand noble Lords’ interest and that it has been widely acknowledged that CCGs, for example, are dominated by trusts, particularly for acute care. I take the gentle encouragement of the noble Lord, Lord Scriven, to understand that more, and particularly to make sure that the voice of primary care providers is heard. That is also the Government’s ambition. We support the idea that primary care should be integral to ICB planning, which is why at the moment at least one member of the ICB will be nominated by primary care providers in the area.
We all know that primary care service providers are predominantly independent entities that hold contracts with the NHS, unlike NHS trusts and foundation trusts, which are largely statutory entities. If all types of primary care service providers were named in the Bill, it would mean that every provider in the area of the ICB would have a duty to contribute to the development of the joint forward plan. We do not believe it would be a feasible option for all primary care providers to contribute to the plans, but I acknowledge the points made by noble Lords about how we can raise the profile and contribution of primary care providers.
I turn briefly to Amendment 117. We agree that it is important to consult the relevant primary care local representative committees, which is why we already have a provision under new Section 14Z52 to introduce a duty to consult anyone the ICB and its partner trusts consider appropriate when preparing the plan. There should also be a summary of the views expressed by anyone consulted and an explanation of how those views were taken into account. We expect members of the primary care sector to be consulted and their views summarised in this way. We understand that NHS guidance will provide for that.
We also want to allow ICBs to focus on arranging safe, high-quality care, and making an additional, explicit requirement in the Bill does not align with our desire to reduce the bureaucratic burden on ICBs. I understand that this is all part of the general debate about whether, if we accepted every amendment about who should be on the ICB, it would be more inflexible and unwieldy. These are conversations we should have in the round about the priorities for ICBs, what should be mandated, what should be in guidance and what the ICB’s duties are expected to be. I hope that we will have those conversations in the round so that we can come to some sort of consensus across the Committee.
Lord Crisp (CB)
The amendment in my name specifically requires ICBs
“to work with the four primary care services … when preparing and revising their five year plans”.
It does not specifically ask for a seat on the ICB. That is a different request. I hope the Minister understand that and will respond to it.
Lord Kamall (Con)
I thank the noble Lord for that clarification and also for the advice he has given me in my first few months in this job. I do appreciate his experience. I will take the noble Lord’s point back and make sure it is clearly understood by the department when we consider how we respond to it. We believe in working with appointed ICBs, but we expect primary care to be consulted.
NHS England has also stressed the importance of ensuring that there are robust place-based structures in place. We hope that the ICB will exercise functions through place-based committees, where a wider group of members can take decisions, and we expect that primary care, including individuals from medical, dental, pharmaceutical and optical committees, will be particularly involved at the place-based level under the principle of subsidiarity. We will have some influence on the drafting of the forward plan of the ICB. Additionally, guidance that NHS England publishes for ICBs will include the commissioning of primary care at the place-based level.
Lord Warner (CB)
I have listened very carefully to what the Minister is saying in response to these amendments but, at the risk of being a historian again, is he aware that influence on key decision-making in the NHS is diminishing for primary care in general and GPs in particular? If we go back to 1990 and the GP fundholding changes to the NHS made by the noble and learned Lord, Lord Clarke of Nottingham, if we move through the Blair years of practice-based commissioning and go to the changes by the noble Lord, Lord Lansley, with clinical commissioning groups, these are three examples where GP influence on decision-making—strategic, local and tactical—is very considerable.
As far as I can see, that has been diminished in this Bill and they have been put back in their box without a lot of influence on key decision-making. They are poked down at the local place level. That is not right. What the Committee is saying needs to happen in the NHS. The Minister must go back to his department and talk through what is happening here, because it is diminishing the role of the GP in particular.
Lord Hunt of Kings Heath (Lab)
My Lords, the noble Lord has said that the Bill came because this is what the NHS wanted. But we must be clear who in the NHS wanted it, and it is obvious that it was the senior chief executives at the local level and NHS England. No wonder primary care has been completely squeezed out of it. Listening to this debate, it seems to me that the proposals from NHS England never had any scrutiny. Ministers just accepted this and, because NHS England does not engage externally, there has not been the testing that you would normally get, and we are having to do it now. Frankly, the wheels are falling off. It is tempting to invite the noble Lord, Lord Lansley, to come in, because clearly CCGs were all about putting primary care in the driving seat. This seems to be removing them altogether and it is worrying.
Lord Lansley (Con)
My Lords, in response to that, may I say that when I was shadow Secretary of State for several years, GPs consistently told me that if only they were given the responsibility, they could do it so much better than primary care trusts? So we gave them the responsibility in ways that were very like the locality commissioning that was the endpoint of the GP fundholding of the noble and learned Lord, Lord Clarke of Nottingham. To be fair to them, there was less money, but no sooner did they take this responsibility than NHS England said, “Hang on a minute, you’re not doing what we’ve told you to do.” It took about 18 months, perhaps slightly less, before NHS England effectively said, “You have no further autonomy. You’re going to be in the sustainability and transformation plans,” which are the forerunners of ICS. I do not think that the clinical commissioning groups ever got the chance to do what they were asked to.
We have now reached the point where, as the noble Lord, Lord Warner, rightly says, they are being written out of the script, but they are not complaining, which is very interesting. They are not complaining because they do not want to be responsible for the budgets; they want to be responsible for the patients. They always said that they wanted to decide how locality commissioning should be done and the good ones have put tremendous things in place in terms of population health management, patient pathways and commissioning linked to those patient pathways. That is why, if we can do something with this Bill, it is to retain all that locality commissioning with GP input. But be prepared for the ICS, the big battalions, to go away and fight with the barons in the big hospitals.
Lord Kamall (Con)
Anyone else want to come in? Look, I thank all noble Lords for their contributions and friendly advice, however put. Actually, I appreciate their passive-aggressive demeanour, in that way. I know it is all well-intentioned and that noble Lords speak from experience of previously tried schemes. The main point here is how we make sure that primary care is better represented and not dominated by acute trusts. I do not think I am going to have the answers to convince noble Lords completely or even partly tonight. Therefore, this clearly needs more discussion and for me to go back to my department, but also, once again, us to have another discussion on these issues between now and Report.
Baroness Cumberlege (Con)
My Lords, can I quickly intervene? Of course, it is absolutely right that one should learn from history. But looking to the future, I just wonder whether the Minister has heard about the movement there is by some foundation trusts to try to take over primary care. I just wonder what the implications of that would be for primary care, whether he and his officials have heard of that and whether they would like to discover what that would do to patient care.
Lord Kamall (Con)
I thank my noble friend; I was not aware of that. But at the end of the day, the result has to be the care that the patient receives. There will always be debates on how you can configure who should be involved at what level, but at the end of the day, it has to be the quality of the care the patient receives. To a wider point, we must also focus on prevention. We are seeing a lot of innovation in the primary sector; we are seeing GP services sometimes merge into primary care centres, taking on medical procedures that were previously considered the domain of hospitals. We have seen more blurring of the lines, and patients welcome that innovation in many cases.
What matters at the end of the day is the experience of the patient and making sure they have a decent service all the way through their life. It is one of the reasons we are talking about integration. In this country, care is literally from the cradle all the way to the grave, as we integrate social care more. That is why some of these discussions we have been having on social care and palliative care have been important. We are aware of that.
There are a couple more points I would like to make before I allow people to get in before the 5.30 pm deadline for getting a teacake. We support the idea that all areas should have an adequate number of GPs. That is why we launched the targeted enhanced recruitment scheme to attract doctors to train in locations that either have a history of under-recruitment or are currently finding it difficult recruiting. The scheme reflects the fact that trainees who are attracted to these areas usually stay on after training. Hundreds of doctors have trained in hard-to-recruit places since the scheme’s introduction, with 500 places available in 2021 and, we hope, 800 in 2022.
We also recognise that each community has different health needs, which emphasises the point noble Lords have made—that it is so important to hear the voice of primary care more loudly. We are taking steps to diversify the general practice workforce, such as by recruiting 26,000 more primary care staff. Making sure we have the correct mix of skills available in general practice is critical to delivering appropriate patient care across England.
One of the issues that we have to appreciate, though, is that as most GP practices are private partnerships and GPs are free to choose where they practise, a general medical practitioners equitable distribution board would have limited influence over the distribution of GPs across England, which is why we have to look at other ways to target those areas that are underserved. That is why it remains critical to continue encouraging trainees to train in hard-to-recruit areas and diversify the primary care workforce to support general practice in meeting the needs of its local community across England.
I have heard, once again, the mood of the Committee. That has become a familiar theme. I hope noble Lords will accept that I am open to further conversations in this area, particularly on how we hear the voices of all those in primary care, not just those of GPs but all of them, including those in ophthalmology, dental care and others. I hope that, in that spirit, noble Lords will feel it appropriate to withdraw or not move their amendments at this stage.
Lord Low of Dalston (CB)
My Lords, I thank the Minister very much for his response and all other noble Lords who have participated in the debate. I moved a rather modest little amendment but I am encouraged that it has stimulated such a rich discussion with so many knowledgeable contributions. If nothing else, my amendment has stimulated a discussion that has emphasised the importance of primary care. If we can take that message away, we will not have been wasting our time. I shall leave it there. I thank everyone for their contributions and the Minister for his response. I am sure he will have been enriched by the way the discussion has focused on the importance of primary care. It has been beneficial all round. I beg leave to withdraw the amendment.
The Deputy Chairman of Committees (Baroness Pitkeathley) (Lab)
Before I call the next amendment, I remind your Lordships that the noble Lord, Lord Howarth of Newport, is taking part remotely.
Amendment 59
Lord Howarth of Newport
“(1A) To this end, an integrated care board must engage providers of non-clinical services, including creative and nature-based services and other services in the voluntary, community and social enterprise sector, ensuring that it has effective channels for dialogue with these sectors.”
Lord Howarth of Newport (Lab) [V]
My Lords, in this suite of amendments to Clause 20, which lays down duties on integrated care boards, I am proposing that we should articulate a duty for ICBs to embrace non-clinical practice in their whole way of working. By non-clinical practice, I am referring to a range of services and interventions that promote human flourishing, such as: engagement with the arts and culture to stimulate the creative imagination; a healthy discovery of meaning, self and personal agency; engagement with nature to provide a sense of wholeness, wonder and well-being; physical exercise and sport to energise the body and mind; engagement in voluntary work to lift people from self-absorption and melancholy, and to enable them so they are useful and valued members of society; and meditation to impart calm and perspective. All this is ancient wisdom that is being rediscovered by more and more people. This rediscovery is, indeed, innovative and the Bill requires ICBs to promote innovation.
In no sense am I suggesting that such practices should substitute for modern medicine where diagnosis and good sense indicate that modern medicine is needed. Modern medicine achieves extraordinary things, but too often we resort to it without first considering non-clinical approaches. As a society, we are over- medicating; witness the almost exponential growth in the prescribing of antidepressants. Our national passion for the NHS should not be an addiction. The NHS needs, gently but firmly, to steer us into asking less of it and taking more responsibility for maintaining our own health. That should be a new norm built into the legislative framework for the NHS that the Bill provides. Unless that happens, the system will collapse under the burden of the demands and expectations that it has created.
Unless the Government systemically address the social determinants of health, we shall not have a healthy society. The Bill, harking back to the time of Aneurin Bevan, who as Minister for Health was also Minister for Housing, rightly describes the provision of housing as a health-related service. Amendment 90 goes further, to insist on well-designed housing and urban and green environments. Research evidence shows that living in greener urban areas is associated with lower probabilities of cardiovascular disease, obesity, diabetes, asthma and mental distress among adults, and obesity, poor cognitive development and myopia in children. In every place that ICBs serve, they should be promoting debate about what good urban design should mean and how it should be achieved. Encouragingly, in the new Ebbsfleet Garden City planners are co-locating cultural facilities alongside a health and well-being hub.
There is a substantial and growing body of high-quality research and evaluation demonstrating that creative health and other non-clinical approaches, as the All-Party Parliamentary Group on Arts, Health and Wellbeing said in its report, Creative Health,
“can help keep us well, aid our recovery from illness and support longer lives better lived … the arts can help meet major challenges facing health and social care: ageing, longterm conditions, loneliness and mental health”,
and
“the arts can save money in the health service and social care”.
Since the publication of that report in 2017, there has been increased recognition of this among health policymakers and in the clinical establishment. Research has been commissioned. The NHS long-term plan, with its new emphasis on prevention, acknowledged the benefits of social prescribing. The National Academy for Social Prescribing was set up. Link workers, linking GPs with community providers, are being funded, though not the community providers themselves. NASP has allocated £1.8 million to its thriving communities fund to increase the scale of social prescribing activities, and the Government have a £5.8 million cross-departmental project aimed at preventing and tackling mental health through green social prescribing.
However, this activity is still marginal and its funding almost indiscernible in the NHS budget. Amendments 104 and 105 make clear that an ICB has the power to fund non-clinical providers and that there must be financial equity between clinical and non-clinical providers. If the NHS will struggle to provide enough initially, the wider levelling-up strategy should enable that funding.
Non-clinical health providers cost a fraction of conventional medicine and represent remarkable value for money. The Evaluation Report of the Social Prescribing Demonstrator Site in Shropshire showed significant improvements in health factors such as weight, physical activity, smoking and blood pressure, and a reduction of up to 40% in GP appointments. Dance is inexpensive to lay on. As the Dancing in Time project in Leeds showed, by improving gait, flexibility and strength, it reduces falls among the elderly, who are expensive to repair.
To fail to invest on a reasonable scale in creative health and other non-clinical services is to look a gift horse in the mouth. This is recognised in some ICSs, with which the National Centre for Creative Health, a charity which I chair, is working on pilot schemes. In the Shropshire, Telford and Wrekin ICS, the personalised care team is using creative health and co-production methods with children and young people suffering from asthma. In the Suffolk and North East Essex ICS, clinicians looking for ways to support patients with long Covid have introduced singing for breathing, which is beneficial for lungs and loneliness. Creative Minds in the South West Yorkshire trust has developed creative activities that now benefit the physical and psychological well-being of 6,500 people a year. One user of the Creative Minds “Art for Well-being” programme, Debs Teale, a trustee of the NCCH, said:
“I am eternally grateful to … Creative Minds for giving me the wonderful opportunity to discover a mind released from the fog of depression. I have been five and a half years medication-free”.
Baroness Barker (LD)
My Lords, it is a pleasure to speak in support of the noble Lord, Lord Howarth. When I read these amendments I was immediately taken back about 20 years, to the offices of a charity that noble Lords might remember called the British Trust for Conservation Volunteers. It had a very worthy reputation. I think most people who knew vaguely of its work but did not know it in any great detail regarded it as middle-class do-gooders in bobble hats who went out and cleaned up local rivers and things that nobody else much bothered about. But 20 years ago, it began to do some of earliest work that charities did in drilling down into not only what they did but the impact of what they did. When the trust did that, it discovered two things. First, it discovered that the volunteers were much more diverse than one would have thought—there were all sorts of people from all sorts of different backgrounds, many of them in urban settings. Secondly, it found that the biggest impact it had was on the mental health of the people who volunteered. As an organisation, it tracked that as best it could in its non-clinical fashion.
I bring my observation up to date, to about three years ago, just before lockdown, when I had the great good fortune to be invited to the offices of Google one night. I remember it was a winter’s night with absolutely filthy weather, and 250 young people—or youngish people—turned up to talk about mental health and tech. The big question was around what we can do, given who we are, who we work for and the data that we are amassing now, about not just what people are doing but what they intend to do and the profiles we are beginning to build up about people’s behaviour.
It is to those two memories that I attach these amendments, because I think the noble Lord, Lord Howarth, is right. Everybody knows the value of this—we all know it as individuals. Who did not go nuts during lockdown and head out to the nearest bit of green space to cheer themselves up? We all know it, but how do we prove it to those in the NHS who, rightly or wrongly, hold fast to scientific data and evidence?
My point is simply that we should be trying to get this on to the agenda of the acute services, rather than primary care, and that we need to do so in a way that is collaborative. I think we should be challenging the acute services to tell us how they would evaluate this—what evidence would convince them? It might be the sorts of biometric evidence that people who are involved in mindfulness are beginning to generate; the fact that we can actually see differences in people’s brain patterns if, over a sustained period of time, they are engaged in things such as mindfulness.
I sincerely hope that we do not pat these amendments on the head and send them on their usual way into the background and to the byways of primary care. I hope that, although the amendments may not make it into the Bill, noble Lords might well challenge the department, NHS England and the acute sector to see this as a far more important part of prevention, particularly in mental health but also in a number of physical conditions, than they might otherwise have done.
Baroness Greengross (CB)
My Lords, I am in favour of the amendments in this group in the name of the noble Lord, Lord Howarth, specifically Amendments 59, 67, 71, 77, 80 and 82. My own Amendment 290 will be debated in group 41 and specifically addresses the importance of social prescribing for people with a dementia diagnosis and how this can form part of a wider care plan.
Social prescribing plays a very important role, not just for people with diagnosed conditions but generally, as part of wider brain health. Research by Arts 4 Dementia found that music-making provides a tool for a total brain workout and improves plasticity in the cortex, which enhances the ageing brain’s cognitive abilities, perception, motor function and working memory. It also improves cardiovascular strength while reducing stress. The Coda Music Trust provides a range of musical social ensembles and bands, as well as courses and classes for learning and well-being. In other studies, drama and poetry have been found to improve concentration and cause new neurons to develop and adapt.
Social prescribing has been recognised as playing an important role. It is part of the NHS long-term plan, and the Department of Health and Social Care has allocated funding to establish a national academy for social prescribing. This growing recognition of the role that social prescribing, specifically of music and art, can play in overall health is a welcome development because many of the programmes that exist at present rely on the voluntary sector.
During the pandemic, these programmes, like most of the voluntary sector, have struggled with funding and with being able to continue their work under Covid-19 restrictions. We also know that many arts venues have struggled through this time and many theatres and music venues now face an uncertain future. This sector therefore needs much more support right now if it is to continue its work. It is crucial that integrated care boards are empowered to promote social prescribing and can work with organisations that provide these services.
Although the evidence for the benefits of social prescribing is growing, more work is needed to research what types of social prescribing are successful for specific conditions, a point that I will elaborate on when we debate my Amendment 290, which addresses social prescribing and dementia. To help promote social prescribing, we need more training for GPs and other health professionals on how and when to prescribe these services. We also need to include arts awareness for mild cognitive impairment in the medical and social care educational curriculum.
There also needs to be greater availability of these services, with links to every GP. The current NICE guidelines for dementia recommend referring patients for these services only post diagnosis when, in fact, to promote overall well-being and brain health, we should encourage them much earlier from the onset of symptoms. For this, we need training, and integrated health boards must prioritise the availability of these services.
I thank the noble Lord, Lord Howarth, for these amendments and fully support their inclusion in the Bill. I look forward to the Minister’s response. I also want to take this opportunity to thank the noble Lord, Lord Kamall, whom I have often heard recently. He confirmed that his blues band, Exiled in Brussels, will play at an event supporting Music for Dementia later this year.
Lord Best (CB)
My Lords, I thank the noble Lord, Lord Howarth of Newport, for his inspiring speech. I declare an interest as a vice-president of the Local Government Association. I also chair the University of Oxford’s Commission on Creating Healthy Cities, which brings together academics, policymakers and practitioners. We hope to support city leaders and their citizens by shedding light on the policy interventions that are most likely to be effective in enhancing the health of their cities.
The Oxford commission is not due to report until later this year, but it is already clear that the two core issues raised by the noble Lord, Lord Howarth, in this group are likely to be central to our conclusions. The first relates to the wider determinants of health creation that take us beyond the integration of health and social care services towards recognising the relationship of public and personal health to other non-clinical services, including those affecting the built environment. The second issue relates to the value of engaging local and community organisations in a variety of ways in achieving health outcomes.
Baroness Morris of Yardley (Lab)
My Lords, I also wish to support the amendments that have been moved by the noble Lord, Lord Howarth, and supported by other speakers. I do not want to make a long speech, but I want to add weight to the argument by standing up and offering support. I will not repeat his arguments, but I want to pay tribute to the work that the noble Lord, Lord Howarth, has done in this regard. He chairs the All-Party Parliamentary Group which produced a report that was pivotal in taking this debate forward. The work that he has done with the National Centre for Creative Health has given us an army of evidence on its importance.
The amendments seem to fall into two groups. There are those around social prescribing for people with dementia as the noble Baroness, Lady Greengross, said, and the notion of health promotion by creating a better environment in which we live and preventing illness. That collection of amendments is an idea whose time has come. There is an amendment for later consideration to which I have added my name, for which the same arguments are being made for sport and recreation. I think of this as the whole area of health promotion, which is looking at non-clinical providers of healthcare. I think these amendments follow on very well from the last group of amendments that was debated.
The noble Lord, Lord Scriven, talked about the aims of this legislation as being about promoting well-being, and the noble Baroness, Lady Cumberlege, gave a very good example of how a community centre that had doctors in it has become a medical centre, and the message that they gave. Every single one of us here could make the arguments that we have heard so far, either from our own example—from our own health and well-being—or from something we have seen.
I wanted to mention two things. First, I declare an interest: I am director of the Royal Liverpool Philharmonic Orchestra, and the work that it does with Mersey Care NHS Foundation is magical. It sometimes goes unnoticed outside the region, but people with quite serious mental health needs are finding their well-being is promoted. They are enjoying themselves and feel more part of the community.
My second example is some work I did in Derbyshire with a charity of which I was patron, First Taste. The artwork it did in a care home meant that the prescription of drugs for sleeping and other things was reduced. All those arguments can be well made but my problem is this: I would have put money on no one standing up and arguing against these amendments. If you could stop 50 people out there and find three who will argue against these amendments, I would say “Well done”.
The danger for this area of policy is that no one is against it, but not enough is being done to get it to the top of the agenda. Sometimes, when no one is against it, you do not have the argument that promotes it up the national agenda. Everyone says “Great”, “We agree”, “It will be a great thing” and nothing happens. The stage of this area of policy is that everybody is doing a little bit. It is in the long-term plan. There are examples of good practice. We have the evidence that it works and the Government are investing some money, but it is never going to be an entitlement or a policy that has been enacted nationally unless something else happens.
In all public sector policies—it is the same in education—the biggest challenge is scaling up good practice. We now have lots of examples of good practice. What we need, and what is behind this amendment, is to scale it up so that it is not just a case of happening to live near an organisation or where somebody is making this happen. The amendments that we have, which are to the general duties of the integrated care boards, will be a step forward in trying to make this a national part of our well-being service. You are entitled to it; it is there and offered to you, no matter where you live.
That is the big task now. It is not making the case for social prescribing or non-clinical providers having a role to play in health promotion, but how we scale it up so that it goes higher up the agenda of people who are developing policy and deciding how resources should be spent in an area. Years ago, this would have been seen as a fringe interest and people might have thought the noble Lord, Lord Howarth, was eccentric in promoting such amendments. It is evidence-based now. It is what people know works and I think it is what people want. We just have to find a way of getting it up the agenda and making it happen. These amendments will go towards that end.
Baroness Tyler of Enfield (LD)
My Lords, I rise briefly to support this suite of amendments put forward by the noble Lord, Lord Howarth. I know how passionate he feels about this issue and how much work he has done in this area over many years. The noble Baroness, Lady Morris, has just taken the words right out of my mouth; I was going to start by saying that social prescribing is a phenomenon whose time has come. I think that is right. People understand that the approach of social prescribing is really opening up opportunities for people to improve health and well-being through non-clinical avenues. That is what this set of amendments is all about.
This is particularly relevant for people with long-term conditions and complex needs, particularly those with mental health conditions, suffering from dementia or experiencing loneliness. The one point I want to make, which I do not think has been talked about yet, goes right back to our opening debate today about how the ambitions of this Bill will be achieved only if there is true integration across health and social care. My big plea is: please do not forget social care when we are looking at this issue. When I say social care, I am thinking both about people who have domiciliary care in their own homes and people in care settings.
Lord Crisp (CB)
My Lords, I congratulate the noble Lord, Lord Howarth, on introducing this very important group of amendments and other noble Lords who have made some very interesting points, such that made by the noble Baroness, Lady Morris of Yardley: this is becoming received wisdom, whereas it might have been regarded as eccentric even five or 10 years ago.
I have three points to make. First, this is a Bill about integration and partnership. It would be good to have a clear message that non-clinical groups such as the ones we are talking about are part of that, in whatever is the appropriate way—a duty or obligation or something of that sort on in the Bill—without being too specific about the detail.
Secondly, the noble Lord, Lord Howarth, made the point that this is the rediscovery of ancient wisdom, not least, as the noble Baroness, Lady Barker, pointed out, through Covid. I am talking about human flourishing going back to Aristotle and many others in the past: the merging of that ancient wisdom with very modern evidence—more evidence all the time about things such as relationships, as well as the arts and everything else that has an impact on our health.
My third point is about impact. I co-chair the All-Party Parliamentary Group for Prescribed Drug Dependence. Last year, 17% of the adult population were prescribed antidepressants. That is a huge amount: when I see such a figure, I always have to remind myself that that means that 83% of us were not. However, 17% is a huge number, and the sort of things that we are talking about can reduce that number to the benefit of the people who would otherwise be prescribed antidepressants, making enormous economic savings, time savings and so on.
Baroness Finlay of Llandaff (CB)
My Lords, I strongly support this group of amendments. I would like to make sure that we realise that the medical humanities as a discipline have now been introduced in many medical schools. In my own, I was rather glad that AJ Cronin’s book The Citadel was introduced in general practice, particularly because, of course, he invented Dr Finlay, but there we are.
Quite seriously, we must not forget that loneliness kills. Loneliness is a true killer; it shortens lives. If people are not moving around well, they fall more and consume healthcare resources. Therefore, having green spaces and things such as sports for health, and so on is important. There is now also a body of evidence that the new intensive care units have used in the way that they are constructed, so that there is a view of outside spaces for those patients, rather than the total sensory deprivation that occurs to them in the very noisy and difficult environment of intensive care. Of course, music is used therapeutically during procedures and so on.
In the hospice world, lots of activities obviously go on in the day centres. As my noble friend Lady Greengross said, there is now good evidence for proper physiological mechanisms that explain why contact with these different disciplines—which were considered to be outside medicine—have a beneficial effect on healing, coping with pain and distress, resolving issues, reframing what is happening to you and so on.
I would like us not to forget that loneliness kills. Importantly, so many patients have said that they have a sense of personal worth when they are still able—however ill they are—to contribute to those around them and to a sense of community. These amendments go to the very heart of being human—that is, the inherent creativity within people that has been forgotten for decades in the provision of health and social care.
I can see that there are difficulties in bringing this into the Bill, but we should commend the noble Lord, Lord Howarth, for the sophisticated way in which he has worded some of these amendments. I hope that they can be built on as we go forward. This could save a huge amount of money for the NHS in the longer term. A huge number of side-effects of drugs could be avoided. People could be fitter. There would be fewer forms. There is a great amount of optimism behind these amendments.
Baroness Pitkeathley (Lab)
My Lords, what I want to say follows on very well from what the noble Baroness, Lady Finlay, said. I want to quote Sir Michael Marmot. He said:
“We need to adopt a health and social care system which prioritises not just the treatment of illness but how it can be prevented in the first place. The pandemic has made it crystal clear … why public health and … social determinants of health are so important. The health and social care agenda must be rebalanced towards prevention.”
This is essentially what the noble Lord, Lord Howarth, is saying. It is not just about the treatment of illness but about preventing it happening in the first place.
I commend my own general practice in north London. In despair at the quantity of antidepressants being prescribed with very little result, it took to organising community groups to do cooking, set up friendship groups and put people in contact with each other. It puts on bring and buy sales—all with people who, perhaps, in the past, might just have been prescribed antidepressants.
I want to say a word about the charitable aspect—the voluntary sector—to which the noble Lord, Lord Howarth, referred. Charities cannot operate unless their core costs are met. My own GP practice which did this wonderful work had to go to the local authority and to the lottery to seek some funding. We have to remember that, if we want voluntary organisations to participate in these wonderful preventive services, we need to ensure that they are properly funded.
Baroness Bennett of Manor Castle (GP)
My Lords, I join pretty much everyone else in commending the noble Lord, Lord Howarth, for tabling these amendments. I have attached my name to Amendment 67, although it could have been to any of them.
It is worth making two broad points. In her wonderful contribution on the last group, the noble Baroness, Lady Cumberlege, used the really key phrase,
“the community provided the health”.
That is what this group of amendments is talking about.
A couple of groups back, the noble Baroness, Lady Thornton, talked about how, if the health system is working for people with learning disabilities, it is working for everybody. If we bring in the kind of institutions, frameworks and supports that we are talking about here—if we think about stopping people getting ill and caring for ill people—we will make our communities vastly better for everybody. This is an important point to make.
Like most noble Lords, I could come up with a list as long as your arm of wonderful places I have visited. I will not, but I will mention one, which brings together three elements of this: creativity, nature and culture. The Green Backyard in Peterborough is the most wonderful space. I defy anyone to walk into it and not smile. It has amazing, colourful, moving sculptures powered by water, with food growing—amazing salads filled with flowers. When I visited, I spoke to the carer of another visitor. This visitor had very profound disabilities—she was blind and non-verbal—but her carer said, “I’ve never seen anything like it. After the first time we came to visit, the next Monday, which she knew was the day we visited, she was all packed up, dressed and ready to go out.” This was obviously catering to someone’s needs absolutely brilliantly, but it nearly got bulldozed and turned into a block of flats a few years ago. Luckily, it was saved, but that is the situation we so often find ourselves in.
I also want to mention Amendment 90, in the name of the noble Lord, Lord Howarth. The noble Lord, Lord Best, has already said a great deal on this, so I will seek to add just a couple of small points—well, one small point and one quite big one. There is something called the lifetime homes standard, which I learned about when I visited Derwenthorpe in York with the Joseph Rowntree Foundation. The thing I remember about it, because it was so simple and obvious, was that the two-storey houses there had all been built with a space between the joists so that, if you needed to put a lift in up to the first floor, where the bedrooms were, it was a really simple and low-cost thing to do. It was a very simple piece of design. This will not be covered in the Health and Care Bill, but this relates to so many aspects of our society. You could say that housing is a health issue. In the first group this morning, we talked about social care and how many people cannot leave hospital and go home because their accommodation is unsuitable. We need to think all the way along the line across our society to make sure that does not happen.
Finally, I want to pick out one or two words in this amendment, which talks about housing and urban environments. I thought here of the New Ground co-housing development in north London, which is for women aged over 50. One aspect of it is looking at how people can support each other, be good neighbours and form a community that can provide support. This morning, I attended a King’s Fund briefing talking about social care and there was a great deal of talk about the need for digital innovation and technology. I tweeted, “What about social innovation?” We have to think about how we organise our societies and urban environments so that people can form those kinds of communities. If you visit any area of new housing being built around the country, there is typically precious little in it to encourage that kind of community development. The housing point is obvious, as is the environment point, but let us not lose the community and urban structure points from that amendment either.
Baroness Walmsley (LD)
My Lords, it has been an excellent debate. We have heard about all the various kinds of arts and the effect of housing. We heard from the noble Baroness, Lady Morris, about sport and leisure. We heard about the importance of green spaces in helping us with our physical and mental health. The noble Baroness, Lady Finlay, rightly mentioned that loneliness kills. If one can address that, it affects not just one’s sense of worth and well-being, as has been said, but one’s sense of community.
Parliament is a community. It sometimes does not feel like it, because we have various groups, political parties, Members, staff and so on, but we also have a lot of all-party groups and this is significant. We have sports, arts and heritage, drama and music groups. I have been a member of the Parliament choir for 22 years and have found great solace in it—I really missed it during the pandemic.
Baroness Thornton (Lab)
My Lords, I am delighted that my noble friend Lord Howarth has brought this suite of amendments in front of the Committee and is bringing the wealth of his experience to our debates on the Bill. He is a great proponent of the role and value of the non-clinical services in healthcare and well-being, and quite rightly too. It would be great if, somehow or other, this could be recognised in whatever comes out of our considerations, though I challenge the Minister to tell us how we might do that.
We support the amendments in this group to establish a role for wider considerations beyond remedial, interventionist clinically-led care. Amendment 90 covers housing. The role of decent housing in good health and in tackling health inequalities cannot be overestimated. Amendment 103A would require IBCs to consult on youth health prevention and treatment through an advisory board consisting of young people. All these amendments have huge merit.
I know that we will have a wider discussion about the role of the voluntary sector and social enterprises in provision of healthcare in a later group. However, voluntary and community organisations and social enterprises have been central to the delivery of non-clinical services in healthcare and well-being, particularly during the pandemic.
Baroness Chisholm of Owlpen (Con)
My Lords, before I respond on this group, I want to apologise for the chaos that I caused at the beginning of this Bill today. I hope that noble Lords did not think I was being discourteous to the House. Luckily, next Wednesday, normal services will be resumed when my noble friend Lady Penn is in her seat.
I am grateful to the noble Lord, Lord Howarth, and other noble Lords for bringing this suite of amendments before the Committee. It was interesting that several noble Lords brought up my noble friend the Minister’s band, Exiled In Brussels, which I think he is now going to rename “Exiled From Brussels”. I can say that there is a YouTube clip of the band which my noble friend said he is willing to send out to everybody, so that is something to look forward to.
On Amendment 59, I recognise the noble Lord’s concern to ensure that the voluntary, community and social enterprise sectors are represented in the Bill. I understand the intention of his amendment. I certainly acknowledge the important work of these sectors and their contribution to our health system. I am sure that we all have examples of how these non-clinical services are of benefit to our health system.
However, our intention, quite rightly, is to use the Bill to set out a framework of duties for ICBs that ensures they fulfil their functions effectively while avoiding being overly prescriptive. The provision in question sets a clear requirement on ICBs to discharge their functions in a way that promotes continuous improvement in the quality of services, particularly in health outcomes.
The intention is to establish a culture of continuous improvement in everything the ICB does, but, importantly, leaving ICBs to decide how this will work for them. Setting specific parameters, as this amendment seeks to do, would in practice narrow the focus of how they may look to improve the quality of services. This may be to the detriment of taking a more holistic approach to how to improve the quality of services. That said, the current drafting of the provision would not prevent ICBs engaging providers of non-clinical services, including those mentioned in the amendment of the noble Lord, Lord Howarth of Newport. Indeed, we would expect that, where appropriate, ICBs would consult with relevant stakeholders, such as those from the voluntary sector, to ensure continuous improvement.
Turning to Amendment 69, co-production, where people, family members, carers, organisations and commissioners work together as equal partners to design and deliver services, is an important principle, and one that we would expect ICBs to champion. This is reflected clearly in NHS England’s draft implementation guidance on working with people and communities, which also sets out several practical steps ICBs should consider to appropriately promote and embody co-production. This includes visibly supporting and sponsoring co-production, and supporting the adoption of co-production approaches where appropriate. I feel it is important to point out that mandating co-production in all circumstances risks narrowing the duty and may lead to other valuable methods of involvement being marginalised. Therefore, while it will often be a desirable aim that we would expect ICBs to pursue, it may not be appropriate in every case, and we want to allow ICBs and patients discretion to determine what is best in their area.
I will address Amendments 71 and 77 together. I am grateful to the noble Lord, Lord Howarth, and the noble Baroness, Lady Greengross, and I appreciate the interest in including social prescribing in the Bill. On Amendment 77, I begin by assuring noble Lords that the Government are absolutely committed to the rollout of social prescribing in line with the NHS Long Term Plan commitment. The plan was to have 1,000 new link workers in place by 2020-21, a target which I am pleased to say has been exceeded, so that we now aim for at least 900,000 people to be able to be referred to social prescribing by 2023-24. As of September 2021, there were at least 1,582 social prescribing link workers in place. Furthermore, in relation to innovation, the Government have set up the National Academy for Social Prescribing, in line with our manifesto commitment, which has continued to support the expansion of social prescribing and promote innovation in health and well-being across all sectors.
The duty to patient choice should be considered by ICBs as part of the broader move towards more integrated, population health-management approaches. This requires embedding more personalised care models that enable patient choice and also consider non-clinical approaches, in line with the NHS Long Term Plan. This commitment is to make personalised care business as usual across the health and care system. Social prescribing and community-based support is already a core component of the NHS’s comprehensive model of personalised care. I hope I have reassured noble Lords of the progress being made and work being done on social prescribing and that they will feel able not to press these amendments.
I turn next to the amendments proposed by the noble Lord, Lord Howarth, and the noble Baroness, Lady Bennett of Manor Castle, which would insert a number of references to the voluntary community and social enterprise and creative and cultural sectors. This Government hugely value the contributions of the voluntary community and social enterprise sector, including creative and cultural entities, to the health and well-being of the nation, and recognise their important role in integrated care systems. However, we feel that the amendments are not necessary, as their intended effect is already possible through provisions within the Bill.
A key principle of the Bill is the legislative flexibility to empower local leaders to develop bespoke solutions to meet specific local needs. This principle is reflected in the current drafting of Clause 20. Several of these amendments would have the effect of being overly prescriptive in areas where we would already expect the VCSE sector to play a key role.
I assure noble Lords that many of these concerns will instead be addressed in guidance. NHS England and NHS Improvement have published guidance relevant to ICBs on partnerships with the voluntary community and social enterprise sector, outlining the importance of the VCSE sector as a key strategic partner in local health systems. It provides guidance on how VCSE partnerships should be embedded in how the ICBs operate. Furthermore, the guidance sets out that, soon after they are established, ICBs will be expected to develop a formal agreement for engaging and embedding the VCSE sector in system-level governance and decision-making arrangements.
I turn to related Amendment 80. I know that the noble Lord, Lord Howarth, has a special interest in this issue, and I listened with interest to his speech at Second Reading on the work of the National Centre for Creative Health, which he chairs. Research is very important, and I am pleased to say that the department funds research in this area through the National Institute for Health Research. The NIHR funds and supports a range of research conducted by multidisciplinary researchers from diverse fields, including social sciences, behavioural sciences and the humanities. For example, the MODEM project, jointly funded by the NIHR and UKRI, reviewed evidence on music therapy and identified that a structured programme of music therapy given by a trained therapist can reduce agitation among people with dementia—which I think the noble Baroness, Lady Tyler, mentioned in her speech.
We do not consider it appropriate or necessary to specify particular research areas in primary legislation. In addition, we expect that ICBs will already promote a range of research, including those on non-medical interventions, and the noble Lord already cited in his Second Reading speech where this has been done by existing integrated care systems.
On Amendment 82, the Government place the utmost value on supporting the health and well-being of NHS staff. We are taking a range of actions to ensure that this remains a priority across the health and care system, and we do not believe that a legislative duty is needed in this area. Over the past two years we have seen as never before the intense pressures on the workforce, and we recognised at an early stage the toll that this may place on the mental health and well-being of health and care staff, with a clear need to prioritise enhanced well-being and mental health support for all NHS and social care staff. We all know that the whole country owes these staff an immense debt of gratitude.
At a national, strategic level, the People Plan, published in July 2020, puts NHS staff health and well-being at its core and ensures that all NHS staff have access to a comprehensive psychological and emotional support package. This includes a dedicated support line that is available for staff 24/7, and free access to mental health and well-being apps. Alongside this, 40 dedicated mental health hubs have been established and are accepting referrals across the country to proactively identify at-risk people and groups and focus on staff with more complex needs, ensuring that they receive rapid access to evidence-based mental health services. To ensure that this offer continues to improve staff mental health throughout 2021-22, an additional £37 million has been invested in 2021-22, building on the £15 million in 2020-21. I hope that the noble Lord, Lord Howarth, will accept that this work is worth while and important and will continue without the need for legislative amendment.
Baroness Bennett of Manor Castle (GP)
Before the noble Baroness sits down, I would just like to go back to some of the earlier amendments and some of the words she used. She said this is included in the guidance on using social prescribing, and that it is expected that ICBs will work with local social enterprises, et cetera. I want to ask a question. If we were talking about NICE-recommended medical treatments or the best possible surgical procedures, would we be saying that it is expected that ICBs will do this as it is included in the guidance? This picks up on the point the noble Baroness, Lady Morris, was saying that this still seems to be somewhere in the second class, and it should be up there in the first class, treated in the same way as a medical treatment or a medical device.
Baroness Chisholm of Owlpen (Con)
Well, I think it is, actually. We all realise how important it is. Social prescribing is a key component of the NHS’s universal personalised care. It is a way for GPs or local agencies to refer people to a link worker. Link workers give people time to focus on what matters and take a holistic approach to people’s health and well-being. They connect people to community groups and statutory services for practical and emotional support.
For instance, a man had bad bronchitis and asthma and was continually going to the doctor and costing the NHS a great deal of money; and it was agreed that a humidifier would be prescribed to him for his house at £800, and that has been a huge success, with the result that he has not gone to the GP once for a whole year. I think social prescribing can work well for those who are socially isolated, whose well-being is impacted by non-medical issues and who routinely present to primary or secondary care as a result. We certainly are taking it seriously.
The Deputy Chairman of Committees (Baroness Barker) (LD)
The noble Lord, Lord Howarth of Newport, is taking part remotely. I invite him to speak.
Lord Howarth of Newport (Lab) [V]
My Lords, I am extremely grateful to the considerable number of noble Lords who have taken part in this reflective, interesting and important debate. I am most encouraged by the appreciation that has been expressed all around the House for the importance of the considerations that I have sought to advance in this suite of amendments.
I am particularly grateful to the noble Baroness, Lady Barker, for her opening speech, which very much set the tone of the subsequent debate, and for sharing with us her memories of Google on a winter’s night. She made a particularly important point about evidence that is developing to demonstrate, for example, that the practice of mindfulness has benign effects on brain development. That is profoundly important for health. This needs to be understood and taken seriously by those who fund research and those who are pioneering practice within the NHS.
The noble Lord, Lord Best, may remember, as I do fondly, that, many years ago—I mention this particularly to the noble Baroness, Lady Bennett of Manor Castle—he showed me the Lifetime Homes project that he led when he was in charge of the Joseph Rowntree Foundation in York. He has been an advocate of the importance of well-designed housing for a long time and is a voice that is hugely respected on this, as on so many other subjects, in your Lordships’ House.
My noble friend Lady Morris of Yardley raised the important point that yes, we have come a long way and these ideas are no longer seen as eccentric, but, at the same time, unless policy is much more clearly enunciated and embedded, little, if anything, will really change. That is a question that the Minister did not adequately address, but I shall come back to it in a moment.
I was also grateful for the support from the noble Baroness, Lady Tyler, and the emphasis that she rightly gave to the contribution that the arts, creativity and other non-clinical services can make to the well-being of people in social care. I should mention that the charity Live Music Now, founded many years ago by Lord Yehudi Menuhin, has been supporting young professional musicians to perform in social care settings for many decades. That is hugely appreciated and beneficial. If his efforts were supplemented by those of the mother of the noble Baroness, Lady Walmsley—indeed, by the noble Baroness herself—so much the better.
The noble Lord, Lord Crisp, has thought more deeply about these matters than almost anyone else I know. Along with other noble Lords, he is a valued participant in the work of the All-Party Group on Arts, Health and Wellbeing. I commend to noble Lords a recent and beautiful article written by him in Prospect magazine, entitled, “What Aristotle can teach us about building a better society”. In it he writes so wisely and so well about health and human flourishing. As he will be aware, I am indebted to him for some of the language I used in my opening speech.
My noble friend Lady Pitkeathley made a crucial point about how essential it is that funding is provided to cover the core costs of the voluntary and charitable organisations upon which we so largely depend for the delivery of non-clinical services.
The noble Baroness, Lady Finlay, gave us the stark warning: loneliness kills. I very much appreciate her deep understanding and acceptance of the propositions that I and others have been making around creative health, and the support that she gave us in the creative health project.
The noble Baroness, Lady Greengross, made a particularly important, specific and practical recommendation that people should be referred for music therapy or other kinds of creative health interventions at the onset of symptoms of dementia without having to wait for perhaps many months for a formal diagnosis.
I am sure that the noble Baroness, Lady Chisholm of Owlpen, who was, after all, a nurse, personally appreciates the significance and value of what we have been talking about, even if she was briefed to bat away these amendments. She sweetened the pill by promising us a viewing of the YouTube clip of the Minister’s band.
I understand why the noble Baroness contended that the Bill should not be overly prescriptive, but, if that is so, I wonder how she answers the crucial question posed by my noble friend Lady Morris of Yardley: if we do not embed these duties—I would contend they are legislative duties—and responsibilities in the formal arrangements of the system, how are we going to get the step change and scaling up? How are we going to get the decisive shift in the culture to make non-clinical approaches truly integral to the practice of health and social care?
I was surprised when the noble Baroness, Lady Chisholm, advised us that these amendments could have the perverse effect of militating against a holistic approach, but she gave encouragement in what she said about the VCSE sector, in the willingness of the National Institute for Health Research to provide funding and in the thoughtful, extended observation she made about staff needs and the importance of housing. She said that housing is a local authority responsibility. Yes, that is technically true, but that is exactly the problem we debated earlier this afternoon, on which my noble friend Lord Hunt of Kings Heath energetically put forward his thoughts, supported by many other noble Lords. If the Bill continues to demarcate the responsibilities of the NHS and local government in the way it so far does, it will fail to achieve integration in very important respects—and surely we do not want that sort of failure.
It is precisely because of the pressures of Covid and of the backlog, which will make huge demands on NHS resources, thinking and energy for a very long time to come, that it is all the more important that we should enact into law a duty on ICBs continually, from the moment of their formal inception and sustained through the years to come, to operate strategies for the prevention of ill health and the positive creation of a healthy society, working in a multitude of ways with the populations they serve. I beg leave to withdraw the amendment and give notice that I do not wish to move any of the other amendments in this group.