Health and Care Bill

Baroness Finlay of Llandaff Excerpts

Lords Hansard - Part 3 & Committee stage
Tuesday 18th January 2022 Lords Chamber

Moved by

[Baroness Finlay of Llandaff]

47: Clause 16, page 13, line 38, at end insert—
“(ea) specialist palliative care services,”Member’s explanatory statement
This amendment would ensure that specialist palliative care services are a core service available equitably across all sectors.

[Baroness Finlay of Llandaff (CB)]

My Lords, to state the obvious, everyone will die. On average, one person dies every minute, and every 22 minutes a child loses a parent. Dying patients are seen in every part of healthcare, and the vast majority will have some level of palliative care need. I declare my interest as a specialist in palliative medicine over decades, and my roles with different relevant hospice and palliative care charities and being employed through the Velindre Cancer Centre.

Amendment 47 would introduce a specific requirement for clinical specialist palliative care services to be commissioned by integrated care boards in every part of England. Amendment 52 is to inform the debate as it draws on the World Health Organization definition of specialist palliative care. These amendments are strongly supported by Marie Curie, Hospice UK, Together for Short Lives, Sue Ryder and the Alzheimer’s Society.

Let me be clear; this is about specialist clinical services. General basic palliative care should be a skill of every clinician. But, until it is recognised as a core specialty, generic services will continue to view it as an extra and learning will not be integrated across all areas. Educating and training are crucial duties in upskilling others. In the pandemic, palliative care has been propelled centre stage as a driver of good practice. Specialist palliative care is a relatively new specialty, which is why it was not included in the early NHS legislation. The other truth, that everybody is born, was recognised by requiring every part of the UK to have maternity services. That has been reiterated in legislation and in Clause 16 of this Bill, along with dental and other services.

The hospice movement grew up outside the NHS, spearheaded by Cicely Saunders, who realised that bringing about change within the NHS was painfully slow. This has meant that a patchwork of services has developed in the wealthier parts of Britain. In some areas great, innovative integration with community social care is happening. But other areas of enormous need are left with almost no service, or no service at all. Now we depend on fundraising events for people to get expert support for pain and other symptoms, and for psychosocial distress. No one would advocate to have a cake sale so that a woman in obstructed labour can have a caesarean section, so why turn a blind eye to ways to improve the quality of life of those with serious and life-threatening illnesses and support their families? Debate in the other place suggested that palliative care is aftercare; it is not. It is not an add-on just before death. It must be an integral part of care so that problems are dealt with in a timely way, not left to escalate into a crisis.

In Section 3 of the NHS Act 2006, clinical commissioning groups had the same general duties as in this Bill, yet significant gaps in specialist palliative care services persist between clinical commissioning groups. Some populations fare particularly badly: people who are homeless or in prison, BAME groups, Gypsies and Travellers, LGBTQ+ people, people with learning disabilities and those living in poverty, alone or with dementia. Yet the way a person dies lives on in the memory of those left behind.

Marie Curie’s freedom of information requests to English CCGs revealed an average spend last year of as little as £19.02 per person aged over 65. Only 35% of CCGs responding offered specialist palliative care services in all care settings overnight and at weekends, yet such services are known to reduce pressure on NHS services and achieve savings by reducing the number of hospital bed days occupied and unplanned admissions.

Research from King’s College London and supported by Marie Curie reveals that of the 23 integrated care systems in England with published strategies, only six identified palliative and end-of-life care as a priority area. Five mentioned broad bereavement support and only three identified relevant measures of success, such as reduced hospital admissions.

In the pandemic, many hospices hit financial instability head on as fundraising dried up. The government bail-out was essential, and I think that everyone was very grateful. In 2008, Wales had tackled this problem head on, aware that if a hospice folded, the clinical core service would still be needed. With just over £2 per head of population investment, we moved to provide core specialist clinical palliative care through an agreed funding formula, moving to seven-day services and 24/7 advice to any health or social care professional with a patient needing help. These services cover hospitals, hospices and community, with increasing integration reaching areas where no services existed. We instigated a paediatric service and an all-Wales unified patient record across the NHS and voluntary sector providers, which I described last week.

The outcomes that we achieved warrant consideration. To quote one nurse:

“The patients have access to specialist palliative care nurses, advice and experience on the weekend, which is great, and if we weren’t there, they wouldn’t have that, and they’d suffer for it. Unfortunately, people deteriorate and die out of hours. They don’t all die Monday to Friday, nine to five.”


At the south-east Wales cancer centre, specialist palliative care is now embedded in the acute oncology service, whose audit revealed that almost three-quarters of the patients presenting to acute oncology had a level of unmet need in palliative care but were unknown to any services at the time. The majority then had same-day, face-to-face palliative care review or were referred to their local team. In the community last year, there were more than 3,700 patient contacts, over 1,000 being face to face. I remind the Committee that that covers a population of about 1.5 million. Many families have “just in case” boxes to make sure that medication is available, and the ambulance service can link in too.

For cancer centre in-patients, the palliative care audit showed that nine out of 10 symptoms improved during the patient’s stay, including pain, breathlessness, constipation and weakness, and nausea scores fell to zero by day seven. Multifactorial drowsiness persisted in some whose disease was progressing rapidly to death.

In England during the pandemic, specialist teams were in place. They have shown that they can facilitate discharge, support staff having difficult ethical and communication dilemmas, and support patients and families, but a Marie Curie survey of carers of people who died at home during the pandemic found that 76% said that their loved one did not get all the care and support they needed, 64% did not get pain management and 65% did not get the out-of-hours care.

This Bill arrives at a critical moment for improving care. In 20 years’ time, 100,000 more people will die each year in the UK. Demand is set to increase rapidly as our population ages and more people live for longer with multiple and complex conditions. The number of people dying with a need for palliative care is projected to increase by up to 42% by 2040. This cannot be left unaddressed, and the solution is at hand. I hope that the Government will finally recognise that they can improve care without increasing overall cost by adopting Amendment 47, to explicitly require the commissioning of specialist palliative care for local populations.

The NHS promised to support people from the cradle to the grave, and it can now realise that promise. I beg to move.

[The Deputy Chairman of Committees (Lord Lexden) (Con)]

My Lords, the noble Baroness, Lady Brinton, is taking part remotely. I invite her to speak.

--- Later in debate ---

I am deeply grateful for the work of the noble Baroness, Lady Finlay of Llandaff, in advocating for these important issues. I hope that I can reassure your Lordships that the Government are approaching them with the seriousness they deserve. Having said that, I hear the concerns from noble Lords—indeed, the word “anger” was used—and I hope that the noble Baroness and other interested noble Lords will continue to engage with the department and my officials between now and the next stage of the Bill. Even though I understand the sincerity and deep feeling of the noble Baroness in laying this amendment, I hope in the spirit of offering further conversations that she will feel able to withdraw it.

[Baroness Finlay of Llandaff (CB)]

My Lords, I am most grateful to everyone who has spoken tonight and who shared their personal experiences and the passion and, indeed, anger that my noble friend Lord Patel referred to. Really, we are at the point where enough is enough. I would love to address every point individually. I greatly appreciate the Minister’s commitment in giving me access to his Bill team and to officials previously and I will take up that invitation with zeal because I will come back to this on Report. I can say now that I will divide the House on Report because enough is enough. We cannot carry on with the lack of action and the continued jumble sales, cake sales and everything else.

The noble Baroness, Lady Masham, asked me about the support for children. As the noble Lord, Lord Patel, pointed out, the cost of putting this right, if you work it out, is less than £20 per person across the population. It is really low. Yes, of course, it involves children. I would like to finish with a tribute to a little boy called Stevie. Stevie told me that he was going to die when his goldfish died. His goldfish died. He then asked that we promise not to give him any more injections. We said: “Fine, we will not give you any more injections, Stevie, we will keep everything controlled.” His third point was for his parents to come in. He made them sit down and hold hands across the bed and promise to never argue again. He died shortly afterwards.

For all those children, all those adults—all those thousands of people—who are dying every minute, we must make sure that we meet their promises, that we give them good care and that they have good symptom control and good psychosocial support as they are dying and that their families do as well. Enough is enough. On that note, I beg leave to withdraw the amendment.

Amendment 47 withdrawn.

Health and Care Bill

Baroness Finlay of Llandaff Excerpts

Lords Hansard - Part 1 & Committee stage
Tuesday 18th January 2022 Lords Chamber

[Baroness Tyler of Enfield (LD)]

I rise to speak to Amendments 51, 98, 141, 151 and 162 in my name and, briefly, the other amendment to which my name is attached. I shall make one opening remark. This group is all about children and young people. I know that all noble Lords feel very strongly about this issue. Children and young people make up 30% of the population but are not mentioned anywhere in the Bill.

Amendment 51 would require integrated care boards to share relevant information and data with key partners in the children’s system and to collect multiagency data from those partners. As the Bill stands, there are a number of crucial areas in which adults are, rightly, set to benefit from improvements to integrated working in ways that children are not. One of the most concerning ways in which it feels to me as though children have been an afterthought in the Bill is in the sharing of data and information.

Barriers to sharing information have been identified over many years as a key barrier to better joint working, commissioning and delivery of services but, due to the invisibility of children in existing data-sharing legislation, the children’s system faces even greater barriers to sharing information than that for adults. However, the measures to improve the sharing of information and data in Part 2 apply only to the adult system. Frankly, I find that inexplicable.

Alongside the noble Lords, Lord Bichard and Lord Hunt, to whom I am very grateful for adding their names to my Amendment 51, I heard numerous accounts of the huge challenges that the NHS and local authorities face in collecting, sharing and interpreting data as part of the recent Public Services Select Committee inquiry into child vulnerability. We heard this time and again. I quote just one sentence from the report:

“poor data-sharing between Government departments and local agencies endangered vulnerable children and their families by undermining safeguarding arrangements and preventing referrals for early help.”

As we heard from the noble Baroness, Lady Masham, following the heartbreaking murders of Arthur Labinjo-Hughes, Star Hobson and other vulnerable children in this country, it is essential that arrangements for data sharing between the health system and local authorities for babies, children and young people are urgently improved. As I have said, Part 2 focuses on data sharing between health and adult social care but does not extend this to the children’s system. It is not just that children are not specifically included in the wording of the Bill; they have been explicitly excluded.

As the noble Baroness, Lady Meacher, said, colleagues in the sector, including the National Children’s Bureau—to which I am very grateful for its help and support on these amendments—have engaged in discussion with officials on this issue. I was pleased to hear that this engagement is going well and is set to continue, but I hope to secure today the Minister’s agreement to look again at this issue, which is in the best interests of vulnerable children in this country.

Amendment 98 would add the discharge of duty as a safeguarding partner to the general duties of ICBs in Clause 20. It would require new regulations that specify how ICBs should perform the statutory child safeguarding duty when it is transferred to them from CCGs, which are obviously abolished as a result of the Bill. Although the statutory guidance Working Together to Safeguard Children already sets out the responsibilities of a safeguarding partner, the recent tragic events that I have just referred to show that a more robust legislative approach is needed to ensure that children are properly protected by a really effective multiagency safeguarding system.

It was heartbreaking, and I know that all noble Lords in the Chamber were shocked when they heard the details of the tragic death of Arthur Labinjo-Hughes, a six year-old boy who suffered prolonged abuse and was murdered by the very people who were supposed to keep him safe. I recently met the NSPCC, which highlighted government data showing 536 incidents involving the death or serious harm of a child due to abuse or neglect in 2020-21.

Sadly, young Arthur’s case is only one of far too many, but health practitioners such as GPs, nurses, midwives and health visitors are in a prime position to recognise and report safeguarding concerns; during medical examinations they might identify signs of physical or sexual abuse. Missed medical appointments can also indicate neglect. As the strategic safeguarding leader, the ICB will be responsible for ensuring that health practitioners are fully supported to work with other agencies on safeguarding and promoting the welfare of children. Alan Wood’s review from 2021, which has been discussed in the Chamber on a number of occasions, makes clear recommendations on strengthening the existing safeguarding arrangements, which came into effect in 2019, including by ensuring effective leadership, data sharing and scrutiny. The Bill offers a golden opportunity to act on these amendments to bolster local health partners’ role as a lead safeguarding partner and to embed effective joint practices that really do keep children safe.

Amendment 141 would require NHS England to assess how well an integrated care board has met the needs of children and young people in its area. In order to make a judgment about this, the amendment would require NHS England to publish an accountability framework for setting out national priorities for children and young people. Among other things, ICBs will have a crucial role in commissioning primary and community healthcare services directly for children and young people. They will play a key role in jointly commissioning services for disabled children and those with special educational needs, and in contributing to education, health and care plans, and they will be crucial in commissioning the joined-up services in the first 1,000 days of life, which the Government, to their credit, are investing in.

However, as we all know, there is unwarranted variation, with the support that children and young people receive in the health service often based on where they live rather than on their level of need. This amendment would create much needed accountability for integrated care boards and provide an overarching framework for children’s health that ICBs can work within, importantly without being prescriptive in any way about how local systems fulfil their duties.

Turning to Amendment 151, Clause 21 requires every integrated care partnership to develop an integrated care strategy. The amendment would require ICPs to consider specifically the needs of babies, children and young people when developing this strategy. I think the Minister knows my concern and that of other noble Lords—the noble Baroness, Lady Meacher, referred to it—that if we do not refer explicitly to children in the Bill, they will not be given priority equal to the adult population’s when it comes to implementation. Sadly, experience shows that when legislation does not explicitly require health systems to consider children, they are often overlooked in subsequent implementation.

Children and young people have distinct development needs. They use a distinct health and care system staffed by a distinct workforce with its own training, and they are covered by distinct legislation. Simply hoping that integrated care systems will take full account of that of their own accord will just not cut it. A more robust legislative approach is needed. Like the noble Baroness, Lady Meacher, I was also pleased to hear that the Minister in the other place recognised the importance of focusing on children and families in the new ICS structures and made a commitment that the Government would develop bespoke guidance for integrated care systems on meeting the needs of babies, children and young people. That is why I support Amendment 177 in the name of the noble Baroness, Lady Meacher, and to which my name is attached, to put this guidance on a statutory footing.

Amendment 162, on Clause 26, would require the Care Quality Commission to work jointly with Ofsted to plan and conduct reviews into the provision of health and children’s social care in integrated care board areas.

Again, I refer back to my experience as a member of the Lords Public Services Select Committee. I can confirm, as the noble Lord, Lord Hunt, will be able to, that the committee investigated the role played by the relevant regulators and inspectorates. Indeed, we took evidence from the senior leaders of the relevant inspectorates and regulators, specifically Ofsted and the CQC. Our conclusion was that, despite the very best intentions, these inspectorates do not work together closely enough or have a truly integrated approach. It is telling that our report revealed that the CQC itself called on the Bill

“to give it the ‘ability to look at [the] care of children across all settings’ as part of its regulation of Integrated Care Systems”.

I believe that the Bill should give the Care Quality Commission and Ofsted powers jointly to hold integrated care systems, service providers and local decision-makers accountable for the long-term outcomes for children’s health, including health inequalities.

I very much support Amendment 177 in the name of the noble Baroness, Lady Meacher. It has been explained and it very much goes with the grain of my other amendments.

I also strongly support Amendment 142 in the name of my noble friend Lady Walmsley, which would provide an opportunity for the Government to ensure that children and young people are prioritised on ICBs while maintaining local flexibility, which is important. An impact assessment would allow for good practice to be shared quickly and for both Houses to exercise effective scrutiny over the implementation of this legislation.

On Amendment 87 in the name of the noble Baroness, Lady Finlay, the idea of the appointment of a strategic clinical lead for children and young people’s health is an excellent proposal, but I will leave the noble Baroness to express that.

In conclusion, the Government have a very important agenda for children. There are a lot of things that they are trying to do. I strongly support most of them but I really feel that we must have an effective legislative framework to allow that agenda to be taken forward successfully.

[Baroness Finlay of Llandaff (CB)]

My Lords, this group of amendments is particularly important because it concerns the next generation, addressing children and young people’s health and social care needs. As has been said, I have tabled Amendment 87. I have also put my name to Amendments 141, 151 and 162, introduced so comprehensively by the noble Baroness, Lady Tyler. I also support the other amendments in this group.

These amendments address how the needs of children and young people aged nought to 25 will be met by the relevant healthcare and social care provision within the area of each integrated care board. A bonus from recognising this in the Bill would be the encompassing of young people with learning difficulties and autism, whom we discussed last week.

I was struck by a figure raised during the debate in the other place. According to Young Minds, 77%—more than three-quarters—of sustainability and transformation partnerships failed to consider children’s needs sufficiently. Only one of the 42 ICSs in existence listed a strategic lead for children and young people. Given the range of agencies and pathways, someone must have responsibility for the integration of services at the local level and for listening to the needs of young people.

More than 12.6 million children aged 18 and under live in England, yet the Bill reads as if it is written by adults for adults. Let us not forget that an estimated 800,000 children in England are child carers and more than 250,000 of them are likely to be providing high levels of care for their relative.

Alarmingly, the UK is fifth from bottom among 27 European countries for infant mortality, and one in six children has a diagnosable mental health condition. The number of children in looked-after care is rising and we have heard terrible stories of children whose lives have been lost through abuse and illness.

Health and Care Bill

Baroness Finlay of Llandaff Excerpts

Lords Hansard - Part 2 & Committee stage
Thursday 13th January 2022 Lords Chamber

[Baroness Fraser of Craigmaddie (Con)]

My Lords, I am very keen to speak to these amendments. This is the first time I have been able to contribute to this Bill, and I apologise for not being here for Second Reading. I was actually talking to Members of the Scottish Parliament about NICE and SIGN guidelines on the day of Second Reading, so I am delighted to have an opportunity to contribute now. I will speak to Amendments 17, 205 and 301. I thank my noble friend Lady Morgan of Cotes for tabling them; I would have added my name to all three if I had got in quick enough.

We all appreciate that health and care are devolved matters. As my noble friend outlined, the Scottish Administration have taken a very different path on health and care over recent years, which perhaps could be characterised as worrying less about long-term funding and pursuing a more centralised approach. The Bill is therefore predominantly and rightly focused on matters relating to England, but a number of clauses addressed by these amendments relate to devolved areas. I note that the Scottish Government and the Cabinet Secretary for Health in Scotland have yet to grant the Bill legislative consent, believing that some clauses do not reflect the devolution agreement. I beg to put that these amendments are slightly different, in that they do not cover a specific area of delivery within devolved nations.

Amendment 17 simply covers how NHS England should consider the impact of any decisions it might make on patient outcomes in the devolved Administrations. Amendment 205 protects the right of access to treatment and services for all citizens throughout the UK. Amendment 301 seems to be simple common sense, in that it ensures the interoperability of data and collection of comparable healthcare statistics across the UK.

I support these amendments on a number of counts. First, the pandemic has highlighted the huge importance of good data, and close collaboration and working, throughout all health and care services in all parts of the UK—whether that is knowledge gathering, information sharing, vaccine development and rollout, or anything else. The pandemic has demonstrated yet again that we are “better together”. In the realm of healthcare, I support any measure that ensures that we do not work in silos and that barriers are not created in the provision of healthcare that prevent seamless co-operation throughout the UK. This will become ever more important as roles change, technology advances and services develop.

We particularly need to ensure a UK approach to data gathering and healthcare statistics, as set out in Amendment 305. The disparities do not just present a barrier to consumers of healthcare—the public: voters, indeed—and their understanding and ability to evaluate standards of care in their area, as my noble friend Lady Morgan just illustrated. The lack of interoperability of data has real and detrimental consequences for health research, patient care, and ensuring and promoting continuous improvement in healthcare. This is before we even consider inconvenience and inefficiency.

My eldest daughter stands in danger of being caught out by the current unsatisfactory situation. As a student at the University of St Andrews, she had her first two Covid vaccinations in Scotland, recorded on the NHS Scotland app under her CHI number, which is the number that NHS Scotland uses to identify patients. By the time it came to her booster and third injection, she was working as a graduate trainee in London. She duly went along in December and queued at a drop-in centre for her booster. However, the two systems do not match, so nowhere can she now show her proof of having three doses of the vaccine—which might lead to some problems if she wants to go to the rugby, a nightclub or somewhere else where she has to show it; or if she wants to travel. The same situation has arisen for many students or others who regularly cross the borders of the United Kingdom for work, study or family reasons. For these reasons, I commend the Minister to look at initiatives such as patient-held records. After all, we should always remember that, importantly, this is the patient’s own data.

Another challenge we faced at the beginning of the pandemic was when consultants across the four nations sought to identify who should be in the shielding categories. Ensuring that the right people with the right conditions were identified and then notified was made far more challenging by the disparity of health data for different populations. It is bad enough that primary care, secondary care and social care data do not speak to each other, but healthcare is far too important to be allowed to become a political football within the UK.

The Prime Minister has put ensuring the viability and security of the union as one of his top priorities. We have heard the excellent recommendations of my noble friend Lord Dunlop, and many times in this Chamber we have been assured that the recommendations will be enacted by Ministers across government departments, so that decisions taken in Westminster and England that affect the devolved nations will be considered proactively, positively and constructively, and we can build mutual respect. This Bill and this moment are an ideal opportunity to put some of these principles into practice. What could be more positive and constructive than legislating for NHS England to ensure that this body considers the impact of its decisions on patient care in Scotland, Wales and Northern Ireland?

Like Amendment 301, where better data will lead to greater transparency, the new clause proposed by Amendment 17, which aims to ensure that the Secretary of State publishes guidance on these matters, also goes some way to ensuring transparency, which is so important in the building of mutual respect. These amendments would ensure that those with different approaches and political views across the UK cannot simply manipulate the delivery of healthcare and sacrifice patient outcomes on the altar of division.

Turning to Amendment 205, at the moment, if a treatment is available to patients in one of our bigger teaching hospitals—say, in London, Glasgow or Edinburgh—should that treatment not be available to anyone in the UK? I refer to my interests in the register, particularly as the chief executive of Cerebral Palsy Scotland. I recall that, when the procedure for children with cerebral palsy, known as selective dorsal rhizotomy, was first performed in the UK, it was available at first only in Bristol. However, NHS boards in Scotland were able to refer suitable patients on an ad hoc basis, with funding following the patient. This saved families having to raise around £80,000 to travel to the United States for the procedure—but it did not just help the families. The practice was able to ensure that good practice and learning were shared. Now, the procedure, pioneered in Bristol, is available in a number of areas across the UK.

Specialist, life-saving cancer services are another example. I think of a recent case where a patient from Glasgow—a good friend of mine—was able to benefit from treatment in Liverpool, which was his only option for treatment in the UK. However, it is not just for rare procedures or difficult cases that this is applicable. I have often seen families of children with cerebral palsy from Belfast, Carlisle or Northumberland who wish to travel to Glasgow or Edinburgh for relatively routine but condition-specific input instead of having to travel to London. At the moment, as I said, these arrangements are made largely on an ad hoc basis rather than being broadly available. This is what Amendment 205 seeks to correct. The NHS is a great British institution. The clue is in the name: it is a national health service. Therefore, should access not apply right across the UK?

I urge the Government to accept these amendments. I cannot see why they would not, as they will not only ensure better co-ordinated healthcare throughout our United Kingdom; they will ensure that patient care for all our citizens, wherever they live, is given due consideration, and they will clearly illustrate the importance that the UK Government place on the well- being of people right across the UK. I look forward to the response from the Minister.

[Baroness Finlay of Llandaff (CB)]

I am most grateful to the noble Baroness, Lady Morgan, for tabling these amendments and starting this debate, because these three amendments are very different.

I welcome Amendment 17. Of course we should consider the devolved Administrations because of all the cross-border flows. As we have just heard, people move around the UK. We have a lot of patients from Wales—I should declare my interests; I will not list them all in Hansard, but I have various roles in Wales and have done various things with IT in Wales as well—who routinely go into England from across north Wales; and in south and mid-Wales, they go across to Hereford and Shropshire. So I say to the Government, please make sure that you do always consider the impact.

We need patient-based clinical information that flows between different systems in a timely manner. The noble Baroness, Lady Fraser of Craigmaddie, referred to patient-held records. I hate to disappoint, but we did a quite extensive research project on them and found that there were all kinds of problems with them, one of the main ones being that, when the patient turned up in ED, they inevitably did not have their record with them—or they did not want things written in it in case somebody else in the family saw them, and so on and so on.

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[Baroness Pitkeathley (Lab)]

My Lords, like the noble Baronesses who have spoken before me, I recognise the difficulty of being too specific about board membership, but I think that paragraph (h) in Amendment 37 in the name of my noble friend, to which the noble Lord, Lord Patel, has added his name, is wide enough to enable patients and carers to be represented. Indeed, given the Government’s commitment to the voice of patients and carers, I find it difficult to understand how they could not accept such an amendment. I know the Minister is extremely committed to that patient and carer voice.

I want to extend that a bit to making sure that we do not forget the vital contribution that charities and community organisations make to health and social care services through their well-documented ability to be innovative and flexible. Your Lordships know that in the course of the pandemic, they immediately operated better delivery mechanisms than the statutory sector was able to because they were able to be flexible. One million volunteers were recruited, and many people had experiences similar to mine, with people saying that it was only through the services of voluntary organisations and charities that they had any kind of support at all, particularly during the first few weeks of the pandemic.

When the Public Services Committee of your Lordships’ House did its inquiry into how public services had reacted to the pandemic, time and again we received examples of where charities were ignored by public service providers. Even if they were consulted at a later stage in planning, it was not to take account of their experience and skills but to assume they would co-operate in whatever role was doled out to them. That is not the way to make the best use of the untold amount of good will, experience and skill that exists in charities, especially in the areas of health and social care. This is a waste of scarce resources and must be recognised in the new structures as they are set out. There are many examples of where these partnerships work well, recognising the different skills on offer, and of where charities are treated as partners, but they must be involved in planning at the earliest stages and be supported financially if appropriate. They will always give a good return on resources.

The other area where charities make a significant contribution is in representing the patient and carer voice. Voluntary sector organisations are often the services that have most contact, especially with vulnerable people. Your Lordships will have endless examples of that. Much is made of how important the voice of the user, patient and carer is when planning or delivering the services. Co-production, co-design and the other buzzwords we hear all the time absolutely depend on being in touch with users and patients. Almost inevitably, the easiest way to access users and patients is through local or national charities which make users their focus, both in the planning of services and the governance of the organisation.

Proper involvement of users, patients and carers often throws up surprises, even pleasant ones, about money. If you really take the views of users and patients, you will often find that what they want from health and social care services is not what is being provided. They will often ask for less provision than we expect, so long as it actually meets their needs, not the needs estimated by the providers. This is a valuable fact when resources are short. It is one more important reason to forge partnerships with the voluntary sector when the memberships of ICBs and ICSs are being set up. Organisations in their areas should be considered as partners which have a great deal to contribute and will do so willingly and productively.

[Baroness Finlay of Llandaff (CB)]

I have two amendments in this group, so I will try to address them very briefly because of time. I am most grateful to the noble Baroness, Lady Thornton, for the way that she introduced this and would like to return very briefly to the issue of public/private potential conflict when public money is being spent, because there is an issue of probity around that. Having shared corporate accountability for the delivery, functions and duties of the ICS could be in conflict with the legal duties of company directors, as has already been pointed out, and therefore creates problems.

I know that the Government recognised this in the other place, but their amendment seems to fall short in two respects. It leaves to the appointed chair of the board the decision on whether a person with interests in private healthcare is incorporated into an ICB. The difficulty is that it provides a condition that their interests in private healthcare could undermine the independence of the health service, but it is very unclear how that will actually be measured. I can see that it would be a fantastic area for legal argument that a precedent had been set in one area that was being worked against by the chair of another ICB. I think this needs to be clarified, because they will be dispensing public money and there are examples already where different decisions have been taken. I will not go into those now because of time.

I turn briefly to the reasons behind the amendments I have put down and declare that I am president of the Chartered Society of Physiotherapy. I am most grateful to the noble Lord, Lord Bradley, for co-signing my amendments. There is a role in recognising that the allied healthcare professionals are the third-largest part of the workforce—the workforce is not just doctors and nurses—and are critical to the long-term plan for the NHS. They work across the health and social care boundary and out into the community. They are integral—physiotherapists in particular—to primary care, and speech and language therapists are essential for children and young people, particularly those with communication difficulties, and that of course includes those with autism and learning difficulties.

I also recognise, though, the problem that you cannot have everybody listed on a board and everybody wants their own so-called representation on it. It will be important that the terms of reference and the metrics by which the function of the board is measured and compared are very clearly laid out, to make sure that there is appropriate consultation at all times with those who are on the receiving end of healthcare, and that people such as allied healthcare professionals are appropriately involved in decisions for the patient groups on which they can have a major impact. Quite often they have a much more major impact than medicine or nursing will do in terms of a patient’s long-term quality of life, and rehabilitation in particular.

So I hope that the Government have listened to this debate and in particular will heed the important warning from the noble Baroness, Lady Thornton, in opening this debate and in the content of the amendments that she has tabled.

[Lord Mawson (CB)]

My Lords, I spoke on Tuesday about the structure that my colleague Paul Brickell, a Labour councillor in Newham at the time, and I, wrote for the then Government Minister Hazel Blears for the new company that would deliver the Olympic legacy in east London. I also described some of the key people who were invited to be directors of this company, with a clear vision and narrative, focused on delivery.

In east London live people from every nation on earth. Indeed, we did some research and we thought Greenland was not represented—but then we found a family in Newham that was from Greenland. Clearly, we could not have a representative from every nation on the Olympic Park Legacy Company, the OPLC—it was not possible.

At that time the noble Baroness, Lady Ford, was chosen as a Labour Peer by a Labour Prime Minister to be the chairman of the board. She was a very experienced player in the regeneration world from Scotland, not east London. I think that at the time she was a little embarrassed that I, an east Londoner, was not chairing it, given all the early work we had done on helping the east London Olympics happen. But I was not a Labour Party member and therefore could not carry the then Government with me, while she could. I was not concerned about this. My colleagues and I in east London were concerned about whether she had the knowledge and skill that could add real value to this important project and the public sector organisation that had been created. She was excellent and had an objectivity I could not possibly have.

We needed both things on the board: deep, local, practical experience and objectivity. I was asked to chair the Regeneration and Community Partnerships Committee, I think because she thought I knew quite a lot about these local issues and delivery, was trusted by local people and had a track record of delivering in place and in local neighbourhoods. Because my colleagues and I had delivered real projects with the local population, we did not know one thing about the place and neighbourhood: we knew, in depth, many things. It was all about finding the right experienced people, not those who said they represented something or somebody. The mayors of Newham and Hackney were there because they were impressive Labour leaders in east London who were turning around troubled local authorities.

I was asked to join the OPLC board as a person with deep, long-term roots in both a place—east London—and a neighbourhood, Bromley-by-Bow. I could speak and reflect back to the board not one thing—say, the environment—but also health: we were responsible for 43,000 patients. I had also been a Mental Health Act manager for quite some years locally. I think the noble Baroness chose me because I had deep and wide experience of the people, place and local neighbourhoods, and because of the practical work we had done in east London over quite some time—three decades, actually. It was about practical experience of place and neighbourhood and delivery. It was not about a person who thought he or she was representing one group or another, or a particular topic.

Experienced people bring many things to the board with them. I worry about the disabled person on a board who thinks they can talk only about disability issues—this is very condescending—or the young person who can talk only about young people’s issues. They can talk and have views on everything; it is about finding the right-quality person. However, they must have in-depth knowledge of what is actually going on locally and a deep understanding of the practical issues surrounding delivery. This is absolutely crucial.

There is a wider problem with some representatives on committees and structures, because they represent other agendas and they have mixed loyalties. They cannot focus on the task of the board because they have mixed loyalties elsewhere. They do not therefore prioritise the needs of the organisation they are sitting on. There is a lack of clarity about this, and I suspect we will all have experienced this on boards we have sat on. We need to get very clear about these democracy and delivery issues—what I call “the two Ds”. I have listened to a lack of clarity around these issues from successive Governments in recent years. We must get this clear if the new NHS structure is to really deliver the transformation we all now want to see and to deal with the health inequalities we rightly all discussed this morning.

Ambulance Queues: Health Outcomes

Baroness Finlay of Llandaff Excerpts

Thursday 13th January 2022 Lords Chamber

[Lord Kamall (Con)]

As the noble Lord will be aware, when the charge was initially announced it was intended to help with social care, which has been neglected for a number of years under successive Governments. Given the pressures of the backlog, the NHS has decided to divert some of those resources to help tackle it. We have invested money in social care in the short-term winter plan, and in the longer term we have announced extra investment to ensure that social care is an attractive career and offers real prospects.

[Baroness Finlay of Llandaff (CB)]

My Lords, does the Minister recognise that his response, saying that this involves a small number of trusts, does not address the data from NHS England for the seven days to January 2, which showed that 23% of all arrivals by ambulance had delays of half an hour or more—that is over 19,000—and that some 10% of patients waited more than an hour to be handed over? This meant that those ambulances were also unable to deliver first aid and first implementation of treatment to people who were waiting. Therefore, when patients arrived at emergency departments, they were even sicker than necessary, and it may be that some lives were lost.

[Lord Kamall (Con)]

The noble Baroness makes an important point. In anticipation of the winter crisis, last year we published the Urgent and Emergency Care Recovery 10 Point Action Plan to look at the direct pressures on not only A&E but the call centres, and at some of the wider system issues. For example, when people cannot get access to their doctor, they tend to go to A&E. At other times, they cannot get the replacement medication they want and have to call an ambulance to go to A&E and get it. We are looking at some of the wider system problems to make sure we address the backlog.

Health and Care Bill

Baroness Finlay of Llandaff Excerpts

Lords Hansard - Part 1 & Committee stage
Thursday 13th January 2022 Lords Chamber

[Lord Scriven (LD)]

My Lords, this is my first intervention on the Bill. I draw the Committee’s attention to my relevant interests in the register, namely as a vice-president of the Local Government Association and a non-executive director of Chesterfield Royal Hospital NHS Foundation Trust.

I support this suite of amendments—particularly Amendments 11, 14, 65, 94, 186 and 195—which explicitly puts the issue of health inequalities in the Bill and makes it central to the aims of the NHS. It also deals with reporting and holding people to account for helping to reduce health inequalities.

The reason for my support is simple. I speak as a former NHS manager who, as a rookie many years ago, in the very early 1980s, was on the general management trainee scheme. For the first three months, our aim was just to go around. I remember asking the very naive question: “Who’s responsible for quality?” I expected the person who was showing me around to say, “Everyone”, but he said, “Follow me.” We went in his car for five miles outside the hospital to the health authority. We then went into a lift, down into the basement and through lots of corridors, and finally came to a door at the end of the corridor. The door was opened and in a dimly lit room was a middle-aged woman, surrounded by piles of paper. I said, “Who’s this?” I was told, “This is Gladys. Gladys is responsible for quality.” It was seen as someone else’s job.

That is why I have cringed a little when the Minister has said, in previous debates and Answers on health inequalities, that the Office for Health Improvement and Disparities is being established. That is well and good, but that office is not responsible for reducing health inequalities; everyone in the healthcare system and its partners must work together to reduce health inequalities. That is why it is really important that this is explicit. It is not just about health issues; it is about people’s income, work, environment, green space and transport. It should be explicit in the Bill as part of the triple aims—which will become four aims—and become part of monitoring. This issue must become central because something that I have learned about the health service is that unless the centre asks for it, and asks for it to be monitored, it just does not get done because it is not seen as important. That is why monitoring this at both local and national level will hold people to account so it does not become Gladys’s responsibility.

The Bill gives us a once-in-a-lifetime opportunity not just to put health inequalities centrally in the Bill but to make them explicit in the way that the NHS and its partners work. With a little extra legal push to the mill, so to speak, as well as the monitoring, the data and holding people to account, I believe that we can finally start to deal with these issues in a systematic way that shows improvement and will allow the NHS and its partners to know where to push a bit harder to get this done. That is why I support the amendments.

[Baroness Finlay of Llandaff (CB)]

My Lords, this debate has shown clearly that attacking health inequalities must go beyond the bounds of the NHS as the impact of external factors is massive. I remind the Government that in 2015 poor housing alone was estimated to cost over £10 billion. That was in part because of the poor housing but it was compounded by inactivity and, as a result, obesity.

We should look at the antecedents of complex problems. Marie Curie’s report Dying in the Cold revealed failures in healthcare, bereavement and grief and the challenges of providing care for those with complex needs. Learning difficulties and autism, for which we often do not know the underlying causes, are disproportionately prevalent among people who are socially excluded and at high risk of homelessness, yet for them managing homelessness alone is particularly difficult because of their overall vulnerability. It has been estimated that autism alone has a twelvefold prevalence in those who are homeless compared to the general population.

The antecedents of many of the problems go back to childhood. They carry a life sentence of their trauma, which feeds into worsening health inequalities, aggravating factors such as alcohol and drugs consumption and other behaviours. Unless we strengthen the wording in the Bill to monitor and do something about the data that comes forward, the proposal of my noble friend Lord Kakkar—it is essential that we address this as a core problem to be tackled—will not be realised. I hope that when the Minister replies he will provide some assurance that the Government will consider strengthening the wording in the Bill in the light of this debate.

[Baroness McIntosh of Hudnall (Lab)]

My Lords, I wonder if I might be allowed to speak at this point for the simple reason that I am shortly due to take over from the noble Baroness, Lady Fookes, in the Chair and if I do not contribute now, I will not be able to at all. I have no special expertise to bring to the scrutiny of the Bill, therefore this is the first time I have spoken on it and it may be the last. I want to speak in support of the contribution of my noble friend Lord Howarth of Newport, right at the beginning of what has been a very long and extremely interesting debate but which, until recently, when my noble friend Lady Pitkeathley mentioned it, did not refer back to the points he raised.

In making my brief remarks, I draw attention to my own interests, which are mostly to do with the arts. I am thinking about what my noble friend Lord Howarth said about the arts sector and what it can contribute. I ask the Minister, when he comes to reply, if he would look to one side of his department—particularly towards the Department for Education and to the Department for Digital, Culture, Media and Sport—for further evidence, in addition to the very strong evidence my noble friend Lord Howarth put forward, of the impact of engagement with the arts, particularly on people suffering from often multiple disadvantages.

It is very clear that the data emerging in relation to education points to a strong impact on the health, particularly the mental health and well-being, of young people in education settings when they are able to engage creatively with the arts and arts practitioners. It would be very easy, in thinking about the huge diversity of issues that have been raised here which bear on health inequality, to see engagement with the arts as a “nice to have” extra—something that, if we get everything else right, we can perhaps add in. But it is more important than that, as the evidence is now strongly beginning to show. I therefore ask the Minister not to forget what my noble friend Lord Howarth said at the beginning of the debate in his reply, and to consider very seriously how health inequalities can be properly and creatively addressed by further engagement with the arts sector.

I will say one last thing, which perhaps seems not quite at the heart of it, but it is important. My noble friend Lord Howarth, in giving his examples, spoke about arts organisations, many of which are trying to contribute to this area. To be able to do that, they need people with skills who can deliver the work. Nearly all the people who can deliver the work and have those skills are freelancers. As we all know, they have suffered hugely in the last two years as a result of the crisis that we have all been through. Freelance workers in all sectors, but particularly the cultural sector, have had a very bad time and quite a lot of them have left. I add that as an additional thing to remember when we look at the expectations we can reasonably—and should—have of the arts sector. It needs to be able to properly support the people it has to engage to deliver the work that it can do.

Health and Care Bill

Baroness Finlay of Llandaff Excerpts

Committee stage & Lords Hansard - Part 1
Tuesday 11th January 2022 Lords Chamber

[Lord Patel (CB)]

My Lords, my knee-jerk reaction was going to be, “I don’t agree with what Lord Lansley says”. However, I have put my knee hammer back in my pocket, because I do agree with him about the importance of using outcomes indicators as a measure of the performance of health in patients. In that respect the outcomes framework has always been a good development. Although Clause 4 focuses on cancer—and I hope we do not change that—it is an example of how it can be used for other conditions to improve healthcare.

The noble Lord has also identified one key omission in this Bill, which I hope we can find a way to fill: who will be responsible for making sure that there is continuous improvement and development in healthcare that measures the outcomes? That is not in the Bill. I hope we might find a way to do that, whether through the mandate or other ways. That is all I have to say.

[Baroness Finlay of Llandaff (CB)]

My Lords, I must declare an interest, because a lot of the outcome measures that are now used are in place at Cardiff University. I will expand a little on and support what my noble friend Lord Patel said about outcome measures, particularly for something such as cancer. That is in part because the disease process itself is marching on all the time. It is different from many other diseases, where there might be a chronic condition and other things happen as a result of it. If you do not intervene rapidly with some cancers, you miss the boat and go from being able to cure it to a situation where you certainly will not be able to.

The other group of outcome measures that I do not think we should forget has just now been developed: family-reported outcome measures. That is the impact on the family. We know about the number of carers that there are. There are child carers and many unpaid carers. Having somebody in the family with a disease process, waiting for something to happen and seeing that disease process getting worse and worse in front of their eyes, has a major impact on the health of others and stacks up problems for the future in the health service.

That is why, when I was on the All-Party Parliamentary Group on Cancer, I strongly supported John Baron in all his efforts to look at the one-year survival times in cancer. Looking at outcomes can be far more informative than looking simply at process targets, which is what we have been looking at too much to date rather than looking at the overall impact of disease.

[Baroness Thornton (Lab)]

My Lords, I will speak to Amendments 7 and 9 in my name. I thank the noble Lord, Lord Lansley, for introducing this debate and I look forward to supporting the noble Baroness, Lady Walmsley. I think we are about to see harmony breaking out between the four walls of the Chamber. The noble Lord, Lord Lansley, and I are I think in accord over these amendments.

Historically, the mandate is part of the attempted change—I think that is probably the right way to put it—to distance the role of government and Ministers from the sound of bedpans dropping, if I might put it like that. Unfortunately, as the noble Lord, Lord Lansley, said, despite the mandate’s intentions, recent Ministers have still tried to micromanage and otherwise interfere with NHS managers. During the passage of the 2012 Bill, the Government had to concede that the Secretary of State remained politically responsible to Parliament for the NHS.

I think it would be fair to say that laying the mandate before Parliament in each year, as was intended, has not brought about energetic debates and wise reflections in either House of Parliament. But the mandate is not without merit. It is good that the NHS knows what is expected of it and should be free from sudden announcements and other surprises. Without something of this nature, it is wholly unclear how accountability works. So we accept that, at least until the next reorganisation happens, there has to be a mandate, and the important thing is to get this right.

For that reason, we support the two amendments from the noble Lord, Lord Lansley. If anybody knows how the mandate ought to be used, it is definitely him. Trying to have clearly stated objectives in the outcomes framework, or some equivalent, and ensuring that the mandate is objective, evidence-based and publicly accountable must be correct.

--- Later in debate ---

[Lord Kakkar (CB)]

My Lords, I support the objectives of this group of very important amendments. In so doing, I remind noble Lords of my interests as chairman of the King’s Fund and of King’s Health Partners. I have seen this work directly in King’s Health Partners through a programme defined as Mind & Body, which proposes to promote pathways of care across the entirety of our health economy that look in equal measure at physical and mental health for all patients, irrespective of their principal clinical presentation. Initiatives such as that important programme could be brought to fruition only because of the emphasis in the 2012 Act regarding parity for physical and mental health. It demonstrates very clearly that legislative intervention can have a profound impact. I very much join in congratulating my noble friend Lady Hollins on her relentless commitment to these issues in your Lordships’ House over the past 10 years, which have had and will continue to have a profound impact.

It therefore seems counterintuitive for Her Majesty’s Government, in bringing forward this important legislation, to move away from the opportunity to emphasise the importance of this parity. Is it sensible to move away from this position? Why not use the opportunity afforded by this important legislation to emphasise once again the importance of parity between mental and physical health in every respect—not only funding but the organisation and supervision of services and the construction of organisations within the NHS—so that, step by step, we can achieve what every Member of your Lordships’ Committee who has spoken in this debate has emphasised?

Will the Minister, in replying to the debate, reassure your Lordships that not proceeding with these amendments does not undermine what has been achieved so far and that what is proposed in the Bill can without the amendments achieve the continued momentum and concentration of focus on this vital issue, to ensure that we continue not only to develop mental health services but to ensure that they can be integrated more broadly into physical health, and that physical health services can be developed to ensure that the mental health consequences of physical conditions can also be appropriately addressed? In taking this holistic approach, we will achieve the objectives of better well-being and health for all our fellow citizens—one of the most important aspects of the triple aim.

[Baroness Finlay of Llandaff (CB)]

My Lords, I should declare my interests as having worked with liaison psychiatry extensively in the cancer centre in Cardiff, and as chair of the National Mental Capacity Forum for England and Wales.

One group that has not been mentioned yet—I appreciate the noble Lord, Lord Warner, mentioning some—is those with impaired capacity and learning difficulties. We should not underestimate the importance of access to psychiatry for those people who develop mental health problems as a result of their physical health problems. To view the two as separate is a fallacy because they are completely integrated in many people. Many people present initially with a physical illness but develop mental health problems which, if ignored, become really major. The opposite also occurs, of course. Those people with learning difficulties and impaired capacity at different levels often have a raft of quite serious physical medical conditions that might be particularly difficult to diagnose because their mental health problems get in the way of their ability to express themselves.

If we are really to drive up the health of the nation at all, we would be completely misguided to ignore the importance of this group of amendments. Like others, I urge the Government to grasp this nettle, put this in the Bill and make sure we finally address this severe imbalance, which has left so many people never accessing the care they need. That applies both to mental health care and to those with mental health difficulties who then fail to access the physical healthcare support they need because they just cannot express their needs properly.

Care Workers: Professional Register

Baroness Finlay of Llandaff Excerpts

Monday 10th January 2022 Lords Chamber

[Lord Kamall (Con)]

As the noble Baroness will appreciate, many people who work in social care are employed by private care home owners and other bits of the sector. If she looks at the minimum wage, there has been an announcement of 6.6%, effective from 1 April, which means that workers will be paid more, but one of the bases of some of the additional funding that we have announced is to convince local authorities to put pressure on private care home owners and others to make sure that they pay staff more.

[Baroness Finlay of Llandaff (CB)]

Given that the Government have clearly expressed the view that social care must be adequately valued, which is to be welcomed, and the comments about pay scales, what is the Government’s attitude to those employers in the private sector who do not hand on pay at time-and-a-half on bank holidays and so on, to their front-line staff? These front-line staff feel exploited and do not receive any pay or reimbursement for travel time between clients, even though they may spend quite a lot of time on the road. They are paid only while they are actually in somebody’s home in the community.

[Lord Kamall (Con)]

Issues such as the way private care home owners treat their staff are all part of the consultation that we launched on 6 January. We are working across government and with the devolved Administrations to seek views on the proposed criteria on which the profession should be regulated, whether there are regulated professions that no longer require statutory regulation, and whether there are unregulated professions that should be brought into statutory regulation. The consultation will run for 12 weeks until 31 March, when we will look at the results before taking further action.

Hospital Beds and Social Care

Baroness Finlay of Llandaff Excerpts

Thursday 6th January 2022 Lords Chamber

[Lord Kamall (Con)]

We have been looking at different pathways out of hospitals, and one of the discharge pathways is step-down care. One issue that the task force has looked at is how we improve and increase accessibility to appropriate step-down care when a patient is unable to go straight to their home.

[Baroness Finlay of Llandaff (CB)]

I will follow on from the question from the Labour Front Bench. Who is taking responsibility for actively recruiting staff so that any step-down beds can be staffed and managed? We have a workforce problem; without actively recruiting back into the workforce people who have experience but currently have left, we will not bridge that gap in manpower and womanpower provision.

[Lord Kamall (Con)]

All noble Lords will appreciate the work and dedication of all our social care workers, especially in these challenging times and with the extra pressure that omicron has brought. Throughout the pandemic, we have provided different types of funding. In December 2021, we announced an extra £300 million to support local authorities working with care providers to recruit and retain staff throughout the winter. This funding is in addition to the £162.5 million announced in October 2021. We recognise the issue, and it is about working with local authorities and others to make sure that this money gets into the system and achieves what it is intended to do.

Breast Screening

Baroness Finlay of Llandaff Excerpts

Tuesday 14th December 2021 Lords Chamber

[Lord Kamall (Con)]

I thank the noble Baroness for raising the importance of co-ordination and sharing information across the devolved Administrations. I have meetings scheduled with health Ministers from the devolved Administrations, and I will make sure that my office puts this on the agenda.

[Baroness Finlay of Llandaff (CB)]

My Lords, following on from the question of the noble Baroness, Lady Ritchie, will the Minister tell us how the stage of presentation of breast cancer has altered over the past two years? How many women presenting with stage 3 and stage 4 cancers had never been screened?

[Lord Kamall (Con)]

I thank the noble Baroness for giving me advance notice of the question, and so giving me the chance to get some information. Data on cancer stages is currently published only annually, and NHS Digital is publishing the data from 2019 on Thursday 16 December. The latest data from 2018 shows that nearly 86% of breast cancers were diagnosed at stages 1 and 2, meaning that about 15% were diagnosed at stages 3 and 4, but this was pre-pandemic. I will make sure that I get the updated data as soon as possible.

Medical Schools: Training Places

Baroness Finlay of Llandaff Excerpts

Monday 13th December 2021 Lords Chamber

[Lord Kamall (Con)]

The noble Lord raises an important question, but the fact is that we are training more doctors, and we are recruiting internationally where it is ethical to do so. On retirements, we are looking at a scheme that lasts until 2024 to allow doctors to come back without it affecting their pension.

[Baroness Finlay of Llandaff (CB)]

My Lords, I should declare that I am a fellow of the Royal College of Physicians. Do the Government accept the report from that body, Double or Quits, which has shown that we need 15,000 medical school places annually? Doubling the number of medical school places to that number would cost £1.85 billion, which is only one-third of what hospitals currently spend on agency and bank staff. Therefore, an increase is an investment to save.

[Lord Kamall (Con)]

I thank the noble Baroness for that question and for the advice and expertise that she has passed on to me in my short time in this place. As part of the expansion, we have opened five new medical schools across England, in Sunderland, Lancashire, Chelmsford, Lincoln and Canterbury. Sometimes we have the training, but it is difficult to find doctors in certain locations. We have tried to move training as close to those locations as possible.