St George’s Hospital: Patient Deaths
Lord Sentamu Excerpts(2 years ago)
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Lord Kamall (Con)
The noble Lord raises a very important point about the complexity of having a number of investigating bodies. When I was being briefed yesterday, I was surprised by the number of ongoing investigations. We acknowledge that there needs to be a consistent approach to establishing and running investigations and inquiries. We are currently looking to develop an effective and user-friendly guide to handling inquiries and involving DHSC policy procurement IT colleagues in the development of a framework. We are working also with the Cabinet Office to ensure consistency across government, so that whatever we do in health is consistent with other investigations.
Lord Sentamu (CB)
My Lords, the murder of Stephen Lawrence really caused a lot of trouble. The Met had a review and another review—and another review. The last person to do an apparently thorough review, Sir William Macpherson, turned up at the inquiry and said, “Your evidence is so awful we cannot listen to it any more.” Kent Constabulary carried out a review, but it did not uncover all the stuff that the Stephen Lawrence inquiry found. It was therefore suggested that there must be an independent police inquiry body so that the police are not marking their own homework. I wonder whether the same thing is happening here and whether this new independent review will uncover all that is required.
Lord Kamall (Con)
The noble and right reverend Lord raises a number of important points about consistency and the number of investigations. Their remits are often different, which can confuse the picture, and sometimes some of the investigating bodies are seen to extend beyond their remit, causing further confusion. In this case it is important to recognise the difference between the coroner’s inquest and the work of the independent mortality review. Coroners’ inquests are different, and an independent mortality review was not undertaken to determine the cause of death in individual cases or to attribute blame. It was all about processes, procedures and culture.
Health Protection (Coronavirus, Restrictions) (Self-Isolation etc.) (Revocation) (England) Regulations 2022
Lord Sentamu Excerpts(2 years, 2 months ago)
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Baroness Walmsley (LD)
My Lords, I would like to ask some questions about data. We are told that the Government’s policy has been data driven. As my noble friend just pointed out, the Prime Minister suggested that the case figures and hospitalisations are going down, when in the last seven days cases have gone up by 52% and hospitalisations by 18.4%. This is a trend: the Prime Minister constantly fiddles the figures. First, we had him misleading Parliament on unemployment figures, then on crime figures, and now on Covid figures. This is very important.
I would like to know why the Government are withdrawing funding from some of the studies that enable us to know what the data is, such as the ZOE study. Without the data, the experts cannot properly advise the Prime Minister and the Prime Minister then cannot, if he chooses to, take the right decisions. Why are we withdrawing funding from these studies? As my noble friend says, if the virus is endemic, we still need to control it and we need the figures to do so.
Lateral flow tests that people can take at home are particularly important, especially in the light of the symptoms of this new subvariant—B2, I think—of omicron because the symptoms start as a bit of a runny nose. If somebody has a runny nose, yes, it could be a cold, but it could be Covid. If we are being asked to be sensible and to protect other people, if it is a Covid runny nose one should stay at home, and if it is a cold one should take precautions, but without the test—and poor people cannot afford £20 a box—people will not know which kind of runny nose it is. Can the Minister say how people on benefits or low incomes, who cannot pay the price that some companies are charging for these lateral flow tests, can afford to have them standing by at home so that when they get symptoms they can check the cause of those symptoms and protect everybody around them?
Lord Sentamu (CB)
My Lords, as I said in this House on Monday, I had to stay at home for seven days because I had a very bad chest cough, a bad cold and a lot of catarrh. I tested myself and the test was negative. Those bad symptoms continued for nearly six days and I tested myself every other day. It was very clear that I had a sudden form of flu, but its effects on me were quite strong. I was encouraged because I was able to test myself and the lateral flow tests revealed that I did not have Covid but had an awful cold and flu.
The programme that the Government embarked on in testing and tracking was world class. When we are still in the middle of this very cold weather, why withdraw free testing in April? It is the only assurance we have. I hope the Government will think again about that possibility, although the regulations have gone. To take responsibility for yourself, you need to know whether you have Covid, otherwise you will go out and infect other people, which you should not do.
The messaging still needs to go out. I was quite shocked when “Look North” said that people in our area who are testing positive and sometimes ending up in hospital had stopped washing their hands. That is a shock. It may be said that we have all grown up and know how to wash our hands regularly, but I am afraid that in some places that has gone, so the messaging should still be going out that for the protection of other people we must take responsibility and wear a face covering, not because it is regulated but to be considerate towards others. Sometimes you should keep your distance when you hear people coughing. You are keeping your distance to try to protect people.
When these regulations have all gone and such things are no longer mandatory, will the Government please continue to inform people that there are some places where you still need to keep your distance, some places where you must continue to wash your hands and some places where wearing a face covering is the responsible thing to do? Although it is not going to be policed, we need to create that culture. It happened during lockdown. I used to be shocked when I went to a toilet and people who had not washed their hands came out. We are now going back to our bad habits. Although the regulations have gone, could the messaging still go out to persuade people that the steps we took during lockdown and before these regulations are still worth doing?
Baroness Merron (Lab)
My Lords, we, too, do not want to see restrictions in place for a day longer than necessary but, as noble Lords have said, lifting the legal requirement to self-isolate needs to be backed up with a plan and an understanding. While it is one thing to acknowledge that free tests cannot go on for ever, while the number of infections remains so high, it is surely sensible to monitor the situation and guard against any new and potentially more severe variants. Not to do that risks being somewhat blindsided by future mutations of the virus. We know that testing is one of the key ways that the return of the restrictions can be avoided. It makes long-term sense to make tests widely available while the threat of a new wave remains.
Questions remain about the implications of the revocation for people’s lives. For example, if you need to care for a clinically vulnerable relative, will you be left out of pocket for that test? After all, should we not be encouraging people to make sensible decisions rather than making it harder for them to do so? I remain unclear about whether unpaid family carers, in particular, will retain access to free testing to allow them to look after their loved ones safely. Perhaps the Minister will comment on this point in addition to confirming that free tests will remain for NHS staff. We cannot have vulnerable patients going into hospital and being treated by NHS staff who have been unable to get tests.
I agree with my noble friend Lord Hutton that this does not feel like the right time to be having this debate, but we are in the situation we are in. In acknowledging that, I echo the points made by the noble Baroness, Lady Brinton, about those who are clinically extremely vulnerable and immunosuppressed. We should have regard to how they are feeling as well as giving them continued practical support. I am sure the Minister will respond to the questions asked by the noble Baroness, Lady Brinton.
I have a question about plans and support for those who live with long Covid. We should not forget that it continues to be a blight on the lives of a number of people. In this regard, it would be helpful if the Minister will tell us about any discussions that have been held with the Secretary of State for Work and Pensions about working with employers to protect clinically vulnerable employees and to assist, through support and guidance, employers of people still suffering from long Covid.
More than 1.3 million vulnerable people are eligible for Covid-19 treatments, such as antivirals. Can the Minister indicate whether they will be eligible for free tests? What about their families, friends and close contacts? Will there be a limit on how many tests eligible people can receive? It would be helpful to have clarification from the Minister to give people the reassurance they need.
The potential confusion in public health messaging has been referred to. On the one hand, there is guidance telling people to self-isolate if positive, yet on the other there are still pressures—financial from employers, or from elsewhere—that force people to go to work. This suggest that the message that people will take is that Covid-19 is no longer a threat, but we know that the pandemic is not yet over. The British Medical Association has argued that asking individuals to take greater responsibility for their actions while taking away free testing is likely to cause more uncertainty and anxiety.
Finally, I shall raise the matter of sick pay with the Minister. What is the reasoning behind the Government’s decision to scale it back? Those who are sick with coronavirus will now have to wait until the fourth day of their sickness before claiming statutory sick pay. We are highly concerned that when people cannot afford to stay at home they will be forced to bring their infection into work. To put this into some perspective, after April some 7 million workers will have to survive on just £38 per week if they find themselves suffering from Covid. Covid is not going anywhere, and it is right that we learn to live with it, but proper provision needs to be in place to help people make the right choices in what is, I hope, a late stage of this pandemic. I hope the Minister will be able to give assurances to your Lordships’ House today.
Health and Care Bill
Lord Sentamu ExcerptsWednesday 16th March 2022
(2 years, 2 months ago)
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Lord Alton of Liverpool (CB)
My Lords, the House will want to move on quickly, so I will not make the speech that I intended to make on this issue, but I would very much like to endorse what the noble Baronesses, Lady Fraser and Lady Stowell, the noble Lord, Lord Balfe, and my noble friend said in their earlier speeches. I know Connie Yates and Chris Gard, who are the parents of Charlie Gard, who died in 2017 of mitochondrial DNA depletion syndrome. Indeed, I have entertained them here in the House, arranged meetings for them and travelled with them. I entirely agree with what my noble friend is trying to do. This will make mediation work; it will create a proper balance and equality of arms. No parents should have to face litigation in these often tragic and troubling circumstances, so this is a good amendment and I hope the Minister will feel he can accept it.
Lord Sentamu (CB)
My Lords, I was patron of Martin House in York, which is one of the amazing hospices that care for children and their parents. I was invited by the parents of a nine year-old, who was having a very difficult and trying time, to talk to clinicians, because they did not think that they were being heard. As we talked, it became clear that that was not true: the clinicians were on the side of the parents, but their language was not helpful. We had this amazing conversation, and as a result the needs of the child and the aspirations of both the parents and the clinicians matched, and we were able to get very careful care. What the noble Baroness, Lady Finlay, is trying to do is recognise that in most cases parents have good desires, and clinicians probably know more than they are willing to say but hold back because of the sheer pain and difficulty that they see on the faces of everybody, and another voice can help in these situations.
Lord Sentamu (CB)
My Lords, I was not going to speak, but I am driven to respond to what I have just heard. I first declare an interest as chair of Christian Aid, which works in some 29 countries, most of which have experienced what I call vaccine inequality. We constantly get letters urging us to try to help.
As far as the British Government are concerned, in relation to some of those countries, the money and the way that they have tried to help—which must be acknowledged—certainly with AstraZeneca, there has been a far greater equity coming out. When we had the Kent variant, the Government were very quick to share that information with everybody else. What I think the amendment is asking is that, when the World Health Organization declares a health emergency, if we have information we should make it available immediately.
Secondly, on the question of equity, we have just had a big Commonwealth service in Westminster Abbey and there are particular people—noble Lords may not believe it—who come from those 54 countries of the Commonwealth who still look to the United Kingdom as giving them not only language but the ability to understand the sheer pressure of inequality. I would have thought that this particular amendment would help us to answer some of our supporters out there in the global south by saying that we are very serious, given some of the help that has been provided—though it has not gone far enough; the antivirals and all those drugs have not been given equitably. I therefore ask the Minister to realise that the issue is not whether we have or have not done enough; it is that, if there is a global health emergency—locally and internationally—the Secretary of State is in a better position sometimes to speak and to help those who are struggling and finding it difficult.
Nkrumah said that Ghana would not be free until the rest of Africa was independent, and I believe the same is true now. I have had my double vaccine and my booster, but I am not fully vaccinated until the rest of the world is vaccinated.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
I thank all noble Lords who have taken part in this debate for the passion they have shown. I think we are all concerned by vaccine inequity—as noble Lords have rightly said, we are getting our third or fourth vaccines while some people have not had their first yet—but we also have to be clear how we get to this stage. It is easy to say, “We spent this much money on public research and that led to the vaccines”, but it is not as simple as that. It may have led to the research but that does not lead to the production of millions of vaccines that can be distributed worldwide. There is a clear difference between pure research and turning that into actual vaccines and, once they are produced, getting them into people’s arms. You can certainly deliver them to countries but they do not always reach the arms. We have heard stories of vaccines being thrown away because of a lack of distribution in particular countries.
The sharing of knowledge has played and will continue to play an important role in the rapid scale-up of Covid vaccine production. The UK Government are very committed to addressing vaccine equity on every front. As the son of people who came from outside the EU—not white, privileged Europe—I believe very strongly in global Britain.
The experience of the pandemic has shown that it is voluntary collaboration that has made real, positive impacts on vaccine delivery. The scale-up of vaccine production at record pace has been driven by more than 300 voluntary partnerships. This unprecedented collaboration around the world has meant that global Covid vaccine production now stands at nearly 1.5 billion doses per month. Voluntary partnerships such as AstraZeneca and the Serum Institute of India, and Pfizer-BioNTech and Biovac in South Africa, show what is possible if you work together.
The intellectual property framework has been crucial in facilitating this knowledge sharing. Indeed, the legal certainty it produces cannot be overstated. It gives innovators the confidence to form partnerships and continue investing in the innovative health products and technologies that have contributed so positively to our global pandemic response. The intellectual property framework similarly supports the production and dissemination of vaccines and other products across the world.
Yes, 97% of the investment in research is public funding, but research is not vaccines. There needs to be a whole chain from that pure research to scaling up and distribution, and universities cannot do that. Waiving intellectual property rights would dismantle the very framework that has facilitated this collaboration. It would undermine not only the knowledge sharing that has helped to develop and produce Covid-19 vaccines at the pace and scale now seen but the framework needed to support the development of new vaccines and treatments, should these be needed in future.
It should also be noted that the least-developed countries are exempt from implementing the Trade-Related Aspects of Intellectual Property Rights—or TRIPS—Agreement, meaning that they already have a de facto TRIPS waiver. In addition, the TRIPS Agreement already provides flexibilities to enable countries to achieve their public health objectives, and we fully support the right of these countries to use these where needed—but you have to build the capacity. Low and middle-income countries can access medicines in times of emergency through flexibilities that allow them to manufacture or import without the consent of the patent holder.
For these reasons, the UK does not consider intellectual property rights a barrier to supplying and improving access to Covid-19 goods. The noble Lord, Lord Russell, can put another £10 in the Christmas bag. Instead, we shall continue to be a visible champion of those elements of the intellectual property framework that support effective knowledge sharing.
The noble Baroness will be aware that we have contributed vaccines through the COVAX scheme—a partnership of the Coalition for Epidemic Preparedness Innovations, Gavi, the Vaccine Alliance, UNICEF and the World Health Organization—but we know that is not enough. As noble Lords have rightly said, we have to learn from what we have done during this pandemic. One part of my ministerial portfolio that I am very proud of is international relations and health diplomacy. A constant theme in my G20 and G7 Health Ministers’ meetings is how we tackle these vaccine inequities and learn the lessons that many noble Lords have rightly raised.
Last week, the British Government hosted the Global Pandemic Preparedness Summit to learn those lessons: to make sure that we brought together all our experiences as countries, learned from those and asked what we could do next time. I was very privileged to host a working lunch with several overseas Health Ministers, as well as Dr Richard Hatchett, CEO of CEPI; Dr Seth Berkley, the Gavi CEO; and Dr Tedros, the director-general of the World Health Organization, sitting next to me. One of the issues that came up in our discussions was, rather than developing and less-developed countries relying on donations via COVAX, how we ensure that, first, there is more local and regional manufacturing of vaccines through public-private partnerships and, secondly, that vaccines get into people’s arms as quickly as possible once they are manufactured or are imported into a country. We need to avoid those situations where vaccines were wasted because they were not stored or transported properly, or where there was difficulty distributing them once inside a country.
With international partners, we are looking at a whole range of issues and new technologies, such as new distribution methods. Some noble Lords may well have read about drones being used to deliver vaccines to certain remote areas. Before using these drones, it is all very well having all these vaccines in the capital, but how do you get them into people’s arms? We have to look at that area. Intellectual property rights are irrelevant here. The fact is that the vaccines are there but you have to get them into people’s arms. We have to train more vaccinators and we need better transport.
We agree that the vaccine supply must be matched by the capacity of health systems to deliver them, and we have been working to strengthen health systems around the world. Our recently launched health systems strengthening position paper sets out this Government’s determination to do more to build overall capacity, from policy through to delivery.
But there are other issues. Just as there are the vaccine-hesitant in this country, there are many vaccine-hesitant people in other countries. Our African vaccine confidence campaign is working with experts in countries such as Botswana, Ghana and Uganda to reinforce communities’ trust and build demand from the ground up. Once again, you can get the vaccines there but you have to get them into people’s arms. We have also been working to minimise constraints on supply chains, such as tariffs. This has been demonstrated by our sponsorship and promotion of the trade and health initiative as well as the unilateral measures we have taken, including tariff suspensions.
We have also provided support for the development of regional manufacturing capabilities. This includes technical support to develop business cases for the manufacture of vaccines in South Africa, Senegal and Morocco. We are working with the COVAX supply chain and manufacturing task force to champion other practical efforts to scale up capacity. We believe that we are doing lots of things with our global partners—with Gavi, CEPI and the World Health Organization.
To be honest, I am incredibly inspired by some of the work that I see going on. This is about building real capacity. It is about transferring knowledge and technology and making sure that we have that capacity. It is about making sure that we live up to global Britain, in which I firmly believe given my own family history—not from white Europe, but from a global perspective. I believe very strongly in that. I believe that waiving intellectual property rights will not help overcome these challenges. I may be passionate about this but I feel very strongly about it. I feel strongly about global Britain. I feel very strongly about my distant relatives who come from developed countries and about my own history, my own heritage. I feel much more strongly about this than noble Lords may well feel.
This is the right approach. I am hugely encouraged by this international co-operation and the potential of new technologies to help. I would be very happy to continue to engage with the noble Baroness. I think we probably share the same passion for making sure that this happens. Given that, I hope she will consider withdrawing her amendment.
Baroness Bennett of Manor Castle (GP)
My Lords, I rise briefly to support Amendment 183. My background in this goes back to March 2020, in those difficult, scary, early days of the pandemic, when your Lordships’ House was operating on a skeleton crew. That led to me, as very new Peer, moving the amendment to the coronavirus regulations that would have allowed for telemedicine. I thank the noble Baroness, Lady Barker, who I note has signed this amendment, for supporting me through that process, because I had little idea about what I was doing in terms of your Lordships’ House. It is worth noting that we were doing that in part in acknowledgement that women would not otherwise have access to the necessary medical service of an abortion, but also because we knew that NHS resources were going to be enormously stretched. We are still in a situation where NHS resources are enormously stretched. Earlier we were talking about the Ukrainian refugees whom we will be welcoming here and the medical services that they will need.
Of course, we want to say that, in this area of medicine, we should be putting resources into all the NHS services that women need, but the evidence is overwhelming that telemedicine abortion is giving women a better service. I pick up the point made by the right reverend Prelate that there may be safeguarding concerns. There is evidence, particularly from MSI Reproductive Choices, reporting a major uplift in safeguarding disclosures, including from survivors of domestic and sexual abuse, with telemedicine.
On the medical side of this is a simple clear fact: since telemedicine has been introduced, complication rates from abortion have fallen by 20%. You do not have to listen to just me on this; permanent provision of abortion telemedicine is supported by eight royal colleges and medical societies, including the Royal College of General Practitioners, the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives and the British Medical Association. I also point out that abortion telemedicine is going to continue in Wales and Scotland, based on the evidence. The arguments are simply overwhelming: this is the best option.
Lord Sentamu (CB)
My Lords, I was not going to speak on this, but I listened to the noble Baroness, Lady Finlay, and that encouraged me to stand up and speak, together with other noble Lords who are a bit cautious about all of this. I was a vicar of an inner-city parish in which there were a lot of teenage pregnancies, and those who made them pregnant tried to force them to have abortions. The only person they felt they could tell was the vicar, not their parents, because their parents would hit the roof. Some of them would get corporal punishment as a result. I found myself in difficult, tricky situations, but I was fortunate, because in the congregation we had midwives and doctors. I simply said, “I listened to what you are saying to me, but I am not medically qualified to give any advice. We have experienced people who can give you that advice.” I was grateful that those midwives and doctors were able to accompany these teenage girls and help them come to a more sensible position.
I speak as somebody who is not against abortion, because the welfare of the mother and her rights need to be protected, but I am concerned about a measure that was brought in because of extreme circumstances. The Government were right, during the pandemic, to allow the kind of arrangement that was set up. But I am with the noble Lord, Lord Bethell, that we should not change overnight a tradition and circumstances that were accepted by the majority who see the right of abortion. We should not say that we will now go down this almost administrative route as the norm. Most people would be very concerned if we were going down a particular route.
I strongly believe, because of my experience of those teenage pregnancies in Tulse Hill, that the role of doctors, specialists in counselling and others is absolutely vital. You cannot do away with that because it is easier at the end of a telephone. You may not believe it, but young boys who had made girls pregnant would put pressure on them to have these abortions, for no reason other than that they wanted to move on to the next young girl. I still find that unacceptable.
Hospitals: Patient Transport
Lord Sentamu Excerpts(7 years, 1 month ago)
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Lord O’Shaughnessy
The five-year forward view delivery plan is a publication by NHS England. We continue to back it to deliver its ambitious plans, which include further increases in diagnostic tests and making sure that even more people survive cancer. We are focused on ensuring that the system is as efficient as possible in order to do this.
The Archbishop of York
My Lords, the Minister speaks with such clear diction that we can hear every word he says. He is not producing a drama, but although I have been listening to him carefully, I do not think that he has answered the Question put to him by the noble and right reverend Lord, Lord Harries. He asked what steps were being taken,
“to reduce waiting times for patients using hospital patient transport”.
I did not hear the answer. All I heard was that the Minister was willing to have a word with him, but it is not just about the noble and right reverend Lord and his wife. A lot of other people are in the same predicament. We want to know what those steps are. That is the nature of the Question and, if I did not hear the response, I apologise.
Lord O’Shaughnessy
I thank the most reverend Primate for giving me the opportunity to come back on this. First, NHS England is working with clinical commissioning groups to make sure that the kind of delays outlined by the noble and right reverend Lord, Lord Harries, do not happen. Also, a series of 39 pilots are being conducted in rural areas which are particularly badly affected by patient transport delays to put in place the kind of transport necessary to make sure that people who cannot get to hospitals and may miss appointments are able to do so.
Health and Social Care Bill
Lord Sentamu Excerpts(12 years, 6 months ago)
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Lord Owen
My Lords, I reiterate some of the comments that have already been made by many noble Lords on the sense of urgency about this issue. Above all, I feel rather like the man in the Bateman cartoon who mentions the words “party politics” in the Health and Social Care Bill in the House of Lords. There is here a very deep question. It is frankly inconceivable that there will be legislation in the next Session; I would think it would be almost inconceivable that there would be legislation on this before the next election, which is currently scheduled for 2015. Politicians simply do not usually go in for a repeat hiding, and this Bill has already had one hell of a political controversy. If we have legislation, it may be all on medical education, but it opens up a whole realm of party politics, which I just do not see being done.
Therefore, I want to make a practical suggestion to the Minister. There is a way through this if there could be bipartisan agreement. One only has to think of a situation in which there is no legislation until 2016 to realise that we are facing a real chasm in medical education and continuity. As I understand the legislation, the Secretary of State is empowered to create special health authorities. Whether he does that or removes the ones that are necessary, that power is there. If not, he could easily take it in the Bill.
There is so much cross-party agreement that doing something about health education is pretty urgent. I would have thought that it would be perfectly possible to meet most of the demands. The noble Lord, Lord Ribeiro, is completely right. We are not in a position to legislate now on anything other than a structure. That structure might be a temporary special health authority. It is not worth prejudging the question but, if it was a special health authority, it would need some form of regulation passed. As long as an agreement could be made—first on the clause that would be in the Bill, along the lines more of Amendment 47B than 47A; and, secondly, with the main substantive regulations for the special health authority done through an affirmative resolution—then it would be perfectly possible for us to move on the creation of this training authority, which has to embrace all the health professions and be pretty wide-ranging, some time at the end of 2012 or early 2013. That would meet the wishes of most people in the National Health Service.
It is really not enough to rest on the fact that there will be a Bill in the next Session of Parliament. I have already tried to convince my own college, the Royal College of Physicians, that it is highly unlikely that this will be fulfilled. As practical politicians, we should ask the Minister to take this away with a measure of real good will to see if there is some way through this issue which does not prejudice the long-term future but allows us to fill a very serious gap.
The Archbishop of York
My Lords, I too support the amendment of the noble Lord, Lord Warner. Proposed new subsection (2) simply says that:
“In discharging this duty, the Secretary of State must establish a body known as”.
It does not tell us the rest of the details. It puts a duty on him or her to establish a body responsible for,
“the oversight, supervision and management of all current functions relating to NHS multi-disciplinary education and training, including post-graduate deaneries”.
How will it deliver that? What is going to be its content? That is for the Secretary of State in the future. But we fail in our responsibility if we miss the opportunity right now in the Bill to flag that up as part of the duty of the Secretary of State.
Noble Lords may remember from Second Reading that I spoke against supporting the Motion of the noble Lords, Lord Owen and Lord Hennessey, because I wanted to ensure that the constitutional duty of the Secretary of State is to promote a comprehensive health service and improve the quality of that service. I told the House that I have recently spent time in three different NHS hospitals: University College, London; St Thomas’s Hospital; and York Hospital. These are teaching hospitals. I was more than content that whenever the doctors saw me they came with a large range of nurses, doctors and those in training of all kinds. I became a guinea pig. I did not mind because I knew that I was in a training hospital. How are we to ensure that our National Health Service has that responsibility of making sure they are training hospitals? We must not assume that our NHS delivery of clinical care is almost like the assembly line of a motor car where you fix it and it goes out okay. It is not that kind of thing. What distinguishes most of the best clinical practice is the fact that our National Health Service has these training hospitals. I would be unhappy to know that the Secretary of State had not established a body, known as Health Education England, with responsibility,
“for the oversight, supervision and management of all current functions”.
Where will those lie when the Bill has been passed?
Last time, when we debated other amendments, there was a worry about the diagram of the proposed structure of NHS reforms in the Bill. I drew one up for myself. Listen: the Secretary of State is on top, then there are other bodies—Public Health England, HealthWatch England, the Care Quality Commission, Monitor, NICE, clinical senates and networks, the NHS Commissioning Board, local Healthwatches, health and well-being boards, the community voluntary sector, local government social and public health, and multiple clinical commissioning groups. Where is education in all this? When the Minister replies, will he tell us where he thinks education is going to lie? If it does not lie within this Bill, with its already very complicated structure, the next time I am being treated in the NHS I will be crying, “Where are those learning as I am being treated?”.
Lord Mawhinney
I am a just a simple Belfast boy. Archbishop of York seems pretty good to me; most of the clergy I know can only fantasise.
The timing of this debate is important in that it reinforces the message that my noble friend got the last time this was debated in this Chamber. I hope that he will tell those who tabled the amendments that they are premature. If he does, he will need to tell them that he will take away the contents of this debate and the previous one and bring back, in whatever way the Government think is appropriate, a means to attach the principle of education and training to this Bill. He knows that I hope that he will do that, but I hope that he is encouraged that I share the views expressed that this is not yet the time.
The noble Lord, Lord Owen, has addressed particularly well the element of perplexity and perhaps confusion in the NHS about the Government’s intention. My noble friend and his colleagues keep going on about the Future Forum. I am sure that it is doing a fine job, and no word of criticism about it will cross my lips—except to say, as a simple Belfast boy, that in a democracy it seems to me that the role of this House is to try to persuade Ministers; it is not its role to try to persuade those who are going to try to persuade Ministers. The Future Forum may have an important role, but I would like us to discharge our role quite clearly. The noble Lord, Lord Owen, has the experience of having served in Cabinet, and I have been extremely fortunate and blessed to have had a similar experience. If my noble friend or the Secretary of State can go to the Dispatch Box and say, “I undertake that there will be legislation”, and specify the Session, we will all believe him. However, if that is not possible, it adds to the importance of bringing forward at least the principle to get this issue into this Bill.
Those of us who are in favour of education and training but want to support the Government are not entirely clear whether we should be tempted by Amendments 47A, 47B or 133, and I have to say to the noble Baroness, Lady Finlay, that I am not tempted by her Amendment 199A. But at some point this House has to make a decision, so I hope that my noble friend will stand up, look the noble Lords who tabled these amendments in the eye and say, “Thank you, it’s been very helpful and I’ve heard what you’ve said. I’ll take it away and I’ll bring something back on Report, which I hope will satisfy the whole House”. In the mean time, I hope that noble Lords will not press their amendments.
Lord Harris of Haringey
My Lords, it is always a pleasure to follow the noble Baroness, Lady Cumberlege. She and I have sat opposite each other at meetings for more years than I care to remember.
However, her belief that the chair of the NHS Commissioning Board will only be able to manage a board of 11 is slightly misplaced. We already know that the person who holds this office will be able to walk on water, with due deference to the most reverend Primate. We know that this individual will have the most extraordinary qualities. Indeed, the Health Select Committee has demonstrated that by the overwhelming vote that it gave him on his appointment. Therefore, any person of such calibre who is able to manage a quango with such an enormous budget must surely be able to manage a board of more than 11 people. That goes without saying.
It is probably unhelpful for the Bill to specify precisely the number of people who will be appointed because circumstances will change. At different times it may be appropriate to have particular people or specialisms involved, but that will change over time. To lay down the numbers too specifically is probably a mistake. Indeed, I am not sure that 11 is a sensible number for the effectiveness of boards. It is too large for the most efficient and effective of boards but it is not quite large enough to bring together all the strands of opinion and expertise that you might wish to bring.
My main reason for intervening was not to pick up on that point but to question a couple of the amendments, in particular Amendment 52C in the name of the noble Baroness, Lady Jolly. The amendment refers to the board,
“including one member who is also the Chair of Healthwatch England”.
That is a misguided amendment. It is very important that the viewpoint of the patient is heard clearly by the NHS Commissioning Board, but it would be wrong to bind HealthWatch England into the collective decisions that will be taken by the NHS Commissioning Board. Had the amendment said something along the lines of, “The chair of HealthWatch England will be able to attend all meetings of the NHS Commissioning Board and to contribute to them fully” rather than talking about membership, it would have been much better.
There is already a concern that HealthWatch England will not be seen as a properly independent organisation, partly because in the Bill it is framed as a committee of the CQC and also because the local healthwatch organisations will be wholly owned subsidiaries of local councils around the country and the money for them will not even be ring-fenced. Under those circumstances, there is a real problem about the reality of the independence of HealthWatch England. Further, to put the chair of that body in the position of perhaps having collective responsibilities for NHS Commissioning Board decisions is potentially a serious mistake. I would like to see a position where the board has the chair of HealthWatch England as an adviser. His advice may or may not be accepted, but it will be on the record what advice has been given.
I hesitate to oppose an amendment moved by my noble friend Lord Hunt of Kings Heath but the same applies to the Chief Medical Officer. He should be there to advise the board—and that advice should be recorded—rather than being a member of the board and therefore being part of that collective responsibility. In framing the structure of the NHS Commissioning Board, there needs to be clarity of thought. There are a number of areas of expertise and interests that ought to be reflected in board membership—those individuals should bring their expertise to the table—but they cannot be there as representatives of those particular interests because they will have to take collective responsibility for the decisions of the board. However, it is also important that you have explicitly there a number of people to give advice. That should certainly include the chair of HealthWatch England and the Chief Medical Officer.
The Archbishop of York
My Lords, I was not going to speak to these probing amendments, but as I have been gratuitously referred to twice it is prudent that I should speak.
The noble Baroness referred to number 11. We should remember that Jesus had 12 disciples; the twelfth betrayed him and so there were eleven left. Then the disciples decided before Pentecost to choose Matthias, so they then had 12 again. They then ran into trouble once St Paul the Apostle came along and they had 13, but they did not know where to put him. Numbers are always dangerous.
I am with the noble Baroness, Lady Murphy. We may need all kinds of characters on the board but it would be wrong to specify them in the Bill. If we do, then we will not have the kind of liberty and freedom to be creative and to enable the Secretary of State to promote a comprehensive health service and improve the quality of service. He needs that to help him promote the health service and then improve it. The board needs to consist of people who have the calibre to do that.
I have sympathy with Amendment 54 but not in the precise form in which it is put. It states:
“The Secretary of State must ensure that a majority of the non-executive members of the Board appointed under subsection (1)(b) have relevant experience”.
Those members should have relevant experience but as to whether they should be a majority, again, the discretion should be left to the Secretary of State and the board. If that is specified, they will all be there in big numbers but might end up not delivering or promoting whatever is required. Yes, the people appointed should clearly have relevant experience of either working in the NHS or serving on an NHS body—the NHS is not the same as Rover cars, Marks & Spencer or Tesco and you need people with relevant experience who are able to deliver properly—but I would go for the Secretary of State having people with relevant experience of working in the NHS or serving on a body without necessarily saying that they must be in the majority.
As these are probing amendments, I shall be interested to hear what the Minister has to say about that.
Baroness Hussein-Ece
My Lords, I want to make a few brief comments on Amendments 50 and 52C. I listened to all of the arguments about the public health specialists being on the national board, and I think it is really important. If we are going to have, or aspire to, a national health service that is about prevention and improving health rather than just treating it, there needs to be somebody on the board who attends or has that specialism and brings in the local government perspective. I was involved nearly 10 years ago in appointing one of the early public health directors. It was a joint appointment between the PCT and the local authority that I represented. That person sat on the senior management board of both the local authority and the PCT and was able to bring that expertise to both of those boards. Importantly, in the local government setting, he was able to bring together the directorships of education, environment and social services and to ensure that, when we were trying to address issues such as teenage pregnancies—which is still a massive problem in this country—it was everyone’s responsibility. It was not just over there; it was not just a health problem: it was a borough-wide problem. In terms of bringing that thinking on to the national stage—as other noble Lords have mentioned in this and other debates—local government has to be seen to be a key member if we are to aspire to improving the health of the population. Someone experienced in public health should have a very strong voice on the national, as well as the local, CCGs .
I now turn to Amendment 52C in the name of my noble friend Lady Jolly, which aims to have as a board member someone who is also the chair of HealthWatch England. I support having the patient’s voice heard at a national level. I listened very carefully to what the noble Lord, Lord Harris of Haringey, was saying: the important thing is to have the voice there. Quite often, with a group of 11 or however many it will be of the “great and the good”, it is very important that we have somebody on that board who is going to represent the wider public as well—a lay person who can bring about some of the thinking that is going on locally around the country. The proposed chair of HealthWatch England might be bound in to some sort of collective decision-making which might sometimes make him or her quite unpopular with the other local HealthWatch organisations across the country. The most important thing we should be focusing on is that there is somebody on the board who has the authority, who can bring the voice of the patient and the public to this board.
Lord Greaves
I am not quite sure why the noble Lord is asking me that question. He is tempting me to make provocative statements in relation to the coalition Government of which my party is a member. I think that it is an open question and the answer can remain open. I am not in the mood to make provocative statements today. I might be tomorrow, and the noble Lord can come back to me then.
The point that I am trying to make before I finish, if the Labour Benches will not interrupt me just one more time—
The Archbishop of York
The Benches opposite are probably provoking you into some kind of statement because of your earlier comment that you were reputed to have influenced the Bill during the pause. Given that influence, why did you not go back to what was working?
Lord Greaves
It is our view that the original proposals were not working at all, and the proposals that we have now are better than the original ones. That does not mean to say that they are perfect, and it is the job of the House of Lords to check that the imperfections in them are removed before the Bill leaves your Lordships’ House.
The point that I was trying to make, which I will finally make once more, is that there is a real difference between the two meanings of “commissioning”. If you are a GP, you can commission services from an existing, static landscape or system of provision for your patients. However, commissioning services on a wider scale, commissioning the very landscape of services and the series of organisations that exist, whether it is deciding to put more money overall on a wide scale into one area of medicine and pulling back on others or just keeping the others going as they are, or whether it is financing capital projects—where to build new hospitals, new health centres or whatever it is—is very different indeed. You need bodies on a larger scale to do that. The idea that practices on their own or small groups of practices could commission that kind of undertaking on a wider scale is nonsense. You cannot rely on the market to provide them all because that will produce chaos and a lack of provision in many areas. That is why the original proposal for GP commissioning groups, which were to be quite small, simply would not have delivered at that level. The original proposals did not indicate in any way how that wider capital commissioning would take place.
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Lord Warner
My Lords, I rise to reassure the noble Baroness, Lady Murphy, and restore her confidence in the Labour Benches on the subject of senates. If the Conservative side can have the Mawhinney-Howe dialogue, why should we not have the Hunt-Warner dialogue on senates?
I can well understand why people would like to be a senator. It sounds very grand. It would be good to put on your CV that you are a member of the senate of wherever—even if it is Birmingham. To some extent, I can understand why the Future Forum thought it would be a good idea to have senates. I can imagine it received a lot of representations from specialists in various parts of the country that perhaps these GP commissioners, as they were then known, were getting a little uppity and needed to be curbed a little and put in their place. Why, then, not give a little more space to the people who really know about these things—the specialists—and bring them together in senates? Yet, since 2006, thanks to the helpful report by Sir David Carter on specialist commissioning, we have gone a long way in putting in place a sensible way for dealing with regional specialties and, on top of that for very rarefied stuff, a national commissioning capability. That has not been around for long. It would not be a bad idea to try to keep some of that learning experience together as we move into this brave new world.
I do not have any problem with networks. Networks have been a proven success. They have done a lot of good and there is a lot to be said for trying to reinforce them, even to put some wording about them in the Bill. But I struggle with senates. We need a really good explanation of what they are out to do. The noble Baroness, Lady Murphy, put her finger right on the button: it is a very good solution but what is it a solution to? I hope we can have some enlightenment on that from the Minister.
The Archbishop of York
In my day-to-day life, I have to do what they call “oversight”. The trouble with oversight is that it is always remote. The person who comes on the round is the parish priest or the diocesan bishop. The moment you begin to take oversight seriously from a distance, you are in real trouble. How do you know that the delivery of what you want will work? I am not so certain that I want this Commissioning Board to have oversight of both clinical issues and the senates. That would lie somewhere else, not with the board. It is to the board that Monitor, NICE, clinical senates and networks, and the Care Quality Commission actually report. I can understand the other factors in the Bill but the moment you include the business of,
“overseeing sub-national clinical senates and networks”,
you are in real trouble. What is that, by the way? I remain uncertain. We certainly need a clear spelling out of what senates are for. That is a separate question from whether the board should oversee their work, let alone if we understood it.
I am not one to suggest that this amendment is helpful. What would be most helpful would be to hear from the noble Earl what are the senates, what are these networks, and where you would locate the whole question of accountability and responsibility. I do not think it is the board; otherwise you are giving it a much bigger function when it already has five functions; and there are further provisions in the schedule. If you really want the board to fail, add on more work. So my view is that it should not have oversight of the sub-national groups. However, I am still confused. Will the noble Earl tell us what the senates are for? Networks I can understand; but what are the senates for? If he explains, we may actually see that this amendment is redundant.
Health and Social Care Bill
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The Archbishop of York
My Lords, I speak as somebody who supports Mind and as somebody with a brother I followed who had acute mental illness and died from it two years ago. I have listened to noble Lords’ speeches, and that of the noble Baroness who moved the amendment, on this amendment and the consequential Amendments 105 and 180. I agree with everything that they have said. It is important to highlight the fact that health and illness include both mental and physical aspects; to me that is not problematic. However, the question I want to ask is, do we still need to speak of them in almost separate categories? The noble Baroness, Lady Murphy, referred to my anxiety; namely, that because we have separated out mental and physical illness, would inserting the words “physical and mental” in relation to illness continue to exacerbate the problem? Is it necessary to put “physical and mental” in this part of the Bill, or will the noble Earl tell us where that matter can be spelt out elsewhere, not necessarily in the Bill?
Noble Lords will probably say of my next point, “We would expect him to say that”. I am one of those who believe that human beings are psychosomatic spiritual entities. The element of the spiritual well-being of people is not on the face of the Bill but I am absolutely convinced that, as it stands, my needs would be taken care of because it talks about,
“the prevention, diagnosis or treatment of illness”.
Illness can be physical or mental but it can also be spiritual. I will not detain noble Lords long but when I first became a vicar of a parish in south London I was invited into a home because somebody said that there was a presence there. I did not understand that phrase but I went into the home where there was a young girl who had not been able to move for nearly three weeks. The GP, a psychiatrist and a psychologist had visited the house. Sometimes the girl shouted a lot in the middle of the night. I went into the house and asked how the girl had got into that difficult state. Somebody said that they had been to a witches’ coven that night where a goat had been sacrificed and the young girl was absolutely petrified that she would be sacrificed next. She could not speak apart from shouting. Doctors, psychiatrists and psychologists had attended the girl. All that I could do was to say a prayer in that little house, anoint the girl with oil and light a candle. I left and received a telephone call later to say that the young girl was no longer terrified and had started to speak. That was not mental or physical illness; there was something in her spirit that needed to be set free.
I am content that the Bill covers all those aspects of the human person simply by using the word “illness” and through establishing a well-being and health board, which suggests to me that that board has a responsibility to ensure that physical, mental and spiritual well-being are taken care of. After all, in our schools these days we emphasise not only the personal, but the physical, mental and spiritual dimensions of a person. Hospital chaplains will tell you that the work they do does not address purely a person’s physical and mental aspects. I do not want to divide up a human person. Therefore, I believe that the Bill covers people’s needs without inserting the words “physical and mental”.
Lord Rooker
My Lords, on balance I agree with the most reverend Primate. I speak purely as a lay person but I am very happy to support the noble Baroness, Lady Hollins. I have no medical training. One almost has to declare that as an interest in this debate. However, mental illness can lead to physical illness and massive social exclusion.
I want to share my experience with the House as it is as relevant today as it was at the time to which I refer. Back in 2003, the then Prime Minister and Deputy Prime Minister commissioned the Social Exclusion Unit to carry out work on how we could attack the cycle of deprivation associated with mental illness. The report was published in 2004 with a 27-point action plan. At that time it was a rule of procedure that a couple of Ministers who were not involved in the matter on a departmental basis chaired the steering group that oversaw the work. I was one of the two Ministers. The other was Rosie Winterton, who is now the Labour Chief Whip in the other place. We launched the report at the headquarters of BT. We did that simply because one of the BT occupational medical staff was on one of the relevant overarching boards, but BT’s record as an employer in relation to the mental health of their employees was absolutely first class. Therefore, we were happy to use the BT headquarters for the launch.
Two departments later, as I travelled round Whitehall departments, I wondered what had happened to the 27-point action plan. These things are developed but the Ministers and civil servants involved with them move on. The relevant civil servants were very surprised to hear from a Minister who had had such a tenuous connection with the work he was asking about. The noble Baroness opposite is aware of this as she was involved with the Social Exclusion Unit. The civil servants told me that the action plan was still in place. I have not familiarised myself with what has happened to it over the past couple of years and I would like to be given an update on it. I would like to share with noble Lords some of the points contained in the factsheet that the Social Exclusion Unit published as they relate to some of the myths that have been mentioned. We need to expose those myths and meet them head on.
Four myths are exposed in the Social Exclusion Unit’s factsheet. I will not detain noble Lords for long as this has been a fascinating debate. The first myth is:
“People with mental health problems are dangerous and violent”.
However, the factsheet adds:
“People with mental health problems are more likely to be the victims rather than the perpetrators of violence. Less than 5 per cent of people who kill a stranger have symptoms of mental illness”.
The second myth states:
“Mental health problems are rare”.
We have heard that myth being busted in tonight’s debate. Indeed, the factsheet states:
“Common mental health problems affect up to one in six of the general population at any one time. Almost everyone will know someone who has had mental health problems at some point in their lives”.
The third myth states:
“People with mental health problems are incapable of work”.
However, the factsheet states:
“US research found that up to 58 per cent of adults with severe and enduring mental health problems are able to work with the right support”.
I will give an example of that in a moment.
The fourth myth states:
“People with mental health problems do not want to work”.
However, the factsheet states:
“35 per cent of people with mental health problems who are economically inactive would like to work, compared to 28 per cent of those with other health conditions. Many successful people have had mental health problems”.
In fact, as part of the exercise, I went for a day and a half around London to look at projects manned exclusively by people with mental illnesses. One was at a restaurant, and the only person involved in the restaurant who did not have a mental health problem was the chef, who had come down from a Park Lane hotel to do the training. Everyone else in the kitchen and the front office had a mental health problem. In fact, nine months later, I took my private office staff for their Christmas lunch there. My visit had been in April and I said, “If I am still around at Christmas we will come here for our private office lunch”. Indeed, we did that. When visiting the three projects, I was driven around by one of the patients. I have never felt as safe in a van driven by anyone else. I had no problem whatever. The idea that normal activity cannot take place or that you cannot be included socially is, of course, a myth.
I want to share one of the other aspects that we put out in a factsheet on this issue. The factsheet states:
“Nearly one-fifth of respondents to the Social Exclusion Unit’s consultation argued that mental health services needed to become more socially focused”—
and more holistic. The factsheet continued:
“GPs issue sickness certificates when they assess that a person cannot perform their usual work. Mental health problems are more likely to be listed on the sickness certificates in the most deprived areas of the country”.
That is another fact that we must take on board.
“It is important to ensure appropriate pathways of care between primary and secondary services; up to 28 per cent of referrals from primary care to specialist services are inappropriate”.
I will not read out all the facts, but shall quote the final two. It is stated:
“The range of services is more limited in rural areas, with specialist services often absent”.
That is the reality of many services, but this is the one that we are dealing with. It continues:
“In 2002, 87 per cent of rural households were 4km away from a GP surgery”.
My final example states:
“A person with schizophrenia can expect, on average, to live for ten years less than someone without a mental health problem, mainly because of physical health problems”.
One therefore has to deal with: stigma and discrimination—and we have heard examples of that; the role of healthcare professionals, which we dealt with in the factsheets relating to employment, welfare and benefits; and the role of families and carers, in particular. I shall leave alone the criminal justice system and other issues. Putting the amendments in the Bill is simple—it does not cost anything in terms of money; it should not upset the parliamentary draftsmen; but it sends a massive signal to the whole structure of the National Health Service that Parliament has highlighted and identified this issue, which relates to both Houses. We do not want it to be put in a backwater. We do not want it to be the first thing that is cut. People have to be treated holistically, because we know that if their mental health problems are not treated properly, physical problems start and we then get the queues at accident and emergency—and other pressures on GPs.
I am therefore very happy to support the amendments in the names of noble Lords from all around the Committee. The work of this Government, which I applaud, was mentioned, and I have provided examples of the work of the previous Government where we were trying to deal with the relationship between social exclusion and mental health. It went right across the board—every government department had a role in this. The issue should not be left just to the health department or the National Health Service. It must be dealt with properly by every department—the economic ones as well as the health ones.
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Lord Turnberg
My Lords, I rise to support these amendments. I agree with virtually everything that my noble friend Lord Warner has said. However, I disagreed with the assertion that Clause 2 may not be the right place for the measure. Clause 2 is headed “The Secretary of State’s duty as to improvement in quality of services”. If there is anywhere that needs improvement, it is in the integration of services. Therefore, I think this clause is the ideal place to insert the measure.
There is general agreement that the principle of seamless care—that is another term for integration, from the point of view I am talking about—for individual patients is a good one and we should support it. By that I mean the ease with which patients can move between one set of carers, hospitals, homes and social care and another. At the moment it does not seem to happen as well as it should in many places, so the Bill is, theoretically, a way in which we can stimulate the mechanism by which it can all happen. However, for integration of care between providers to happen with the minimum of disruption to the individual patient, we need to ensure that there is much more collaboration and consultation between them. It is not only between doctors, nurses and other carers that this collaboration is needed, but particularly across the divides between those funding and managing the different care streams. That is where these amendments can help.
At the moment, we have patients waiting for far too long, as we have heard, in an environment unsuited to their needs—elderly patients sitting in acute hospital beds waiting far too long to go home or into social care. A range of problems get in the way, such as a lack of planning, a lack of facilities, or closure at the weekend of offices where these arrangements should be made. To me, integrated care means the close working arrangements that allow not only the rapid and efficient transfer of patients but the ability to discuss the best course of treatment for a given patient. It means the ready consultation between different specialists, perhaps in different hospitals. It means different trusts, whereby patients can have access to the best treatment available.
I am reminded of the example of orthopaedic surgeons, some of whom specialised closely in hand surgery or re-do hip surgery—second operations on hips that have gone wrong the first time round. Those highly specialised orthopaedic surgeons are not available in every hospital. The ability of one group of orthopaedic surgeons to transfer a patient to the best care possible in another hospital should not be thwarted. We should not be putting any barriers to ready consultations and, if necessary, the transfer between hospitals of patients seeking the forms of treatment that are most relevant to them.
Of course, competition is seen as a driver to improving standards. However, let us be clear; there must be a balance between competition and integration, and between competition and collaboration. I am pleased that Monitor will, I believe, have a role in improving integrated care. I hope that we can persuade the commissioners and providers to support integration also. That is why I support these amendments.
The Archbishop of York
My Lords, I also support the amendment. Like the previous noble Lords who have spoken, I think that this amendment should be put into this part of the Bill. As the noble Lord has just said, the Secretary of State’s duty is to improve the quality of services. The greatest need in our nation is to ensure that the quality of services is improved. How is that to be done? The amendment is a helpful pointer to integrating the clinical delivery of health and social care. The Secretary of State should have a duty to make sure that the delivery of those is integrated. I also know that if that is not done, the duty—already provided for in the first two subsections—will not be carried out. Integrating the delivery of services will be important.
I already have my copy showing how the new NHS structure will work, and if the noble Earl wants a copy, he is more than welcome to have one. The proposed structure of the reformed NHS under the Bill is complex. Some of the relationships are not clearly defined. I happen to believe that integrating the delivery of health and social care will go some way to addressing this complex structure. People will know that the two areas are being integrated in their delivery. The NHS Commissioning Board is of course key, and will become even more so in the case of the failure of a clinical commissioning group. I should have thought that the Commissioning Board needs to know that it is working to make sure that both services are integrated.
It is also clear in the Bill that the role of Monitor will need to be defined and watched carefully if it is not going be the route for introducing harmful levels of competition. If you are going to integrate the delivery of health and social care, Monitor and whoever is delivering will have to be sure that this is being done in an integrated way. Part of the solution, it seems to me, is to ensure the clinical integration of the delivery of health and social care. The amendment is intended to ensure that there is another, further duty on the Secretary of State to ensure the delivery is integrated.
Lord Davies of Stamford
My Lords, it is clear from all the contributions this evening what an important element in all medical care integration is. Of course, all of us have intuitively known that all along. If any of us have a medical problem, we all hope that we will get a diagnosis which will integrate the perspectives of the different specialists who may be relevant and the results of different diagnostic tests and that we have a package of care prescribed for us that is coherent and will be delivered in a predictable way with a clear structure of responsibility for delivering it. No one would deny that.
Amendment 12 is about the integration of social care, secondary care, and hospital care, NHS care. This is the first opportunity to discuss the issue. Things are not working well at all in this area, and I do not think that they ever have. I know from my experience in Lincolnshire—and it will be hard to persuade me that Lincolnshire is very different from any other part of the country in this matter—that there is a whole mass of perverse incentives and behaviours at the expense of the patient. If any social worker under pressure of a budget is confronted with a crisis—some old person who can no longer cope in some way—his or her first reaction, naturally, is to try to secure an admission to an acute hospital, especially if the patient under means-testing would be a drain on their budget, to get the patient on to the National Health Service.
Equally, any social worker is extremely reluctant to accept patients from acute hospitals on discharge. All kinds of ruses are adopted to try to keep the patient a bit longer on the NHS budget rather than on their budget. At present, there are financial penalties, at least in theory, for social care organisations and social services departments of local authorities which decline to accept patients who need social care as a condition of their discharge from an acute hospital, but there are all kinds of ways of avoiding that and delaying the evil moment when the patient suddenly falls on to the budget of the social services department. That system is not working well at all. That causes enormous anxiety, literally every day of the week—it is not an exceptional situation—to patients, their families and carers, who are the victims of it.
The perverse incentives can work in exactly the other way. I remember all too clearly how, at the time of the previous Conservative Government, they closed down most of the geriatric and other chronic wards and facilities in general hospitals, pushing patients out on to the means-tested social care sector. That was very cynical. There may sometimes have been clinical excuses for doing that, but they were just excuses. I knew at the time that the motivation was to try to massage the growing deficit of the NHS, which would have been even worse if it had been accounted for on the basis of constant business. I remember talking about it to the Secretary of State at the time, but she asked me not to say anything about it in public. It was a scandal. That is another example of the perversities that can exist in this area.
Sadly—I deeply regret this—the Government have not taken the opportunity to adopt the obvious solution, which would have been the radical reform, which is to integrate social services with the NHS and the provision of medical care. That worked extremely well in Northern Ireland, where I had the privilege of being shadow Secretary of State for several years. I saw how that system worked, where there is integration. Two distinguished noble Lords from Northern Ireland are here, the noble Lord, Lord Alderdice—the noble Lord, Lord Empey, has just left the Chamber. I think that they will bear me out in saying that it works extremely well in Northern Ireland.
I am quite sure that the Government considered the theoretical possibility of adopting the Northern Ireland model in England. Why did they not do it? In what respect is Northern Ireland different from England such that a system that works well in Northern Ireland could not work well here?
Health and Social Care Bill
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The Archbishop of York
My Lords, let me declare an interest in this Bill as a previous patient of the National Health Service. In 2008, suffering salmonella as soon as I arrived from overseas, I was treated for nine days at University College London. I received excellent treatment. It was co-ordinated and first rate. In May 2008, at St Thomas’s Hospital, I was admitted and stayed for 12 days for the removal of a rather nasty appendix. I was looked after well, it was well co-ordinated and wonderful. In August this year, at York Teaching Hospital, I was treated for repairing my rotator cuff and removing my uvular because it was affecting my throat. It was fantastic and well co-ordinated.
All three hospitals are teaching hospitals. The question that we need to ask ourselves is: will this Bill raise and improve the standards in our teaching hospitals? I am doubtful because if you are a teaching hospital it means that sometimes things may be delayed and may not happen so quickly. They have to work hard. Will it improve the teaching hospitals of our country? I am doubtful. My Archiepiscopal colleague, the most reverend Primate of all England, Dr Williams, in the New Statesman on 9 June in a speech on education said:
“With remarkable speed, we are being committed to radical, long-term policies for which no one voted. At the very least, there is an understandable anxiety about what democracy means in such a context”.
A number of noble Lords have repeated the same view: that the Bill has no mandate. It was not in the manifesto. It will not do simply to repeat the statement that it was in the coalition agreement. Joe and Jane public did not vote on it. That is why there is anxiety in the nation and that is why there is a lot of worry about it. Therefore, the Government would be wise to persuade the public, the professionals and most of all the staff of the NHS that it is in their interest.
The best way of doing that is to allow proper scrutiny of the areas that have caused the greatest anxiety. From listening this morning, I think that the amendment by the noble Lord, Lord Owen, does that. The area of anxiety that it addresses is the extent to which the Secretary of State is still responsible, and it allows parliamentary counsel to help in the scrutiny of that particular part.
The noble and learned Lord, Lord Mackay, agrees with the right reverend Prelate the Bishop of Bristol that the role of the Secretary of State is a foundation issue. The Secretary of State has responsibility for the health of the nation. He said that since this is a foundation question, we had better deal with it quickly. But will time allow us properly to examine the foundation and secure that the foundation is good? It does not seem to me that in the short time available we will do that. Time will run out and I agree with the noble Lord, Lord Winston, that this will not improve the National Health Service. It may do other things but health is somewhere else.