Health and Care Bill

Lord Crisp Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

[Lord Crisp (CB)]

My Lords, I shall speak to Amendment 112 and 17 others that are in my name. I am very grateful to the three noble Lords who have added their names to these amendments. These are terribly straightforward; it is the same point in a number of different contexts. As we put it in the explanatory statement, the amendments

“would require Integrated Care Boards to work with the four primary care services … when preparing and revising their five year plans, in the same way they are required to work with NHS trusts and NHS foundation trusts.”

It is a very simple, straightforward point and a matter of proportion. It is appropriate to give a similar level of influence and respect to primary care as we give to acute services.

I will mention that there are some practical difficulties —obviously, there are many more primary care services than NHS trusts—and come back to that at the end. If it is not obvious enough that we should do this, I want to pull out three points about why this is so important; I expect that others will mention other points. I am talking here about GP surgeries, as opposed to the other three services, although I totally endorse everything that my noble friend Lord Low just said about ophthalmology services.

First, if it is true, as Members across this Committee have argued for however many sessions it has been, that a large part of the future is community-based, then alongside public-health figures and their clinical work, it is primary care—nurses and others, not just doctors—who will be the essential guides and specialists to help all those place-based, arts, non-clinical and inequalities-busting activities that we have talked about for a considerable part of this debate. They have that key role.

Secondly, I was dismayed by the way the Government criticised GPs recently. Primary care is under enormous pressure and I do not understand why the Government chose to do that. A large part of the problem is that there are simply not enough primary care specialists of all kinds, including GPs, and I do not think any progress has been made towards the promised 5,000 extra GPs. Primary care is under enormous pressure throughout the country and, while I greatly welcome the focus in the Bill and in government policy on waiting lists, I believe that it will be here in primary care that we will see the real battle for the future of the NHS. It is really important that we give those who are doing so much in our services the respect, influence and prominence that they deserve.

My third and perhaps, in some ways, biggest point is that primary care is changing very fast in all kinds of ways; it is an area where there is enormous innovation. As the Royal College of GPs itself says about the role of the GP, there is a place for one-off consultations—a place for the GP on the railway station, or wherever, where you can have a very quick consultation—but there is an even bigger place for the sort of continuing role based on the relationships between a GP and their patient that we are familiar with traditionally and which I thought the noble Baroness, Lady Cumberlege, described so well in describing her father as knowing his patients “inside and out”. That relationship, however, is not just with individual patients; it is a relationship with the community. Many GPs have taken that role, but more are taking on the role of a relationship with their community.

Some GPs are rewriting this role so that it is more of a public health role in some ways. There is Sir Sam Everington at Bromley by Bow, whom the noble Lord, Lord Mawson, mentioned in his great, eloquent speech on our last occasion in Committee, and others such as Dr Gillian Orrow, who is bringing together groups in the community and leading Growing Health Together in Horley. Others are taking on wider roles, such as Dr Laura Marshall-Andrews in Brighton. People are thinking about their role in a very different and important way and I apologise for giving three southern examples—they happen to be ones I know very well, but I know that this sort of innovation is going on around the country. More generally, of course, we can think about social prescribing and the way that that is changing primary care.

Here is the really big point: these doctors, nurses and others in primary care are acting as clinicians, of course, but they are also agents of change. They are the animateurs, the facilitators enabling local health-creating activity. For that reason, we need to have people like them fully engaged in the planning and all the mechanisms of the new NHS structures so that they can have the influence needed for the future.

I come back to the practical note I made at the beginning. Of course it will be difficult to engage primary care appropriately in every way and there might not be the same structure and arrangements in every part of the country, but it is really important that we get these primary care inputs into the five-year plans, their monitoring, planning and discussion so that they can really influence what will happen in the future. I understand that the Royal College of GPs is in discussion with the Department of Health. I urge the Minister to encourage his officials to find a way to make this obvious thing, which needs doing, work. It is vital that we do not disfranchise a key and currently quite largely demoralised sector or, as importantly, lose their valuable contribution.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I have Amendments 117 and 218 in this group. I have also put my name to the series of amendments put forward by the noble Lord, Lord Crisp, but I start by endorsing what the noble Lord, Lord Low, had to say. I hope the Government will come back sympathetically in relation to that.

My Amendment 117 would ensure that primary care professions would have mandated roles within integrated care partnerships, with members appointed by each of the four practitioner committees: the local medical, dental, pharmaceutical and optical committees. Secondly —and this is very consistent with the amendments from the noble Lord, Lord Crisp—this would ensure that, in preparing their annual strategic forward plan, the integrated care board and its partner trusts and NHS foundation trusts would need to consult the relevant primary care local representative committees and publish an explanation of how they took account of those views when publishing their plan.

I have the same arguments as the noble Lord, Lord Crisp, and I will not repeat them because he put them so well. History has shown that, even when clinical commissioning groups were nominally under the control of GPs, they often found it very difficult to get the rest of the system to listen to their issues and concerns. I agree with the noble Lord that there is now so much pressure on primary care that there is a great risk that they will be ignored in the work of the ICBs in particular. That would be a great pity. It is not just GPs, but the other parts of the primary care world. The noble Lord, Lord Low, already referred to ophthalmologists and opticians, but there is also this conundrum about the ability of pharmacists to take some of the load off the system but there is also often the inability of the local NHS to talk to them and embrace them sufficiently.

I hope the Minister will be sympathetic. If he says that he is not willing to tell ICBs that they must embrace representatives of the local committees then there is now a clear conflict. He is saying that it is up to the local ICBs to decide, but it has become abundantly clear that NHS England is giving out very heavy-handed guidance about who should be on ICBs. I would make this point to him: you cannot have it both ways. Either you leave it up to ICBs and withdraw this guidance, or Parliament has a role and a right to determine the governance arrangements. The action of NHS England in being so heavy-handed, such as saying that local councillors cannot serve on ICBs, means that the argument he put forward really does not stand up any more.

I move to my Amendment 218. On this one I must remind the House of my membership of the board of the GMC. The noble Lord, Lord Crisp, talked about the crisis in workforce issues generally, which I am not sure we are going to get on to today now. In relation to GPs, it is very apparent that not only do we have a chronic shortage but there is a grossly inadequate distribution of GPs throughout the country. Recent data, published by NHS England in November, shows that the primary care network covering an area in Gloucestershire described as 4PCC and comprising Cadbury Heath, Close Farm, Hanham and Kingswood had an average list of 1,138 patients per full-time equivalent GP. There are some others with similar figures. At the other end of the scale, Shore Medical primary care network in Dorset had an average list of 7,317 patients per full-time equivalent GP. York Priory Medical Group PCN had an average list of 7,154 patients per full-time GP and the Marsh Group PCN in Kent had an average list of 7,040 per full-time equivalent GP. These are huge disparities and there are many other areas that have average lists of under 1,600 and plenty with averages of more than 6,000.

The situation is really reminiscent of the situation before the start of the NHS. That is why in 1948 the Medical Practice Committee for England and Wales started work. It was charged with ensuring equitable distribution and, to a large extent, I believe it achieved its objectives. It was abolished in 2001 and I had better confess to the House that, I am afraid, I took through the legislation abolishing it. However, we were at the start of a massive expansion in the workforce at that time and felt that at that point the kind of bureaucratic way in which the MPC worked probably was no long fit for purpose.

We have a real problem here and confirmation of the dire situation was provided recently in research by the University of Cambridge’s department of primary care. A team including Dr Rebecca Fisher found that the significant GP workforce inequalities I have talked about are increasing and that workforce shortages disproportionately affect deprived areas. If you look at the situation in deprived areas, practices often have lower CQC scores, lower quality and outcome framework performances and lower patient satisfaction scores. Patients in those areas often have shorter GP consultations despite the fact that they have more complex health needs.

General practice is paid according to how many patients they have, with an adjustment made for the workload associated with those patients. Since 2004, the global sum allocation formula, known as the Carr-Hill formula, has been used to make that adjustment. However, Fisher argues that the consultation length is a flawed proxy for need and that the formula has long been widely acknowledged to be incapable of accurately weighing needs associated with socioeconomic deprivation. In 2020, after accounting for need, practices serving deprived areas received about 7% less funding per patient than those in non-deprived areas.

There is also the targeted enhanced recruitment scheme. This offers trainee GPs a one-off payment of £20,000 when joining a practice in an area that had long-standing difficulty in getting more doctors. However, this has not made a significant difference and clearly is not the answer to this enormous problem.

In the amendment—and I am very glad to have the support of the noble Lord, Lord Warner, and the noble Baroness—I have proposed the creation of

“the General Medical Practitioners Equitable Distribution Board”

as a first step. I envisage the board being invested with discretionary powers of negative direction, as was the MPC. It would consider applications from primary care networks, and they would be expected only from adequately doctored, or more than adequately doctored, PCNs. It would be a way of intervening in the market and making it more difficult to appoint GPs in those areas that are already very well supplied with doctors.

I accept that this is not the only approach, but it is an approach that has worked in the past. Frankly, I do not think that we can carry on without some major intervention to try to spread the load, because it is clear that all the odds are stacked against you if you are in an area of high deprivation where there are many more patients per GP. You get burnout among the professions and things become very difficult indeed. It looks as though financial incentives are not the answer. Clearly, we need to get more GPs into those areas to lessen the load, and then improve the quality and outcomes. I hope the Minister will be prepared to take this back and give it some consideration.

--- Later in debate ---

[Lord Kamall (Con)]

I thank all noble Lords who spoke in this debate for once again increasing my understanding of some of the challenges within the system, in addition to briefings I have had thus far. I thank the noble Lord, Lord Low, for his patience and his just-in-time mode of operation and, more than that, for his contribution to the debate today. We appreciate that people with learning disabilities experience a higher prevalence of visual impairment than the general population, and that this prevalence increases with the severity of the learning disability. Children with learning disabilities are, for example, 28 times more likely to have a serious sight problem, and over 40% require glasses.

NHS England continues to responsible for the contracting of the NHS sight testing service. This will eventually be transferred to ICBs. Sight tests are widely available across the country through our very dedicated primary ophthalmic services workforce. Those eligible for a free NHS sight test include children, those on income-related benefits and those at particular risk of eye disease. We expect that those with severe learning disabilities should meet the eligibility criteria in other ways, and for these reasons we do not believe that, at this moment, extending eligibility further is necessary. Where those with learning difficulties are unable to access NHS sight tests on the high street, hospital eye departments also provide routine eyecare services and ongoing care. Children are usually referred on to hospital eye services via visual assessments delivered by specialists in special schools. Others are referred by GPs, school nurses or high street practices. We have also seen the development of special pathways in some parts of the country that cater specifically for adults with learning disabilities and we want to make sure that, via the NHS England central team, we share best practice on a national level, so that all regional teams and all ICBs can benefit from learning from the local initiatives and pilots.

NHS England also tells me that it recognises that more needs to be done to ensure equality of access. That is why the NHS long-term plan committed to ensuring that children and young people with learning disabilities, autism or both in special residential schools have access to eyesight, hearing and dental checks. In order to fulfil this commitment, there is a proof of concept programme building on the work by SeeAbility in London, which was launched in 2021, to provide sight tests and dispense glasses on school premises. My honourable friend the Minister for Care is due to make a visit to one of the schemes.

I now turn to the amendments on primary care providers. I understand noble Lords’ interest and that it has been widely acknowledged that CCGs, for example, are dominated by trusts, particularly for acute care. I take the gentle encouragement of the noble Lord, Lord Scriven, to understand that more, and particularly to make sure that the voice of primary care providers is heard. That is also the Government’s ambition. We support the idea that primary care should be integral to ICB planning, which is why at the moment at least one member of the ICB will be nominated by primary care providers in the area.

We all know that primary care service providers are predominantly independent entities that hold contracts with the NHS, unlike NHS trusts and foundation trusts, which are largely statutory entities. If all types of primary care service providers were named in the Bill, it would mean that every provider in the area of the ICB would have a duty to contribute to the development of the joint forward plan. We do not believe it would be a feasible option for all primary care providers to contribute to the plans, but I acknowledge the points made by noble Lords about how we can raise the profile and contribution of primary care providers.

I turn briefly to Amendment 117. We agree that it is important to consult the relevant primary care local representative committees, which is why we already have a provision under new Section 14Z52 to introduce a duty to consult anyone the ICB and its partner trusts consider appropriate when preparing the plan. There should also be a summary of the views expressed by anyone consulted and an explanation of how those views were taken into account. We expect members of the primary care sector to be consulted and their views summarised in this way. We understand that NHS guidance will provide for that.

We also want to allow ICBs to focus on arranging safe, high-quality care, and making an additional, explicit requirement in the Bill does not align with our desire to reduce the bureaucratic burden on ICBs. I understand that this is all part of the general debate about whether, if we accepted every amendment about who should be on the ICB, it would be more inflexible and unwieldy. These are conversations we should have in the round about the priorities for ICBs, what should be mandated, what should be in guidance and what the ICB’s duties are expected to be. I hope that we will have those conversations in the round so that we can come to some sort of consensus across the Committee.

[Lord Crisp (CB)]

The amendment in my name specifically requires ICBs

“to work with the four primary care services … when preparing and revising their five year plans”.

It does not specifically ask for a seat on the ICB. That is a different request. I hope the Minister understand that and will respond to it.

[Lord Kamall (Con)]

I thank the noble Lord for that clarification and also for the advice he has given me in my first few months in this job. I do appreciate his experience. I will take the noble Lord’s point back and make sure it is clearly understood by the department when we consider how we respond to it. We believe in working with appointed ICBs, but we expect primary care to be consulted.

NHS England has also stressed the importance of ensuring that there are robust place-based structures in place. We hope that the ICB will exercise functions through place-based committees, where a wider group of members can take decisions, and we expect that primary care, including individuals from medical, dental, pharmaceutical and optical committees, will be particularly involved at the place-based level under the principle of subsidiarity. We will have some influence on the drafting of the forward plan of the ICB. Additionally, guidance that NHS England publishes for ICBs will include the commissioning of primary care at the place-based level.

--- Later in debate ---

I will finish on a point that we talked about earlier today, the problems of funding social care. The funding cuts that local authorities have received over the past 10 years are such that it can be really difficult for them to find the money for this sort of activity in social care. I really hope that the powers that these amendments envisage ICBs having would go across the whole range of health and social care and will not just be limited to people in healthcare settings.

[Lord Crisp (CB)]

My Lords, I congratulate the noble Lord, Lord Howarth, on introducing this very important group of amendments and other noble Lords who have made some very interesting points, such that made by the noble Baroness, Lady Morris of Yardley: this is becoming received wisdom, whereas it might have been regarded as eccentric even five or 10 years ago.

I have three points to make. First, this is a Bill about integration and partnership. It would be good to have a clear message that non-clinical groups such as the ones we are talking about are part of that, in whatever is the appropriate way—a duty or obligation or something of that sort on in the Bill—without being too specific about the detail.

Secondly, the noble Lord, Lord Howarth, made the point that this is the rediscovery of ancient wisdom, not least, as the noble Baroness, Lady Barker, pointed out, through Covid. I am talking about human flourishing going back to Aristotle and many others in the past: the merging of that ancient wisdom with very modern evidence—more evidence all the time about things such as relationships, as well as the arts and everything else that has an impact on our health.

My third point is about impact. I co-chair the All-Party Parliamentary Group for Prescribed Drug Dependence. Last year, 17% of the adult population were prescribed antidepressants. That is a huge amount: when I see such a figure, I always have to remind myself that that means that 83% of us were not. However, 17% is a huge number, and the sort of things that we are talking about can reduce that number to the benefit of the people who would otherwise be prescribed antidepressants, making enormous economic savings, time savings and so on.

[Baroness Finlay of Llandaff (CB)]

My Lords, I strongly support this group of amendments. I would like to make sure that we realise that the medical humanities as a discipline have now been introduced in many medical schools. In my own, I was rather glad that AJ Cronin’s book The Citadel was introduced in general practice, particularly because, of course, he invented Dr Finlay, but there we are.

Quite seriously, we must not forget that loneliness kills. Loneliness is a true killer; it shortens lives. If people are not moving around well, they fall more and consume healthcare resources. Therefore, having green spaces and things such as sports for health, and so on is important. There is now also a body of evidence that the new intensive care units have used in the way that they are constructed, so that there is a view of outside spaces for those patients, rather than the total sensory deprivation that occurs to them in the very noisy and difficult environment of intensive care. Of course, music is used therapeutically during procedures and so on.

In the hospice world, lots of activities obviously go on in the day centres. As my noble friend Lady Greengross said, there is now good evidence for proper physiological mechanisms that explain why contact with these different disciplines—which were considered to be outside medicine—have a beneficial effect on healing, coping with pain and distress, resolving issues, reframing what is happening to you and so on.

I would like us not to forget that loneliness kills. Importantly, so many patients have said that they have a sense of personal worth when they are still able—however ill they are—to contribute to those around them and to a sense of community. These amendments go to the very heart of being human—that is, the inherent creativity within people that has been forgotten for decades in the provision of health and social care.

I can see that there are difficulties in bringing this into the Bill, but we should commend the noble Lord, Lord Howarth, for the sophisticated way in which he has worded some of these amendments. I hope that they can be built on as we go forward. This could save a huge amount of money for the NHS in the longer term. A huge number of side-effects of drugs could be avoided. People could be fitter. There would be fewer forms. There is a great amount of optimism behind these amendments.

Health and Care Bill

Lord Crisp Excerpts

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

[Baroness Neuberger (CB)]

My Lords, I want to pay tribute, as other noble Lords have, to the noble Baroness, Lady Thornton, for her very thoughtful introduction. It is remarkable and absolutely wonderful to see consensus breaking out across the Committee. I will speak specifically to Amendments 152, 156 and 157 in the name of the noble Lord, Lord Young of Cookham, whose words on the need to make this really serious by stating it on the face of the Bill I echo.

I am a former chief executive of the King’s Fund and am currently chair of University College London Hospitals and Whittington Health. These issues are very dear to my heart and the hearts of those institutions. I also want to say thank you to Crisis for its briefing and add to the words of the noble Lord, Lord Young of Cookham, in praise of Pathway, which has done the most extraordinary work in this area over very many years.

I want to talk particularly about the NHS-funded Find & Treat service, which was set up 13 years ago and is run by UCLH, which I chair. This service was set up in response to a TB outbreak in London and aimed to provide care for people experiencing homelessness and people facing other forms of social exclusion. The service did exactly what it says on the tin: it went out and found people—and still does—who were at risk of contracting TB, wherever they were sleeping, and offered them diagnosis and treatment. Back in 2011, a study concluded that this service had been not only effective in helping to treat people with TB who were experiencing homelessness but cost effective in doing so, both in terms of costs saved to the health service and improved quality and length of life for the people receiving care. Fast-forward a decade and the evolution of this service meant it could be similarly mobilised at the beginning of the Covid pandemic. It provided urgent and necessary care to people who continue to experience the poorest health outcomes.

The King’s Fund published a report in 2020 on delivering health and care for people sleeping rough. It supported the need for inclusion health services to be provided much more broadly than at present. Importantly, it also concluded that local leadership is absolutely vital in crafting that approach and said that local leaders should model effective partnership working across a range of different organisations.

Embedding inclusion health—I cannot say I really like the term, but everybody knows what it means—at the level of integrated care partnerships will help ensure that our healthcare system can no longer ignore, forget or overlook people who are all too often considered “hard to treat”, despite proven interventions showing the opposite. It will ensure that integrated care partnerships and systems take that vital first step towards closing the gap of the most significant health inequalities in our society by having to recognise and consider people facing extreme social exclusion and poor health outcomes in their local areas.

We all know that there will be considerable discussion during the course of this Bill on the need not to be overly prescriptive and burdensome to ICSs and ICPs by way of legal duties. But ICSs and ICPs know all too well the realities of failing to support people with complex and overlapping needs. I know that the chair of my own North Central London ICS, Mike Cooke, is sympathetic to the spirit of these amendments and believes it is important that extra steps are taken to meet the health needs of the most excluded, such as street homeless people. The chief executive of UCLH, David Probert, and the chief executive of Whittington Health, Siobhan Harrington, concur in thinking that if we extend the aspiration to reach out to excluded groups to something that all ICSs, ICPs and systems must focus on, it would be hugely beneficial for planning and joining up systems to avoid inappropriate or unnecessary admissions and poor care planning. Plenty of people want to do this within our health system.

I support Amendments 152, 156 and 157 and look forward to working with the Government and colleagues across the House and within the NHS to ensure their success in achieving a critical and long-needed systemic change to our health and care system. Addressing the needs of the most excluded has to be on the face of the Bill.

[Lord Crisp (CB)]

My Lords, I will make three very practical points about the impact of some of these amendments. First, on tobacco, we have heard from at least two noble Lords that half the difference in life expectancy between the rich and the poor in society is due to tobacco. It seems a no-brainer that work on this has to be continued. I also make the point that it took something like 50 years after the evidence was first available for the control of tobacco to be put into legislation, despite the efforts of the noble Lord, Lord Young of Cookham. It is not a quick win; we need to persevere, keep the pressure on and keep this very firmly in NHS plans at all levels.

Secondly, I want to pick up on the vital point that housing needs to be much more integrated with health and care. Let me take us back in history to 1919 and the first Ministry of Health, which had responsibilities covering health, housing and planning for many years, understanding the very important links there. Covid has shown that a house and home is an absolute foundation for health and well-being in all kinds of ways. I will not labour that point at this stage in proceedings, but will pick up another that has not come up, which is how important housing is to the provision of NHS services.

Seven years ago, the Royal College of Psychiatrists asked me to look at the reasons for the pressure on admissions to mental health acute wards. I did so; I think it expected me to say that those wards needed more beds, but I came out saying that we needed more housing. I found that something like one-third of the patients in mental health acute wards in adult hospitals either had been admitted because there was nowhere else for them to go or were staying there because there was nowhere for them to live to be discharged to. Housing was the biggest issue. Of the 25 NHS trusts around the country, only about three had specific, strong links with their local housing associations. There is a really big pressure for integration there.

Thirdly and finally, I come to Amendments 152 and 157 about the so-called inclusion health services. I agree with my noble friend on the nomenclature and that the naming is rather awkward, but these are extraordinary vital. We have heard examples of services that work; the issue here is how we can make sure that those services are spread and used elsewhere. I remind the House that, when we talk about inequalities, we all, including me, talk in fairly general terms. If you have a quantum of money and invest it in the health of the well-educated middle classes, you will get a small gain. If you invested that same quantum of money in the needs of this group, you would have a massive gain. That should inspire us to keep the pressure on the Government to make sure that we put tackling inequalities absolutely at the heart of the Bill.

Health and Care Bill

Lord Crisp Excerpts

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

[The Lord Bishop of London]

My Lords, I am grateful to the noble Lords who have tabled the amendments in this group. I am very aware of the expertise that exists within this Chamber. As we have heard, mental health has not always been funded in the same way as physical health. However, we have seen improvements, not least in the way we speak about our own mental well-being. We have seen a reduction in stigma and an improvement in services, but the pandemic has taught us that there is a huge unmet need around mental health, and I suspect we will not know the full impact of the pandemic for a number of years. Clearly, those groups of people requiring support around their mental health will include us and our children as well as our health and social care workers.

I am aware that in our churches, we do a lot, like other faith communities and other community groups, to support people’s mental health and enable their mental well-being to flourish, not least through our faith activities and our worship. Churches put on many activities, such as dementia cafés; we make available our outdoor spaces for people to undertake gardening to improve their mental well-being; we do walking; we reduce loneliness and isolation, to name just a few. But we are aware that we are not mental health professionals. We walk with people, often in the early stages of mental illness or while they are waiting for referral, and what those within our churches know is that the length of waiting is getting longer. The wait for access to mental health services, particularly talking therapies, has got much longer.

The noble Lord, Lord Patel, and the noble Baroness, Lady Tyler, mentioned the figures; we see the personal impact of that, as people’s lives are put into great crisis and they struggle. Not least, it brings stress to their family and friends, and it impacts on their ability to earn. As has already been said, it impacts on their physical health as well. I recognise that we have increased our determination to ensure that there is parity between physical and mental health funding but I believe we require legislative levers to make this happen. Therefore, I support particularly Amendments 5, 12 and 136 as well as Amendment 99. As we have already said, we need legislative levers at every level to address this parity. My belief is that this will contribute to not just the mental well-being of the community but its physical well-being.

[Lord Crisp (CB)]

My Lords, it is a great pleasure to follow the right reverend Prelate, a former esteemed colleague, and I had better follow her and the noble Lord, Lord Stevens, in declaring an interest as a former chief executive of the NHS in England—as opposed to NHS England—as Permanent Secretary at the Department of Health and as an honorary fellow of the Royal College of Psychiatrists. I support most of the amendments in this group and shall speak particularly about Amendments 5, 12 and 136, about expenditure, and Amendments 91, 92 and 99, about parity of esteem and ICSs.

The most telling comment, I think, from my noble friend Lady Hollins was when she said that mental health is too often forgotten. It is a really sad point. I am struck, when I look through the amendments we are considering today, how the legislation is trying to catch up with where we have got to as a society and how we think about health. It is obvious with mental health. I thought the great speech by the noble Lord, Lord Howarth, emphasising the role of the nonclinical—the people outside the health system and their role in health—and of salutogenesis, the creation of health, not just pathogenesis, the dealing with disease, was really impressive. The other area where this is very obvious is where we are going to come to in a bit, talking about inequalities in a later group.

This is very much part of the new agenda, but it is interesting that we still have the overhang of what I think of as the 20th-century model of healthcare, which is about the acute sector, not the primary sector; it is an NHS focus; it is about doing things to people, rather than with people; and it is about illness. This Bill is, in a way, the first health Bill of the 21st century and it is really important that it sends out some very clear messages and that so many of these amendments can be picked up to make sure those messages are sent out very clearly.

I will pick up the detail very briefly. Amendments 5, 12 and 136 from my noble friend Lord Stevens of Birmingham on measuring and increasing expenditure on mental health—or at least showing the Government’s hand and revealing what they are expecting—and, later, the monitoring of it are fundamental. However, let me put in a caveat: they are pretty blunt. They are imperfect, because they are about inputs rather than outcomes and outputs, thinking of some of the things we talked about earlier. They can also be gamed.

Also, as the noble Baroness, Lady Jones of Moulsecoomb, said, physical and mental health are not distinct; actually, most people in civil society treat mental and physical health at the same time, so there will be some arbitrary distinctions. I remind noble Lords, as we all know very well, that there is a major problem for many patients with mental health problems in trying to access help with their physical health. As Professor Sir Graham Thornicroft has said, mental health diseases are killer diseases, because people die earlier—sometimes because of that impact on physical health.

These are imperfect measures. However, I support them as a blunt instrument for offering steering and pushing the system the right way. They are a real measure that will help bring about change and they should be supported at the macro level.

Amendments 91, 92 and 99 are about achieving parity of esteem within the integrated care systems, and it is right that they are broader based, because people have to make choices at a local level about what they are doing. It is really important that the planners on those boards take full account of mental health and achieve parity of esteem across the whole spectrum, from levels of investment right the way through to ensuring that people with mental health problems can access physical healthcare when they need it. As the noble Baroness, Lady Hollins, reminded us, in 1948 the first meeting of the World Health Assembly defined health as being about

“physical, mental and social well-being”.

It is time we got back to that.

I applaud these amendments and very much hope that the Minister will indicate the Government’s support for a much bigger emphasis on mental health in supporting these and other amendments.

[Lord Warner (CB)]

My Lords, I support these amendments, particularly Amendments 5, 12 and 136, so powerfully spoken to by the noble Lord, Lord Stevens of Birmingham.

As a kind of self-appointed historian to this Committee, I will take us back to 2005-06. There was a massive public consultation, leading to the White Paper Our Health, Our Care, Our Say. A thousand people of diverse socioeconomic and age backgrounds gathered in Birmingham to vote on what the public thought were the top priorities for the NHS. Much to the shock of the six members of the ministerial team—including me—who attended that event, and the top management of what was then the Department of Health, led by the noble Lord, Lord Crisp, the public were several decades ahead of the political, managerial and clinical decision-makers of our revered NHS.

It has taken us a really long time to catch up. We have moved since then through a period in which, with great rhetoric, we have inserted into legislation a desire for parity of esteem between physical and mental health. However, no one of any political party has had the temerity to do what the noble Lord, Lord Stevens, has done in suggesting we should actually put our money where our mouth is. It simply has not been done.

The NHS, in my experience, is quite strong on doing things if you give it money. If we do not start putting into the allocations some requirements to at least level up, as the noble Lord, Lord Stevens, says, we will make no progress whatever with our rhetoric. I strongly support these amendments and hope the Government will listen very carefully to this House. I, for one, will be quite happy to march into any Lobby in support of amendments which give some financial equality of recognition to the needs of those with mental health problems.

While I am on my feet, I mention a group which is neglected even within the mental health set-up—those with autism. It is one of the great disgraces of this country that we have such poor arrangements for diagnosing young people, particularly girls, with autism. We need to do a better job of putting our money where our mouth is on that subject.

Health and Care Bill

Lord Crisp Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Lord Crisp (CB)]

My Lords, I first congratulate my noble friend Lord Stevens on an excellent maiden speech. I agree with him that there are substantial opportunities in this Bill, although some things are missing, some of which he referred to, such as mental health and determinants of health. As other noble Lords have discussed, however, I feel the complexity of some of these processes and the difficulty of getting one’s mind around how this will actually work.

I agree with so much that has been said about social care, particularly on the cap. I trust that your Lordships’ House will send this back to the other place rapidly for it to think again. I also agree with many points that have been made on the workforce, although I would make a single observation—that we need to pay attention to changing roles as well as to numbers. In the case of primary care, it will not look in 15 years’ time as it does now. This is for all kinds of reasons, including the way that nurses are taking on a much bigger role; they will continue to do so, and I suspect they will be the lead providers in primary care in 15 years’ time. That is a simple prediction that I may come to regret.

When you make a change such as this, you disrupt the system and some arrangements that used to work. There are two more specific points that I should like to explore in Committee. One is how we ensure that primary care—GPs, but primary care more generally—still has a significant role in approving plans. I recognise that there are practicalities around that, but it is vital that it retains some impact. I also think it is very important that foundation trusts can maintain sufficient independence of action. I know that the concern of NHS Providers is about control of capital in that regard. Some things need to be explored further.

However, my main observation is to follow other noble Lords in saying that we are talking here about integrating health and social care, but that is 20% of the issue; there is so much more outside that. We know all about social determinants; many have mentioned them. We know the massive impact of education, employment, training and housing—both positive and, I may say, negative—on health, and we know the science that underpins that: about relationships, how social isolation leads to dementia; how exercise, exposure to nature, and such aspects, make change. We need to capitalise on that.

I want to make two points that are slightly different from what others have said. First, this is not just about prevention. Prevention is about the causes of ill health; we need to be thinking also about the causes of health, and the two things are often run together in ways that are unhelpful. Creating health is about creating the conditions for people to be healthy and helping them to flourish. It is about human flourishing, eudaimonia, if one wants to go back to Aristotle.

The second point, which goes alongside it, is that the health of the individual is intimately connected with the health of the community in which they live. This is a point that the noble Lord, Lord Mawson, in particular, exemplified with his discussion about Well North, but also his early experience in Bromley by Bow. There are now examples all over the country of people starting to bring together the things that improve communities with the things that improve individual health. That is a vital part of the future. We have known that for years, but we have not known how to connect it properly with the NHS. I speak as a former chief executive of the NHS in England who failed to make that happen.

My question to the Minister is: how will the Government ensure that those other groups in society—voluntary organisations, housing associations, employers, schools, educators and so on—contribute to creating health and, thereby, supporting the NHS to do its vital work? We need to see health in terms of wonderful healthcare and services and prevention of disease, but also creating the conditions for people to thrive. The underpinning thought here is that our health as individuals is intimately connected with the health of our communities, of society at large and, ultimately, of the planet.

People with Learning Difficulties and Autism: Detention in Secure Settings

Lord Crisp Excerpts

Thursday 28th October 2021 Grand Committee

[Lord Crisp (CB)]

My Lords, I, too, congratulate my noble friend Lady Hollins on getting this debate. I want to spend a moment on those congratulations. At a time of Covid, climate change and geopolitical tensions, it is really important that we do not neglect some of the smaller-scale issues. This issue affects 2,000-plus people and their families, but it is not millions, and it is not the billions who live on this earth. In that sense, it is small scale, but for these families this is massive and all-embracing. I also note that Covid has affected people differently and has been a healthy reminder of the inequalities in our society, and this is a massive and rather hidden inequality. So I congratulate my noble friend on the way she opened the debate, spreading out all the issues that are involved.

I want to say a few words about the current situation and focus on the plan, the non-existent plan. We are talking here about 2,000-plus people, 210 of whom are children who have learning disabilities and/or autism. I have been out of touch with this sector for some time, but I sense from the briefings that I have been getting that all we are doing is warehousing these people. They do not need to be there. They are admitted because there is nowhere else for them to go, and they cannot leave because there is nowhere else for them to go. Meanwhile, while there, they deteriorate. It is a dangerous environment for many, and goodness knows what it does for the children and their education, socialisation and development.

I know that similar things are happening to acute adult mental health admissions because I have done a recent review on that, and people are stuck in adult in-patient units, but the difference is that we are talking about people being in this situation for 5.4 years on average. They go in now and come out, possibly in 2027, or, looking backwards, they would be coming out into today’s world from the very different world of 2015, or, as a child, growing from 11 or 12 to 16 or 17 through the early years of adolescence. We can all imagine the personal tragedies behind these bald figures.

So what is the plan? I mean “what is the plan?” and not “what is the policy document?” My noble friend Lady Bull made the terribly important point that this is small enough to count. They can all go on somebody’s list and somebody can tick them off when they are moved out of hospital.

I have had a lot of great briefings from organisations, great descriptions of the problem and great advice. We know what good looks like. There are lots of overlapping recommendations. There is a lot of discussion of inspection and holding to account, but I do not see anything about personal responsibility and who is responsible for delivering the change.

I joined the NHS in 1986 from a background in industry and charitable sector as—in those days’ language—the unit general manager of a mental handicap unit and I am familiar with this sort of problem because in those days we had a target to remove children from mental handicap hospitals. I make these comments as a manager.

Public sector planning can just mean a document all carefully worked through with timelines, targets and many wise words. A plan is not a document but something that is going to happen, but it does not mean anything if there is not somebody charged with implementing it and for whom there are consequences, frankly, of both success and failure. I was staggered to hear the noble Baroness, Lady Hollins, point out that some of the people who appear to be responsible for implementing this do not know how many people they are responsible for in this situation.

We need money to sort some of this out, I am sure, but a person is the most important first step. Money can be wasted, and a responsible person can fight for the money. Of course, quality and safety are also vital; this is not just about getting people out of one bad situation in hospital or inpatient unit and putting them in another bad situation in the community.

I will not labour what happened 35 years ago—but it happened. There was both money and responsibility and it happened. I remember quite a lot of pressure coming down the system to me as a unit general manager to make sure that it happened. At that stage, no more children were living in hospitals. It may not be quite like for like for where we are today, but it is tragic to hear how far backwards we have gone in 35 years.

Therefore, my questions for the Minister are of course: what is the plan and who will be responsible for delivering it? Will whoever is personally responsible also be impacted by their failure or success in achieving the plan? Let me add that this is just the sort of small-scale thing where ministerial leadership can make a massive difference. If a Minister took an interest and wanted to make it happen, they could really make it happen. I know it is not the Minister’s brief, but will he raise this with his ministerial colleague, the Minister for Care? My simple point is: who is going to get a grip on this?

Ageing: Science, Technology and Healthy Living (Science and Technology Committee Report)

Lord Crisp Excerpts

Wednesday 20th October 2021 Grand Committee

[Lord Crisp (CB)]

My Lords, I am not a member of the committee so it gives me great pleasure to say that I thought this was a really excellent report. The science was fascinating and it was very readable as well. I almost thought I understood most of it, which was gratifying. It deserves a wider audience for bringing it all together in the way that it does. It is also a privilege to follow on behind a distinguished doctor and to be followed by a distinguished nurse; I suppose that is the right place for somebody whose background is in health management.

I want to pick up three points. Two of them are about the Government’s response and the other is about something specific within the committee’s report. As a health manager, perhaps the right place for me to start off is with that nexus of issues that noble Lords have talked so much about: the multimorbidity, the unplanned cocktail of drugs that people are taking and the lack of co-ordination. Very interestingly, there was also the point that the noble Lord, Lord Kakkar, picked up about older people not being included in drug trials. Indeed, as the report said, there was no real research being done on ageing in general, as opposed to the more specific points as a whole.

This area of co-ordination and oversight of what is happening with old people’s medication and their health is vital. I am not sure the committee’s recommendations were strong enough—other things could be there—but, frankly, the Government’s response was bland, as if to say: “Yes, you have already got a designated clinician.” I do not know if many older people know that, and I speak as somebody with a 97 year-old father-in-law. The truth is that it is left to the family. It is left to the individual, the family, the carers, the friends, and so on. That is another manifestation of inequality, because of access to having people who can help you.

I liked the point made by the noble Lord, Lord Kakkar, that maybe this can be picked up in the forthcoming Bill or the debate in the House about it. But I would like to ask the Minister if he recognises that there is inadequate co-ordination and oversight of older people’s health and medication. Will he ensure that the department and the NHS do more to address this?

My second point refers to the committee itself. The whole document treats older people as a problem and a burden, but what about the contribution and value that they—or perhaps we—bring to society? One may say that is not within the scope of what the committee was looking at, but I have seen a lot of evidence that having a meaning and purpose in life is good for your health. However, being undervalued and seen as helpless—as most of us are reduced to being helpless when in the health system—or not being in control, which is a vital part of one’s health and self-esteem, is bad. We should not forget that whole range of issues. They are susceptible to good evidence, good policy and good thinking that recognises the role and contribution of older people. There is an admirable focus in the report on the causes of ill health, but there needs also to be thought about the causes of health. There needs to be more research in that area.

I shall also pick up a point that the noble Viscount, Lord Ridley, raised, even though he is not in his place. I do not disagree with him on the importance of research but this is about research and society; it is not one or the other but both. Research is vital but he caricatured public health as being about advising young people to do healthy things. That is not often going to work; I suspect I agree with him. Having said that, just by chance this morning I was on a webinar Zoom call with Everton Football Club, which is doing remarkable things to teach young people about health using that very strong force of role models, so that area is not a guaranteed failure.

A good public health approach is much more about enabling people to have a good life, in the sense of making sure that they are secure. Love comes into this, as does education, opportunity and all the things that enable people to be all they can be. It is what Aristotle referred to as eudaimonia and is normally referred to as human flourishing. The public health aspect of dealing with inequalities, but going wider than that, is really important. This committee is right to have picked up both the biological science in research and the society aspects.

Let me pick up one final point. In its last chapters— I think it is recommendations 20 to 23— the report presses the Government on how serious they are about this challenge and how determined they are to do it. Have they got somebody in charge of it? Is there going to be the impetus, energy, support and mobilisation to make something happen? Those are really important issues. Again, I thought the government response on this was bland, at best. There was no indication of the energy and importance of this issue in the way that it needs to be taken forward. Will the Minister reassure the Committee that it is not only about whether the grand challenges are going ahead in this form, but that these issues around health, ageing, science and technology are to be picked up in the appropriate fashion?

World Health Organization: Pandemics

Lord Crisp Excerpts

Tuesday 9th March 2021 Lords Chamber

Asked by

[Lord Crisp]

To ask Her Majesty’s Government what plans they have to strengthen the role of the World Health Organization to support the management of future pandemics.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Bethell) (Con)]

My Lords, the UK is a strong supporter of the WHO and an advocate of reform to ensure that it further strengthens its ability to respond effectively to health emergencies. The UK is taking a leading role on reform through our seat at the WHO Executive Board and our G7 presidency. We are working with international partners to push for a stronger early warning system, reduced risk of zoonotic diseases through better surveillance and improved compliance with international health regulations.

[Lord Crisp (CB) [V]]

My Lords, I am delighted that the UK Government are providing support to the World Health Organization, contributing to COVAX and taking this very important role of reform. Further to the Independent Panel for Pandemic Preparedness and Response report, which talked about the World Health Organization being

“underpowered to do the job expected of it”,

will the Government ensure that this is discussed at G7 and that the world will commit to doing whatever it takes to ensure that the WHO is able to respond even more effectively to pandemics in the future?

[Lord Bethell (Con)]

My Lords, the Government are extremely committed to pandemic preparedness. We support the principle of a pandemic preparedness treaty, and we have laid out at UNGA a very clear programme for enhancing global pandemic preparedness. We look forward to the publication of the Independent Panel for Pandemic Preparedness and Response report shortly, and I reassure the noble Lord that this is top of the agenda at our G7.

International Year of Health and Care Workers

Lord Crisp Excerpts

Monday 1st February 2021 Lords Chamber

Asked by

[Lord Crisp]

To ask Her Majesty’s Government what plans they have to celebrate the World Health Organization’s International Year of Health and Care Workers in 2021.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Bethell) (Con)]

My Lords, to celebrate the work of health and care workers, there are symbolic interventions, such as the social care workforce CARE brand for shared identity and our powerful recruitment advertising, which highlights the remarkable contribution of health and care workers. However, the most important celebrations are tangible: the investment in new recruitment, the £30 million fund for those seeking mental and occupational health support, and the people plan, which is addressing the practical and cultural challenges that workers face in the workplace.

[Lord Crisp (CB) [V]]

I thank the Minister for that very positive response and I agree with him about concrete measures. The World Health Organization has adopted the slogan “protect, invest, together”, which is very powerful and sets out the priorities very well for this year. The Minister will no doubt be aware that there is discussion at the World Health Organization and elsewhere about the need for a new societal compact with health and care workers to whom we owe so much, perhaps similar to the military covenant. Would Her Majesty’s Government support the creation of a compact or covenant setting out our responsibilities to health and care workers, which mirror and match their professional responsibilities and duties towards us? If they have not considered this, will they do so?

[Lord Bethell (Con)]

My Lords, I applaud the WHO’s values of “protect, invest, together”. One of the commendable things during this awful pandemic has been the way in which British society has reconnected with the values of the healthcare community. It has rediscovered the contribution of nurses, doctors, healthcare workers and those in social care. A new relationship has been forged between civic society and healthcare; this is commendable and we should build on it. On the idea for a compact, it is not something that we are working on at the moment as far as I am aware, but I would be glad to take his idea away and find out whether we can develop it any further.

Covid-19: Vaccinations

Lord Crisp Excerpts

Wednesday 13th January 2021 Lords Chamber

[Lord Bethell (Con)]

My Lords, I am enormously grateful for my noble friend’s kind words. I think that, as a Government, we would prefer to be judged at the third act of this important performance, so I think it is probably too early to take too much praise, but I would like to say a massive thanks to the British nation.

In three ways, the nation has really stood up. The amount of collaboration between different groups—I alluded to it in my previous answer—between the Army, industry, the NHS and local authorities has been enormous. At the beginning of this pandemic, there were arthritic elements to the way in which Britain is governed that meant that different parts of our political and administrative machinery did grind into action slightly slowly, but, my goodness, over the vaccine deployment it has been absolutely athletic, and I take my hat off to every part of the machinery of government. On the union, this has been such a strong example of a national solution: all of Britain has come together in order to purchase and deploy the vaccine. Lastly, I would observe the resilience of the British public. It makes me enormously proud that the country puts the elderly and the infirm first and stands by and celebrates the weakest and most vulnerable in our society being put first in the queue. That is a national quality we should all be proud of.

[Lord Crisp (CB) [V]]

My Lords, I congratulate everyone concerned in the progress being made with the vaccinations, while recognising that there are issues to be addressed, not least that of accelerating the whole process. In passing, I note that I would be very happy to be vaccinated at 4 am if it sped things up. I will ask about testing and vaccination for a particularly vulnerable group; children excluded from school are the among the most vulnerable in the country, and I pay tribute to the approved alternative education providers and others working with them during the pandemic. I have been contacted by one of the directors of one of these providers, who tells me that, unlike schools, they are not being provided with lateral flow tests to help them protect children in school and staff. If I write to the Minister, will he take the matter up? Can he ensure that all such approved providers receive the tests and that their staff are given a high priority for vaccination—at least as high as that for teachers?

[Lord Bethell (Con)]

I am grateful to the noble Lord for flagging this important issue. He is entirely right that those who are sometimes overlooked by society and fall between the cracks are often those who either suffer from the disease or are vectors of infection. It is a public health priority to ensure that people such as those excluded from schools are not overlooked or in any way left behind. I would be very grateful if he could write to me with the details.

Medicines and Medical Devices Bill

Lord Crisp Excerpts

Report stage & Report stage (Hansard): House of Lords & Report: 1st sitting & Report: 1st sitting: House of Lords
Tuesday 12th January 2021 Lords Chamber

[Baroness Walmsley (LD) [V]]

My Lords, I support this amendment. When we discussed this issue in Committee, I raised the matter of Section 57A of the Patents Act 1977 and the Minister pointed out that compensation needs to be awarded to a patent holder for any loss of profits as a result of the use of a Crown use licence and argued that this should be set against the potential savings that purchasing more affordable generic alternatives enabled by a Crown use licence could bring about. Tonight, I repeat that this has never been tested in court.

The noble Baroness, Lady Sheehan, and the noble Lord, Lord Alton, mentioned Orkambi. The fact is that if the Government had issued a Crown licence and Vertex had decided to take the Government to court for compensation, the Government would probably have won the case, because they had a very strong case. Any reasonable person would have concluded that three years of failed negotiations showed that Vertex could not make the case that the NHS would definitely have bought the product from them had a Crown use licence not been issued. Had they taken the thing to court, the Government would probably have won the case, and the fact that they did not means that they really missed an opportunity to set a useful new precedent by fighting an interpretation that would render the entire Crown use provision next to useless.

I shall add just a few words about the Covid-19 pandemic. Many countries, such as Germany, Hungary, Canada and Australia, have made alterations to their patent laws to make issuing a compulsory licence easier, in the interests of public health. That is because, in those countries, it is accepted as a valuable tool that can help overcome pricing and manufacturing barriers to accessing crucial vaccines, medicines and diagnostics which could help save millions of lives. Will the UK Government follow this example, set a precedent, next time the opportunity presents itself, and make the necessary changes to our law to make it easier, not more complex, to use our legal right of issuing a Crown use licence to protect public health?

[Lord Crisp (CB) [V]]

My Lords, I am very pleased to add my name to the amendment in the name of the noble Baroness, Lady Sheehan. I shall be brief and limit myself to one central point, because the arguments have been put so well by noble Lords who have already spoken. At its heart, this amendment is about achieving the right balance between the public interest and private interests. In this particular context, it is clear to me that the Government should commit themselves clearly to safeguarding the public interest and to taking action on—let me stress this—those rare occasions when it will be necessary.

This is particularly vital, as other noble Lords have said today and on earlier occasions, because, sadly, there is a history of price gouging and exploitation of the public. There has also been lack of transparency and, of course, one should also note that the development of many treatments and vaccines have benefitted from public investment. I hope the Minister will be able to make the commitments that the noble Baroness, Lady Sheehan, has requested.

[Baroness Jolly (LD) [V]]

My Lords, the purpose of this amendment, tabled by my noble friend Lady Sheehan, with cross-party support, is to ensure that fair and affordable access to medicines for all must be a consideration when regulations are made with respect to human medicines. This is key for two reasons. The first is to ensure that medicines, including on the NHS, are available at a fair price. We know that the NHS buys medicines at an industrial scale and is very able to be tough in its bargaining to get a good deal for the taxpayer. The second is that the British Government used to play a pivotal role, through DfID, in helping many across the world in the eradication of polio and other life-changing or life-threatening diseases. Will the Minister outline what criteria are used now that DfID has been subsumed by FCDO?

On Covid-19, collaboration on the production of vaccines is critical. What is being done by the Government to collaborate in this life-saving mission? Time is of the essence. Can the Minister tell us where we are now and outline what support is going to those who have neither the contacts nor the money to fund these vaccinations? Our economy has taken a serious hit, but we have a moral duty to support those with no industry, and so no income. I endorse all the comments from the noble Lord, Lord Crisp, who has many years’ experience of these issues—many more than I have. I would be grateful if the Minister could answer my questions.