Health and Care Bill

Lord Hunt of Kings Heath Excerpts

Lords Hansard - Part 2 & Report stage
Thursday 3rd March 2022 Lords Chamber

[Baroness Thornton (Lab)]

With the leave of the House, I thought it might be useful if I used my slot to speak right now on leaving out Clause 40. First, I thank the noble Lords, Lord Patel and Lord Lansley, and the noble Baroness, Lady Walmsley, for putting their names to this amendment. The noble Lord, Lord Patel—with whom I spoke this morning, and who is definitely on the mend, so I hope we will see him next week—said how strongly he supports the amendment. I will speak very briefly because we have already said much of what needs to be said about saving the Secretary of State from himself—as the noble Lord, Lord Lansley, said, I think. This is what this amendment is about.

Clearly, this is not what the NHS asked for in the Bill. It did not ask for this power. It has been added to the Bill—by a previous Secretary of State, I suspect—and I hear rumours that even the current Secretary of State is not a great fan. Why would any Secretary of State want to have this power—to be lobbied and drawn into any minor local dispute, particularly as we head towards a general election?

I have a small anecdote. A small coastal town had a small hospital with an accident and emergency department. It could not be properly staffed, it regularly closed for random periods, and far too often patients arrived there only to be moved to the larger A&E 20 miles down the road. Proposals were made to close it—and of course, outrage ensued. “Save our A&E”, people said, even though it was unsafe. Local politics were poisonous, and the blame for the closure was thrown on opponents, whichever side they were on.

However, over time, good communications, clinical leadership and, eventually, bringing local people into the team, got the proposal moving. People understood what was needed and why, and the reconfiguration process went through its stages, with external reviews and analysis by the national clinical advisory team, which all gave reassurance. The clincher came when a distinguished clinician leading the review told a meeting that he would personally go and paint over the road signs for the A&E, because it was so unsuitable. It shut, which probably means that lives were saved.

The process of rational argument and proper analysis works, and on this occasion we should not just leave it to local politics to decide what reconfiguration means. The Secretary of State has enough powers to direct the whole NHS in its fullness, but should not be involved in what may be very small reconfigurations indeed. We agree, and many people in the NHS and its organisations agree, that this clause should be removed from the Bill.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I have no doubt that when the Minister responds he will say that the Secretary of State is likely to use this power very rarely. The point is that the moment the health service knows the Secretary of State has such a power, that will immediately influence its behaviour in relation to any improvements or major changes of services likely to lead to opposition from the local Member of Parliament. I think that the Minister is responsible for innovation in the health service, and this will put the kibosh on innovation and service changes.

Written on my heart is Kidderminster General Hospital. The Minister may not recall this, because it is a long time ago now, but Worcestershire Health Authority made proposals to reconfigure A&E services and close Kidderminster General Hospital. The then Member of Parliament, David Lock, who was a loyal member of the Government, bravely defended that decision. He lost his seat in 2001, and it has been written on the hearts of many MPs since then that they do not defend that type of change, because they might lose their seats.

I cannot believe that the Government wish to give the Secretary of State the nightmare of that kind of lobbying—I am trying to tempt the noble and learned Lord, Lord Clarke, to intervene here, because he knows what MPs do. What we have at the moment is a very good system, at arm’s length, and it beats me why on earth the Government want to do this. We need to do the business and get rid of the clause. I suspect that we shall not see it back again.

[Baroness Walmsley (LD)]

My Lords, Amendment 84 is intended to remove the powers of the Secretary of State, in Clause 40, to intervene in decisions on reconfigurations of health services. I said in Committee, and I say again, that those powers are very dangerous. We have recently seen how the Government’s powers to provide or withdraw funding for a proposal to, say, build a new school or improve infrastructure in a particular constituency have got them into trouble. Political considerations have trumped public interest. In the media they call that pork barrel politics—not a very complimentary phrase, I am afraid.

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[Lord Kamall (Con)]

I thank the noble Baroness for clarifying that. Of course, we completely understand the concerns that have been raised. The Secretary of State must use regulation-making powers where they exist, rather than using the power of direction to achieve what could be achieved under regulations.

Turning to the allocation of resources to the ICBs, the Government have no ambition to use this power to interfere with individual allocations of money to the system. It will not be used to interfere with the independent Advisory Committee on Resource Allocation. NHS England will continue to make funding allocations to ICBs to support them to deliver functions via the target formula, in order to reduce inequalities between patients. We have attached safeguards to this power to make sure it is not misused. Any exercise of this power must be done transparently: it must be made in writing, be published and be made in the public interest. This will enable Parliament to challenge Ministers and hold them to account.

Turning to Amendment 84, Clause 40 and Schedule 6 will allow the Secretary of State to better support effective change and respond to stakeholder concerns, including views from the public, health oversight and scrutiny committees and parliamentarians, in a more timely way. The clause and schedule will ensure that key decisions made about how services are delivered are subject to democratic oversight.

It is a misapprehension that the Secretary of State currently has no role in the decision-making process for reconfigurations. He does and without these provisions that role will continue. However, currently, referrals usually come at a very late stage in the process, which represents neither good value for the taxpayer nor good outcomes for patients.

I understand the concerns from noble Lords, including former Ministers, about how these powers might be used. But I have been asked to make clear that we expect the vast majority of reconfiguration decisions to continue to be managed by the local system—

[Lord Hunt of Kings Heath (Lab)]

I am sorry to interrupt, but does the Minister not take my point that it is not that Ministers will have to use those powers; it is that they have powers that will change behaviour immediately in the health service? That is the issue.

[Baroness Walmsley (LD)]

Before the Minister answers that question, I wonder if he would be kind enough to answer two from me. He just gave a list of what the powers will not be used for, but could he tell us what sort of thing the powers will be used for and under what circumstances? Can he also say why previous Secretaries of State—some of whom are not very far from where I am standing now—did not feel the need for those powers and still felt themselves accountable for the health service?

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[Lord Hunt of Kings Heath (Lab)]

My Lords, it is a great honour for my two amendments to be grouped with that in the names of the noble Lords, Lord Alton and Lord Blencathra. As the noble Lord has discussed the supply chain, I should declare my interest as president of the Health Care Supply Association, although I am not speaking on its behalf when it comes to my strongly supporting his amendment, which sets the context for my own two amendments.

We debated this issue very fully in Committee. I think that the House believes strongly that the commercial exploitation of body parts in all forms is unethical and unsavoury. When it is combined with mass killing by an authoritarian state, we cannot stand by and do nothing. In 2019, the China Tribunal, led by Sir Geoffrey Nice QC, stated:

“The Tribunal’s members are certain—unanimously, and sure beyond reasonable doubt—that in China forced organ harvesting from prisoners of conscience has been practiced for a substantial period of time involving a very substantial number of victims.”


In June this year, 12 UN special procedure experts raised the issue of forced organ harvesting with the Chinese Government in response to credible information that Falun Gong practitioners, Uighurs, Tibetans, Muslims and Christians had been killed for their organs in China.

Currently, human tissue legislation covers organ transplantation within the UK, where we have a very ethical approach, but it does not cover British citizens travelling abroad for transplants, and British taxpayers’ money will pay for anti-rejection medication regardless of where the organ was sourced or whether it was forcibly harvested from prisoners of conscience.

I shall not repeat all that I said in Committee, but I have had a helpful meeting with Ministers for which I thank them. In that meeting and in subsequent meetings, the Minister was concerned that my amendment in relation to organ tourism would penalise vulnerable people seeking to pay for a transplant. I have thought about that carefully, but, in the end—and the noble Baroness, Lady Kennedy, expressed so well why this Bill is highly appropriate for these kind of amendments—we have to draw a line in the sand. That is particularly so today, in the horrific circumstances that we meet. We have to draw a line in the sand and send out a powerful message globally that we will not support these abhorrent practices in any way.

My Amendment 162 comes later, but I shall seek the opinion of the House at that time.

[Baroness Northover (LD)]

The noble Lord, Lord Hunt, has very effectively introduced the amendments to which I have put my name, Amendments 162 and 173, and I wish briefly to express the support of these Benches for those. We also support Amendment 108, to which my noble friend Lady Brinton has put her name.

As noble Lords know, we have been inching forward on these matters with Ministers, and I welcome that forward movement. I note, however, recent warnings from Ministers that, for example, there are “opportunity costs” in implementing these measures, as ensuring that proper standards are enforced requires effort and potential cost. I understand that. Nevertheless, we cannot allow ourselves to become complicit in any way in organ tourism where the source of those organs is forced or where selling the organ is to address appalling poverty.

Some say that this trade may be declining in and from China. If so, that is welcome and might reflect international pressure, not least on the Chinese medical profession. It is not clear that those involved in the China Tribunal and the Uyghur Tribunal would agree that it is declining.

Even if we were to accept that, and Ministers seemed to indicate that they thought that might be the case, we are also hearing now of an increase in the selling of organs in Afghanistan because of the dire situation there. There have been recent reports of journalists seeing the scars of those who have sold their kidneys. That is a terrible indictment of our walking away from Afghanistan and failing to address the appalling conditions that we have left there. How can we regard such potential “donors” as being anything other than the most extremely vulnerable? How can you put that up against the vulnerable who may need to have donations?

As for the bodies exhibitions, we have discussed before how distasteful they are—but then we realise with horror exactly where these bodies seem to have been sourced: among other things, from Chinese prisons. We should never have condoned that, turning a blind eye. I agree with the noble Baroness, Lady Thornton, who argued in Committee that they should simply be banned. There is no reason whatever to agree to their continuation.

I now hear that the Government may argue—and this is incredibly familiar—that these amendments are flawed. As the noble Earl knows, often Ministers are given briefs that say, “This is a flawed amendment, so turn it back.” I am very familiar with them. In those circumstances, the best thing is for your Lordships to pass these amendments, because Ministers know, or should know, that the essence is extremely clear, and with government lawyers we can work out how best to sort out any unintended consequences. I hope that I do not hear anything about these amendments being flawed—and I say that to the Box. I therefore commend them to your Lordships.

Health and Care Bill

Lord Hunt of Kings Heath Excerpts

Lords Hansard - Part 2 & Report stage
Tuesday 1st March 2022 Lords Chamber

We are at a milestone moment, and I sincerely hope that this amendment really will be game-changing. It is the start of a new journey, and this is the first step for the Department of Health and the NHS to guide integrated care boards as they look to develop over time the services that their local population need. Now delivery plans need to be communicated to integrated care boards and providers as they work together on the journey to integration and ensure fair access for all to the palliative care that people desperately need, often at the most vulnerable time in their life.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I pay tribute to the noble Baroness, Lady Finlay, for her outstanding work in this area. I was very moved by the remarks of my noble friend Lord Howarth in tribute to the care given to Baroness Hollis, who was such a tremendous force for good in your Lordships’ Chamber over many years.

Can the noble Earl clarify the point that has already been raised? In the letter from Ministers of 26 February it was said that the amendment would add palliative care services to the list of services that an ICB must commission. On the face of it, the amendment seems rather more permissive. Proposed new subsection 3(1) in Clause 16 states:

“An integrated care board must arrange for the provision of the following to such extent as it considers necessary to meet the reasonable requirements of the people for whom it has responsibility”.


There is then a list, which starts with “hospital accommodation”, which the ICB must arrange for—then on page 17 are a couple of provisions that seem rather more permissive.

The nub of the issue is this: we have fantastic palliative care in the mainly voluntary sector as well as in the National Health Service itself, but it is very patchy. The health service has been very reluctant to give long-term certainty to hospices and other providers of palliative care services, insisting on short-term contracts. The real question to the noble Earl is this: will this change as a result of this amendment? Where is the beef that will actually get the message across that we expect the health service to do a lot better than it has been doing in support of palliative care services?

[The Lord Bishop of London]

My Lords, I declare my interests in the register. I join in thanking the Government for having listened in Committee. I hope that this will make a difference not just to the lives of those whose lives are shorter but also their families, so it is very welcome. I pay tribute to the noble Baroness, Lady Finlay, but also to my friend, the right reverend Prelate the Bishop of Carlisle, who put his name to Amendment 17.

As I say, I welcome this amendment. As the chair of the UK Commission on Bereavement, I have been reminded recently of the inconsistency of palliative care, which other noble Lords have spoken of this evening. It affects not only those who require palliative care but also their family and friends, and it leaves a legacy into bereavement, which we should not underestimate. I too was reassured to hear the Minister say that palliative care must be commissioned, but I share again the concern of the noble Lord, Lord Hunt. In Amendment 16, the word “appropriate” is used, and it is not quite the same thing. Could the Minister reassure the House about the Government’s expectations regarding the nature of palliative care services that the ICBs will commission? How will they ensure that that is delivered in a way that creates consistency? It is care that is rightly deserved by people in our communities, which also reflects the skill and hard work of our palliative care practitioners

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[Lord Scriven (LD)]

My Lords, I support the amendments in the name of the noble Lord, Lord Crisp, to which I have added my name. I think the noble Lord had to table these amendments because the Minister said when we discussed this in Committee that his challenge was to ensure that

“primary care is better represented and not dominated by acute trusts.”—[Official Report, 20/1/22; col. 1854.]

We expected something to come back that did exactly that, because the very fact the Minister said that suggested that the Government had accepted that there was a potential imbalance with the role of primary care.

I come back to the purpose of the Bill, which I did a number of times in Committee. The purpose of the Bill is to bring about effective integration, improve health outcomes and reduce health inequalities. That is underpinned by making primary care central to healthcare planning and ideas about healthcare, following through on those plans and having primary care as an equal partner in the ICB. So we moved away from who we want on the board to asking very simply for primary care to be treated as an equal in the planning, implementation and monitoring of what will happen in health and social care in the area. It is disappointing that, despite the Minister’s suggestion that he would go away and look at this, nothing new has come back since Committee to deal with that.

What new has come back on Report which makes sure that primary care can be better represented and not dominated by acute trusts in this new system? My worry is that the Bill giving this to NHS acute trusts and foundation trusts signals which are most important within the system. If primary care does not have that equity, there will be unrealistic expectations and uninformed decisions made in planning for final decisions and tactical, not transformational, systems and services, which will not represent the full view of primary care. It is for those reasons that I support the amendments of the noble Lord, Lord Crisp, and look forward to the Minister bringing to the House’s attention what new proposals are in here on Report to do with the challenge that he set himself: to ensure that primary care has a bigger voice and is not dominated by the acute sector.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I added my name to the amendments of the noble Lord, Lord Crisp, and echo the remarks of the noble Lord, Lord Scriven, on the Minister’s offer in Committee to go back to see how the potential dominance of acute trusts could be mitigated by ensuring that the voice of primary care was heard loud and clear in the various decision-making bodies.

It is a pity that it is a very late hour, because primary care warrants a much wider debate, given the challenges it undoubtedly faces. We are all aware of the workforce issues, such as the reluctance of many GPs to take on partnerships and that so many GPs will do only part-time work, partly because of the pressures. It is because of those challenges and because primary care is so valued in this country that we need some assurances that the people running the new system being introduced through this legislation will be concerned with and listen to primary care.

It is somewhat ironic. The noble Lord, Lord Lansley, is not here any more, but in a sense, we are seeing a transformation from what he hoped would be a GP-led system through clinical commissioning groups to one which looks very strongly acute care-led in the integrated care boards. As someone who was spent quite a lot of my time in the health service around acute trusts, I do not particularly worry about acute trusts being listened to, because we depend on them so much. We really need assurance that integrated care boards will take primary care seriously.

Finally, whatever concerns and reservations we on this side of the House had about clinical commissioning groups, some GPs undoubtedly rose to the challenge of leadership within them. I should be very concerned if they were lost from the new arrangements. It would be good to know that the Government recognise that and will ensure that a place is found for them in the new system.

[Baroness Whitaker (Lab)]

My Lords, I rise to support Amendments 30 and 34. On Amendment 30, I echo the widespread concern of the professional bodies and expressed by the noble Baroness, Lady Finlay, that rehabilitation should be a core service in the NHS. It is inseparable from healing, and healing is often impaired if rehabilitation is not there.

On Amendment 34, it will be important to know whether the proposed integrated health boards will be in contact with services outside the NHS where health can be a critical factor, such as education and criminal justice. As we said in Committee, many speech and language professionals are not NHS employees. How will they be brought into the integrated system?

Health and Care Bill

Lord Hunt of Kings Heath Excerpts

Lords Hansard - Part 1 & Report stage
Tuesday 1st March 2022 Lords Chamber

I end with a plea to my noble friend that the Government, MHRA, NICE and NHSE all work closely together, not just among themselves but with the industry and with all patient organisations and clinicians, to make swifter regulatory approval a reality, in keeping with the ambitious government life sciences vision, which I support.

[Lord Hunt of Kings Heath (Lab)]

My Lords, as this is my first contribution on Report, I declare my interests as a member of the GMC board and president of GS1, the British Fluoridation Society, the HCA and HCSA.

I welcome what the Minister said about research and its importance, and some of the tensions between practical work as a clinician and the crucial importance of clinicians engaged in research. The amendments that he introduced are very welcome, but like the noble Baroness, Lady McIntosh, I am disappointed that he has not brought similar amendments forward in relation to NICE. One suspects that it is something to do with money; he thinks that giving away amendments on research is cost-free, whereas there might be a resource implication when it comes to NICE. That is a pity.

The noble Baroness has talked about a postcode lottery in this country on the outcome of NICE judgments, but we also have a European postcode lottery. The fact is that NHS patients have much less access to modern new medicines and devices than those in many other countries. Stats that I have seen on medicines suggest that, for every hundred European patients who can access new medicines in the first year they are available, just 15 UK patients have the same access. We know that even when NICE has given its blessing to new medicines and treatments, take-up in the NHS still lags behind that in other countries.

I think that the noble Baroness, Lady McIntosh, and I were somewhat puzzled by the ministerial response in Committee in this area. We know that the NHS uses all sorts of rationing devices to prevent those new medicines and devices being allocated generally throughout the NHS, notwithstanding what NICE has to say—that is why I support the noble Baroness’s amendments. Essentially, my two amendments seek to build on the principles that she has referred to.

Amendment 171 relates to three issues which I think remain from Committee. The first relates to the links between licensing and reimbursement processes. Happily, the MHRA has established two new licensing pathways, ILAP— the Innovative Licensing and Access Pathway—and Project Orbis, for cancer medicines. This is very welcome; it is designed to speed up access.

However, the challenge with faster licensing decisions is that NHS reimbursement decisions need to speed up too, otherwise medicines can be placed on the market but cannot be made available to patients on the NHS. To its credit, the MHRA has designed this into ILAP, because NICE is directly involved in ILAP, and licensing and reimbursement decisions can be joined up. However, in respect of Project Orbis, there has been no such effort. Late last year, breast cancer patients faced the worrying situation where a drug, Trodelvy, which offered them hope, was licensed through Orbis but was not then available on the NHS. My amendment would therefore ensure that NICE acted to issue guidance on Project Orbis medicines as close to licensing as possible, as it does for ILAP.

Secondly, the amendment would clarify that NICE alone is responsible for determining its methods, as an independent body should be. In its recent methods and processes review, it concluded that

“there is an evidence-based case for changing the reference-case discount rate to 1.5% for costs and health effects. However, because of the wider policy and fiscal implications and interdependencies that are beyond the reach of this review, no change to the reference-case discount rate”

could be made. It further stated:

“Reducing the discount rate will make most technologies appear to be more cost effective.”


We are therefore in a situation where NICE wants to make a change to its methods, which would result in more medicines being made available to patients but is being stopped from doing so. That is not acceptable. NICE should be free to determine its methods, including the discount rate.

The final effect of the amendment would be to clarify the role that the current voluntary scheme, VPAS, and the statutory scheme play in reimbursement decisions. These schemes essentially cap the NHS’s expenditure on drugs, meaning the exposure of the taxpayer to spending on drugs is limited. The problem is that the health service then adds a whole host of other mechanisms to restrict access to medicines as well. My own view is that once we have VPAS and the statutory scheme in place, we do not need those other mechanisms.

Amendment 178 builds on this. I have already referred to the Project Orbis scheme. It has great potential, but unfortunately, as Gilead has pointed out, there is a lack of alignment across the system between government, the MHRA, NICE and NHS England, which has an impact on timelines for approval. This is particularly concerning in light of moves by other countries such as France to legislate to enable early access to innovative therapies prior to a cost-effectiveness assessment, with any difference in the final agreed price rebated by the company. We need an integrated access and funding pathway for medicines licensed by Orbis, prior to NICE approval, modelled on the French system, whereby companies rebate any difference in price following the decision by NICE.

The final point I will make is that we also need to deal with NICE capacity issues. In January 2022, NICE highlighted in its board papers that approximately 20 evaluations were paused in 2021-22 due to capacity constraints because of vacancies. This is despite increased industry fees paid for health technology assessments. While NICE’s vacancy rate has reduced, the same board papers note that:

“Organisational capacity continues to be the key risk for NICE ... strategy, and gaps in hard to fill specialist roles in a competitive global market.”


I would like the Minister to respond to this.

More generally, I hope that the Minister can give us some assurance that he and other Ministers recognise that all these initiatives to speed up access, excellent though they are, will come to very little unless they can sort out the NHS side of things and get rid of some of these rationing mechanisms which have been put in place.

[Lord Sharkey (LD)]

My Lords, like the noble Lords, Lord Patel and Lord Kakkar, I have added my name to the government amendments in this group. These amendments directly address the criticisms which we made in Committee that, as things stood, a duty to promote research lacked any real force. Since we made these criticisms, we have met with the Minister and his officials to try to strengthen this research duty and make it more meaningful and concrete. These amendments, and the others in the next group, are the result of our discussions.

The Minister has explained, and given some examples, how they would help. The importance lies on what new things the amendments put in place. They require the NHS to explain, in its business plans and annual report, how it proposes to discharge, or has discharged, its research obligations. They also require a performance assessment of ICBs, which includes how well they have discharged their research duty and their duty to facilitate and promote the use of evidence in research. I thank the Minister and his team for their extensive engagement on the question of research in the NHS. I am pleased that we have strengthened the research duties of the Secretary of State and the ICBs. I am particularly pleased that progress will now be formally reported and assessed.

I should also mention that, in his letter of yesterday, the Minister listed a number of non-legislative measures either being taken or developed for facilitating or fostering a culture of research within the NHS, and for holding to account the people responsible for delivering this.

Finally, the noble Lord, Lord Patel, has asked me to say how sorry he is that he cannot be here today. He wanted the House to know that he supports the Government’s research amendments and is grateful for their co-operation in generating more research in the NHS. As the noble Lord, Lord Kakkar, has said, he is at home recovering from Covid, and I am sure that the House wishes him a speedy recovery.

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[Baroness Whitaker (Lab)]

My Lords, as well as supporting Amendments 9 and 12 and the rest of the group, I would like briefly to add my support for Amendment 31 in my capacity as patron of the British Stammering Association. This amendment is very much welcomed by the Royal College of Speech and Language Therapists, for all the reasons that we set out in Committee. It would do much to improve the expertise available for these damaging difficulties with the basic human need to communicate and the capacity to swallow, so I hope the Government adopt it—I am sure they will, because it is a government amendment. I am very grateful.

[Lord Hunt of Kings Heath (Lab)]

My Lords, before the noble Baroness, Lady Walmsley, speaks, I congratulate her and the Minister on Amendment 31. I also want to ask a question. It very much looks as if the integrated care board is marking its own homework, because the duty to keep the experience of members under review is placed on an integrated care board. It is then for the integrated care board itself to make a judgment as to whether it

“lacks the necessary skills, knowledge and experience”.

Quite clearly, any board that has already appointed a group of members is almost certain, in undertaking its review, to come to the conclusion that it was altogether wise in appointing the members with the balance it did. Who is going to monitor this? Who is going to check?

What if you are a local nursing body concerned that nursing issues are not being debated and reflected enough within an integrated care board? What do you do? Who do you go to? As far as I can see, apart from judicial review proceedings there is absolutely no way you can get any change. That is why—and I pay tribute to the noble Baroness, Lady Walmsley, for her work on this—you need amendments like my noble friend Lord Bradley’s to make some specification in relation to those critical areas where it is essential that the board has members with the relevant experience.

My second point for the Minister is this. In introducing her Amendment 9, my noble friend Lady Thornton essentially said that the Bill already lays out constraints on integrated care boards in relation to potential conflicts of interest. All she seeks to do is to extend that to sub-committees of the integrated care board, including place-based committees, which will commission a huge amount of health service provision in future. For the life of me, I cannot see how those sub-committees can be constituted under any different principle from that of the integrated care board itself. Unless the Minister really comes up with a convincing answer on this, I think the House should make its views clear.

[Baroness Harding of Winscombe (Con)]

My Lords, as this is my first contribution on Report, I begin by declaring my interest as the recently stepped-down chair of NHS Improvement and NHS Test and Trace.

I commend the noble Baroness, Lady Walmsley, and my noble friend the Minister and support Amendment 31. In Committee, we debated in considerable detail the constituent elements of the ICBs. I think it hugely important that integrated care boards have a loud, strong, forceful voice for mental health, public health and prevention in all its forms, but I also think it really important that we enable a board to be a proper board.

The noble Lord, Lord Hunt, questions whether a board would ever assess its own competence and members. Any really good, functioning board in the public and private sector views that as one of its primary obligations. The first line of defence to ensure that a board is performing well is whether it is actually doing an assessment every year of whether it has the appropriate skills. Yes, you should have second and third-line assessments through the CQC and NHS England, but it is the role of a board, and we should let them do that. I believe that Amendment 31 holds these boards to account to do that.

The amendments we have already debated today, enshrining the obligations around public health, health inequalities and mental health, ensure that that is the clear objective of those integrated care boards. I encourage my noble friend the Minister to hold firm and support his amendments and not the others.

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[Lord Kamall (Con)]

My Lords, despite what the noble Baroness, Lady Thornton, said at the beginning about this perhaps being the end of the harmonious start to our debates so far, I feel that this has been a helpful and constructive debate. I am grateful to noble Lords for bringing these issues before the House.

Let me start with Amendment 9, as I understand the wide interest in the membership of the committees of the board and potential conflicts of interest. We firmly agree that conflicts of interest must be handled carefully, and have included multiple references to that in the Bill. We also recognise the concern that ICBs should not allow private providers to control commissioning decisions, which is why we added the amendment relating to private providers in the other place, in paragraph 4 of Schedule 2.

Furthermore, in the helpful discussions we have had with noble Lords since then, there has been mutual recognition that we need to balance the importance of protecting the core values and public nature of the NHS while not overly restricting the membership of ICBs. I am pleased that the amendment to Schedule 2 balances on that tightrope and gives appropriate reassurance. We think that it is reasonable to allow private providers and social enterprises to sit on some committees and sub-committees of the ICB, as barring them risks blocking sensible integration and joint working.

I am also aware of the mixed reactions to this amendment from stakeholders. Many noble Lords will have seen the NHS Providers Report stage briefing, which states that

“there could be circumstances where a local private or voluntary sector provider would be well placed to join a joint committee with a focus on integrated service delivery whereby the usual arrangements to identify and manage conflicts of interest would, and should, apply.”

It goes on to say:

“It does not seem reasonable … therefore to further restrict the membership of those committees in a way which is prescriptive in law.”


Further, the NHS Confederation stated in its Report stage briefing that this amendment

“risks critically undermining integration by reinforcing a rigid, out-dated purchaser-provider split and derailing the fundamental purpose of these reforms.”

As it so eloquently put it:

“The current reforms aim to facilitate collaborative working by bringing all partners in local areas around the table to plan the most effective and the most efficient way to deliver care. This, by its nature, involves bringing providers of services, alongside commissioners, into committees and sub-committees of the ICB to plan how care is delivered”.


Potential conflicts of interest are inevitable in commissioning, especially when we are looking to increase integration and bring multiple bodies together. The ICBs will be required to manage conflicts of interest as part of their day-to-day activities. That is set out in the Bill and will be part of their constitution as well.

For all committees, the board of the ICB will have to determine what functions they exercise, their membership, and the level of oversight of their decisions. The board of the ICB cannot delegate a function and claim to be no longer responsible for how it is discharged, and will be held to account for this by NHS England.

Also, ICBs will be clear and transparent about interests, and how they are being managed. We think that transparency will prevent poor decision-making. New Section 14Z30 makes it clear that an ICB must maintain and give public access to a register of interests for members of its committees or sub-committees. There must be arrangements in place to ensure that conflicts are managed not just for ICB members but within committees. The constitution of the ICB must also include the arrangements to be made to discharge the functions under new Section 14Z30 and a statement of principles to be followed by the board in this regard. This will all be supported by guidance from NHS England. We are quite determined to tackle conflicts head on and not shy away from this issue.

[Lord Hunt of Kings Heath (Lab)]

My Lords, if NHS England is determined to tackle conflicts of interest head on, why is it building them into the whole structure of integrated care boards? Let us think about an integrated care board discussing future strategy: it would inevitably discuss where the priorities will be. That inevitably means that money will follow the priorities. At what point in those discussions do the major providers, who will be sitting round the table, have to withdraw from because of a conflict of interest? At heart, this ambiguity is built in, so it is not surprising that my noble friend wants to see consistency right through the system, including the sub-committees.

[Lord Kamall (Con)]

I thank the noble Lord for that intervention because I was just about to come to it. I should add that new Section 14Z30 very clearly requires ICBs to manage conflicts of interest at sub-committee level.

We think that the approach we have outlined will be more appropriate and possibly more effective than simply barring individuals with a conflict of interest—which, I encourage noble Lords to note, would also include NHS Providers and local authorities— from all committees with a commissioning function. First, this approach is broader than what the noble Baronesses might have intended. Secondly, many committees will have a range of functions, and commissioning may be only a small part of their activity. This approach risks creating a series of duplicated committees with similar interests to enable commissioning decisions to be taken in line with the amendment. This risks undermining one of the very purposes of this reform: to reduce bureaucracy and increase integration.

On Amendment 10A, we are clear that chief executive pay should be value for money. The pay framework is based on our ability to attract the highest-quality candidates. ICB roles, such as the chief executive, are some of the more complex in the health system. Experienced chief executives of trusts already exceed the suggested £150,000 per annum remuneration. Therefore, we do not believe it would be realistic to expect them to take a pay cut to take up a role with such a portfolio.

I remind noble Lords that putting the salary of an ICB chief executive into the Bill would be inappropriate. Such a lack of flexibility would be extremely unusual for a senior position and risks salaries declining in value over time, precisely as ICBs take on more responsibility as they become more established. This would fundamentally weaken ICBs’ ability to recruit and retain senior management. I also warn that directly tying pay to performance is likely to make it significantly harder to recruit chief executives to more challenging ICBs—precisely the organisations that we would want to recruit the very best leaders.

I hope I can reassure noble Lords that the recruitment process will ensure that only the most qualified people can take up these roles. All ICB chief executive appointees across England need to demonstrate how they meet—

Covid-19: Lateral Flow Tests

Lord Hunt of Kings Heath Excerpts

Thursday 10th February 2022 Lords Chamber

[Lord Kamall (Con)]

I must say to my noble friend that I was not aware of that, and therefore I will have to go back to the department. If he could write to me about that, I will be happy to respond.

[Lord Hunt of Kings Heath (Lab)]

My Lords, can the Minister say how many British companies are caught in this and waiting for approval? Can he also say how many billions of pounds we have spent importing these tests from China?

[Lord Kamall (Con)]

I will try my best to answer the questions, but if I do not, I hope the noble Lord will accept a written response. Some 25% of approved devices are from UK manufacturers, but it is important, as a fair and neutral regulator of market access that all applicants are treated equally. The Government are working to review applications for devices submitted by the process. At the same time, while we want to make sure that the British tests are of the highest standard, we are determined to harness the power of the UK’s leading diagnostic industry. We will continue to be enormously engaged with UK manufacturers and trade bodies to support a thriving domestic diagnostic industry.

Health and Care Bill

Lord Hunt of Kings Heath Excerpts

Lords Hansard - Part 1 & Committee stage
Wednesday 9th February 2022 Lords Chamber

I thank the noble Baronesses, Lady Cumberlege and Lady Smith of Newnham, for supporting this amendment, and I hope the Minister will consider it favourably. If not, I reserve the right to bring it back. I beg to move.

[Lord Hunt of Kings Heath (Lab)]

My Lords, in speaking to my Amendment 297D, I thank the noble Baronesses, Lady Masham and Lady Brinton, for their support. However, I also express my general support to the noble Baroness, Lady Greengross, the noble Lord, Lord Howarth, and the noble Baroness, Lady Hodgson, for their amendments. The common theme of this collection of amendments is the question of how we support vulnerable people.

My amendment is about the experience of many of us who have seen the harm caused to our loved ones in care homes during Covid when visits were not allowed for so long. Even now, it can be difficult to visit in some homes because of the Covid restrictions that continue or where a member of staff or visitor has Covid and then 14-day long impositions are imposed. It is a bit rich when one hears in the media that all restrictions are being lifted, because for many of us, in practice those restrictions have not been lifted at all.

The Joint Committee on Human Rights in its report on care home blanket bans and other excessive restrictions recommended that regulations for care and treatment should include a requirement to ensure face-to-face contact wherever possible between residents and the people most significant to them. I do not underestimate the difficulties faced by care homes in the past two years. They have faced huge challenges. My personal experience is that many of them have risen to the challenge and provide high-quality care. But even before the pandemic, serious concerns were growing about the use of care home visitor bans to punish relatives for complaining about standards of care. Indeed, as far back as 2016, the “Victoria Derbyshire” programme reported that hundreds of care homes were guilty of this method of what it described as institutional abuse. In 2019, the Relatives & Residents Association was coming across at least one case per week and warned the problem was increasing.

One woman found her mother dressed in other people’s clothes, left in her own urine and with her hair unwashed for weeks. The Local Government and Social Care Ombudsman upheld the daughter’s complaint, reporting that after raising her concerns with the care home, she and a doctor were prevented from seeing her mother when they tried to visit. The care home later told the ombudsman the ban was because of a previous incident reported to the police of the daughter and her partner’s behaviour, but could not provide any evidence that an incident had occurred or was reported to the police.

As visiting restrictions are, hopefully, going to be relaxed in the weeks ahead, I am afraid we have the prospect of seeing more residents’ families being victimised in this way. Helen Wildbore, director of the Relatives & Residents Association, has found from its helpline calls that relatives and friends play a vital role in spotting potential human rights violations, particularly around abuse and neglect. When they are locked out by bans, people in care lose crucial support: their advocate and confidante—they might be the only person they tell about their concerns. Sometimes residents are even threatened with eviction or actually evicted in reprisal for complaints about their care. The Joint Committee on Human Rights was told about a family whose mother was threatened with eviction after they merely asked to discuss concerns with the head office of a care home.

These are the kinds of abuses my amendment seeks to tackle and get over the problem that regulations are not sufficient. These regulations may specify the standards of care against which care providers are regulated by the CQC through its inspection process, but the CQC is not going to pick up individual complaints, so there is a gap. There is a strong case for a statutory duty of care sitting alongside CQC regulations to require care providers to facilitate such contact with families as is reasonably practical and to prohibit evictions where non-vexatious and non-repetitive complaints are in progress. In my amendment, I am not proposing that. All I am asking for is a review; an independent review charged with examining these options. I hope that the Government will agree that there needs to be some reflection on what has happened and how we can prevent this kind of abuse in the future.

[Baroness Cumberlege (Con)]

My Lords, I should like to speak to the amendment proposed by my noble friend Lady Hodgson.

From the age of five, I was a child of general practice; it was my world. I accompanied my father on home visits, patients came to our house and the telephone rang constantly—my mother was the secretary and took all calls. My father loved his patients and they loved him. He knew them inside and out, and their families as well. He attended road traffic accidents, of which I have to say there were plenty, and he delivered babies at home—he never lost one. I remember him telling me one day when he came back from a birth that it had been a very difficult birth, but the mother praised my father for having helped her to produce a very healthy little boy. “Doctor”, she said, “we will call the baby after you. What is your name?” My father replied, “Lambert”. “Right”, said the father, “we will call our son Tom.” I mention this only because maternity has been the love of my life, and in this area relationships are critical to a safe and good experience. In my youth, maternity was part of general practice.

After being appointed much more recently to chair the maternity review for England by Simon Stevens—as he was then; now, of course. the noble Lord, Lord Stevens of Birmingham—I was determined to introduce relationship care, sometimes called “continuity of carer”, where the final “R” stands for relationship. We have much respected and credible research from the Cochrane Collaboration in Oxford which shows that women who receive relationship care are less likely to have a preterm birth, less likely to lose their baby before 24 weeks and less likely to lose their baby overall.

We now have in the NHS 371 relationship teams with 2,355 midwives in place where the midwife provides all three elements of midwifery care: prenatal, birth and postnatal care, which is sometimes called follow-up care. In the James Paget Hospital, 90% of maternity care is provided through continuity and it has a waiting list for midwives to join the hospital. Through this initiative, we are transforming maternity care. The women and their families value hugely the relationship with their known midwife, and the midwives who are providing this care absolutely know that what they are doing is the right way to work. They would leave their hospital and go to one that provided such care if their hospital gave it up.

Listening to my noble friend Lady Hodgson, is not this what she seeks for general medical practice? Her amendment is well drafted and reflects an interesting report produced by the Royal College of General Practitioners, entitled The Power of Relationships: What is Relationship-based Care and Why is it Important? and published in June last year. In his foreword, Professor Martin Marshall, chair of the college, writes:

“COVID-19 has radically changed the face of general practice. We have moved from a predominantly face-to-face service to one in which most consultations are delivered remotely, either by telephone or video call … Remote consultations are certainly here to stay. For many patients, they enable quicker and more convenient access to a GP appointment, which of course is hugely important.”


But then he asks the following questions:

“But should speed and ease of access be our primary measures of effectiveness? They are certainly easier to quantify. But what about the quality of care? What about the relationship between doctor and patients which, to me, is the essence of general practice?”


He goes on to say that

“The evidence for the benefits of a trusting relationship is compelling—better patient experience; better adherence to medical advice, fewer prescriptions, better health outcomes, better job satisfaction for doctors and even fewer deaths.”


Indeed, he says that the relationship between the patient and their GP is as important as the scalpel is to a surgeon:

“If relationships were a drug, NICE would mandate their use.”

Elective Care Recovery

Lord Hunt of Kings Heath Excerpts

Monday 7th February 2022 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, will the plan contain workforce assumptions? In particular, what will it say about the retention of current staff, the recruitment of more staff and more training places?

[Lord Kamall (Con)]

The noble Lord rightly raises the issue of our brilliant workforce, who are at the heart of our plans for recovering services. The NHS’s delivery plans are focused on how we can transform these services and do things differently, not just asking staff to do more of the same. The monthly workforce statistics for November 2021 show that a record number of staff are working in the NHS, with over 1.2 million full-time-equivalent staff, which is over 1.3 million in headcount. This includes record numbers of doctors and nurses. In addition, we are recruiting new staff and focusing on different recruitment programmes and on retention, which many noble Lords have raised. We want to make sure that the excellent staff in our health system are happy and kept happy.

Health and Care Bill

Lord Hunt of Kings Heath Excerpts

Lords Hansard - Part 1 & Committee stage
Monday 31st January 2022 Lords Chamber

[Baroness Hodgson of Abinger (Con)]

My Lords, I support this amendment, so ably moved by my noble friend Lord Blencathra and supported by the noble Baroness, Lady Kennedy, and the noble Lord, Lord Alton. Noble Lords have already heard the well-versed and evidenced arguments put forward and, while the amendment does not specifically refer to China, there can be no doubt that the well-documented example of the horrific treatment of the Uighur people in Xinjiang province would fall under its scope.

We have all heard today about the hundreds of millions of pounds-worth of healthcare goods that have flooded into this country since the start of the pandemic, much of it sourced from China. We would expect our Government to make every effort to disentangle our supply chains from implication in these atrocities, so was any due diligence carried out throughout our procurement process? This amendment would correct that oversight if it was not.

I do not want to repeat everything that has already been said by others, but I want to highlight the importance of the risk-assessment aspect in proposed new subsection (3). I anticipate that the Minister will highlight the work already being done by government departments to weed out companies with slave labour in their supply chains. Perhaps sometimes they are being asked to perform an impossible task, because I understand that supply chains in the Uighur region of China are almost entirely opaque. It is suggested that the area is rife with systematic forced labour, that audits there are worthless and that workers live in fear and terror of telling the truth. Indeed, as we have already heard, the US Government have just passed legislation presuming that all imports from the region are tainted unless proven otherwise.

Surely, it is our responsibility, as a signatory to the genocide convention, to do all that we can to prevent genocide when there is a serious risk of it taking place. This amendment builds on the work that we have already done in this regard. We cannot continue business as usual with China or any other state that condones or supports genocide. I ask the Government to act urgently to ensure that our supply chains are not tainted by goods made with Uyghur forced labour. I ask Members on all sides of your Lordships’ House to join us and reassert our commitment to global human rights and to provide the protection against genocide, wherever it is needed, by supporting this amendment.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I too support the amendment of the noble Lord, Lord Blencathra. As we are really talking about procurement in the NHS, I should declare my interest as president of the Health Care Supply Association.

It is entirely reasonable to use NHS procurement rules in this way. The noble Earl knows that Clause 70 is intended to give wide discretion to Ministers to bring in a new procurement regime. I see no reason why this cannot be part of that regime.

I sometimes think the NHS operates in isolation from what is happening in the world, but it cannot operate in isolation from the terrible things that the noble Lord, Lord Blencathra, and other noble Lords have spoken about. I hope the noble Earl will be sympathetic.

--- Later in debate ---

Moved by

[Lord Hunt of Kings Heath]

224: After Clause 80, insert the following new Clause—
“Access to NHS dentistry
The Secretary of State must, within one year of the passing of this Act, publish a statement setting out what measures the Government is taking to ensure universal access to NHS dentistry.” Member’s explanatory statement
This new Clause would require the Secretary of State to publish a statement of what measures the Government is taking to ensure universal access to NHS dentistry.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I hope that I do not slow us down again after the provocative words of the noble Baroness, Lady Chisholm, but I am going to talk about access to dental treatment and fluoridation. Although the House is somewhat empty, I expect that as the debate goes on it might fill up a little.

We had an Oral Question this afternoon about dentistry, and I do not want to repeat everything that was said then. I have enjoyed debating dental issues with the Minister, the noble Earl, Lord Howe, for many years. He will know that there is widespread concern about the lack of access to dentistry. At Oral Questions the Minister, the noble Lord, Lord Kamall, referred to the £50 million that had been provided, but I am afraid that the 350,000 treatments that it will pay for are a drop in the ocean compared with the 38 million patient treatments that have been lost as a result of the pandemic.

Many people are finding accessing dentistry almost impossible at the moment. The Minister referred earlier today to people being able to use the access centres, and to the 111 service, but I am afraid that it has broken down in many parts of the country. One is led to the conclusion that dentistry issues are not a priority. Many adults and children are suffering in pain because of their lack of access. The Government must focus on this and develop a proper strategy. I pay tribute to Healthwatch for its work in this area—it has had a lot of interest from members of the public—and to the BDA for its briefings.

Treatment is one thing, prevention is another. Here, I must remind the Committee of my presidency of the British Fluoridation Society. This brings me to effective preventive measures. I welcome Clauses 147 and 148. Unfortunately, the noble Lord, Lord Scriven, is not here to hear me say this, but essentially, giving this responsibility to local authorities has proved to be a failure. Not one local fluoridation scheme has gone through under the auspices of local authority leadership, and we must conclude that leaving it to local authorities is likely to mean that we will not see fluoridation developed in any part of the country.

So this is a national issue and it is right that the Secretary State should take over responsibility; it is also right to acknowledge that, in September last year, the four Chief Medical Officers stated:

“As with all things in medicine and public health there is a balance of risk and benefit.”


We have certainly learned that in the last two years. As they said:

“There is unquestionably an issue with tooth decay in the UK and an entrenched inequality which needs to be addressed. Fluoridation of water can reduce this common problem … On balance, there is strong scientific evidence that water fluoridation is an effective public health intervention for reducing the prevalence of tooth decay and improving dental health equality across the UK. It should be seen as a complementary strategy, not a substitute for other effective methods of increasing fluoride use.”


I think that is a very wise assessment of the situation. The effectiveness of fluoridation of water supplies to improve oral health has been evident for many decades. Some communities such as my own—Birmingham—have taken advantage and, as a result, we generally enjoy good overall oral health, but progress in spreading these benefits has been very slow. The transfer to local government, I am afraid, did not work.

So I strongly support the thrust of these clauses; in fact, they are the two most welcome clauses in the whole Bill. The question, however, is whether they will bite, and this is what lies behind my amendments. Amendment 260 concerns the consultation process. I do not think I have got the wording in quite the right place—frankly, trying to find my way through the Water Act and changes to it over the last 20 years or so proved beyond me—but the intent is to ask: if there is to be consultation about schemes, please can we move away from the local consultations that have to be gone through at the moment? They are an absolute nightmare. They bring out opposition from national bodies that causes mayhem in the locality.

The issue is not the practicalities of the scheme but about going back over the principle. The very fact that the Government have brought these clauses has decided the principle of the benefit of fluoridation. If there is to be a consultation, for goodness’ sake, let us have just one instead of the myriad local consultations that have obviously got in the way of progress in the past.

My Amendment 261 is part probing. Currently, the Bill gives the Secretary State power to make regulations to require a public body to meet the costs to the Secretary of State in relation to fluoridation schemes. I would be interested to hear from the Minister the reasons and circumstances under which they would be used. My concern would be that asking too hard a subvention of local bodies might inhibit the progress of fluoridation schemes. Amendment 262 requires the Secretary of State to ensure that a programme for implementing water fluoridation schemes is established within 12 months of the Bill being passed. I would like to see a report every three years, laid before Parliament by the Secretary of State, on the progress made in implementing new water fluoridation schemes. The basic purpose would be to ensure that the Government get on with this, establishing more schemes and spreading the benefits across the entire community as soon as possible. I beg to move, and hope that I have met the noble Baroness’s test.

[Baroness Northover (LD)]

My Lords, I will speak in support of Amendments 260, 261 and 262 in the name of the noble Lord, Lord Hunt, on water fluoridation.

The NHS rightly prides itself on being evidence-based. Nevertheless, when Ara Darzi became health Minister, he was concerned that, in a number of areas such as the treatment of diabetes, there was not a full assessment of regular outcomes, as opposed to the fantastic clinical trials on new treatments for specific diseases. Hence, he introduced his atlas of outcomes. It showed, for example, absolutely unacceptable different outcomes for diabetes if you lived in Cornwall—where you were more likely to lose a leg—compared with Essex. There were serious lessons to be drawn from that, which needed to be applied in other areas, too.

NHS Dentistry

Lord Hunt of Kings Heath Excerpts

Monday 31st January 2022 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government, further to Healthwatch England’s report What people have told us about NHS dentistry, published on 20 December 2021, what steps they are taking to address the issues faced by those attempting to access NHS dental care.

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

Practices are currently prioritising patients based on clinical need, and a new activity threshold has been set at 85% to safely increase access. A one-off additional £50 million, recently secured for NHS dental services this financial year, will urgently give more people, including children and others who are vulnerable, access to vital dental care. We are working with the NHS, Health Education England and the British Dental Association to improve access through dental system reform.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the £50 million one-off payment for 350,000 appointments is a drop in the ocean compared to the 38 million appointments that have been lost during Covid. The Healthwatch report shows that parents are having great difficulty accessing NHS dentistry for their children, who may be suffering pain and unable to eat, and we know about adults who are indulging in self-care because they cannot find an NHS dentist. When will the Government get to grips with this problem and develop a proper strategy for dealing with it?

[Lord Kamall (Con)]

As the noble Lord will know, anyone can have access to an NHS dentist—they do not have to be registered with the practice in question—and when they are unable to find a practice, they can ring 111 to get information. In addition, over 700 urgent dental care centres remain open across the country.

Health and Care Bill

Lord Hunt of Kings Heath Excerpts

Lords Hansard - Part 2 & Committee stage
Monday 31st January 2022 Lords Chamber

[Earl Howe (Con)]

I apologise to the noble Baroness, because she was making a significant point. I am not sure that I share her perception that those who buy bottled water in supermarkets necessarily do so as a reflection of their lack of trust in tap water; a lot of it has to do with some myths around the benefits of bottled water. However, be that as it may, I will take advice and write to the noble Baroness. I am not sufficiently sighted on the issue she raised and the evidence behind it, so it is probably appropriate if I look into it and write to her.

[Lord Hunt of Kings Heath (Lab)]

My Lords, this has been a very interesting debate. On dental access, a number of noble Lords—my noble friend, the noble Baroness, Lady Bennett, the noble Lord, Lord Storey, and the noble Baroness, Lady Walmsley, among others—commented on the great difficulty that many people have at the moment in getting access to an NHS dentist. The noble Lord, Lord Storey, focused in particular on children, which is my particular concern. More energy needs to be put into developing a dental strategy. On thoughts of contracts, anyone who has been a dental Minister will know that the problem with contracts is that dentists always overperform, and the Treasury then claws back in future years, leading to unhappiness and misery in the profession. The fact that the pilot schemes, on which I think work is being based for a future contract, have now stopped, or are going to be stopped, is a great pity, and it does not show positive intent.

On fluoridation, I was delighted that the noble Lord, Lord Young, intervened. A couple of debates ago I was watching on the screen, and he chided me for what I thought was a perfectly formed piece of legislation at the time, many years ago. He talked about his experience as a Minister 42 years ago. I think it was because of his work that I, 37 years ago, as secretary of the Edgware/Hendon Community Health Council, organised public meetings in part of the Borough of Barnet on fluoridation, prior, we hoped, to the then area health authority implementing a fluoridation scheme. Although the public meetings came out strongly in favour of fluoridation, of course nothing happened. I am afraid that the experience in Barnet and Edgware and Hendon was repeated up and down the country, which is why I applaud the Government for doing what they are doing now.

The noble Baroness, Lady Northover, spoke very eloquently about the evidence from deprived areas. Sandwell, next door to Birmingham, is high up in most indicators of poor health, except in dentistry. That is because, unlike Liverpool, Birmingham City Council took the decision in the 1960s to fluoridate the water supply and Sandwell got the benefit. The result is that, in general, oral health in the West Midlands is very good indeed.

I listened with great interest to the noble Lord, Lord Reay. He mentioned the Jauncey judgment, which unfortunately I remember. I remind him that, although Lord Jauncey ruled that Strathclyde Regional Council was exceeding its powers in seeking to fluoridate the water system, he accepted that the amount of fluoride it wanted to put into the system would have no significant adverse effect on health, that fluoridation had been shown to be harmless and that it would be effective. When we quote Lord Jauncey, we need to quote the whole judgment, rather than just whether Strathclyde was found to have the power to put fluoride in the water.

I will not repeat what the noble Earl, Lord Howe, said. In only September, the Chief Medical Officers spoke in their judgment about the effectiveness and safety of fluoride. I was very glad to hear the point the noble Earl made about expansion; I am very glad that it is on the Government’s mind. I look forward to the consultation, which I take will be a national one, if there is going to be an expansion; that is very good news indeed.

On cost sharing, I register that this Bill is full of little clauses which give Ministers powers to do something in the future, when they know what they want to do. I mention procurement regulations in Clause 70 at the same time; I think that is going a bit too far. Having said that, I beg leave to withdraw my amendment.

Amendment 224 withdrawn.

--- Later in debate ---

I hope this House gives serious consideration to this amendment. The stories in the Times about considering further NHS reforms are disturbing and have serious implications for this Bill on Report. They should give the House pause for thought in giving the Secretary of State the powers of direction being sought. If another NHS reform is being cooked up in Victoria Street, it raises the question of why Parliament is labouring so long on this Bill.

[Lord Hunt of Kings Heath (Lab)]

I shall say a few words in support of the noble Lord, Lord Warner; I put my name to his original Amendment 285 and, obviously, I very much endorse what he said. Reading the Select Committee report again, I find it as fresh as ever and its analysis of the issues faced in the NHS are exactly the pressures we see at the moment. Let us be clear: it was a hard analysis. We are all proud of the NHS, but the report rightly pointed out that it performs poorly in comparison with many countries on many indicators. In acute care, we have worse outcomes for survival for stroke and heart attacks, we lag behind comparable European countries for cancer survival, and we have fewer beds, fewer doctors and fewer nurses per head than OECD averages. As capacity is so tight, it is no wonder, given the current pressures post pandemic, that the NHS is struggling to meet the challenges it faces. We have talked about dental access, but we could talk about the horrendous waiting times for treatment or the dreadful ambulance waiting times which are frightening for people with very serious illnesses.

The Government’s approach is one initiative at a time on the whim of the Secretary of State at the time. We have already got the Messenger review which is bringing in a general to tell the NHS how to manage its services. How many times have we introduced people before? I think Secretary of State Hunt established the report by the noble Lord, Lord Rose. He clearly wanted Rose to say that NHS managers were useless. Of course, the noble Lord did not say that. He said that Ministers are useless at creating circumstances in which managers can thrive. Messenger will come out with the same response and his report will also be rejected because what these reports all say is that the way Ministers lead from the centre is non-conducive to the sensible management of the NHS at local level. Bringing some long-term planning to the NHS with the proposals that the noble Lord, Lord Warner, suggests seems to be eminently sensible. I hope this is one of the issues that we will take to Report because it is fundamental to the future.

I was a bit nonplussed because I was rising to support my noble friend Lady Thornton on her Amendment 281, but she is yet to speak to it. It is always good to see the noble Lord, Lord Lansley, in his place. When we debated the future of Public Health England in the 2011 Bill that led to the 2012 Act, we warned that placing PHE firmly within the department would lead to a complete misunderstanding among all of us about who was responsible for its performance. Lo and behold, we had the Covid crisis and that is what happened. Noble Lords will remember that at the beginning Ministers were briefing that PHE was hopeless and that they had lost confidence in it, and that led to the rushed announcement by the previous Secretary of State about the setting up of the UK Health Security Agency. No one knew, because Ministers kept quiet, that they were accountable for PHE and that PHE staff are officials. They are civil servants directly responsible to Ministers for their performance. The Joint Committee inquiry into Covid identified this. Yes, there were issues with Public Health England’s performance, but Ministers should take responsibility.

We risk repeating the problem with the UK security agency, because, again, it is being set up as an agency part of the department, under the control of Ministers. Once again, when trouble arises, we will see the same pattern of Ministers trying to escape their responsibilities for what is performed by this particular agency. The reason I support my noble friend is that I think she is absolutely right in seeking to place this agency on a more independent basis, so that it can be seen to account for what it does and we can avoid the ambiguity being built into the current situation.

[Lord Scriven (LD)]

My Lords, I also want to rise to support Amendment 285 in the name of the noble Lord, Lord Warner. I was very happy to put my name to that. As the noble Lord said, I was also a member of your Lordships’ Committee on the Long-term Sustainability of the NHS and Adult Social Care.

Noble Lords who have been following this set of Committee days will realise that this amendment goes to the heart of a lot of what we have been talking about, which is the conflict between short-termism and long-term planning. The Bill is about the integration of health and social care, improving health outcomes and reducing health inequalities. They are not short-term fixes; it is a long-term journey, which will mean long-term plans.

As an independent body, this body does not stop Ministers being able to control health policy. It sets out a framework of what is required in terms of staffing; what the issues will be in terms of disease profile; what will happen in terms of demand; and for seeing how successful the Government have been, not just in being able to give a press release about certain amounts of money going to a certain area but in whether the long-term benefits of that money are achieving better health outcomes, reducing health inequalities and getting the right staffing to the right places to get a better health and social care system for the people of England. That is what this body is about. I think that, of all the amendments we have discussed—I probably would say this, because my name is to it—this is one of the most important, because it deals with the conflict between the priorities of short-termism and long-term planning.

I also want to say, as the noble Lord, Lord Warner, did, that I was astounded, as a former health service manager, that no one in the Department for Health planned for long-term care in the healthcare system. We expected the answer that at least there was somebody in a darkened room doing it. But there was absolutely nobody doing it; it was all about the whim of the Minister. In reality, that was what came out.

I think this amendment actually helps with the central purpose of this Bill, of integrating healthcare, reducing health inequalities and improving health outcomes, because it is long-term. I think it is absolutely right that this House and the public understand how the Government are doing against independent reviews at five, 10 and 15 years. We will be able to see whether the right staff, the right money and the right focus on prevention versus dealing with the acute sector are actually happening, and whether Governments, of one or two or three colours, over a period of time, are improving the healthcare system the population and leading to better health outcomes.

I also support Amendment 281, which the noble Lord, Lord Hunt, has talked about. For me, public health has been kicked for too many years between different parts of the care and health system. In particular, when you have an executive agency whose primary responsibility is to plan and then co-ordinate public health—not just at government level, but within local government and across government—if it is not independent and is not a statutory body, yet again it just plays to the whim of Ministers. I will give an example of why it is not working in its present form, based on something that has just happened in the last few weeks.

Health and Care Bill

Lord Hunt of Kings Heath Excerpts

Lords Hansard - Part 3 & Committee stage
Wednesday 26th January 2022 Lords Chamber

[Lord Lansley (Con)]

My Lords, I shall be brief. I put my name to Clause 40 stand part, and I think that is the best way to go. I shall add one or two things. First, as Secretary of State, I asked the now noble Lord, Lord Ribeiro, to lead the independent reconfiguration panel, and I never had cause to regret doing so. Secondly, I can say something which other noble Lords cannot, because I am on this side, and I am hoping that we continue to have Conservative Secretaries of State for many years hence. They will be much better off if they do not do this. If the Government take Clause 40 out, they will equally not regret doing so.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I described at Second Reading, or at some point in a meeting with the Minister, an attempt to save Ministers from themselves. I do not understand why on earth the Government want to put this burden on them. The Government have set out an ambitious programme for reform of the NHS. Why put in a clause that guarantees that that reform will be stalled? We know that reconfigurations—most of us have experienced the issue locally, if not nationally—are very difficult. There is always local opposition, often from some leading consultants, and to get it through you have to be very determined. The noble Lord, Lord Warner is right; once Ministers can intervene at any point—for example, if an MP’s local services are threatened with an unpopular change—even in the Lords, the pressure on them to intervene can be huge.

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[Lord Lansley (Con)]

If anyone cares to look at it, it was also a very good illustration of the benefits of the Independent Reconfiguration Panel. Not only did it do something that Ministers could not do; it also did something that NHS management did not do. It is not that we are giving it back to the NHS to do what it likes—it genuinely does something independent.

[Lord Hunt of Kings Heath (Lab)]

Indeed, we have a rigorous process involving the overview and scrutiny committee, as has been said, plus an Independent Reconfiguration Panel. As the noble Lord, Lord Stevens, said, it is rather like the last debate: before us we have a set of amendments which seek to constrain the power of Ministers, and then an amendment which seeks to remove this power. I am clear that we should try to remove this power, and that this is the best course. It will be very interesting to hear from the Minister exactly why Ministers want to put this burden on them, and what benefit they can possibly see in it.

[Lord Warner (CB)]

My Lords, I want to briefly make clear my support for this group of amendments and try to be consistent with what I said on the previous group. The only amendment which causes me to have pause for thought is Amendment 183. The NHS, perfect in every form of course, has been known to have its arteries fur up occasionally. Sometimes there is a need for scale in some services. I want to mention three or four services where scale, after clinical consideration, is important. Pathology is a good example, where we need to have more scale than many of the local pathology departments. Another one, which the Royal College of Surgeons has advocated, is elective surgery hubs, which may mean taking stuff away from a particular local hospital. Another good example is the issue of stroke specialisation, which is beneficial for patients. I have given you three examples where we do not want to totally neutralise the Secretary of State. Sometimes Ministers have a use; it may be few and far between, but occasionally they have some use. We do not want to say that you cannot ever be a catalyst for change. That seems a bit drastic in Amendment 183, and I ask the noble Baroness, Lady Cumberlege, to think about that, because sometimes scale is important, with clinical advice for the benefit of patients.

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[Lord Kamall (Con)]

The Secretary of State will be advised by the Independent Reconfiguration Panel, especially where there is a difficult decision that takes time, just as in the case of the Medway.

On Amendment 182, the Secretary of State’s decision-making process must already take into account the public law decision-making principles, all relevant information and his legal duties, including the public sector equality duty. The Secretary of State is also under several duties in the National Health Service Act 2006, including to promote a comprehensive health service and to support continuous improvement in services.

[Lord Hunt of Kings Heath (Lab)]

There are a lot of marginal seats, and there is going to be a general election in two and a half years—maximum. A lot of the reconfiguration proposals usually relate to smaller places with smaller hospital or DGHs because their viability is often in doubt. So it is quite clear to me that any MP, particularly government MPs, will immediately take any threat of that sort to their local services to the Secretary of State. That will not speed up the process; it will guarantee the opposite. The signal that I would get from the health service as a result of this is: “Forget reconfiguration proposals until after the next election because you ain’t going to get any through.” That is why we think this is a disastrous move.

When the Minister says there will not be many interventions, that is just nonsense. The moment that MPs know the Secretary of State has the power to intervene at any stage, they will be knocking at the door of the Government, who will wilt under that pressure, because that is what happens. Then they will go back and say, “We need to have an independent review of that before you start the process.” There are so many dodges available to a Minister, if you want to dodge making a hard decision in this area, that it will completely paralyse the health service. That is why this debate is so important because it is related to the last one; the result of Ministers gaining direct control will be to delay and reverse, and I am afraid that the hopes that Ministers have for a dynamic, forward-looking health service will come to nothing.

[Lord Warner (CB)]

My Lords, following on from the noble Lord, Lord Hunt, I ask the Minister to consider the point that I was trying to make about Amendment 183. The Minister and the Government have got this the wrong way round: if he is actually concerned about levels of efficiency, the supply of services and the issue of scale—and the issue of scale is a very real one—then he needs to be at the front of the process, not the end of it. It is a bit late in the day to be having these ideas about scale in a particular set of services when you have gone through the agony of the local consideration of reconfigurations. As a Minister, it would be better, if I may say so, to set out your views at the beginning with the clinical arguments for why this makes sense. Doing it at the end is bound to lead to suspicions. That is why I was asking the noble Baroness, Lady Cumberlege, to look at the wording of Amendment 183. I say to the Minister that he is putting his involvement at the wrong part of the process.