Health Bill

Lord Mawson Excerpts

Committee stage
Wednesday 28th October 2026 Lords Chamber

[Baroness Gerada (CB)]

My Lords, one of the people who I have most admired over the years is the American paediatrician, Professor Don Berwick—some of your Lordships may know him—who is an international expert on healthcare and a great advocate of the NHS. In fact, he led the Mid Staffs review in 2013. In the States, he led Medicare and Medicaid under President Obama. It always struck me that Don Berwick wrote us a birthday card on the NHS’s 60th birthday. It was a long card and I urge your Lordships to read it one day. He offered a simple prescription for the NHS: “Stop restructuring”. He warned that successive reorganisations drained the workforce’s “energy and confidence” and argued that stability makes improvement easier. Does the Minister agree that his advice would be well taken?

[Lord Mawson (CB)]

My Lords, I welcome this debate and I certainly support the amendment. I am encouraged by the letter that we received today that there is an open mind within government and a proper discussion taking place about these very important issues. I am a practitioner, as many of your Lordships know, and we are involved in trying to build some of this new health infrastructure around the country. Indeed, today I have been involved in quite an exciting conversation about a health innovation campus in Huddersfield that we are supporting, which has major implications for this Government’s direction of travel—a lot of which I support—around place, collaboration and other things that the Prime Minister has talked about.

However, we are also in touch at the front end with what is actually happening on the ground, and the word I keep hearing from colleagues across the country is “chaotic”, which is a worrying word to be hearing. Therefore, this debate and the detail that is being discussed today really matter for the NHS, for patients and for those of us who are trying to build this infrastructure. Therefore, I am encouraged that the Minister is starting off in an open, transparent and conversational manner in Committee. It is very helpful.

One of my concerns about the changes taking place at the moment is that there does not seem to be a clear vision about prevention. Those of us who have been involved in this space—in my case, I have been involved in east London, and now nationally, for over 40 years—know that on the ground, in very challenging communities, the real determinants of health often have nothing to do with doctors. If you asked our GPs in Bromley-by-Bow, they would tell you that a person getting a job does more for a person’s health than anything to do with doctors. That is why, in Bromley-by-Bow, we ended up building 97 businesses with local people, because we got real about the social determinants of health. It is about whether you have a decent home that is not damp. It is why we built a housing company, which now has 10,000 properties and owns 34% of the land in Poplar. It is to do with whether your relationships in your family are in a good place and whether you feel part of a community—all these things. The numbers that people far cleverer than me come up with say that the impact of all this is 70% to 80%.

I am not clear, with this real opportunity to reform the NHS in this century and with the things we now know, what this Government are saying about the prevention agenda and how clearly they are or are not joining the dots around the social determinants. Part of this conversation is really important, but part of it needs to be about the prevention agenda. As we work our way through Committee, we need far more clarity about what that will mean in practice and in detail in communities across this country.

[Baroness Harding of Winscombe (Con)]

My Lords, it is a privilege to follow the noble Lord, Lord Mawson, and the noble Baroness, Lady Gerada, who between them have many decades more experience than I do of NHS and health and care reorganisation. I have only one major experience from the inside: the last time we were debating the restructuring of the NHS in 2021-22. At the time, as someone from the private sector, I was somewhat surprised to discover that the NHS got on with the reorganisation before the legislation was passed. It is even odder this time: the NHS has started before the legislation but without a plan itself.

Therefore, I welcome this amendment from my noble friend Lord Howe. It is essential that we understand the plan and the timetable, what it will cost and what benefits it will bring. It really is very straightforward. If that does not exist, the idea that it can be complete by 1 April next year is completely gobsmacking. Maybe I am just an innocent businesswoman who does not understand the ways of the NHS, but it just does not seem right. I think this amendment is basic common sense.

Much as I hear the words of wisdom from Don Berwick, I support merging NHS England with the Department of Health. I saw from the inside, particularly during Covid, how important it is to have clear political accountability. I support the basic premise, but I am very worried that the tendency will be to centralise rather than to push resource out to the regions and local communities. As the noble Lord, Lord Mawson, just said, it is at the local ground level that change really happens.

I am very supportive of seeing fewer people employed in organisations that bear the NHS brand but do not actually treat patients. There are tens of thousands of people who are all trying hard and doing valuable work, but they are a long way away from patients. As we bring NHS England into the department, I would love to see, as part of this amendment, a clear breakdown of the cost savings at the national, regional and local level, so that we have sight of whether we are really pushing accountability, and resource and capability, down to where change will bring the benefits that we all seek.

--- Later in debate ---

[Baroness Thornton (Lab)]

My Lords, I do not intend, by and large, always to follow the noble Lord, Lord Lansley, if I make a remark to your Lordships’ House, and I will not go into the reasons for health inequalities, because they have been spoken to very adequately by the noble Lord, Lord Patel, and my noble friends Lady Royall, Lord Hunt and Lady Nargund. However, I want to say something about social care because, although the noble Lord, Lord Lansley, is quite right about public health and the need for prevention, none of this is going to work or be delivered—I make no apologies for saying this and I will keep saying it—including the 10-year plan and integrated care, unless we also address the issue of social care inequalities. As I am chair of the Social Care Institute for Excellence, the Committee would be expecting me to talk about that.

We recently did research, which has been published, about the inequities experienced by people who use social care. I thought it might be useful to remind the House what that said, because it will sound very familiar when we are talking about health inequalities. It was about people with lived experience, because our work in SCIE is based on people with lived experience, and co-production. It said:

“These policy and practice implications are reflected … by participants: a named point of contact to help them navigate the complex system … better continuity of carers to improve the quality of care and reduce the burden of having to explain one’s needs”,


as we hear time and again,

“clearer and more proactive information to ensure everybody is aware of their entitlements … investment in the workforce to encourage greater professionalism and retention … more consistent provision across areas to reduce the postcode lottery”.

We could be talking about the inequalities we have just been debating; the same applies in social care. The reassurance I seek from my noble friend the Minister is that that will be recognised as we go through this legislation.

[Lord Mawson (CB)]

My Lords, I found this an interesting debate, and I am sympathetic to the amendment of the noble Baroness, Lady Bennett, and particularly that of the noble Lord, Lord Patel, because he is right that very little is actually being learned. My colleagues and I have listened, over the years, to lots of conversations about health inequalities. When you spend your life in very challenging housing estates and see very little changing, you know about the distance between all the words and the practice.

That is why, many years ago, we decided to focus on practice and the doing of things, rather than the talking about things. We began to realise what every parent knows: that you only really learn by doing. When I started to work with GPs, originally in east London, they began by telling me that was how you became a GP. You saw one, you did one and then you taught one; it was a very practical matter. Businesses and entrepreneurs nowadays know that you learn by doing things. Yet in the state, which often feels so out of date in the NHS, there is no learning by doing culture. There is a learning by writing very fine reports, often at 60,000 feet, that seem very unengaged with practice.

Over the years, it has been interesting to observe what happened through practice. The Bromley-by-Bow model is well known, so I will not use it, but the noble Earl, Lord Howe, knows that I was also responsible for the transformation of a street following a murder and 10,000 illegal injections being given out in a housing estate. There were some terribly violent circumstances going on at the time. When I brought the first key people on the street together, all of them—the GP, the school and the housing association—were saying, “We cannot deal with this on our own. We need to do it together. These things are so interconnected”, and we built together the St Paul’s Way Transformation Project, which started with nothing and led to a new £40 million school, a £16 million health centre, 600 homes and now a new primary school.

We joined it up, and Professor Brian Cox and I led our 14th science summer school in June this year, with a masterclass at the end of it on quantum physics, for the children from the same housing estates. It is the same children and same families, and now they have one of the best performing schools in Tower Hamlets. The noble Earl, Lord Howe, helped us greatly at one key point with learning by doing, when he met the whole group—housing, health and education—when the NHS was getting in the way of us completing on the deal for the health centre. He was very helpful in enabling that to actually happen.

It was Duncan Selbie, the chief executive of Public Health England in 2015, who gave me £20 million and said, “Andrew, take this culture that you’ve been developing into the north of England”. We built 10 learning by doing innovation platforms in Rotherham, Bradford, Doncaster and Bootle, all of which were about bringing people together to learn about these matters. It was interesting that when I met the public health officials in each of these places, who were lovely people quoting all the same data that I had heard many times before, and said to them, “What are you actually going to do about that data?”, there was absolute silence. It was not their fault. They did not have the skills to know how to turn fine words into practice for some of the most challenging communities in this country.

It is my view that one of the things being missed in this moment is the serious need to get real about innovation and learning by doing. My colleagues and I—I declare my interests—are at the moment creating at place, on the ground, with local people and professionals, what we call these learning by doing innovation platforms, so that we bring together the actual GP, business person and local resident, and you begin to explore these issues together because in the modern world, health is everybody’s business. It is not just a matter for GPs. It is interconnected and we need to explore what that means.

My concern about where we are at the moment in discussing this Bill, which is a fantastic opportunity for this Government, and this country, to move into a form of health that is of this century and not last century, is that we are going to end up building a lot of biomedical boxes around this country that do not explore these interfaces in some of our most challenging communities. The noble Lord, Lord Patel, is right; we need to worry about why he is right and why things are not being learnt.

I finish with the thought that it is our experience over the years that, sadly, we have to say that, in so many respects, the NHS is not a learning organisation. We must have hosted 70 Government Ministers to our work over the years. They all come and say, “Wow, this is fantastic, we need to do more of it”. I can name the four who did anything practical about that, and the other 66 sit on a list in this pocket. This is not to do with bad people. It is about whether, as a nation, we are now going to get upstream into prevention and health creation and create a learning by doing environment in which we all learn together, and in which local people are part of all of that process.

[Baroness Pidgeon (LD)]

My Lords, this is a very important group of amendments, and it has been a really excellent debate. One of the most pressing issues facing us is the widening gap in health outcomes between different communities. Healthy life expectancy has fallen in recent years and the gap between the most and least deprived areas of England, as we have heard, now stands at almost 20 years.

The point made earlier by the noble Lord, Lord Crisp, when he talked about the role of the department being one of leadership for health across government, not just running the NHS, is really important as we approach this group of amendments. We have heard clearly that the current legislative framework places relatively weak duties on government to address these wider determinants of health and tackle inequalities.

The House of Commons Health and Social Care Select Committee, in its scrutiny of the Bill, called for a stronger focus on improving the nation’s health and tackling inequalities, emphasising the need for clearer accountability and a more robust approach to prevention across government. Many of the amendments in this group would help to achieve that aim by ensuring that reducing health inequalities becomes a central objective of health policy, and that progress is measured and reported transparently.

My noble friend Lady Walmsley’s amendments, spoken to by my noble friend Lady Tyler, and Amendment 7 from the noble Lord, Lord Patel, would strengthen the duty on the Secretary of State to take steps or action, rather than simply “have regard to”. That is really important. Amendment 14, tabled by the noble Lord, Lord Patel of Bradford, and supported by so many Members of the House today, would require the Secretary of State

“to have specific regard to reducing inequalities”

in coastal communities. The point has been made clearly about the added complexities for such communities, whether those are workforce related or in local service provision. Those are really important.

My Amendment 20 looks at health inequalities in urban areas and requests a strategy and an annual report. Impact on Urban Health, which is part of Guy’s & St Thomas’ Foundation, recently reported its State of Urban Health research and found that preventable mortality is 2.7 times higher in the most deprived urban neighbourhoods in England than in the least deprived. Urban areas also face some of England’s starkest health inequalities, with people living just streets apart experiencing significant differences in health. You have only to look over the river to the London Borough of Lambeth, where Impact on Urban Health is based: females who live just over a mile apart face an eight-year gap in life expectancy. As we have heard, these inequalities are driven by unfair and avoidable differences in everyday environments. These include exposure to air pollution, differences in housing quality and access to healthy, affordable food. I pulled this area out for specific attention: rather like the coastal communities amendment, it needs specific action.

My noble friend Baroness Tyler spoke strongly to Amendment 18, which would require a cross-government health inequality strategy and subsequent annual reports to Parliament on progress. That would focus minds and energy across government and would address the key point from the Health and Social Care Select Committee, as well as many of our suggestions in amendments and today’s debate.

If we are serious about narrowing the gap in healthy life expectancy and giving everyone the opportunity to live a healthier life, then action on the wider determinants of health and tackling health inequalities must sit at the heart of the Bill, not at its margins. I look forward to hearing the Minister’s response.

Tobacco and Vapes Bill

Lord Mawson Excerpts

Report stage
Tuesday 3rd March 2026 Lords Chamber

[Lord Mawson (CB)]

My Lords, I support the amendment from the noble Lord, Lord Young. Supporting a smoke-free society is the right direction of travel, in my view, but I also worry about contact with reality.

A road map should also include the potential unintended consequences of cannabis smoking in a smoke-free country, with real targets and interventions. Walk across London and other towns and cities and smell the cannabis smoking on every street corner. People are breaking the law, with the police doing virtually nothing about it.

Cannabis has profound long-term health implications in the young. Some of us have worked in this space and have to deal with them. What are the unintended consequences of the Bill for the uptake of cannabis smoking among the next generation? I ask the Minister: what work have the Government done on the unintended consequences of this policy, and what do they plan to do about the potential uptake and increase in cannabis smoking, and the increase in illicit dealing on our streets?

[Baroness Walmsley (LD)]

My Lords, I thank the noble Lord, Lord Young, for tabling Amendment 202, to which I have added my name. It would require the Government to publish, every five years, a road map to a smoke-free country: in other words, a plan for the event rather than a review after it.

There are two essential components to achieving a smoke-free country. The first is that no one should start smoking at all. I hope that the Bill will successfully achieve that over time; the Government have shown great ambition in this area. The second component is that all current smokers are supported to quit, so that everyone stops. On this second part, the Government have been a little quieter, until recently. We have heard about the recent success of targets met for the number of pregnant women smoking at the time of delivery: I think it has gone down by half. However, the rates for other groups remain stubbornly high and we are not seeing the same targeting interventions. We need to ensure that we have this type of focus, energy and commitment with other groups, where we know that smoking rates are higher. Plans for these groups could be located in the road map being proposed.

For example, mental health is a key priority area for the Liberal Democrats. There is a dual causal relationship between smoking and mental health: if you smoke, it increases your chances of developing mental health conditions and, if you already have a mental health condition, you are more likely to smoke. Nearly half of those with a serious mental illness in England smoke, alongside a quarter of people with depression or anxiety, compared with 11.6% of the general population. High rates of smoking in this population have a disastrous impact on physical health, particularly for those with a serious mental health illness who, on average, live 15 to 20 years less than someone without. It is estimated that smoking accounts for about two-thirds of this reduced life expectancy.

The pervasive false narrative that smoking somehow alleviates mental health symptoms urgently needs to be addressed, as it creates so many challenges when we are trying to support these smokers to quit. If the Government are going to publish a strategy, a dedicated section on how they will bring down smoking rates in this group would be extremely welcome and needed. I welcome the Government’s concession that vaping vending machines should be allowed in secure adult mental health settings; this should certainly help this population to quit.

Amendment 206, tabled by the noble Lord, Lord Lansley, would require the Government to publish a review of the Bill. I welcome government Amendment 205, which does something similar but with a lot less granularity. However, would the Minister give us a little more information about where the Government will get their evidence to underpin the review? Can she assure the House that that evidence will be independent and not influenced by any lobbying or so-called evidence put before the Government by big tobacco, or anybody else who would benefit from slowing down the elimination of smoking in the UK?

The intent of this review should be to support the legislation. As several noble Lords have said, the smoke-free generation is a novel policy and we need to demonstrate the impact and evaluate implementation to encourage other countries to follow. There are also many regulations on the way, along with those from other government departments, on nicotine products. A clear analysis of how these policies will work together would be very welcome.

However, the review must not be viewed as a sunset on the smoke-free generation, and I would welcome comments from the Minister on what, at this point, we know will not be in the Government’s review. For example, the Bill’s impact assessment notes that many of the health impacts of the rising age of sale will not be seen for 10 years, so we should be mindful that this part of the Bill is playing a very long game. There may be early data that we are on the right track and the review will perhaps be able to look at compliance, retailer feedback and all the other things that the noble Baroness, Lady Fox, mentioned. I feel that much of this falls into the scope of her Amendment 207.

Finally, Amendments 91, 120, 201 and 216, tabled by the noble Baroness, Lady Hoey, raise concerns about the Bill’s implementation in Northern Ireland. I have been reassured by the Government’s response to the TRIS process, which lays out in some detail their response to the concerns raised, but, as the noble Lord, Lord Forbes of Newcastle, mentioned, the legal opinion published in the Daily Mail was commissioned by the Tobacco Manufacturers’ Association. Without seeing it, I cannot really comment other than to say it is not surprising that the industry is laying the ground for future legal challenges. It is, as we know, highly litigious and wants to chill the appetite for tobacco control globally. It all goes to show, I suppose, that if you put two lawyers into a room, you get three opinions. There are, as we have heard from the Minister on other occasions, other legal opinions out there that say that the Bill is compatible, but I leave the noble Baroness to answer for those concerns. However, I support the Government to press on with this vital public health legislation, and to plan it and review it as required.

Terminally Ill Adults (End of Life) Bill

Lord Mawson Excerpts

Committee stage
Friday 21st November 2025 Lords Chamber

[Lord Falconer of Thoroton (Lab)]

I do not feel insulted by being called “you”, but I do not think that the noble Baroness, Lady Fox, properly understands how the Bill operates. The two doctors and the panel have to be satisfied that the person is reaching a voluntary decision of their own, uncoerced and unpressured. Codes of practice will determine how that is done and, what is more, the panel with the three experts on it also has to be satisfied. The noble Baroness, Lady Fox, is saying that that is a tick-box exercise. With respect, no: this is obviously a very serious matter. I expect the doctors and the panel doing it to take it seriously.

[Lord Mawson (CB)]

My Lords, as the noble and learned Lord knows, I have spent a lot of my life working with people in housing estates in the East End of London. Research we did some years ago discovered that virtually every nation on earth is represented in the housing estates where I worked. I have spent a lot of my time, nearly 40 years, working with Bengali families. We know each other quite well, but do I really know what is going on in the minds of that community or with that single mother, trapped in a house, who does not speak English after all these years? The truth is that I do not. It is really difficult to know. In the same way, I find it difficult, as a Yorkshireman, to help southerners understand what is really going on in Yorkshire. Even though I have tried it many times, the quality of their fish and chips really does not cut it.

One of my problems with this overcertainty is that it feels like a very white, English conversation, when actually this country is a global community, with people from many different cultures, all over the world. What concerns me is the practicality of much of the discussion that I have listened to today, and I have no idea how you actually understand coercion or encouragement—I think that is a really important word—in practice. Having spent many years of my life with these people, I would not pretend to know what I was really hearing, at such a point, and what it meant for their life in practice.

[Lord Falconer of Thoroton (Lab)]

I completely agree that the noble Lord and I might well not understand what people from different cultures would say, but the two doctors and a panel would have to understand that sufficiently to reach a conclusion. If they do not, they cannot provide the satisfaction that is required by the Bill. The idea that the people who will make the Bill work are all from a particular class, demography and education is, with respect, wrong.

[Lord Mawson (CB)]

Will we have enough people from these different cultures with the skills and knowledge to enter into that kind of understanding, whether they are doctors or on the panels? It is really difficult to understand how that practical proposition will work in the real world—in the East End of London.

[Lord Falconer of Thoroton (Lab)]

That will very much depend upon the number of people who apply from particular groups, and I think one can be pretty sure, on the basis of the impact assessment, that there will be sufficient numbers.

Mental Health Bill [HL]

Lord Mawson Excerpts

Committee stage
Wednesday 22nd January 2025 Lords Chamber

If the Minister is minded to resist the amendment, can she tell the House how the Government propose to deal with these massive problems of withdrawal? I am very happy to receive a letter or to have a meeting to discuss this. I commend the amendment to the House.

[Lord Mawson (CB)]

I support Amendment 148 from the noble Lord, Lord Crisp. I have just arrived back from a three-day event with Professor Brian Cox in Northern Ireland, where we had been bringing together the NHS, schools, the business community and the public sector around a whole programme on innovation and how we think about the future with regard to these matters, taking the principles that we originally developed at the Bromley by Bow Centre in the East End of London, now nationally across the country.

If I look like I am in recovery, it is because I am—I have literally just landed trying to get back here. I apologise that I could not take part in the Second Reading, because being a working Peer, sometimes it is not very easy to fit all this into the diary. One does one’s best.

I am very aware of the questions that the noble Lord, Lord Crisp, is raising. Indeed, I tabled a number of Written Questions this week about this very matter. I support the amendments because we have a very serious problem out there. My GP colleagues are telling me, as the noble Lord, Lord Crisp, has said, that one in five adults in England is on antidepressants; it is one in four in Scotland. This is a really serious problem.

As a country, we need to return to a discussion and a conversation, as the Health Secretary—I hope, in the spring—prepares to help us rethink the future of the NHS. We need to return to the question that we asked 40 years ago in the East End of London, the fundamental question: “What is health?” What we see happening here is serious for hundreds of thousands of people and is driving a culture. We also need to start to worry about what is happening within the machinery of the NHS and the state, as it drives these sorts of cultures.

Finally, as I put down in one of my Written Questions, we need to be asking, practically, “How much is it costing the taxpayer to drive these kinds of cultures?” It is serious, but the problem is also an opportunity, if interest is raised in the work of those of us who have been doing stuff on the front line for many years with our GP colleagues. I see the noble Lord, Lord Clement-Jones, there: we have rebuilt a street together, with a £40 million school, a £60 million health centre, 600 homes and now a primary school, exploring this, in what when we began was a dysfunctional housing estate.

There is a real opportunity out there, but we now need to get real about antidepressants.

[Baroness Fox of Buckley (Non-Afl)]

My Lords, I have some points I would like to probe in this group.

I especially welcome Amendment 95 and the proposed new clause:

“Ascertaining and learning from patients’ experiences of hospital treatment”.


The noble Earl, Lord Howe, made very powerful and moving points; we could really take those on board. I have some reservations, however: we live in a complaints culture. I am concerned that this important notion of learning from patients’ experiences does not become a way of stigmatising hospital staff and psychiatrists, with people queueing up to point the finger. There are many people I know who have experiences of hospital who will, at a particular time, tell you it was a terrible experience, and then, at another time, acknowledge that it saved their life. It depends on what phase they are in, in relation to their illness, in some ways—it is about their perspective. So I both welcome it and challenge it.

I am very keen, as we all are, that treatments are taken seriously, whether administered in hospital or in the community. As the noble Lord, Lord Crisp, and the noble Baroness, Lady Hollins, note in Amendment 148—for me, the most important amendment in this group—we need to be alert to when, for example, the use of psychiatric medication as a treatment creates a problem of dependency. We all know that this is a growing problem. We must consider that.

On the tenor of Amendments 50 and 51 from the noble Baronesses, Lady Tyler and Lady Bennett, on non-drug-based forms of medical treatment, I am less convinced by the emphasis here. I am worried about simply giving a wholly positive view of psychological and therapeutic treatments, because it perhaps misses some of the changes in today’s culture that lead to the overprescription of, for example, antidepressants.

When I was working in community mental health many moons ago, the fashion among progressives in the therapeutic community was often anti-psychiatry, anti-hospital and most definitely anti-pharmacological interventions, with a huge hostility to the pharmaceutical industry. I did not always go along with it, but that was the kind of mood. Peculiarly, I would argue that, today, it is therapeutic experts, counsellors and psychological practitioners who, by becoming diagnostically trigger-happy in labelling people as ill, are creating a huge demand both for third-party interventions, as I have discussed in previous speeches, and for treatment. That often leads to a clamouring, especially among younger people, for pills to help them to cope with the travails of life, and it has been egged on in some ways by therapeutic practitioners.

I had my attention drawn to this when, at the Academy of Ideas, I organised a debate on young people, mental health and those kinds of issues. The audience was largely young people, who said that the problem was that psychiatrists, GPs and doctors would not listen to them and would not believe that they were mentally ill. They demanded treatment and were quite aggressive. It was young people saying, “Where are my tablets?”, and I thought, “Oh, life’s changed slightly”. The psychiatrists in the room were trying to hold the line and gently suggest that maybe they were not ill, but that led to an even more hysterical reaction: “How dare you say I’m not ill?” They went on to explain how they had had a chat with their school counsellor, and they were sure they were ill, and they wanted the tablets.

If we can take a popular example that I appreciate might get me into the heart of an argument that I do not want to be in regarding the slippage between autism and mental illness, I am going to talk about ADHD. ADHD is the fashionable disorder of the day. Huge numbers of students and school pupils are demanding that their neurodevelopmental disorder is recognised and catered for. In my view, it is often diagnosed promiscuously and that is leading to huge demands that are detrimental to education and likely to make councils go bankrupt and schools collapse—but that is for a different debate and a different Bill. ADHD is also leading to a demand for tablets.

I go along with those who were warning about overdiagnosis. The Times reports that 278,000 people in England are on central nervous system stimulus to treat ADHD, and there was an 18% hike in prescriptions for ADHD drugs between April 2023 and March 2024. In the US, the figures are startling, and we should be wary of them, with 7 million American children who are said to have ADHD. As the New York Times has said, there is a danger that we are using stimulants to suppress

“all spontaneous behaviour in normal children”

by pumping them with Ritalin and other calming drugs and sedating normal children. In a broad sense, that is a worry.

Talking of treatments, I think the noble Lord, Lord Crisp, made the point that a social problem is being created of people feeling that if they are ill, they cannot go to work and of over-giving them drugs. All sorts of problems go along with that. Is it not tragic that so many people want to have these drugs, either for themselves or for their children, in order to feel that they can cope, when they are really not that ill or not ill at all, but they have the label? I am wary of inappropriate treatments, but perhaps the problem needs to be looked at differently, as stemming from inflated and expansive diagnostic criteria often deployed from within the therapeutic community rather than psychiatry.

We should not be naive in thinking that non-drug-based therapeutic interventions are virtuous per se. Counselling, for example, has extended its reach into British society so much that it is now a rare family that has no experience of the phenomenon. I am sure that we all know that going to a therapist or counsellor is, to say the least, a mixed bag when, ironically, they end up saying that you need to have third-party intervention or medical intervention. It is bad for the nation’s health.

NHS: Long-term Sustainability

Lord Mawson Excerpts

Thursday 18th April 2024 Lords Chamber

[Lord Mawson (CB)]

My Lords, I thank the noble Lord, Lord Patel, for this timely debate. My colleagues and I at the Bromley by Bow Centre have been at the cutting edge of innovation in primary healthcare for 35 years. We entered this space by accident following the tragic death of a local resident, Jean Vialls, in an East End housing estate in May 1991. Jean’s death led to a senior-level inquiry at a London hospital, which picked apart the lives of an East End family in very challenging circumstances who had been badly let down by the NHS and its siloed culture. The inquiry also challenged the NHS on its lack of attention to detail, its management systems and its culture, which had forgotten who the customer was. Sound familiar.

We were told at the time that lessons would be learned but, 35 years on, I can assure noble Lords that few lessons have actually been learned by the NHS. Indeed, my GP colleagues tell me that getting up stream and creating more integrated responses to health needs gets harder to do, not easier. In the course of this well-documented and tragic encounter, we began to realise that in poor communities at least 70% of the determinants of health are social and not biomedical; they have nothing to do with doctors. The NHS business model was absolutely the wrong way around and there was a desperate need to get up stream into the prevention agenda.

Our practical response, as an increasingly entrepreneurial culture took root in Bromley, was to build the first working model of an integrated primary healthcare centre that moved beyond just health and social care and embraced housing, employment, business, the arts and education, and so on. We have created 97 businesses with local people over the years. We started to join the dots. Even with the support of the then Prince of Wales, now the King, this work was done against a prevailing culture in the NHS that talked about innovation but rarely grasped the nettle. Today, the Bromley by Bow Centre is responsible for 55,000 patients on four sites, and has been taken national through the Well North programme, which I lead—here I declare my interest. The centre today hosts 2,000 visitors each year, from across the world. There has been all this work and learning, but so little in practice has actually changed. One hospital medical director we work with described the NHS as a blancmange when it comes to innovation: it wobbles when innovative ideas and practice are first introduced but always returns to shape and form. This is not a sustainable culture.

What needs to be done? Here are seven brief steers, based on many years of practice. First, we must stop treating the NHS like a religion and be honest about its condition: it is ill and broken. Business as usual is not an option. It needs radical surgery over a 10 to 20-year period.

Secondly, we need cross-party agreement to stop the constant meddling of countless politicians and endless restructuring. I was involved in the 2012 Olympics programme for 19 years, from day one. Our focus was on creating a real legacy in east London from this once-in-a-lifetime opportunity. Early on we focused on gaining cross-party support for a 25-year programme—go and have a look at the results.

Thirdly, we must take seriously Dr David Haslam’s concern that if we carry on with the present NHS business model, it will absorb 100% of GDP by 2070. It is not sustainable; we are creating a dependency culture.

Fourthly, we must create a learning-by-doing culture, and move away from so many expensive, outdated reports that few read.

Fifthly, the modern world is about people and relationships, not processes, and so we must nurture them at all levels of the NHS.

Sixthly, technology is not the answer to everything but it is a fantastically useful tool. We must start small, interfacing the technology with people and their practice, and use it to grow organic cultures that work. Stop trying to land big solutions from above.

Seventhly, we have always found, right across the country, individuals and localised groupings that were able to deliver this more joined-up, entrepreneurial approach. At the moment, this is true, for example, in Bradford, York, Rotherham and east London, among others. However, they are not in general supported and encouraged, and thus the approach does not become established more broadly. As has recently been observed, the NHS has more pilots than British Airways—why not get behind these good people, long-term, and build a culture based on innovation, integration and entrepreneurship.

My question to the Minister, and to the Opposition if they were to come into government, is this: given the present spending trajectory and business model, what percentage of the UK’s GDP does the Government estimate that the NHS will soak up by 2070, and what are they doing about this challenge? Who in the department is thinking about this problem?

Draft Mental Health Bill

Lord Mawson Excerpts

Tuesday 28th June 2022 Lords Chamber

[Lord Kamall (Con)]

I could not agree more with the noble Baroness. One thing we must be well aware of is that, although there are pressures and we are asked for more funding, the Government alone cannot do all this. Sometimes officials, be they from local or national government or from another state organisation, are mistrusted by vulnerable people. Local civil society groups, voluntary organisations and, often, those who have suffered the same problems themselves and then been inspired to set up their own organisation to support others—who can empathise with the situation many of these poor women are in—are sometimes the best first point of contact. As the Government spend more on this, we must make sure that we are not squeezing out the voluntary sector or local civil society, but working in partnership with them.

[Lord Mawson (CB)]

My Lords, my colleagues and I have been involved in this space for many years. I was in conversation with my colleagues just last week. I agree with the noble Baroness, but one of the challenges we face is the financing when organisations try to create this more integrated environment. The money and the streams coming out of the Treasury are endlessly pulling apart the very services that need to be connected. I encourage the Minister and his colleagues to look at some of that. In Bromley-by-Bow we are still dealing with 62 different funding sources from government, with all the attendant bureaucracy that is trying to deal with this problem.

[Lord Kamall (Con)]

The noble Lord makes a very important point from his own experience. I thank him for all his engagement and for educating me on what happens in the community. We must be careful because often, these issues are not simple or binary but are multi-faceted, and we then have different initiatives from the Government, which overlap. There is probably an incredibly complex Venn diagram of who is responsible, where the funding pots are and at what level you get the funding—is it local government, national government or philanthropy networks, for example? I would love to make it easy—but will I be able to?

Also, whenever you have change there are often winners and losers. Often, those who lose out because of change are very concentrated and make their voices heard, while the winners are dispersed and we do not hear them saying, “This is a great change.” Therefore, we must be very careful with any change in funding. However, the noble Lord makes an incredibly important point. We must ensure that we are not squeezing out civil society and pulling people in many directions, and that it is much easier to access finance. The noble Lord, Lord Glasman, made the point that as a Labour Peer, he is incredibly proud of 1945 and the welfare state, but that he worries that in doing such things, sometimes the state squeezes out local community groups and breaks the bonds in local communities. We must ensure that we get the right balance.

Health and Care Bill

Lord Mawson Excerpts

Lords Hansard - Part 1 & Report stage
Monday 7th March 2022 Lords Chamber

[Baroness Merron (Lab)]

My Lords, this group of amendments concerns the licensing of non-surgical cosmetic procedures and other important considerations, such as hospital rehabilitation accommodation and the doctors’ register of interests. They all relate to the interests of patients.

I shall address particularly the issue of cosmetic procedures and I start by thanking the Minister and his Bill team for giving so much support, showing such interest and bringing this into being today. I know we all welcome it; it is much appreciated. I am glad to have taken part in the meetings and to have tabled an amendment in Committee relating to cosmetic regulation. The amendments before us today have been very much welcomed by medical associations, because we all know that lack of regulation has been a ballooning problem. For example, the Save Face organisation received more than 2,000 complaints of botched procedures in 2020 alone and the true number, as we know, is likely to be higher.

The other point to make is that this is a fast-moving industry and I am glad that these amendments will be able to keep pace with an ever-changing landscape. We have seen a significant rise in recent years in the number and type of non-surgical aesthetic procedures performed in the UK. Practitioners, both medically and non-medically trained, are performing procedures without even being able to evidence appropriate training and the required standards of oversight and supervision of procedures that can be described only as high- risk. When they go wrong—and we have all heard the stories of intense and lasting damage from untrained practitioners carrying out procedures in unlicensed premises—we all know that it will then fall to the NHS to pick up the pieces. This, today, is a meaningful step in protecting more people from rogue operators.

I close by thanking noble Lords for their contributions not only to this debate but to shaping the legislation. Once again, I thank the Minister and his team for all their efforts. I hope we will come to see a much safer set of non-surgical cosmetic procedures than we have at present.

[Lord Mawson (CB)]

My Lords, just before the Minister stands, I rise to support Amendment 184ZA in the name of the noble Baroness, Lady Cumberlege.

Over the last 28 years, it has been my privilege to work with a fantastic team of GPs in the East End of London who are now responsible for 43,000 patients. I know what great GPs and doctors are like. If I am honest, however, I have also had to deal with a number of dodgy doctors, which is a very difficult matter to deal with. One doctor undertook female circumcision in his practice, unbeknown to the health authority for quite a period of time. He ended up marrying his practice manager and, some years later, he murdered her. Another practice, when I dug under the carpet, had bought a cheap fridge from B&Q and, over a period of three years, kept 10,000 injections at the wrong temperature and injected 10,000 patients with dead, illegal injections. Another doctor, as we learned when we took over his list, had countless ghost patients. As a result, I started to discover what ghost patients are. It took our team two years to sort out the realities of who were and were not real patients.

For the sake of GPs and patients, we need to protect them in the way the noble Baroness is suggesting. Doctors are flawed human beings like the rest of us, and we need to protect them from themselves and from us. It is really important that these things are taken seriously. This amendment puts its finger on a very important matter.

[Baroness Wyld (Con)]

My Lords, this morning, I told my three daughters that they needed to be more assertive at school, but I have completely failed to intervene tonight. I will be very quick in paying tribute to the noble Baroness, Lady Merron, and my noble friend Lord Lansley, who is not here tonight, and in thanking the Government for the amendments on cosmetic interventions. I sponsored the Botulinum Toxin and Cosmetic Fillers (Children) Bill in this House, which assisted with the regulation of non-surgical interventions for children. At the time, we said that this was only the start and that there was a lot more to do. We acknowledged that others had done a lot of spade work, and I pay tribute to all those who have done yet more spade work. I want to put on record my appreciation to the Government for listening and reacting.

Integration White Paper

Lord Mawson Excerpts

Thursday 10th February 2022 Lords Chamber

[Lord Kamall (Con)]

The only legislation I am aware of is the Health and Care Bill; this White Paper complements that, just as the adult social White Paper does. This is not legislation.

[Lord Mawson (CB)]

My Lords, I welcome the White Paper and the direction of travel. I thank the Minister and his colleagues for being willing to listen to me and colleagues in the NHS who are involved in actual practical pieces of innovation in this space. It is good to see real examples of the implications for real people in this White Paper. There is also lots of focus on practical and detailed changes—for example, streamlining training and qualifications and shared outcomes. I wonder whether sufficient attention is paid to the social determinants of health and getting upstream with regard to prevention. Is there still too much assumption that the state is doing all the work? The private and voluntary sectors are the major delivers of care. Does the model of partnership proposed fully reflect this? The Minister might like to reflect on that.

Finally, as always, the devil is in the detail and will be all about implementation. One of the ways of achieving this focus is, as I have said before, through establishing innovation platforms that embody the ideas of not only the White Paper but the Health and Care Bill, levelling up and many other current initiatives. Innovation platforms can start to bring together some of these initiatives. It is our experience on the ground that a lot of the public sector systems and processes are not in place and are not fit for purpose. There needs to be innovation in this space. The problem could be an opportunity if we start to join some of this up. How do the Government intend to join up these various initiatives?

[Lord Kamall (Con)]

In many ways, the answer is not what the Government intend to do but what happens at the place-based level. As the noble Lord has reminded me on a number of occasions, some of the projects that he has been involved in and other social enterprises have been really good at bringing people together. Sometimes it has been led by local councils; sometimes it has been led by social enterprises; sometimes it has been led by networks. I completely understand the premise of the question and agree that it has to be a partnership. It is not just a state, but social enterprises, co-operatives, local movements and local civil society all working together with common aims. Go to any part of this country and you will see a number of these people working together. We have to make sure that there is no overlapping or duplication. This is the real aim of what we are trying to get, making sure that people talk about health and social care but well-being as well.

Health and Care Bill

Lord Mawson Excerpts

Lords Hansard - Part 1 & Committee stage
Wednesday 26th January 2022 Lords Chamber

[Baroness Wyld (Con)]

My Lords, I support my noble friend Lord Farmer. I declare my interest as a non-executive member of the board of Ofsted. I apologise for not being able to speak at Second Reading for my own family reasons. I echo everything that the noble Baroness, Lady Tyler, said. It was a real pleasure to serve with her on the Public Services Committee.

I will praise the Government first, which is always wise. They are showing great commitment to family hubs and I believe that they are committed to the rollout. What concerned me when the committee took evidence from certain members of the Government was a sense of a lack of urgency. Everybody agreed that this was a brilliant idea, but different people from different departments had different ideas about how they should work.

We also took evidence from families, in private and in public. The stories we heard over and again were, as others have alluded to, that, “This could have been prevented if it had been addressed in a joined-up way”. We particularly heard from young children, “I had to tell my story over and again.” Imagine the trauma. This could have been prevented under a different model. These situations did not have to happen.

We have the building blocks to make sure that these situations do not happen, but I do not think the legislative framework is in place to help us to address that. For that reason, I am persuaded by my noble friend Lord Farmer and I am happy to support his amendment.

[Lord Mawson (CB)]

My Lords, I am very supportive of what the noble Lord, Lord Farmer, said. My colleagues and I have been in this space for 37 years and we have built rather a lot of things in it. It has been very interesting to watch what happened in east London, when this new scheme from a new Government arrived in the middle of a group of communities that already had well-established relationships with very vulnerable families, with a whole range of opportunities emerging. I am sure it was unintentional—it is part of the danger of being overinfluenced by the idea that local authorities will sort this stuff out in the same old usual way that they have tried to before—but it was very disruptive for the social enterprise sector, which was already doing this stuff very effectively, with all the numbers to show it. I will not go into the detail now, but when you look at the detail of what actually happened, the present facilities cost £100,000 more than those being delivered by the social enterprise sector.

These ideas are really important. I am happy to take the noble Lord into this in a lot more detail. I encourage him to spend more time in the detail in some real places to look at the unintended consequences of what happens when new government programmes arrive in communities, with the best will in the world, with an overconfidence in what they think the state can deliver. I am very happy to have a further conversation with the noble Lord, but the detail of the long-term relationships with these families really matters.

[Lord Warner (CB)]

My Lords, briefly, I support these amendments, partly from my own experience as a director of social services and Children’s Commissioner, but also because of the points that the noble Lord, Lord Mawson, raised.

I have three key points from history. As a director of social services in the 1980s and 1990s, I offloaded my local authority family centres to the voluntary sector because a survey of parents suggested that they would not come to a service run by the organisation that was likely to take away their children. That was a perfectly rational position and we should listen to what people say about that.

Fast forward to 1999 and parenting orders under the Crime and Disorder Act. We find that compulsion brought parents to the party but, when they actually attended, they found—not so much men but women—that they were being treated and given skills that enabled them to manage children, largely teenage children, much better than they had been. It was a great shame that we used the criminal justice system to bring people to a parenting tuition experience that they should have been given many years before.

This is a final point from history. Michael Gove made me—this was madness on my part, as well as his—children’s commissioner for the failing Birmingham City Council children’s services. Ofsted report after Ofsted report had been telling them of their deficiencies. We found that the group they could not handle, for which they had no effective responses, was teenagers. If we are to make any progress in helping people to help the family unit, we need to address the support given to parents during the teenage years, because they are really struggling, particularly mums.

--- Later in debate ---

Moved by

[Lord Mawson]

159A: Clause 22, page 32, line 29, at end insert—
“223CZA Financial duties of NHS England: the principle of subsidiarity(1) NHS England must exercise its functions in accordance with the principle of subsidiarity, and must promote the principle throughout the integrated care system in particular by ensuring that integrated care boards observe the principle.(2) The principle of subsidiarity is that responsibility for deciding how and where to use resources is as far as possible to be delegated to local areas in order to meet local needs and to promote local groups working collaboratively.(3) In doing so, the process and timing of procurement should take account of the benefits of long-term relationships and stable partnerships in delivering sustainable integrated solutions to local health issues.”

[Lord Mawson (CB)]

My Lords, I have listened carefully to the debate taking place in Committee over the last few weeks with great interest and noted the growing consensus that now exists across this Chamber for transformation and change. These debates have shown the House at its best. It is clear that the Government now have before them an opportunity to transform not only the NHS, its culture and its ways of working but the public sector, much of which is not fit for purpose in this century. People inside and outside these systems know this—listen to those who are leaving for early retirement.

As well as listening, I have been talking to colleagues around the country: those inside the NHS systems; those responsible for the development of the ICSs; and those outside who seek to transform the health and care world and who wish to partner with these systems. I will share a few concerns that I have heard, because they relate to my two amendments, Amendment 159A and 210A.

First, colleagues both inside and outside NHS systems have heard fine words from Governments before about change and transformation in health and care, but they are sceptical. They know that the Civil Service and government systems and mindsets are not fully fit for purpose. The Civil Service’s culture and mindset need to transform; it needs to get interested in what is happening among young entrepreneurs in Bradford, for example. The voluntary and social enterprise sectors need the Government to go beyond fine words and deal with, for example, the situation that my colleagues at the Bromley by Bow Centre have to deal with every day as they navigate—as the noble Baroness, Lady Cumberlege, mentioned last week—41 different funding streams coming up the silos from the Treasury, at enormous cost and wastage of time, as they try to deliver integrated services. If we are to build a more integrated health and care programme, these practical issues are going to get worse—not just in east London but across the country—unless we address this now.

Many years ago, we had a secondee from the Treasury in Bromley who told us how all tax revenue was paid into one bank account. How much does it cost to then spread this out across 41 government departments and programmes, only for it all to be brought back together to address the multiple, complex and interlocking issues that somewhere like Bromley by Bow faces? How much cost does all this add? No one knows. Is it 20%, 30% or more? No wonder we have a productivity crises.

The Single Regeneration Budget programme was an early attempt, some years ago now, by the Civil Service and the Government to bring funding streams together. What lessons have been learned in government and the Treasury from it? I suspect there is no memory of this programme in the system.

There is also a danger of the NHS and public sector culture imposing itself on the voluntary and social enterprise sectors, as they try to innovate and generate new ways of working—what I call putting old men in new clothes. I have seen this in the housing association movement, which I was involved with in the very early days, and in what happened to children’s centres, which were launched in Bromley-by-Bow by a Labour Government, which then unwittingly undermined our integrated model and ways of working with local families.

My colleagues in parts of the country can already see the NHS centrally trying to impose its old processes on them as they innovate, at the very moment there needs to be a two-way street and real learning taking place. The centre needs to learn from the micro, from the innovation platforms we have created, not impose its outdated systems on them. Government needs now to show a clear resolve to transform the culture of the NHS or people will become even more cynical. The whole system and culture desperately needs change, and the way into this is via the micro and practical details.

Yes, it will take time, but first we must be clear about why we are taking these initial early steps and where we are trying to get to. There is a real danger of our Civil Service systems unwittingly deepening poor-quality outcomes and a dependency culture. The centre should see these innovation platforms as a place that can teach the centre, not the other way around. I declare my interests here. We need new behaviours from NHS England, not last-minute processes that want everything tomorrow. The macro needs to learn from the micro; the whole system needs to return to first principles and create an environment which encourages healthy communities.

Levelling up is surely about addressing the UK’s productivity gap, especially in marginalised communities, and one way of doing that is via a healthy and thriving population. It is also the only way to stop the NHS taking an ever-greater percentage of the UK’s GDP. I suggest health is now everybody’s business.

My two amendments fit within this mindset and suggest some first steps that could be taken along this road. Let me now deal with my first amendment, Amendment 159A. True subsidiarity cannot be achieved without delegation of resources and the authority to allocate in a way which will achieve the intended and agreed objectives. For example, systems may wish to ensure that discretionary local services such as community centres, community transport, struggling family support and meals on wheels should be prioritised and sustained ahead of further spend on health capacity, given their key role in supporting ongoing independence and social cohesion and preventing the need for health services.

Place systems may choose to pool delegated resources in order to commission collaborative services at scale, where they jointly agree that they are not best placed to provide such services, and such discussions are already taking place in mature systems. For example, in north-west Surrey we have agreed to jointly commission dermatology services across two place systems. The point is that delegation to place does not work against the development of services at a wider scale where that is appropriate, but the recognition of this needs to come from the place level.

True transformation—true to the spirit of the Bill and the long-term plan and to achieving the intended benefits of integration—cannot be achieved without the freedom to invest those resources in a way which can unlock long-term benefits. This may require speculative investment in some cases, as well as investment in preventive services which do not offer rapid returns but are essential to maintaining the ongoing sustainability of services. We would not expect any of this to be done without due diligence on the capability of place-based partnerships and appropriate levels of holding to account for achievement of improvements and results. The ICS will have a key role in not only ensuring that funds are delegated appropriately but supporting place-based systems to build the capability to manage delegated funds effectively.

We need to make leaps in how health services are now delivered through integrated services and offers to populations, by thinking radically about who can support people best, and in what way, to keep them healthy, look after them at home where possible and provide services which understand people as individuals and meet their needs holistically.

This degree of change in public health, prevention and provision of services needs innovative and broad-based collaborations and partnerships between organisations—health organisations, local authority organisations, VCSE and business—tailored to fit the needs of the place. These relationships are not quick to build; they take time and effort. The work takes years and the impact can be seen only through long-term relationships and stable partnerships. For this to succeed, the ICS will need to embrace the principle of subsidiarity, delegating meaningful responsibilities and accompanying budgetary responsibility to place level. This may mean that standard procurement cycles and processes do not immediately bring the outcomes that the Bill envisages. More innovative processes and timings may be needed to ensure that the benefits brought through long-term relationships and stable partnerships are given time to be achieved.

Let me now deal with Amendment 210A. In general, NHS bodies do not currently make best use of their local voluntary community, social enterprise and faith sectors when procuring services to achieve key health outcomes, especially in prevention and early intervention services. This is all well understood but, somehow, we never seem to get beyond one-off experiments or short-term, time-limited initiatives. By contrast, the best local authorities have been procuring and partnering with their VCFS for many years, though this has become more difficult with recent funding pressures. There is an opportunity, therefore, for health colleagues to learn from their local authority colleagues in the ICS on best practice in this regard.

With NHS vacancy rates at their highest levels, together with waiting lists for treatment, now is the time to take a whole-system approach and look more collaboratively across the local community. There is also a strong value-for-money argument. Simply waiting for people to become seriously ill, which is what is happening in practice at the moment with regard to many mental health services—but not by design—and could equally be applied to services for struggling families, leads to very poor outcomes and is very expensive. Using VCFS organisations and others, with a combination of staff and local volunteers to create a coherent health-oriented rather than illness-oriented approach, will pay dividends, but only if there is real intention and focus over a sustained period of time. This is a long-term play, not a quick win, but vital none the less.

Traditional models are not working for the groups which can offer most value. Local charities and social enterprises tend to be funded on a hand-to-mouth basis using grants, so most cannot permanently invest in their services. This is despite a huge growth in charitable giving from the public, directed in the main at the NHS.

In north-west Surrey, we are looking at how we can give similar prominence to local charities supporting areas of deprivation and communities in need, but more needs to be done to enable charities and voluntary sector groups to be assured of ongoing funding to provide core services. Keeping such VCS groups active is essential to achieve insight into the needs of communities. There are innovative approaches such as Tribe, a platform developed by a technology business- person, Richard Howells, simply because he had become so frustrated by the inabilities of the NHS and care services to deal with his own mother’s care needs. Richard did not write a research paper; he created a practical solution, which is pretty impressive. When he shared this practical solution with the NHS centrally, there was a lot of interest and fine words but, in actual detail, no follow through.

We now need to allow these insights at the most granular level to inform the commissioning and targeting of services. Without this, we will not be able effectively to respond to specific areas of inequality or health risks, leading to ill health and pressure on services. The existing models of voluntary sector support need to be developed to enable and promote micro- enterprise creation on a far greater scale. This both protects the quality of services and enables individuals to gain training, support and income. It has the potential to open up a currently untapped resource of care support, which is critical in places such as north-west Surrey, where community care staff vacancies run at around 40%.

Employment and volunteering are themselves key determinants of well-being. Place-based systems will wish to use their spending power to leverage this benefit and invest directly in local employment, where it can be demonstrated to be the most effective use of resources. In north-west Surrey, we have achieved a virtuous cycle of supporting furloughed airline workers during lockdown through recruiting them into the hospital workforce, supporting the delivery of services and well-being of clinical staff, and reducing the risk of those individuals developing physical or mental health problems through inactivity and stress.

--- Later in debate ---

This has been a helpful debate on an important matter. I hope I have been able to reassure noble Lords that we are already taking a sensible approach in the provisions in the Bill and that making amendments to it is not necessary. I therefore hope the noble Lord, Lord Mawson, will feel able to withdraw his Amendment 159A and not to move Amendment 210A when it is reached.

[Lord Mawson (CB)]

My Lords, I thank the Minister for those helpful thoughts and reflections. First, on NHS England, we need to be very sure that a two-way street is established, because I worry that systems such as this are not learning organisations—we know this from experience—and they now need to become such if they are really to embrace an environment that is about innovation and more entrepreneurial activity. I put that on the record. We will watch what happens; I am sharing with noble Lords what is actually happening now, live, in some of these services around the country as they try to establish new ways of working.

I pass on apologies from the noble Baroness, Lady Andrews, and the noble Lord, Lord Clement-Jones. They have supported these amendments but, because of the change in the timetable, were not able to be with us today. This debate is being watched around the country, and I am aware of a very interesting dialogue going on with people both inside and outside the system. We should all be encouraged by that and should build on it.

With regard to the Report stage and to these two amendments and my earlier amendment, my colleagues and I, with others in the system, will reflect on these discussions. We will, I hope, talk further with the Minister and other colleagues and think about what the next steps might be. For now, I beg leave to withdraw my amendment.

Amendment 159A withdrawn.

Health and Care Bill

Lord Mawson Excerpts

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

On the specific question of procurement, the NHS is already publicly committed to purchasing only from suppliers who are aligned with its net-zero ambitions by 2030. Last year, NHS England set its road map, giving further details on the expectations of suppliers to 2030. Once again, I hope noble Lords will accept that as real progress.

[Lord Mawson (CB)]

I thank the Minister. Can I just give an illustration about the local on this issue? I am certainly not an expert on climate change, but I am a practical person who worries a lot about granularity and the gap between a lot of talk I have heard over many years on all sides of this Chamber—with very large amounts of money cited, et cetera—and the realities in this building.

I am trying to buy an electric car at the moment, as a responsible citizen. When I went to have a look at the multi-storey car park below this building—the local—and wondered where I am going to plug it in when it arrives here, I ended up talking to one of the facilities managers, who was a very nice man. I asked him how many plug-in points there were underneath this building—again, the local. He said, “I don’t know, Lord Mawson, but I will look into this”.

He was diligent and came back to me. We started to have a conversation about it, and he began to suggest that I need to carry a cable in my car with a three-pin plug. I pointed out that my office is across St Margaret Street, in Old Palace Yard, on the third floor, so maybe I should run it across there with a carpet over it and up to the third floor to plug it in there. We had this amusing conversation. I said, “Well, go on then, tell me: how many are there in this building, where all this chatter and talk is taking place?” His answer was that there are two. I suggest that the gap between reality and rhetoric is very large indeed. If we are really going to deal with these issues—as we must—we must now become intensely interested in the NHS and in all the systems of government about practicality and the procurement machinery, which I suggest is not working.

I talked to one of the facilities people yesterday about my office, which has a light switch with a notice over the top of it telling you how to use it. It is completely ludicrous. She told me that that system is going to be different to all the systems here in the Palace of Westminster; none of it is joined up.

I think the Minister is right. The clue is in the local, but all our systems and our civil servants must now become interested in practicality and the local if we are really going to get serious about these matters. It is absolutely crucial to get procurement right, because without that, we will never deliver this.

[Lord Kamall (Con)]

I thank the noble Lord, Lord Mawson, for that intervention, and I completely agree. There are some incredibly inspirational projects going on in our local communities, tackling and addressing the green agenda, and sometimes, top-down, we may feel good about it in this place, but it really affects working people and those who face higher costs and we have to be very careful.

On the specific question of procurement, the NHS is already publicly committed to purchasing only from suppliers which are aligned with its net-zero ambitions by 2030, and last year, NHS England set out its roadmap giving further details to suppliers to 2030. This is supported by a broad range of further action on NHS net zero and we hope that by pushing this through at NHS England level, but also with ICSs, we can see some of that local innovation as local trusts and local care systems and even health and well-being boards respond to those local challenges—others could learn nationally. To respond to the question of the noble Baroness, Lady Walmsley, NHS England will publish the world’s first net-zero healthcare building standard; this will apply to all projects being taken forward through the Government’s new hospital programme, which will see 48 new hospital facilities built across England by 2030.

There is political consensus on green issues. and we should pay tribute to the noble Baroness, Lady Bennett, and the Green Party for making sure, over the years, that the green agenda has been put at the centre of British politics. We find green policies in all the election manifestos of the mainstream parties: that is in no small part due to the noble Baroness’s party and to the noble Baroness herself. So, even while we may disagree on how to achieve some of these things, there is no doubt that we are not going to reverse on our commitment. Whatever Governments are elected in future, all are committed to a carbon net-zero strategy and a cleaner environment. So, I must gently disagree with her that these amendments are necessary.

I would like to have further conversations with the noble Lord, Lord Stevens, given his experience, on why he feels that, despite all the great work that the NHS has been doing, these amendments are still necessary. I would like to have further conversations with him and others, but at this stage, I ask the noble Baroness to withdraw the amendment. Across the political spectrum, we must make sure that we are pushing the NHS to deliver, not only at the national level but at the ICS level and even lower, at the place level that the noble Lord, Lord Mawson, speaks so eloquently about.

--- Later in debate ---

[Baroness Finlay of Llandaff (CB)]

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

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

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

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

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

[Lord Mawson (CB)]

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

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

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

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

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

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

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

[Baroness Harding of Winscombe (Con)]

My Lords, I too spoke on Tuesday about my concerns about listing the specific membership for the NHS England board. I have similar concerns to those that the right reverend Prelate and the noble Lord, Lord Mawson, have just set out. However, there is a slight difference with this issue, in that the core purpose of an integrated care board is to integrate. So I recognise the very real concerns that noble Lords across the Committee have mentioned about the importance of being able to hear the voices of all the different elements of our health and care system, to hear patients’ needs loud and clear and to make it a board that genuinely works, as the noble Lord, Lord Mawson, has just set out.