Amendment 59

Health and Care Bill - Committee (4th Day) – in the House of Lords at 5:15 pm on 20th January 2022.

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Lord Howarth of Newport:

Moved by Lord Howarth of Newport

59: Clause 20, page 16, line 20, at end insert—“(1A) To this end, an integrated care board must engage providers of non-clinical services, including creative and nature-based services and other services in the voluntary, community and social enterprise sector, ensuring that it has effective channels for dialogue with these sectors.”

Photo of Lord Howarth of Newport Lord Howarth of Newport Labour

My Lords, in this suite of amendments to Clause 20, which lays down duties on integrated care boards, I am proposing that we should articulate a duty for ICBs to embrace non-clinical practice in their whole way of working. By non-clinical practice, I am referring to a range of services and interventions that promote human flourishing, such as: engagement with the arts and culture to stimulate the creative imagination; a healthy discovery of meaning, self and personal agency; engagement with nature to provide a sense of wholeness, wonder and well-being; physical exercise and sport to energise the body and mind; engagement in voluntary work to lift people from self-absorption and melancholy, and to enable them so they are useful and valued members of society; and meditation to impart calm and perspective. All this is ancient wisdom that is being rediscovered by more and more people. This rediscovery is, indeed, innovative and the Bill requires ICBs to promote innovation.

In no sense am I suggesting that such practices should substitute for modern medicine where diagnosis and good sense indicate that modern medicine is needed. Modern medicine achieves extraordinary things, but too often we resort to it without first considering non-clinical approaches. As a society, we are over- medicating; witness the almost exponential growth in the prescribing of antidepressants. Our national passion for the NHS should not be an addiction. The NHS needs, gently but firmly, to steer us into asking less of it and taking more responsibility for maintaining our own health. That should be a new norm built into the legislative framework for the NHS that the Bill provides. Unless that happens, the system will collapse under the burden of the demands and expectations that it has created.

Unless the Government systemically address the social determinants of health, we shall not have a healthy society. The Bill, harking back to the time of Aneurin Bevan, who as Minister for Health was also Minister for Housing, rightly describes the provision of housing as a health-related service. Amendment 90 goes further, to insist on well-designed housing and urban and green environments. Research evidence shows that living in greener urban areas is associated with lower probabilities of cardiovascular disease, obesity, diabetes, asthma and mental distress among adults, and obesity, poor cognitive development and myopia in children. In every place that ICBs serve, they should be promoting debate about what good urban design should mean and how it should be achieved. Encouragingly, in the new Ebbsfleet Garden City planners are co-locating cultural facilities alongside a health and well-being hub.

There is a substantial and growing body of high-quality research and evaluation demonstrating that creative health and other non-clinical approaches, as the All-Party Parliamentary Group on Arts, Health and Wellbeing said in its report, Creative Health,

“can help keep us well, aid our recovery from illness and support longer lives better lived … the arts can help meet major challenges facing health and social care: ageing, longterm conditions, loneliness and mental health”, and

“the arts can save money in the health service and social care”.

Since the publication of that report in 2017, there has been increased recognition of this among health policymakers and in the clinical establishment. Research has been commissioned. The NHS long-term plan, with its new emphasis on prevention, acknowledged the benefits of social prescribing. The National Academy for Social Prescribing was set up. Link workers, linking GPs with community providers, are being funded, though not the community providers themselves. NASP has allocated £1.8 million to its thriving communities fund to increase the scale of social prescribing activities, and the Government have a £5.8 million cross-departmental project aimed at preventing and tackling mental health through green social prescribing.

However, this activity is still marginal and its funding almost indiscernible in the NHS budget. Amendments 104 and 105 make clear that an ICB has the power to fund non-clinical providers and that there must be financial equity between clinical and non-clinical providers. If the NHS will struggle to provide enough initially, the wider levelling-up strategy should enable that funding.

Non-clinical health providers cost a fraction of conventional medicine and represent remarkable value for money. The Evaluation Report of the Social Prescribing Demonstrator Site in Shropshire showed significant improvements in health factors such as weight, physical activity, smoking and blood pressure, and a reduction of up to 40% in GP appointments. Dance is inexpensive to lay on. As the Dancing in Time project in Leeds showed, by improving gait, flexibility and strength, it reduces falls among the elderly, who are expensive to repair.

To fail to invest on a reasonable scale in creative health and other non-clinical services is to look a gift horse in the mouth. This is recognised in some ICSs, with which the National Centre for Creative Health, a charity which I chair, is working on pilot schemes. In the Shropshire, Telford and Wrekin ICS, the personalised care team is using creative health and co-production methods with children and young people suffering from asthma. In the Suffolk and North East Essex ICS, clinicians looking for ways to support patients with long Covid have introduced singing for breathing, which is beneficial for lungs and loneliness. Creative Minds in the South West Yorkshire trust has developed creative activities that now benefit the physical and psychological well-being of 6,500 people a year. One user of the Creative Minds “Art for Well-being” programme, Debs Teale, a trustee of the NCCH, said:

“I am eternally grateful to … Creative Minds for giving me the wonderful opportunity to discover a mind released from the fog of depression. I have been five and a half years medication-free”.

The Lived Experience Network, or LENs, brings together people with lived experience of ill health who provide powerful personal testimonies of the benefits of creativity and the arts to their own health and well-being. As the Bill recognises in the requirement for ICBs to promote the involvement of each patient, the voices of people with lived experience should always be heeded as we shape the health service and consider the prescriptions and treatments that are appropriate.

The culture of the NHS is predominantly science-based, technical and bureaucratic. Doctors and nurses of course seek to imbue their practice with empathy. Some of the wise among them recognise, in the words of Dr Elaine Yeo, in a recent letter to the Guardian, that

“general practice is an art—the art being when to use the science.”

It is time the science knew when to use the art.

Medical education and training, which the Bill states it is the duty of ICBs to promote, must be the fountainhead of culture change in the NHS. The education of clinicians, public health specialists and other health and care professionals should follow the example of pioneering medical schools, such as the University of Exeter Medical School, which has a compulsory study unit enabling students to work with creative practitioners. A new master’s in creative health at UCL has a strong practice-based component, delivered in partnership with community organisations. In York, Dr Nicola Gill delivers a CPD course for GPs on the power of the arts and the value of community-based resources for self-care and care of patients.

Noble Lords will have understood the purport of the amendments in this group and it would be excessively laborious for me to explain each one. I invite the Committee to look at them as a whole and to consider whether ICBs should be under a legislative duty to work in full partnership with non-clinical providers to gain the benefits they can offer for the health and well-being of individuals and communities.

As the noble Lord, Lord Mawson, reminded us in an earlier debate:

“A human being is fundamentally a creative being.”—[Official Report, 13/1/22; col. 1237.]

I know that the Minister, the noble Lord, Lord Kamall, will need no persuasion of the salutogenic virtues of the arts. He is himself a musician—a bass guitarist, indeed. I do not know whether his band is still called Exiled in Brussels; I hope he has not renamed it Exiled in Whitehall, because, like all of us, he needs to think positive, not least in accepting these amendments. I beg to move.

Photo of Baroness Barker Baroness Barker Liberal Democrat Lords Spokesperson (Voluntary Sector), Deputy Chairman of Committees 5:30 pm, 20th January 2022

My Lords, it is a pleasure to speak in support of the noble Lord, Lord Howarth. When I read these amendments I was immediately taken back about 20 years, to the offices of a charity that noble Lords might remember called the British Trust for Conservation Volunteers. It had a very worthy reputation. I think most people who knew vaguely of its work but did not know it in any great detail regarded it as middle-class do-gooders in bobble hats who went out and cleaned up local rivers and things that nobody else much bothered about. But 20 years ago, it began to do some of earliest work that charities did in drilling down into not only what they did but the impact of what they did. When the trust did that, it discovered two things. First, it discovered that the volunteers were much more diverse than one would have thought—there were all sorts of people from all sorts of different backgrounds, many of them in urban settings. Secondly, it found that the biggest impact it had was on the mental health of the people who volunteered. As an organisation, it tracked that as best it could in its non-clinical fashion.

I bring my observation up to date, to about three years ago, just before lockdown, when I had the great good fortune to be invited to the offices of Google one night. I remember it was a winter’s night with absolutely filthy weather, and 250 young people—or youngish people—turned up to talk about mental health and tech. The big question was around what we can do, given who we are, who we work for and the data that we are amassing now, about not just what people are doing but what they intend to do and the profiles we are beginning to build up about people’s behaviour.

It is to those two memories that I attach these amendments, because I think the noble Lord, Lord Howarth, is right. Everybody knows the value of this—we all know it as individuals. Who did not go nuts during lockdown and head out to the nearest bit of green space to cheer themselves up? We all know it, but how do we prove it to those in the NHS who, rightly or wrongly, hold fast to scientific data and evidence?

My point is simply that we should be trying to get this on to the agenda of the acute services, rather than primary care, and that we need to do so in a way that is collaborative. I think we should be challenging the acute services to tell us how they would evaluate this—what evidence would convince them? It might be the sorts of biometric evidence that people who are involved in mindfulness are beginning to generate; the fact that we can actually see differences in people’s brain patterns if, over a sustained period of time, they are engaged in things such as mindfulness.

I sincerely hope that we do not pat these amendments on the head and send them on their usual way into the background and to the byways of primary care. I hope that, although the amendments may not make it into the Bill, noble Lords might well challenge the department, NHS England and the acute sector to see this as a far more important part of prevention, particularly in mental health but also in a number of physical conditions, than they might otherwise have done.

Photo of Baroness Greengross Baroness Greengross Crossbench

My Lords, I am in favour of the amendments in this group in the name of the noble Lord, Lord Howarth, specifically Amendments 59, 67, 71, 77, 80 and 82. My own Amendment 290 will be debated in group 41 and specifically addresses the importance of social prescribing for people with a dementia diagnosis and how this can form part of a wider care plan.

Social prescribing plays a very important role, not just for people with diagnosed conditions but generally, as part of wider brain health. Research by Arts 4 Dementia found that music-making provides a tool for a total brain workout and improves plasticity in the cortex, which enhances the ageing brain’s cognitive abilities, perception, motor function and working memory. It also improves cardiovascular strength while reducing stress. The Coda Music Trust provides a range of musical social ensembles and bands, as well as courses and classes for learning and well-being. In other studies, drama and poetry have been found to improve concentration and cause new neurons to develop and adapt.

Social prescribing has been recognised as playing an important role. It is part of the NHS long-term plan, and the Department of Health and Social Care has allocated funding to establish a national academy for social prescribing. This growing recognition of the role that social prescribing, specifically of music and art, can play in overall health is a welcome development because many of the programmes that exist at present rely on the voluntary sector.

During the pandemic, these programmes, like most of the voluntary sector, have struggled with funding and with being able to continue their work under Covid-19 restrictions. We also know that many arts venues have struggled through this time and many theatres and music venues now face an uncertain future. This sector therefore needs much more support right now if it is to continue its work. It is crucial that integrated care boards are empowered to promote social prescribing and can work with organisations that provide these services.

Although the evidence for the benefits of social prescribing is growing, more work is needed to research what types of social prescribing are successful for specific conditions, a point that I will elaborate on when we debate my Amendment 290, which addresses social prescribing and dementia. To help promote social prescribing, we need more training for GPs and other health professionals on how and when to prescribe these services. We also need to include arts awareness for mild cognitive impairment in the medical and social care educational curriculum.

There also needs to be greater availability of these services, with links to every GP. The current NICE guidelines for dementia recommend referring patients for these services only post diagnosis when, in fact, to promote overall well-being and brain health, we should encourage them much earlier from the onset of symptoms. For this, we need training, and integrated health boards must prioritise the availability of these services.

I thank the noble Lord, Lord Howarth, for these amendments and fully support their inclusion in the Bill. I look forward to the Minister’s response. I also want to take this opportunity to thank the noble Lord, Lord Kamall, whom I have often heard recently. He confirmed that his blues band, Exiled in Brussels, will play at an event supporting Music for Dementia later this year.

Photo of Lord Best Lord Best Crossbench

My Lords, I thank the noble Lord, Lord Howarth of Newport, for his inspiring speech. I declare an interest as a vice-president of the Local Government Association. I also chair the University of Oxford’s Commission on Creating Healthy Cities, which brings together academics, policymakers and practitioners. We hope to support city leaders and their citizens by shedding light on the policy interventions that are most likely to be effective in enhancing the health of their cities.

The Oxford commission is not due to report until later this year, but it is already clear that the two core issues raised by the noble Lord, Lord Howarth, in this group are likely to be central to our conclusions. The first relates to the wider determinants of health creation that take us beyond the integration of health and social care services towards recognising the relationship of public and personal health to other non-clinical services, including those affecting the built environment. The second issue relates to the value of engaging local and community organisations in a variety of ways in achieving health outcomes.

Our Oxford commission is learning about the underlying causes of health inequalities, looking at interventions that address healthy lifestyles, such as: combatting poor diet and obesity; the value of social prescribing, which is getting a good airing tonight and will get even more as the Bill progresses; healthy transport, such as encouraging walking and cycling, with linked impacts on air quality; and healthy homes in healthy environments.

It is the last issue, housing and place, that I want to address in the context of, in particular, Amendment 90 in the name of the noble Lord, Lord Howarth of Newport. I hardly need to emphasise the significance of housing as a health issue. Obviously, homelessness causes every manner of physical and mental health problems, and your Lordships’ debate on Tuesday drew attention to the exclusion of homeless people from the healthcare system.

However, housing conditions impact on a vastly larger number of citizens. Overcrowding clearly has serious health impacts, as revealed in the Covid statistics, for example. Cold and damp conditions lead directly to hospital admissions and excess winter deaths. In his analysis of health inequalities, I note that Sir Michael Marmot has given housing a very high priority. For later living, homes that are in bad condition and/or have unmanageable steps and stairs mean not only hospital admissions for older people but serious delays in hospital discharges and swift readmissions. Incapacitating housing drives older people into costly and unpopular residential care. Better housing is key to the health and well-being of our ageing population.

As the All-Party Parliamentary Group for Housing and Care for Older People—and I declare my interest as its co-chair—has long maintained, health, care and housing represent three legs of the same stool. All three components need to be integrated through the new ICBs in a way that health and well-being boards have not be obliged to achieve. Such a duty for ICBs has special resonance in relation to older people for whom getting the right housing is fundamental to health, whether by right-sizing to accessible, manageable, companionable, new accommodation that can also end years of loneliness or by retrofitting unsatisfactory, unhealthy, existing homes.

The health and social care White Paper demonstrated dawning recognition of this housing dimension with a planned boost to grants for home adaptations. Now the Bill before us takes a step in the same direction. The clause to which Amendment 90 draws our attention states that:

“Each integrated care board must exercise its functions with a view to securing that the provision of health services is integrated with the provision of health-related services,” wherever this would improve the quality or outcomes or reduce health inequalities. It adds that

“the provision of housing accommodation is a health-related service.”

This duty in the promotion of integration seems to me to represent a very welcome breakthrough in the recognition of the health impacts that housing can achieve and demands, at last, the greater integration of health and care and housing which a number of us have sought for so long.

Amendment 90 seeks to extend the inclusion of housing in the duty on ICBs to promote integration to embrace the wider environment. Health is certainly enhanced by access to nature, parks, green spaces and a quality urban environment, as the noble Lord, Lord Howarth, noted so, without wanting in any way to diminish the reference already in the Bill to housing, I certainly support the addition of reference to the wider environment.

The other aspect of the amendments tabled by the noble Lord, Lord Howarth, in this group calls for recognition of the role of

“the voluntary, community and social enterprise sector and creative and cultural bodies.”

These various organisations—perhaps exemplified by the enterprises established by the noble Lord, Lord Mawson, to whom fully justified tributes have been paid this week—can make a fundamental difference not only to the way local needs are recognised and services are provided but to the buy-in, the acceptability, of actions within local communities that are necessary but seldom universally popular.

In keeping with my housing theme, I wish to highlight the voluntary and community bodies that comprise the non-profit social housing sector which, while being regulated but independent of the state, contributes immeasurably to the nation’s health. Today, social housing providers are almost universally present throughout country, working in partnership with local authorities. Many are themselves community-led enterprises doing brilliant work which is improving health and well-being.

Although we need the scale of provision achieved by today’s major housing associations, which have developed over the last 50 years from tiny origins to massive social businesses, some of the most innovative and entrepreneurial social housing bodies are those that remain embedded in their local communities, such as the housing charity Giroscope in Hull, which provides housing, employment and training by renovating derelict and empty properties. It helps ex-offenders, the long-term unemployed, those with mental health problems and those recovering from alcohol and drug misuse. The Leathermarket community-led housing organisation works in partnership with Southwark Council to develop truly affordable homes designed by and for the local community, as witnessed on a recent visit from your Lordships’ Built Environment Select Committee. These community-based housing enterprises are among hundreds of varied initiatives up and down the country that deserve the recognition proposed by these amendments.

In conclusion, I welcome the inclusion of housing in the Bill, as part of the integration of services to achieve health and well-being objectives. I support the amendments in the name of the noble Lord, Lord Howarth of Newport, in extending this to embrace the wider urban and green environment that impacts health and well-being. I also commend the noble Lord’s amendments that would give prominence in the Bill to the voluntary and community bodies of which, I maintain, those with housing objectives now represent an important part of the country’s social fabric. I support the amendments.

Photo of Baroness Morris of Yardley Baroness Morris of Yardley Labour 5:45 pm, 20th January 2022

My Lords, I also wish to support the amendments that have been moved by the noble Lord, Lord Howarth, and supported by other speakers. I do not want to make a long speech, but I want to add weight to the argument by standing up and offering support. I will not repeat his arguments, but I want to pay tribute to the work that the noble Lord, Lord Howarth, has done in this regard. He chairs the All-Party Parliamentary Group which produced a report that was pivotal in taking this debate forward. The work that he has done with the National Centre for Creative Health has given us an army of evidence on its importance.

The amendments seem to fall into two groups. There are those around social prescribing for people with dementia as the noble Baroness, Lady Greengross, said, and the notion of health promotion by creating a better environment in which we live and preventing illness. That collection of amendments is an idea whose time has come. There is an amendment for later consideration to which I have added my name, for which the same arguments are being made for sport and recreation. I think of this as the whole area of health promotion, which is looking at non-clinical providers of healthcare. I think these amendments follow on very well from the last group of amendments that was debated.

The noble Lord, Lord Scriven, talked about the aims of this legislation as being about promoting well-being, and the noble Baroness, Lady Cumberlege, gave a very good example of how a community centre that had doctors in it has become a medical centre, and the message that they gave. Every single one of us here could make the arguments that we have heard so far, either from our own example—from our own health and well-being—or from something we have seen.

I wanted to mention two things. First, I declare an interest: I am director of the Royal Liverpool Philharmonic Orchestra, and the work that it does with Mersey Care NHS Foundation is magical. It sometimes goes unnoticed outside the region, but people with quite serious mental health needs are finding their well-being is promoted. They are enjoying themselves and feel more part of the community.

My second example is some work I did in Derbyshire with a charity of which I was patron, First Taste. The artwork it did in a care home meant that the prescription of drugs for sleeping and other things was reduced. All those arguments can be well made but my problem is this: I would have put money on no one standing up and arguing against these amendments. If you could stop 50 people out there and find three who will argue against these amendments, I would say “Well done”.

The danger for this area of policy is that no one is against it, but not enough is being done to get it to the top of the agenda. Sometimes, when no one is against it, you do not have the argument that promotes it up the national agenda. Everyone says “Great”, “We agree”, “It will be a great thing” and nothing happens. The stage of this area of policy is that everybody is doing a little bit. It is in the long-term plan. There are examples of good practice. We have the evidence that it works and the Government are investing some money, but it is never going to be an entitlement or a policy that has been enacted nationally unless something else happens.

In all public sector policies—it is the same in education—the biggest challenge is scaling up good practice. We now have lots of examples of good practice. What we need, and what is behind this amendment, is to scale it up so that it is not just a case of happening to live near an organisation or where somebody is making this happen. The amendments that we have, which are to the general duties of the integrated care boards, will be a step forward in trying to make this a national part of our well-being service. You are entitled to it; it is there and offered to you, no matter where you live.

That is the big task now. It is not making the case for social prescribing or non-clinical providers having a role to play in health promotion, but how we scale it up so that it goes higher up the agenda of people who are developing policy and deciding how resources should be spent in an area. Years ago, this would have been seen as a fringe interest and people might have thought the noble Lord, Lord Howarth, was eccentric in promoting such amendments. It is evidence-based now. It is what people know works and I think it is what people want. We just have to find a way of getting it up the agenda and making it happen. These amendments will go towards that end.

Photo of Baroness Tyler of Enfield Baroness Tyler of Enfield Chair, Children and Families Act 2014 Committee, Chair, Children and Families Act 2014 Committee

My Lords, I rise briefly to support this suite of amendments put forward by the noble Lord, Lord Howarth. I know how passionate he feels about this issue and how much work he has done in this area over many years. The noble Baroness, Lady Morris, has just taken the words right out of my mouth; I was going to start by saying that social prescribing is a phenomenon whose time has come. I think that is right. People understand that the approach of social prescribing is really opening up opportunities for people to improve health and well-being through non-clinical avenues. That is what this set of amendments is all about.

This is particularly relevant for people with long-term conditions and complex needs, particularly those with mental health conditions, suffering from dementia or experiencing loneliness. The one point I want to make, which I do not think has been talked about yet, goes right back to our opening debate today about how the ambitions of this Bill will be achieved only if there is true integration across health and social care. My big plea is: please do not forget social care when we are looking at this issue. When I say social care, I am thinking both about people who have domiciliary care in their own homes and people in care settings.

I will briefly use a quick example. My mother has been in a residential care home for a number of years with a range of complex issues and conditions. I have seen first-hand the difference that it makes when there are activities. Sometimes there are arts activities, sometimes it is music or a musical quiz. The difference to my mother’s well-being and sense of mental health is enormous—as, indeed, is her sense of agency and empowerment, because she used to be an artist. Once that was understood, it was even possible to organise an event where she was sharing her knowledge and her expertise with other residents. I know that did a massive amount to boost her self-esteem. Very sadly, however, during the pandemic and lockdown, there were so many times when residents were confined to their rooms and unable to go into communal areas, or when the person who normally delivered these activities was not available, so these events did not happen. It was only a matter of weeks before I saw my mother’s well-being really go down very dramatically indeed. I am therefore massively in favour of this group of amendments, designed to support vulnerable people who are lonely, isolated or experiencing poor mental health, or have learning disabilities.

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

Photo of Lord Crisp Lord Crisp Crossbench 6:00 pm, 20th January 2022

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

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

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

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

Photo of Baroness Finlay of Llandaff Baroness Finlay of Llandaff Deputy Chairman of Committees, Deputy Speaker (Lords)

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

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

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

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

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

Photo of Baroness Pitkeathley Baroness Pitkeathley Deputy Chairman of Committees, Deputy Speaker (Lords)

My Lords, what I want to say follows on very well from what the noble Baroness, Lady Finlay, said. I want to quote Sir Michael Marmot. He said:

“We need to adopt a health and social care system which prioritises not just the treatment of illness but how it can be prevented in the first place. The pandemic has made it crystal clear … why public health and … social determinants of health are so important. The health and social care agenda must be rebalanced towards prevention.”

This is essentially what the noble Lord, Lord Howarth, is saying. It is not just about the treatment of illness but about preventing it happening in the first place.

I commend my own general practice in north London. In despair at the quantity of antidepressants being prescribed with very little result, it took to organising community groups to do cooking, set up friendship groups and put people in contact with each other. It puts on bring and buy sales—all with people who, perhaps, in the past, might just have been prescribed antidepressants.

I want to say a word about the charitable aspect—the voluntary sector—to which the noble Lord, Lord Howarth, referred. Charities cannot operate unless their core costs are met. My own GP practice which did this wonderful work had to go to the local authority and to the lottery to seek some funding. We have to remember that, if we want voluntary organisations to participate in these wonderful preventive services, we need to ensure that they are properly funded.

Photo of Baroness Bennett of Manor Castle Baroness Bennett of Manor Castle Green

My Lords, I join pretty much everyone else in commending the noble Lord, Lord Howarth, for tabling these amendments. I have attached my name to Amendment 67, although it could have been to any of them.

It is worth making two broad points. In her wonderful contribution on the last group, the noble Baroness, Lady Cumberlege, used the really key phrase,

“the community provided the health”.

That is what this group of amendments is talking about.

A couple of groups back, the noble Baroness, Lady Thornton, talked about how, if the health system is working for people with learning disabilities, it is working for everybody. If we bring in the kind of institutions, frameworks and supports that we are talking about here—if we think about stopping people getting ill and caring for ill people—we will make our communities vastly better for everybody. This is an important point to make.

Like most noble Lords, I could come up with a list as long as your arm of wonderful places I have visited. I will not, but I will mention one, which brings together three elements of this: creativity, nature and culture. The Green Backyard in Peterborough is the most wonderful space. I defy anyone to walk into it and not smile. It has amazing, colourful, moving sculptures powered by water, with food growing—amazing salads filled with flowers. When I visited, I spoke to the carer of another visitor. This visitor had very profound disabilities—she was blind and non-verbal—but her carer said, “I’ve never seen anything like it. After the first time we came to visit, the next Monday, which she knew was the day we visited, she was all packed up, dressed and ready to go out.” This was obviously catering to someone’s needs absolutely brilliantly, but it nearly got bulldozed and turned into a block of flats a few years ago. Luckily, it was saved, but that is the situation we so often find ourselves in.

I also want to mention Amendment 90, in the name of the noble Lord, Lord Howarth. The noble Lord, Lord Best, has already said a great deal on this, so I will seek to add just a couple of small points—well, one small point and one quite big one. There is something called the lifetime homes standard, which I learned about when I visited Derwenthorpe in York with the Joseph Rowntree Foundation. The thing I remember about it, because it was so simple and obvious, was that the two-storey houses there had all been built with a space between the joists so that, if you needed to put a lift in up to the first floor, where the bedrooms were, it was a really simple and low-cost thing to do. It was a very simple piece of design. This will not be covered in the Health and Care Bill, but this relates to so many aspects of our society. You could say that housing is a health issue. In the first group this morning, we talked about social care and how many people cannot leave hospital and go home because their accommodation is unsuitable. We need to think all the way along the line across our society to make sure that does not happen.

Finally, I want to pick out one or two words in this amendment, which talks about housing and urban environments. I thought here of the New Ground co-housing development in north London, which is for women aged over 50. One aspect of it is looking at how people can support each other, be good neighbours and form a community that can provide support. This morning, I attended a King’s Fund briefing talking about social care and there was a great deal of talk about the need for digital innovation and technology. I tweeted, “What about social innovation?” We have to think about how we organise our societies and urban environments so that people can form those kinds of communities. If you visit any area of new housing being built around the country, there is typically precious little in it to encourage that kind of community development. The housing point is obvious, as is the environment point, but let us not lose the community and urban structure points from that amendment either.

Photo of Baroness Walmsley Baroness Walmsley Co-Deputy Leader of the Liberal Democrat Peers

My Lords, it has been an excellent debate. We have heard about all the various kinds of arts and the effect of housing. We heard from the noble Baroness, Lady Morris, about sport and leisure. We heard about the importance of green spaces in helping us with our physical and mental health. The noble Baroness, Lady Finlay, rightly mentioned that loneliness kills. If one can address that, it affects not just one’s sense of worth and well-being, as has been said, but one’s sense of community.

Parliament is a community. It sometimes does not feel like it, because we have various groups, political parties, Members, staff and so on, but we also have a lot of all-party groups and this is significant. We have sports, arts and heritage, drama and music groups. I have been a member of the Parliament choir for 22 years and have found great solace in it—I really missed it during the pandemic.

My noble friend Lady Tyler said that we must not forget about social care. I was very interested to hear about her artist mother and how she had shared that within her social care setting. My mother was a singer, as am I. When she was in her 70s, we were rather amused because she would talk about going and “singing for the old people” in the local care home. She did that to great effect. She got a lot out of it and so did they. I say to the Minister that I have been known to sing with the jazz band of the noble Lord, Lord Colwyn, so if he is looking for a vocalist for his blues band, I might just audition.

If Parliament as a community can benefit from all these things, then every community can. It is absolutely right that the noble Lord, Lord Howarth, should raise these issues. I would be interested to hear how the Minister feels that this principle can be incorporated in the new world of integrated care services.

Photo of Baroness Thornton Baroness Thornton Shadow Spokesperson (Equalities and Women's Issues), Shadow Spokesperson (Health) 6:15 pm, 20th January 2022

My Lords, I am delighted that my noble friend Lord Howarth has brought this suite of amendments in front of the Committee and is bringing the wealth of his experience to our debates on the Bill. He is a great proponent of the role and value of the non-clinical services in healthcare and well-being, and quite rightly too. It would be great if, somehow or other, this could be recognised in whatever comes out of our considerations, though I challenge the Minister to tell us how we might do that.

We support the amendments in this group to establish a role for wider considerations beyond remedial, interventionist clinically-led care. Amendment 90 covers housing. The role of decent housing in good health and in tackling health inequalities cannot be overestimated. Amendment 103A would require IBCs to consult on youth health prevention and treatment through an advisory board consisting of young people. All these amendments have huge merit.

I know that we will have a wider discussion about the role of the voluntary sector and social enterprises in provision of healthcare in a later group. However, voluntary and community organisations and social enterprises have been central to the delivery of non-clinical services in healthcare and well-being, particularly during the pandemic.

Photo of Baroness Chisholm of Owlpen Baroness Chisholm of Owlpen Baroness in Waiting (HM Household) (Whip)

My Lords, before I respond on this group, I want to apologise for the chaos that I caused at the beginning of this Bill today. I hope that noble Lords did not think I was being discourteous to the House. Luckily, next Wednesday, normal services will be resumed when my noble friend Lady Penn is in her seat.

I am grateful to the noble Lord, Lord Howarth, and other noble Lords for bringing this suite of amendments before the Committee. It was interesting that several noble Lords brought up my noble friend the Minister’s band, Exiled In Brussels, which I think he is now going to rename “Exiled From Brussels”. I can say that there is a YouTube clip of the band which my noble friend said he is willing to send out to everybody, so that is something to look forward to.

On Amendment 59, I recognise the noble Lord’s concern to ensure that the voluntary, community and social enterprise sectors are represented in the Bill. I understand the intention of his amendment. I certainly acknowledge the important work of these sectors and their contribution to our health system. I am sure that we all have examples of how these non-clinical services are of benefit to our health system.

However, our intention, quite rightly, is to use the Bill to set out a framework of duties for ICBs that ensures they fulfil their functions effectively while avoiding being overly prescriptive. The provision in question sets a clear requirement on ICBs to discharge their functions in a way that promotes continuous improvement in the quality of services, particularly in health outcomes.

The intention is to establish a culture of continuous improvement in everything the ICB does, but, importantly, leaving ICBs to decide how this will work for them. Setting specific parameters, as this amendment seeks to do, would in practice narrow the focus of how they may look to improve the quality of services. This may be to the detriment of taking a more holistic approach to how to improve the quality of services. That said, the current drafting of the provision would not prevent ICBs engaging providers of non-clinical services, including those mentioned in the amendment of the noble Lord, Lord Howarth of Newport. Indeed, we would expect that, where appropriate, ICBs would consult with relevant stakeholders, such as those from the voluntary sector, to ensure continuous improvement.

Turning to Amendment 69, co-production, where people, family members, carers, organisations and commissioners work together as equal partners to design and deliver services, is an important principle, and one that we would expect ICBs to champion. This is reflected clearly in NHS England’s draft implementation guidance on working with people and communities, which also sets out several practical steps ICBs should consider to appropriately promote and embody co-production. This includes visibly supporting and sponsoring co-production, and supporting the adoption of co-production approaches where appropriate. I feel it is important to point out that mandating co-production in all circumstances risks narrowing the duty and may lead to other valuable methods of involvement being marginalised. Therefore, while it will often be a desirable aim that we would expect ICBs to pursue, it may not be appropriate in every case, and we want to allow ICBs and patients discretion to determine what is best in their area.

I will address Amendments 71 and 77 together. I am grateful to the noble Lord, Lord Howarth, and the noble Baroness, Lady Greengross, and I appreciate the interest in including social prescribing in the Bill. On Amendment 77, I begin by assuring noble Lords that the Government are absolutely committed to the rollout of social prescribing in line with the NHS Long Term Plan commitment. The plan was to have 1,000 new link workers in place by 2020-21, a target which I am pleased to say has been exceeded, so that we now aim for at least 900,000 people to be able to be referred to social prescribing by 2023-24. As of September 2021, there were at least 1,582 social prescribing link workers in place. Furthermore, in relation to innovation, the Government have set up the National Academy for Social Prescribing, in line with our manifesto commitment, which has continued to support the expansion of social prescribing and promote innovation in health and well-being across all sectors.

The duty to patient choice should be considered by ICBs as part of the broader move towards more integrated, population health-management approaches. This requires embedding more personalised care models that enable patient choice and also consider non-clinical approaches, in line with the NHS Long Term Plan. This commitment is to make personalised care business as usual across the health and care system. Social prescribing and community-based support is already a core component of the NHS’s comprehensive model of personalised care. I hope I have reassured noble Lords of the progress being made and work being done on social prescribing and that they will feel able not to press these amendments.

I turn next to the amendments proposed by the noble Lord, Lord Howarth, and the noble Baroness, Lady Bennett of Manor Castle, which would insert a number of references to the voluntary community and social enterprise and creative and cultural sectors. This Government hugely value the contributions of the voluntary community and social enterprise sector, including creative and cultural entities, to the health and well-being of the nation, and recognise their important role in integrated care systems. However, we feel that the amendments are not necessary, as their intended effect is already possible through provisions within the Bill.

A key principle of the Bill is the legislative flexibility to empower local leaders to develop bespoke solutions to meet specific local needs. This principle is reflected in the current drafting of Clause 20. Several of these amendments would have the effect of being overly prescriptive in areas where we would already expect the VCSE sector to play a key role.

I assure noble Lords that many of these concerns will instead be addressed in guidance. NHS England and NHS Improvement have published guidance relevant to ICBs on partnerships with the voluntary community and social enterprise sector, outlining the importance of the VCSE sector as a key strategic partner in local health systems. It provides guidance on how VCSE partnerships should be embedded in how the ICBs operate. Furthermore, the guidance sets out that, soon after they are established, ICBs will be expected to develop a formal agreement for engaging and embedding the VCSE sector in system-level governance and decision-making arrangements.

I turn to related Amendment 80. I know that the noble Lord, Lord Howarth, has a special interest in this issue, and I listened with interest to his speech at Second Reading on the work of the National Centre for Creative Health, which he chairs. Research is very important, and I am pleased to say that the department funds research in this area through the National Institute for Health Research. The NIHR funds and supports a range of research conducted by multidisciplinary researchers from diverse fields, including social sciences, behavioural sciences and the humanities. For example, the MODEM project, jointly funded by the NIHR and UKRI, reviewed evidence on music therapy and identified that a structured programme of music therapy given by a trained therapist can reduce agitation among people with dementia—which I think the noble Baroness, Lady Tyler, mentioned in her speech.

We do not consider it appropriate or necessary to specify particular research areas in primary legislation. In addition, we expect that ICBs will already promote a range of research, including those on non-medical interventions, and the noble Lord already cited in his Second Reading speech where this has been done by existing integrated care systems.

On Amendment 82, the Government place the utmost value on supporting the health and well-being of NHS staff. We are taking a range of actions to ensure that this remains a priority across the health and care system, and we do not believe that a legislative duty is needed in this area. Over the past two years we have seen as never before the intense pressures on the workforce, and we recognised at an early stage the toll that this may place on the mental health and well-being of health and care staff, with a clear need to prioritise enhanced well-being and mental health support for all NHS and social care staff. We all know that the whole country owes these staff an immense debt of gratitude.

At a national, strategic level, the People Plan, published in July 2020, puts NHS staff health and well-being at its core and ensures that all NHS staff have access to a comprehensive psychological and emotional support package. This includes a dedicated support line that is available for staff 24/7, and free access to mental health and well-being apps. Alongside this, 40 dedicated mental health hubs have been established and are accepting referrals across the country to proactively identify at-risk people and groups and focus on staff with more complex needs, ensuring that they receive rapid access to evidence-based mental health services. To ensure that this offer continues to improve staff mental health throughout 2021-22, an additional £37 million has been invested in 2021-22, building on the £15 million in 2020-21. I hope that the noble Lord, Lord Howarth, will accept that this work is worth while and important and will continue without the need for legislative amendment.

On Amendment 90, we recognise, as we heard from the noble Lord, Lord Best, that good-quality housing is a vital component of a healthy life, and we support the ambition of closer collaboration between the health system and the planning system. However, housing is a local authority function, and we do not need to duplicate responsibilities by placing specific duties on ICBs. I hope I can give noble Lords comfort in that, in many places, integrated care partnerships are also intending to consider housing needs in their areas, alongside health, public health and social care needs, as part of the integrated care strategy. The ICP model is flexible enough to allow the right people to take part in the discussion.

I have spoken for rather a long time, but this is an important subject. I hope I have reassured noble Lords that it is very much part of health going forwards, but I regret that the Government cannot accept these amendments, and I ask noble Lords to withdraw or not move them.

Photo of Baroness Bennett of Manor Castle Baroness Bennett of Manor Castle Green 6:30 pm, 20th January 2022

Before the noble Baroness sits down, I would just like to go back to some of the earlier amendments and some of the words she used. She said this is included in the guidance on using social prescribing, and that it is expected that ICBs will work with local social enterprises, et cetera. I want to ask a question. If we were talking about NICE-recommended medical treatments or the best possible surgical procedures, would we be saying that it is expected that ICBs will do this as it is included in the guidance? This picks up on the point the noble Baroness, Lady Morris, was saying that this still seems to be somewhere in the second class, and it should be up there in the first class, treated in the same way as a medical treatment or a medical device.

Photo of Baroness Chisholm of Owlpen Baroness Chisholm of Owlpen Baroness in Waiting (HM Household) (Whip)

Well, I think it is, actually. We all realise how important it is. Social prescribing is a key component of the NHS’s universal personalised care. It is a way for GPs or local agencies to refer people to a link worker. Link workers give people time to focus on what matters and take a holistic approach to people’s health and well-being. They connect people to community groups and statutory services for practical and emotional support.

For instance, a man had bad bronchitis and asthma and was continually going to the doctor and costing the NHS a great deal of money; and it was agreed that a humidifier would be prescribed to him for his house at £800, and that has been a huge success, with the result that he has not gone to the GP once for a whole year. I think social prescribing can work well for those who are socially isolated, whose well-being is impacted by non-medical issues and who routinely present to primary or secondary care as a result. We certainly are taking it seriously.

Photo of Baroness Barker Baroness Barker Liberal Democrat Lords Spokesperson (Voluntary Sector), Deputy Chairman of Committees

The noble Lord, Lord Howarth of Newport, is taking part remotely. I invite him to speak.

Photo of Lord Howarth of Newport Lord Howarth of Newport Labour

My Lords, I am extremely grateful to the considerable number of noble Lords who have taken part in this reflective, interesting and important debate. I am most encouraged by the appreciation that has been expressed all around the House for the importance of the considerations that I have sought to advance in this suite of amendments.

I am particularly grateful to the noble Baroness, Lady Barker, for her opening speech, which very much set the tone of the subsequent debate, and for sharing with us her memories of Google on a winter’s night. She made a particularly important point about evidence that is developing to demonstrate, for example, that the practice of mindfulness has benign effects on brain development. That is profoundly important for health. This needs to be understood and taken seriously by those who fund research and those who are pioneering practice within the NHS.

The noble Lord, Lord Best, may remember, as I do fondly, that, many years ago—I mention this particularly to the noble Baroness, Lady Bennett of Manor Castle—he showed me the Lifetime Homes project that he led when he was in charge of the Joseph Rowntree Foundation in York. He has been an advocate of the importance of well-designed housing for a long time and is a voice that is hugely respected on this, as on so many other subjects, in your Lordships’ House.

My noble friend Lady Morris of Yardley raised the important point that yes, we have come a long way and these ideas are no longer seen as eccentric, but, at the same time, unless policy is much more clearly enunciated and embedded, little, if anything, will really change. That is a question that the Minister did not adequately address, but I shall come back to it in a moment.

I was also grateful for the support from the noble Baroness, Lady Tyler, and the emphasis that she rightly gave to the contribution that the arts, creativity and other non-clinical services can make to the well-being of people in social care. I should mention that the charity Live Music Now, founded many years ago by Lord Yehudi Menuhin, has been supporting young professional musicians to perform in social care settings for many decades. That is hugely appreciated and beneficial. If his efforts were supplemented by those of the mother of the noble Baroness, Lady Walmsley—indeed, by the noble Baroness herself—so much the better.

The noble Lord, Lord Crisp, has thought more deeply about these matters than almost anyone else I know. Along with other noble Lords, he is a valued participant in the work of the All-Party Group on Arts, Health and Wellbeing. I commend to noble Lords a recent and beautiful article written by him in Prospect magazine, entitled, “What Aristotle can teach us about building a better society”. In it he writes so wisely and so well about health and human flourishing. As he will be aware, I am indebted to him for some of the language I used in my opening speech.

My noble friend Lady Pitkeathley made a crucial point about how essential it is that funding is provided to cover the core costs of the voluntary and charitable organisations upon which we so largely depend for the delivery of non-clinical services.

The noble Baroness, Lady Finlay, gave us the stark warning: loneliness kills. I very much appreciate her deep understanding and acceptance of the propositions that I and others have been making around creative health, and the support that she gave us in the creative health project.

The noble Baroness, Lady Greengross, made a particularly important, specific and practical recommendation that people should be referred for music therapy or other kinds of creative health interventions at the onset of symptoms of dementia without having to wait for perhaps many months for a formal diagnosis.

I am sure that the noble Baroness, Lady Chisholm of Owlpen, who was, after all, a nurse, personally appreciates the significance and value of what we have been talking about, even if she was briefed to bat away these amendments. She sweetened the pill by promising us a viewing of the YouTube clip of the Minister’s band.

I understand why the noble Baroness contended that the Bill should not be overly prescriptive, but, if that is so, I wonder how she answers the crucial question posed by my noble friend Lady Morris of Yardley: if we do not embed these duties—I would contend they are legislative duties—and responsibilities in the formal arrangements of the system, how are we going to get the step change and scaling up? How are we going to get the decisive shift in the culture to make non-clinical approaches truly integral to the practice of health and social care?

I was surprised when the noble Baroness, Lady Chisholm, advised us that these amendments could have the perverse effect of militating against a holistic approach, but she gave encouragement in what she said about the VCSE sector, in the willingness of the National Institute for Health Research to provide funding and in the thoughtful, extended observation she made about staff needs and the importance of housing. She said that housing is a local authority responsibility. Yes, that is technically true, but that is exactly the problem we debated earlier this afternoon, on which my noble friend Lord Hunt of Kings Heath energetically put forward his thoughts, supported by many other noble Lords. If the Bill continues to demarcate the responsibilities of the NHS and local government in the way it so far does, it will fail to achieve integration in very important respects—and surely we do not want that sort of failure.

It is precisely because of the pressures of Covid and of the backlog, which will make huge demands on NHS resources, thinking and energy for a very long time to come, that it is all the more important that we should enact into law a duty on ICBs continually, from the moment of their formal inception and sustained through the years to come, to operate strategies for the prevention of ill health and the positive creation of a healthy society, working in a multitude of ways with the populations they serve. I beg leave to withdraw the amendment and give notice that I do not wish to move any of the other amendments in this group.

Amendment 59 withdrawn.

Amendments 60 to 71 not moved.

House resumed.

House adjourned at 6.45 pm.