Earl Howe:

Moved by Earl Howe

3: After Clause 4, insert the following new Clause—“Duties as to reducing inequalitiesIn section 13G of the National Health Service Act 2006 (NHS England’s duties in relation to the reduction of inequalities)—(a) in paragraph (a), for “patients” substitute “persons”;(b) in paragraph (b), after “services” insert “(including the outcomes described in section 13E(3))”.” Member’s explanatory statementThe Amendment extends NHS England’s duty in relation to the reduction of inequalities in access to health services to cover people before they are patients. It also makes it explicit that the duty to have regard to the need to reduce inequalities in outcomes for patients covers outcomes such as the quality of experience undergone by patients.

My Lords, in moving Amendment 3 I will speak also to the other government amendments in this group, in the name of my noble friend Lord Kamall. Of the many critical topics we discussed in Committee, our debate on health inequalities stands out as one that prompted unanimous and emphatic agreement from all Benches on the need for us to recognise in the Bill the centrality of the inequalities issue. My noble friend Lord Kamall and I took it as our mission to respond to the compelling points raised by noble Lords by bringing forward government amendments on Report, which I now do. These are issues and points of principle about which the Government—not least my noble friend the Minister—feel very strongly.

As the House will know, we think it important to empower local health and care leaders to pursue new and innovative ways to tackle disparities in the most appropriate way for their area. However, we should not miss the opportunity to ensure that this Bill reinforces those intentions in other ways. The amendments are designed to ensure that the Bill fully reflects the strength of the Government’s ambition to address disparities by levelling up every area of the country.

First, we will put beyond doubt that tackling disparities should be an integral factor when making decisions across the NHS. This was something that NHS England’s four purposes for ICSs made clear. The triple aim duty was always intended to support achieving those purposes, and these amendments strengthen the duty on NHS England, NHS trusts and ICBs so that, when decisions are made by NHS bodies, consideration will always be given to the effect of those decisions on disparities. What does that mean? It means that NHS bodies should consider the wider effects of their decisions on the inequalities that exist between the people of England with respect to their health and well-being and the quality of the services that they receive.

We are also going further by strengthening the more specific duties that complement the triple aim. Disparities are not limited just to health outcomes or access; they relate also to the experience of the care that is received. For example, the independent Commission on Race and Ethnic Disparities reported that Asian patients are more likely to report being less satisfied with GP services than their white, black African and black Caribbean counterparts. These amendments seek to strengthen existing duties as to reducing health inequalities on NHS England and ICBs by explicitly including patients’ experience of care, the safety of services and the effectiveness of services to create a more holistic duty that addresses how disparities manifest themselves in health and care.

When it comes to inequalities in access to health services, we can go further. The duties currently focus only on people who are already using or accessing health services. This fails to address those who do not or cannot access health services—and, as we powerfully heard in Committee, these include many socially excluded and marginalised persons, who are more likely to have preventable health conditions. The point is fully taken, and we have therefore tabled an amendment to ensure that the duties placed on NHS England and integrated care boards as regards reducing health inequalities require the consideration of inequalities in access for “persons”, rather than simply “patients”. The intention here is to improve outreach, as well as access by socially excluded and marginalised groups.

Lastly, we recognise the crucial importance of information on which to base targeted action. The Covid vaccination campaign was unprecedented in the way that it focused activity on every community across the nation, especially where there were disparities in the uptake of the vaccine. Fundamental to that success was the ability to collect and analyse data from across the system so as to target resources in the most effective way.

Our amendment will require NHS England to publish a statement describing certain NHS bodies’ powers to collect, analyse and publish information relating to disparities in health, together with NHS England’s view on how these powers should be exercised. Those bodies will be required annually to review and publish the extent of their compliance with that view. We hope and believe that this will power the evidence-based drive to reduce disparities in health across the country.

I hope that, together, these amendments provide the reassurances that noble Lords sought from their various amendments tabled in Committee. In conjunction, these changes will strengthen the ability and the resolve of the health and care system to take meaningful and impactful action. I commend them to the House and beg to move.

My Lords, in thanking the Minister for having introduced so thoughtfully and elegantly this important suite of government amendments that address the question of inequalities, I would like to pass to the Minister and the Front-Bench team the thanks of my noble friend Lord Patel, who regrettably is unwell, recovering from Covid-19, but who of course spoke with great insight and passion in Committee on this matter, and indeed has engaged actively with the Front-Bench team subsequently in ongoing discussions.

The noble Earl has done something quite remarkable and absolutely essential. There is no need to rehearse the very strong arguments that were made in Committee around the necessity at this particular time to ensure that every element of the National Health Service is able not only to focus its resource and thought quite clearly at the elements of the triple aim but to ensure that, in a tension with those important pan-NHS objectives, the system is never allowed to forget the importance of addressing the inequalities and disparities that regrettably continue to be an abject failure of the delivery of the healthcare system.

Her Majesty’s Government, in proposing these amendments, deal not only with questions of access and outcomes but ensure that data is appropriately collected and all NHS organisations are obliged to pay attention to those data and to act accordingly; that is a very powerful statement and a powerful act of leadership. But beyond that, in ensuring that the patient’s voice and the public’s voice is heard in these matters, this will set a new tone and new direction for the delivery of healthcare in our country, and Her Majesty’s Government are to be strongly congratulated.

My Lords—

My Lords, I apologise; when there are so many amendments in one group I can never work out just when people who are moving subsequent ones further down the line, as it were, ought to rise.

I will speak to Amendments 63, 65 and 67, and begin with an apology that I was not able to be here to speak to those in Committee. I too had a positive test, although I have to say that I had no symptoms. None the less, I was self-isolating, and therefore was not able to be present in the Chamber.

I welcome the amendments tabled by the Government. I chair the Public Services Committee in this House. In our first report, we looked at public services through the mirror of Covid. We noted and reported, and indeed debated in this Chamber, the significant uncovering or rediscovery of the extent to which inequalities in our society affect people’s health. I am pleased that the Government are responding with some of their own amendments.

My amendments, which are supported by other noble Lords around the Chamber, relate specifically to what I understand the National Health Service calls “inclusion health communities”. For me, these are people living with complex needs in different sorts of communities. I have spent much of my working life involved with such communities and have tried to concentrate on that work in this House. The amendments seek to ensure that the NHS has a much more systematic approach to the health needs of people with complex needs and marginalised communities.

This of course involves people who have been rough sleeping—I know the Minister talked about that in Committee—but it concerns more than just that group. Those who have been rough sleeping do not have access to primary care because they do not have a settled address, but other groups are affected, such as those who have been trafficked, women who are being sexually exploited and the Gypsy, Roma and Traveller communities. The Public Services Select Committee recently held a very short inquiry into Gypsy, Roma and Traveller access to public services, which again exposed a real challenge with health and access to health services. All the data shows, and the stories from these communities tell of, very poor health outcomes, with average life expectancy being 10 to 12 years less than that of the settled community. There are some estimates which put that much higher.

As I said, I welcome the Government’s concern to address health inequalities, but having read very carefully what the Minister said in the earlier debates and in letters, it seems to me quite clear that the Government and the NHS remain behind the curve on this, I am sorry to say. I thank the sector for its briefings, which have been both moving and very useful in painting the picture of just how we are letting these communities down. As long as we do that, we will have significant inequalities and therefore significant pressures both on and from those communities. They not only end up with poorer health outcomes but are driven to the most expensive end of healthcare. They end up in A&E because they do not know how else to access anything and normally go there far too late in whatever is going wrong with them.

I want to illustrate what I am trying to say with two different stories. I hope this will help the Minister and Members understand where we are coming from. Professor Aidan Halligan was an incredible, innovative leader in the NHS. I got to know him when I was in government and he was working in the Department of Health. He was always interested in what I was doing in tackling rough sleeping, both in the early part of my ministerial career and then when I was Minister for Social Exclusion at the end of it.

Aidan became interested in, among other things, how to get better healthcare for homeless people. He was shocked by what he encountered when he started to look at it. I agreed to chair a meeting in the House of Commons for him to bring together people to address the issue. More than 200 people turned up. That meeting and discussion inspired him to work initially with University College Hospital on developing a responsive survey. He soon set up a charity, which he appropriately called Pathway, which has flourished, to work with the NHS to ensure more responsive healthcare for the homeless. Tragically, Aidan died in 2015, but his legacy of compassionate leadership and response to the homeless lives on. Pathway teams now work throughout the country, although not, unfortunately, in every area or trust area.

The second story comes around Changing Lives, which was known as the Tyneside Cyrenians when I introduced some pilot projects from the Cabinet Office to look at a more holistic service for people with complex needs. The Tyneside group had a new model for outreach work for rough sleepers that employed people with lived experience as outreach workers. They negotiated with the local National Health Service to have a community matron attached to the team so that appropriate referral and treatment could take place.

This was the most successful pilot in the country, and when I left government I kept in contact with it. I went on its board and eventually became chair. We developed the whole organisation and did a lot more work with women. Appropriately, we changed the name to Changing Lives. We developed the principles of working with people with complex needs so that they too were involved, and getting health and other services involved at a more appropriate level than the emergency services. That initial pilot scheme demonstrated to Newcastle how much money it saved, because the “frequent flyers”, as it called them, did not end up in A&E. That is why I say that it has more to recommend it than the very important aspect of making sure that health outcomes are better for people.

Some of the subsequent work we developed through Changing Lives, particularly with those who were exploited sexually, groomed and so on, and those with addictions, has been innovative and transformative. I recommend that the Government look at how they can establish such programmes, but then make sure that they are normal. That is the problem that these amendments address. There are some really good examples around the country where innovative charities work with the NHS to develop good practice, but by no means is that universal or automatic.

Also, Pathway and Changing Lives include people with lived experience—these days they call them “experts by experience”—in the design and delivery of the service. That makes a huge difference. I know that the Government have said that in general they are in favour of this, but they need to get hold of it to demonstrate that that can be done to a much greater extent.

I understand that the Government and the Minister are concerned about this issue, but the reality is that the Minister sought to reassure the House with measures such as Core20PLUS5. How the NHS keeps coming up with such peculiar and strange hidden titles is beyond me; it is not a phrase I use when I talk to people who have been living on the streets. Anyway, I am told that Core20PLUS5 is one programme that can be used. Then there are JSNAs. They are good and important but not sufficient to get the outcomes we need for both the NHS and the people I am talking about.

I hope that the Government will think again and see how they can systematically ensure that proper attention is paid to how we can enable these communities to access decent services. It is possible—I have tried to be positive and show that—but it must be done throughout the NHS and systematically in partnership with those people who know what it is like to have difficulty in accessing services because they have been excluded for so long. We really must make sure that we make a massive difference on tackling these health inequalities.

As gently as I can, I must point out to the noble Baroness that this not the occasion to move her amendments; we will come to that later. She has correctly spoken to her amendments in this group but we will come to them sequentially later.

My Lords, now that we are on Report, I must remind the House that I am a vice-president of the Local Government Association.

I rise to speak to Amendments 63, 65 and 67 in this group, to which I am a signatory along with the noble Baroness, Lady Armstrong of Hill Top. I will not repeat the points made in Committee and this afternoon unnecessarily because I am confident that the Government are listening to what has been said and wish to see progress towards levelling up health outcomes and tackling health inequalities. It is the right thing to do.

I lend my support to three policy solutions in particular. The first is the significant opportunity presented by the forthcoming health disparities white paper. The Government should not miss the opportunity that this presents because it can clearly set out how exactly they propose to lead on tackling the poor health outcomes of inclusion health populations. I hope that the Minister will work closely with the voluntary and inclusion health sectors to shape what the White Paper will say. Secondly, I support the idea of creating a task force from the Department of Health and Social Care and NHS England to help drive forward the Government’s work to reduce health inequalities for the most marginalised. Thirdly, I urge the Government to take this opportunity to update guidance to specify explicitly that the NHS does not exist in a vacuum and that secure, safe housing is critical to an individual’s health and well-being. I hope that the Minister will be able to confirm that statutory guidance and the White Paper will reflect all these matters.

Having said that, these three amendments—Amendments 63, 65 and 67—are still important. I welcome yesterday’s letter from the Minister, the noble Lord, Lord Kamall, explaining the package of government amendments now also proposed. I am pleased that that letter confirmed the Government’s commitment to tackling health inequalities. It is very positive to see the reference to “persons”, not just “patients”, in Amendment 3 as an important statement of principle both for inclusion health and to improve outreach, as the noble Earl, Lord Howe, said earlier.

Progress has been made following Committee but I still seek reassurance from the Minister that the Government will dedicate the necessary time and resource to tackling the poor health outcomes of inclusion health populations, who can all too easily fall through the gaps in provision.

My Lords, it is a pleasure to speak to this group of amendments. I declare my interest as chair of Look Ahead, a housing association that specialises in working with people with complex needs. I am delighted by the Government’s new amendments in this area—I believe that they go a long way—but I am disappointed that housing appears to have been omitted from the government amendments.

Amendment 65, which adds housing to this section, is one that I would particularly want to support. I want to take a phrase from my noble friend Lord Crisp: health—and here I would add, “including mental health”—is made at home. However, if you do not have a home, you cannot make physical or mental health. Driving in this morning because of the Tube strike, listening to “Woman’s Hour”, which I do not always manage to do, I heard a dramatic example of somebody who has fled domestic abuse and been temporarily rehoused by the council, but has no white goods. She is diabetic, so her insulin is out of control because she cannot keep it cold. What a straightforward example of how housing and simple equipment can facilitate good health.

Another example is where we discharge people to safe accommodation, where they have the opportunity for rehabilitation or to cope with a long-term disability that may have occurred as a result of an accident. This requires sheltered and semi-independent living accommodation to be built. If those issues are carefully considered by our new boards, together with housing locally, we will find a way forward, to reduce the distress of significant illness and domestic violence, to enable young people in family breakdown to move to bedsits rather than to the streets, and to make care leavers feel safe—as well as older people then knowing that there is somewhere that they can move to. We know that those with significant incomes are increasingly moving, because they can fund themselves, to sheltered accommodation, which reduces loneliness and gives all sorts of advantages in later life.

I again thank the Government and remind them that, tragically, the average age of death of people experiencing homelessness remains at 46 years for a man and 43 years for a woman.

My Lords, I do not want to detain the House for too long, as there is an awful lot of business to think about on Report. However, as I put my name to Amendments 63, 65 and 67, tabled by the noble Baroness, I want to press the Minister on the question of data.

I am advised, as I am sure others are, by really experienced charities, which say that one of the real challenges here, which will be a challenge for the ICSs when they are trying to do a great job in terms of compliance on disparities, is that the data on inclusion health populations is very incomplete. While there have been efforts to collect data on housing status, for example, that has been relatively incomplete and unsuccessful. So what I want to hear from the Minister is how we can be sure that through the development of this commitment to tackling health inequalities with an evidence-based approach, populations such as the inclusion health population are not invisible because the data is so difficult to collect. Is this something that the forthcoming white paper could pick up? Will it focus on how the health system leaders will get the tools that they need to do a really great job for these populations, who have such complex needs and who really draw on the health service, A&E, et cetera, in a very intense way? There is such potential to make real progress, whether it is in the interests of people coming out of care, sex workers who are really challenged, or homeless people. We are all only a few steps away from that, are we not? So I would be interested to hear from the Minister whether that drive to collect comprehensive data to inform this work can be channelled in some way through a forthcoming policy initiative.

My Lords, from these Benches I thank the Minister and the whole Front-Bench team for the way they have engaged with the House on the issue of doing something really serious about addressing health inequalities.

Many of us put down amendments in Committee: dealing with inequalities was dotted all over the Bill. We even suggested that perhaps we needed a quadruple aim—an additional aim. The Government have taken a different but none the less effective approach, and I really welcome the fact that dealing with health inequalities has been made integral to the first two aims of the triple aim.

The Government have done two things that I particularly welcome. The noble Lord, Lord Kakkar, mentioned the engagement of the noble Lord, Lord Patel, with the Bill team on making sure that data can be collected. Without collecting the data, you cannot analyse or take action on addressing health inequalities.

The second thing, which the Minister mentioned in his introduction, is government Amendment 21, which is about the experience of people in the health service. He mentioned that the experience of people from an Asian background can sometimes be poor. I can give him an example of where that has been the case. My daughter has a friend, an Asian gentleman, who had a very painful physical injury. Very unusually, although his physical problems have now healed, he has been left with a mental scar because of his experience with the health service. This is very unusual, but he was not treated with compassion or respect. Indeed, it was more like discrimination—so I really welcomed what the Minister said about the importance of the experience of people from all demographics and ethnic backgrounds in the health service. It is vital.

I turn to the amendments from the noble Baroness, Lady Armstrong. Like all noble Lords, I have been watching the television recently, looking at the pain that the poor people of Ukraine are going through and seeing children, mothers and whole families huddled in cold, damp cellars. Some of them are taking several days to drive to the border to go to a country that will welcome them, perhaps with even more open arms than we do. It occurred to me that those people, when all this is over—and let us hope it will be over very soon—will probably be suffering from mental and physical illness. It also then occurred to me that there are people in this country who have poor-quality housing, insecure housing or no housing at all. When you put those things together, it is not surprising to realise that such people will be suffering from more serious and more frequent physical and mental ill-health than the rest of us who are in good-quality, secure housing. So the noble Baroness has hit on some very important issues about health inclusion communities and about the importance of housing to making health, and we support what she has to say.

I end by sincerely thanking all three Ministers and the Bill team for the way they have addressed this issue of health inequalities, and I really look forward to it making a real difference in future.

My Lords, the noble Baroness, Lady Walmsley, expressed that very well indeed. From these Benches, I say how much we welcome these amendments and thank the Minister for introducing them. I also join the noble Lord, Lord Kakkar, in regretting the fact that our friend Naren Patel—the noble Lord, Lord Patel—is not with us today. His speech on this in Committee was outstanding, as his speeches always are. In fact, the whole debate was the House at its very best in expressing its view.

We welcome these amendments, and I was very pleased to add my name to Amendment 3 on behalf of these Benches. I was not as energetic as the noble Lord, Lord Kakkar, who put his name to all of them, but that was a symbol of the fact that we supported all these amendments.

We support them because, as people have mentioned, they recognise the importance of addressing inequalities from the top to the bottom of the National Health Service, and of monitoring, counting and research—not a tick-box exercise to say that you are tackling inequalities. As I have mentioned before, I am a non-executive member of a hospital in London. In fact, I have just completed three days of its workforce race equality training. That was three days out of my life during the course of this Bill, but it was definitely worth while. It absolutely was not always comfortable, and nor should it have been. It did indeed raise issues, many of which were raised in research published on 14 February by the NHS Race & Health Observatory. It basically says that the NHS has a very large mountain to climb in tackling race inequalities and inequalities across the board. It is a worthwhile report, which I am sure the noble Earl will be paying attention to in due course.

I also want to say how much I support my noble friend in bringing forward her amendments on the homeless. Coming from Bradford, I am particularly fond of a GP surgery called Bevan Healthcare, named after the founder of the National Health Service. It was started by my local doctor in Bradford, who spent his spare time providing GP services on the street to the homeless. From that, the NHS was commissioned to provide a GP surgery specifically directed to the needs of people who are itinerant and homeless, working girls and so on. It is still there, and it is a brilliant example of how to deliver the service, and of the money it saves the NHS at the end of the day. As I think my noble friend Lady Armstrong said, if you get this right then people do not end up in emergency care or worse.

We hope that the Minister will respond positively to these amendments. I thank him, his team and the Bill team, who addressed this issue thoroughly and with a great deal of success.

My Lords, this has been a very fruitful discussion and I am most grateful to all noble Lords who have spoken. I especially thank my noble friend Lord Young of Cookham, the noble Baronesses, Lady Walmsley, Lady Thornton and Lady Hollins, the noble Lord, Lord Kakkar, and the noble Lord, Lord Patel, in his absence, the King’s Fund and the Health Foundation for their contributions, both inside and outside this Chamber, in shaping this debate and the amendments before us.

Without wishing to repeat what I said earlier, I commend the government amendments to the House as they will strengthen the ability and resolve of the health and care system to take meaningful action on tackling health disparities. I next thank the noble Baronesses, Lady Armstrong of Hill Top and Lady Morgan of Drefelin, and the noble Lord, Lord Shipley, for tabling their three amendments and for the focus they bring to the issues of housing and homelessness. I found the account of the experience in government of the noble Baroness, Lady Armstrong, and the work of Professor Aidan Halligan, whom I too remember with great respect, compelling. I agreed with so much of what she said.

Let me say straight away that the Government are committed to improving the health outcomes of inclusion health groups, as they are known. That is precisely why we tabled the Amendment to expand the inequalities duty placed on NHS England and ICBs beyond simply patients to incorporate people who struggle to access health services such as inclusion health groups, but there is much more to say on this.

We have been clear throughout our engagement on integrated care partnerships that housing and homelessness services are essential in improving poor health for many. As my noble friend mentioned in Committee, the Bill already provides that ICPs may include the integration of those services in their integrated care strategy. We will continue to encourage the inclusion of housing and consideration of inclusion health groups in our guidance for ICPs. I hope that that is reassuring and will convince noble Lords that Amendment 65 is unnecessary.

I was very interested to hear what the noble Baroness, Lady Thornton, had to say about Bevan Healthcare. My noble friend Lord Kamall tells me that he has been a long-term supporter of a charity called Vision Care for Homeless People. It is not surprising that, with my noble friend in the Department of Health and Social Care, he and the department have been driving forward a wider agenda aimed at improving the lot of homeless people.

The noble Lord, Lord Shipley, referred to the health disparities white paper which we will be publishing later this year. That will take a broad look at the factors that affect people’s health and will focus on the people and places facing the worst health outcomes. It will mean looking at the biggest preventable killers, such as tobacco and obesity, as well as the wider causes of ill health and access to the services needed to diagnose and treat it in a timely and accessible way. It is important to emphasise that that endeavour will not be confined to the Department of Health and Social Care; it will be a cross-system endeavour, relying on close working among the NHS, wider health and care services and across central and local government.

It is also important to mention the Levelling Up White Paper. The Government’s focus on preventing homelessness will be renewed by working across government and with local partners to tackle the root causes of homelessness, in order to make sure that the flagship rough sleeping initiative continues to provide support tailored to local areas.

The pandemic highlighted in further stark contrast the importance of integrated care and the need for key services to work closely together to support those experiencing homelessness. Integrated care partnerships will bring together the NHS, local authorities and the voluntary sector, and it will be their job to develop strategies to address the public health and social care needs of people living in their areas, including people experiencing homelessness.

Legislating for new structures is one thing, but what are the Government actually doing to improve health outcomes for people experiencing homelessness or rough sleeping? Work is going on as we speak. We recently announced in the spending review £640 million, to be spent by 2024-25, to tackle homelessness and rough sleeping. This fund will build on progress already made in this area, including support for substance misuse through the rough sleeping initiative. Through the NHS long-term plan, the NHS has committed £30 million for specialist mental health services for people sleeping rough—that is £10 million a year by 2023-24. This year, we are delivering £52 million for substance misuse treatment services for people sleeping rough, and that will fund evidence-based treatment and wraparound support, including for those with co-occurring mental health needs.

The noble Baroness, Lady Morgan of Drefelin, aptly referred to the need for comprehensive and accurate data. I quite agreed with everything she said. We initially looked very carefully at whether there was a statutory basis on which to issue guidance in this area and, in the end, we concluded that there was not. But the amendment that we have proposed requires practical steps which we believe will achieve similar policy aims.

In practice, NHS England must produce a document that sets out NHS bodies’ powers in relation to health inequalities information, together with its view of how those powers should be exercised, as I mentioned earlier. That is bolstered by a requirement for those bodies, in their annual reports, to review the extent to which they have complied with NHS England’s view. In our opinion that essentially squares the circle of the need for this crucial area not to fall between the gaps. I will of course supply the noble Baroness with any further information that I can on how those plans look like they are shaping up.

Finally, defining inclusion health groups in law is very difficult. We have therefore committed to putting a more in-depth explanation of the term in guidance, as well as advice on identifying these groups and their health needs. We recognise that the populations most at risk from health disparities may vary between localities and may change over time; that is an obvious truth. By not defining the term in legislation, we allow bodies to react to their own local and system population’s needs, as seems appropriate to them. We feel that statutory guidance is a better vehicle for helping to set out how health and care services can better identify and address the needs of these groups when drawing up the integrated care strategy.

I ask the noble Baroness, Lady Armstrong, not to move her amendments when they are reached and I beg to move Amendment 3.

Amendment 3 agreed.