You have not heard what I am going to say yet.
I thank all noble Lords who have taken part in this debate; it has been fascinating. It has touched on a number of things that I feel strongly about personally. Before we go further, and given my background and that of my right honourable friend the Secretary of State, I want to assure noble Lords that we both feel very strongly about inequalities. I say that as someone who grew up in a working-class immigrant community. I was born at Whittington Hospital; I also accessed North Middlesex hospital and Chase Farm Hospital, with which I know the noble Baroness, Lady Tyler, is associated, though I am not sure I will get any more points for that, to be honest.
One thing I feel strongly about, and saw in many areas when I was an MEP for London, is where the state has failed, whichever Government was in power. I have worked with non-state, local community, bottom-up projects which understood the issues in their communities far better than any national or local politician—there was sometimes even a distance between them and their local ward councillor, as the noble Lord, Lord Mawson, and I were discussing the other day.
I thank the noble Baroness, Lady Thornton, not only for the thoughtful way in which she opened the debate and introduced the amendments but for pointing out some of the people who are often forgotten; for example, the homeless. I have worked with a number of local community homeless projects, such as the
Hope Foundation in Acton and Vision Care for Homeless People. Perhaps I may also do a quick advert for the Take One, Leave One project, which is based outside Vauxhall station on Fridays, between 12 pm and 3 pm —people can leave excess clothes and homeless people can pick them up. I urge any noble Lords passing through Vauxhall station on a Friday to support this.
Sex workers, the Traveller community and drug users have been mentioned. Sometimes we think that these issues are remote from us and will not affect us—but everyone is only one of two steps away from homelessness. A broken family, mental health issues, your friends saying, after a while, “Actually, you can’t stay on my sofa any more”—where do you go? When I have met homeless people, they have quite often come from a very different place, not the stereotype that we often hear. They have come from quite a stable family, a good relationship, a good job: but two or three things have gone wrong in their life and suddenly they are homeless. It happens to many people who resort to such desperate measures.
Another thing I am slightly concerned about, if I am honest, is that when I was a young child growing up in immigrant communities, there was a distrust of authority. We see the difficulty, for example with the vaccine schemes, in trying to reach some of those communities. It was not only authority that we were quite suspicious of and concerned about but—I hope noble Lords will forgive me for using this phrase—white, middle-class do-gooders who thought they knew best what was best for us as working-class immigrant people and could tell us what was best for us, rather than listening to us and our real concerns. Quite often we felt that they had captured the agenda, and that was why the money and resources which were supposed to be helping us did not reach the people who needed help: it got captured by the white, middle-class do-gooders.
I pay tribute to the noble Lord, Lord Howarth, and the noble Baronesses, Lady Greengross and Lady McIntosh of Hudnall, for the emphasis on the arts and creative industries. Sometimes, music and the arts are a way of overcoming this distrust, learning about the culture of those communities and also aligning the culture and the issues with some of the very real problems and tensions we face. The noble Lord, Lord Desai, talked about prevention being better than cure. It is an issue we talk about constantly in the department, and the NHS also talks about it. The noble Lord, Lord Desai, as an economist, will acknowledge that economics is often simply about the allocation of scarce resources and finding the most efficient way of achieving that.
My late father once told me, “Never forget where you came from and what you were”, and this is one of the reasons I feel very strongly, as do many noble Lords across the Committee, about the issue of inequalities. How do we tackle this, what is the best way to do it? Will putting it in the Bill solve all the problems? Actually, it will not, but we can discuss how we can make it more effective, and not just feel, “Great, we’ve got it in the Bill, job done”. It has to be more than that. As the noble Lord, Lord Scriven, said, it cannot just be an institutionalised Gladys; it has to be more than that. So, I am deeply grateful that we gave this issue the time it deserves. It is really important
for me personally. We want to tackle health inequalities and ensure that everyone has the same opportunity to enjoy a long and healthy life, whoever they are, wherever they live and whatever their background or social circumstances.
I hope I can assure the noble Baroness, Lady Greengross, with whom I have had a number of conversations about music and dementia. I have volunteered, perhaps rather rashly, to organise a fundraiser with my band and other bands for that. I hope that does not give me an excuse to lay the YouTube link to my band in the Library: I shall try to avoid that temptation.
However, to deliver on the commitment on 1 October, we launched the Office of Health Improvement and Disparities within the Department of Health and Social Care—the noble Lord, Lord Scriven, anticipated that I would say this—and we also set up a cross-government ministerial group to identify and tackle the wider determinants of poor health and health disparities. It is important that this cannot be top-down; we have to go to some of the social enterprises and local communities, but also we must not prejudge, prevent or duplicate the work of the integrated care systems in this. NHS England is already tackling health disparities through the NHS long-term plan. That sets out a clear intention to set measurable goals and to make differential allocations targeted at reducing health inequalities and disparities. This has resulted in funding increases to some of the most deprived parts of the country.
As we know, making sure that these deprived areas get the most funding does not mean it will trickle down to those who really need it; it could well be captured by some of the do-gooders I mentioned earlier. The noble Lord, Lord Howarth, talked about those targeted interventions. NHS England and NHS Improvement is also taking forward the Core20PLUS5 initiative as an approach to addressing health inequalities. This will focus on improving outcomes in the poorest 20% of the population, along with inclusion health groups and five priority clinical focus areas.
2.15 pm
I shall now turn, if noble Lords will allow me, to Amendments 14, 94, 186 and 195. I am grateful to the noble Baronesses, Lady Thornton and Lady Tyler, and the noble Lord, Lord Patel. I hope I can reassure them that much of what they ask for is in the Bill. First, NHS England and integrated care boards have a duty with respect to health inequalities. The duty requires them to have regard to health inequalities in both access and outcomes for patients in the provision of health services. NHS England and the ICBs will have regard to this duty alongside the triple aim and, in NHS England’s case, when it produces guidance on the triple aim. NHS trusts and foundation trusts will, along with the ICBs with which they partner, have to prepare a joint forward plan each year, which will include plans for discharging the ICBs’ health inequalities duty.
The noble Lords, Lord Kakkar and Lord Shipley, and the noble Baroness, Lady Harding, talked about the triple aim. This triple aim is directly conducive to addressing health inequalities. Having organisations consider the wider effect of their decisions will encourage
more collaboration and engagement with communities on how best to meet their needs. For example, the aim of
“considering the health and well-being of the people of England”
means we have to look at those populations with the greatest levels of need, including those not currently accessing services. Indeed, when you ask how an ICB is reaching this aim, the obvious question is, “What about inequalities? Are you just reaching part of the population or the whole population?” So, I assure noble Lords that it really is implicit.
Similarly, it is a key aspect of improving the quality of services to consider those areas within the ICB or the ICS area where they need improvement. You cannot just say “Everything’s great in the richer areas and we’ve considered the wider population”. We mean the wider population, all the population, wherever they come from, whatever their background and whatever their wealth level. To support this, we expect guidance from NHS England to make it clear how bodies can discharge the triple aim duty in such a way as to address inequalities.
I now turn to Amendment 11, in the names of the noble Lord, Lord Patel, and the noble Baroness, Lady Walmsley. This places a statutory duty on NHS England to publish guidance about the collection, analysis, reporting and publication of performance factors by relevant NHS bodies with respect to inequalities. We agree that collection of accurate and timely data is an essential part of the department’s commitment to tackle health disparities in terms of planning, goal setting and the use of evidence-based interventions. As my noble friend Lord Bethell said, seeing that data made real to him and others the fact that there were these disparities, and it is important that we continue collecting it. However, we feel that collection of data on disparities and protected characteristics can be best achieved through operational guidance. We want to offer flexibility for the system to adapt the focus and methods of that data collection and analysis, and the power to do that is in the Bill.
We will continue to work with counterparts in the NHS and other system partners to make sure that this data is adequately identified, reported and assessed, and which further amendments, if any, will be required for the ongoing work. High-quality data is fundamental to our approach to reducing the stark disparities in health that exist in the country. If any policy changes are identified which require legislation, we do not rule out bringing them forward.
I turn now to Amendments 61 and 63, for which I thank the noble Baroness, Lady Walmsley. These amendments would add to the duties currently in the Bill on ICBs with regards to health inequalities. I hope I can reassure the Committee that we feel that this is already done. As members of local health and well-being boards—place-based, not just at the ICS level but at the place, as the noble Lord, Lord Mawson, talked about so eloquently—ICBs will be closely involved in the development of local joint strategic needs assessments, which are the means by which local leaders work together to assess and understand the needs of local people. We are concerned that it might duplicate this effort if an entirely separate assessment were to be
made of one aspect of local needs. Perhaps we could look at ways to draw out this particular aspect so there is no duplication. Furthermore, it is our view that ICBs could not effectively discharge their duties in respect of inequalities if they did not identify the inequalities they are seeking to address, making use of the most up to date evidence and data available and learning from each other what data is collected. Is the data collected in a local ICS really giving a better picture as compared with elsewhere?
To help the process, NHS England has published a range of tools and resources to help NHS organisations to take effective action on inequalities, and continues to develop a health inequalities improvement dashboard, making sure that we learn from that data so that we monitor, measure and inform actionable insight to make improvements to narrow those health inequalities. It covers the five priority areas for narrowing health inequalities in the 2021-22 planning guidance, as well as the Core20PLUS5 programme.
I turn now to Amendment 65, in the names of the noble Lord, Lord Patel, and the noble Baroness, Lady Tyler, which would add a further explicit duty to implement systems to identify and monitor inequalities. It is the Government’s view that the ICBs could not effectively discharge the duties already contained in the Bill in respect of inequalities if they did not already do so; nor could they have any confidence that the actions they take are being effective if they do not monitor the outcomes achieved. You simply cannot do it if you are not monitoring. Furthermore, ICBs will have a duty to publish an annual joint forward plan setting out, among other things, how the ICB will discharge its duty in respect of reducing inequalities. Again, this could not be effectively done without having first identified those inequalities. Taken together, I hope the noble Lords might agree that this meets the intention of their amendment.
I turn to Amendment 66, in the name of the noble Lord, Lord Young, and spoken to so eloquently by the noble Lords, Lord Rennard, Lord Faulkner and Lord Crisp. This amendment would expand the duty on ICBs to have regard to the need to reduce inequalities to include modifiable risk factors such as smoking. We do not feel that this amendment is necessary, given the considerable work we are already doing in this area. We have reduced smoking rates in England over the years to a record low of 13.5% in quarter 1 of 2020, and we are aiming for England to be smoke-free by 2030. In a previous debate, in answer to a question about the plan asked by my noble friend Lord Young, we also identified those areas. Indeed, the noble Lord, Lord Rennard, referred to some of the statistics on the high levels of smoking still prevalent in some of our poorer communities. Our publication of a new tobacco control plan next year will include an even sharper focus on that issue.
We are also investing £27 million to establish specialist alcohol care teams in the 25% of hospitals with the highest rates of alcohol dependence-related admissions. We really have not, as a society, properly got to the stage where alcohol is seen as a social tool that loosens tongues and may make people relax, but the step from alcohol doing all those things to relax people to its abuse has a terrible impact on people’s lives. Moreover,
it not only has direct health impacts but plays a role in murders, suicides, drownings and so on. We have to recognise what alcohol does as a drug and its terrible impact.
We also have an extensive strategy for tackling obesity, including some of the measures already debated on less healthy food and drink that are being introduced via the Bill. We are concerned that introducing an amendment as specific as this may not be the most effective way to prioritise actions to meet local population needs, a phrase so eloquently used by the noble Baroness, Lady Neuberger.
I turn next to Amendments 68 and 95, in the name of the right reverend Prelate the Bishop of St Albans. The Government are determined to address long-standing health disparities, including the geographic disparities experienced in rural and coastal communities. I pay tribute to my noble friend Lady McIntosh of Pickering and the noble Baroness, Lady Pitkeathley, who have constantly raised the issues of inequality of health outcomes in rural and coastal areas and how people there access services. For that purpose, the Bill already contains a requirement for the commissioning bodies to tackle these health inequalities, as well as a requirement to protect, promote and facilitate the rights of patients. This means allowing patients to choose to be treated outside their ICB area, particularly if that makes more sense, as alluded to by the right reverend Prelate. To support this, we expect ICBs to actively co-operate with each other for tackling these inequalities. We understand the duty to reduce inequalities to also encompass the need to reduce inequalities between patients with respect to geographical locations, such as rural or coastal areas. The proposed triple aim will also require ICBs to consider the quality of services that can be accessed both in communities but also geographically. I hope I have given the right reverend Prelate the Bishop of St Albans some reassurance on this.
Moving on, I turn to Amendments 152 and 157, in the names of my noble friend Lord Young and the noble Lord, Lord Shipley. These amendments would require the ICP to have regard to the needs of inclusion health populations. A number of noble Lords have spoken about the sort of clumsiness of that title of “inclusion health”. While we agree with the sentiment, I hope I can assure the noble Lords that these populations are already captured in the legislation. As noble Lords will be aware, the integrated care partnership will be tasked with developing a joint strategy to address the health, social care and public health needs of its system, based on the needs identified by the already-existing health and well-being boards, which are better placed to tackle these issues. The joint strategic needs assessments include the health needs of these populations, and those who need to be included more. The strategy prepared by the ICPs to address this will enable them to objectively identify what the inequalities are and target them. The ICP will be tasked with promoting the partnership arrangements. We hope that this will remove some of the traditional divisions between different healthcare services and between the NHS and local authority services.
I would like to touch on some of the work already ongoing in this area. For example, this year alone we delivered £52 million for substance misuse treatment
services for people sleeping rough. This will fund evidence-based treatment. One of the criticisms of public health sometimes is that there is not enough evidence-based research, and it is essential that we have it. We will look at treatment and wraparound support for those with co-occurring mental health needs.
Let me turn, finally, to Amendment 156 in the names of my noble friend Lord Young and the noble Lord, Lord Shipley, and spoken to by the noble Baroness, Lady Watkins. It relates to the integrated care strategy, and how the ICP will be required to set out how the assessed needs in its area will be met. We recognise that health inequalities are driven by a range of complex factors. The noble Baronesses, Lady Watkins and Lady Finlay, and my noble friend Lord Bethell said this. These complex factors go way beyond people’s physical and mental health, and touch on some of the wider economic and societal issues, such as the one the noble Lords raise in this amendment. The Bill already ensures that services that have an effect on health, but are not health or social care services, are included in the clause that the noble Lords seek to amend. Even without this amendment, ICPs will be able to comment on whether housing services—which the noble Lord, Lord Crisp, raised—among other health-related services, will need to be better integrated with the provision of health and social care.
This has been an excellent and—I accept—long debate, as the noble Baroness, Lady Walmsley, said. It was probably one of the issues that I was most looking forward to learning and hearing more about. I was impressed by the level of commitment and the passion with which noble Lords spoke. I hope I have been able to give some measure of assurance that the Government take this issue extremely seriously. As I said at the beginning, both my right honourable friend, the Secretary of State and I, given our personal backgrounds, feel very strongly about this. We do not want it this to be captured once again, as it has been captured over many years, by the do-gooders.
I request that noble Lords do not press their amendments but, given the strength of the feeling that I have heard, it would be remiss of me not to offer further discussions with noble Lords so that we can close the gap in the understanding—as the noble Lord, Lord Kakkar, and my noble friend Lady Harding said—that it cannot be too NHS-centric. We have to work out how to address that gap. We think the Bill meets it; clearly, noble Lords across the Committee feel that it does not. Let us have further conversations. I hope noble Lords feel able, in that spirit, to withdraw or not move their amendments at this stage.