My Lords, I will speak on a number of amendments in this group that relate to health. They illustrate just how far this Bill stretches and the breadth of its potential impact on matters of public interest. Health is now firmly brought to the fore. Clause 44 inserts new provisions into existing legislation to place a duty on all combined authorities and combined county authorities to have regard to the need to improve the health of the people in their areas and to reduce health inequalities when they exercise their functions. The same duty is applied to mayors of mayoral combined authorities and mayoral combined county authorities.
This represents a welcome shift. It means that health and health inequalities are no longer seen as an issue solely for the NHS or public health bodies, but I hope that the Department of Health and Social Care is aware of these proposals. If it is not and is not fully engaged, we will not get too far. Instead they must be taken into account across the full range of decisions made by combined authorities, whether they relate to transport, housing, planning, skills or economic development. That is an important change, because many of the factors that shape health outcomes sit well beyond the health system itself.
I thank the noble Baroness, Lady Bennett, for her Amendment 159, which seeks to broaden the list of health determinants and health outcomes to be considered as part of this new duty. The concerns that she raises are understandable and I am sympathetic to the desire to reflect the full complexity of what really drives health inequality. However, I ask the Minister whether she believes that combined authorities will have both the capacity and the practical power and resources to deliver against such an expanded list. In the Government’s view, is this expansion feasible? While ambition is welcome, we must ensure that any duty placed on local institutions is deliverable and affordable, rather than well intentioned and unrealistic.
My Lords, I thank all noble Lords who have submitted amendments on health improvement, which is an important topic. I am pleased that we will have this duty on local authorities at mayoral combined authority and combined county authority level. As other noble Lords have said, it is an important step forward.
The Government are committed to building a fairer Britain. To do that, we must ensure that people can live well for longer and spend less time in ill health. Our response, our reimagined NHS, will be designed to tackle inequalities in both access and outcomes, as well as to give everyone, no matter who they are or where they come from, the means to engage with the NHS on their terms.
With our colleagues in the Department of Health and Social Care, we remain committed to reducing the gap between the richest and poorest in healthy life expectancy—an ambitious commitment that shows that the Government are serious about tackling health inequalities and addressing the social determinants of health. We support NHS England’s Core20PLUS5 approach, which targets action to reduce health inequalities in the most deprived 20% of the population and improve outcomes for the groups that experience the worst access, experience and outcomes in the NHS. As the noble Baroness, Lady Scott, said, tackling health inequalities requires a whole-government effort, as does making sure that the best facilities are available across the country. That is why we are working across departments, from housing and education to employment and welfare, to make sure that health is built into all policies and runs as a golden thread through everything taking place.
I now come to the specific amendments, a number of which would make additions to the list of general health determinants. Before I turn to the individual amendments, I note that the scope and definition of “general health determinants” in the Bill has been intentionally and carefully crafted to be broad and flexible. I will write to noble Lords in answer to the questions from the noble Baroness, Lady Scott, about how those determinants have been drawn up and what consultations have been done on them.
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A driving purpose behind the health improvement and health inequalities duty is to promote a focus by combined authorities and combined county authorities on reducing health inequalities and the adoption of the “health in all policies” approach that I have already mentioned. Combined authorities and combined county authorities are experts in their local areas; they are best placed to decide how to consider general health determinants for their communities. The Bill, as currently drafted, allows them to do this without being restrictive. There is clearly a balance to strike, and the Bill illustrates a number of important health determinants to give clarity to our intent and indicate areas where authorities are likely to be able to act.
Setting out large numbers of individual determinants runs the risk of restricting flexibility, because it can be seen as implying that the specific determinants to be considered are only those which are set out in detail in the Bill. We must strike a balance here between having an exhaustive list, which people feel they cannot go beyond, and a more general determination, which is the way we have chosen to go, so that people can tailor it to their local needs.
I am glad that we are aligned on the overall merits of the new duty, but I am concerned that the suite of amendments proposed would risk opening the door to an ever-expanding list, which would, in turn, undermine the outcomes-focused and locally responsive nature of the duty. Over time, that might impede the creativity and ambition for local areas to tackle their own needs.
I turn now to Amendment 160. The Government recognise the importance of warm, affordable and sustainable energy in supporting good health and reducing health inequalities. As with the previous group of amendments, setting out many individual factors in the definition of general health determinants risks narrowing that flexibility and, as I said, opening the door to an ever-expanding list.
Of course, we recognise that too many households in England cannot afford to heat their homes at a reasonable cost, and that this may lead to cold homes, as well as damp and mould, which affects the health of residents. The Government recently set out, in the new Fuel Poverty Strategy for England, our approach to lift 1 million households out of fuel poverty, alongside the warm homes plan. Our plans to bring forward regulations in the rental sector implement the warm homes plan and make energy more affordable for low-income households; it will deliver a step change in progress to alleviate fuel poverty. Our actions will upgrade the nation’s homes, help families to cut their energy bills and tackle fuel poverty. Ultimately, the Government have been clear that the answers to the challenges around energy security, affordability and sustainability all point in the same direction—to clean, low-carbon energy.
In December 2024, we launched our Clean Power 2030 Action Plan, which set out a detailed plan for achieving the target of clean power by 2030. Our clean power target means transitioning to an electricity system that produces at least 95% of Great Britain’s electricity generation from clean, low-carbon sources by that date, so that clean energy could be supplied to all consumers through our national electricity networks.
I turn now to Amendment 161, also in the name of the noble Baroness, Lady Boycott, which highlights the importance of exposure to water pollution and resilience to flooding and heatwaves. I answer this question when it has been raining for about 50 days—it feels like it has—so it is a pertinent question. The Government fully recognise these environmental factors in shaping health outcomes and health inequalities. Clause 44 already includes environmental factors and explicitly allows for consideration of any other matters that affect life expectancy or the general state of health.
For clarification, this amendment is another one that would only apply to combined authorities, not to combined county authorities, thereby creating inconsistency in how the duty operates.
Amendment 163 highlights the importance of communities being able to meaningfully shape local decisions that impact their health and well-being. This Government recognise the importance of ensuring that local decisions reflect the needs of communities and support better health outcomes. The definition of “general health determinants” already includes matters of personal behaviour and lifestyle and explicitly allows for consideration of any other matters that affect life expectancy or the general state of health. Furthermore, the Bill already introduces a new requirement on all local authorities to make appropriate arrangements for effective governance of any neighbourhood area under Clause 60. This provision will strengthen the ability of local people to shape decisions made by their local authorities. Adding Amendment 163 to the Bill would risk duplication between the duties of local and combined authorities. This ambiguity would make it harder for local authorities to engage coherently with their communities on the issues that matter to them.
I turn to Amendments 164 and 165 on the importance of diet and nutrition, including concerns about the consumption of ultra-processed foods. The Government encourage healthy eating and exercise, and our 10-year health plan clearly sets out a mission to tackle obesity and encourage healthier diets as part of our shift from sickness to prevention. The definition of “general health determinants” already includes matters of personal behaviour and allows for consideration of any other matters that affect life expectancy or the general state of health. More broadly, the Government are taking decisive action to tackle the obesity crisis, including banning the sale of energy drinks for under-16s, cracking down on junk food advertising, extending the soft drinks industry levy to sugary milk-based drinks and making it mandatory for large food businesses to meet targets and report on the sale of healthy foods.
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In opening this group, the noble Lord, Lord Addington, spoke about public access to fitness, sport and recreational facilities. These issues are clearly important and, as always, he made a compelling case for the role that access to physical activity plays in improving health outcomes. Many noble Lords will agree with the principles that he set out. It will be interesting to hear from the Minister whether she believes that placing such matters in the Bill is either necessary or proportionate.
The amendments to Clause 44 tabled by the noble Baroness, Lady Freeman of Steventon, seek to align the list of health determinants more closely with academic research. The points that she raises are thoughtful and well made. I would be grateful if the Government could explain how the existing list of health determinants was arrived at. Who decided what should be included and by what process? Was there any consultation and were academic experts involved? Understanding how this list was developed is important so that we have confidence that it is robust and evidence based. In particular, I found the reference to “educational opportunities and attainment” in Amendment 161A especially interesting. Education is widely recognised as a key driver of long-term health outcomes and I will listen carefully to what the noble Baroness has to say on this matter.
I also note the amendments tabled by the noble Baroness, Lady Boycott, particularly those that relate to climate and pollution. These amendments raise issues that are often cited as having implications for public health. However, they also serve to underline a broader issue that runs through this group. The difficulty is not simply whether individual factors can be linked to health outcomes but how far such a list should extend. If climate-related risks and pollution are included, should the same apply to noise pollution, as raised by the noble Baroness, Lady Freeman? What about resilience to heat waves, which was also raised in this group? Each of these can be argued to have relevance but, taken together, they illustrate the challenge of scope. At some point a judgment must be made on where the boundary of general health determinants is drawn. That judgment is important for maintaining clarity and focus within the Bill and ensuring that the resulting duties are workable.
This returns me to the underlying question raised by the group. Who determined which health determinants should be included and on what criteria? What evidence or metrics were used to reach these conclusions? Without greater clarity on this point, it is difficult to assess whether the approach taken is sufficiently defined and proportionate. In that context, will the Government commit today to publishing an explanation as to how these decisions were reached? In particular, will the Minister set out who was consulted in the development of this list, what evidence was relied on and what criteria were used to determine inclusion or exclusion? Providing that clarity would assist the Committee in understanding the rationale behind the approach taken and assessing whether the duty, as framed, is appropriately defined and justified.
Before I sit down, I go back to my plea in the last group. As I have said before, if any of this is going to work, the Department of Health and Social Care will have to be involved. It will also have to work with local government and, by working with it, be willing to devolve power and moneys locally. I look forward to the Minister’s response.
The Bill lists some of the broad and interconnected factors that shape health, life expectancy and healthy life expectancy. Combined authorities, combined county authorities and mayors can directly impact these factors, such as standards of housing, employment prospects and environmental factors, through the delivery of their wider functions. Given the importance of these factors as inarguable determinants of health, the Bill strengthens the duty and adds clarity by listing them explicitly. Although some examples are provided, it is not our intention to set out a definitive list—we feel that that would be constraining. We recognise that combined authorities and combined county authorities are experts in their local areas and are therefore best placed to decide how to determine and act on the factors most relevant to improving health and reducing health inequalities in their own areas.
I am grateful to the noble Lord, Lord Addington, for tabling Amendment 158 and, as ever, for championing the importance of public access to fitness, sport and recreational facilities. This amendment would require combined authorities to consider the level of public access to fitness, sport and recreational facilities when exercising their functions. The general health determinants already include matters affecting lifestyle, access to services and environmental factors, and explicitly allow for consideration of any other matters that affect life expectancy or the general state of health. I am not being pedantic—nobody loves a clever clogs—but, to be specific and clear, I note that the amendment would apply only to combined authorities and not to combined county authorities, thereby creating inconsistency in how the duty operates. I apologise that I shall have to point that out with a number of these amendments, but it is important to clarify that.
I now turn to Amendments 159 and 167 in the name of the noble Baroness, Lady Bennett of Manor Castle. I appreciate that her intention is that the health improvement and health inequalities duty, and the definition of general health determinants within the duty, are broad and impactful. A driving purpose behind the health improvement and health inequalities duty is to support combined authorities and combined county authorities in reducing health inequalities and adopting a “health in all policies” approach. The effect the amendments would have is unclear because of the potential interactions with both “health inequalities” and “general health determinants” in Clause 44.
As I mentioned, the Bill has been drafted to provide a broad and flexible definition of “health inequalities” to ensure that differences in aspects such as life expectancy, general health, mental health and disabilities can all be captured in its scope. This allows combined authorities, combined county authorities and mayors to focus on the broad underlying causes of health inequalities and to tailor their responses to key local issues. Similarly, the framing of “life expectancy” or “general state of health” is intentionally broad and does not exclude mental health, disability or healthy life expectancy, all of which are legitimate dimensions of what one might regard as health and are reflected in mainstream methods for describing health states or health impacts.
I turn now to the large group of amendments: Amendments 159B, 160A, 161A, 163A, 163B, 165ZA, 165B, 167A, 167B, 167C, 167D, 167E, 167F and 167G. I am grateful to the noble Baroness, Lady Freeman of Steventon, for her diligence in tabling them and recognise her assured intention to ensure that the definition of general health determinants reflects academic research and is impactful.
As drafted, the list of general health determinants already requires combined authorities and combined county authorities to have regard to environmental factors, employment prospects, earning capacity and access to public services, and explicitly allows for consideration of any other matters that affect life expectancy or the general state of health. Health inequalities are already defined within the duty as inequalities between people of different descriptions living in an area, and it is therefore not necessary to restate this within the general health determinants.