Grand Committee
Arrangement of Business
The Deputy Chairman of Commitees (Viscount Simon)
My Lords, if there is a Division in the Chamber while we are sitting, this Committee will adjourn as soon as the Division bells are rung and resume after 10 minutes.
Welfare Reform Bill
(13 years ago)
Grand CommitteeRead Full debate Read Hansard Text Read Debate Ministerial Extracts
The Parliamentary Under-Secretary of State, Department for Work and Pensions (Lord Freud)
My Lords, if I may intervene briefly, I promised on Monday to provide some timetabling indicators of provision of information about entitlement thresholds for PIP and passporting arrangements for carers. I am happy to confirm our intention to provide entitlement thresholds for PIP and information on the likely impact of these ahead of the consideration of this part at Report stage.
Noble Lords will wish to be aware that we are looking carefully at the interaction between universal credit and carers’ allowance. In the interests of providing a smooth taper of benefit provision as carers return to work, a carers’ element is included within the universal credit structure, which of course removes the cliff-edge effect. That is why we have done that. In order for noble Lords to have the fullest possible picture of provision for carers as we debate universal credit, I will also aim to provide more information about the passporting arrangements from PIP to carers’ allowance prior to the start of Report stage. Thank you for your indulgence.
Lord McKenzie of Luton
I thank the Minister for that statement. It is very helpful in being able to schedule and make progress on Report.
Lord Wigley
My Lords, as I was saying before I was interrupted a couple of days ago, these amendments touch on a critical consideration—namely, the need to ensure that those making assessments can identify factors that may make it difficult to engage meaningfully, fairly and objectively with the applicants: disabled people, whose condition of course fluctuates, as has been mentioned already, and for whom communication itself is often a challenge.
Nowhere is this more evident than among those whose difficulties arise from the autistic spectrum of disorders. As was pointed out by the noble Lord, Lord Touhig, on Monday, on the autistic spectrum not only are no two people the same, but the same person may exhibit different characteristics over a period of time.
The Minister will, I am sure, have noted from Monday’s debate that many of those who contributed—the noble Lords, Lord German, Lord Addington and Lord Touhig, and the noble Baronesses, Lady Howe and Lady Healy—highlighted the challenge of proper assessment in the context of autism. The noble Baroness, Lady Healy, emphasised the need for assessors to have specific training in autism, and access to expert champions. The noble Baroness, Lady Grey-Thompson, who moved the amendment, warned of the dangers of incorrect decisions where assessors base their conclusions on face-to-face interviews without professional knowledge and without experts’ evidence. Given the extent to which autism factors have run through this debate, may I urge the Minister to address the points raised in that autism context?
In particular, I urge the Minister to ensure that in dealing with problems of face-to-face assessments, safeguards be written into the Bill, so that wherever there is ample expert written evidence available, applicants do not have to go through unnecessary face-to-face assessments. The Bill should stipulate that all assessment will take into account expert reports and evidence as a first tier in that assessment process.
Secondly, there should be a requirement that those undertaking assessment have appropriate training, including in autism. This is something about which Autism Cymru, the organisation in Wales, feels particularly strongly. Also, in every assessment centre there should be available to assessors appropriate experts or champions in mental, intellectual or cognitive disabilities, including autism.
The third point I want to underline—and these have all been raised in different ways by noble Lords who have contributed to this debate—is that the Bill and regulations must specify that parents and carers are categorically allowed to support disabled individuals at every stage in the assessment process. Those without such support should be told of their rights to an independent advocate.
Finally, I turn to the position of lifelong awards in the context of Amendments 86F and 86G, to which I have added my name. The Government have said that they want all awards to be for fixed terms apart from in exceptional circumstances, and that there will be some sort of built-in review process. Surely the Minister must realise and accept that there will be people who are sadly not exceptional, whose condition is a lifelong one and for whom the worry and uncertainty of regular reviews are an unnecessary imposition, the cost of which is a waste of public money. Does not all common sense say that those with a degenerative disease, for example, should not have to face repeated assessments? In this group there are more than 300,000 adults, as I understand it, with autism, whose core condition will not change; there are some 70,000 with MS and 20,000 with Parkinson’s disease, whose condition is incurable. Retesting these people is no more than pandering to the tabloid agenda we heard about in the last sitting.
I urge the Minister to take on board these amendments and to facilitate lifelong awards where appropriate.
Lord Low of Dalston
My Lords, I have put my name to Amendment 86ZB in this group. These amendments, which would dispense with a face-to-face assessment where there is appropriate written evidence, have considerable overlap with Amendment 86ZZZV in the name of the noble Baroness, Lady Campbell, in the next group. So, if I may, I will say what I have to say on the matter now and spare the Committee the repetition when it comes up later especially since, with apologies to the Committee, I have to leave for the airport at 3.15 and may not be around when we come to the later discussion.
Lord Low of Dalston
I particularly support the idea of a trial period before incurring huge public expenditure in reassessing 2 million disabled people, many of whom really do not need it, for example, if their circumstances are unlikely to change. Where there is written evidence of severe impairments, it is simply common sense to accept that evidence and avoid putting people through costly and potentially distressing face-to-face interviews. Setting out criteria that would signal eligibility for PIP without an interview is an administratively simple way to indentify those who have severe impairments that have already been assessed through written evidence as giving rise to a higher level care or mobility need.
The Government have said that they do not think it is right that we should judge people purely on the type of health condition or impairment they have, making blanket decisions about benefit entitlement. One can understand their desire to personalise the assessment process when the impact of an impairment may not be clear. However, it is obvious that in some cases the impact is clear from written evidence and beyond dispute in terms of its implications for the rate of PIP that should be awarded. For some groups of people it is perfectly clear from the severity of their impairment that they should be eligible for enhanced rates of PIP without further assessment. For example, if someone is deafblind, a face-to-face interview to establish that they have mobility needs of the highest level is barmy. If someone has no sight at all or no legs, no further assessment is needed to confirm that they have a high level of mobility need. In cases such as these, a face-to-face interview is simply a waste of money. In addition to avoiding unnecessary stress for severely disabled people, this amendment would save money for the taxpayer. It feels pretty much like a no-brainer to me.
Baroness Thomas of Winchester
My Lords, I strongly support this amendment and perhaps I might read it out, because it is a long time since we first started talking about it. It would insert:
“including a requirement for the decision maker to collect evidence from the claimant’s own health care professionals as a part of the decision making process”.
There is a strong suspicion that this is not always done. The only thing that I would quibble with in that amendment is that not only does the decision-maker have to collect evidence, it has to be taken into account when the decision-making process is gone into.
My question for my noble friend is about a sentence that I found in one of the documents we were given—I cannot now remember which one it is. It says:
“Decision Makers will change erroneous decisions rather than send them to a Tribunal”.
The next sentence says:
“If a claimant’s points at issue are not resolved, they can still appeal to the HM Courts & Tribunals Service”.
I had to go to a tribunal having had my papers re-examined, presumably by a decision- maker. What will change about the process now with PIP? I am not quite sure, reading between the lines, what the two sentences that I have read out mean. Are things going to change from now, or not?
Lord Touhig
My Lords, I have already spoken in this debate but I ask the Committee’s indulgence to make one other brief comment. The noble Baroness, Lady Gardner of Parkes, has tabled Amendment 86ZAA in this group. Yesterday, she was mortified when she realised that she has a commitment today which it is impossible to break and she cannot be here. I know that she has apologised to the Minister. She has asked me to extend that apology to the whole Committee and asked that I make one brief comment on her behalf. If she had been here, she would have said that if a person has a clearly diagnosed and irreversible condition, they should not be required to have continuing assessments as it causes them concern and adds unnecessary cost to the system. I think that point has been made by other noble Lords in the debate, but the noble Baroness was really keen to get that point on the record and, again, she apologises for not being here today.
The Lord Bishop of Blackburn
My Lords, I speak broadly in favour of this group of amendments, which address the fact that the assessment of individuals for eligibility for PIP is a complex and very stressful process both for those being assessed and for assessors, unless the assessors are appropriately trained and supported. That is a vital point that we must take on board: that the assessors must be well trained and well supported.
I remain concerned about the tests that the assessed are being put through, the activities and the scoring. I am not one of those bishops who have not come up through the ranks, as it were; I have spent most of my ministry in parishes. From a long ministry in parishes—I still visit the elderly regularly—I have seen parishioners able one day to prepare and cook a meal, and to be able to do virtually everything for themselves. Then I have gone in the next day or the next week and they can do very little unaided. These tests can be no more than a snapshot and we must again take that on board.
All along I have believed that there will be a real need for the most careful monitoring: the assessment cannot be made on a tick-box basis. That, I am afraid, is how it looks to many of us at the moment. It is essential that the tests and assessments are made by those who are adequately trained and qualified and have the perception to see that someone’s performance the next day will perhaps produce a different score.
The Earl of Listowel
My Lords, I hesitate to speak because I was not present at the previous part of this debate. However, after listening to today’s debate and reading part of Hansard’s previous report, I am prompted to ask a question. It may have been answered already and, if so, I apologise for doing so. In the sensitive processing of asylum immigrant applications in the immigration system, continuity of contact with the case officer—continuity of the relationship between the person being assessed and their case manager—has been found to be helpful. I would be interested to hear from the Minister what possibilities there are for that continuity of relationship in this context.
Lord McKenzie of Luton
My Lord, this is an important group of amendments which addresses aspects of the assessment process. As we have heard, some of the underlining concerns which the amendments seek to address are drawn from experience of the work capability assessment and the difficulties which this has created for disabled people. They all raise points which deserve our support, although I expect the Minister will say that, at least in part, they can be covered in regulations. To the extent that he does so, I hope the noble Lord will take the opportunity to put clearly on the record how each of these matters will be addressed.
The noble Baroness, Lady Grey-Thompson, cited WCA examples to emphasise the importance of evidence from the claimant’s healthcare professionals being part of the assessment process, with the obligation on the DWP to organise this. Notwithstanding that we now have a bio-psycho-social model and that the condition or impairment that an individual has may in some cases be of limited value in assessing an individual’s ability to participate in society, this will not always be the case, and there is a clear risk that without it the assessment could be significantly adrift. A process which does not incur the kind of charges which individuals face, to which the noble Baroness, referred, is important.
The amendment of the noble Lord, Lord German, concerning advocacy is also to be supported. As he acknowledged, the explanatory note to the draft assessment criteria is clear that an individual will be able to bring a friend or advocate to a face-to-face consultation. The implication is that such a person could be there to help with the process and not be just silent company. Indeed, I believe that was confirmed by the Minister in the other place when the matter was raised there. Presumably training for staff will enable assessors to sort out advocates who are trying to lead individuals. Claimants must be entitled to know that there is a right for them to be accompanied.
On Monday, my noble friend Lord Touhig gave a clear example of how this could be important. He raised the example of when someone was asked about a bus journey and gave an answer, which of itself would have been extremely unhelpful and misleading to the assessment process. Having an advocate there to help with that explanation would have been hugely important.
The noble Lord, Lord Addington, is a consistent advocate for those with autism and I have no doubt that his plea that those undertaking assessments should be properly trained in mental, intellectual and cognitive disorders will be supported by the Minister. Can the Minister confirm that this will be the case for decision-makers? Perhaps he can also say what is the planned position in respect of access to specialists, which is another key component of the noble Lord’s amendment.
It is understood that the department has recently begun a tendering exercise for the assessments to be undertaken by a third-party supplier. Will the Minister say what specifically is being sought in respect of access to this type of expertise? Presumably, the specification has been developed at this stage. Therefore, can he also tell us what that specification indicates in respect of the numbers, the likely volume of face-to-face assessments and the numbers of likely exceptions to those face-to-face assessments? Perhaps he can also say something about the overall numbers. When this issue was debated in another place, reference was made to the prospect of some of the assessments being able to be undertaken at home—a more comforting and aware environment for some claimants. Perhaps the Minister can update us on this and also say how it is being dealt with in the specification.
We had a number of detailed and knowledgeable explanations from those concerned with autism, including from my noble friends Lord Touhig and Lady Healy and again, this afternoon, from the noble Lord, Lord Wigley. Their amendments seek relief from face-to-face assessment in certain circumstances where there is sufficient medical and other evidence on which to base a clear judgment. The challenges which face-to-face interviews can present for individuals with an autism spectrum condition were graphically described by my noble friend Lady Healy. She said that it is not just the nervousness or anxiety that is experienced at the approach of a difficult event, but dread and terror. The Minister demonstrated sympathy with this point of view at Second Reading. We hope that these amendments will enable him to say a little more in support of that proposition.
Lord Freud
My Lords, I would like to start by responding to the noble Baroness, Lady Grey-Thompson, on her Amendment 86ZZZUA. Obtaining the right evidence for assessors and decision-makers will be a key part of the assessment process for personal independence payment, enabling us to make the best decisions regarding an individual’s claim. Such evidence might come from a range of sources, but in particular from the healthcare professionals involved in supporting disabled people on a regular basis. This may sometimes be the individual’s GP, but in other cases will not be. Many individuals, particularly those with longer-term conditions, may not have not seen their GP for some time and another professional might be much more relevant. This is why we want individuals to tell us who we should be seeking evidence from, as they will know best.
We will encourage individuals to provide this evidence to support their claim or, if they cannot, to let us know who it would be best for us to approach directly. We do not wish to create a two-tier system, as feared by the noble Baroness. However, I do not necessarily think that we need to gather such evidence in every case. In some cases what the claimant has already told us, or provided alongside their claim, will be sufficient. In other cases, information from a health professional might be likely to add only limited value. We must remember here that what the condition or impairment is, or its severity, is often not critical in the assessment; it is the impact of it that matters. The gathering of additional evidence should be decided on the merits of individual cases.
The noble Baroness referred to learning from the work capability assessment used in employment and support allowance. Although it is important to be clear that ESA and personal independence payment are very different benefits paid for very different reasons, we are seeking to learn from the experience of delivering the work capability assessment. As part of this we are looking closely at the findings of the independent review of the assessment carried out by Professor Malcolm Harrington to see where we can improve the design of the personal independence payment claim and assessment processes. For example, we recognise the need to ensure that these processes are empathetic, that we gather the best possible evidence and that assessors are given the training and support they need.
I turn now to the amendments tabled by the noble Lord, Lord Touhig, and the noble Baroness, Lady Gardner. Evidence will also enable us to make the best decisions about how an individual's claim should be dealt with, including whether a face-to-face consultation is necessary.
We recognise the importance of the assessment process being carried out sensitively and proportionately. We have made it clear that we believe that face-to-face consultations should form part of the claim process for most individuals. Consultation will play a key role in creating a fairer, more objective and transparent assessment, providing individuals with the opportunity to put across their views on how their impairment affects their everyday lives.
However, where there is already sufficient evidence on which to make a decision on entitlement, we completely agree with noble Lords who argue that a face-to-face consultation should not be required. In such cases, entitlement would be considered on the basis of paper evidence only, and we have the flexibility in legislation to allow for that.
In doing so, we are ensuring that we will have a tiered assessment—as recommended by the National Autistic Society, and referred to by the noble Baroness, Lady Healy and the noble Lord, Lord Wigley—a process where we consider evidence provided by the claimant first, then any additional evidence gathered and then carry out a face-to-face consultation only if needed.
However, we do not agree that there should be different rules or processes for different groups of people, and especially not on the basis of impairment type. Exempting individuals from the face-to-face consultation on the basis of their impairment would undermine one of the key principles of the new benefit, which is to treat the individual as an individual. The noble Lord, Lord Touhig, argued the point well when he said that when you have seen one person with autism, you have seen only one person and that no two people with autism are the same.
The only exception to that principle is where individuals are claiming under the terminal illness provisions, whom we will not expect to attend face-to-face consultations. I am sure that all noble Lords will accept the need to make an exception under those circumstances.
Picking up the point made by the noble Lord, Lord Wigley, on the frequency of reassessments, we will take a personalised approach to setting the length of awards, varying the frequency and formats of awards and reviews depending on the individual’s needs and the likelihood of the impact of their health condition or impairment changing. Some people will have short-term awards; others longer; and some will receive ongoing awards. It is also important to state that reviews may not always necessarily involve face-to-face consultation. We recognise that it will be important to ensure that the review process is applied sensitively and appropriately.
Having discussed the need for face-to-face consultation, I feel that this is an appropriate juncture at which to turn our attention to my noble friend Lord German’s amendment regarding the attendance at a face-to-face consultation of a suitable person alongside the claimant. We appreciate that some individuals will be able to participate in a face-to-face consultation only with the additional support of someone whom they know and trust. It has always been our intention that individuals should be advised that they can bring with them another person—be it a relation, friend or professional who supports them—in order to help them or to remove any anxiety that they may feel in undertaking a face-to-face consultation. Indeed, the Minister for Disabled People made that exact point during debate in the Commons. That will apply to all claimants.
I agree with my noble friend that the suitable person should not just be a bystander to proceedings. They should be able to play an active role in supporting the claimant and ensuring that they understand the assessor’s questions and requests in order to help them to answer them on their own. Where the claimant is not able to speak for themselves as they should, with the claimant’s consent, they should be able to engage with, and respond to, the assessor directly to ensure that they are provided with the necessary information—particularly in the context of all of our concerns with the community on the autistic spectrum. I hope that that reassures my noble friend and noble Lords more generally on this critical point.
This important measure does not need legislation. We have already made a clear commitment to it and are building it into our processes, guidance and within the commercial framework with the successful assessment supplier.
Lord Wigley
Before the Minister sits down, he mentioned the possibility of developing in conjunction with the National Autistic Society an initiative to augment training. Is he aware of the scheme that has been running in Wales, under the autism plan that was adopted by the Government of Wales, with training work undertaken by Autism Cymru with Careers Wales and to some extent with Jobcentre Plus itself? Last February, an online booklet was published for Careers Wales and Jobcentre Plus, and there were similar publications on autistic conditions relating to the advocacy service and GP practices. Are these the sort of initiatives that the Minister sees being developed in conjunction with the National Autistic Society?
Lord Low of Dalston
Before the Minister concludes, I am sorry if I was not paying attention, but I did not hear him respond to the points made about our amendment about cases where the written evidence was clear and unambiguous, where there were very high levels of need which, the nature of the impairment made clear, were unlikely to change. I heard the Minister say that the assessment process would be implemented with flexibility, but my impression was that the avoidance of a reassessment would be a pretty exceptional situation. Those of us who support Amendment 86ZB believe that cases where people's circumstances are unlikely to change and their high levels of need have been unambiguously and unequivocally evidenced are not isolated exceptions. That is a widespread and general circumstance. Can the Minister respond a bit more positively on that?
Baroness Thomas of Winchester
Will the Minister also respond to my question, when I asked whether the sentence:
“Decision Makers will change erroneous decisions rather than send them to a Tribunal”
is a change from the present system?
Lord Freud
My Lords, taking those questions in the order that I fancy, let me start with the noble Lord, Lord Low. If I did not make it unequivocally clear, let me do so: where the written evidence is unequivocal, we will take decisions on the written evidence and continue to do so. I hope that that is absolutely clear, and I am sorry that I did not say that with enough emphasis.
On the point made by the noble Lord, Lord Wigley, the National Autistic Society is undertaking some extremely good initiatives. I was just considering one in Northern Ireland with Jobcentre Plus. To be honest, I was not aware of that particular one mentioned by the noble Lord, but that is exactly the kind of initiative that we will want to incorporate as we build the programme. We understand that the issue of autism is important.
My noble friend Lady Thomas refers to how the WCA works, rather than how the PIP might work, because we have not completely developed it. The best I can do on that issue is to write to her setting out the position precisely. I hope that that is satisfactory for her.
Baroness Grey-Thompson
My Lords, I thank all noble Lords for their contributions on this group of amendments and the Minister for his comments. I feel that I am not knocking at a completely shut door. However, I still believe that those who should be allowed to be consulted should be made more explicit in the Bill. I also accept that, in some cases, collecting additional evidence from the claimant’s medical practitioner may be unnecessary as the decision may be clear-cut. I think the noble Baroness, Lady Thomas of Winchester, for highlighting the fact that information should be used, not just collected. That has given me plenty of food for thought on my future wording.
There has been strong support for the use of the best evidence possible so that we can arrive at the right decision for the disabled people concerned and be effective in the use of public money. To not take medical evidence into account or use appropriate support advocacy, as mentioned by the noble Lords, Lord Wigley and Lord German, would be a false economy. However, we are still missing something.
As regards the financial cost and the cost in time of an appeals process—not to mention the stress that that will cause to the great number of people who will have to go through it and the fact that it could block up the system—I would much rather the money go into people’s pockets than into the process. On the testing process, it does not matter whether you ask 20 or 200 questions, if the claimant is not able to give the best answer or the right answer, or the answers are not correctly linked together in the process, you will not get to the right decision and will be left in a situation where there is a huge number of appeals. I am not asking for more money to be spent; only that it is spent in the right place.
The Minister referred to the correct training for assessors to ensure that they reach the right standard. That is incredibly important. However, I am not convinced that we are yet in the right place; there is still much work to be done. I shall return to this issue at a later stage. However, I beg leave to withdraw the amendment.
“( ) must provide for a minimum one year trial period for the assessment process to be implemented on new applicants and a formal independent review of the trial period before the assessment process is used to transfer existing DLA recipients; ( ) must provide for disabled people’s organisations to be involved in the assessment process; and( ) must provide for people with significant costs of living as a result of an impairment or health condition or both, who are unlikely to experience a change in any or all of the health conditioning impairment or costs of living over a five year period, to not undergo more than five yearly assessments.”
Baroness Campbell of Surbiton
My Lords, the amendment seeks to enhance disabled people’s confidence in the new testing system and to ensure that limited government resources are not wasted on an ineffective or inappropriate assessment system. It dovetails well with the group of amendments we have just debated.
We are well aware now—as the Minister has recognised —that there have been enormous inadequacies in the work capability assessment approach to incapacity benefit reform, which has seen thousands of disabled people unhappy and inappropriately found fully fit for work when they were not. The system wastes considerable public resources, and appeals alone cost £19.8 million last year. It is deeply worrying that the DWP estimates higher costs for correcting procedural or assessment failures this year. This is despite the assessment having run for three years already at an annual running cost of £100 million for the assessment alone and ignoring DWP costs. I am sure that the Government wish to avoid introducing another assessment system which invites such public controversy and which seems to represent such poor value for money.
Trialling is absolutely necessary. It is somewhat ironic to suggest to disabled people receiving DLA that their needs are no longer affordable but that £675 million is available to pay for the new PIP assessment. As we have heard, this benefit helps with the basic essentials of living, including illness and impairment-related diets, heating and help with personal care and equipment. My amendment would ensure that money is not wasted on an ineffective test by providing an appropriate trial period for new claimants and a report to Parliament on the implementation of the new testing system. This approach offers a better chance to improve the process before disabled people currently receiving DLA are transferred to the new system. Let me explain in more detail what I propose.
Baroness Wilkins
My Lords, at the risk of replaying the record, this is an important amendment because it would go a long way to protect the Government from facing the same sort of vilification that they have received from their introduction of the work capacity assessment for employment and support allowance. Much more importantly, it would protect disabled people from facing the anxiety, illness and ill health they have experienced while undergoing the headlong rush to reassess the 1.5 million claimants for incapacity benefit. That reassessment has gone ahead despite the fact that the Government know that the assessment criteria are seriously flawed.
As the Minister of State at the DWP, Mr Chris Grayling, said in the other place on 24 October:
“We have received suggested descriptors for mental, cognitive and intellectual function from Professor Harrington’s working group. Given that they represent a substantial departure from how the current assessment works, we are considering what impact they will have and will come forward with proposals soon”.
That is fine. He went on:
“The challenge facing us is that the recommendations will involve a complete change of the work capability assessment, not simply for mental health issues, but for physical issues, and is therefore a multi-year project”.—[Official Report, Commons, 24/10/11; col. 8]
Let us not make the same mistake again. Or rather, please let the Government not make the same mistake again.
I was going to quote from the lady I mentioned in an earlier debate, a GP who attended a recruitment evening for Atos assessments, and who wrote in the BMJ this year. The figures that she was quoted about what a doctor could earn from the assessment process were, I found, quite shocking.
Sessional doctors work a minimum four sessions a week, and are paid per item: £51.37 for non-domiciliary disability living allowance examinations, for example. The application forms for sessional doctors state :
“10 DLA domiciliary visits cases per week would earn £40, 211.60 per annum”.
I ask the Minister—and I apologise if he has already given this answer to the noble Lord, Lord McKenzie—what is the Government’s estimate of the cost of re-examining the thousands of people whose conditions will not change, or will only worsen? And can he remind us how often he is expecting them to be reassessed ?
Lord Touhig
My Lords, like many noble Lords I am a great fan of pre-legislative scrutiny, because I think it improves the quality of the legislation we pass. I also have great faith in this Committee system, because we go through a Bill line by line in order to improve it, amend it, and make good law as a result. I certainly support this amendment, because a trial period does make sense.
I look across at my good colleague the noble Baroness, Lady Browning. She and I sat on the Public Accounts Committee in the other place. Time and again we considered reports from the National Audit Office which showed that some great government scheme, some great initiative, had gone billions of pounds over budget, or gone over time. Inevitably we found that these things had not been trialled beforehand, to see if key elements of the proposals would work effectively.
Some unfortunate Permanent Secretary would be brought before the Public Accounts Committee, and like modern-day Draculas, we drew a lot of blood in our interrogations. Inevitably, this Permanent Secretary was not responsible for what the department had got wrong, anyway; it was the previous incumbent, but that is by the by. We were seeking to learn lessons, but inevitably it was like closing the door after the horse had bolted. If only more care had been taken, or things had been trialled and piloted beforehand, then things would not have gone wrong in the way that they did.
If the Government take this amendment on board, it has the potential to save millions of pounds. If the Bill does not take account of this, then somewhere down the track the NAO will come in, in two or three years, and find that there has been some great failure, or some great cost. The Public Accounts Committee will have to investigate, and the Department for Work and Pensions will be held up again as having failed to pilot or introduce a scheme in a good or effective way, as it promised it would. The amendment makes a lot of sense, and I hope the Minister will see that.
Baroness Browning
My Lords, this is the first opportunity I have had to contribute to the Committee. I declare my interest both as the named carer of an adult with autism and as, I believe, somebody who will need to attend the assessment meeting with him. I am that other person, so I am more than personally interested in this legislation.
My friend the noble Lord, Lord Touhig, made a good point about getting good value for money and making sure a system works. However, there is another point about trialling it with new applicants. I remain cautious about the ability of a lot of people newly recruited for the purpose to carry out what will be really quite difficult balances of judgment across a wide section of people, particularly those with learning disabilities, mental health conditions and autistic spectrum disorders, some of whom will have two or all three of the conditions.
I refer the Minister to my personal experience over many years: I am very proud to have raised the very first debate on Asperger’s syndrome in the House of Commons many years ago. When it came to getting contracts signed for people to get people into paid employment, one of the contract requirements was that the various agencies and commercial companies had a full understanding of this range of really quite difficult disabilities. All too often that training and preparation was based on reading up and taking a bit of advice. It never, ever, made the mark.
To give an example, in the case of people on the autistic spectrum it is well known—if I am to generalise and as has been said quite rightly they are individuals who will all display individual characteristics—that their lack of imagination and inability to express and understand non-factual things, as opposed to in some cases a quite high level of ability in understanding factual information, very often leads one to read in manuals and books about autism that if you converse with somebody on the spectrum it is best not to deal in generalities but to deal with specific questions that require specific answers. Some of the contracts that have been issued in the past to get people with autism into work have led the people assessing their aptitude for employment to carry out conversations that frankly beggar belief. I have had some personal experience of this. The questioning would be very much along the line not of, “How are you?”—that is a difficult question to answer—but “Do you live in your own home?”, “How many chairs do you have in your sitting room?” and “What size is your television screen?”. There was a mistaken belief that this was a normal conversation that somebody on the autistic spectrum would feel comfortable with. In one example the person being questioned was actually very intelligent and felt straightaway that they were being patronised, as any of us in this Room would have done.
Therefore, a lead-in period is needed to assess not just the value for money and the way in which this new system is working but also to allow for time, which is really needed, to make sure that the people carrying out these assessments have a working knowledge of some of the more complex conditions and a much better understanding to be able to make their judgment.
I hope the Minister will listen carefully to the points that are being made to allow a lead-in time for new applicants so that we can get this right.
Lord Boswell of Aynho
My Lords, I have not spoken much in Committee on these issues but, very briefly and in support of what has been said, I, too, should like to register my concern. Having had the benefit of reflecting on what has been said so far, there seem to be two underlying themes. The first is that there is a need for the system—that is, the Minister and his officials who are acting on the legislation that we are in the process of enacting—to proceed with a degree of humility. I do not mean fawning or trying to say that there are no problems, or that it is impossible for a Minister to take a decision. A Minister always has to take a decision, or officials must do so in his name. However, I detect in the Minister’s responses this afternoon a readiness to understand that past practice has often been defective and is often, if I may say so, seen to be penal by the individuals concerned when they are in this process as claimants. Therefore, the process needs to be more sensitive to their needs and more conscious of the limitations of the human who has the power to bestow or withdraw the benefit. There should also be more understanding of the fallibility of the system.
Of course, we have to reach a conclusion but the idea of at least some process of iteration, evaluation and progressive change is important. I read the assessment criteria for PIP again today. They say explicitly that trying to get it right is an “iterative process”. That is what we are all trying to do, including the Minister. We are all trying to get a sensitive response. It is important that the process is sensitive not only to the establishment of this situation but to its evolution and development, the representations that are made to it by interested parties and the light of experience.
That brings me to my second point, on flexibility. If we eventually say, “We’ve done an awful lot of consultation and this is where we are. That’s it”, we will get into the danger that the noble Lord, Lord Touhig, reported. That is, if it becomes the law of the Medes and the Persians, we could then find that we are overtaken by events or experience and that it is not good enough. We would then be creating unfair or penal situations, or we would have to tear up the legislation and start again.
All I should like the Minister to say—I think he will want to signal something like this—is that the Government understand that this is an extremely sensitive area, particularly in relation to people on the autistic spectrum, but also more widely. We need an understanding that the system is on the side of individuals who are involved in this process. It is not designed to leave them out, humiliate them or create embarrassment for them; it is designed to be fair to them. I think there is a wish to do that. Fallible officials who need training, and may need retraining or development in this process in the light of experience, should also understand that they, too, are part of this process of discovery. The more we move away from the conventional model of opposition—of advocates and a decision—that we have always enjoyed in the Anglo-American system, towards an understanding that we are trying to hammer out a process that is fair to individuals and reflects their genuine needs, the better and happier we shall be.
Baroness Howe of Idlicote
My Lords, I support this suggestion, which would solve an awful lot of problems. It would clearly give the Government time to catch up with their own aims and put them into practice much more clearly and in a way that other people will understand and be able to act on. There is a need for training and, from what we have heard from those who have practical experience, a need for retraining of some of the so-called experts. I am also slightly worried by what the noble Baroness, Lady Wilkins, said at the end of her contribution about huge sums of money being paid for “expertise” in this area. There was, almost inevitably, a comparison with the individual at the receiving end. Maybe we cannot afford to give them more but it is a small sum compared to what the expert gets. This is another opportunity to strike a better balance.
The Earl of Listowel
My Lords, I support the amendment. Does the Minister think that it might be worth while if he made a few comments on the issues of continuity and supervision of staff? I hesitate to ask because I am unfamiliar with this area but in the areas of the asylum and immigration process, which has some similarities, and in social work and work with vulnerable children and families, the two themes seem to be, first, continuity of relationship wherever possible and, secondly, good quality supervision.
Lord Freud
I apologise to the noble Earl, Lord Listowel, for not responding to that point previously and I intervene to do so. There is a huge difference between a one-off assessment—which you may not repeat for another five or 10 years or never again—and an ongoing relationship in the Immigration Service. It is not a relevant analogy at all.
The Earl of Listowel
I suspected it might not be. For people with fluctuating conditions, where there is a likelihood of their going back on repeated occasions, perhaps one could sort out within a particular group individuals who would benefit from having regular contact with the same person. In the spirit of co-production, some individuals who are going to be assessed on a repeated basis may perhaps like to choose the person they deal with. However, as I say, I do not know how it works in practice at the moment so this may be by the by.
On listening to this debate, the question of the supervision which takes place in the social care arena seems to be pertinent. I am grateful to the Minister for making it possible for a social worker to visit the officials working on this and to discuss matters of supervision. In social care it is very important for front-line staff to receive quality supervision on a regular basis for three purposes: first, to check that they are doing the right job; secondly, to check that they are receiving the right continual professional development; and, thirdly, to ensure that they are not responding inappropriately to the clients.
On the third purpose, we all come to life with our experiences, and some assessors may find it difficult to work with particular clients who rub them up the wrong way. They need to be able to go to their supervisor and say, “Look, I feel really uncomfortable working with this person. I am not sure it is actually anything to do with them. Can you help me to sort this out?” They need a sounding board, if you like. That is one aspect.
On the continuing professional development side, this is a training aspect to check that they are continually building on their understanding of, let us say, autism. They will start from a point of ignorance but, in the course of years of experience, they will learn more and more. They are helped to do so and their supervisor ensures that they get the opportunities for that learning and enrichment. It is a draining job and the people doing it need to be recognised, supported and enriched. I have covered those three points but, as I say, I am not sure it is pertinent.
The proposal for a trial arrangement might allow an opportunity for us to find the most effective kind of supervision we can afford to provide and where there are opportunities to build continuity of relationship with clients.
I have an amendment later in the Bill which relates to how one manages the system and the culture in this area. If the people at the very top of some of these organisations had experience of social care—if one could be confident that there was a senior social worker at the top of the Jobcentre Plus arrangements, or whatever—they would have the necessary insight and the understanding to help people on the front line who will need a system of this kind to assist them in working with vulnerable adults. In that way, even with limited resources, the best outcomes could be achieved in the circumstances.
However, I will come to that amendment later. I look forward to the Minister’s reply.
Baroness Grey-Thompson
My Lords, I support the noble Baroness, Lady Campbell of Surbiton, and this amendment is also in my name. It is vital to ensure that the new framework is right, and this amendment gives me some comfort in what is a very difficult time for a huge number of disabled people. The noble Baroness, Lady Howe of Idlicote, mentioned time. That time is required.
If someone has a health condition that is likely to improve, or a newly acquired impairment to which they are likely to adapt, no one would argue that the costs might not change over time and that there should not be a reassessment. For example, the costs of someone who is a lower leg amputee will be very different in the first 18 months or two years after the amputation from what they may be 20 years later when they have adapted to it. However, when someone has a health condition or impairment that is unlikely to change and the costs are likely to remain the same, it does not make sense to keep sending them for more face-to-face assessments. For people in this situation it should be enough to confirm with the claimant’s healthcare professionals that their condition is unchanged. I feel very strongly about this because the following claimant told the MS Society how she feels about the prospect of face-to-face assessments. Many like her find this process very strange given that so much is known about the condition, including that it will only get worse and not better. When such claimants have to talk to a stranger about some very intimate details of their life it can have a devastating effect on them. The claimant said:
“I am already dreading the day when I have to sit in front of someone and explain myself to them … When I am already seeing a neurologist and a whole team of people who help me to try and live as best I can with MS … This is just not fair in my eyes. … Shame on the people who have come up with these changes which once again affect real people who have no choice but to try and live with this illness”.
Baroness Lister of Burtersett
My Lords, I wish to speak briefly in support of the hobby horse of the noble Baroness, Lady Campbell of Surbiton, which we should take seriously. I was struck by what she said about how a trial period in which disabled people’s organisations were involved could do a lot to restore confidence in the system. I am sure that I am not the only noble Lord who has been struck by the e-mails, letters and faxes that I have received, which demonstrate that that confidence is at rock bottom. There has been a catastrophic loss of confidence. The noble Baroness is offering the Government perhaps not an olive branch, because that suggests that a war is going on, but an opportunity—I suggest that the Government would do well to grasp it—to listen to what is being said, accept this amendment with its trial period and involve disabled people’s organisations. That could go a long way to restore confidence in this system.
Baroness O'Loan
My Lords, I apologise to the Committee that I was unable to be here at the beginning of the proceedings. The amendment tabled by the noble Baroness, Lady Campbell, to Clause 78 has to be considered in the light of the UN Convention on the Rights of Persons with Disabilities. I draw particularly to the Committee’s attention the fact that paragraph o of the preamble to that convention provides that,
“persons with disabilities should have the opportunity to be actively involved in decision-making processes about policies and programmes, including those directly concerning them”.
The proposal for a trial period and the involvement of disabled people’s organisations in the assessment process will undoubtedly enhance that process, but it will also put the United Kingdom in a position in which we are in compliance with our obligations under the convention. I am sure the Minister will be aware that it will be most important to have a review in terms of having confidence in the Government’s new system, and to ensure that injustice is not done and that people do not lose the right to benefit simply because of a flawed assessment process, particularly one that is not conducted by those with the necessary expertise, as was referred to by a number of noble Lords.
I refer the Committee to Articles 19 and 20 of the UN Convention on the Rights of Persons with Disabilities, which are particularly relevant in terms of the opportunities that disabled people need in the context of this amendment. It is also cost-effective; more importantly, it is respectful of the rights and dignity of people with disability. As the noble Baroness, Lady Grey-Thompson, was saying, when they are unlikely to experience any change in the health impairments from which they suffer and which result in significant costs, they should not be required to be assessed more than once every five years. It is a human rights issue. The assessment process itself, as we have been told, will take a toll on such people and it would be disproportionate, unnecessary and unproductive to require more regular assessment.
Lord McKenzie of Luton
My Lords, a compelling case has been made for a trial period before the system goes live in its fullest extent. When this was debated at the other end there was some debate around the difference between a pilot and testing, and what that meant in government legalese. The proposition seems very clear: we want to see it working in practice before it is more widely available, for all the reasons that have been advanced by noble Lords about confidence, which I link with the issues of co-production, value for money and testing the capacity of providers. If it is to be meaningful, this would have to be done together with whoever will end up being the provider. It could not be done just with DWP staff, with providers coming in later. We acknowledge what is clear from the documentation we have: there has been an enormous amount of testing and engagement to date. However, that is not the same as or a substitute for having the final subject of the trial criteria in place and knowing where the thresholds are.
The amendment says that the trial period should be in respect only of those new claimants. I wonder quite why we are adopting that cut-off point. Is there not also going to be an issue for existing DLA recipients who have to go through the process and how that is handled, with all the communications and sensitivities around that? In particular, I think we know there will be some who are in receipt of DLA at the moment who will go through an assessment process and not be able to end up on PIP. I would be interested in the noble Baroness’s view on why she has pitched it at just new claimants, rather than people currently on DLA who will have to, in a sense, be recycled through the new process.
I want to make a point about capacity as well. We do not know who the new providers will be. Certainly, if they can earn the sums that my noble friend Lady Wilkins referred to, you would think that there should not be a capacity issue—certainly not in terms of numbers. However, I recall an instance a couple of years ago when, for industrial injuries benefit, the condition of miner’s knee was recognised as something that had to be compensated. Trying to pull in capacity to get those assessments done was, frankly, the devil’s own job because the existing providers did not have enough people to help out, certainly not in the timeframe that was wanted. Although, in a sense, the system will not be fully up and running even in that one-year trial period, this seems to be an important opportunity to test that capacity—not only in terms of the numbers but the processes and how people are being dealt with, and the levels of expertise that we expect to be available. This is a real opportunity to try it.
One thing that strikes me—it has been part of the whole debate over this Bill—is how pervasive the problems with the WCA are right across the spectrum. If we knew when that was introduced what we know now, there would have been much more careful testing of it, as is requested and sought by this amendment. Therefore, I do believe it is important to see how it is happening in practice before it is rolled out more widely, whether that is over one year or a different period.
Lord Freud
Let me take each of the noble Baroness’s amendments in turn. On the trialling of the assessment, I am sure that noble Lords are aware that it is possible to test out and evaluate the assessment process without trialling it. There is, indeed, an advantage to testing over trialling, because the former can be done without affecting an individual’s entitlement to benefit.
The noble Baroness will be aware of the testing we undertook throughout the summer with more than 900 disabled volunteers, and the informal consultation that took place alongside it. Both were very effective, and allowed us to review, revise and improve the draft assessment criteria from the draft published in May to the draft with which noble Lords have recently been provided. We are now seeking further views on that.
For our testing, using independent experts has demonstrated that our proposed approach to assessment is both reliable and valid. This testing included individuals on the autistic spectrum. This is not the end of the matter, though, as we believe the development of the benefit processes, including the assessment, should be and will be an iterative process. Therefore, in addition to testing of the assessment, we have created a specific development group to engage with a broad spectrum of disability organisations, to understand their views on a range of issues related to the delivery of the benefit. We have also created a number of customer research panels made up of groups of disabled people who share similar characteristics. We will seek to test our processes in a model office environment, allowing us to see how they work without affecting individuals. These processes will be vital in helping us gather insight first-hand from individuals on whom the process may impact.
Turning to the independent review of the trial referred to in the amendment, I first state that I do appreciate the importance of such reviews, and will talk about that in more detail later. However, undertaking this after only one year of operation would not provide adequate time for the assessment process to bed in. It would not allow enough time for sufficient data to be captured, as it requires people to go through the full claims process in this time, and there are inevitable lags in the production of statistics. Any subsequent analysis would therefore provide an unrealistic impression of how the benefit was operating.
There are, of course, other means by which we seek to evaluate and improve the operation of the new assessment. The assessment and its associated process will remain living tools, and we will continually carry out internal evaluation work to monitor their performance. We will therefore not have to wait for the outcome of the independent review to learn from and take action based on operational and individual experiences.
The second element of the noble Baroness’s amendment is the involvement of disabled people’s organisations in the assessment process. Let me assure the noble Baroness that we have involved disabled people’s organisations in the development of this policy from day one. We are trying to approach this work in a co-produced way, seeking the views of disabled people and their organisations at each stage. I have mentioned in earlier debates that our assessment development group comprises members of Equality 2025 and Radar. Both have provided critical support, direction and challenge throughout the process of developing the assessment criteria.
We also held a 16-week informal consultation on our initial draft of the assessment criteria, which sought the views and opinions of disabled people and their organisations. This process helped us to revise the initial draft assessment criteria and develop the second draft, which has lately been made available. Most of the changes that we have made have been as a direct result of the input of disability organisations. We are now seeking views on the second draft and, importantly, the proposed weightings, before we reach any firm views on the entitlement thresholds. We then intend to carry out a full consultation on the entire assessment criteria, including the weightings and thresholds.
Equally, we are involving disabled people and the organisations that represent them as we design the operational processes for personal independence payment. To achieve this, we have created a dedicated working group specifically for this purpose. The group’s membership has been drawn from a wide number of national and grass-roots, user-led organisations, and it is currently working with us on a range of operational issues. We also see disabled people’s organisations playing a key role in the delivery of the new benefit, helping to inform individuals and guide them through the process. This could include assisting them in making claims, providing evidence to help support their case and/or attending assessments with them to provide support and reassurance. We are undertaking work to strengthen and expand our partnership arrangements with local organisations that represent disabled people and ensure that they have all the relevant information about PIP.
Meanwhile, there is nothing in the legislation to prevent disabled people’s organisations being involved in the delivery of assessments. The key for us is ensuring that, regardless of which organisation or organisations deliver the assessment, they have the capacity to do so, and that individual assessors have the requisite skills and experience. Disability organisations have been free to participate in the procurement exercise for the assessment, which is now under way, either as prime contractors or as partners of such organisations. Whatever the outcome of this exercise, we will ask the assessment provider to work with disability organisations and seek their input, so that we can deliver the best possible service to claimants.
The final element of the noble Baroness’s amendment is intended to ensure that individuals whose condition is unlikely to change over five years should not have to undergo an assessment more often than once every five years. We will discuss this issue in more detail in a later group of amendments. However, we know that disabled people’s lives are varied and that health conditions and impairments affect people in many different ways. As I have said before, we therefore do not feel it would be appropriate to make blanket rules for particular groups of people.
Under personal independence payment, we want individuals’ treatment to be tailored to fit their personal circumstances. This includes our approach to award length and review date, which should also be personalised. Such an approach would be able to take into account the likelihood of the impact of an individual’s health condition or impairment changing. We know that for some people a shorter-term award might be appropriate. For others, a longer-term award might be appropriate, while, for those with the severest disabilities, an ongoing award might be right. We absolutely do not want unnecessary reviews of claims, both to reduce the impact on individuals and to ensure that we do not waste money.
The noble Baroness, Lady Wilkins, raised the question of the overall cost of delivering DLA reform over three years. This was included in the 2010 Budget Red Book at £675 million.
Baroness Wilkins
I asked about the cost of reassessing people with conditions that will not improve or where there will be no difference.
Lord Freud
My point is that we will try to minimise those costs by not having reassessments in those circumstances. I cannot put a precise figure on it but I can tell the noble Baroness that our ambition is to have as low a cost as possible in those circumstances. Assessors and decision-makers should be empowered to make these decisions based on the circumstances of the case and with the aid of departmental guidance. These matters should not be prescribed by the Government through legislation. Only by doing it that way will we achieve the personalised approach we desire.
Baroness Hollis of Heigham
My Lords, can I make one proposal to the Minister? He may not feel able to accept this amendment—although given the strength of feeling in Committee I hope very much he takes it back and reflects on whether he can move more than he has been able to do today, otherwise I am sure it will come up on Report. Can he at least consider, as a fall-back position, that for a year new applicants who have been refused and existing applicants who are currently on DLA who will lose entitlement under the proposed new PIP would have a further personal review stage put into the system? This would involve not just the decision-maker but the disability organisations so they can work through the material themselves to see whether they would uphold the decision.
The Minister and the department will need additional knowledge-building within the decision-making process. The best way to do that in that first year may be to look at the cases that are being refused or declined and reconsider them before the applicant is notified. This would ensure that errors have not been made and that the decision-maker understands fully—in the light of real expertise coming from the relevant associations and organisations—where that may take him or her. I would suggest a further stage of at least 12 months of a review process within the department in which rejections are analysed a second time around with the help of representatives from disability organisations which are experienced in these matters so that we build up expertise.
Lord Freud
My Lords, I am very happy to reflect on that rather interesting point. I will go back and think about that very hard.
Lord McKenzie of Luton
I wonder if the Minister just could deal with this point also. In his response he explained—and I think we would accept—that a lot of testing, engagement and assessment is going on. That is what you would expect of the noble Lord. However, what it does not achieve—and I think the amendment is trying to—is a gentle start to the process, so that it does not start fully over a condensed period. A key lesson from the WCA is not so much its background philosophy or some of the assessment processes, although they have been refined by Harrington, but what happened in practice. There was a disconnect between the two to a certain extent. The thrust of this and perhaps the challenge is calling it a trial period. It is really the timeframe in which it is introduced which seems to be particularly important.
Lord Freud
My Lords, I am very sympathetic to the thrust of the noble Lord’s point. Noble Lords will be aware that when we designed the universal credit we did it on a trajectory. It is really important that we get the right trajectory on all these introductions. In that context, rather than having a formal trial which has some very specific implications around that process, I take the point about a trajectory of introduction. Indeed, we are looking very hard at the optimum trajectory of introduction.
Baroness Campbell of Surbiton
I thank the Minister for his response. There is a lot in it, so I will deal with each part in turn. I thank other noble Lords for their contribution to this amendment. They have expanded it and given it colour, depth and breadth, and I am very grateful to them for that. I was particularly grateful to the noble Lord, Lord Boswell, for saying that this is a process of discovery. It is a process of discovery, not just for the assessor but for the disabled person.
Noble Lords will understand that this is a very old, tried and tested benefit which has enormously benefited disabled people in making them more emancipated and independent. For me, as an old researcher, not to trial this seems absolutely crazy. I was heartened to hear the Minister’s comments with regard to the testing that went on over the summer. I am aware of it and I have tried to get as much information about it as I can. It is still a bit secretive, but I will do my best to get hold of more information. However, it is not a trial. It is not the real thing. The 900 test assessments are just testing out questions and testing the ground, not the life that a person will have to lead after they have been given their award. I still believe that a proper controlled trial is very important for this incredibly complex benefit. It seems simple but what it gives people is complicated.
That takes me to the contribution of the noble Baroness, Lady Howe, who pointed out that the reliance on judgment in relation to people with learning difficulties and people with mental health problems would itself be tested. Again, I am in a bit of a conundrum here as the Government have stated again and again that one of the reasons for reforming this benefit is so that they can better target people with mental health problems and people with learning difficulties, who are not necessarily seen as recipients of disability living allowance as they can walk, talk, leave the house without a wheelchair and move around. I am afraid that the assessors will still see disabled people in terms of their medical condition. Independence will be seen in terms of whether someone can give an affirmative answer to the questions: Can you walk? Can you see? Can you pick up a cup? Can you go down the road? If we are to target a significant group who have probably not benefited from DLA in the way that people with physical impairments have done in the past, that is another reason to hold a trial.
I know that the Minister and the Government are very keen to involve disabled people in the process and have done their best to co-produce, but the few people who have been involved are the very people who have come back to me to say, “Jane, we must have a trial, because this is a very big step for both the assessors and disabled people”.
For all those reasons, I am keen that we return to the issue of a trial. The trajectory might be a way to slow the process down. The reason why we decided to table the amendment just for first-time claimants, not for those going for their reassessment, was because that would be manageable. There would be another year for those of us who are awaiting this change to look at what is going on and how it would affect current recipients. So it was a practical issue.
For all those reasons, we will need to return to the issue of trialling, analysis and evaluation. In the mean time, I will do my best to get hold of all those testing papers in the depths of the DWP and then, we hope, we will not feel that it is so necessary to have a trial. For now, I beg to withdraw the amendment.
“(d) must disregard aids and adaptations used by a person in assessing their mobility”
Baroness Thomas of Winchester
My Lords, as we all know, at last we have the second draft of the PIP criteria, with the responses to the consultation analysed and with the Government's response. We now have to call aids and adaptations “aids and appliances”, although aids and adaptations was the phrase in the consultation. I declare an interest in that I use a huge number of aids and adaptations, as I expect my fellow Peers along this Bench do too. The confusion about the name reflects a bit of confusion about the whole issue in the DWP. I must say that I am not much the wiser having read both “The approach to aids and appliances” on page 32 of the explanatory note and “How aids and appliances should be considered”, on page 17, but I start on page 6. Under the heading, “Refining the draft criteria to produce a second draft”, the sixth bullet point states:
“To ensure that the assessment does not unfairly penalise individuals who choose to use aids and appliances to improve their independence, the assessment now also considers cheap, widely available aids and appliances which can ‘reasonably be expected’ to be used, in a similar way to Disability Living Allowance. We also recognise that aids and appliances do not necessarily remove barriers and may attract costs; therefore descriptors which refer to these normally attract a scoring descriptor”.
The last thing we need is for those who make the most of every aid and appliance they can find to be unfairly penalised; or for those who do not even try to find suitable aids and appliances which might help them to be rewarded. Aids and appliances should be complementary to benefit entitlements, not in competition with them.
Many respondents to the consultation, we are told, argued that the use of an aid or an appliance does not necessarily remove a barrier to participation, and they are quite right. We cannot be certain that the Government believe that. They state at paragraph 4.25:
“Some respondents felt that we should not take the use of aids and appliances into account in the assessment. We do not feel that this approach is appropriate as we want entitlement to Personal Independence Payment to be based on an individual’s level of participation in society. As such, if individuals are participating well with the help of aids or appliances, we believe that this should be reflected”.
What does this mean? There is no useful “for instance”. However the next paragraph goes on to say that it is recognised that,
“barriers and costs may not be removed by the use of support aids and so descriptors describing the use of an aid or appliance to carry out activities will usually attract a score in the assessment”.
These two sentences must be read together so that the first is at all times qualified by the second, although we do not know what score might be given in the assessment.
Baroness Wilkins
My Lords, I support this amendment. The range of people who will need aids and adaptations is enormous. One of the groups who are not highlighted in the new criteria is those people who need communication aids, which can be extremely expensive and of which there is, at the moment, a very erratic supply. Whereas a child might be given a communication aid and be able to communicate with the world by using it, after the age when education finishes it becomes a very dodgy business. We are talking about a huge range of people. In the area of mobility, the cost of special shoes is £100. It is such a complicated area that the Government would be extremely wise to think again.
Baroness Campbell of Surbiton
My Lords, I am also extremely supportive of this amendment. It is a government misuse of the social model to withdraw support by saying that if you have a decent wheelchair-adapted house and car your disability goes away. That was quoted to me by a DWP civil servant as a social model assessment. That is exactly why I tabled an amendment on social model assessment—so that we can teach assessors what the social model really means.
The noble Baroness, Lady Thomas, is absolutely right. If I were assessed today, I would probably be taken off DLA. I have my wheelchair, my adapted house, my car and some personal assistance. However the cost of maintaining that is absolutely phenomenal. My disability has gone away; it is away today. I feel equal to all who are here but tonight it might be different. Therefore, I am absolutely in favour of placing this in the Bill. It is a perverse incentive to account for aids by means-testing. It means that people might stop using their electric wheelchairs and adapted cars to get the benefit. They might hide them in the garage or swimming pool. Apparently people put their cars there to hide them from the taxman. As noble Lords can see, I am very supportive of this amendment.
Baroness Grey-Thompson
My Lords, I also support the noble Baroness, Lady Thomas of Winchester. When I first looked at this area, I found it quite confusing and some of it not very simple to understand. Some aids and adaptations are taken into account for the assessment. For example, for the mobility component, any aid that the person can use to assist them in walking is taken into account. However, someone who can self-propel a wheelchair will qualify because they are still unable, or virtually unable, to walk.
I declare an interest as a wheelchair user and someone who spends considerable time making sure that I can get the right aids and equipment for me to live as normal a life as possible. As the noble Baroness, Lady Campbell of Surbiton, has said, you try to get as much independence as possible. For me, it is about getting a small chair that means I can fit into every lift in this building, which is a challenge when they are all built into the various chimney stacks; and one that is light enough to push for more than 50 metres, which does not get you very far in your Lordships’ House on the very expensive carpet that we have here. I also need to get it in and out of my car. I spend a lot of time making sure that equipment is right for me but I could easily buy a chair with wheels that are 16 inches in diameter, rather than 11 inches, and that weighs 30 kilos instead of four and a half. That would change my impairment considerably but I want to be as independent as possible. Those aids and adaptations make my life easier but they do not stop the patronising attitude that is out there. They do not stop the barriers.
I also want to encourage disabled people to be as fit and healthy as possible but we could be in a situation where we prevent people exercising and doing physical activity because they are penalised for doing so. Again, in my case, I spend several hundred pounds on the right cushion to sit on to ensure that I do not get a pressure sore. A cushion cover for that cushion is around £120. This costs the National Health Service considerably more than it would if I sat on a piece of old, tatty foam. However, if I sit on a piece of old, tatty foam, I might be in a better position to be considered for DLA in the future. It is the same with adaptable housing, and lifts and ramps. We are getting into a very difficult situation here, where the things that should be making disabled people’s lives easier, to enable them to contribute, will actually encourage them to think about things in a very different way.
It is very important we get this right. We do not want to push disabled people back into their houses, or ghettoise them. We are in a real danger of doing that if we do not find the right balance, and make sure that disabled people have access to the right equipment to enable them to live as independent lives as possible, and to contribute towards society.
Lord McKenzie of Luton
My Lords, it is with a degree of trepidation that I rise to speak, having just heard those contributions. This issue presents a real conundrum. There is an argument that asks, if the social model is to identify the broader challenges to living that confront disabled people, is it unreasonable to take account of provisions and innovations of aids and appliances that society has developed to help people in their daily living? However, it is easy to state that; as the contributions we have just heard made clear, there is a question of what that will mean in practice.
We could recognise that the use of aids and appliances will not always remove the barriers that people face; we have certainly heard that explained. We should also recognise that not everyone will have access to aids and appliances, or indeed adaptations, which could enhance their quality of life. There is a conundrum that is recognised in the November 2011 Explanatory Note. If account is taken only of aids and appliances that people have and—other things being equal—that produces a low award, there is a potential disincentive to acquire those very aids and appliances that will improve people’s lives.
As I understand, what is currently proposed—as the noble Baroness, Lady Thomas, identified, this mirrors the current DLA formulation—is that the assessment will take account of aids and appliances that are normally used and can reasonably be expected to be worn or used. This seems to penalise those who have not yet acquired those aids and appliances. They will have a zero or low award, and not have the money to acquire the facilities. I wonder if it would not be a more reasonable approach, if there is to be some recognition of aids and appliances in the assessment, to take account of what people have initially, with some acknowledgement that, at a reassessment at some stage in the future, you might add those that people might be reasonably expected to use. At least that way, there is a transition.
We know that some aids can be differentiated from others on the basis that in themselves they do not overcome all the issues of mobility. Attaching higher scores for these circumstances—although we do not know what the tariff will be—does not seem unreasonable. The more I have thought about this, and the more contributions I have heard, the more difficult an issue I think it is.
Lord Freud
My Lords, I owe my noble friend Lady Thomas an apology and a clarification. I incorrectly attributed her question about reconsiderations in the previous group to ESA, when of course it applied to PIP. The new provisions on reconsiderations contained in Clause 99 will make a difference, but I suggest that we have a separate debate on that later clause, as it is a wider issue than just in relation to PIP.
Baroness Hollis of Heigham
How many points do you need altogether if one produces 10 and the other produces 12?
Lord Freud
My Lords, this is a matter to be revealed at a somewhat later date. I am pleased to have provided a timetable of when this matter will become clear. However, the direction of travel is clear: the maximum number of points on that one is 15.
I almost want to call the noble Baroness, Lady Campbell, my noble friend, but I am not allowed to do so. I invite the noble Baroness to join me; I have to find an appropriate enticement so that I can call her my noble friend. However, I must disagree with her concerns. I suggest that she is likely to score very highly in the assessment by way of the very aids and appliances that she has highlighted. As I said, electric wheelchairs are right at the top of that measure at 15 points. We will produce case studies by the time PIP is debated on Report which clearly illustrate how individuals who successfully use aids and appliances will continue to receive PIP in a similar way as they do with DLA.
I turn to the noble Baroness’s second amendment. We are committed to personal independence payment, like disability living allowance, being an extra-costs benefit for disabled people, to spend on whatever they see fit. Our experience of DLA tells us that in some cases the money will go towards the cost and upkeep of specific purchases or activities, such as aids or appliances, or that it may simply become part of the disabled person’s budget paying for things as and when they come up, such as the need for shopping deliveries or taxis. The clear intent is that the mobility component should be used to help improve the disabled person’s ability to get around but we have no wish to prescribe how they should spend the money.
Given that the purpose of the benefit is to contribute to disability-related costs such as aids and appliances, and that there are other support means available, we do not think we should be paying for aids and appliances in addition to this. Given these comments and the reassurances that I hope I have given on how aids and appliances will be treated in the assessment, I urge the noble Baroness to withdraw her amendments.
Lord McKenzie of Luton
I do not think that the noble Lord has helped me with my conundrum. Is it not the case that the assessment will take account of aids and appliances that people have as well as aids and appliances that it might be reasonable for them to have? If that is the case, in that latter category is that not a double whammy as, other things being equal, people would get a lower assessment and a lower or zero award, and therefore would not have the wherewithal to acquire some of the aids and appliances which would positively improve their lives?
Lord Freud
This is the Catch-22 that a number of noble Lords have pointed out today and in the past, whereby denying oneself an obvious aid is used as a method or device to maintain a higher level of PIP. Clearly, we want to discourage that because we want people to maximise their opportunities in life. The noble Lord referred to a period in which to obtain an aid. However, that drives straight down the other path of starting to multiply the number of reassessments, which we do not want to do. There is a balance to be struck here but most people are able to get aids and appliances. They may not get the four-and-a-half kilo device of the noble Baroness, Lady Grey-Thompson. That is half the weight of my bike.
Baroness Grey-Thompson
My Lords, if I might interject, one of the issues is the cost of aids and equipment. You can buy a fairly okay wheelchair for £250. You can buy a semi-custom fit chair for about £3,500 and you can probably spend £6,000 on a chair. However, some aids and adaptations are very difficult to get, such as a stair lift, which costs £2,500. I tried to get one fitted in my house when I was pregnant but no company in the country would fit a stair lift in my house as the stair lift was not insured to carry two people, and as a pregnant woman I counted as two people. However, there were companies that were prepared to put one in for someone who wanted to carry their dog up the stairs. A through-the-floor lift costs £18,000. If you live in the south-east of England, moving to a bungalow is just not an option because it is so expensive. There are all these costs that keep adding up, and it is very difficult for disabled people even to think about getting the right equipment because of the huge cost.
Lord Freud
Clearly, one has to be absolutely sympathetic to this point. As we all know, levels of equipment can vary hugely. However, the point on this particular issue is that we will look at only readily available, cheap aids and appliances, which can be reasonably used. That will be the definition and it is the definition used today in DLA, so we are effectively porting that approach over. I think I have already asked for the amendment to be withdrawn.
Baroness Thomas of Winchester
My Lords, I think that proves my point about the confusion over this issue. This has been an extremely illuminating debate. I am very grateful to my fellow Peers along this Bench. We have heard about special shoes, small chair-lifts for small chairs, stair lifts, carpets, lifts in the House of Lords, cushions and so on. I fear that the confusion in my mind over how aids and appliances will be taken into consideration has not been entirely removed. I shall read what the Minister said with care. If I were younger, I would go to my assessment having borrowed the electric wheelchair of the noble Baroness, Lady Wilkins. That would be the answer. I could cross my fingers behind my back and say that it was mine, and I would then get all the points that I needed. There are some real problems.
However, I end on a note that the Minister might enjoy. The prize for the best disabled lavatory that I have ever come across goes to one in the Department for Work and Pensions in Caxton House. It should be open to the public for general inspection. I hope my noble friend will pay it an official visit at his convenience. It has an electric control that you press, which means that it goes up and down without any effort on the part of the user. As an example of a brilliant adaptation, it takes the top prize. For the moment, I beg leave to withdraw the amendment.
The Deputy Chairman of Committees (Baroness Harris of Richmond)
My Lords, it might be appropriate to have a break at this moment, so I suggest that the Committee adjourns for 10 minutes.
Baroness Howe of Idlicote
Baroness Howe of Idlicote
I will speak also to Amendment 86AB in my name and that of the noble Countess, Lady Mar, who sends her sincere apologies. Her absence is due to an unbreakable and important appointment. The amendments would ensure that people with fluctuating conditions, such as multiple sclerosis or some mental health conditions, are not unfairly denied PIP simply because their condition is fluctuating. As noble Lords will be well aware by now, such people may not necessarily have had a particular impairment at every point in the past six months but may well have experienced one at some point in the past six months.
To highlight the unpredictability with which people with fluctuating conditions have to live, I share an example from the MS Society of a man with multiple sclerosis. It highlights the unpredictability of a condition which can fluctuate not only month-to-month and week-to-week, but day-to-day and even hour-to-hour, as the right reverend Prelate mentioned earlier. The man states:
“Fatigue is where your body just shuts down. It doesn’t make an appointment with you to do so and you have to just rest immediately. I have to just lie down until it passes. I cannot even talk”.
Yet the current wording of the Bill could be interpreted to mean that a person must have been consistently unwell for the previous six months to qualify for PIP. The Bill states:
“whether, as respects every time in the previous 6 months, it is likely that if the relevant ability had been assessed at that time that ability would have been determined to be limited or (as the case may be) severely limited by the person's physical or mental condition”.
That wording suggests that people with fluctuating conditions will not qualify if they are not consistently ill for the required length of time, regardless of the severity of their condition. I do not know if that is its intended meaning, but given the context in which PIP is being introduced—a desire to save some 20 per cent of the budget, as has been referred to previously—and to reserve PIP for those with the greatest needs, we cannot afford to take that risk.
My amendment, therefore, changes the wording from “every time” to,
“the majority of the time”,
to allow for fluctuations in conditions and for people with fluctuating conditions to be supported accordingly through qualification for eligibility for PIP. My amendment also addresses the retrospective qualifying PIP period, which is currently set at six months—this has also been referred to. That means that a claimant must have been unwell for at least six months before they can apply for PIP. In my view, six months is too long to wait before receiving financial assistance, when the costs incurred during that time from impairment may be substantial and highly detrimental to an individual's quality of life. My amendment therefore changes the requirement from six to three.
Continuing with an “every time” approach that fails to recognise fluctuations would prevent the PIP assessment from accurately recording the severity and extra cost of a condition. If someone has a severe impairment that occurs only about 50 per cent of the time, they will not meet the qualifying condition; whereas someone who has a moderate impairment for most of the time will meet it. That seems extremely unfair. For example, if someone with MS or severe depression has had a few good days in the past six months and if the relevant ability had been assessed during those good days, it is conceivable that the assessment may determine that the relevant ability is not limited by their condition.
The Deputy Chairman of Committees
My Lords, if Amendment 86ZC is agreed to, I cannot call Amendment 86A by reason of pre-emption.
Baroness Thomas of Winchester
My Lords, I support the amendment that was powerfully moved by the noble Baroness, Lady Howe. I shall also speak to my Amendment 86A, which enables an eligible person to receive PIP after three months rather than six. The balancing corollary of that amendment is my next amendment, Amendment 86B, which changes the length of time that a person's condition is estimated to last from six to nine months, so the envelope of time in these amendments is not being stretched beyond a year. It is just being differently configured, which fulfils the Government’s desire to align PIP with the definition of long-term disability in the Equality Act.
I gather that another simplification which the Government want is to align the waiting time for PIP with attendance allowance. They have cited the approval of several organisations for this change, but is my noble friend really telling us that these organisations would rather people waited for six months for PIP just for the sake of this alignment? This is certainly not my experience.
The reason my amendment seeks to keep the qualifying period to three months is very simple: some conditions of a long-term nature may have a sudden onset; some may not have such a sudden onset but might be able to be diagnosed only several weeks after the onset of symptoms. People with rheumatoid arthritis, for example, which affects about 400,000 people in the UK, are often only given an official diagnosis after six weeks of certain specified symptoms. I mention that disease specifically because arthritis in general forms 18 per cent of the DLA case load; it is at the very top of the list.
Next on the list are mental health conditions at 17 per cent. For anyone suffering from a severe mental health condition, applying for DLA would not be the first thing they think of, and waiting for six months, when PIP comes in, to help with care is a very long time.
There are then those diseases which may have a devastating impact on people immediately, such as a severe stroke or heart attack, a serious accident, amputation or an unexpected diagnosis of cancer which demands challenging treatment straightaway. We may hear a little more about that from the noble Baroness, Lady Morgan. People with any of these conditions may need the extra help which PIP could give comparatively quickly to stop them from falling into debt as they manage their condition with all its ramifications.
This is even more important in these days when local authorities are so overstretched financially that they are becoming reluctant to carry out more than minimal adaptations to people’s homes, let alone provide adequate help with caring. Those affected may need to buy for themselves various mobility aids, safety devices and other equipment, or perhaps set up a home alarm system. Their homes may need extra heating; they may have increased laundry requirements; they may need special diets; and they may have to rely on expensive taxis to get to hospital appointments and for other purposes. If the social model of disability means anything at all, then a disabled person is likely to have to rely on taxis if they want to go out and about, particularly during the winter.
Turning to those conditions which are not sudden onset such as my own—adult onset muscular dystrophy—it would be foolish for someone to try to get PIP too early while they are still able to manage their impairments relatively easily because they will almost certainly fail the assessment. On the other hand, if they know that they will have to wait, whatever happens, for six months before receiving any extra resources, they may decide they should at least start the process, particularly if they are beginning to fall into debt with managing their condition.
So when should they start the claim? I understand from what the Minister for Disabled People said in the Public Bill Committee in the Commons that the qualifying period for PIP starts at the point where someone is first entitled to it regardless of whether a claim has been received, and that even a lengthy spell in hospital can be part of the waiting period. That may be a helpful message for someone who has had a stroke or a bad fall, but it is not always possible to know exactly when a person might qualify.
At present, the waiting time for DLA is three months. By changing it to six months, the Government have said that this is not about saving money but about the right benefit going to the right people, or words to that effect. Presumably, by doubling the waiting time, they believe that three months is too short a time to be able to assess someone’s condition. They are possibly thinking that someone who has suffered, for example, quite a severe stroke might apply straightaway for PIP but, after six months, might be much better and able to manage the impairments they still have. However, looking at the case load for DLA, only 3 per cent of claimants have stroke-related conditions. This is presumably because the majority of stroke patients are past retirement age and thus past qualifying for the first time for DLA.
If PIP is to be an in-work as well as an out-of-work benefit, which it is, surely it is better to allow a person to claim the benefit after three months, not six, as it is likely to help them get back to work and to participate once again in society more quickly, for example by travelling to work by taxi or by taking a cab to the station.
The table of conditions that people who claim DLA are diagnosed with is very illuminating. People with both osteo- and rheumatoid arthritis, which as I said come top of the list, are very unlikely to get better after three months. Those with stroke-related conditions and malignant diseases are each just 3 per cent of the total. It is not as though a large number of DLA claimants with these conditions are trying to claim after their condition has improved. In fact, the table shows that the Government’s argument about a person’s condition not being stable after three months does not really stack up. I read from the table that most people almost certainly do not apply for DLA at present until they really feel they have to.
To sum up, six months is a long time to wait for extra resources if a person has had a diagnosis of a long-term severe condition. The Minister in another place talked about a person’s condition settling down. However, for many of us our conditions never settle down—they go on progressing. If the Government are implacably opposed to retaining the three-month waiting time for PIP, maybe they would agree to, say, an assessment on the papers after a year so that a person’s entitlement can be looked at properly again. I think this will come up later on.
If the Government insist on the six-month waiting time for all applicants, I fear it will be understood to be about saving money in the short term in the hope that people will be put off from applying. I am encouraged to hear that my noble friend and his fellow Ministers are still listening and I hope this means they are hearing all the arguments for changing the qualifying period back from six months to three.
Baroness Morgan of Drefelin
My Lords, this is a very important debate. I support the idea of keeping the qualifying period for PIP at three months. I also hope this debate will look at the idea of the prospective period moving from six to nine months if the Minister sees that as an appropriate practical way of dealing with the Government’s intention to align the qualification period for PIP with the Equality Act, as I understand it.
I, like many, am extremely concerned that the proposals here will have a devastating impact on disabled people, especially those with sudden-onset conditions such as cancer. Cancer patients often see sudden changes in their household income combined with significant cost escalation on diagnosis. This can make cancer patients particularly vulnerable to financial difficulties and in need of immediate financial support.
Why do people with sudden-onset conditions need support immediately? We know that cancer treatment and its debilitating effects can often begin very quickly after diagnosis, as the noble Baroness, Lady Thomas, has already explained. The associated support needs arising from that treatment are often immediate and, importantly, the first six months can be the period when extra costs are at their greatest as people try to adjust their outgoings to their reduced income. Research by Macmillan found that 80 per cent of cancer patients who experienced increased costs reported that they were greatest in the first six months.
Baroness Grey-Thompson
My Lords, I support the noble Baroness, Lady Thomas of Winchester, in Amendment 86A, and I believe she has covered the amendment very clearly. I also find the qualifying period worrying. As the noble Baroness, Lady Morgan of Drefelin, has said, the first months are often the period when extra costs are at their greatest, and just as people are trying to adjust their outgoings, they are also adjusting to the impairment or illness.
I do not believe that it is the case that they will be able to receive support elsewhere. Social care support may be available, but that is means-tested and has its own application and assessment process, which we have debated quite a lot this afternoon. Support from the NHS can be very limited and not immediate and I do not think we should assume that appropriate help is that easy to find.
In Committee in another place, the Minister for Disabled People stated that this proposal was not being driven by the need to make significant savings, so why are we making this change? It has been argued that, for example, in the case of someone who has had a stroke, it may not be clear at three months what their long-term needs may be, and that may also be true at six months. However, their costs are likely to be very high during these initial stages. While no one, me included, wants to see repeated assessments, we have heard a lot about giving help to those who most need it. In the initial months following diagnosis we should look at the qualifying period as detailed in the amendment because those are the people who will need immediate help.
Baroness Lister of Burtersett
My Lords, I support the amendments which seek to revert to the existing qualifying period of three months. The noble Baroness, Lady Thomas of Winchester, said that six months is a long time to wait for extra resources, and we have heard from a number of noble Lords about the significant additional costs which can be incurred during this period.
However, there is a further twist in the tale—the benefit cap—which we will be discussing next week. PIP exempts people from the benefit cap but, of course, if you cannot qualify for PIP for six months then you would not only have to wait for additional resources but could find that your own resources are being significantly depleted during this period. This is very worrying. Can the Minister say whether any estimate has been made of the number of people who may be caught in this way? I suspect that it is not a large number, but one person is one person too many. It could be potentially very frightening for people to find that they might have to face this horrible benefit cap.
I hope that the Minister will accept the amendment. If not, and the six-month period goes ahead, a perhaps minimalist way of addressing the question—although it does not really address it—is that someone who qualifies after six months should have the money backdated to cover what they lost through the benefit cap.
Baroness Campbell of Surbiton
My Lords, I support the amendment. I hate the term “alignment”. I worried about it enormously when it was used by the Government in connection with the proposal that mobility allowance should be removed from people in residential care homes because they wanted to align it with hospitals. We are now back to “alignment” again.
One of the major problems that nurses and doctors in specialist units face in trying to discharge their patients with brain injury or the onset of MS, which causes vast deterioration, is getting their support sorted out so that they can leave the hospital. DLA with a time limit of three months is cited as being difficult to get into now, so raising it to six months is wrong. We forget that people do not on day one think of their long-term disability—whether that be a spinal injury, a brain injury or something that is sudden and quick—and say, “Ah, I must put in my DLA request now so that I will get it in six months’ time”. That just does not happen.
This is another delay for people who find themselves in an appalling situation, in a crisis, and having to face even further barriers to the support that can give them some independence, enable them to get back into the community and return to their families as soon as possible. The three-month eligibility period should remain. The six-month period will cause more problems. Hospitals will despair about discharging people and it could mean that disabled people will have to leave work earlier than they would have because they are not getting the support that they require quickly to keep them mobile and to enable them to stay in work. It is a lose-lose situation.
Lord McKenzie of Luton
My Lords, we have had a powerful set of contributions on the amendments. I hope that the Minister will have ringing in his ears the important question: if it is not about cost savings, why on earth are the Government seeking to do this? We have heard powerful presentations, especially from my noble friend Lady Morgan, about the costs that confront people. My noble friend Lady Lister has just made an extremely important point about the interrelation of this with the benefit, as well as the other challenges that come with the proposals.
The amendments are intended to deal, first, with the issue of fluctuating conditions; and, secondly, to alter the assessment period for access to personal independence payments. Looking first at fluctuating conditions, the amendments would ensure that those whose physical or mental condition limits their ability for the majority of the time, rather than continuously, would still be eligible. As drafted, the Bill suggests that people with fluctuating conditions would not qualify if they are not consistently ill for the required length of time, regardless of the severity of their condition. That is the case with the current work capability assessment, which, as we know, consistently fails people with fluctuating conditions such as mental health problems or multiple sclerosis.
The new draft criteria published on Friday contain some welcome recognition of the need to ensure that people with fluctuating conditions are not disadvantaged under the PIP assessment, so that where someone needs more than one descriptor within an activity, the time period can be counted cumulatively towards the thresholds of 50 per cent of days needed to satisfy one descriptor. However, what evidence is there to show that the method of taking account of the needs of people with fluctuating conditions will be both accurate and fair while meeting the aim of not disadvantaging those people during the assessment?
The Bill will extend the qualifying period before claimants can receive PIP from the current three months under DLA to six months. People will continue to have to demonstrate that their impairment or health condition will last through a further six months to qualify. That increases the total period for which individuals will have to demonstrate need from nine months to one year. The amendments would retain the one-year period, but split it so that claimants will have a three-month waiting period only but will have to demonstrate that their impairment is likely to last for an additional nine months. We support the amendments.
A wide range of organisations have expressed their concerns about that change. As the Disability Benefits Consortium put it, DLA eligibility is based on individuals experiencing additional costs as a consequence of their impairment or health condition.
“Making people wait longer will place further burdens on those adjusting to sudden onset conditions such as stroke, or people who experience the immediate debilitating effects of treatment such as cancer”—
we have heard strong testimony to that this afternoon—
“as well as penalising those whose impairment or condition has gradually worsened over a period of time and have already had to deal with additional costs prior to passing the threshold for PIP. To require additional costs to exist for six months before offering any financial assistance will push even more disabled people into debt”.
The noble Baroness, Lady Thomas, made that point very strongly.
If applied to disabled children, it will also place increased pressure on families trying to adjust to their child's impairment or health needs. The Government have stated that that change will not bring about any significant savings, but we believe that it will have a significant impact on disabled people. As we have heard, the Equality and Human Rights Commission has also raised concerns in this area, stating that the change from a three to a six-month waiting period may also undermine the Government's stated aim to support disabled people into work and enable them to remain in work. Further, newly disabled people without support for the six months may not be able to continue in their current employment or be able to find suitable alternatives.
Macmillan has highlighted the particular problems of people with cancer, as did my noble friend Lady Morgan. Macmillan states:
“For people with cancer, where treatment and its debilitating effects can begin very quickly after diagnosis, support needs are often immediate. Macmillan believes people with sudden-onset, long-term conditions should be able to claim support as soon as their support needs arise. We are flatly opposed to increasing the qualifying period from three to six months”.
Macmillan also points out that DLA is the only non-means-tested support available to cover the immediate costs of a person’s illness or disability during this period, and says:
“The outcome of delaying payment by yet another three months will be that cancer patients who are struggling to pay their bills or mortgage payments will face more debt and more stress”.
As we have heard, the Government’s policy briefing note for this proposal gives the justification for this change that of aligning the definition of disability with that used in attendance allowance, and with that,
“generally used for the Equality Act 2010”.
The guidance in the Equality Act in fact specifies that someone is to be considered as having a disability if they have an impairment that will last at least 12 months, or for the rest of their life, but this says nothing about how long somebody should have to wait before they are assessed as having this disability.
The policy briefing note also states:
“While we acknowledge that some impairments or conditions may appear long-term at their outset, and that additional costs may arise as a result, this may not always be the case. Where disability-related costs do arise early on, for instance as a result of having to make frequent hospital visits for treatment, additional support mechanisms provide an element of coverage before the qualifying period is satisfied, for example through the NHS travel costs scheme or other social security benefits”.
However, as Macmillan states, these types of support are usually means tested, unlike disability living allowance—or PIP, which is intended to meet the additional costs that arise through a disability for somebody, whatever their income level. Will the Minister please list the types of support that the Government think will be available to people in this situation, and which will be available to those people who have built up savings which exclude them from normal means-tested benefits? Can the Minister say whether any additional cost would be expected from changing from a six-month waiting period and a six-month expected disability to a three-month waiting period and a nine-month expected disability? If this would not be an additional cost, what on earth is the rationale for asking people to wait an additional three months in order to receive vital support?
Lord Freud
My Lords, I thank noble Lords for tabling these amendments and welcome the opportunity to respond on this important feature of personal independence payment. The required period condition has given rise to a great deal of considered and reasoned debate today. The debate has also been informed by the not inconsiderable assistance of briefing provided by the likes of Macmillan Cancer Support and the Disability Benefits Consortium, as well as many others over the past few months.
The amendments seek primarily to shorten the qualifying period before the personal independence payment can be paid. They also increase the onward period over which someone must be expected to satisfy the conditions of entitlement and modify how someone can satisfy the required period condition. Taken together, I was pleased to see that Amendments 86A to D preserve the overall required period condition of 12 months. I therefore welcome the fact that these amendments explicitly accept the principle that personal independence payment should be paid only to people whose needs arise from long-term conditions. This is a fundamental aim of personal independence payment and ties our definition of long-term disability in with that used in the Equality Act.
Under disability living allowance, people currently have to satisfy a three-month qualifying period and a six-month prospective test. These rules were put in place when the old attendance allowance and mobility allowance were merged to form DLA in 1992. However, for personal independence payment we are designing a new benefit; one fit for the 21st century, so it is only right that we looked at what it is the most appropriate length of the qualifying period and prospective test.
I know how much these changes to the qualifying period have worried certain groups of disabled people and their representatives, most particularly those representing people who have been diagnosed with cancer or who have experienced sudden-onset conditions. Noble Lords may be interested to learn that the changes found support in our consultation, in particular the link with the Equality Act definition.
Perhaps it may help to reassure noble Lords further if I set out that the required period condition is not a money-saving measure, nor is it meant to deny disabled people support where the impact of their condition is long-term. This is about having a mechanism which can identify, assess and pay a valuable cash benefit to individuals who have a long-term health condition or impairment which results in burdensome financial costs, regardless of income. Personal independence payment is not designed to assist individuals dealing with short-term needs.
Where there are immediate and ongoing costs which can cause financial difficulties, or have an effect on someone’s ability to participate fully so that their levels of independence may begin to suffer, there is a range of means-tested and non-means-tested support to help people through some of the shorter-term burdens, both financial and practical. I acknowledge that this help may not be available to all, but all provision has to be dictated by balancing need and an individual’s capacity to meet it from their own resources.
Baroness Hollis of Heigham
Can the noble Lord give us examples of that? Like others, I have nursed people through cancer—three people, including my late husband—and what we need is what does not exist, which is an upfront grant to cover costs until the condition has stabilised. During those six months, in his situation, I was all right, as I could throw money at it, but I noticed that in the waiting rooms for chemo and radio, then back to chemo and then to radio, a constant theme for the people there—some were feisty, some were broken, some were defeated and some were coping—was the huge financial pressures, particularly on those who did not have an adequate income or adequate family support to allow them to cope. If the Minister cannot move in this direction, he has to come up with something that will do the same job.
Lord Freud
My Lords, among the elements available in the shorter term are healthcare, travel costs, free prescriptions or aids and appliances provided by the NHS or the local authority. Following the request by the noble Lord, Lord McKenzie, it may be easier for me to write with a list of particular supports.
Baroness Morgan of Drefelin
If the Minister is going to write, would he also look at explaining how many of those are dependent on local authority provision? Much of the kind of help that he is talking about is sometimes dependent on having DLA.
Lord Freud
My Lords, when I write I will try to do a full breakdown of what is available.
Lord Boswell of Aynho
Picking up the point made by the noble Baroness, Lady Lister, perhaps my noble friend could also indicate any of those benefits which might be susceptible to the benefit cap under the proposals of this legislation.
Lord Freud
I will do that. However, it would be preferable to look at that issue in the context of the benefit cap rather than this context. We will be looking at that soon—I was hoping to say very soon.
I will go through those social security benefits. I should mention in this context of additional support—I pay tribute to Macmillan for its highly motivated campaign—that parking charges at hospitals are increasingly being waived for people attending treatment who have been diagnosed with cancer. I appreciate that some of these support functions can take a while to be assessed and put into place, and that they may not be available in all areas, but I suspect that that may be a debate for a different day and, indeed, a different forum. For example, if there is a delay in putting in place financial assistance to help someone meet transport costs necessary to go to and from out-patient treatment, that is a matter for primary care trusts to resolve. It is not the place for a long-term benefit for long-term needs to step in to meet shortfalls or delays in such provision.
I have also listened with interest to the arguments presented in support of those who suffer sudden-onset conditions such as stroke or traumatic injury. While the immediate effects of such a sudden-onset condition may be highly debilitating, it is important that we consider the role that the National Health Service plays. Following a sudden-onset condition, it is doctors and nurses who will be caring, stabilising and treating the individual while their condition remains acute, and it is the hospital which will be responsible for the individual’s disability-related needs in their entirety during treatment.
Baroness Morgan of Drefelin
I am sorry to interrupt the Minister again. Does he agree that one of the thrusts of modern health care—particularly in cancer care, where I have an interest—is to try to keep people at home for as long as possible and not requiring hospitalisation? One of the brilliant aspects of the DLA that I was trying to describe means that determined, independent people going through tough treatment can stay at home, saving the NHS thousands and thousands of pounds on hotel fees. We have to look at this issue in a joined up way.
Lord Freud
I am trying to make the point that it is the responsibility of the NHS to deal with rehabilitation and treatment issues. It is not the function of DLA to do that, nor will it be the function of PIP. It is a different support mechanism. It may be that noble Lords would like to put in a particular support function in those circumstances, but it is not what PIP is meant to be.
Baroness Morgan of Drefelin
In that case, perhaps I may ask another question. If this is not what it is for, we need to understand what the implications are. People who have DLA now and are being treated for cancer—to give an example of a sudden-onset condition—are utilising the benefit in that way. As I understand it, DLA is meant to be used in a way decided by the client. It is important for people to keep their independence—to stay at home and look after themselves—and to stay positive. Surely we want to encourage that.
I understand the Minister says that that is not the purpose of the benefit, but I am confused: it is a product of the benefit which is of benefit to all of us. If it is being changed, we need to understand the implications and the evidence of what the knock-on effects might be elsewhere in the system.
Lord Freud
Let me go on a little further and try to pull this issue back. Noble Lords have said that, in practice, DLA is being used in a slightly different way to the long-term intention, and that that is tied to three months as opposed to six months. I have said that it is not a matter of money but of coherence. I have heard many strong views expressed in Committee about noble Lords’ discomfort with the move to six months and so I will take this matter back—that might be a slight overstatement—and look very closely at what we are hearing, not only from here but from elsewhere. This is not one-way traffic; some people are more concerned that if you go to an earlier assessment it implies that you will have more reassessments, which some groups dislike rather more. So it is not all one-way traffic for people who are affected.
Baroness Lister of Burtersett
I apologise for interrupting the noble Lord. I am sure that the Committee is extremely pleased to hear him say that he will take this away. I hear what he says about it not being one-way traffic but, given that the Minister is writing to the Committee already on this issue, it might be helpful if he could list the organisations which are supporting the move to six months and those organisations who are against it, so that the Committee can weigh the balance of opinion for itself.
Lord Freud
I have slight jitters about that level of transparency, apparently.
Lord Freud
No, no, no. The Treasury is not a disability organisation, let me assure you. Those who know the Treasury well will be absolutely confident in that description.
As I said, it is not a cost matter. It is a matter where people’s sensitivities have been very clearly expressed. We will go away to look at that very, very closely. Some of the observations in this room today will help us in that consideration.
I do not know if there are any other points I really need to make. I just reassure or assure the noble Baroness, Lady Howe, that the required-period condition will not be a snapshot in time. The legislation makes that quite clear by talking about the likelihood of the assessment being met on any particular day. It means that if someone is likely to meet the conditions for the majority of the time, they can safely be taken as being more likely than not to meet them than if we were just randomly to pick a day.
The other issue I need just to touch on, which is often misunderstood, is that during people’s stay in hospital, when the cost of their disability-related needs are being met, individuals will already be fulfilling the required-period condition for personal independence payment. The noble Baroness, Lady Campbell, was concerned that filling in your DLA or PIP assessment form was not the first thing on your mind.
That means that when someone is able to leave hospital, perhaps with a care plan in place and further rehabilitation scheduled, they may well have satisfied some or even all of the qualifying period. That currently exists for DLA and is often misunderstood, with people thinking that they become entitled only after they have filled in and submitted the form. The qualifying date starts on the day that the needs arise—the day you have the accident that has caused a particular problem, for instance—not from when the claim form is submitted. I acknowledge that some conditions that arise gradually and it is very difficult to pinpoint the precise day.
With those observations and commitments to reflect, I ask the noble Baroness to withdraw the amendment.
Baroness Howe of Idlicote
My Lords, it has certainly been a very interesting series of questions—and some answers—with different issues under the different amendments within this group. I will certainly want to reflect on what has been said about my amendments, as well as on some of the issues that have arisen, as to whether they have been as satisfactorily answered as they could be.
The noble Baroness, Lady Morgan, made the point about parking costs and so on. We know that some hospitals have begun to make exceptions, but it is fairly appalling that it is going on at all. We would all like to know how widespread is the removal of the requirement to pay for parking if you are going in for a number of cancer treatments.
My other point is that we are not just talking about the actual sufferer but the effect on the entire family—the husband or wife who may very well be put in a position where their own finances are being appallingly hit. There is a lot more that we are going to want to talk about, perhaps on Report, but perhaps by then there will be rather clearer instructions that we will all be able to say meet our points. I hope so. Perhaps I am being a bit over optimistic. Under those circumstances I will, for the moment, withdraw my amendment.
Baroness Grey-Thompson
Baroness Grey-Thompson
I beg to move Amendment 86DZA standing in the name of the noble Baroness, Lady Wilkins. The noble Baroness apologises, but she is unable to be present as she has an amendment to the Health and Social Care Bill in the Chamber.
This amendment is designed to ensure that disabled people receiving the new benefit—whether it is the personal independence payment or DLCA—before pensionable age are able to continue accessing support after they reach that age. I declare an interest in that I am a recipient of DLA.
This amendment would maintain the requirement that disabled people meet eligibility criteria, but would offer a significant reassurance to disabled people that their support will not diminish with age. Sir Bert Massie, as cited in Monday’s debate, has suggested that disabled people, “Join us or die”, given that the incidence of impairments and experience of health conditions increase with age, and that more than half of disabled people develop their impairment or health condition in adult life.
The older we get, the more we need support with the higher cost of living, and with the health conditions and/or impairments that life brings. DLA currently provides vital support to 845,000 disabled people over pensionable age in meeting their higher essential costs of living. This support offers a significant lifeline, and was planned for in the original legislation when DLA was introduced by the noble Lord, Lord Newton, and others, in the Social Security Contributions and Benefits Act 1992. That Act specifically refers to the age limit not applying to a DLA award made before someone attains the upper age limit. However, the Welfare Reform Bill does not make the same guarantee for the new benefit.
Clause 81 allows for regulations to be made to allow for exemptions, and the Explanatory Notes to the Bill indicate that allowing PIP to continue to be received after someone reaches pension age could be such an exemption. This would be welcomed, but leaves a gap in clarity which needs urgently to be addressed. I am aware that the Government believe that this issue should be covered by regulations. This was not the case in the original 1992 legislation, and I am unconvinced that it should be the case now.
My concern is due in part to the Public Bill Committee stage in the other place, where the Minister for Disabled People stated that the Government wanted entitlement to be addressed in regulations, to allow for flexibility. Such flexibility could include altering this entitlement in the future, and denying support to disabled people reaching pensionable age. It would offer a significant boost in confidence for many disabled people to receive reassurance during the passage of the Bill that their support will not be withdrawn at pensionable age.
Disability Alliance, and many other charities, are being approached regularly by disabled people worried about what the current plan will mean when they reach pensionable age, and whether support will end. Readers of Disability Now will also have seen this issue raised by other concerned disabled people and their families. This amendment would clarify the position and put many minds at rest.
The Dilnot Commission highlighted the pivotal role that DLA plays in preventing high-level needs escalating. This is a particularly important issue for people who are in receipt of the mobility component of DLA, as there is no equivalent to this under attendance allowance—the current disability benefit available to people who seek help after they pass pensionable age. Receiving DLA helps disabled people manage health, and prevents some avoidable NHS costs occurring. Receiving help after pensionable age could also help disabled people avoid entering council-funded residential care homes at all or prematurely. Therefore, this amendment potentially offers further financial savings in the long term, but requires the Government to work collectively and not allow a DWP silo approach to ignore the NHS and local government costs of not permitting an entitlement to be carried over to pensionable age.
Lord McKenzie of Luton
My Lords, I can be brief on this. The noble Baroness has covered pretty much every point that I had in my script. We support this and the proposition that it should be in the Bill.
I take the opportunity to ask a couple of questions. In terms of transition, what is the position of someone aged 65 or over who is in receipt of DLA, which expires because it is time-limited? Will somebody in those circumstances be able to refresh that claim, including a mobility element, or will they have to move on to PIP or attendance allowance? In respect of attendance allowance, is it the intention to align the lower and higher rates of that benefit with the enhanced and standard daily living components of PIP?
Lord Freud
My Lords, we have made a number of commitments in relation to people aged 65 and over. Noble Lords may be aware that alongside the Government’s response to the consultation on DLA reform, we also published a policy briefing in May that set out our policy objectives and proposals. We intend to make regulations for personal independence payment that will allow people who have reached the upper age limit to continue to receive personal independence payment. Our priority is to support those individuals with established, long-term health conditions or impairments that would put them at a financial disadvantage over a long period. We fully understand that receiving this benefit is important for those aged 65 and over, particularly for those in receipt of the mobility component. We also know about their concern that the loss of entitlement could affect their independence.
The intention behind this amendment is to ensure ongoing support throughout later life for individuals whose abilities are limited earlier in life, recognising that they may have had less opportunity to earn and save for later life. I can assure noble Lords that this is also our intention and that it can be achieved without amendment to the Bill, but instead through regulations. As it currently stands, the amendment would potentially widen the scope of the personal independence payment and undermine our intention of creating a more affordable and sustainable benefit.
Turning to the current rules, broadly speaking, current DLA provisions have a one-year linking rule. This allows individuals over 65 to renew an award within one year of their previous award without losing DLA entitlement. Similarly, we intend to allow a linking period for PIP. This will support those individuals who reach the upper age limit and have a break in their claim through temporary improvement, provided the individual makes a claim within a defined period and continues to fulfil the eligibility criteria for PIP. As with DLA, there will be restrictions on new and existing claims for those over the age of 65. As I have said, our priority is to target support, through PIP, on disabled individuals with established, long-term health conditions or impairments, who may incur extra costs throughout their early lives and would have had less opportunity to save for retirement. Those individuals who develop care needs later in life, as part of the natural ageing process, will continue to be able to claim attendance allowance provided they meet the eligibility criteria.
Under Clause 81 we already have a power to make secondary legislation and to provide for exceptions. By setting out these provisions in regulations we can ensure that the legislation can be adapted in response to any future changes in the social care system which might affect pensioners. The Personal Independence Payment Implementation Development Group will strive to ensure that policy design and delivery in respect of people aged 65 and over is informed by disabled people and their representatives.
On the question raised by the noble Lord, Lord McKenzie, on what happens to DLA recipients over the age of 65 whose fixed term expires, we have made it clear that they will not be within the scope of PIP for the time being. That means that existing recipients of DLA aged 64 or over at April 2013 would be invited to reclaim DLA towards the end of an existing fixed-term award. At this stage we have made no decisions on the rates of PIP or how these will compare with other benefits.
Baroness Hollis of Heigham
In that case, how does the Minister establish any smooth movement on to attendance allowance, given that attendance allowance is not coming within UC?
Lord Freud
Clearly, that will be one of the issues we will need to take into account when we sit down to establish these rates. Given these reassurances on our approach, I urge the noble Baroness to withdraw this amendment.
Baroness Grey-Thompson
My Lords, I thank the Minister for his comments, especially around what happens when those currently on PIP reach pensionable age. The noble Lord, Lord McKenzie, raised further crucial issues regarding clarity in relation to people over 65 who currently receive DLA. If the amendment is too wide, as the Minister suggested, I am sure that the noble Baroness, Lady Wilkins, would be very happy to meet with the Bill team before Report to determine the correct words to put down. As the noble Baroness is still discussing the Health and Social Care Bill in the Chamber, she will need time to consider the Minister’s comments. I am sure that she will return to this at a later stage. I beg leave to withdraw the amendment.
Lord McKenzie of Luton
Lord McKenzie of Luton
My Lords, I am happy to give way to the Minister, who I think wants to say something.
Lord Freud
If the noble Lord agrees, it might be valuable if I make clear where we stand on this issue. We have already announced that we will not remove the mobility component of DLA from people in residential care from October 2012, as was originally planned. We have also said that we will review the position on the personal independence payment. This is precisely what we have done. We are now considering the findings of the recently published review into provision for the mobility needs of care home residents by the noble Lord, Lord Low, before we announce our final decision.
We have listened to what disabled people and organisations of and for people with disabilities have said. I will ensure that, when we introduce the personal independence payment from April 2013, disabled people are treated fairly regardless of their place of residence. Our final decision will take account of this, of the findings from the Low review and of our own work within the department. I am sorry that I am unable to give noble Lords the final decision today but—I will not use “soon” or “very soon”—I hope to get it to them in the not too distant future. With this reassurance, I urge the noble Lord to withdraw the amendment at the appropriate moment.
Lord McKenzie of Luton
I am grateful to the Minister for that statement; I take a degree of comfort from it. It is a pity that he cannot speak definitively, because that might have truncated some of our discussion. Notwithstanding what he said, I will deliver my script—or bits of it, anyway—because others want to contribute to the debate. Do the Government accept the conclusions of the report by the noble Lord, Lord Low?
The Deputy Chairman of Committees (Baroness McIntosh of Hudnall)
My Lords, I am sorry to interrupt but before a debate begins the amendment needs to be proposed.
Lord Freud
My Lords, I am sorry for the delay. I was trying to work out whether we were sympathetic or very sympathetic to the report from the noble Lord, Lord Low; I think it is somewhere between those two.
Lord McKenzie of Luton
This is a rather odd process where we have the answers before the proposition; perhaps we should move to that procedure.
I shall try to truncate what I was going to say because we take encouragement from what the Minister said. I start by asking when we get to hear the announcement. The Minister has given us a very clear indication about that. I hope that it will reflect the clear findings of the review of the noble Lord, Lord Low: that removing the mobility component of disability living allowance from those in residential care would be unfair and irrational.
The justification given for the policy proposal is that there has been an overlap with the support provided by local authorities to help with mobility costs, but the review has shown comprehensively that no such overlap exists. Having received responses from 46 local authorities, with an impressive total of 828 written submissions, the review found that, in general, the support provided by local authorities was aimed at meeting a different category of mobility need from that supported by DLA mobility. It states:
“Local authority funding for mobility focused on the support needed to meet assessed care needs, for example travel to a day service, rather than a personal need like visiting friends and family. There was therefore no overlap between the support provided by DLA mobility and that offered by local authorities”.
The review also found that DLA mobility is key to meeting the personal mobility needs of care, stating that the evidence received by the review overwhelmingly showed that DLA offers personalised support and provides the individual with choice and control over how their mobility needs are met. As the review concludes,
“it is DLA mobility that provides the most appropriate means of meeting personal mobility needs. If the rights of disabled people are to be preserved then it is vital that DLA mobility, and its successor under PIP, are retained for people living in residential care”.
I will not develop that point further, although we should place on record our appreciation to the noble Lord, Lord Low, for all the work that has gone into the review, including the clarity of the conclusion and analysis included in the report.
I shall deal with just one further point. We hear a lot about the Government having no money throughout this Committee stage. We should remind ourselves, especially in view of the encouragement that the Minister has just given us, that savings to the tune of £160 million a year from 2013-14 onwards have been booked in respect of this matter. There was a hint from the debate in the other place that those savings were, if not specifically arising from this proposal, of a general nature and, in so far as they could not be achieved by changes to the mobility payments would otherwise have to be met by DLA claimants. Can the Minister be clear on that? If the Government are persuaded to change their stance on mobility payments, will any budgetary shortfall have to be met from elsewhere within the DLA/PIP projections, or will additional funding be provided elsewhere by the Government to meet the fact that that saving, which was never real, will not arise?
Lord Freud
My Lords, that is a leading question, as I have learnt to appreciate from the noble Lord, Lord McKenzie. Clearly, it is a substantial amount of money and one reason that it is so difficult to come up with the early warmth and sympathy that people want to hear is because this is tough to find. We have been doing a lot of work in this area. As your Lordships saw with the restructuring of the universal credit, we took all of our projections in a unit and it is completely impossible to balance them all off. You could pick anything on the balancing act but there is no specific direct link into DLA overall because, as I said, we are doing PIP on a bottom-up basis, not the top-down basis of a target. We are trying to find the level at which people need genuine support. It is not a link in the budgetary, top-down way implied by what is behind that question: have we just taken it from another bit of the DLA? No, we have not.
Lord McKenzie of Luton
In which case, I am doubly grateful for the Minister’s response. I think that was clear in relation to the budgetary item, although I will read the record to make sure that my understanding is correct. However, I am sure that the tenor of his indications will be warmly and widely welcomed. It would be helpful, particularly for all those people who have been made very fearful by the original proposals, if those conclusions could be announced as soon as possible. In which case, I beg leave to withdraw the amendment.
Baroness Hollins
“Carer’s allowance
In section 70 of the Social Security Contributions and Benefits Act 1992 (invalid care allowance), for subsection (2) substitute— “(2) In this section, “severely disabled person” means a person in respect of whom there is payable either an attendance allowance; a disability living allowance by virtue of entitlement to the care component at the middle or higher rate; or a personal independence payment by virtue of entitlement to the daily living component at the standard or enhanced rate or such other payment out of public funds on account of his need for attendance as may be prescribed.””
Baroness Hollins
My Lords, the purpose of this amendment is to seek clarity from the Government about future eligibility for carers’ allowance. I know that there has been earlier discussion about passporting with respect to carers’ allowance and I apologise if there has been any discussion of it today. Unfortunately, I have had to attend to amendments on the Health and Social Care Bill and I have not been able to listen to earlier parts of the debate today.
Of the 6 million carers in the UK, 72 per cent of them are financially worse off because of their decision to become carers. The high living costs that illness and disability bring, coupled with the loss of earnings, result in a heavy financial burden on most carers. More than half said that they were in debt as a result of caring and two- thirds said that they used their own income to pay for the care of the person they looked after. Given that the unpaid work they do contributes an estimated £119 billion to the United Kingdom, we ought to do more to help carers.
If I might give the Committee an example, Tony gave up work to care for his wife Laura, who is partially blind and has memory problems following a car accident. They have two young children. Laura needs Tony to be there to help her to wash, dress and use the toilet and she struggles to prepare food on her own. Tony would love to go back to work but does not wish to leave Laura on her own during the day. Tony claims carers’ allowance and Laura receives the middle-rate care component of disability living allowance. The family has had support from social services cut, because their council has just raised its eligibility criteria to critical and Laura has been assessed as having only substantial needs, not critical needs. If, following assessment for the new PIP, Laura received the standard rate of the PIP daily living component, and if this did not provide a gateway to carers’ allowance for Tony, the family would stand to lose more than £55 a week, or £222 a month. Tony would have lost his only income and would be forced to claim jobseeker’s allowance, even though he knows he cannot work because of the care and support his family need.
Under the current system, eligibility for carers’ allowance is established through the middle or higher rate care components of the disability living allowance. The transfer from disability living allowance will see these three rates—lower, middle and higher—replaced by only two under the personal independence payment. Although we know that PIP will be used as the gateway for carers’ allowance, the Welfare Reform Bill currently does not make clear how claimants currently claiming through DLA will be categorised. It is disappointing at this late stage of the Bill’s progress that such information remains unavailable.
Many families rely on DLA to cover basic living costs, additional care and support, transport, aids and adaptations, as has been extensively debated here. To put this help at risk because of a lack of clarity is unforgivable. I hope that the amendment will give us an opportunity to scrutinise this area of the Bill, particularly in regard to carers’ allowance and its relationship to personal independence payments.
Were it to be decided that entitlement to carers’ allowance would be established only through the enhanced rate of personal independence payment, it would be reasonable to assume that thousands of carers would no longer be eligible for carers’ allowance. It is likely that the Government’s proposed cut of 20 per cent to the budget for DLA will have an impact on claimants of carers’ allowance because the benefits received by the person they care for will be affected, and setting the eligibility rate at enhanced only will amplify the effect.
It is therefore of great importance to ensure that those who are on the middle or higher-rate care components at present continue to receive benefits, regardless of how they will be classified under the new system. We cannot allow thousands of carers to lose their benefits because of these changes. We owe it to carers not only to clarify what is currently unclear but to guarantee that those receiving benefits at the moment will not have them taken away under the new classification—a kind of double whammy.
A statement from the Government confirming which of the daily living component levels will passport to carers’ allowance would be welcome, and a commitment to ensuring that both levels of the PIP daily living component will act as gateways to carers’ allowance eligibility even more so. I beg to move.
Lord Freud
My Lords, perhaps I might again interpose slightly out of order in the interests of clarity. I am grateful to the noble Baroness, Lady Hollins, for tabling the amendment and for making some valid points. I revert to my opening comments today on the timing of the information. We aim to get more information on the passporting arrangements from PIP to carers’ allowance prior to the start of the Report stage, which I hope will satisfy the request. I should add that we are sympathetic to the position of carers—which I hope is recognisable code—and the Government recognise the important role that people with caring responsibilities have in our society. We are continuing to listen very carefully to the contributions that we receive.
I cannot at this stage add anything further. I therefore urge the noble Baroness to withdraw her amendment, which clearly we will be able to consider in more detail in a little while.
Baroness Hollis of Heigham
My Lords, I apologise to the Minister for being fractionally late and therefore missing his statement. Had I been here, I would no doubt have been pushing him on the questions I now want to raise.
Although we welcome and very much appreciate that the passporting arrangements will be with us before the start of Report, we also need to know the statistics, the numbers. In other words, to what extent will the existing case load of people on middle and higher-rate DLA go through into PIP? Will some of those on the lower rate now come into PIP? If carers are passported, as the Minister gave us hope to believe, from both rates of PIP, will that mean there will be more carers in future because some lower-rate carers will be joining them, or will some disabled people on what is currently the middle rate of DLA, which entitles their carer to receive carers’ allowance, fall out of PIP altogether?
Until we know the mapping of the numbers we cannot understand the implications of the very helpful information the Minister is going to make available. The crude fact is that any carer who is now on CA who finds that the person they are caring for will fall out of middle-rate DLA—therefore they may fall out of even a relatively supportive interpretation of the new PIP arrangements with both tiers entitling you on to it—will then find themselves suddenly excluded from having carers’ allowance. Because they are caring for someone for 35 hours a week, that will vanish. As a result they will be exposed to full, in-work conditionality even though the care needs of that person—35 hours a week—will not disappear.
We need to know those numbers and they are issues that we are going to have to reflect on in Committee before we get to the relevant clauses associated with DLA and ESA. Will the noble Lord kindly say whether he will be able not just to tell us before Report, as I hope, that both the upper and lower rate of PIP will entitle you to carers’ allowance but how those two populations rub on to the two existing populations? Will there be losers as well as possibly gainers among carers with all the possible implications they will be exposed to? The Minister may be able to tell us what happens to disabled people and the numbers coming into the PIP framework.
Baroness Howe of Idlicote
My Lords, I hope the Committee will forgive me for coming in at this stage. Earlier today, Carers UK asked me to ask a supplementary on this which is not dissimilar from what we have just heard. There are more than 560 carers receiving carers’ allowance and so on and they may well transfer over into PIP. The Minister has made it clear that decisions are going to be made and will be looked at in detail, but these are the questions Carers UK wanted me to ask. First, what assessments are being made on the impact of carers of the two options available—establishing eligibility through both rates or just through the enhanced rate of the daily living component? Secondly, if the Minister is unable to announce a decision—which he obviously is—on which rate will lead to eligibility for carers’ allowance, will he publish the assessments of the impact on both options so that the Committee can discuss their implications?
Baroness Hayter of Kentish Town
My Lords, I start by thanking, I think, the Minister for his very helpful responses on three months rather than six. That was on residential and now we are to have this early announcement. It leaves those of us who prepared speeches throwing them away. There is a nice bucket here with all of them. Nevertheless, I am always delighted to be able to do that and we thank the Minister for what he has just said.
The amendment, which also stands in the name of my noble friend Lord McKenzie, would establish in the Bill that PIP will act as the gateway for the carers’ allowance and that both rates of the PIP daily living allowance would deliver eligibility. We welcome the fact and therefore do not need to go through all the reasons why we needed to have this. We welcome that we will have that information on passporting before Report, whenever that may be.
Lord Freud
My Lords, as always, the questioning is pinpoint in its precision to rip open any veils that I may be draping over myself. I speak in the spirit of Salome. As I said, before Report begins, I will provide more information about the passporting arrangements from PIP to carers’ allowance. I cannot say more than that today or in practice, as noble Lords are aware, I would end up making the announcement, which I am not in a position to do. Threshold information for PIP will be available prior to the specific Report discussion on that part of the Bill.
Baroness Hollis of Heigham
Does the Minister accept the point that my noble friend made very fully, that we cannot do it that way around? It is back to front. We have to know what the thresholds are for PIP to know which and how many carers will be passported on, on either assumption, whether it is one band or both bands. The Minister has been very sympathetic on this, but unless we have that information, the information on carers will tell us only the mechanism, not the effect. We have to know the effect.
Lord Freud
My Lords, I feel slightly as though I have trapped myself, and I will explain exactly why. I spent a lot of time on the carers’ allowance. I was very worried about the cliff edge at £100 earnings, and so I reinserted a carers’ element into the universal credit, very deliberately, to get rid of that and to have a smoothed effect. I have spent some money—or we the taxpayers have spent some money; it is not out of my own pocket—and I find myself slightly hoist on my own petard by the noble Baroness, Lady Hollis, by making a subtle connection between the universal credit and the carers’ allowance. This was not there originally, when it was a carers’ allowance.
I see that there is a connection—I have created it, but it is fairly narrow—to get that taper to work. It does not undermine the way in which we think about carers and the way in which we look at the universal credit. As I say, I will be able to explain the principles of how the allowance will work right at the start. We will see the actual numbers later when we start to look at the real carers’ allowance. I think noble Lords should be more tolerant of me than they are being.
Baroness Hollis of Heigham
I should be very tolerant of the Minister if he had answered the question. However, my question was not about tapers and the interplay of carers’ allowance; that is a genuine set of questions, but not the one I was trying to explore. I was saying that because carers’ allowance is a passported benefit, we have to discuss, and have to know, how many people will be entitled to the original benefit, from which carers are passported, to calculate how many carers will or will not continue to qualify for carers’ allowance. If they do not qualify for it absolutely, then they come into the in-work conditionality issues that some of us are worried they may be exposed to. For once I think the Minister has not understood where I was coming from on this, which was not about tapers and the interplay; that is a separate bundle of issues that we will no doubt seek to tease out.
Let us assume that both levels of PIP, standard and enhanced, entitle you to a carers’ allowance. That would be very good news. However, we need to know how many disabled people are entitled to the standard rate of PIP, and whether it is just the people currently on the middle rate, or some of the people currently on the lower rate as well, or fewer people than who are on the middle rate now, who will be entitled to that lower rate. Only then can we work out how many carers will be affected, numerically. We cannot discuss, therefore, the extent and the value of a passported benefit until we know the original client group on whom that passport is dependent.
Lord Freud
My Lords, as I have tried to explain, we will introduce PIP from the bottom up. We will try to find the people who need the money and there will be winners and losers in that process. In particular, the PIP process is far more understanding of mental health issues. I do not think looking at absolute numbers undermines the principles of how you create the universal credit. It does not undermine our considerations of the principles of the universal credit but we need to understand the impact of PIP and the carers’ allowance in relation to it. We shall have that information in time and debate it in great depth. I am committing to providing those figures at the right time. It is not a trivial but a hard commitment. The timing has been produced under pressure from the Committee and I hope that it is accepted in the spirit with which it has been obtained.
Baroness Hollins
My Lords, I know that the Minister is genuinely concerned about carers and I take some comfort from the code carefully contained in his earlier response. Carers UK and other groups representing carers are concerned, but they are also very aware and advocate for a better deal for carers. For a long time carers have not had enough financial and other support and it is important that someone should speak up for them in this respect.
I look forward with great interest to further developments. I beg leave to withdraw the amendment.
Lord De Mauley
My Lords, I suggest this a convenient moment for the Committee to adjourn until Monday at 3.30 pm.
House of Lords
Unemployment: Young People
(13 years ago)
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Lord Peston
To ask Her Majesty’s Government when they expect the level of youth unemployment to begin to fall.
The Parliamentary Under-Secretary of State, Department for Work and Pensions (Lord Freud)
The most recent forecast from the independent Office for Budget Responsibility is for unemployment to level out and then fall from the second half of 2012. There is no separate forecast for youth unemployment, but this would be expected to follow a broadly similar trend.
Lord Peston
Am I to understand, when thanking the Minister for that Answer, that the Treasury does not look specifically at youth unemployment when considering its policies? Is it the case that no Minister in the Treasury, no official and none of its excellent economists or statisticians has a view on when the rate of increase in unemployment, especially for young people, will become a rate of decrease?
Lord Freud
Well, my Lords, the forecasts have now gone to the Office for Budget Responsibility and are the basis for planning. Clearly, the forecast that I have just given noble Lords is somewhat out of date and we are looking to have another later this month. Clearly, the implication of what the Governor of the Bank of England has just said is that growth will, on his forecast, run at 1 per cent this year and next, and this will be built into those kinds of forecasts.
Lord Roberts of Llandudno
My Lords, faced with the tremendously high rate of youth unemployment, is it not time that both parties accept that under both of them youth unemployment has increased? Is it not time that we put by party differences and had a united effort to tackle the problem of youth unemployment?
Lord Freud
Yes, my Lords. It is very easy to get tied up with the tyranny of round numbers. The reality is that we have a genuine structural problem that has grown over the last decade and needs handling in a comprehensive way.
Lord Howarth of Newport
Is it not the case, particularly in old industrial areas, which have found it very hard to attract new private sector investment, that by withdrawing public sector expenditure too fast and abandoning regional development strategies, the Government are condemning young people to continuing unemployment?
Lord Freud
My Lords, of course we are not withdrawing regional support. We have put in a £1.4 billion growth fund and have a series of programmes designed to help young people. We have help in terms of work experience, the sector-based work academies and the work programme, which will together provide support for 350,000 youngsters over the next two years.
The Lord Bishop of Blackburn
My Lords, I am grateful to the Minister that he refused to adopt a false optimism in his reply. We all know from previous recessions that the impact on young people, particularly their morale and self-respect, lingers long after the recession is ended and creates ongoing social problems. Would the Minister agree that, instead of decimating youth services at this time, the Government should be seriously investing more in such work so that we have some chance of avoiding the loss of a whole generation to cynicism and hopelessness?
Lord Freud
My Lords, I was very impressed, as I am sure many noble Lords were, with the report by Professor Wolf on what has been going wrong for young people. Her conclusion was that there are four things that young people need: a job, proper educational qualifications, apprenticeships or work experience. This Government are trying to concentrate on really effective solutions for young people.
Lord Knight of Weymouth
My Lords, the Government inherited falling youth unemployment, yet this is the eighth consecutive monthly rise in unemployment and precedes the eurozone crisis. This crisis is down to this Government’s decisions to scrap the EMA, to cut post-16 education funding and to scrap the future jobs fund, and an austerity plan that has choked off growth. How bad will it get before the Government realise that you reduce the deficit by growing jobs, thereby cutting the cost of benefits and increasing tax receipts? When will we get a credible jobs plan, or will it take another million youngsters on the scrapheap before the Government finally get it?
Lord Freud
My Lords, let me assure you that we get it all right. We have inherited a really poor structural position of youth unemployment—
Lord Freud
No—let me tell you the real figures. The total number of unemployed and inactive youngsters went up from 1.4 million in 1997 to 1.45 million now and 1.39 million last year. That was an increase during the longest boom that this country has ever seen. Why did that happen? That was not cyclical, it was structural.
Lord Roberts of Conwy
My Lords, my noble friend will be well aware of the even higher youth unemployment rates in Europe, particularly in Spain. He will also be aware of the comparatively low youth unemployment rate in Germany. Is there not a great deal that we can learn from the Germans in this?
Lord Freud
Indeed, my Lords. The Germans have had a long tradition of apprenticeships and that is something that we need to copy and build on. We have put in money to fund an additional 250,000 apprenticeships over this spending review; we had 442,000 apprenticeships starting last year, an increase of 50,000; and we are putting in measures today to encourage smaller firms to take on apprentices.
Lord Martin of Springburn
My Lords, apprenticeships and the initiatives that the Government are embarking on are good news for young apprentices. However, will these apprenticeship schemes be spread evenly throughout the country?
Lord Freud
My Lords, clearly our intention is to put support where it is most required. Therefore, the schemes will be widespread but naturally there will be an emphasis on the areas that need most support.
Supreme Court: President
(13 years ago)
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Lord Pannick
To ask Her Majesty’s Government whether they have plans to amend the Constitutional Reform Act 2005 so that the president of the Supreme Court is not required to chair the selection commission for the appointment of his successor.
The Minister of State, Ministry of Justice (Lord McNally)
My Lords, the noble Lord will be aware that this is one of the matters being considered by the Constitution Committee of this House under the chairmanship of the noble Baroness, Lady Jay. However, the Government are committed to implementing the recommendations of the Advisory Panel on Judicial Diversity, which was chaired by my noble friend Lady Neuberger, including the recommendation that no judge should be directly involved in the selection of their successor. We are considering this issue along with the evidence presented to the House of Lords Constitution Committee and will shortly start a broader consultation on the matter.
Lord Pannick
I am grateful for that very helpful answer. Does the Minister appreciate that there is some urgency about this because the president of the Supreme Court, the noble and learned Lord, Lord Phillips of Worth Matravers, is retiring next summer? I think that the Minister is saying that he agrees that it is highly undesirable that a retiring judge, however distinguished, should play so significant a role in the appointment of his successor. Can he please indicate that there will be some urgency in the way in which the Government deal with this?
Lord McNally
There will indeed be urgency and, as the noble Lord knows, we have had some very good advice on the matter from the noble and learned Lord, Lord Phillips, himself.
Lord Bach
My Lords, perhaps I may say how much we on the opposition side welcome the Minister’s response to the noble Lord, Lord Pannick. If the Government will act urgently on the point that the noble and learned Lord, Lord Phillips, has spoken about, we will do everything that we can on our side to make sure that such a matter goes through Parliament as quickly as possible. Perhaps I may ask briefly about judicial diversity, in which I know the Minister has a particular role. Are the Government satisfied that they are doing enough to make sure that our judiciary is diverse enough? Many judges at all levels have spoken about this in recent weeks and it is a matter of considerable concern.
Lord McNally
I thank the noble Lord for his initial remarks about co-operation, which will again help with the sense of urgency. On the question of judicial diversity, one of the most encouraging things in recent days is the way in which members of the senior judiciary have been going public on the need for urgency on the matter. It is a fact that four members of our 161 judges in the High Court are of black, Asian and minority background. In England and Wales, four out of 42 members of the Court of Appeal are women and we have one woman on our Supreme Court.
Lord Tebbit
Will my noble friend consider that what we need on the judges’ Bench are the best judges? They should be selected solely and absolutely on merit and there should be no more talk of integration and diversity among judges than among Olympic athletes.
Lord McNally
My Lords, I could not agree more with my noble friend. The difficulty is that sometimes the idea of choice on merit slips into “chaps like us”, and that is what must be avoided.
Lord Faulks
My Lords, do the Government have any view on the so-called tie-break principle, whereby if there are two candidates of entirely equal merit there will be a favouring of either female applicants or members of the ethnic minorities?
Lord McNally
Yes, my Lords. This is often called the “tipping point” criterion: whether, if there are two candidates of absolutely equal merit, the one from the black and ethnic community or the woman should be given the post. I go back to the point made by the noble Lord, Lord Tebbit, that the aim should be to get the best person for the job. That is something that I believe in but, if there are two candidates of absolutely equal merit and one is a woman or from the black and ethnic minorities, you might take into account that they have had a greater struggle to reach that point of merit. That may come into your final conclusion.
Lord Borrie
May I question the Minister’s view that diversity has been sufficiently practised by the Government and is being pushed in the way in which it is being pushed in discussion in this House? The most recent appointments to the UK Supreme Court were of two men: one came up the usual route from the Court of Appeal and was promoted; the other has not had any full-time judicial experience but is a distinguished Queen’s Counsel. Those are the most recent appointments, yet, as the Minister himself said, there are several women members of the Court of Appeal. Are they being sidelined?
Lord McNally
I do not think one should take a snapshot of the last two appointments and say that means that there is no diversity. There will be four appointments to the Supreme Court in the next 24 months. Let us wait and see.
Lord Elystan-Morgan
Where there are two candidates of absolutely equal merit, is it not the case that the appointing body only has one of two choices: either to toss a coin or to apply the relevant provision of the Equality Act?
Lord Cormack
My Lords, is it not comforting that one of the latest appointments to the Supreme Court has written a definitive history of the Hundred Years’ War?
Lord McNally
Indeed. I always go along with the dictum of Denis Healey—the noble Lord, Lord Healey—that you should look for people with hinterland.
Baroness Deech
My Lords, do the Government acknowledge that the combination of high tuition fees and the cuts in legal aid will have a very bad impact on diversity at the young end of the legal profession, especially the Bar, and that there will be less diversity in years to come unless it is made possible for young people of all backgrounds to get a start at the Bar?
Lord McNally
We will be debating in the near future the cuts in legal aid. Where I do share concerns is that to get into the legal profession, whether as a barrister or a solicitor, requires a financial commitment that could have an adverse effect on social mobility. That is something that the Government will have to address.
Bahrain
(13 years ago)
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Lord Hoyle
To ask Her Majesty’s Government what representations they have made to Bahrain regarding a fair retrial in the civilian courts for the 20 doctors and nurses detained in relation to the protests there.
The Minister of State, Foreign and Commonwealth Office (Lord Howell of Guildford)
My Lords, on hearing of the sentences imposed on the medical and nursing professionals by a Bahraini special tribunal on 29 September 2010, my right honourable friend the Foreign Secretary led the international criticism by issuing a statement of the UK’s deep concern at the disproportionate sentences. He called on the Bahraini judicial authorities to follow due process carefully and transparently. The Parliamentary Under-Secretary of State, Alistair Burt, also called the Bahraini ambassador in London the next day to reiterate our concern, and the UK’s national security adviser also raised the case of the medical staff during his recent visit to Bahrain.
Lord Hoyle
I thank the Minister for that reply. I hope he will agree that when we condemn the violation of human rights, we should do so with all countries that do that. Will he do his best to use this country’s influence with Bahrain to ensure that when the trial of these people comes about it is fair and transparent and is witnessed by observers from different countries?
Lord Howell of Guildford
Yes, we will certainly do that. One can draw some cautious optimism from the fact that the retrials are by civilian courts. The military courts have been closed and certain detainees have been released—not in this case, of course. A substantial commission report on human rights is about to be published next week that will cover all aspects of the kinds of concerns that we have and the noble Lord rightly has about what has been going on in Bahrain.
Baroness Falkner of Margravine
My Lords, on the subject of the international commission of inquiry, which is due to come out on 23 November, will my noble friend tell the House whether he has complete confidence in the impartiality of this commission? He will know that the opposition parties in Bahrain were very concerned at the delay in the publication of the commission’s report and fear that there had been external pressure for the commission to revisit its findings?
Lord Howell of Guildford
I believe my noble friend’s concerns to be unfounded. There were delays. It is a massive report and there were sheer technical problems in getting it forward in due course. As for impartiality, it is by all accounts—we have not seen the full detail yet—a substantial report that has gone into everything in great detail. One of the members is the distinguished British jurist, Sir Nigel Rodley, and there are other distinguished jurists and impartial members on it as well. I am fairly confident that this will be a very substantial report. It will be published at the same time as it is presented to the authorities in Bahrain and I think it will carry matters forward substantially.
UNESCO
(13 years ago)
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Lord Rennard
To ask Her Majesty’s Government what representations they have made to the Government of the United States following the withdrawal of United States funding from UNESCO.
The Minister of State, Foreign and Commonwealth Office (Lord Howell of Guildford)
My Lords, the United Kingdom has urged the United States to pay its assessed contributions to UNESCO until at least the date of Palestinian accession to UNESCO was decided. It is not yet clear which programmes might be affected by the US decision to withhold its assessed contributions to UNESCO.
Lord Rennard
My Lords, does the Minister agree that it is simply morally wrong potentially to withdraw funding from UNESCO projects that may save thousands of lives in future tsunamis, educate people about the Holocaust and foster free media in some of the newly emerging democracies of the Middle East in retaliation for others simply disagreeing with the United States about Palestinian membership of UNESCO? Does the Minister think that we should tell our friends in the United States that this is the way to lose friends and fail to influence people?
Lord Howell of Guildford
We do think it wrong—and we have raised this with our United States colleagues—that the United States should not merely consider withdrawing its contribution for the future, which, it is argued, is necessarily triggered by existing law in the United States, but should stop the contribution that was already due this year and on which UNESCO has already made spending plans. Obviously, the sudden withdrawal of commitments that have already been made will cause grave difficulties. A lot of people will lose their jobs and UNESCO has had to freeze all new plans. That is wrong; I agree with my noble friend. We raised this matter with the State Department and the point is being debated. Of course, the matter will be put to Congress, which is the driving force in this issue, but the general point that my noble friend makes is quite right.
Baroness Deech
Does the Minister recall Britain’s withdrawal from UNESCO for a long period in the 1980s, which unfortunately was part of the continuing use of UNESCO as a political and ideological tool? Can pressure be brought to bear on UNESCO to do something about Syrian behaviour, given Syria's recent speech to UNESCO about the importance of youth and women's education and so on, which seems a bit odd in the current circumstances?
Lord Howell of Guildford
The kind of pressure that can be brought to bear on UNESCO, and may have to be brought to bear as it faces the huge cut of 22 per cent in its budget, is to suggest that it should streamline and improve its administration. There have been improvements; it has made progress, and it is focusing on some very valuable programmes, as my noble friend pointed out. On the specific issue of Syria and Syrian projects, I cannot comment as I have no details. I will look into the matter. Broadly, there is now a British member on the UNESCO board, and we believe that UNESCO, which had some difficulties in the past, is improving and can focus on valuable things, of which the tsunami warning programme is a very good example.
Baroness Falkner of Margravine
Does my noble friend accept that as UNESCO's new Secretary-General is attempting to put it on to a much more streamlined and efficient path, the shortfall in funding will only undermine her position? Have the UK Government been in touch with other Security Council members to see whether they, as well as the G20, might be able to assist in making up the shortfall, at least on a temporary basis until UNESCO can revise its budget?
Lord Howell of Guildford
It is early days for that. We will have to see whether the United States follows through on what appears to be its intention not merely to withdraw future funds but current funds as well. A very large number of countries—107—voted for Palestine's membership of UNESCO. There were 52 abstentions and 14 countries voted against. Therefore it was a fairly solid commitment to Palestinian membership. On the question of funding, we will have to wait and see how the matter turns out. Certainly there are major difficulties to be faced and resolved.
Lord Liddle
My Lords, noble Lords on this side of the House all share the concerns about the future of UNESCO and agree with the Minister’s comments. The fundamental issue behind this question is how strongly we are prepared to make clear to the United States our difference of view on the recognition of Palestinian statehood. While the Government’s position was sympathetic, it was ultimately a decision to have no position—to vote neither for nor against. How does this advance the peace process and the cause of a two-state solution, given the present stalemate and Israel's very recent decision to announce further settlements that will be deeply counterproductive? Should we not be more robust on these issues?
Lord Howell of Guildford
That is, of course, a broader question. The noble Lord is absolutely right that the question of Palestinian statehood lies behind the question of whether partial arrangements, as it were, for statehood should be made by Palestine applying to various UN organisations, of which UNESCO is one. It is the judgment and view of Her Majesty’s Government that the way forward must be by negotiation for the emergence of the Palestinian state. We reserve the right to recognise the Palestinian state at the moment of our choosing. We take the view that a fragmented application to UNSECO and other bodies is probably a mistake and will delay negotiation. We also take the view that, if the matter is to go to the Security Council—I say “if”—and if then, as is almost certain, the Americans vetoed it, that, too, would set back negotiation very substantially. It may be rather limited now but it is going to be even more limited—indeed, it will screw it up completely—if that course is followed. There are plenty of ifs and buts in the future. Beyond that, there is the possibility that it might go to the General Assembly as well, but all these matters have yet to be decided.
Lord Brooke of Sutton Mandeville
My Lords, how often do Her Majesty’s Government receive representations from our allies about our own decisions on international subscriptions?
Lord Howell of Guildford
I did not hear the precise words—were they “how often”?
Lord Brooke of Sutton Mandeville
On how many occasions do Her Majesty’s Government receive representations from our allies on our decisions on international subscriptions?
Lord Howell of Guildford
I have absolutely no idea. The world is not like that. It is not a question of representations. Obviously there are discussions in the corridors at multinational meetings on who is going to subscribe to what. That is perfectly natural, but we make our own decisions in the end.
Lord Dubs
My Lords, is not the real issue that, given that no sensible negotiations are taking place, the Palestinians have very few options left and that their bid to become members of the United Nations, and initially of UNESCO, is the only way forward for them? If we keep talking about negotiations when they are not happening, are we not simply saying, “Let us leave it as it is”?
Lord Howell of Guildford
I am not sure that the noble Lord has got that right at all. It is perfectly true that Mr Netanyahu is not, or does not appear to be, a great proponent of negotiations at the present time, but the quartet is proposing some views. We think that there are pressures that can carry negotiation forward and we are not at all convinced that the Palestine statehood idea, if it went to the Security Council and produced the veto and the freezing up of negotiations all round, would be much of an improvement on the situation. I agree with him that it is not good, but it would certainly be very much worse in our view if we followed this course.
Lord Grocott
My Lords, in terms of acts that could be considered to be threatening to any future peace talks, surely there can be no equality between on the one hand the Palestinians wanting full membership of UNESCO, which is a fairly benign movement in its way, and on the other hand a profoundly aggressive movement: the continuing extension of settlements in the Occupied Territories? There really is no equality, surely, between those two acts.
Lord Howell of Guildford
No, none whatever. We regard the continued expansion of settlements as illegal, most unwise and highly provocative. That is part of the broad scene, and that must halt as part of the move forward to the negotiation that will bring Palestine to its full and rightful statehood. I agree. I am not quite sure what point the noble Lord is making. There is no comparison at all.
Local Authorities (Contracting Out of Community Infrastructure Levy Functions) Order 2011
Baroness Hanham
That the draft orders laid before the House on 7 September and 10 October be approved.
Relevant document: 29th report from the Joint Committee on Statutory Instruments, considered in Grand Committee on 9 November.
Business of the House
(13 years ago)
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Baroness Royall of Blaisdon
My Lords, given the pressure of business in this House and the lack of business in the other place, all noble Lords are anxious to know when this longest-ever Session of Parliament will end. I would therefore be grateful if the noble Lord the Leader of the House could confirm the information given by his right honourable friend the Leader of the House of Commons on Thursday 10 November, at col. 454 of Hansard, that the Queen’s Speech will be held in May.
The Chancellor of the Duchy of Lancaster (Lord Strathclyde)
My Lords, the noble Baroness the Leader of the Opposition quite correctly gave notice of her question to my office just before Question Time, and I am very grateful to her.
I have not had time to consult my right honourable friend the Lord Privy Seal, Sir George Young, and neither he nor I wish to mislead either House in any way. However, I have now had his words drawn to my attention, and I have read them, so perhaps I can give some context and perspective to the words he used. He was answering a question from his opposite number about the desirability of autumn versus spring State Openings. He was referring to a Statement that he had made on 13 September, when he said that State Openings,
“will, in future, ordinarily take place in the spring, rather than in the autumn”.—[Official Report, Commons 13/9/10; col. 34WS.]
That is very much what he intended to say. The context of this is the new Fixed-term Parliaments Act under which Sessions will run after general elections in May, and from May to May. That was what he was trying to say.
My right honourable friend may also be taking a very pessimistic view of the progress of business in this House. I think that the usual channels have a plan to deliver this Session in a timely manner, and I hope that we can do better than that.
Lord Peston
Can the noble Lord clarify one bit of his answer? This has not only been a very long Session; it has now also become about the most boring Session of my 25 years in this House. Is he saying that the facts of the matter are that the Government have not made up their mind at all about when the Queen’s Speech will be?
Lord Strathclyde
My Lords, it is very much subject to the progress of business. As to the quality of legislation, beauty is in the eye of the beholder.
Lord Grocott
My Lords, I wonder whether it would be helpful to the House if, rather than explaining the context in which Sir George Young made his Statement in the other House, we actually repeated the words that he used. He said:
“I made a statement, I think, last year on the fact that the Queen’s Speech will be held in May to coincide with the fixed election dates of every five years”.—[Official Report, Commons, 10/11/11; col. 454.]
That promise—and I think that I can put it in those terms—was repeated endlessly during the passage of the Fixed-term Parliaments Bill by, I think, the noble and learned Lord, Lord Wallace of Tankerness. I even put down an amendment to try to ensure that there would be a fixed date for the Queen. Given the Government’s obsession with fixed-term Parliaments—which I oppose, but the Bill has been passed—there should be fixed Sessions. Surely there is a logic to that. Frankly, if the Queen’s Speech is not in May of next year, it will be very close to breaking faith with the clear undertakings given during the passage of the Fixed-term Parliaments Bill. I therefore ask the Leader to do more than just consult his colleague down at the other end—perhaps they should try to get their acts together.
Lord Strathclyde
My Lords, we will make an announcement in the first part of next year about when the actual date will be, and we are very happy to stick with spring. It is true that this Session has been very long, for reasons which I think will be readily understood. However, we believe that from the start of the next Session, we will go towards annual Sessions that will aim to finish around April or May.
Lord Higgins
My Lords, is it not becoming rather ridiculous that we still have not had a debate on the crisis in the eurozone? Perhaps the expression “fiddling while Rome burns” would be appropriate in this context. The usual debate on the Chancellor’s normal Statement is not really a substitute for a debate on the crisis in the eurozone. We need to debate both.
Lord Strathclyde
My Lords, I am very grateful to my noble friend the government Chief Whip, who tells me that there is a debate planned on the eurozone on 1 December.
Lord Foulkes of Cumnock
My Lords, returning to the Queen’s Speech, in all seriousness, is this uncertainty not causing tremendous problems for people planning ahead—not just Members of the House of Commons but Members of the House of Lords, all those involved in the State Opening and, not least, Her Majesty the Queen? Is it not incumbent upon the Government to say now when the State Opening is going to be held so we know exactly how to plan ahead for next year?
Lord Strathclyde
My Lords, the noble Lord, Lord Foulkes, does a good job of righteous indignation on this subject. I assure him that in past years it has been entirely normal to announce the date of the Queen’s Speech about four or five weeks in advance, and we aim to do precisely the same this year.
Lord Soley
I admire the Leader’s ability to put this in perspective. I have to say, it is easier to get things in perspective if you do not have to stand on your head. Is not the reality behind this that actually, as Members on all sides of the House have said, the problem for the House is the quantity and quality of the legislation being brought before it?
Lord Strathclyde
My Lords, I have already answered many questions on this. The quantity is no greater than similar Sessions after a general election, and of course Parliament is trying to improve the quality by putting amendments and occasionally defeating the Government.
Health and Social Care Bill
(13 years ago)
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Baroness Thornton
My Lords, I rise to intervene on this Motion today with a very heavy heart—and empty-handed, because the Government have refused to release the risk register on the implementation of the Health and Social Care Bill, as instructed in the judgment of the Information Commissioner last Friday. I am grateful to the Minister for his letters to me and other noble Lords explaining the Government’s position on this matter. Thorough explanations are helpful but they do not make this a right or just position for the Government to take. The Government inform us that they need 28 days to consider this issue. I would just make the point that the Department of Health has had a whole year to think about this issue.
Noble Lords may recall that I drew this important matter to the attention of the House on Monday and specifically asked the Minister to assist the House in its deliberations by making the risk register available. I am most grateful that the noble Baroness, Lady Williams, supported my appeal. Since Monday, it has become clear that the well respected Conservative MP, Dr Sarah Wollaston, made the same plea to her own Secretary of State in a letter to the Evening Standard.
I beg the leave of the House to say I have nowhere else to raise this important matter. I do not wish to delay the House but I want to make two points and ask two questions of the Minister. There is a precedent that I urge the Minister to consider. In 2008 the noble Earl’s then honourable friend, Miss Justine Greening MP, recently promoted to the Cabinet, used an appeal to the Information Commissioner to get the release of the risk documentation on the Heathrow third runway. I am sad to report that my own Government did not cover itself in glory in this matter, refusing to part with the information for more than a year. However, the key difference between then and now is that of course the third runway was not the subject of a very large piece of primary legislation that aims to bring radical change to our NHS and that the information we are being denied could be very relevant to our deliberations.
I have already written to the noble Earl about this matter and intend to follow the same route as my right honourable friend John Healey MP by putting an FOI request in for the most recent risk register about this matter. I urge other noble Lords who share my concern to do the same. The reason I am doing this is because the Secretary of State suggested yesterday that the version of the risk register that my right honourable friend John Healey asked for would now be a year out of date. I regard that as both a glib and disrespectful remark.
The Minister told the House on Monday that most of the information from the risk register is included in the impact statement that was published when the Bill arrived in the House. Can the Minister say exactly how much of the risk register is contained in the impact assessment and how much is not? Perhaps the Minister might assist the House by publishing the information that is not contained in the impact assessment but is in the risk register. The Government say that this is a very secret document, but also that it is available. I am sure that the House would like to know which it is.
Finally, there is a course of action open to the House, which is to refuse to resolve itself into a Committee on the Bill as an expression of its concern about this matter. I have discussed this course of action with several noble Lords, and we have a genuine dilemma here. Many feel that it is a very serious error to refuse to place this information at the disposal of the House when we are considering this important Bill. On the other hand, we are all aware of the amount of work that there is to be done on this Bill. I do not intend to divide the House today, but I reserve the right to come back to this issue if it is not resolved at least within the time allotted by the judgment of the Information Commissioner. The Minister may also need to arm himself with the information contained within the risk register, because I, for one, will be asking him, at all the appropriate moments in the debates to come, whether that issue is mentioned in the risk register and what it says.
Lord Warner
My Lords, before the noble Earl responds, may I offer him a little piece of advice, as a former Health Minister who had to take controversial legislation through this House? I would say to him that if I had been confronted with this situation, I would have gone to my boss, the Secretary of State for Health, and asked him to facilitate the passage of this legislation through the House by making this information available to the House.
Baroness Williams of Crosby
My Lords, I, too, wish to ask the Minister one additional question. Can he give any idea of how quickly the proceedings that he mentioned in his recent letter to Members of the Committee will take? He showed in that letter that there needed to be discussions with other ministries and that there needed to be consideration of whether an appeal should be brought. I know that he appreciates, as much as the rest of the House does, that our debates in many areas would be very much affected by knowing what is in the risk register, and in particular, perhaps, those parts of it that the noble Baroness, Lady Thornton, suggests could be made available. Can he give the House any idea of the probable timetable, as we are all conscious of the fact that the debates might have to be repeated all over again if the information in the risk register is relevant to the things that we are talking about?
Lord Campbell-Savours
My Lords, I read the report the other day and it seems to me that the Government are refusing to publish because they have got something to hide. We want to read this document. The Information Commissioner’s report is a fascinating document which repeatedly, under a number of paragraph headings, states that the Government should publish this document and act in a transparent way in the public interest. That phrase is repeatedly referred to in the course of the document. It is quite incomprehensible that the Government should have taken this very silly decision—a sort of ostrich in the sand approach to these matters.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I fully appreciate the strength of feeling that noble Lords have on this matter and I hope that the House will accept my assurance that I have no wish to be, or to appear, unnecessarily obstructive over the release of data which your Lordships may feel should be in the public domain.
However, I should bring the House up to date. The ruling of the Information Commissioner carries with it very significant implications, not only for my department but for every department across government. The risk register is a basic tool for the management of policy implementation. It is a working document which informs advice to Ministers. Publication of departmental risk registers, were this to become routine under the Freedom of Information Act, would fundamentally affect the day-to-day working of government. In this context we are of course looking carefully at the issue of precedent, and I am grateful to the noble Baroness for having raised this.
The Government, as a whole, must therefore consider whether or not to appeal the Information Commissioner’s ruling. Officially, we are allowed 28 days from the date of the ruling in which to do this. Consequently, I regret that I cannot make any specific commitment on these matters today. I emphasise that the Government’s wish to take some further time to consider the way forward is in no way an attempt to string this matter out in a needless or obstructive manner. We intend to act with maximum speed. If a decision is taken not to appeal the Information Commissioner’s ruling, we will proceed to comply with it immediately.
I hope, however, that noble Lords will understand the Government’s view that it is reasonable to allow time in which to take a decision on a matter that is both complex and important. Meanwhile, I am very willing to consider the noble Baroness’s constructive suggestion that I should examine whether there are any risks covered in the Department of Health risk register which have not already been placed in the public domain and which could be provided without further ado. I shall give a progress report to the House on these issues at the earliest opportunity.
Lord Hunt of Kings Heath
“( ) Each clinical commissioning group has the function of safeguarding the comprehensive provision of NHS services.”
Lord Hunt of Kings Heath
My Lords, this group of amendments brings us to the general function of clinical commissioning groups. New Section 1F to be inserted in the National Health Service Act 2006 under Clause 7 states:
“Each clinical commissioning group has the function of arranging for the provision of services for the purposes of the health service in England in accordance with this Act”.
I suppose that, in many senses, clinical commissioning groups are the flagship of the Government’s reforms, but that those functions are not particularly inspiring. I would have thought that the Government would have wished to set out a rather more ambitious remit. My amendment seeks to do that and is quite specific that the clinical commissioning groups should have the function of safeguarding the comprehensive provision of NHS services.
It is very important that words to that effect are in the Bill in order that clinical commissioning groups are under no misapprehension that they have an obligation to ensure that patients receive comprehensive services. Recently, the Secretary of State has felt it necessary to intervene with primary care trusts because there has been evidence that in order to balance their books, they have been putting restrictions on treatments both in terms of the actual treatments but also in artificially delaying access to non-urgent treatment for a number of weeks. The Secretary of State has ruled that this is unacceptable.
The question that arises is: if that situation arose with clinical commissioning groups, what is there to be done to ensure that CCGs are reminded that their job is to ensure that their patients receive comprehensive health services? Essentially, that is what my first amendment is about. It is of course linked to Clauses 10 and 11. As we have already generally agreed, Clause 10 is one of the essential parts of the Bill’s intention to change the foundation of the NHS. The clause would remove the Secretary of State’s duty under Section 3 of the NHS Act 2006 to provide key listed health services to meet all reasonable requirements throughout England and, crucially, would remove the area-based responsibilities of primary care trusts.
In Clause 10, we see in their place the clinical commissioning groups—the bodies responsible for persons on lists and other persons usually resident in unclear and potentially non-contiguous areas. As far as I can see, those specified services would clearly have to be provided for everybody except, arguably, emergency care. In addition, Clauses 8 and 9 would in effect remove from Section 3 public health functions such as immunisation, screening and health promotion, so these PCT services would not have to be covered by clinical commissioning groups. I have to say that the provisions of Clauses 8 and 9 are particularly opaque, and the interface with Clause 10 in unclear. I would also point out to the noble Earl that new charging powers are proposed in Clause 47 for those services that are free at present, although I think that the noble Earl has suggested that they would be commissioned by local authorities and would not be part of the National Health Service. My Amendments 76 and 77 would delete Clause 10 entirely, retain Section 3 of the 2006 Act in its entirety and add a new clause that would give clinical commissioning groups the duty to arrange provision for all persons usually resident in their area and, as regards emergency care, for everybody present in their area.
I was going to put a number of questions to the noble Earl, but he has written a letter that relates both to the pilot schemes to make it easier for people to move between GP practices and, if they move, to stay on with their old practice if they are likely to return to their former residence. That would apply, I suspect, to people such as students. He has also given some details about the general responsibilities of the national Commissioning Board in relation to patients who cannot find a GP who will take them on. That is helpful, and I certainly think that there will be time later on to discuss this in more detail. On the pilot schemes, one of the issues will be the approach taken when patients turn up at one of these GP practices and ask to go on its list. We know that reception sometimes can be a very good experience and sometimes not so welcoming. That factor should be kept in mind.
A second issue arises from the noble Earl’s letter, particularly about the allocation of patients on GP lists. As the NHS Commissioning Board will hold the contracts of GPs—it would be deemed a conflict of interest if clinical commissioning groups held them—the Commissioning Board itself will be responsible for allocating patients to lists if they cannot get on a particular list. How on earth is this practically going to happen? Does this not make it inevitable that not only will the NHS Commissioning Board have to establish regional offices, but, given the size, it will need local offices so that the public can get in touch with it? Presumably that means, too, that the NHS Commissioning Board will oversee the system for complaints made against GPs in terms of their primary care delivery function. So there are quite a lot of difficult issues here about how practically the NHS Commissioning Board will carry out its duties. As for the allocation of patients, what will happen about patients with severe learning difficulties or complex mental or physical health problems, or asylum seekers and the homeless, those of no fixed abode who traditionally have often found it difficult to get on a list? How will the NHS Commissioning Board know what to do about this unless it has some kind of local presence? I do not believe it can be done from the headquarters of the Commissioning Board in Leeds—or at least it would be very difficult to do so.
I know that we have discussed the issue of the clinical commissioning groups not being area-based, and I will come back to that. The noble Earl’s maps are very instructive. I would point out that the Heart of Birmingham PCT hardly covers the catchment area of the Heart of England NHS Foundation Trust. That is a matter of great regret to me because it currently has a thumping great surplus, unlike the PCTs that serve my own foundation trust. I can no doubt look to the noble Earl for a helpful intervention in that—or perhaps not.
Lord Warner
My Lords, I speak to Amendment 79 in my name and those of the noble Lord, Lord Patel, who unfortunately cannot be here today, my noble friend Lady Pitkeathley and the noble Baroness, Lady Murphy. Our purpose is to focus clinical commissioning groups on the needs of the 18 million of our fellow citizens with long-term conditions.
We spend an awful lot of time and money in our healthcare system preoccupied with acute hospital care. Indeed, 50 per cent of NHS expenditure goes on acute hospitals. However, day in, day out, week in, week out, the bulk of NHS activity—some 75 per cent of it—goes on good, bad and indifferent treatments for people with long-term conditions. Of course, some of these people have acute episodes, often because their routine care has been neglected. For example, 10 per cent of NHS expenditure goes on people with diabetes. The number of people being treated with diabetes is rising. We know how best to look after people who suffer with diabetes but too often we neglect basic, routine care and maintenance of the condition, seemingly waiting for the inevitable crisis to occur.
The scale of long-term conditions is, in my view and that of the colleagues who signed this amendment, sufficient to draw particular attention to their needs in the Bill. That is what the first part of Amendment 79 does by adding the words,
“especially persons with long-term conditions”,
to Clause 11 at line 12 on page 7. However, we want to go further. A very high proportion of those with long-term conditions need help, both from the NHS and from adult social care services. That is why the second part of that amendment specifically requires clinical commissioning groups to pay attention to their need to secure improvement in the integration of health and social care in the delivery of services. Of course, we have already had one discussion on integrating health and social care services at the point of delivery, including specifying a definition and I suspect that we shall come back to integration on a number of occasions as the Bill progresses. I shall certainly return to this issue on Report.
In the mean time, I hope we will receive a more constructive response from the Minister to this amendment, placing a clear responsibility on clinical commissioning groups from the outset to focus on securing improvement in the integration of health and social care in the commissioning of services. We need to move from the rhetoric of integration to requiring it to happen in legislation. I beg to move.
Lord Ramsbotham
I wish to speak to Amendment 80. I wonder how many noble Lords are aware of the historic nature of the proposed insertion into the 2006 Act of new Section 3B(1)(c). It is the first time that mention has been made in a Bill of the requirement on the Secretary of State for Health to provide services or facilities for those detained in a prison or in other accommodation of a prescribed description.
When I was appointed Chief Inspector of Prisons in December 1995, I had to give up the chairmanship of Hillingdon Hospital National Health Service Trust because I could not guarantee the time required, but during my chairmanship I was particularly grateful that my extremely able director of mental health insisted that I trained as a lay assessor so that, in his words, I could be of some use to the hospital. What neither of us realised at the time was that he was enabling me to appreciate, at once, the full and avoidable horror of the situation that I found during my first prison inspection of Holloway, during my second week in post. He educated me about both the complex requirements of those suffering from mental health problems and what it was possible to provide for them.
That understanding fuelled my fury at finding that none of what I had been accustomed to at Hillingdon was present in the largest female prison in England in 1995, despite the appalling numbers of women with varying degrees of mental health problems. When I remonstrated about that, I was told that uniquely in the country, prison healthcare was not, and never had been, the responsibility of the NHS but had been retained by the Prison Service. I was then told that the director of prison health, a doctor, was not responsible for the provision of healthcare, merely for advising the prison’s board, which was actually responsible. When I asked how many of the prison’s board had medical experience or qualifications, I was told none.
So I set about trying to change this nonsense, writing a thematic review of the situation in 1996, entitled Patient or Prisoner?, in which I recommended that the NHS takes over responsibility as soon as possible. I quoted the vast well of psychiatric morbidity, exacerbated by the treatment of and conditions for prisoners being wholly unsuitable for those suffering from mental health problems, which invariably made them worse. I simply could not understand how this situation had been allowed to continue since 1947, not least the continued failure to include the needs of the 500 or so prisoners whose transfer to high or medium-secure hospital accommodation was recommended each year in National Health Service estimates. That meant that provision was always a matter of chance because of competition with funded community needs. Years of lack of NHS budgetary provision for any aspect of prison healthcare, including the additional expense that released prisoners add in the community, remain a millstone around the NHS neck.
It seemed abundantly clear to me that prison health was a public health issue, because every single prisoner except, for the very small number, sentenced to natural life was going to come out and the state of their mental and physical health when they did so was a matter of public interest. Not only was offender health not regarded as a matter of public health, but GPs had to fight to get information from prisons about any medical treatment a prisoner had received. That was of doubtful quality, because we found that only 10 per cent of prison medical officers were qualified to act as GPs in the NHS. In other words, not only did anyone going into prison disappear from the NHS radar screen, but the authorities seemed to disregard the fact that imprisonment—paid for by the taxpayer—presented a priceless opportunity to identify and initiate, or pick up and continue, essential mental and physical health treatment. This could then be continued on release to the benefit not just of the prisoner but also of the community into which he or she returned. It all seemed unbelievably short-sighted and, frankly, stupid.
In the event, the NHS was made responsible for prison healthcare in 2003—seven years later, or longer than World War Two; so much for the speed of governmental decision-making. Since then, there has been considerable improvement, particularly when good primary care trusts have taken very seriously their primary care contract responsibilities with individual prisons. The same has not been so true of mental health contracts, largely because provision has in no way been able to match demand. I shall never forget speaking to members of the first mental health in-reach team to go into Wandsworth. They had expected to have to deal with a few very serious cases; instead they found that they were swamped by the 70 per cent of the prison population who were suffering from one or more identifiable personality disorders. It did not make them sectionable, but suggested that there was something affecting their behaviour that, if identified, could be mitigated. However, as the resources to carry out the identification were, and are, lacking, mitigation was, and is, denied—a process that should be of public concern.
My reasons for spelling all this out are to explain why my proposed amendment is an appeal to the Minister to withdraw the words, “other accommodation of a prescribed description”, and substitute detailed descriptions of that accommodation. I say that because the Secretary of State is required to commission services for a number of entirely different places of detention with very different requirements. Public and privately run prisons require primary, secondary and mental health contracts appropriate for their population type, whether man, woman or child. Privately run secure training centres and local authority-run secure homes require child-centred services. Privately run immigration and removal centres, about whose healthcare provision there have been many complaints, require a range of services, including specialist knowledge of tropical diseases. In addition, if the Government adopt the diversion schemes recommended by the noble Lord, Lord Bradley, there must be appropriate psychiatric and nursing provision in both police and court cells, in which people may have to be held until moved to appropriate NHS accommodation.
The Department of Health is very fortunate to have an able director of offender health, Mr Richard Bradshaw, who can provide the necessary descriptions very quickly because he is well acquainted with the differing needs. I therefore ask the Minister to accept this amendment in the spirit in which it is meant, which includes trying to ensure that the dreadful situation that I have described is never allowed to reoccur in any prescribed place of detention.
Lord Kakkar
My Lords, I shall speak to Amendment 83 in my name and that of my noble friend Lord Patel. This amendment proposes that:
“Regulations must require the Board to commission services for veterans who have lost limbs”.
The purpose of the amendment is to ensure that those who have served our nation and who have quite rightly received the highest standards of care—both in theatre in the battlefield at the time when they sustained horrific injuries, then during their immediate aftercare back here in the United Kingdom and thereafter while remaining members of the Armed Forces receiving ongoing rehabilitation—can be certain that, once they are discharged from the services and return to civilian life, they are able to avail themselves of the necessary specialist services for years and decades hence. There is no doubt that what is achieved in battlefield salvage is quite remarkable, and those who sustain horrific injuries that some time ago would not have been survivable are now saved and can continue, from a young age, with the prospect of a good quality of life. However, the injuries, particularly the limb losses and multiple limb losses that they have suffered, will require ongoing specialist care.
Her Majesty’s Government have recognised the importance of this area and the noble Earl’s honourable friend the Member for South West Wiltshire, Dr Andrew Murrison, has recently published a report, A Better Deal for Military Amputees, in which he reviews both what is achieved acutely for these brave servicemen and what their ongoing clinical and other needs may be. He makes a number of important recommendations in the report. He suggests that a nationally commissioned service for veterans is the best fit for service-attributable amputees and, of the options he puts, looks at the option most likely to deliver the most for the wider amputee community. He goes on to make a specific recommendation that:
“Ministers should take appropriate powers to provide for national commissioning of specialist prosthetic and rehabilitation services for amputee veterans through a small number of multi-disciplinary centres in England, adequately resourced and determined through a tendering exercise”.
He puts the question that:
“Ministers will have to consider the extent to which existing legislation and the Health and Social Care Bill which is currently before the House of Commons”—
it was at the time—
“permit the national specialist commissioning of special provision for amputee veterans, tabling any necessary secondary legislation or amendments to Clause 11 in the Health Bill”.
So there is a broad recognition by those who have been commissioned by Her Majesty’s Government to look at this issue. The commissioning of specialist services for amputee veterans to ensure their long-term good clinical outcomes—that they may avail themselves of advances in the future, which are going to be dramatic and important in the decades hence and which could have an important impact on their ability to function—and that they have a high quality of life will only be achieved through national specialist commissioning of amputee services.
The Prime Minister, in his response to the report, stated the following:
“I am passionately committed to our Armed Forces. As a country and as a Government we have a particular duty to servicemen and women injured on operational duty. This report maps out a clear strategy for ensuring that those brave people can be confident they will receive the same levels of access to prosthetic limbs and specialist care from the NHS as they do at Headley Court. They deserve nothing less. Based on the recommendations in this report, this Government will make the resources necessary to meet that need”.
This amendment provides an opportunity to ensure that those needs are met. I strongly believe that only through the specialist commissioning of these particular services will the long-term interests of our brave service personnel, who have lost multiple limbs and who have to contend with that in their veteran lives, be properly secured. I hope very much that Her Majesty’s Government and the noble Earl will consider this amendment seriously.
Baroness Pitkeathley
My Lords, having put my name to Amendment 79, I support the powerful case made by my noble friend Lord Warner for the inclusion of long-term conditions and integrated services in the Bill. I particularly draw your Lordships’ attention to those long-term conditions that can be fluctuating as well as progressive. While it may be progressive in an overall sense, an illness such as multiple sclerosis has periods of varying intensity, when needs are different, and even periods—sometimes quite long periods—of remission. It is very important, therefore, that services are not only commissioned across health and social care—it is very important that there is a whole package of support; that is of such significance to users and their families—but also that those packages of care are flexible enough to cope with the varying progress of these illnesses.
The last thing that an MS sufferer, for example, wants when a period of remission suddenly ends with a fresh attack, as it frequently does, is to go back to square one on clinical commissioning, especially as far as the integration of clinical and social care commissioning is concerned. They do not want to go back to starting the assessment process or back to judgments about need and the abilities of their families to care for them, and so on, with all the delays and distress associated with reassessment and all the unnecessary expense that these processes involve. That applies very much also to those with certain mental health conditions, which are also fluctuating in their intensity. So proper care across integrated services not only prevents acute episodes but also helps to support caring families to participate in care effectively, as they wish to do, thus saving scarce resources as well as meeting the needs of those who are suffering.
Lord Cotter
I shall speak to Amendment 81B, to follow on from what the noble Lord, Lord Hunt, said. Brevity will be my watchword, of course, because we do not wish to drag out proceedings. This is a particularly important amendment, referring as it does to commissioning for rare conditions. There are many such rare conditions that people suffer from, but I refer particularly to one called arthrogryposis, which my wife has suffered from from birth to today. As with many people who have struggled with a rare condition from childhood to the age she is now, it has been difficult to get not just treatment but diagnosis. She was originally not diagnosed with this condition, which is associated with the nervous system and the muscles and mobility. Throughout her life she had the difficulty of being misdiagnosed, and then when she was diagnosed she had difficulty getting treatment. I welcome the amendment for that reason.
Many people have that struggle to get the treatment that they need appropriately in their area. For example, we recently went to Birmingham, where they have done some research work. It is so important to get research work done for rare conditions, to establish where they came from and whether people were born with them. I so much welcome—as my wife and others with her condition will welcome, as well as those with other conditions of various sorts—the fact that we are drawing attention to the need for commissioning for rare conditions. You could say that only a small proportion of the public has each rare condition but, when you add all the rare conditions together, there is quite a proportion of people with those problems.
I draw to a close on that basis and hope that the Minister will consider this very carefully, as we and many other people have had experience of rare conditions, with the difficulty of diagnosis and treatment and of getting it recognised throughout their lives.
Baroness Murphy
My Lords, this is an interesting group of amendments about how prescriptive the powers and duties should be for CCGs and about dividing up who should do what between the groups and the board. We have to be careful about how prescriptive we want to be, because it may vary in different areas according to the board’s confidence in the ability of groups to commission. However, I take the point that there are some fundamental principles which we would like to see in each of these groups. That was why I added my name to the amendment tabled by the noble Lord, Lord Warner, and others, about the need to strengthen the co-ordination of health and social care. This is fundamental to the care of so many people. In my view it is a requirement, not an option, that it should be in the forefront of commissioners’ minds.
I am sympathetic to the amendments on special conditions and rare conditions, but—coming back to what the noble Lord, Lord Warner, said—the areas where we need most improvement include everyday, ordinary, complex multiple conditions of older people and simple but common surgical emergencies. It is the ordinary, everyday things that we need—ensuring that we have the right commissioning groups at the right level and that they concentrate on these broad responsibilities relating to the population.
I support the question that underlines Amendment 82, in the names of the noble Baroness, Lady Thornton, and the noble Lord, Lord Hunt of Kings Heath. This is about how agreement will be made between health and well-being boards and the commissioning intentions. We need some understanding of the ground rules which will underpin those negotiations. My experience of negotiating contracts in the NHS is that they can be an awful long time in coming and being finalised unless you have some clear ground rules. I wonder how far the Government have got in thinking about that.
I wish to speak to Amendment 178 on behalf of the noble Earl, Lord Sandwich, and the noble Lord, Lord Mancroft, neither of whom are in their place today. This again is about clinical commissioning groups’ awareness. Amendment 178 is a plea that commissioning groups should take into account—particularly into financial account—what is already being provided for voluntary organisations. Often these provide a more cost-effective and responsive service to client groups. In the noble Lords’ minds particularly were services for those who misuse drugs or alcohol, but there are also services in mental health or in specially targeted support and rehabilitation for specific ethnic groups. For example, a support worker from the same ethnic community can be so vital in establishing mutual trust and compliance with a care plan.
I very much hope that commissioning groups will take into account what is already being provided when they commission. Of course, I understand that alcohol and drug misuse services will be commissioned largely by local authorities. This is entirely positive because they often have a greater understanding of the involvement of voluntary organisations in being able to contribute to a wider service than the NHS often does. Nevertheless, this is an important amendment.
Baroness Armstrong of Hill Top
My Lords, I wanted to intervene on this group of amendments because I have been trying, without success, to find out how to table an amendment relating to how the new architecture will deal with the most chronically excluded. Some of them will require alcohol services, which we shall come to later, but many of them will require other medical services. In addition, many of them will not have a fixed abode or will not have a fixed abode for very long. Therefore, they will be moving around.
When I asked the chief executive of the Commissioning Board who would deal with these people, I was rather concerned to be told that it would be clinical commissioning groups. CCGs might do so, but I am not convinced that they necessarily will. First, CCGs may well not be very aware of the numbers involved, particularly if they are not inner-city commissioning groups, and they may well not be aware of the complexity of response that such people will require. These will be people who require some medical intervention as well as other forms of intervention and support.
At the moment, much of the medical attention that these people receive is fragmented and is often not the appropriate intervention, and they can be a real nuisance in places such as A&E. The Government need to listen to those in the voluntary sector who say, “We need a new approach to how we work with people with these multiple conditions and we need to make sure that we get it right”. However, the NHS has a responsibility—it does not stand outside this—and this matter will need to be looked at on a wider and more expansive level than simply that of the CCG.
In this country we assume that, because we have GPs, people will automatically be registered with them and will be looked after. However, my experience of working with these most frequently disturbed and disadvantaged people has been that they fall through the net again and again, and somehow we have to make sure that that does not happen. Due to work that I have done in the past and because I am currently involved with a voluntary organisation, I have previously discussed with the Minister ways in which that can be achieved effectively. I do not pretend that it will be easy or that we can simply lay something down in legislation and it will all happen. However, somewhere in the middle of that there is a way forward.
I hope that in considering the amendments—particularly those of my noble friend Lord Hunt—the Government will work on this issue and come back with clarification that this group of people will not fall through a net in the new architecture.
Lord Greaves
My Lords, I want to pick up on a point that I made on Monday. We are discussing the role, duties and powers of CCGs, and I want to talk about commissioning services. Where contracts are negotiated with existing providers—whether they are within the National Health Service, the voluntary sector or the private sector—it is fairly clear to see how the system will operate. However, I am not clear—and perhaps the Minister can enlighten me—about the role of CCGs in promoting and creating new services or facilities within the NHS.
The example that I particularly want to refer to concerns the provision of new health centres in my own area of east Lancashire. These are new significant capital schemes but they are not the direct responsibility of the hospital trust. Where the responsibility is that of the hospital trust, it will no doubt be responsible for the provision of new capital schemes. Here we have facilities that will be partly occupied by GPs; they may well be occupied in part by community-based services that are now the responsibility of the hospital trust. The hospital trust may wish to make use of the facilities as outreach facilities for day patients, and so on, but they do not fit neatly into the hospital trust. At the moment, they are the responsibility of the PCT. The existing primary care trust in east Lancashire has now approved in principle the provision of three health centres in three towns—Great Harwood, Clitheroe and my own town of Colne. Because of the changes and the fact that the PCT is not responsible in the future, it has now been passed to the cluster of PCTs, which is at a Lancashire level, and will have to be approved by the strategic health authority.
These are all bodies that in future will not exist. Who will be responsible for this kind of capital project within the NHS in future? It is not just a question of commissioning within an existing landscape of provision in different sectors, but a question of commissioning new services and new capital projects that do not fit into the hospital trusts. Will that be done at a national level? Will it be the responsibility of the CCG? Who will be responsible for the provision of finance for this kind of project?
Baroness Masham of Ilton
My Lords, this group of important amendments illustrates that good care for all is what is needed. I shall say a few words on Amendment 79 on long-term conditions. As has been said, there are many long-term conditions, and there is great anxiety all over the country because of the change. What the Minister says today will be very important and may allay some of the distress. There is a shortage of district nurses, which is an important issue for people who need dressings for leg ulcers, for example, which can last for a long time.
On a positive note, there is telecare and telehealth and other new technology for monitoring. People can be monitored in their own homes. If something goes wrong, people can call emergency services. Scotland is doing much better than England, and other countries in Europe, such as Poland and Holland, are using the system a lot. England could do a lot better for people with long-term conditions.
All the amendments in this group are exceedingly important and I am glad that my noble friend Lord Ramsbotham mentioned prisons and people in cells. When I went to see prisoners being processed, a GP was trying to fathom out what to do with a really serious alcoholic. I asked, “What are you going to do?”, and he replied, “If only I had some rehabilitation services for alcoholics, I wouldn’t have to send him to prison. What will happen is that he will be in and out all the time”. Many things can be made better, and I hope that the noble Earl will give us some hope when he responds.
The Countess of Mar
My Lords, I rise briefly to support Amendment 79 moved by the noble Lord, Lord Warner, although he should not have moved it at this stage perhaps; he should have just spoken to it.
As the Minister knows, I am concerned about people with CFS/ME. They are the most neglected, denigrated and discriminated-against group in the country and there are some 60,000 of them who are severely ill, which means that they are homebound and bed-bound. They have multi-system symptoms, which are far too often neglected. They have co-morbidities—one person that I know of, who has had ME since she was 15 and is now 30, has severe gynaecological problems but because she has ME they are not going look at those. Also, she gets no social care. It is very important that these services are thoroughly integrated and that people understand that because you have ME it does not mean to say that all you need is a little bit of CBT and GET and you can get up and go. We have got to provide for people who are severely ill. So I support the noble Lord, Lord Warner, and the noble Baroness, Lady Pitkeathley.
Earl Howe
My Lords, CCGs will be under a duty to arrange for services to meet the reasonable requirements of patients for whom they are responsible. This is the language of the current duty on the Secretary of State in Section 3 of the 2006 Act and will remain one of the fundamental principles in the future. Additionally, under their discretionary power in new Section 3A inserted by Clause 11, CCGs will have the power to arrange the provision of services and facilities for the people for whom they are responsible where that will improve physical and mental health or improve the prevention, diagnosis and treatment of illness in those people. However, CCGs do not have commissioning responsibility for all services—for instance, those that the NHS Commissioning Board will commission. For that reason, Amendment 60A would be inappropriate. However, the Bill is already expressly designed to ensure that the comprehensive health service is maintained and that patients’ needs are meet.
Amendments 76 to 78 seek to revise the commissioning responsibilities of CCGs, as set out in Clauses 10 and 11. In effect, Amendment 76 would give each CCG responsibility for commissioning for everyone normally resident in its area, removing the link between the provider of primary medical services with whom a person is registered and the CCG responsible for commissioning services for them. We think it is important to maintain this link. PCT responsibilities currently include people who may be registered with a GP in that area but who live outside the geographic boundaries of the PCT, so this is not something new. Clause 10 also includes some necessary provisions for the Secretary of State to clarify the responsibilities of CCGs in regulations—for example, when a CCG has ongoing responsibility for a patient’s care even if they are no longer a registered patient of a member of that CCG, which is an important element of the policy of continuing healthcare, and when somebody might be excluded from their responsibility, which might apply to patients registered with a GP in England but living in another part of the United Kingdom.
Amendment 78 would change the discretionary power that CCGs would have under new Section 3A into an obligation. That would go much further than the current discretionary powers of the Secretary of State. It would place CCGs in the situation of being legally obliged to arrange any services that it felt were appropriate to meet a patient’s needs. This would conflict with their duty under Section 14P to exercise their functions effectively, efficiently and economically, and could leave them open to challenge. These are judgments that commissioners, as now, need to be able to weigh up themselves in order to achieve the best possible services for their patients with the resources that they have available.
Lord Greaves
In the example that I provided, it is not a service that I am talking about; it is a facility—a new building that hosts a series of services, some of which will be GP services, some of which may be commissioned by the CCG, and some of which may be hospital services. Who, in future, will be responsible for deciding to build a new building in, say, Clitheroe, and commissioning the contracts and so on in deciding to do it?
Earl Howe
I am grateful to my noble friend, and I apologise that I did not cover that point. There are, of course, capital budgets. These exist at the moment and will continue to exist. The Commissioning Board will hold them. Where a capital project such as a building needs to be pursued, that money—as opposed to revenue money, which of course funds the commissioning of care—will be used to finance projects that are shown to be cost-effective and necessary to meet the needs of patients in a local area.
Lord Greaves
I would like to get to the bottom of this while we are talking about it. At the moment, those capital funds are provided either through the PCT or by the PCT from the money it has in the bank. In future, who will hold the funds to fund those capital projects?
Earl Howe
They will be held in the first instance by the NHS Commissioning Board. I anticipate that if a CCG or a group of CCGs wishes to establish a new service that involves a new building, a dialogue will take place with the board to bid for the necessary funds.
The noble Baroness, Lady Armstrong, put a very important question to me about the needs of the homeless. As I have indicated, CCGs will have responsibility for meeting the reasonable secondary care needs of the homeless. CCGs are responsible for unregistered patients in their area as well as those who are usually resident. Primary care for the homeless will be, as now, accessed through GP practices, either as registered or temporary patients, or through open-access GP services, such as GP-led health centres or bespoke services for the homeless. It is important that the needs of the homeless are factored in to the plans not only of CCGs but of the joint health and well-being strategies formed at local authority level. Clinical commissioning groups will participate in formulating them.
Just to clarify the point I made to my noble friend Lord Greaves, I perhaps should have made it clear that the Commissioning Board could in practice allocate capital budgets to a CCG or a group of CCGs. I hope that was implicit in what I said. I re-emphasise that clinical commissioning will deliver better outcomes only if we allow clinicians the autonomy to identify the needs of their patients and communities and to make the key decisions about how best to meet those needs. With that in mind, I hope I have provided sufficient reassurance to the noble Lord for him to withdraw his amendment.
Lord Warner
Can the noble Earl help me, before we get to Report stage, on the issue of the integration of services? He used the same argument he used previously, which is essentially that integration is a process and what we should be concerned with in the future is the outcomes framework. The problem for those of us who want to see something more on integration in the Bill is that we cannot quite see how we can change the culture on integration without having something in the Bill. Outcomes frameworks deliver results later on in the process. We see in the future what has happened. The difficulty many of us have is that we do not believe that that future will arrive unless we are more vigorous in this legislation about specifying some requirements on integration. Will the Minister write to a number of us before Report stage to explain how the outcomes framework will deliver that change of culture without words in the Bill about integration, particularly integration between health and social care? I do not expect an answer today, but I would like a clearer answer than the noble Earl has been able to give to satisfy us that we do not need some words in the Bill.
Earl Howe
I understand the point the noble Lord is making and I will be happy to write to him and other members of the Committee. The Bill already provides a framework of powers and duties which will support more integrated approaches to meeting patients’ health and social care needs, ranging from requirements to ensure that use is made of research in the health service to the close relationship between commissioners and the local authority and the health and well-being board. We ought not to forget that the NHS Commissioning Board guidance under new Section 14Z(6) could well cover the exercise of this function of integration. I accept the noble Lord’s point that in large measure it is a matter of changing cultures and one cannot achieve that through the written word in a Bill that goes through Parliament. However, I would be happy to put some flesh on the bones for noble Lords in writing and I hope that that will be helpful.
Lord Cotter
My noble friend has given a careful response, as always, to the points made. However, will he accept that there is a very special need for focus on rare conditions and the struggle to get both diagnosis and treatment? I hope my noble friend will take note of this because I can attest, through my wife, that there is a lifetime struggle from childhood to get these issues addressed. I hope that will be borne in mind.
Earl Howe
I am grateful to my noble friend and I did mean to make specific reference to his speech, which I found very impressive. He is of course absolutely right. There is no doubt that the commissioning of specialised services in recent years has improved in many areas but it is still variable. I do not believe I am misrepresenting those who champion the cause of patients with rare conditions by saying that they welcome the fact that the commissioning of specialised care will now fall to the NHS Commissioning Board. In other words, the commissioning will be done once and not, as at the moment, very frequently 10 times at strategic health authority level. It is absolutely clear that for all sorts of reasons greater consistency and better quality need to be injected into the commissioning of specialised care. The points my noble friend made were ones that we certainly subscribe to.
Baroness Williams of Crosby
When the noble Earl was talking about the relationship between health and well-being boards and the local commissioning groups, he said that consultation would be expected but that in the last analysis if there was no agreement there would be no question of the health and well-being board having to approve of the CCG’s plans. In the event of a serious difference of opinion, for example, about provision for the homeless or provision for special needs in a community, would there be any possibility of referring the matter up to the board or would it just be left to them to try to reach the best agreement they could?
Earl Howe
Part of the function of the board is to support decision-making at a local level if that is ever required. If there were a serious disagreement of the kind my noble friend describes, I envisage that the resources of the board could be made available to the decision-makers at local level to try to find a way through whatever disagreement had occurred.
Lord Hunt of Kings Heath
My Lords, I am grateful to the noble Earl, Lord Howe, for his response. Essentially what he is saying is that the reasonable requirement duty based on current legislation, together with the discretionary power in Clause 11, is sufficient to ensure that clinical commissioning groups will commission in a comprehensive way and deal with the many specific issues raised by noble Lords in this very interesting debate. He went on to assure us that if they are not doing that, the annual assessment based on outcomes alongside clinical commissioning guidance will make sure that CCGs are kept up to scratch.
My concern as to whether that is going to be sufficient partly comes because of the attitude of some GP practices to what one might call “difficult to reach” patients; for example, homeless people or people with mental health problems. We have heard about the rare disease issue. I am sceptical that the views of GPs in their surgeries are somehow going to be translated into a much more comprehensive vision the moment they step inside the door of the clinical commissioning group. That, at heart, is where people’s concerns are. I agree that framing an amendment to satisfy this point will not be easy, but I suspect that we will all want to come back at Report to try to button this down.
My noble friend Lord Warner referred to the question of interventions, which is relevant to this. I am still not clear. The Secretary of State has been right to intervene with PCTs on the question of artificial waits for treatment but CCGs will do the same because they will have the same problems with resources. We were told last week that we have got this cancer fund, about which there will be no option. Ministers will make other promises in the future and yet money is being taken out of the health service. There is bound to be tension around the CCG board table. What if it decides that the 18-week wait is no longer important to it or it has a rule that if it is not urgent, a patient has to wait for a certain amount of time—because it is a way of controlling its costs? Where, then, is the intervention going to be?
My final point is about this whole question of the mechanism of health and intervention. I have not picked up the local field force yet—this is an innovation. However, it is quite clear that the NHS Commissioning Board, at a local level, will have to be a local player. It has the right of attending health and well-being boards, and presumably, if we do not get integrated health and social care, it will have to take advantage of that presence. It will hold the contracts of all GPs, so I assume that it will deal with complaints. The local field force will have to deal with the allocation of patients to practices where GPs are refusing to accept them. I am left with a sense that, in fact, there will be quite a large bureaucracy at the local level; the difference being that now it is under a proper public board. In the future it will be an outpost of a massive organisation based at the centre. I question whether that really is an improvement on what we have.
This has been a good debate. I sure we will want to come back at Report stage on the reassurance we need about comprehensive commissioning by CCGs, but, at this stage, I beg leave to withdraw the amendment.
Lord Beecham
Lord Beecham
My Lords, we now come to the important area of public health. This is the time for your Lordships’ House to dip its collective spoon in the good part of this curate’s egg of a Bill. I have to say that, of course, in the context of this Bill, “good” is a relative term, but I very much welcome the reversal of the 1973 reorganisations—the splitting off of public health from local government—and the recognition, implicit and indeed explicit in the Bill, of the need for the closest possible relationship between public health services and the wide range of local government services which contribute to the promotion and improvement of the public health of individuals and whole communities.
In this context, of course, it is critically important to recognise the need for a high degree of professionalism, and in particular to ensure that public health specialists are thoroughly engaged at a senior level within local government and that they have a considerable measure of independence, both at national and at local level. There are amendments that we will be discussing—not necessarily in this group but as we go through the Bill—that address those particular issues.
One amendment in this group that I will not be moving or speaking to today is Amendment 94A, which relates to the making of Public Health England into a special health authority. By the vagaries of grouping, Amendment 267, in the name of the noble Lord, Lord Patel, relates to a later part of the Bill, although it could have been grouped with my amendment. It would be discourteous of me to anticipate that debate, given that the noble Lord’s amendment is down for future discussion. In general, we need to examine the role of government and their capacity either directly or through any of the other bodies created by the Bill to deal with the broader issues of public health at the local and national level.
Amendment 60B is the first amendment in my name. It simply incorporates the concept of promotion of public health as well as protection and improvement of public health in the rubric to Clause 8. It strikes me as a more positive and perhaps wider responsibility, which is echoed in some of the amendments we will discuss in this group about promotion through information, publicity and the like. It also perhaps has slightly less of a strictly medical connotation than the original rubric contains.
More significantly, Amendments 67A and 75ZZA relate to the proposed requirements on the Secretary of State to produce annual reports in dealing with the public health impact of budget changes and, as regards Amendment 75ZZA, in respect of finance generally. As ever, there is a significant issue around finance, which cannot be dealt with in terms of the context of the Bill. But it is critical that the reform is carried through with a workable system of financing the new arrangements. Considerable concerns about that have been voiced in response to the consultation documentation about funding the public health service from a number of quarters, including local authorities, the Faculty of Public Health and other organisations.
The difficulties of course are that at the moment public health is funded through the PCTs. It is by no means clear what the total quantum will be defined as in terms of the money to be redistributed direct to local authorities—ring-fenced, as we know it will be—let alone how that quantum will be distributed by way of formula. In addition, there is the new concept of the public health premium which will be used to reward those authorities which achieve an improvement in the public health of their area.
These are difficult matters. The Select Committee suggested that the public health impact of financial changes should be the subject of report. Both amendments simply follow the recommendations of the Health Select Committee of the House of Commons. I hope that the Minister will be able to agree them or at least agree to consider them and come back on Report.
I have been looking into this issue with the Local Government Association and this morning I received some advice stating:
“We are no nearer an announcement on the distribution formula or quantum after the third trawl for data. We remain concerned that it may be dealt with in isolation from wider issues about the design of the wider systems and the role and cost of Public Health England”.
Clearly, the finance will not be dealt with in the Bill but we need to know as we go through the Bill and approve—I hope improve—the proposed structures, how the financial system would work. Perhaps in reply the Minister could give an indication of when it would be expected that the financial framework will be explained and judgments might then be made about the adequacy or otherwise of those arrangements because they will impinge heavily on the eventual outcomes that we are all seeking.
Amendment 69ZA will extend to local authorities the duty to have regard to and promote the health equalities agenda, which we have discussed previously in relation to the national Commissioning Board and the national players, as it were. It seems to me sensible that there should be a matching requirement for local authorities to have particular regard to that issue.
Lord Warner
I apologise to the House for my enthusiasm to get in to this debate on public health, which I regard as a key part of this Bill. I am extremely supportive of much of the thrust of the Government’s approach. I rise to speak to Amendments 62, 64, 65 and 68, which are in my name and in the name of the noble Lord, Lord Patel—and, in the case of Amendment 62, also in the name of the noble Lord, Lord Walton. Unfortunately, neither of those noble Lords can be with us today. However, I strongly support the remarks made by my noble friend Lord Beecham.
These amendments to Clause 8 are aimed at strengthening the Secretary of State’s duty on the protection of public health. Let me make clear that, as I said, I very much welcome the Government’s emphasis and commitment on public health and support the thrust of their changes. It is time for us to give much more prominence to public health if we are to relieve the pressures on the NHS in the coming years. However, I believe that we could go further than the Government have in terms of the Secretary of State’s duty, as currently expressed; hence these amendments.
Amendment 62 requires the Secretary of State, when taking steps to protect the public from disease or other dangers to health, to do so on the basis of,
“using the best scientific and other evidence available and without regard to special interests”.
The first prong of this amendment is to cement evidence-based policy into the discharging of the Secretary of State’s duty to protect public health, and to make clear the use of science in doing so. All Governments like to claim that their decisions are evidence based—nothing surprising or new in that—but all too often they are not. For example, it has been a very long haul getting all government departments to have chief scientific advisers. Even now, the Treasury has only recently appointed its first chief scientific adviser.
Your Lordships’ Science and Technology Committee, of which I am privileged to be a member, is currently looking at the experience of chief scientific advisers in different departments, and it is very clear that their status and influence vary considerably. In the area of public health, it is absolutely clear that using a strong scientific evidence base, including the social and behavioural sciences, is very important indeed. Nowhere was this more important than in the controversial issue of banning smoking in the workplace and in public places. The dangers of second-hand smoke were discounted until the scientific evidence made that position untenable. If I may say so, we are now seeing a rerun of that debate over the issue of smoking in cars and the danger to children of second-hand smoke. Without going into particular issues, I want to emphasise the importance of Health Secretaries—of all political persuasions—making public health policy and taking decisions on the best scientific evidence available, and of requiring them to do so in statute.
The second prong of Amendment 62 is something of a belt-and-braces approach, requiring the Secretary of State to not be overinfluenced by special interests. There have been long-running concerns about the influence of the tobacco, food and drink industries on successive Governments over public health policy. I am not making a party political point here. All Governments have been subjected to pressures by those particular special interests when they have tried to deal with protecting public health. I will not go over the ground in detail because it is well documented and in the public arena.
However, the issue has been given a new burst of life because of this Government’s attachment to nudging public behaviour in the right direction rather than legislating. Again, the Science and Technology Committee of your Lordships’ House, under the chairmanship in this case of the noble Baroness, Lady Neuberger, produced a report recently on this issue. While the nudge approach can be useful in changing public behaviour, that it is a sufficient remedy in many critical areas, such as obesity, is not supported by good evidence. The result is that powerful interests backed by skilful marketing can still defeat important public policy advances.
Lobbying by powerful special interests is a feature of all western democracies, and a potentially dangerous one in the sphere of public health. We should take the opportunity of this Bill to require future Health Secretaries in this position not only to pursue science-based policies but to resist the blandishments of special interests. Amendment 64 is a simple substitution of “must” for “may” in terms of the steps that the Secretary of State should take in carrying out his duties set out in new Section 2A(2).
Amendment 65 extends the final item of that list of steps, so that services made available assist the public to take,
“responsibility for improving their health and well-being, including access to their own medical records”.
Many of the pressures placed on the NHS result from lifestyle choices that we all make that can damage our health. We need to make it a central tenet of public health policy that we should assist people to take more responsibility for their own health and well-being, rather than simply expecting others to bear the cost of treating them when they become ill. Obesity is a good example. In most cases, the solution lies literally—if I may put it this way—in our own hands. Accessing and probably holding our own medical records would reinforce that personal responsibility. This Government, like the previous one, rightly emphasise personal responsibility alongside rights. In the sphere of public health, Amendment 65 gives a push to that approach. I hope that the Government will accept it in the spirit in which it is proposed.
Finally, Amendment 68 extends Clause 2A(4) to give the Secretary of State a bit more help in carrying out his duties to protect public health. This amendment requires the Secretary of State to appoint an independent standing advisory committee on public health of no more than 15 people to provide advice on a regular basis as well as when the Secretary of State seeks it on a particular issue. The reports of that committee will be available to Parliament and the committee can report to the Secretary of State on any matters of concern that it has about the state of public health. I would envisage this committee being a major focus for the provision of scientific evidence to underpin public policy in this area under Amendment 62. I think that Amendment 68 is self-explanatory and its benefits self-evident in an area as important as public health.
I hope that the Minister will see these amendments as constructive strengthening of the Government’s ambitions on public health and enabling a helpful legacy to be left to the next Health Secretary whenever this current Health Secretary chooses to leave his job. I believe that these amendments go with the grain of the powerful, recent report on public health by the Select Committee, which proposes further strengthening of the Government’s powers. I hope that the Government will be sympathetic to these amendments and to Amendment 95, in the name of the noble Lord, Lord Patel, to which I have added my name.
Baroness Jay of Paddington
My Lords, I wonder whether my noble friend could help me with something that seems to be implied in his very eloquent deliberations about the amendments. I agree with him entirely that, in the public health arena, political leadership—the role of Governments of whatever party—is enormously important, particularly, as he said, in resisting the blandishments of external lobbies and so on. Does he see a potential conflict between the additional powers which he is advocating for the Government and the Secretary of State in this area, which I would entirely support, and the decision of the Government to reduce the powers of the Secretary of State in general for health services, healthcare and the promotion of general health matters in the way in which the Committee has discussed at some length on earlier clauses?
Lord Warner
My Lords, my noble friend raises a very important point. I can see some differences of approach here. Today, I am speaking on the rather narrow issue of helping the Secretary of State to be a powerful influence in improving public health. Of course, it is for your Lordships' House to debate further, as we progress through the Bill, whether we want Clause 1 to go a little further than the Government seem to want in terms of the Secretary of State’s responsibilities. I have sympathy with my noble friend in seeing a slight confusion on the part of the Government in some of these areas.
Baroness Williams of Crosby
My Lords, I wish to express strong support from these Benches for the amendments spoken to by the noble Lord, Lord Warner. Perhaps I could mention one or two points. It is clear that the emphasis on public health, important as it is at the national level, must also be reflected at the local level. I say again, therefore, that the amendments about expecting clinical commissioning groups to have at least one board member with public health experience are important in reflecting the kind of things about which the noble Lord, Lord Warner, has spoken.
I also believe that the noble Lord has put forward in Amendment 68 a very interesting idea that ought to give a higher profile to public health advice on how to deal with diseases and illnesses in the population as a whole. Obviously I share the views expressed by the noble Baroness, Lady Jay, on the importance of putting the Secretary of State squarely behind these issues, and I shall give one example of that. The Bill provides for extensive redress on issues related to smoking and alcoholism, and perfectly properly so. People are perhaps more reluctant to point the finger in relation to some of the serious public health issues arising from the food industry, issues which have great implications for the food industry's relations with the overall economy. There has over many years been a very slow response to growing evidence that certain foods, particularly foods directed at children and young people, have a substantial impact on health. If one looks at the ways in which those foods have been advertised, with an emphasis on how attractive they are, not only so that people will taste them but so that there will be a certain addiction to them, one will see an issue on which there should be a major consultation between the Department of Health and that industry. So far that has largely been limited to issues such as labelling, which is sometimes so complex that the ordinary consumer would not easily pick it up.
There is a continuing emphasis on, for example, foods that attract young children but which contain high levels of salt, sugar and so on, which is all the more serious in a country such as ours which, sadly, has a growing problem of obesity. I strongly suggest that the Government should look closely at Amendment 68 and the idea of establishing a standing advisory committee on public health. I would also point out the importance of assigning responsibility all the way up to the Secretary of State to ensure that these negotiations with industries and special interests which are crucial to the nation's health are conducted at the highest level and that public health is recognised as a full companion to all the other aspects of health. In that respect, I am very pleased indeed that the Government have put emphasis on the independence of the public health area and allowed public health to be taken out of the Department of Health and given its own status. That is a very long step forward.
Baroness Finlay of Llandaff
My Lords, I have some amendments in this group to which I would like to speak. The first is Amendment 62A, a probing amendment which seeks a government response. This amendment would require the Secretary of State to report annually on the steps taken in relation to the duties listed in the Bill. Currently we have the Chief Medical Officer’s annual report, which is excellent and provides an enormous amount of information particularly on matters relating to public health. However, given this Bill and the dramatic changes we will see in the delivery of healthcare across England, it seems important that we should have regular annual reporting that can be tracked from year to year against a specific set of headings. Over the years this would create comparators that could be used to see whether the quality and health improvements on which the Bill is focused are being achieved.
Similarly, I have amendments about undertaking an audit of healthcare providers’ processes and outcomes in terms of how they improve public health and implement the public health advice they receive. Amendment 71A, another probing amendment, suggests changing the wording of the provision so that there is an obligation to consider diagnosis and treatment rather than diagnosis or treatment, as the Bill currently provides. I tabled this amendment because I was somewhat horrified to see that the Bill provides a requirement to consider treatment but not to ensure that the diagnosis guiding the treatment is correct. Treatment for the wrong condition will result in morbidity and mortality related to the treatment plus progression of the underlying condition. I wonder whether that might not be a drafting issue which the Government might be inclined to look at again.
I have taken further advice on my Amendment 69A and have decided not to press it. I can therefore spare the Minister the trouble of trying to respond to it.
However, perhaps I may give a little evidence in support of this pressure to require reporting and audit at every level. There is high-powered and strong evidence from public health itself. Public health is a competency set, not a separate discipline. All public health practice needs epidemiology, biostatistics and a commitment to organisations and community understanding, with a focus on prevention and the implementation of evidence into practice. Evidence is not just a matter of, “Yes, there is evidence”, or, “No, there is not”. There is a hierarchy of scientific evidence in relation to public health.
It is important to understand that there are five criteria in relation to the reporting requirements that I am asking for. First, there may be evidence of no benefit. Secondly, there may be no evidence of benefit. Thirdly, there may be uncertain evidence of benefit. Fourthly, there may be evidence of efficacy. Fifthly, there may be evidence of both efficacy and effectiveness, which means that these interventions would incontrovertibly improve efficacy and seem feasible for large-scale implementation based on effectiveness trials. So that is very high-level evidence, and the others are hierarchies right down to the first I listed, which was a reason for decommissioning and stopping the use of an intervention.
Perhaps I may give some examples of where that hierarchy has influenced clinical practice and the reason why public health cannot be divorced from clinical practice. Even though this has been put on local authorities and will have a strong influence, I hope it will not become divorced from clinical practice. It needs to be linked to commissioning by GPs for the following reasons. First, it has been demonstrated that general practitioners and clinicians can save money if they provide advice on health in the consultation as well as dealing with the presenting complaint. Secondly, involving clinicians in detecting alcohol problems as part of a routine consultation has been shown to save money and lives. Thirdly, in nurse-led clinics there is evidence of cost-effective secondary prevention when they are used for targeted areas such as coronary heart disease. They can be extremely effective. Fourthly, drug treatment is a public health issue and there needs to be close working in the clinical setting to make sure that the use of drugs in conjunction with the appropriate use of pharmacy advice can maximise health benefit. Fifthly, primary care itself is more effective where public health is involved in the way that primary care is delivered. A very powerful trial conducted in the USA has shown that to be the case. Last but not least, high-tech interventions that at first sight might seem expensive, when properly evaluated in public health terms, have been shown to save lives and money, so they become an investment for savings.
Those are just some of the examples of why we need public health right at the heart of the changes, but we also need the monitoring that public health can bring to ensure that things that should happen are happening.
Lord Clement-Jones
My Lords, from the outset the noble Lord, Lord Warner, and my noble friend Lady Williams have hit the button on this debate. Like the noble Lord, Lord Warner, I am a sceptic about nudge theories and think that they need to be investigated. I thought that the House of Lords committee under my noble friend—my former noble friend—the noble Baroness, Lady Neuberger, interrogated the issue extremely well. We are in an obesity crisis. We are expecting 50 per cent of adults to be obese by 2020 and I believe that we are going to have to do something rather more drastic than simply nudge people. Personally, I am quite attracted to the idea of a fat tax. Let us see the evidence of whether a nudge is going to prevent us from facing a major obesity crisis by 2020 that is even greater than the one that we already have, or whether a fat tax is the only way that we are going to get there. The spirit of the amendment moved by the noble Lord, Lord Warner, is absolutely correct in that respect.
Very ingeniously, the noble Lord has introduced the idea of patient control over their own records. I do not know whether this is the right place in the Bill to be debating this issue, but I do know that it is an extremely important suggestion. Patients should have control over their own records, which should not be simply under the control of the local GP. It is increasingly important for pharmacists to have sight of a patient’s records—with the consent of the patient; that is the essential control—and that other healthcare professionals should do so. There should not be a monopoly on the sight of patients’ records for general practitioners. With the consent of patients, other health professionals should be able to see them. We will then have proper integration of healthcare without expecting GPs to be the gatekeepers for all an individual’s healthcare needs.
I do not know whether we are starting the debate that was referred to at Second Reading, but this is an important area which I hope will be discussed further during the course of the Bill.
Baroness Cumberlege
My Lords, I should like to make a short intervention to ask my noble friend one or two questions. When I was a Minister I was responsible for the Health of the Nation policy, which I much enjoyed. At the time we introduced the five-a-day programme. That was 21 years ago, so we can see how long it has taken to get that message deep into the psyche of the British people. There is something about promoting good health and habits of living to the population—it takes a very long time.
I want to speak to Amendments 62, 65 and 68. I was very much hoping that we would have a debate on Amendment 94A, which is about Public Health England. But courtesy is the hallmark of this House and, as the noble Lord, Lord Patel, is not here, it is absolutely right that we should not debate it today.
On Amendment 62, on scientific and other evidence, from the noble Lord, Lord Warner, it is the “other evidence” that I want to ask my noble friend about. As my noble friend Lady Williams said, other evidence is something that you build up, and I am quite concerned about how we are going to get this evidence into health and well-being boards and how we will ensure that the Government have enough evidence that builds from the bottom up. One problem is with access to data; if we are going to have joint needs assessments through the health and well-being boards and strategies, and if that information on the ground cannot be shared, it will be very difficult to ensure that we have joint needs assessments. The GPs have those data and share them with other people in the National Health Service, but I do not believe that at this time they can share them with local government. That will be a very important issue because, although they are anonymised data, if you are going to run a public health programme on obesity you really need to know exactly in what geographical area that obesity is at its worst so that you can target it. When you are looking at the needs of individuals, you may have information about the numbers of people who have diabetes or coronary heart disease, but it is when you link those diseases to individuals that you get back to the previous debate that we were having on long-term conditions. Linking some of this stuff together is absolutely critical, and maybe my noble friend could think about that in the intervening time and write to me—and to other noble Lords, if they are interested.
I agree with my noble friend Lord Clement-Jones that this may be not quite the right moment to discuss medical records, but I really cannot resist it, although I will be brief. Some 21 years ago, in this House, from the place where my noble friend now sits, I made my maiden speech on medical records, so it is something that I have quite an interest in. When I produced a policy document on changing childbirth, one recommendation was that women who were pregnant should hold their own medical record, sometimes known as hand-held maternity notes. That has had an enormous impact; it has made those women feel that they are very important—they are pregnant and they are going to have a child and a whole readjustment to family life. That is a very important time in a woman and her partner’s life, and it acted as a sort of passport to them. Bearing in mind that 30 per cent of women who are pregnant are obese, which has a huge impact on the next generation, it seems to me that having hand-held records or access to or ownership of your own records is terribly important. Of course, we have the red book that women get about their children so that they can share that information with health professionals.
My last point is on Amendment 68 and the standing advisory committee. I absolutely understand why the faculty of public health and other people like that idea. I am not sure whether that advisory committee, as has already been suggested by the noble Baroness, Lady Finlay, will make an annual report. That is possible. We will have the Chief Medical Officer’s report annually, as she said, which is a very brave and independent document; the Chief Medical Officer says how it really is, and I know that it is very often extremely uncomfortable for the Government.
Lord Turnberg
My Lords, I am also pleased that public health receives such a high profile in this Bill. I speak to Amendment 60B and one or two others in this group. There seem to be several aspects to the public health parts of this Bill being probed by these amendments. However there is one area of public health that might fall between too many bodies and where we might usefully explore how we can arrange for them to be better co-ordinated. The area is child and maternity services.
As I understand it, local authorities will be responsible for child public health services; the Commissioning Board for health visitors and immunisation services; and clinical commissioning groups for child health and maternity services. That will require all sorts of collaborations to be set up, and that is always a recipe for some problems. I hope that the noble Lord can give us an idea of how these sets of services can be rationalised in some way.
I shall now speak to Amendment 62 and some others. Clause 8 describes the Secretary of State’s duty to protect the public’s health. It details a number of specific responsibilities which, it so happens, are currently undertaken by the Health Protection Agency. I would like to comment on them. I have extolled the virtues of the HPA on a number of occasions, having observed it closely as the chairman of its predecessor, the PHLS, some years ago. Incidentally, the hero of the noble Baroness, Lady Cumberlege, is an employee of the Health Protection Agency. It is a remarkable organisation and the envy of the world. It jumps on outbreaks of infection very rapidly and has prevented many an epidemic. There are many examples of that.
I reiterate this because the HPA is to be swept up into a new arrangement, as we have heard, much more directly under the influence of the Secretary of State. Thank goodness it will not be within the Department of Health, but it will be very close to it. My fear is that we will weaken something of great value to the country. I have some specific questions for the noble Earl.
First, is it expected that all the current functions of the HPA will be taken on board, or are we to lose some? The list is pretty comprehensive but it may leave things out. If so, what would be lost and what would be preserved? Secondly, is it intended that all the staff will move across? They currently work as a very efficient and effective team—a lean, mean team—and any break-up will have an effect. Thirdly, is funding to be affected in the changeover? Will the new organisation have access to external research grant income? That is very important if it is to keep ahead of the infections, which keep changing every day. I have mentioned this before and the noble Earl has responded, but I should like him to respond again more forcefully on whether the organisation will have access to the Wellcome Trust grants, the Medical Research Council and others outside of the NIHR. One of the duties of the Secretary of State is to take steps that include,
“the conduct of research or such other steps as the Secretary of State considers appropriate”.
Finally, will the body have the degree of independence that will allow it to give advice to the Secretary of State unfettered by Civil Service restrictions?
I hope that the noble Earl can help us with these questions, because there is considerable unease in the HPA at the moment.
Lord Ribeiro
My Lords, I should like to speak very strongly in support of Amendment 65 in the name of the noble Lord, Lord Warner. Were the noble Lord, Lord Patel, here today, I am sure that he would also speak strongly in support of it because he raised the issue of patient records yesterday when we had a meeting with Professor Steve Field of the Future Forum. We were discussing information provision for patients and the use of computer records. He said that for many years when working in maternity he had given patients their own notes, and in all that time he could remember only two occasions on which the notes had gone missing. On one occasion, the patient reported that a dog had eaten the notes and, on the other, the notes were left on a bus and shredded, someone having recognised that they were important. Therefore, only two sets of notes were lost over a period of some 20 years. Patients are perfectly capable of looking after their own notes. When I was a surgeon in Ghana in 1974 it was certainly quite common for patients to come to the clinic with their notes, which often would otherwise have been lost.
The final message that came through was that we have spent billions of pounds on creating paperless records and computer records and are about to spend even more. The information that we were given yesterday at the Future Forum was that we should be looking at what can be done locally, bearing in mind that GPs have a computerised system of records. We heard another anecdote about an old lady who went to the out-patients’ clinic for her appointment and the consultant said, “I’m terribly sorry but we’ve lost your notes today”. She put her hand into her handbag and came out with a memory stick, saying, “Doctor, it’s all on here”.
I hope that the Minister will take note of Amendment 65 because I feel that it may well stimulate us to look again at patient records and the use of technology. We are, after all, in the 21st century and, although paper records are wonderful for us to have as a tactile instrument, they do not always contain the information that we need.
Baroness Northover
My Lords, given that my hard-working noble friend Lord Howe deserves at least a short break, I shall be addressing these amendments. If I do not cover them sufficiently comprehensively, given the time, I shall be very happy to write to noble Lords.
This is a very large group of amendments covering Clauses 8, 9, 14 and 19, which together set out the fundamental legislative basis for the new public health system. I thank noble Lords for their general welcome of these provisions, which of course put public health very much front and centre in the new system.
The Public Health White Paper sets out the Government’s commitment to protecting the population from serious health threats, helping people to live longer and to enjoy healthier and more fulfilling lives, and to improving the health of the poorest the fastest. At a national level, there is a clear rationale for accountability for health protection to rest with the Secretary of State. The nature of various threats to health are not, of course, always amenable to individual or local action. They require a clear line of sight from the Secretary of State down to local services.
Clause 8 inserts new Section 2A and gives the Secretary of State a new duty to take steps to protect the health of the public in England. In practice, Public Health England, the national component of the new public health system, will play a key role in health protection, bringing together a fragmented system and strengthening the national response on emergency preparedness. It is our intention that it will be an executive agency of the Department of Health. Public Health England as an executive agency will have an operational distinctiveness that will allow it to build and maintain its own identity. Agency status will support the ability of scientists in Public Health England to give expert, objective and impartial scientific advice, which noble Lords have called for, to both the Secretary of State and more widely. I entirely share the view of the noble Lord, Lord Warner, that we must make use of the best scientific and other evidence available. We intend to set out clear proposals shortly on how the Secretary of State and Public Health England will receive professional advice. I am confident that those proposals will at least match the intention of the noble Lord’s amendment.
Lord Warner
I hesitate to interrupt the noble Baroness on her debut at this point, but does she understand that by its very nature an executive agency is within a government department and does not have the same level of independence as a non-departmental public body? We are seeing played out in the public arena at present some of the consequences when there is disagreement between people in an executive agency and a Minister. That concerning the Home Office is currently being played out on the front pages of our newspapers. Does she agree with me and, I think, my noble friend Lord Turnberg, that having scientists in an executive agency fetters their freedom compared with in a non-departmental public body?
Baroness Northover
The noble Lord flags up a concern that has been expressed about the independence of the new organisation. I would point out the example of the Met Office, which is arranged in a similar way. What it does on climate change may not always go down well with the Government of the day, yet it has no reluctance in coming forward with the evidence that it has.
It is extremely important that it should have that expert advisory position. That is why it was moved out of the Department of Health, which was the original proposal. The noble Lord will know that it was going to be within the Department of Health, but the Future Forum flagged up that concern and the decision was taken that it be arranged in this way, to address the points that the noble Lord has raised.
Coming back to what I was saying about the Health Protection Agency, I remind noble Lords that Clause 53 abolishes that agency and repeals the Health Protection Agency Act 2004. That is central to the Government’s plans for unifying national health protection activity and creating a more transparent and accountable service under the Secretary of State. In so many ways the Health Protection Agency has done an outstanding job, and we certainly pay tribute to those who have worked within it. It has established an outstanding international reputation, as the noble Lord, Lord Turnberg, pointed out. Public Health England will be able to build on that recognised expertise not only from the Health Protection Agency but from other organisations that we can draw into our public health system. There was talk about whether this should be a special health authority. The noble Lord, Lord Beecham, said that he wished to address this later on, so no doubt we will come back to this and to the points the noble Lord, Lord Warner, made about independence and why we are not proposing to do things in quite that way.
Baroness Finlay of Llandaff
I am grateful for the reassurance that the noble Baroness does not see any way of uncoupling diagnosis from treatment. I am not terribly comfortable with the furniture analogy. Pieces of furniture are not as complex and integrated as human bodies.
Baroness Northover
I have a feeling that carpenters might disagree. Nevertheless, I take on board what the noble Baroness says, and I hope that I have reassured her.
Where was I? I think that I have covered the points spelled out by various noble Lords on research and evidence. Research and evidence would rightly run right the way through these arrangements, and I would have expected noble Lords to flag this up. It is absolutely crucial that evidence underpins the work that is done. I heard what was said about nudging, and so on. The Select Committee itself said that it welcomed the exploration of new ways of doing things, provided that they do not dislodge other ways of assessing things. It is extremely important that, in all these areas, you assess what the impact of something is. I hope that noble Lords will be reassured. We will come on to this in a minute.
Lord Warner
I suggest the noble Baroness reads the report of the inquiry chaired by the noble Baroness, Lady Neuberger, which makes it very clear that the scientific evidence to back up nudge as a way forward is extremely weak.
Baroness Northover
I hear what the noble Lord says. To judge so quickly something which has only exploded on to the agenda relatively recently does not seem to me to be terribly scientific. As a former social scientist, I do not think that that is giving quite enough time to assess it. However, the Government absolutely hear what the noble Lord says. We need a range of ways of exploring things. If people suggest ways of probing and investigating areas, then all those areas need to be assessed properly, and given due time to take effect.
I was about to come on to the point that, in this Bill—noble Lords have flagged this up—there is provision for continuing to measure children even though that public health responsibility has gone over to local authorities. It underpins our understanding of the extent to which we have obesity among children. It is extremely important that it is carried forward, and I think that that bears out the Government’s commitment to continued research.
I have covered patient records. The noble Lord, Lord Turnberg, asked about child services. I know that my noble friend will be coming back into full view in a minute, and will address some of these areas, so maybe that is best covered then. We are extremely concerned to make sure that, across all areas, these matters are properly co-ordinated.
I have addressed the point raised about the separate annual reports. The Secretary of State is reporting generally, across all these areas. I hope that I have not missed out any key areas. There was a question from the noble Lord, Lord Turnberg, about Public Health England. It will indeed be able to receive research funding from the majority of sources from which the HPA is currently receiving research income. This was a key point that was flagged up by noble Lords last night, and it has been confirmed. Research is clearly vital for the specialist expertise required in Public Health England.
I appreciate noble Lords’ probing on all these important areas, but I hope that at this stage the noble Lord will be happy to withdraw the amendment.
Lord Beecham
My Lords, I am grateful to the Minister for her reply, although I shall resist the temptation to follow her into the realm of rearranging the furniture or even the deckchairs on the NHS “Titanic”. She rather missed the point of Amendment 69ZA, which adds to the provision in the Bill that will require each local authority to,
“take such steps as it considers appropriate for improving the health of the people in its area”,
the duty to take such steps as are appropriate to tackle the problems of health inequalities. That is the point that the amendment seeks to enshrine in the Bill. It is a duty that will lie on the Secretary of State for national purposes, but not for local purposes.
Baroness Northover
I am sorry that the noble Lord feels that I did not adequately deal with that. The point I made is that moving public health to local authorities will join up a lot of the other factors—housing, the environment and so on—for which they have responsibilities. As the Marmot review highlighted, that should help to address some of those areas.
It is also worth bearing in mind that the Equality Act introduced by the previous Government is relevant across all these areas and in terms of the groups with protected characteristics. Many of those who suffer from particularly bad health would be covered by that.
Lord Beecham
My Lords, it is surely clearer to have in one place the responsibility for reducing health inequalities. The amendment simply adds to the Bill:
“and shall, in doing so, take such steps as are appropriate to reduce health inequalities”.
That is the right place to have it when one is delegating that responsibility. The noble Baroness referred to the ring-fenced grant, which will, of course, apply to the public health function but, as she has just said, the public health function is not confined to what might be described as health expenditure. This duty to reduce health inequalities as part of local government’s new responsibilities should be embodied in statute, to ensure it in the consideration of the rest of local authorities’ functions and budgets.
I noted the remarks of the noble Baroness, Lady Williams, who is not in her place. She seemed to think that the Government have given independence to public health bodies. I hope she is right in her inference, but I am not so sure. We will return to this matter when we discuss Public Health England and other aspects of the Bill, including the role of public health specialists and directors of public health within local government. There are amendments that reinforce the independence of such postholders which are necessary additions to the Bill. I accept that the Government’s aspirations may be in line with that, but it seems to me that the Bill does not go far enough in providing them.
I want to return briefly to my amendment, which I do not think the Minister referred to, which is based on the recommendations of the Select Committee report on the public health impact of budget changes for the national level of public health, which affects Public Health England and the local authorities. I refer to the observations of the Select Committee:
“The Department of Health must also make clear how the actual level of funding for public health will relate to the historic baseline. We seek reassurance from the Department that, in setting the public health budget, it will take account of objective measures of need. This must apply in respect of both the national budget and allocations to local authorities”.
The next paragraph says:
“Although the Department of Health states that, in the current reduction of NHS management and administration costs, frontline public health services are being protected, we have heard evidence to the contrary. Furthermore, the Department has failed to give a convincing account of its distinction between frontline and non-frontline spending in public health services. Unless it can do so, the suspicion will remain that it is an arbitrary distinction and that public health services are suffering, and will suffer, in consequence of the cuts that are being made”.
In relation to the health premium, which as yet we have barely explored, the committee said:
“We are concerned about the proposed introduction of the Health Premium. We believe there is a significant risk that, by targeting resources away from the areas with the most significant continuing problems, it will undermine their ability to intervene effectively and thereby further widen health inequalities. Although many witnesses welcomed the proposed ring-fencing of public health budgets … and the Committee understands the short-term attractions of this approach, it does not believe it represents a desirable long term development”.
After further analysis, the committee said that,
“the ring-fenced public health budget should operate for no more than three years”.
Baroness Northover
I am sorry that the noble Lord thought I did not cover the first point. I did not make myself clear. With regard to the total figure for the health premium, which I mentioned briefly—and the Department of Health will be publishing something shortly—there is consultation on that. There is always controversy over how best to do that. I recognise what the Health Select Committee says about not wanting to have an inadvertent removal of money from where it is most needed to an area that might need it less, which appears to have done better and so on. These things are clearly very complex, as the noble Lord will know, and there is consultation on how best that should be taken forward so that it is most effective and does not have that unintended consequence.
Lord Beecham
Of course there is consultation going on. It has been going on for an inordinate amount of time and we need to see the outcome of that—as indeed does local government—during the passage of this Bill, I hope. These are critically important matters which at the moment remain opaque, to put it mildly. Of course there will be a report in due course, but the financial aspects of that report must be consistent with the thrust of the policy, and on that we are clearly not in a position to make a judgment. This is a matter to which we will clearly have to return, possibly in conjunction with the Bill, possibly separately. If local authorities are to undertake these increased responsibilities, there will have to be a satisfactory system to make possible the operation of the machinery that the Bill is creating.
Having said that, I acknowledge that these are all probing amendments. I hope that the Government will look at some of them with a view to possibly adopting them in future. On that basis, I beg leave to withdraw the amendment.
Lord Warner
Lord Warner
My Lords, I do not wish to prolong this debate. I was very grateful for all the support that I got around the House for some of the ideas in these amendments. I wish to give notice to the Minister that I remain unconvinced by what has been said so far—that the Secretary of State’s duty will be exercised in a way that guarantees he takes account of independent scientific evidence. We will return to that later in this debate, but in the mean time I will not move my amendment.
Lord Sharkey
Lord Sharkey
My Lords, each of the four amendments in my name is a probing amendment. All the amendments refer to one particular aspect of NHS activity: public health information and advice campaigns. The Department of Health has a long and distinguished history in deciding which issues need such campaigns, and actually running, funding and monitoring the campaigns. In this area there is a very large body of experience and expertise that resides in the Department of Health. Many of these public health campaigns have been very successful. Thousands and thousands of lives have been saved as a direct outcome, and these campaigns are an established and key part of the public health armoury.
The most obvious part of many public health information and advice campaigns is often the mass media component, but there is always much more to it than that. In June 2004, the Health Development Agency noted that these campaigns typically also involve the mobilising and supporting of local agencies and professionals who have direct contact with the campaign target, bringing together partnerships of public, private, professional and voluntary organisations, and encouraging local and national policy changes so as to create a supportive environment in which people are more able or willing to change their behaviour. Devising and managing these campaigns is a demanding and difficult job. The Department of Health has been doing this job very well for decades. Importantly, it has been doing this job centrally. This is not just a reflection of the current NHS architecture. For the public health and information campaigns to work efficiently, simple direction and control is a necessary requirement.
The Department of Health is running a national obesity campaign and a national dementia campaign. In January there will also be a national campaign aimed at raising awareness of the symptoms of bowel cancer. Each of these campaigns builds upon a solid foundation of knowledge and experience of the issues, and of what it takes to run a successful campaign—knowledge and experience held, not exclusively, but very largely, in the Department of Health. Each of these campaigns can reasonably expected to be directly responsible for saving thousands of lives, and for improving the efficiency of the NHS.
The success of the original and groundbreaking HIV/AIDS campaigns in the 1980s, under the direction of my noble friend Lord Fowler, is well known. That success continues. Recently, regional pilots of dementia and bowel cancer campaigns have shown, for bowel cancer, a 48 per cent increase in the number of people visiting their GP with symptoms, and for dementia, 63 per cent of people aware of the campaign said that they would visit their GP if they saw any possible symptoms. There is a long-standing and proven ability of public health information and advice campaigns to generate early awareness and early action, both things absolutely critical for dealing effectively with some of the more serious medical conditions.
Success rates in cancer treatment are a prime example of this. We know that England’s cancer survival rates are currently poorer than those of many comparable countries. I know that we are part of the International Cancer Benchmarking Partnership to try to understand why this is, but without waiting for a definitive answer, it is quite clear that early diagnosis is an absolutely critical factor. In Improving Outcomes: A Strategy for Cancer, published in January of this year, the Department of Health notes that improving public awareness of the signs and symptoms of cancer and encouraging people to visit their GP when they have these symptoms, is a key ambition. That is why the Department of Health last year provided £9 million to support cancer awareness campaigns. It is a crucial feature of these campaigns, and most others, that they are very largely given priority, direction and funding centrally by the Department of Health.
My concern, and the point of my amendments, is that in the new architecture of the NHS, this central direction and funding will disappear, either suddenly, or more likely, gradually, as current and planned campaigns reach the end of their lives. I entirely accept that the Government understand the merit of public health information and advice campaigns and would want them to continue. I am much less certain, however, that they will continue in any effective form if responsibility for them is diffused throughout the system and central control and funding vanishes. It is not of course that I think that there will be local objections in principle to public health information and advice campaigns, but in hard-pressed localities there may well be a temptation to assign lower priorities and less funding to them. Even if the local need for such campaigns is acknowledged and acted on, making sure that the campaigns are properly devised, properly run and properly integrated will present difficulties without clear central oversight.
Baroness Gould of Potternewton
My Lords, I support these amendments, which are so relevant to recent proposals in the Select Committee report on HIV/AIDS. The Bill calls for the Secretary of State to take steps to promote public health in England from disease or dangers to health. Without a doubt the most effective way of achieving that aim is through the provision of public information, advice and awareness-raising campaigns, first, in respect of prevention and, secondly, in respect of early treatment and care.
That proposal would mean the promotion of early testing as well as testing for the estimated 22,000 people who have HIV but do not know that they are infected and who, as a consequence, are likely to transmit the disease further. It would also ensure the availability of testing. At the moment the venues for testing are fairly restricted but the Government are considering proposals by the HPA and NICE to widen the range of settings where testing might take place, particularly in areas of high prevalence. We await the Government’s decision on those reports. The need to raise awareness of early testing is crucial to prevent onward transmission of the disease. There is no better example than the evidence obtained from antenatal clinics which have had campaigns and have given information to pregnant women about mother-to-child transmission and where the number of such cases is now extremely low. That advice should be taken by the Government.
I raise these points specifically because the Government’s response to the Select Committee on the need for awareness-raising campaigns did not give the assurances that we might have hoped for. While there are campaigns currently targeted at those most at risk of HIV—we hope that they will continue, but we are not certain that that will be the case—it was very short-sighted that there was no guarantee of the inclusion of HIV on any national sexual health campaigns, if in fact there are to be any. This amendment would be helpful in making that happen. There was a complete rejection of campaigns directed at the general public. Those were not considered to be necessary, yet we know that there is a growing diversification of HIV into other communities. For those people, early diagnosis is essential.
There was, however, a welcome for a web-based campaign run by the National AIDS Trust, which is specifically designed to get prevention and awareness messages to the general public. In a sense, therefore, we have a little contradiction in the need, and the process does go round in a circle. Lack of awareness by the public is one reason why the stigma of HIV persists and why there are so many mistaken beliefs about HIV. It is often the fear of that stigma that deters people who might be at risk from going for HIV testing or even STI testing. Effective awareness-raising campaigns would overcome some of those difficulties and are essential if we are to promote early testing and reduce the levels of HIV, which are growing each year, and thus reduce the levels of transmission.
It seems to me that not to have those campaigns is not only poor health practice but economically short-sighted. The HPA suggests that, if we had prevented the estimated 3,800 or so HIV infections acquired in the UK in 2010, we would have saved over £35 million annually, or £1.2 billion over a lifetime of cost. Treatment is very expensive. That seems to me an enormous amount of money when compared to the cost of running effective and regular public awareness-raising campaigns. Surely common sense tells us that the campaigns should continue.
Baroness Masham of Ilton
My Lords, these amendments relating to campaigns are very important. My question is: who will be carrying them out? I would like to highlight the problems of late diagnosis of HIV/AIDS, tuberculosis, hepatitis B and C, and meningitis.
Many people are living with HIV/AIDS who do not know that they are infected. There needs to be sensitive targeting of campaigns. If diagnosis is late, the condition is much more difficult and expensive to treat, as has been said. There are often co-infections of HIV/AIDS and tuberculosis. Late diagnosis in TB is very dangerous. Along with the growing problem of drug-resistant TB, there is extensively drug-resistant tuberculosis, which is very dangerous and much more expensive to treat and takes much longer.
I would like to mention the effective and important work of the group Find & Treat, which goes out to find homeless and other people who are difficult to find, who may have TB, and test them. The group now wants to test for co-infections, which would be much more effective and less expensive in the long run. This type of infection is on the increase. There is a fear that, unless local authorities and the National Health Service work together, there may be fragmentation, and these people, who should be treated early, may fall through the net. Find & Treat needs all the support that it can get to carry on this very important work.
Hepatitis B is very infectious, but there is now a vaccination, which is good. However, there is no vaccination for hepatitis C. Both types of hepatitis have been found to be a huge problem in prisons. There is a problem of liver disease with hepatitis C. Early diagnosis is important for all infections. In the case of meningitis, there have been far too many tragedies because of late diagnosis. The public—and doctors—need to be reminded continually how important this issue is by means of campaigns and guidelines. My GP always waits for guidelines from the Department of Health.
Baroness Randerson
My Lords, I speak in support of these amendments tabled by my noble friend. I strongly welcome the provisions in this Bill that ensure that the NHS and local governments work together on public health. I believe that these provisions are long overdue. However, as my noble friend said, we need to ensure that central responsibility and control is retained to be able to have high-profile, national public health campaigns.
I am the co-chair of the All-Party Parliamentary Group on Hepatology and I participate today from that perspective. I wish to speak especially about hepatitis C. In the summer, the group produced a report emphasising the points that I am making about the importance of national public health campaigns. The current proposals will affect those suffering from this disease and will improve the response at a local level. However, they will also ensure that we need a national response. Hepatitis C is a preventable and curable cancer-causing, blood-borne virus. The main groups affected are intravenous drug users, or those who have been, and certain ethnic groups from south Asia who were also badly affected because, very tragically, they were immunised in childhood during mass immunisation campaigns using dirty needles.
As has been said, a stigma is attached to hepatitis C, as it is to HIV/AIDS. As a result of that stigma, it has largely been ignored by government ever since it was first identified in the late 1980s. Deaths from the disease are rising; mortality has risen by between 39 and 45 per cent since 2005 and the number estimated to be affected is between 250,000 and 466,000. I say “estimated” because the majority of those affected are undiagnosed. That is the key point in relation to public health campaigns.
The picture in Britain is not the same as the picture in most of the rest of Europe. Elsewhere deaths from the disease are falling because there have been high-profile public campaigns and strategies to deal with the disease. As a result, diagnosis has been very much earlier. I said that the majority of people suffering from the disease are undiagnosed, but why is that? They are undiagnosed because it is a tricky disease. It remains asymptomatic for 10, 20 or even 30 years, and by the time the symptoms occur it may be too late for a cure. It is certainly very possible that any attempts at treatment are very complex and expensive. That outcome can be a result of the stigma, but it can also be a result of ignorance because we have had no big public health campaigns. There is ignorance on the part of clinicians and the public. Delayed diagnosis costs not just lives but a great deal of money. There is a range of clinically effective and cost-effective treatments for the disease that can cure and that are recommended by NICE, and more and better treatments, due to go to NICE in the near future, are in the pipeline.
That is the background. As I see it, that is how the Bill will help, but it needs to be improved in order to help even more. The local government NHS LINk will enable local public health campaigns to focus on local needs. Given the list of at-risk groups that I have described, it is obvious that an area with a high population of those from south Asia, for example, will be enabled to target their health messages appropriately. An area that is aware that it has a particular problem with drug use will do the same. Of course, many people will be affected by the disease who do not live in those target areas, and they need to be screened and treated in the same way, so local campaigns need to supplement and bolster national information campaigns, not replace them.
We have already heard from my noble friend reference to the dementia campaign that is currently being run, and there has been reference to the AIDS campaign. I would say very strongly to the Minister that we need a hepatitis C campaign of similar impact. Without the proposals in these amendments, I believe that there might not be sufficient obligation on the Government to co-ordinate these campaigns. I very much look forward to Minister’s response on this issue.
My final point is that successful national and local campaigns will inevitably have a knock-on effect on commissioning services. More patients will be diagnosed, and that will mean more needing treatment. In the long term, of course, there will be a fall-off in the demand for treatment because of higher public awareness and, one hopes, very much safer behaviour as a result. That fall-off will take years, however, and it is essential that GP services, hospitals services and, for example, drug and alcohol action teams all have the increased capacity brought into line at the same time as such campaigns take place. It is therefore even more important that there is the central control and direction to which I referred. That is just one example; other noble Lords have given similar examples, and I urge the Minister to give this serious consideration.
Lord Davies of Stamford
My Lords, there is no provision on the Order Paper for debates on Clauses 8 or 9 to stand part. Rather than risk taking up the time of the House by necessarily opening such a debate, I wanted to make a few general remarks under the heading of this group of amendments because it touches on Clauses 8 and 9.
All of us in this Committee are very concerned about public health. It is a priority for anybody in public life and really must be. Some telling points have been made both this morning and this afternoon, and I particularly retain the remarks about the importance of addressing the threat of obesity, which we know causes an awful lot of medical conditions, and the very important issue of tobacco smoking. We have made tremendous progress in public health by bringing down smoking. The results are already clear in the reduction of the incidence of some of the cancers. It is also important to address the threat of sexually transmitted diseases, and some very good and sensible things have been said about AIDS and hepatitis B and C. To that list I would add chlamydia, which does not normally have fatal consequences but has very sad consequences for infertility. It is far too widespread at the present time.
There are a number of other areas about which we should all be concerned. One that concerns me is the introduction into this country of tropical diseases by airline passengers and the great importance of making sure that clinicians are properly trained to identify the symptoms as rapidly as possible and to deal with them. The facilities are there to quarantine where necessary people who have highly infectious tropical diseases.
Another public health risk that we ought to be aware of is the danger of strains of bacteria emerging that are immune to antibiotics, very largely as a result of the excessive and irresponsible prescribing of antibiotics—sometimes quite disgracefully as a placebo—and a lack of discipline on the part of patients in completing a course of antibiotics. That is a serious issue that has not been addressed by any public campaign, as far as I know.
All of us are concerned about the danger of a viral epidemic in the form of some new strain of flu or something of that kind. We are very much aware of it because the media talk about it a lot. That has not gone away; we must not get complacent about that. I am glad that in the area of the protection of public health, the Government have made it clear that, unlike in the area of the provision of clinical treatment, the Secretary of State has a clear responsibility stated explicitly and unambiguously in the Bill.
However, the Government have missed an opportunity to simplify and rationalise the bureaucratic structures and lines of accountability. That would have been very desirable. What is emerging here is an extremely complex structure of responsibility. The Secretary of State uniquely has responsibility for taking necessary measures for the protection of public health but shares that responsibility with local authorities in the area of improvements to public health. The Bill makes it clear that the Secretary of State “may” and local authorities “must” take measures in this area, so there is the prospect of a highly undesirable situation in which the Secretary of State takes such action but that duplicates what local authorities are doing. I do not think we have heard in the course of the debate exactly how the Minister envisages the relationship between Public Health England, the Secretary of State and local authorities with their new medical officers developing. I almost called them “medical officers for health” because I think this is a revival of that old concept, and they did a wonderful job in their time. However, I believe that they are going to be called “directors of public health” and are to be established under Clause 9 by all local authorities.
We need to understand what the relationship between these bodies is going to be. The noble Baroness, Lady Northover, said earlier that the Health Protection Agency is to be abolished. That is what it states in the Bill, but I understand that actually it is going to be subsumed more or less in toto into Public Health England. We need some transparency on that. I would like to know how many people are going to be involved in the agency because these bodies can be extremely expensive. We want to make sure that we are getting proper value for public money.
I am particularly concerned about the suggestion in Clause 19 that the Secretary of State may devolve on to clinical commissioning groups or the National Commissioning Board his responsibilities in the public health area. So there we have another bureaucracy that has the potential to become involved without being clearly defined. There is a frightening element in that clause which provides that any liabilities arising as a result of the involvement of the National Commissioning Board or clinical commissioning groups in the public health area will accrue to those bodies and to no one else; in other words, not to the Secretary of State. The Secretary of State is not delegating his authority; he is not using the National Commissioning Board or clinical commissioning groups as his agent under his direction, which would be an appropriate thing for him to do; but rather he is abandoning his responsibility to this completely different set of bodies whose main job is in the area of diagnosis and treatment. Again, that is a very confusing picture.
The proliferation of bodies and lack of clarity about bureaucratic responsibilities should be a matter of concern to us all for at least three reasons. The first is that it makes it very difficult for the general public. I find it difficult to understand exactly what the hierarchy of responsibility is. Human beings never give of their best unless their responsibilities are clearly defined and demarcated so that they can be held responsible for those areas for which they really are responsible. They are simply hopeless if other people might be equally responsible. We have not talked about the health and well-being boards. What have they got to do with public health? It is quite unclear to me, but presumably they have some role in this area. It is very confusing and I think that that is very undesirable.
The second reason is the matter of cost. Anybody who has dealt with the NHS as a Member of Parliament, as a business or in any other context knows that one of the great troubles with the NHS is that whenever a decision needs to be taken, there are around 26 people in the room from at least 12 different departments and agencies. That is extremely bad from the point of view of clear decision-making. It means that all decisions take a long time and the costs go up indefinitely. It seems that we have a formula in the area of public health for the replication or even the aggravation of that problem.
The third reason why we should have clarity of responsibility in this area is because people do not perform if they can simply get out of any kind of sense of responsibility by saying that it is someone else’s fault. We are providing endless opportunities for excuses to be made and for people to avoid their responsibilities. I would be very relieved if the Minister could reassure me that these fears are groundless and give clear reasons why that is so.
Baroness Hollins
My Lords, I shall speak briefly about the importance of information in an early diagnosis. I have two areas to focus on. First, people with learning disabilities often get a late diagnosis and suffer terribly because of it, with an earlier death as a consequence for many. Often that is because of a lack of accessible information. I speak as the executive chair of a social enterprise, called Beyond Words, which designs pictorial information to try to bring health and social care information to people who cannot read. Any public health information campaigns need to remember that not everybody can read information easily; it has to be designed to be inclusive.
Secondly, I have a question about how the accessibility of information about the bureaucratic structures of the NHS will help with early diagnosis. This is to do with the current “choose and book” system. Something that has happened to a close relative of mind in the past few weeks made me realise that I do not know how the Bill is addressing the whole issue of better choice for patients. I will briefly tell noble Lords the story. It is about somebody who needs an early diagnosis for what seems like a serious, rare, long-term condition and who has been referred through the choose and book system to four different hospitals to see four different specialists in different areas, where those specialists cannot easily communicate with each other because their hospital systems do not speak to each other. The person concerned chose the hospitals that offered the earliest appointments, which is what most people do and what choose and book offers you. You take the first appointment because you are worried, but the hospital consultant is unable to refer to a consultant in the same hospital with whom they would be able to consult. The patient has to go back to the GP and back through the choose and book system. It is not working.
There is something about information and early diagnosis here as well. I could not see where, apart from under information, I could raise this issue. I look forward to hearing a response from the Minister.
Baroness Northover
My Lords, Amendments 65A, 71ZA, 97A and 133A seek to raise the priority within the Bill of public health information advice designed to encourage the early diagnosis of serious conditions. Improving early diagnosis is an important objective across the whole health system, which includes the new public health system. I am very grateful to noble Lords for raising such a significant issue.
I completely agree with my noble friend Lord Sharkey as to the important role of information advice campaigns. I hope that I can reassure him that the changes to public health will not see the end of such campaigns. Where such campaigns work, we want to see more of them. We know how important early diagnosis is in treating cancer, for example. Thus, people coming forward for bowel cancer screening can be diagnosed at a stage where the disease is totally curable.
The noble Baronesses, Lady Masham and Lady Gould, emphasised other areas in which treatment is more effective earlier but also where there is a risk of infection, such as HIV, TB, hepatitis and meningitis. The noble Lord, Lord Davies, flagged up other STDs, among other issues. We are well aware of the importance of these areas. This is also where local authorities’ involvement in public health should assist rather than detract. The noble Baroness, Lady Gould, rightly flagged up this issue in relation to HIV/AIDS. No doubt we will return specifically to the points that she has raised when we debate HIV/AIDS on 1 December, World AIDS day, a debate to which I am responding. I look forward very much to our discussions then.
We will no doubt come back later to wider discussions of Public Heath England and the directors of public health, to which the noble Lord, Lord Davies, referred. Perhaps his notions can be revisited then when attached to the appropriate amendments.
As I outlined in the debate on the previous group of amendments, Clause 8 sets out the Secretary of State’s new duty to take steps to protect public health. It illustrates this duty with a list of steps that would be appropriate for the Secretary of State to take. That list includes the provision of information and advice. Amendment 65A would amplify that to specify that this could include information in campaigns around early diagnosis. I should explain that the list in Clause 8 is neither prescriptive nor exhaustive. The amendment would not therefore either require or give the Secretary of State a new power to do anything that the clause does not already accommodate.
Similarly, Amendment 71ZA would have the equivalent effect on a list of steps that local authorities may take under their new duty to improve public health. As we have already said, local authorities’ new responsibility will include behavioural and lifestyle campaigns to prevent serious illness and they will be funded accordingly. The Department of Health is also working with stakeholders from the NHS, local government and voluntary and community sectors to finalise the operational design of the new public health system. We expect to publish proposals shortly and they will set out how we expect to promote early diagnosis through the system.
Of course, the NHS will continue to play an important part in public health, a point emphasised by the noble Baroness, Lady Finlay, earlier. The Bill allows the Secretary of State to mandate or agree particular services that will be the responsibility of the NHS Commissioning Board. Amendment 97A seeks to ensure that he will consider early diagnosis campaigns when he does so. I hope that the noble Lord, Lord Sharkey, will be reassured that this is something which we are already considering. I can also reassure noble Lords that the objective of Amendment 133A is already met by the clause as drafted. Where the Commissioning Board is engaged in early diagnosis campaigns, then the duty to promote the integration of services would automatically apply to those campaigns just as they would to any other health, or health-related, services.
I emphasise that we especially expect advice and information to continue to play a major role in early diagnosis and local authorities will be able to contribute to that. Meanwhile, Public Health England, too, will be able to manage and support effective national campaigns. We will be publishing further detail shortly on how the different levels of the system will work.
In short, I believe that we are in total agreement with noble Lords about the principles underlying their amendments and with what noble Lords have said in the debate. We share their desire for improvement in this area. We all know what huge potential early diagnosis offers and the vital importance in this of public health campaigns. The Bill as drafted offers all the necessary support for that ambition. I therefore hope that the noble Lord will accept that and withdraw his amendment.
Lord Beecham
My Lords, as we are in Committee, I can repair my omission in failing to anticipate the Minister’s response to what has been a very good debate. I congratulate the noble Lord, Lord Sharkey, on tabling these amendments. I take issue with him slightly over one matter he mentioned: the relative performance of this country in terms of cancer survival rates. Recent reports make clear that they have improved substantially and are now beginning to outstrip those of other comparable health services. However, that does not detract at all from the thrust of the amendments.
The Minister referred to bowel cancer screening. That is but one example of the importance of early diagnosis, and public information can certainly assist in that context. As some of your Lordships may recall, I have some personal experience of this because my wife died of colon cancer last year. Her symptom was constipation, which is not a predominant symptom. Relatively speaking it is a less frequent symptom, but even now it is not something that some of the literature and material produced by cancer charities refers to. That is an illustration of the need for clear information to be given. There has been a very successful campaign about stroke, which was temporarily halted and then resumed. There is clearly a role for that kind of campaign. I should have thought that the Government could accede to the request for these duties and responsibilities to be included in the Bill.
Although I certainly strongly support the amendments, there are perhaps two riders that I might add. The first is that information, which of course can be in many forms, is not of itself necessarily enough. For example, information in labelling on food does not convey very much to people. This is an example of nudging not being enough. In some cases what is needed, apart from information, is action, and I hope that, as part of their public health agenda, the Government will take a rather firmer line in making requirements of the food industry and others concerning what goes into the nation’s diet.
The other rider relates to the efficacy of some kinds of campaigning. This does need to be measured. Some campaigns—noble Lords have referred to them—have been extremely effective; others, less so. The rather dramatic advertising about HIV and AIDS in the early days was not thought to have been particularly effective. It seems to me that in the interests of effectiveness and efficiency—that is, in terms of the expenditure involved—we need to evaluate what sort of campaigning and publicity works.
With all those qualifications, such as they are, I strongly support the noble Lord’s amendments. I hope that the Government will take another look at whether sending a very clear signal by having these kinds of amendments made to the Bill would assist what we all agree across the House is a prime responsibility and a prime opportunity for the Government to advance the public health agenda.
Baroness Northover
My Lords, my apologies if I leapt up far too soon. I caught the noble Lord’s colleague’s eye and it looked as though no one would be speaking from that side of the Chamber. However, I am incredibly glad to hear what is in fact cross-party support for this kind of campaign. The noble Lord is absolutely right: the part that charities play and have played in many of these campaigns is absolutely critical, not the least of which is Cancer Research UK and its various campaigns. Therefore, I thank the noble Lord for his contribution.
Lord Sharkey
I thank all noble Lords who have spoken to the amendments and I thank the Minister for her response. I should also like to register the propensity of all Governments to make sudden cuts to public information campaigns. Last year, the Government announced a freeze on their £540 million annual publicity budget. On 29 May this year, they announced a partial thaw, with expenditure of £44 million on four campaigns in England. This followed the publication of a Department of Health report called Changing Behaviour, Improving Outcomes, which found that, for example, after the cessation of campaigns, calls to the Change4Life information line fell by 90 per cent, calls to the FRANK drugs line fell by 22 per cent and visits to the NHS Smokefree website fell by 50 per cent.
All that illustrates my continuing concern that it is too easy to cut public health information campaigns and that it might be even easier in devolved organisations. Therefore, notwithstanding the Minister’s helpful response, I continue to believe that we need safeguards against such cuts written into the Bill. I look forward to discussing this again on Report. I beg leave to withdraw the amendment.
“( ) providing services for the prevention and treatment of harmful drinking and alcohol dependence.”
Baroness Finlay of Llandaff
My Lords, I hope the Committee will agree that it would be more convenient to discuss the spirit of this amendment when we come to the later group of amendments that focus on issues around alcohol—the group beginning with Amendment 71 —and that the other amendment in this group, Amendment 74B, warrants a short debate in its own right. I beg to move.
Baroness Thornton
My Lords, I thank the noble Baroness. This small amount of grouping and degrouping was partly to do with having everybody present and correct for a good debate on alcohol and its dependency.
However, Amendment 74B in my name and that of my noble friend Lord Beecham raises an important issue. I was heartened to hear the Minister say that there is a list in Clause 8 that was not exclusive, because this amendment is about a list that is not exclusive that we want to put in the Bill.
I start by marking the fact that today is national COPD day. It is appropriate that when discussing public health, we should mark the fact that millions of our fellow citizens have chronic obstructive pulmonary disease, and many of them have it as a result of their lifestyle choices that they made possibly when they were very much younger. It is very appropriate that in this debate about public health, what leads people into chronic conditions should be part of it. I also mention the fact that today—not unrelated to this—the British Medical Association issued its call for a ban on smoking in cars and an extension of tobacco regulation, which also merits some consideration.
Amendment 74B places in the Bill a by-no-means-exclusive list of matters that are important for the improvement of public health. We are trying to tease out whether and how a comprehensive approach to public health, which takes account of all pertinent matters, becomes possible in the framework that the Government are outlining for the promotion of public health. For example, the list includes issues such as employment or the lack of it, poor quality housing and its effects on health, air and water quality, and so on. They all concern the improvement of public health.
One of the reasons behind the amendment, and its place in the Bill, is that it also concerns the disbursement of grants and loans in Clause 9(4). As has already been said, we are also exploring what the Secretary of State and local authorities might, and could be expected to spend their funding on. I return to the question raised by my noble friend Lord Beecham about the public health premium. If we apply the proposed list in the amendment to my home town of Bradford, where there are very high indices of deprivation, how will the areas with the most severe and serious deprivation qualify for a public health premium when they are starting from such a very low base? I am sure that there is an answer to that question but I would like to have it on the record.
Evidence was given by the Association of Directors of Public Health to the Health Select Committee when precisely that point was raised. I hope that if the Government cannot answer my question now, they will be able to address it when they respond to that excellent report.
Baroness Gould of Potternewton
My Lords, it is interesting that there is not a universally accepted definition of public health. There are, however, broad domains of public health, be they health improvement, health protection or health services. The Faculty of Public Health defines public health as:
“the science and art of promoting and protecting health and wellbeing, preventing ill-health and prolonging life through the organised efforts of society”.
That is a very broad definition. It could almost include every range of local government services. It seems to me that there is a need for some guidance on what aspects should be included in the ring-fenced budget. We have previously been told that there will be no breakdown of the budget within that ring-fencing, which makes it even more important that some guidelines are laid down. The frequent reply from the Minister has been that we leave it to each local authority to determine what public health is. But while I appreciate that there will be a variation in needs between different authorities in different areas, some guidance and priorities might be useful to them.
I am delighted that my noble friend has highlighted sexual health as being important because there is a great deal of concern that sexual health will not be a favoured issue for many local authorities. Furthermore, as regards HIV for instance, there is no understanding that there is all too often a relationship between the required long-term care and other aspects of local government services. There is also concern that, unless it is highlighted, there will be a lack of understanding by local authorities of the divide within the commissioning arrangements for HIV and contraceptive services between the National Commissioning Board’s responsibilities and their own—for prevention and testing in the case of HIV and for the establishment of clinics for special cases in the case of contraception. Guidance would give local authorities greater clarity of their roles and responsibilities and the fact that they are a key player in this process of integration. I am sorry to refer again to the response to the Select Committee report on HIV and AIDS, but it is so topical. The Government identify that integration where possible—whatever that means—will be by the NHS Commissioning Board, clinical commissioning groups and health and well-being boards. That will apply to all health services so there is no need to have a special duty applying to the integration of specific services, such as sexual health and HIV. However, I think that is a misjudgment. Having some identification priorities would give guidance as to which areas require special duties.
At Second Reading, the Minister referred to the Advisory Committee on Resource Allocation, which is an independent expert committee that has been asked to advise on a public health formula to inform the distribution of the public health grant across local authorities, saying that it intends to publish further detail later this year. So I appreciate that we are not going to get the detail for which I would have asked on the distribution of that grant. If we could get some detail, that would be very helpful, but perhaps I may remind the Minister that there is only two months left this year and I hope that we will get that response before the end of it. The calculation of spend on public health, including sexual health services, must be based on robust and accurate data, so can the Minister identify how that can be achieved without a specific definition of what it should include? I appreciate that the Minister has so far always rejected the idea of coming up with a definition and he certainly might not agree with the list that is before him. Nevertheless, I would be grateful if he could rethink this. There needs to be some principle laid down to make sure that local authorities understand what public health actually means.
Baroness Northover
My Lords, Amendment 66 would add alcohol services to the list of examples that the Secretary of State may take under his new duty to protect health and Amendment 74B would add a number of steps, including one on alcohol, to the equivalent list of steps for local authorities to take up under their new duty. I appreciate the decision by the noble Baroness, Lady Finlay, to regroup and we will discuss her amendments a little later. However, the noble Baroness, Lady Thornton, followed by the noble Baroness, Lady Gould, decided that the group should stay in place.
Adding to the Bill's list of steps that may be taken may highlight an issue but would not materially alter the situation. The noble Baroness, Lady Thornton, with her governmental background, is clearly extremely familiar with the function served by these indicative lists. I appreciate her indication that she is probing on this. Obviously it is extremely important in these different areas.
I also note the definition of public health that the noble Baroness, Lady Gould, quoted. I scribbled down the part about the science and art of promoting health and well-being through the organised efforts of society. That illustrates that this is an evolving and moving area. We hope that it will evolve and move because public health has now been put with local authorities. By joining up all the different areas we wish to join up, we hope that the field of public health will move along. Therefore, it is not appropriate to put in the Bill such a definition, which is set at a particular time, because of the evolution that I hope will expand in a way that the noble Baroness—who clearly is not satisfied—will be happy with.
Baroness Gould of Potternewton
We are talking about a ring-fenced budget; we are not talking about a general local government budget. Therefore, there must be some guidance on what should go into that budget. I do not mind whether it is a definition in the Bill or guidance, but something must be done to make sure that we know what is in the ring-fenced budget.
Baroness Northover
The noble Baroness is absolutely right. This is not simply philosophy. Therefore, regulations will provide that guidance. In the mean time, I say that this is an issue on which we have spent considerable time working. She is probably aware of the July 2011 update to the public health White Paper. If she is not, I suggest that she looks at it. Paragraph A.10 on page 27 contains a list of the areas in which we expect local authorities to engage. I am sure that the noble Baroness, Lady Thornton, will be pleased that the list starts with tobacco control. The noble Baroness, Lady Finlay, may note that the second item is alcohol and drug-misuse services. Other issues that noble Lords have mentioned are also listed, such as obesity and community nutrition initiatives. The list is long.
Baroness Thornton
The Minister is giving a list—and there are at least two further lists in Clauses 8 and 9. I cannot see why my list should not be in there, too.
Baroness Northover
I can see the temptation. The list in the Bill is indicative. These lists are always subject to much debate about what goes in and what stays out. I fully understand why the noble Baroness wishes to add her list. However, we would resist adding to the list in the Bill, which is, as she knows, indicative. We appreciate people's contributions to what needs to be covered in these areas. I point out to her that the list—no doubt we will spend many hours debating the regulations—includes all sorts of things, such as mental health services and dental public health services. I will not read out the whole list. If noble Lords think that something is on it that should not be there, or that other things that are not on it should be, I am sure that we will consider those points as we debate the regulations.
I noted a response to the noble Baroness, Lady Hollins, but I think that I may be referring to a previous debate. She is absolutely right to emphasise that we have to make sure that everything we do is patient-centred. All the changes must focus on that. It is a challenge for everybody. Perhaps people have tried to do it before. No doubt we will have problems trying to do it ourselves, now and in the future, but that has to be the focus. Therefore, we have to remember the diversity of the patients that we are talking about. I am sorry; that answer belonged in an earlier debate.
I know that we will return later to debate alcohol. I hope that noble Lords will not press the amendments in this group.
Lord Rooker
“( ) The Secretary of State shall appoint a Chief Environmental Health Officer for England.
( ) The Chief Environmental Health Officer for England shall give advice to and report to the Chief Medical Officer for England on all such aspects of environmental and public health as are relevant to the public health functions referred to in this section and the duties referred to in section 2B of this Act.
( ) The Secretary of State shall report to Parliament annually on the work of the Chief Environmental Health Officer for England.”
Lord Rooker
My Lords, this is a brief probing amendment that is mirrored by my noble friend’s Amendment 75A, which is identical. I originally thought that I had tabled this as a new clause and it had appeared as an amendment. I would like to take the opportunity, by the way, to apologise to the House for being missing when a couple of the amendments that are in my name were moved by other noble Lords. My absence was unavoidable.
The reason for the amendment is straightforward: it is to test the views on the creation of a chief environmental health officer for England. Historically, of course, there has been a chief environmental health officer position since the days before 1974, when I was elected to the other place. It was abolished, I think, on 1 April 1974 during the massive reorganisation that year. That was the last time local authorities had the lead responsibility for public health services. Each local authority had a medical officer of health in those days—in Birmingham, in fact, we called them the chief medical officer of health.
Today, England has a Chief Medical Officer of health, but not a chief environmental health officer. The amendment, and my noble friend’s new clause, proposes that the Secretary of State should appoint a chief environmental health officer for England. In Wales, there is a chief environmental health officer in post. In Scotland and Northern Ireland, there are arrangements that are similar to that. Indeed, there are things happening in the devolveds that are streets ahead of what is happening in England. I have to say that my experience is that Westminster, in the centre, is completely unaware of it all, mainly because, regretfully, there is not a degree of communication. The respect agenda is not actually being played out in practice. Nevertheless, these things are happening elsewhere and there is a good case for making similar arrangements in England. This would recognise the role played by environmental health in promoting health and well-being and the importance of assuring environmental health input into policy-making at the highest level. That is part of the key issue: to get it involved at the highest level.
There are some other amendments, for a further debate, that relate to the complications—again, unique in England—of two-tier local government. This issue does not arise in Wales, Scotland and Northern Ireland. There is a complete mishmash in England. The way in which we inherited the current two-tier local government structure was not planned. That actually highlights some of the difficulties with environmental health, which cannot be done and is not done at county level, of course, although I will save that point for other amendments.
England currently lacks this input into policy-making at the highest level. The appointment of a chief environmental health officer would assist in that area. I am very guided in this by the Chartered Institute of Environmental Health. It has made some very positive remarks about the Bill and given some input into this part of the Bill, in no way to whinge or criticise but rather to strengthen the Bill.
It is envisaged that the chief environmental health officer will focus on a preventive approach to achieving good health outcomes, and in particular on the wider determinants of good health and well-being. The postholder will be able to review the relevant data and advise the Department of Health, Public Health England, NICE and the Chief Medical Officer. It is envisaged as part of the package of proposals and amendments that the chartered institute has proposed that the chief environmental health officer answers to the Chief Medical Officer to have that input into preventive strategies and the wider determinants of health, in the widest sense that the public understand it, and to oversee the development of good practice within local authorities and their partner organisations.
Baroness Finlay of Llandaff
My Lords, I hope that the Government will be able to give some assurance that environmental health will be recognised in the new public health services that will be established. I became acutely aware of the importance and contribution of environmental health when I chaired the House of Lords Science and Technology Select Committee inquiry into allergy. Environmental health officers were most helpful on issues around climate change, air quality, diesel particles and the hyperallergenic effect of high levels of diesel in making pollen more allergenic.
When I chaired the inquiry into carbon monoxide poisoning, I had a great deal of help from the Chartered Institute of Environmental Health on gas safety and gas regulation. It brought its engineering and architectural expertise to inform that inquiry. It is important to be aware that although these professionals are called environmental health officers, they come from a broad range of backgrounds and bring in engineering, architecture and what you might broadly call environmental physics to inform the health debate. They are complementary to but not duplicated by the provisions in standard public health medicine.
Lord Greaves
I echo everything that the noble Baroness, Lady Finlay, has just said. The noble Lord, Lord Rooker, has raised some extremely important issues and hit some serious problems at the heart of the Bill. I am not sure that his solution is the right one, but it needs discussion. I am sorry that the noble Baroness, Lady Gould, in not in her place because she made the important point that the meaning of the phrase “public health” has evolved over the years. The core Public Health Act 1936 was about the role of local authorities in relation to public health and what we now call environmental health.
In the 1974 local government reorganisation, public health functions were split. Half went to the health service, the other half remained with local government, and the phrases “environmental health” and “environmental health officers” were largely invented at that time to distinguish the new environmental health service from what had previously been public health. Of course, in two-tier authorities environmental health is a function of the lower-tier authority.
The noble Lord, Lord Rooker, made a very important point. We have some amendments coming up, probably in a few hours’ time, when we will discuss this, so I will not say a great deal more about that now except to make the basic point that it is very important indeed that environmental health functions, which already rest with unitary authorities but in county and district areas will rest with district authorities, are properly integrated with the rest of the public health function.
As the noble Baroness, Lady Finlay, said, the things that environmental health officers and departments do are astonishingly varied. If a problem is clearly a public health or environmental health problem, they will find the expertise, go out and get expert advice if it does not exist within that authority, and tackle it. It is a very important function indeed. However, at the national level, environmental health, as defined in the Local Government Act 1974, rests with the Department for Communities and Local Government, not with the Department of Health. It probably ought to rest with the DCLG because it is very clearly a local government function, but again, at the national level, the Government need to take action to integrate it into the new, very important public health functions of the Secretary of State.
Lord Whitty
My Lords, as my noble friend Lord Rooker has said, I have an amendment in this group that is precisely the same as his, except that it was directed at a different point. My noble friend has made a strong case for this particular dimension of addressing environmental health issues, but there is also the wider issue of the lacuna in the Bill, as has been touched on. There is one major shift that the White Paper, the post-pause White Paper and now the Bill are driving for: the shift of public health, including environmental health, to local authorities. However, the Bill itself reflects very little of that. The noble Baroness, Lady Thornton, in response to the group of amendments before last, referred to the fact that work was being done on it and said that she hoped this would see the light of day fairly soon.
The establishment of Public Health England as part of the department-cum-executive agency is hardly reflected in this Bill at all. The issues that relate to the respective role of the local authorities, to which my noble friend Lord Greaves has referred, are not reflected in this Bill at all. We have a major shift, going back to pre-1974, that makes public health the responsibility of local authorities. We have a recent history in which all the expertise in environmental health departments has been seriously squeezed because the requirements are mostly non-statutory. EHOs have been diverted on to other issues. We are coming into a further famine of local authority funding. The local authorities will be receiving this new public health responsibility at a time when their total resources are being squeezed and restricted and other priorities are impinging.
Before this Bill completes its course, we need greater clarity on how public health and environmental health responsibilities are to be carried out; what the structure of them is going to be; what the co-ordination among local authorities, and from the centre to the local authorities, is going to be; what the exact role of Public Health England is going to be; and, frankly, at least some broad indication of how that is being resourced.
Lord Greaves
The noble Lord raised the question of funding. Does he agree that this will perhaps be exacerbated in two-tier areas because the ring-fenced public health funding will go to the top-tier authorities, whereas the environmental health functions will remain with the lower-tier authorities—which indeed are extremely squeezed on their funding because this is what we call “other services”, which are not regarded as a priority—and finding a way of getting some of that funding down to the lower-tier environmental health authorities is a question that needs to be looked at?
Lord Northbourne
My Lords, perhaps I may intervene now to ask the Minister to say, when he is winding up, what happens if the local authority does not do what it is supposed to do? It is not impossible. In fact, there is a great variety, as we sit here today, in the performance of local authorities. They are managed by elected members, who want to please their electorates, so there are all sorts of arguments for thinking that not every local authority is going to be very enthusiastic about these additional objectives.
Lord Whitty
My Lords, I will leave that question for the Minister, because it clearly raises wider issues. I totally agree with the noble Lord, Lord Greaves, that one of the most acute effects of all this will be at the district level, where the funds are less protected, and where there is already some difficulty and some serious variability in performance and resourcing.
Given the Government’s support for the establishment of a chief environmental health officer at the centre to help co-ordinate all these issues and—if you like—to punch the weight of environmental health in the other range of priorities which the Department of Health has to pursue, I would ask the Minister this. Will the assessment of public health and the ongoing process she described in trying to defend the Bill from not spelling this out in great detail, lists or no lists, be available to us before we complete the consideration of this Bill, the exact timescale of which looks ever lengthier? Nevertheless, before we reach final conclusions on this, we need to have greater clarity on the direction in which the Government are going on public health, and, I would argue, on environmental health in particular.
I shall mention one other issue that relates to this. The abolition of the HPA also has significant implications in this area. I intend to come back to this at a later stage, but some of the functions of what are currently statutory authorities are going to go to Public Health England, as I understand it, and there is some confusion there as to how that will be carried out, what authority those roles will have and what their local manifestations will be. Under the new structure we will have health protection units around the country. So that is just one more complication here. By Report we ought to have some greater clarity in the strategy of the Government. I ask the Minister to give us an indication of that.
Lord Rea
My Lords, I had not intended to intervene on this amendment, but just from memory, I can think of several areas where the presence of an environmental health officer at the centre would perhaps have speeded things up. The noble Baroness, Lady Finlay, alluded to air quality, but there are other examples as well. I am old enough to remember the smog of 1951 and the enormous benefit of the Clean Air Act which followed a few years later. I was also in your Lordships’ House when lead-free petrol was debated, and when that became law nationally. There is also the question of food safety—the noble Lord, Lord Rooker, will know all about this—particularly the BSE epidemic, when it became necessary to ban animal-sourced feed for ruminant animals. Again, that required national legislation. Local environmental health officers, who do a fantastically important job, would not have been able to deal with these things on a local basis.
Lord Beecham
My Lords, in my youth—your Lordships might think it a rather sad youth—I was, at age 25, opposition spokesman on Newcastle City Council on a pre-Seebohm health committee, which had two remarkably effective and powerful chief officers. One was the medical officer of health, and the other was the chief public health officer. That was the designation of what I suspect we would now call environmental health officers. They were a very powerful combination and very influential within the council. But the point is that they were working together, which is precisely what my noble friend’s amendment seeks to achieve at national level. In later debates we will undoubtedly discuss the role at local level. It is absolutely right to identify this as a core function.
The noble Lord, Lord Rea, referred to one aspect of the role of such officers in environmental issues affecting public health. Perhaps I may revert for a moment to the previous debate and my noble friend Lady Thornton’s proposal to list some matters for inclusion as public health issues in the scope of the duties of local authorities and the Government. Several of those—including nutrition, air and water quality, adequate housing standards, fuel poverty, and possibly even occupational health—will fall within the domain precisely of this kind of appointment. It therefore seems to me that working alongside the chief medical officer of health, or reporting to him—a position of the kind covered by my noble friend’s amendment— would be entirely appropriate and effective. That binary combination or approach would ensure that, across the range of public health issues, there would be the best leadership and the best advice would be available to Ministers at national level and, similarly, at the local level. If it were to be matched, as I hope it would be, that advice would be available to local authorities.
The noble Lord, Lord Northbourne, referred to variations in the practice of local authorities in terms of the resources they devote to this topic. That was undoubtedly true in the past and will no doubt be true in the future, but it is also true at present. The practice of primary care trusts in terms of the way that they allocate budgets is by no means uniform, although I am not necessarily suggesting that it should be. But that is precisely one of the difficulties that I suspect we will encounter when the Government are forced to determine how much is currently being spent, how much perhaps should be spent and how much is to be allocated through any formula-based system under the ring-fencing scheme to be pronounced.
Individual authorities will have different ways of applying core funding, but that does not represent a substantive change from what we have now. Indeed, I would hope that, given greater public accountability, we will have a better outcome than we have had in the existing pattern. I warmly endorse my noble friend’s amendment.
Baroness Northover
My Lords, I thank the noble Lord, Lord Rooker, for giving me the opportunity to highlight the outstanding work that environmental health officers carry out in district councils as well as in the private and voluntary sectors. The Chartered Institute of Environmental Health, to which he referred, also does an excellent job in presenting the issues nationally and in liaising with central government. They will all continue to play a crucial and developing role in public health.
The noble Lord has long been a doughty fighter on environmental issues. I remember my astonishment when, as a Minister, he granted an amendment which I had tabled that he had been refused permission to grant. I therefore feel very mean in suggesting that I will not be reciprocating today. However, when the noble Baroness, Lady Finlay, raised her points, I was rather glad that, when acting on the Energy Bill in relation to the point for which she fought on preventing carbon monoxide poisoning, I was at least able to grant something there, although I know that that was more limited than what is being sought now.
I should stress that environmental health officers, along with other local authority staff, will be very much inside the group of professionals and practitioners in local government who will form part of the wider public health workforce. Consequently, we expect many opportunities for them in the future to contribute to and to shape local plans and priorities. Surely that will help transform this area, because public health, as I indicated, needs to be defined widely. In its new location it will change in order to have the effects that we wish to see. The noble Lords, Lord Beecham and Lord Rea, are right to urge working together, especially given the history of these officers.
At the national level, the Chief Medical Officer will have a central role in providing impartial and objective advice on public health to the Secretary of State for Health and to the Government as a whole. She will be the leading advocate for public health within, across and beyond the Government, advocating the design of policies that improve health and well-being. We are clear that this role includes advising on environmental health issues as well, and that the Chief Medical Officer will in turn continue to be able to seek such advice on environmental health and other issues whenever necessary just as she can do now. The Government believe that, as valuable as environmental health expertise is, this makes the post of chief environmental health officer unnecessary.
The noble Lord is of course right to urge discussion across devolved areas in all fields, as we can learn from each other. He might be reassured that the Chief Medical Officers of the various Administrations meet regularly, and that Public Health England, like the Health Protection Agency, will in some ways have a remit that extends beyond England and thus offer the chance to learn from the experience of others. We remain confident that Ministers will receive high-quality advice from the CMO on environmental health. I stress that we also need to look internationally and draw on research and experience very widely in this field. We can learn a lot from that.
The noble Lord’s amendment calls for the Secretary of State to,
“report to Parliament annually on the work of the Chief Environmental Health Officer”.
We agree on the need for transparency and believe that the Secretary of State’s accountability for public health at the national level is a major strength of the new system. This is why Clause 50 of this Bill requires the Secretary of State to publish an annual report to Parliament on the working of the comprehensive health service as a whole, which will include his and local authorities’ new public health functions.
The noble Lord, Lord Whitty, asked what the Government are going to do about ring-fencing the budget. Some of the issues that he raised were discussed in the first grouping on public health. I do not know whether he was in his place at the time. If he was not, he should be reassured that his noble friend Lord Warner intends to flag up some of the concerns that he raised in a later grouping, and we have various other groupings in which his concerns will no doubt be flagged up. I point out in relation to our discussion on the previous group that we will be using regulations to set out what essential services local authorities have to provide. Noble Lords can also see what is in the White Paper.
I want to clarify what will be covered in regulations so that if I was not clear in the last grouping, I can be clear now. Essential services that we think need to be delivered consistently across the country—for example, dealing with local emergencies—will be included in regulations. We will use publications like the updated White Paper, which I quoted earlier, to set expectations about the totality of services to be covered by the public health ring-fence. I hope that that provides clarification.
My noble friend Lord Greaves talked about the co-operation between different councils—county councils, district councils and so on. District councils have local insight and expertise. In many cases they will have the lead on key services affecting health and well-being, such as housing and environmental health. Health and well-being boards will play a big part in local health improvement activity and must find themselves able to involve local councils so that they work most effectively.
The noble Lord, Lord Northbourne—sorry to startle the noble Lord—wondered what would happen if local authorities do not carry out their duties. The Secretary of State does not have a conventional performance management role with local government—I am sure that those in local government will be pleased to know. However, he does have the power to intervene and ensure that particular services are provided if a local authority fails to do so. Local authorities will also have to account for their use of their ring-fenced grants, and the power exists to recoup money if the conditions attached to the grant are not met. I hope that that reassures the noble Lord.
In summary, it is very clear that environmental health is and will continue to be a very important component of the public health system, which will be led locally by directors of public health. I hope that the noble Lord is prepared to withdraw his amendment.
Lord Rooker
My Lords, I am grateful to the Minister for her reply, and particularly for reminding me about the favour that I did her. It proves that Ministers can make policy at the Dispatch Box. I accepted her amendment against advice; I used the excuse that there would have been a government defeat if I had not. She cannot use that tonight because I shall not press the amendment anyway, but I am very grateful that she remembered that.
I do not want to make a long speech. The Minister said that the work of environmental health officers is absolutely fundamental. They are the unsung heroes of policing a system in this country for our citizens on a whole range of issues, whether food, air quality or other matters. The public are aware of them only when things go wrong. I am reluctant to go down this route, but I declare an interest of chairing the board of the Food Standards Agency, which is a government department, and that is why I do not speak on it in this House. Environmental officers are unsung heroes and they deserve our support. They provide a 24/7 operation and they go into areas where, by and large, police officers would go in only pairs. Late at night they visit takeaway enterprises and so on. They do an enormous amount of work.
I also hear what the Minister said in answer to the point about discussion between the four Governments in the UK. If the only link between the four UK Governments on the respect agenda is between the four Chief Medical Officers, we are in dead trouble. Although that is important, it is more important that Ministers in the four Governments who have similar responsibilities talk to each other. Devolution means that things will be done differently—we are not looking for a one-size-fits-all situation—but it is crucial that there is co-operation, consultation and information. Major changes take place without any contact whatever with other Governments and it is the same in this area. There is no doubt that that causes problems. I am sure that we will turn in more detail to the issues relating to local government in regard to other amendments and we may or may not come back to this on Report. In the mean time, I beg leave to withdraw the amendment.
Lord Northbourne
Lord Northbourne
My Lords, since I set down these amendments a good deal of water has passed under the bridge. Fortunately, that will enable me to be briefer than I otherwise would have been. The first and most important thing that happened was the excellent debate on Amendment 11 in the name of the noble Baroness, Lady Hollins. I do not wish to reopen that debate this evening but I want to draw attention to two rather more fundamental matters in addition to what was mentioned in that debate.
The main one is what we mean by health. Do we believe, and do the Government believe, that health means simply freedom from illness or disability, physical or mental? Or do we believe that health can and should mean more than that? I dare say the noble Lord, Lord Layard, if he were in his place—he certainly spoke on Amendment 11—might have supported me in suggesting that health relates both to physical and mental well-being and that we should be doing much more to promote mental well-being, a subject on which the noble Lord, Lord Layard, has written an excellent book. I quote in this context the Childcare Act 2006, which defines well-being on page 1:
“In this Act ‘well-being’, in relation to children, means their well-being so far as relating to—
(a) physical and mental health and emotional well-being;”—
emotional well-being is an important one—
“(b) protection from harm and neglect;
(c) education, training and recreation;
(d) the contribution made by them to society;
(e) social and economic well-being”.
The important thing is physical, mental and emotional health and also such things as self-confidence and self-esteem. I should like to ask the Government to define what they mean by “health” in the Bill. I should also like to ask the Government to place more emphasis in this Bill on prevention—on services and policies to prevent a lack of health rather than focusing mainly, as the Bill does at the moment, on trying to repair the damage when things have gone wrong.
I am not sure whether technically I should withdraw those two amendments or whether I should do so at the end. I will now go on to Amendments 71ZAA, 72A and 97ZA. These amendments are intended to probe the Government’s intentions on two further issues which I consider to be very important. The first is my concern about whether the Bill will effectively and adequately address the health needs of children. That concern is also raised by the noble Lord, Lord Ramsbotham, who unfortunately is not in his place, in an amendment which I support, Will it provide the services that children need? In that context, why does the Long Title of the Bill specifically refers to “adult social care services” but makes no mention of children’s care services?
My second concern relates to the role of parents in securing the physical and mental health of their children. I doubt whether this Bill shows enough concern for the role of parents, especially in the very early years, in promoting good mental and physical health for their children. The Bill’s emphasis seems to be more on clinical interventions to treat ill-health rather than on preventing it in the first place. Only last week, the NSPCC published new research showing that more than 20 per cent of babies born today have mothers who are either dependent on drugs or alcohol or who are subject to domestic violence. How will the Bill address that problem? Too many mothers and fathers today cannot give their children the care and education they need because they themselves have never experienced a happy, supportive home life. Today, we as a society have done very little to help those parents to help their children. How will the Bill help in that situation?
Recent research shows that the majority of a child’s brain development takes place in the last months of pregnancy and in the first two years after birth. This is the time when nearly all children spend most of their time in the care of a parent. Children are learning from their environment every hour of every day. The lessons they learn are often hard to dislodge. What they learn in those years is crucially important if they are going to progress smoothly and confidently into nursery school, reception class, primary and secondary school and on to a healthy adult life. Yet, as far as I can see, the Bill makes little or no mention of the preparation of parents for their important role in developing the physical, mental and emotional health of their child. Parental responsibility in that context ought to be deeply embedded in the Bill because healthy children grow up to be healthy adults who themselves are more likely to have healthy families. Research shows that, from the financial point of view, early intervention is extremely cost-effective. In the context of the Bill, what is the Government’s policy on preventing ill health? On that note, I should like to withdraw the amendment.
The Deputy Chairman of Committees (Lord Brougham and Vaux)
The noble Lord cannot withdraw the amendment until he has moved it. The Question is whether Amendment 68AA shall be agreed to.
Lord Northbourne
I beg the Committee’s pardon. I was trying to withdraw the amendment before having moved it. I beg to move.
Baroness Williams of Crosby
My Lords, I am not quite sure whether the amendment is before us or not, but I shall make a brief assumption that it is and then I will allow the noble Lord to decide whether to sustain or withdraw it.
As we all know, the noble Lord has made a very distinguished contribution to the whole issue of the status and well-being of children and it is fair that we should recognise that. In particular, he has gone to a great effort to underpin the importance of early education and such things as the Sure Start programme. I want to add two points. The first is that, as a former Secretary of State for education, I remember working very hard to try to persuade my colleagues in the educational world that there should be an emphasis on education in parenting.
It is perfectly true that the early stages of a child’s life are vital, but as the noble Lord, Lord Northbourne, has pointed out, research shows that the link between what a child becomes and its parental inheritance is very close indeed. One of the more disturbing pieces of recent research shows the close link between an abused child and an abuser. Many young people who are abusive parents are in fact the children of abusive parents. Tragically, this dreadful tradition can move on from generation to generation. I simply want to make the point that it is not just a case of Sure Start for the child, it is also a case of proper education and training for the parents.
I have often felt that we should try to link sex education with parental education to bring out above all the extraordinary responsibility that a human child is because it takes so long to grow up compared with the young of most other species. A human child is dependent for many years, and I believe that we should put more emphasis on that than we do. However, it is not fair to make the Department of Health the sole responsible power for addressing this difficult subject. It requires a degree of working between departments, including education and other departments. I simply want to put on the record before the Minister replies the importance of securing co-operation between the Department of Health and the Department for Education, and for that matter social care on this particular set of issues.
My last point is quite straightforward. One of the aspects of training children in parenthood is to allow them to see what it is like to care for a young child. Some teenagers at school will not necessarily have younger siblings. Long ago when I was the prisons Minister—I should have talked about this when the noble Lord, Lord Ramsbotham, was in his place—I introduced a group of offenders, all young boys, to the task of helping in the care and support of children with Down’s syndrome. That relationship had an amazing effect on both parties. The young offenders suddenly realised that they were responsible for someone much younger than themselves who was dependent on them, while the Down’s syndrome children suddenly had older brothers who were devoted to them and to whom they could address their huge capacity for affection. There is a lot of room for bringing young people together with children and teaching them something more than we know now about what it is to be a parent and the huge responsibilities involved in that role.
Baroness Thornton
I should just say how pleased I am that the noble Lord, Lord Northbourne, has brought his great experience and commitment to the children and the family into this debate. I urge him to remain in his place for the debate that we are going to have very soon on children.
Earl Howe
My Lords, as the noble Lord, Lord Northbourne, mentioned, the two amendments in this group, Amendments 68AA and 69AA, are essentially dealing with the same matter on which we had considerable debate on an earlier day. Both seek to make an explicit reference in the provisions of the Bill to improving the physical and mental health of the population. I can well understand that the noble Lord with his extensive knowledge and experience of child health in particular should have tabled these amendments. The other amendments to which he spoke are in a later group. I shall respond briefly to those, but I hope that he will forgive me if I do not do so at length, because I think that there will be other noble Lords when we get to that group who will want to expand even more fully on the issue of children’s health.
I shall not dwell again, if the noble Lord will forgive me, on issues raised in the course of the earlier debate, on 2 November, but I reassure him that all references to illness throughout the Bill relate to both physical and mental illness. Illness is defined in the 2006 Act to include mental illness. Equally, it is not for nothing that we have chosen the name health and well-being board to refer to the mechanism at local authority level to define the health needs and priorities of a local area and set a health and well-being strategy to guide commissioners. That sense of well-being is to be at the forefront of commissioners’ minds. The Bill does not provide an explicit definition of health, but I assure the noble Lord that it recognises that well-being means more than the absence of illness and needs to be addressed separately. The approach in the NHS Act and other legislation is that health is simply given its ordinary definition and is not redefined.
The noble Lord, not for the first time, spoke compellingly about the importance of parents in supporting both the health and well-being of children. I could not agree with him more. The whole spirit of the measures set out in this Bill is to give more control and empowerment to patients. For children, that includes their parents. As such, I ask the noble Lord not to despair by reason of the lack of words in the Bill on this topic, as the intent is most certainly there. It is not for nothing, either, that the Bill places duties on the Secretary of State and other bodies in the Bill to exercise their functions with a view to securing continuous improvement in the quality of services. The agenda set by the noble Lord, Lord Darzi, in the last Government runs through this Bill like a thread, and it is our ambition for clinical commissioning groups that the prevention agenda should be centre stage for them, as it already is for practice-based commissioning groups, which are looking at what we call the QIPP agenda—quality, innovation, productivity and prevention—as a way of driving efficiency and better quality care into primary medical services. I am sure that all noble Lords’ ambition is that the NHS should not just be a national treatment service; it should be a national health and well-being service in the fullest sense.
On the public front, I am sure that the noble Lord will have noticed that in Clause 8 new Section 2A is inserted into the 2006 Act. I draw his attention to subsection (2)(d) in that new section, which refers explicitly to prevention in the area of public health.
We will come to the other amendments spoken to by the noble Lord when we come to a later group, but I will just comment very briefly on them at this point.
As regards Amendment 71ZAA, our general approach is not to specify particular services in the Bill. It already allows the Secretary of State or local authorities to take steps to improve the health of the people of England or the people in the local authority’s area. Once again, it is a case of making that general provision. Bear in mind that if we specify one group of people, it carries the implication that we are excluding others, which of course we do not want to do.
The same point applies with Amendment 97ZA. Strictly speaking, Amendment 99A is unnecessary. The mandate is clearly relevant to other government priorities. There are already established mechanisms for ensuring that policy is consistent across government and therefore we would fully expect the Department for Education to provide input on any relevant parts of the mandate. I hope that the noble Lord will be reassured by my brief comments on this matter. His comments are well taken; equally in the light of what I have said, I hope that he will feel able to withdraw the amendment.
Baroness Hollins
My Lords, I might add that Amendments 68A and 69A refer back to Clause 1 and the Secretary of State’s duty to promote a comprehensive health service,
“designed to secure improvement … in the physical and mental health of the people of England”.
Of course, I support the amendments and note that their purpose is different from the purpose of my own extensively debated and supported amendments, which sought to ensure improvement in the quality of services for people with illness. I specify both mental and physical illness. Rather than speaking about mental health, I actually speak about illness. Instead of detaining the House now, perhaps I could speak to the Minister at a later date.
Earl Howe
My Lords, I should be happy to speak to the noble Baroness on this topic. I have been reflecting on it since our debate some days ago. I do not suggest that the amendments tabled by the noble Lord, Lord Northbourne, are designed to do exactly the same as those of the noble Baroness, however they draw our attention to a similar definitional issue.
Lord Northbourne
I am most grateful to the noble Earl for giving so many excellent assurances on the questions that I asked him. I apologise profoundly to the noble Baroness, Lady Williams, for nearly cutting her out of the debate. For some reason I was confused about the procedures. I beg leave to withdraw the amendment.
Baroness Finlay of Llandaff
My Lords, I am grateful to the House for being so accommodating in moving the amendments slightly so that we can discuss alcohol now. The reason for this group of amendments is because of the ever increasing problem and toll on our society from alcohol misuse. These amendments are designed to ensure that alcohol misuse is a national priority for the Secretary of State and a priority for local authorities and clinical commissioning groups. Amendments 328, 329 and 331 ensure that local organisations have levers in their responsibility to promote integration; and that health and well-being boards and health and well-being strategies take into account alcohol misuse and are devised with appropriate expertise in alcohol misuse.
Turning to the individual amendments, we passed over Amendment 66 briefly for convenience, but it links to Amendment 71, which changes the duty on the Secretary of State from “may” to “must” because of the danger to health that alcohol poses. Alcohol is a major and growing public health concern. Alcohol misuse affects 4 per cent of the population and more than 10 million people drink above the recommended limits. The prevalence of liver disease, to which alcohol is the major contributor, is growing and is set to overtake stroke and coronary heart disease as a cause of death in the next 10 to 15 years. This is set out in the Department of Health’s document on developing a national liver strategy, published last year.
Last year, more than 1 million hospital admissions were due to alcohol misuse. This represents a doubling in the number of admissions over eight years and the rise is becoming exponential. The estimated cost of alcohol-related harm to the NHS in England is £2.7 billion based on 2006-07 prices. However, the overall cost to the nation from all aspects of alcohol abuse is £20 billion. The Exchequer gets back only £13 billion from tax on alcohol, so there is a £7 billion gap. We just cannot leave that unaddressed. Amendment 72 would insert a new subsection to state that one of the steps that local authorities and the Secretary of State might take to improve public health is,
“providing services for the prevention and treatment of harmful drinking and alcohol dependence”.
In Clause 9, local authorities will take new responsibilities for public health. As PCTs and strategic health authorities are abolished and their responsibilities are transferred to clinical commissioning groups and the Commissioning Board, there is a need to make sure that nothing falls through any gaps. Local authorities’ new public health responsibilities will be supported through their ring-fenced budget of £4 billion, which we have already heard about. However, at present they are unaware of how much funding they will actually receive, and there is a real danger that, with a squeeze on local government’s finance, the budget may be used to fill other gaps within the increasing number of responsibilities that local authorities will be taking over.
The Bill does not specifically state that local authorities will have responsibility for alcohol services, but those of us who have put our names to these amendments are keen to see that in the Bill. It has to become a statutory responsibility, given that the problem is evergrowing. The Department of Health’s consultation on commissioning and funding routes for public health stated that the commissioning of treatment, harm reduction and prevention services for alcohol and drugs will be the responsibility of these local authorities.
The public health outcomes framework includes outcomes on the rate of hospital admissions per 100,000 for alcohol-related harm, and the NHS outcomes framework includes a measure of the mortality rate among the under-75 age group from liver disease, based on a set of conditions where alcohol contributes to 50 to 60 per cent of liver disease overall in the country.
The voluntary sector providers of alcohol services risk a disinvestment in their services if they are not given sufficient priority. They find that their services are already often marginalised and stigmatised because they are dealing with a marginalised and stigmatised group. Some alcohol services that are currently funded by the National Treatment Agency for Substance Misuse will be integrated into Public Health England, and the future of its funding is unclear.
Alcohol services have tended to be a Cinderella in public health, with smoking and illegal drug misuse tending to be prioritised over alcohol. I completely welcome the emphasis on smoking cessation and tackling illegal drug misuse but I regret that alcohol has slipped past and the problem has escalated in the process.
To put this into perspective, on average £136 is spent on dependent drinkers, compared with more than £1,300 on dependent drug users. Yet we know that the social toll on the health, particularly of children in families where there is a problem drinker, can be as great as the toll where drug abuse is going on. The cost of smoking has been estimated to be £2.7 billion a year, which is the same as the cost to the NHS of alcohol. The problem is no smaller than smoking.
The wording in Amendment 202 is designed to ensure that clinical commissioning groups have a duty to make reducing alcohol-related harm a priority. General practitioners have a crucial role to play in identifying, assessing and referring people with alcohol use disorders. General practitioners have tended to under-identify alcohol misuse and, unfortunately, GPs identify only about one in 67 males and one in 82 females who are hazardous and harmful drinkers. Detection in general practice is currently woefully inadequate. Less than one-third of GPs use an alcohol-screening questionnaire.
The Government have indicated that 15 per cent of QOF funding will be assigned to public health and primary prevention indicators from 2013. All the proposed public health indicators are focused on smoking, and the indicator for screening for alcohol misuse has to date been rejected. There is strong evidence that brief intervention and advice in primary care can lead to one in eight people reducing their drinking to sensible levels, so it becomes a very cost-effective and clinically effective intervention. That has been demonstrated in 22 randomised control trials, so there is a very high level of evidence for this clinical intervention.
Amendments 238 and 239 are designed to ensure that the joint health and well-being strategies takes into account the drinking levels in the local population and, in preparing those strategies, that the people who have experience in alcohol services are involved. The joint strategic needs assessment must include an examination of levels of hazardous, harmful and dependent alcohol use in the population and must widen the scope of the local authority with its partner clinical commissioning groups in preparing the health and well-being strategy to include alcohol service representatives.
These joint needs assessments will be very important in underpinning the overall direction taken with funding and commissioning services. That is why Amendment 331 requires health and well-being boards to include expertise in alcohol and drug services in the preparation of reports and strategies on the health and well-being boards. It is worth noting that the criminal injury compensation from alcohol-related injury alone is substantial and is a cost that we are handing on to the next generation. There is also a cost to the private sector from alcohol abuse, which comes completely outside any health costs, such as when premises are damaged, sometimes very severely and set on fire in alcohol-fuelled criminal activity.
Overall, integration is essential. If we are going to spend £400 million per annum on dealing with alcohol-fuelled injury that results in hospital admissions and violent woundings, one must remember that that is only the cost of those that have been recorded by the police. The actual cost just from injuries and woundings is possibly twice that. With an overall cost of £21 billion to the public purse from alcohol abuse, I suggest that this cannot be ignored in the Bill. I beg to move.
Baroness Hollins
My Lords, as my noble friend Lady Finlay has eloquently explained, alcohol misuse is one of the major public health challenges that we face in the UK. It causes wide harm to individuals and places a significant burden on the National Health Service. Even more widely, it has a devastating effect on families, on communities and within wider society, and it is vital that the reforms to the NHS are effective in helping to address this challenge. This is an important debate in an uncertain time for alcohol services. I understand that local authorities are set to commission alcohol services out of their ring-fenced £4 billion budget, but there is no guarantee how much of that will go to alcohol services. Furthermore, public health is a wide-ranging area and there are concerns that alcohol services may have to compete with wider public health initiatives.
I hope that the Government will use this important opportunity to show how alcohol services will be prioritised in the reforms. I know that one particular opportunity lies in the Government’s alcohol strategy which is expected in the near future. I would welcome a commitment from the Government that this strategy will make clear how alcohol services will be made a priority in local authority delivery and in primary and secondary NHS care. At the same time primary care and the new clinical commissioning groups will need to continue to play a key role in screening and treating people with alcohol misuse problems, and it is vital that they are incentivised to do so.
The quality and outcomes framework is a vital primary care lever to ensure that GPs prioritise specific conditions. At present there is one very limited QOF indicator on alcohol to provide lifestyle advice to patients with hypertension. The Government have indicated that 15 per cent of the QOF funding will be assigned to public health and primary prevention indictors from 2013. However, at present all of the proposed public health indicators are focused on smoking, and the indicator on screening for alcohol misuse has, regrettably, been rejected.
What is clear is that integration of services will be the key to ensuring that people with alcohol misuse problems are not lost in the system and that the various agencies involved in care work together. The amendments in this group make the important case that people who understand alcohol misuse and alcohol services should be involved in health and well-being boards and in producing health and well-being strategies. Health and well-being boards seem to present significant opportunities ahead, but only if alcohol is made a clear local priority.
Lord Wigley
My Lords, I rise with some trepidation as this Bill applies to England only, although there are some consequential effects on Wales. As I was speaking in Grand Committee on the Welfare Reform Bill upstairs a moment ago on initiatives in Wales which should be copied in England, I hope that initiatives in this area will be copied by the National Assembly for Wales and I very much hope that the spirit of the amendments, some of which I have my name alongside, can be taken on board by the Government, even if the wording is not perfect.
I welcome the address made by the noble Baroness, Lady Finlay, in opening this debate and pay tribute to the work that she has undertaken in this context, which is recognised all round. I come from a generation in Wales where we used to have to smuggle ourselves out to the pubs because of the general ban on alcohol that used to exist. In previous generations, understandably and rightly, there had been a clamping down on alcohol use in Wales. My parents’ generation referred to whisky, for example, as medicine and very rarely used it. In fact, the pledge was a general feature of society there. My generation was responsible for a movement in another direction. The pendulum swung and is still swinging in that direction and it is time to start it swinging back.
I have no doubt at all that alcohol is one of the greatest problems that we have in our society today. I say that not as a teetotaller although I restrict myself two months of the year to not touching the stuff because it is so important that we have self-discipline as well as discipline that may come from the statute book. But in terms of violence, the break-up of families, poor performance at work—one remembers David Lloyd George’s initiatives in the First World War to try and clamp down on alcohol because of the effect on the war effort—criminality, injuries and the pressure on accident and emergency departments in hospitals, and the social disruption that arises from it, we can see the effect all around. The effect seems to be hitting people younger and younger. Children at the ages of 11, 12 and 13 are showing the effects of alcohol. That cannot be acceptable.
I realise that in an area of social responsibility such as this it is sometimes difficult to legislate. However, there must be pressure to turn the tide in another direction. Amendment 202 refers to establishing a duty to reduce alcohol harm. Amendment 328 covers the assessment of alcohol damage in local communities. Amendment 329 would provide appropriate places for representatives of alcohol services. These modest steps, taken together, would add up to a message that would come across. I implore the Minister, even if he cannot accept the amendments, to accept the thrust of the argument that lies behind them, because we have to do something about this great scourge of our society today.
Lord Brooke of Alverthorpe
My Lords, I hope that the noble Earl will accept these amendments. In many respects they are very modest. I have grave doubts about the extent to which we will be able to influence the course of events in this arena with the changes that we have before us. I am grateful to him for responding in his long letter of 20 October to all of us who raised a variety of questions at Second Reading. He endeavoured to address some of the topics that I had raised on alcohol, labelling, licensing and so on. However, I still believe that ultimately the major issues on alcohol policy will need to be addressed at the centre.
One can do nothing about the cost of alcohol at local level. It must be done centrally. That is being addressed—but inadequately. The marketing of alcohol is something over which local authorities and well-being boards will have no control whatever. The drinks industry is increasingly marketing on the internet and targeting youngsters, particularly in the social networking sphere. I heard recently that one-third of young girls aged 13 to 16 surveyed in Essex are suffering blackouts from excessive drinking. If they continue to drink like that, they will not be ill immediately—they will have good fun and games—but within 10 years, when they get to their late 20s, they will have real problems. What will health and well-being boards be able to do about that? I have been pestering the noble Earl on the labelling issue for quite some time. Nothing can be done about that at local level.
There is one issue that we could have done something about at local level, but we missed our chance. The noble Lord, Lord Clement-Jones, will recall that when we debated the Police and Social Responsibility Bill, we addressed the freedom that people now have to issue licences on a much more liberal basis than used to be the case—we now have a proliferation of off-licences everywhere—but were unable to effect any changes that would have given local authorities greater powers to limit the way in which licences are granted locally. Again, nothing can be done by health and well-being boards.
These are major topics and I wonder how much power there will be to change the course of events. These issues all link to related topics such as obesity and diabetes. It is important that we do not delude ourselves into believing that there will be massive changes without a strong drive from the centre. The nudge-nudge approach will not work with the big drinks industry. Neither, as the noble Baroness, Lady Williams, mentioned this morning, will it work in the context of food, with salt, fats and sugar. These are real problems for people and very little change will be effected at local level; it must all be done centrally.
I come back to the amendments before us. They are very modest and I see no reason why they cannot be accepted. In particular, I will look at the endeavour to achieve change at GP level. Many GPs have been very innovative. Initiatives have been offered to them to effect changes and a number of them have taken up the cudgels and worked adventurously to identify the problems at local level in their communities. Many more have not been doing anything like what should have been done. The Government have declined to accept the screening possibility that was mentioned. Again, I hope that they will be prepared to review their position on that.
Overall, I urge the Government not to reject the modest changes here, but to accept the amendments.
Lord Turnberg
My Lords, I should like to speak to the amendments in the name of the noble Baroness, Lady Finlay of Llandaff, and others. I do not think that it is necessary for me to reiterate the dangers of excessive alcohol consumption. The damage done by alcohol is obvious to anyone who visits an A&E department on a Friday or Saturday evening—and indeed, now, almost every evening during the week. It is the cause of more than 1 million admissions a year to hospitals—that is, admissions to hospital beds, not to the A&E department. Liver disease is spiralling out of control. All of this has been described very eloquently by the noble Baronesses, Lady Finlay of Llandaff and Lady Hollins, and other noble Lords.
I want to concentrate on the sort of things that we might be doing—in addition to the things suggested, very modestly, in these amendments—with regard to two aspects, prevention and treatment. It is pretty obvious that the system of voluntary pledges with the alcohol industry does not work. It has not yet worked, and does not look like it ever will. The drinks industry is not in the business of reducing alcohol consumption. We cannot suggest that it is. We have tried the voluntary pledges system, and it is obviously not having an impact.
I agree entirely with my noble friend Lord Brooke of Alverthorpe that we need a national strategy. We cannot rely on local authorities alone. In any national strategy, I fear that we have to focus on the price of alcohol. Our history has shown that every time the price of alcohol goes up, the incidence of liver disease and death from liver death goes down. It is the most effective measure. The Government have suggested that we should look at the minimal unit price, which is the price based on VAT and duty, as the minimal level. That is a pretty pathetic level and it does not work. I am reliably informed by Sir Ian Gilmore, who is a guru on the effects on alcohol, that this price measure affects no more than one in 4,000 drinks that are on sale. You have only to go to the supermarket. It is still possible, for example, to get three litres of 7.5 per cent cider—which is the drink of choice of many—for £2.99, and if you are lucky you can get a two-for-one offer, too. Price is critical. It is clear that the Department of Health is not responsible for pricing, duty and so on, but it must put pressure on for a rise in the price. It is not very popular with journalists, and it is even less popular with politicians. Nevertheless, it is an important measure.
I shall talk about treatment. There is no doubt that the best results from treatment come where there is an integrated team approach to patients suffering from the effects of severe alcohol ingestion. That is a team which combines specialist nurses, specialist doctors, primary care doctors and their team in an integrated way. A good example of that service is the one run by Dr Kieran Moriarty in Bolton. It is a very good system. Unfortunately, there are too few of those sorts of arrangements available. We need many more. They work, because you can actually do something with them. You prevent further damage from alcohol by aborting the effects of alcohol very early on. It works.
There is a lot that is needed, and a lot that can be done. We certainly cannot rely on the drinks industry to put up the price. We have to do something nationally. We have to enhance the alcohol services. I hope we can see some action here. I support these amendments as a first step.
Baroness Masham of Ilton
My Lords, providing services for the prevention and treatment of harmful drinking and alcohol dependence is essential. Alcoholism ruins many lives. There is a very worrying rise in liver disease, especially among young women, caused by a combination of hepatitis C, which we have discussed today, and dangerous levels of drinking. It is causing great pressure on hospitals’ liver disease wards.
Those in young offender institutions and prisons have often been involved in domestic violence, drink-driving, fights and violent crime due to too much alcohol. For years, prisons have had money for drug-abuse rehabilitation, but very little for alcohol misuse, although the problem has been bigger. As a result of the problems alcohol contributes to crime, I hope that the Government will try to promote alcohol-misuse rehabilitation in prisons. It should not be left out.
Huge pressure is put on the staff of A&E departments, especially on Friday and Saturday nights, by alcohol abuse. One young doctor who works in an A&E department here in London told me the other day that he was concerned that it took so much longer to attend to patients who were drunk that he felt that some other patients were being put at risk. Alcohol abuse can cause all sorts of problems. It should have concerted effort spent on it. Many voluntary organisations help with alcohol-abuse rehabilitation, but the private centres are very expensive and are not available to most people. There is also the problem of coaddiction to drugs and alcohol which has affected many young lives.
Lord MacKenzie of Culkein
I have put my name to Amendment 202 which deals with general practitioners. I do not intend to detain the Committee because the points I was going to make have already been eloquently made by the noble Baroness, Lady Finlay of Llandaff, and others. I want to reiterate the point about general practitioners not identifying alcohol misuse. For the life of me, I cannot understand why there is no quality assessment framework indicator for screening for alcohol and why that is not part of the programme. There is evidence that screening works, as the noble Lord, Lord Brooke of Alverthorpe, said. It is clinically cost-effective. There is an urgent need to prioritise the issue of alcohol abuse, and this amendment gives us that opportunity. I hope that the Minister will be able to say something positive about that this evening.
Lord Northbourne
I rise to support the amendment moved by the noble Baroness, Lady Finlay. One thing that has so far not been mentioned is that it is important to think about the alternatives to alcohol and to regular alcohol use. I used to spend a certain amount of time with very disadvantaged young people, and a great deal of their problem was boredom, inferiority complexes and no belief that there was any real future for them, so let us also think about all sorts of other things that they might be doing.
Lord Rea
My Lords, as a former GP, I echo the words of my noble friend Lord MacKenzie. Screening for alcoholism should be added to the QAF measures in view of all the reasons that have been eloquently adumbrated by other people. I want to raise a fairly basic problem which is the cost of alcohol services. At the moment, a lot of these are funded as outreach programmes by PCTs, and those are going to be transferred to local authorities. They will have to be paid for out of the index-linked £4 billion-odd that is going to be given to local authorities for this purpose. Perhaps the Minister could say whether the actual cost of running these alcohol services is being taken into account when considering how that £4 billion is going to be calculated. There are also plenty of other services being transferred to local authorities.
Baroness Thornton
My Lords, I rise to comment on these excellent amendments, and to support my noble friend Lord Beecham who has his name against Amendment 71. Amendment 71 is one of those very small amendments that changes “may” to “must” but it is actually at the heart of this discussion. What we are talking about here is how national campaigns will be linked to local action, and how they will be funded.
I start by reminding the Committee of some of the key components of this Government’s health policy on the harmful use of alcohol: banning the sale of alcohol below cost price; reviewing alcohol taxation and pricing to ensure that it tackles binge drinking without unfairly penalising responsible drinkers, pubs and important local industries; overhauling the Licensing Act; local authorities having more powers to remove licences and refuse grants that are causing problems; allowing councils and police to shut down establishments; doubling the fines for underage alcohol sales; and local councils being able to charge more for late-night licences.
My noble friend Lord Brooke put his finger on it, as did my noble friend Lord Turnberg, when he expressed scepticism as to the efficacy of these when you link them to the responsibility deal pledges on labelling. As part of the public health responsibility deal agreed with the Government in March 2011, UK alcohol beverage companies have pledged—that is an interesting word to use in this context—to implement a health labelling scheme to better inform consumers about responsible drinking. This pledge is in line with the industry’s response to the Department of Health’s consultation in May 2010 on options for improving information on the labels of alcoholic drinks to support consumers in making healthier choices in the UK. I do not think this is going to work.
Will the Government be reviewing their national campaign on alcohol and the misuse of alcohol in the light of this Bill? We have a national policy and a campaign, presumably run and directed by the Secretary of State for Health through the public health agency within the department. We have to look at what will actually happen on the ground and indeed address the dangers or risks that are posed by this Bill. A key question is the distinction between primary prevention and secondary prevention, which is complex in relation to the prevention of alcohol misuse. It is a concern when interventions cannot be clearly delineated as primary and secondary prevention. It seems that the reforms being proposed here will make that worse, not better.
Multiple commissions across one therapy, such as alcohol misuse, may cause uncertainty over who is responsible for funding services considered for both primary and secondary prevention. The worst case scenario is that neither the directors of public health nor the GP consortia commission secondary prevention services because the directors of public health are focused on primary prevention, awareness and information, the GPs are focused on treating the physical complications and harms relating to alcohol, and the hospitals are mopping up the people who turn up needing treatment for alcohol abuse.
If we are to tackle the fact that the number of hospital admissions was over a million in the last year, and that it is estimated to cost the NHS £2.7 billion a year—almost twice the equivalent figure for 2001, with the costs to society being even greater—there has to be co-ordination between national and local, and some direction about how these programmes will be carried through at local level. On these Benches we are therefore very sympathetic to what we see as a series of rather modest and focused amendments. We hope that the Minister will be able to look upon them with some sympathy.
Baroness Northover
My Lords, Amendments 71, 71A, 72, 74A, 202, 328, 329 and 331, make alternations to local authorities’ new duty for public health. In introducing this group, the noble Baroness, Lady Finlay, has made a very powerful case, as one would expect from somebody who has campaigned for a very long time in this area. Clearly, the harm caused by alcohol is unacceptably high, and everyone has to play a role in reducing its harmful use. She is absolutely right in her campaign on this. As she says, 1.1 million hospital admissions were alcohol-related, out of a total of 14 million admissions, at a cost of £2.7 billion. It is of course extremely striking that 13 per cent of 11 to 15 year-olds reported drinking in the last week. I am acutely aware of the particular vulnerabilities of children and young people in this regard. The British Crime Survey suggests that alcohol is linked to half of all violent crime, so you can see the significance of what we are talking about here.
Can I assure the noble Baroness, Lady Masham, that indeed, we are very acutely aware of how many prisoners have alcohol problems, as well as drug and mental health problems? As a Whip in the Ministry of Justice, I can assure the noble Baroness that we regard this as extremely important and that we are seeking to tackle it.
Local directors of public health in local authorities will have a key role in tackling alcohol harm. Can I assure the noble Baroness, Lady Finlay, that this will need to be addressed at every level of the health service and public health? That is why it receives such prominence in the paper that I referred to earlier. Again, I refer to the fact that public health, itself in the past very much a Cinderella service, is now at the front and centre of these changes. We hope that the involvement in local authorities will help to change this.
There are a number of steps that need to be taken; I would like to flag up some that the Government are taking at the moment. The noble Baroness, Lady Thornton, made reference to a number of these, and we are fully aware that this is a range of things, and that neither this Government nor the previous one, in all the range of things that we have undertaken so far, have made a dent in this problem. We recognise that this problem is driven by economic and social change, and it needs to be addressed in that regard, and understood very fully. In terms of relevant things which are happening, local directors of public health and local authorities will have a key role in tackling alcohol harm. We know that engaging with those drinking above the lower risk guidelines early on, and providing advice or referral for treatment for those who need it, does work, and that that is helpful.
While the health services have made improvements, much more needs to be done to identify consistently early signs of drinking above the lower risk guidelines, and to offer advice whenever and wherever the opportunity arises. I know how difficult this is with teenage children.
The coalition’s programme for Government, to which the noble Baroness, Lady Thornton, referred, committed to a ban on the sale of alcohol below cost. It also committed to review alcohol taxation and pricing to ensure that it tackles binge drinking. The Treasury published its review of taxation on 30 November 2010 and set out changes to duty on beer.
I hope that the noble Lord, Lord Turnberg, will be reassured that we will bring together the Government’s approach in an alcohol strategy, which is to be published towards the end of this year. We are reforming the Licensing Act via the Police Reform and Social Responsibility Act to enable local communities to ensure responsible retailing of alcohol. Also mentioned was the consultation on the public health outcomes framework.
Lord Turnberg
In the review that the Government are undertaking, will they take note of the publication on alcohol by the Academy of Medical Sciences, produced by Sir Michael Marmot two or three years ago? It recommended a whole series of things to do. Unfortunately, the Government of the day sexed it down and we were not able to move much further with it. I hope that this Government will take it into account.
Baroness Northover
I note what the noble Lord has said in regard to his Government. I would be astonished if those working on this strategy were not bearing that in mind, but I will check. I can assure the noble Lord that, in the unlikely event that they are not, I will bring the review to their attention so that they can factor it in.
The noble Lord, Lord Rea, asked whether the current spending on alcohol is included in local authorities’ funding for public health. I can assure him that that is the case and that what is being spent by PCTs on commissioning alcohol services will be reflected in the resources transferred to local authorities.
Amendments 66 and 72 would add,
“providing services for the prevention and treatment of harmful drinking and alcohol dependence”,
to the list of steps that the Secretary of State and local authorities may take under new Sections 2A and 2B. However, the Bill already gives the Secretary of State and local authorities the ability to take appropriate steps to address harmful drinking. The new public health responsibilities in this Bill give local authorities a ring-fenced grant to ensure that local authorities have the resources to deliver their public health responsibilities, including alcohol misuse services. Obviously, there was discussion of that ring-fence grant previously. I think it is a move forward that, instead of public health being part of the overall NHS and subject to being raided, there will be a ring-fenced grant.
Clinical commissioning groups are already under a duty—under Section 3 of the NHS Act, as amended by Clause 10, and under new Section 3A—to commission services as they consider appropriate as part of the health service or to secure improvement in the physical and mental health of their population. Given the scale of the problem, it would be astonishing if that was not part of how they see their responsibility.
I can further reassure your Lordships’ House that the importance of services which reduce alcohol-related harm will not be overlooked. The Secretary of State will set the strategic direction of the NHS through the mandate to the NHS Commissioning Board. This should be the route for highlighting priorities for the health service and I have no doubt that debates in Parliament, such as this, and in the wider sphere will help to influence that.
Amendments 328 and 329 would require joint strategic needs assessments to include an assessment of alcoholism in the local population and the involvement of representatives from alcohol services in the preparation of the joint health and well-being strategy. While we fully support the principle that the joint strategic needs assessments need to be comprehensive, we do not feel that it is necessary to include this amendment in the Bill. The scope of this assessment will naturally include the needs related to harm from alcohol. However, we have retained the power for the Secretary of State to issue guidance on the preparation of the joint strategic needs assessment. We will ensure that it covers the need to consider alcoholism, which I hope will reassure noble Lords.
Amendment 329 would require local authorities and clinical commissioning groups to,
“involve representatives from alcohol services”,
in the preparation of the joint health and well-being strategy. While there is no representative of alcohol services in the local area on the health and well-being board, it would still be able to involve experts as appropriate or invite them to be members of the board. On Amendment 331, which would require health and well-being boards to include,
“a representative from alcohol and drugs service”,
the same point applies: they could be a member of the board or their advice could be sought. The legislation sets out a minimum membership for these boards—
Baroness Thornton
I am slightly disturbed that so far the Minister has given us lots of coulds and maybes and “there is no reason why they should not”. Given the scale of this problem, I think that the Government need to look carefully at what goes on the face of this Bill and what is put in regulations about the problem of alcohol abuse.
Baroness Northover
I think that that point comes through loud and clear from this debate. I note what the noble Baroness said about what goes into the Bill or in regulation. She will know, from her experience of government, that generally speaking you do not put this sort of thing into the Bill. However, I take on board very much what she said about regulation, and I will take that back to the department.
The noble Baroness rightly focused on the joint strategic needs assessment and analysis of the current and future health and social care needs of an area. This would include the health and social care needs that are alcohol-harm related. Health and well-being boards would be able to involve people as necessary. As I said, noble Lords have made a very strong case for tackling alcohol abuse, which is very much economically and socially driven by the changes that underlie why this has come about. I have no doubt whatever that this issue will continue to dominate our debates, whether over regulation or over the Secretary of State’s mandate. This is a difficult area to tackle, as we know and as the previous Government knew, and it is best tackled as a cross-party attempt.
If only putting such matters into the Bill was a panacea. However, I am sure that the noble Baroness recognises that that is not the case. We realise that a range of measures must be taken, and I can assure the noble Baroness, Lady Thornton, that we constantly review the effectiveness of what we do. If we did not, I am sure that noble Lords would ensure that we did. I hope, therefore, that the noble Baroness will agree to withdraw her amendment.
The Archbishop of York
As the Minister resumes her seat, I would ask: if the matter is so serious, what is the problem with changing the word from “may” to “must”? What difficulty does that bring? Seeing the seriousness of the matter, why do the Government continue to say, “We will watch this”, “We will do this”, or “There will be a review of this”? This is a very simple amendment. I would have thought that they could, for once, admit and accept that the amendment be inserted, instead of postponing for some future thing. What is the real problem? I have not heard an answer to why “may” must remain and “must” must not be inserted.
Baroness Finlay of Llandaff
I am extremely grateful to the most reverend Primate for that very eloquent and sensible interjection at this stage. I know that, in responding, the Minister has tried to be reassuring, but I note that she said that the scale of the problem is such that it would be astonishing if it was not addressed.
The Minister also said that it would not be a panacea to put it into the Bill, and there I disagree because it is not a panacea putting things in legislation. We have to protect the children growing up in this country who are abused through alcohol-related harm. They are bereaved by the deaths of their parents through alcohol. They are becoming the next victims of excessive misuse of alcohol. To do that, we have to put things into the Bill. We have seatbelt legislation, which has dramatically decreased the number of children who die in road accidents. We have legislation about smoking in public places, which has dramatically decreased smoking. In Wales, we are actively looking at smoking in confined places and at legislation on domestic abuse, precisely because of the alcohol-fuelled domestic abuse problem that is escalating, as my noble friend Lord Wigley said earlier.
I am most grateful to all noble Lords who have contributed to the debate. The call for something in relation to general practitioners has been overwhelming from several noble Lords. I remind the House that secondary care is being evermore squeezed—squeezed until the pips squeak—and is taking a hit for the failure of alcohol-misuse control in our communities. That is where massive expenditure is incurred. It all seems to come together and it seems as though that is the final sump. The financial hit alone deprives other patients with other conditions from being looked after properly.
I shall not divide the Committee on this today, but I say to the Government that the failure of the Ministry of Justice to bring in pilots to control excessive drinking and drunkenness in our city centres, through allowing sentencing schemes for magistrates, has strengthened my resolve. Unless we get something in the Bill, all the strategies and persuasion in the world will not turn around this ever-increasing toll—the graph goes up and up. At this stage, I shall withdraw the amendment but I shall certainly return to it on Report. I hope that the Minister and the Bill team will engage in some constructive discussions as it would be much better for everyone to reach a compromise on this rather than to have to divide the House.
Lord Ramsbotham
“( ) providing services to improve communication skills in children and adults;”
Lord Ramsbotham
My Lords, I was hoping to speak in support of my noble friend Lord Northbourne, who introduced a whole cluster of amendments which had at their heart not just parenting but the development of our children. I do not want to bore the House but my interest in this subject goes back to an occasion when I visited a young offender institution in Scotland. When I was walking round with the governor of the prison he said to me that if he had to get rid of all his staff, the last one out of the gate would be his speech and language therapist. I asked why and he said, “Because none of the children can communicate, either with each other or with us, and unless they can communicate there is absolutely nothing that we can do with them, or for them, and that includes their education, their discipline, their healthcare and indeed their general well-being”. Therefore this group of amendments—Amendments 72A, 81A, 200A, 201ZA, 327B, 327C, 329A, 331C, 333B and 91A—is all to do with getting speech and language communication needs for our children, which is the most common disability shared by children and adults in this country, put properly into the context of the Bill.
I think it is recognised that communication skills are the key life skill and the single most important factor in determining a child’s life chances. They are the means by which people form relationships and make choices and by which people access education, employment and society in general. Over the past few years—ever since I first became aware of this problem—I have been worried that nobody seems to be grasping the fact that every child’s communication ability must be assessed properly and as early as possible in life so that they can be given the best possible chance.
Following that experience in the young offender institution I was responsible for a two-year pilot with speech and language therapists in two young offender institutions. This pilot proved conclusively that if an assessment had been carried out much earlier those offenders may well have not ended up in the institution and that a very large number of them would not have been excluded or evicted from education because they would have been able to engage with their teachers. I have therefore been trying to interject in various education and justice Bills over the past six years the need for such an assessment to be built in to the education of this country. It is interesting that Northern Ireland has listened—now every child there is assessed for their communication skills at the age of two. That might be very early but, on the other hand, it also identifies potential problems. The amelioration of those problems can then begin early enough for the children to be able to engage in education.
Unfortunately, although that need has been accepted in education and justice Bills, nothing has happened because neither the education nor the justice department is responsible for funding those who have to make the assessment. Indeed, in 2005, when this pilot scheme came to an end, the Minister—Mr Paul Goggins—was invited to examine the funding of the possible provision of assessment. He could not work it out because neither the Ministry of Justice nor the Department for Education was willing to fund. When it came down to it, we found that individual speech and language assessors were the responsibility of individual primary care trusts around the country. Some of them decided that the assessors were essential and some of them did not and, therefore, it became a postcode lottery.
If we accept that communication difficulties severely limit an individual’s participation in education, in the world of work and in their family and community life then it stands to reason that unidentified speech and language problems can pose a secondary challenge, as they lead to diminished social skills, poor educational outcomes, anti-social behaviour, unemployment and mental health problems. In other words, all the factors that arise from a failure to assess communication skills and to enable people to communicate as well as possible can become a public health issue. I believe that it should be regarded as such, which is why these amendments mention the need for those who are responsible to have an integrated approach in order to ensure that all the relevant healthcare professionals liaise with each other and make certain that every child is given the proper start in life to enable them to engage with all the things that follow. This will require liaison with education and other authorities. I am not going to list all the various things that speech and language therapists can do, but one of the problems at the moment is that the assessment in many places is left, for example, to district nurses who have been trained by speech and language therapists. That is fine, except that we are told that the funding for speech and language therapists is to be cut and therefore it may be that their ability to train those who carry out these assessments will be inhibited.
I ask the Minister to ensure that this issue is examined properly and that the various authorities should be instructed to make these assessments in order to make certain that all our children can access that vital education and the other factors that will make their lives either possible or a failure. I beg to move.
Baroness Massey of Darwen
My Lords, I shall speak to Amendment 97. I agree with the noble Lord, Lord Ramsbotham, about the need for communication skills, but this set of amendments is really all about improving services for children. It is interesting to note that so much has been said during our debates on the Bill about the importance of the co-ordination of services of all sorts, but I would suggest that nowhere should services be better co-ordinated than those for children. That is absolutely crucial to success. I was interested to read the letter sent by the noble Earl, Lord Howe, after our previous sittings. He kindly circulated a series of paragraphs which stated on children’s issues that:
“We are determined to build in children’s health explicitly and clearly throughout the new system, including through the mandate … We want the NHS to play its full part in safeguarding and promoting the welfare of children and we expect the NHS to continue to improve processes for protecting children”.
I welcome those words, but I will seek further reassurances from him on their validity.
In amending Clause 20, I want to ensure that the Secretary of State will publish an annual mandate specifying the objectives that the NHS Commissioning Board must seek to achieve. This amendment would require that the mandate includes objectives related to improving services for children.
Children and young people are significant players in NHS services. Children account for around 40 per cent of the workload of GPs while making up 19 per cent of the population. Around 26 per cent of those attending A&E departments are children. Every year, about one in 11 children receives specialist out-patient care in hospital, while one in 10 to 15 is admitted for in-patient care. All these are key statistics. However, I suspect that while children and young people make significant use of NHS services, they and their families are often let down by a health system that is incoherent and affords only a low priority to child health services. I want to see this improved. Noble Lords may remember that Sir Ian Kennedy, when reviewing child health services, concluded that there was a,
“varying quality of services … with a large number in need of significant improvement”.
He also said that children were given a low priority when compared with adults, that they often received inappropriate or poor quality treatment or had to travel long distances. He identified a lack of co-ordination between the NHS and other services such as education provision. The question of co-ordination between services is something which comes up all the time. He also pointed out the low investment in services for the early years and a failure to provide safe environments within NHS settings.
I realise that there are particular challenges for children and young people with complex needs. Often little attention is given to how the system delivers for disabled children and young people, but I shall leave it to my noble friend Lady Wilkins to address that. The support group, Every Disabled Child Matters, highlights the range of challenges faced by disabled children and their families in securing good healthcare, but again I shall leave the detail to my noble friend.
The NHS mandate must include priorities for child health. This would ensure that tacking these issues is made a priority within the health service. It is appropriate to include objectives for children's health, because child health services operate on a separate system to those of adults, with separate structures and relevant partners. For example, children receive support from a wide range of child-specific professionals, such as health visitors, community paediatricians, children's nursing services and specialist treatment centres. So again the issue of co-ordinating according to age comes up strongly.
The difference between child and adult health structures is very much demonstrated when disabled young people make the transition from child to adult services, as indeed when other children make the transition to adult services. Without specific objectives for the issues in the system for children's health, there is a concern that the mandate will be ineffective in achieving change for children and young people. So I hope that the Minister will be able to respond positively to this. I suggest that the Government should amend Clause 20 to ensure that the NHS mandate sets out priorities for improving services for children and young people. They should also publish a policy statement setting out how it envisages the revised reforms will deliver improvements for children’s health in general.
Baroness Wilkins
My Lords, I speak to the amendments to which I have added my name, and urge the Minister to ensure that speech, language and communications needs are treated as a core public health issue in this Bill.
As the noble Lord, Lord Ramsbotham, said, communication is a basic life skill which underpins everything we do, particularly in this House. Good communication means that we connect with other people; we share ideas, thoughts and emotions and forge the relationships which all people require. Indeed, UNESCO believes that effective communication is one of the 10 core life skills that all human beings should have if they are to thrive.
Speech, language and communication needs are the most common disability experienced by children or adults, with over 20 per cent of the UK population experiencing problems at some point in their lives. These difficulties often start from birth. It is sobering to note that in some parts of the UK, particularly areas of social deprivation, upwards of 50 per cent of children are starting school with poor language skills, and poor language is linked to poor behaviour in young children. Two in every three language-delayed three year-olds have behaviour problems. Problems in later life follow with poorer employment prospects.
The earlier that any communication difficulties can be identified, the earlier solutions can be found, and the earlier help can be delivered. The centrality of communication is why this group of amendments focuses on establishing effective joint working and integrated commissioning for speech, language and communication needs. It requires the NHS to work in close partnership with education providers and local authority children's services. This is by far the most effective way of working. It also emphasises how important it is to deliver help early.
Amendment 81A to Clause 12 requires the NHS Commissioning Board to conduct an assessment of pre-school age children's communication skills. The impact of communication problems and their significance underlines why we believe that their assessment should be directed centrally by the board and not left to the local discretion of clinical commissioning groups. Last year's review of children's services within the NHS conducted Sir Ian Kennedy found that GPs, who will be the lead commissioners for clinical commissioning groups, have little or no experience of paediatrics as part of their professional training. Indeed, GPs often have a limited understanding of children with speech, language and communication needs. Central direction and support from the NHS Commissioning Board is vital in this. Further amendments within the group underline this point by requiring clinical commissioning groups to exercise their functions with a view to improving communication skills in children and young people. They must do so in close partnership with education or children's services. Currently people with speech, language and communication needs all too often miss out due to the divide in commissioning between health and education services.
This divide can mean that resources in terms of skills and equipment are not used effectively. Integration is vital to maintain and improve outcomes. The final two amendments within the grouping also address the necessity for integrated working by the new health and well-being boards when seeking to advance the health and well-being of the local population of the area they serve. If we are to move forward and ensure that all children and young people with communication problems are given the support they need to address them, then I would urge acceptance of these amendments.
Baroness Armstrong of Hill Top
My Lords, I am sorry that the noble Lord, Lord Northbourne, was not here to move his amendment. However, I think that the general principles that the other amendments in this group address are very much what I want to bring to the attention of the House and the Minister. We now know so much more about the development of children. In the 18th and 19th centuries there was a great amount of dirt and other problems in the streets. This aspect of public health was taken up by municipal authorities, which had to build drains and sewerage. It was seen as critical to the future of this country. It also, of course, had an important effect on people’s health.
We now know much more. In my last job in government, I was the Social Exclusion Minister and had the enormous privilege of introducing to this country the Family Nurse Partnership Programme. In learning about that evidence-based programme, which affects the development of children more advantageously than any other single programme in the world, I discovered a little about what neurologists and others now know about brain development. The truth is, if we do not support parents and children in those early months and years, by the time they are three, they are so far behind it will take the rest of their lives to compensate for what they have not had in those early months.
I listened to the debate on alcohol and wanted to intervene. In family nurse partnerships, mothers learn that if you drink alcohol in pregnancy, it will affect the brain of the foetus and therefore the child. It has been incredibly successful, therefore, in giving young women the determination not to drink, because they want the best for their child when it is born. These are all things that we now have a lot of knowledge about.
Recently, I was at a meeting where a neurologist talked about research into the stress put on children and what elements in the body can be measured to tell whether or not there is stress and what can be done about it. Stress can lead to violence and violent behaviour. We know about these things, but they did not know about them in the 18th century, when they began talking about public health. We did not know about it when I was growing up, but we know about it now. That means we have a responsibility to take it into account and build the early development of children into our understanding of public health. We must make sure that we address it. It should not be until we get to extremes, when suddenly somebody notices that a particular child is developing in a difficult way, such as noble Lords have talked about, when children end up in the criminal justice system. We know what will happen to children if we do not pay attention to this: they will end up in the criminal justice system, and they are more likely to end up with an alcohol or drug dependency. We know these things now and, in my view, we have no option but to take account of them as a matter of public health. Therefore, I believe that we have to write that into the Bill.
Baroness Whitaker
My Lords, I rise to support Amendments 72A, 81A, 91A, 200A, 201ZA, 327B, 327C, 329A, 331C and 333B—all amendments on speech and communication. I think that Amendment 218A should also have been included because it deals with integration—in this case, for the commissioning groups. I hope that when the Minister deals with that later amendment, he will be able to recall this debate.
I support these amendments very warmly for all the reasons that the noble Lord, Lord Ramsbotham, and my noble friend Lady Wilkins have set out so cogently. I should also, in this very brief intervention, like to draw attention to the excellent BBC film “The Kid’s Speech”—not “The King’s Speech”, although that was very good too—which graphically portrayed not only the crippling effects of stammering on children’s development, as well as on their happiness, but also an integrated way to deal with it, employing educational as well as physiological expertise. I commend this short documentary to anyone who wants to understand why it is so important to help these children properly early on.
The assessment and treatment of speech, language and communication problems must come within public health. I asked the Minister about this when I made a few remarks at Second Reading. However, with that vast marathon of questions, I quite understand that he did not have time to reply, although I hope that he will be able to do so at the end of this debate. The information must be accessible to those with low literacy and poor understanding. Finally, there must be integration not only with the health and social care services but also with education and children’s services, or we shall fail that very large number of children with speech, language and communication difficulties.
Lord Clement-Jones
I, too, support the amendments of the noble Lord, Lord Ramsbotham. He clearly has a great deal of support in the Committee for the amendments, on which he spoke so eloquently, as did the noble Baroness, Lady Wilkins.
I come at this as a former chairman, and now the president, of Ambitious about Autism, the autism education charity, and also as a very strong supporter of I CAN, the communications charity for children. I also strongly believe that speech, language and communications needs should be regarded as a public health issue. As both the noble Lord, Lord Ramsbotham, and the noble Baroness, Lady Wilkins, highlighted, speech, language and communication needs are the most common disability experienced by children or adults, and it is now being recognised that communication is indeed the single most significant factor in determining a child’s life chances. Because our economy has become increasingly dependent on communication-based employment, the fitness of a person in this century will be defined ever more in terms of his or her ability to communicate effectively. The economic impact on society of people whose communication disability renders them unemployable is significant and is growing year on year. As a society, we need to recognise this issue and find ways to improve the communication skills of children and adults.
As has been pointed out by the noble Lord, Lord Ramsbotham, a number of primary care trusts and local authorities in England have indeed already recognised the importance of boosting early language and communication development. They have aligned the work of speech and language therapists with the Healthy Child Programme and Sure Start children’s centres to create a powerful public health approach based on primary prevention.
However, in contrast, many commissioners—this was also mentioned by the noble Baroness, Lady Wilkins—as reported by Sir Ian Kennedy last year in Getting it Right for Children and Young People, have a limited understanding of children with speech, language and communication needs. Many of these local areas are still not doing enough to address these needs, and it is clear that the economic and social benefits of early intervention and prevention of speech, language and communication needs must be much better promoted. That is why the approach indicated by these amendments is so important and why I support them.
Baroness Finlay of Llandaff
I have added my name to one of the amendments in this group but support many of the others. The key issue is that children often need accurate diagnosis but do not get it. It is the way in which you detect learning difficulties of all sorts—sensory impairment and motor impairment. The need for a range of services integrated to support children is critical because as they grow up, unless their needs are addressed early they become greater; they do not decrease.
I shall illustrate that. A little girl, whom I shall call Emily, is eight. She was born prematurely but by the time she is eight, having had a stormy neo-natal period, she has epilepsy, cerebral palsy and swallowing difficulties. She is wheelchair-dependent, partially sighted and has communication difficulties. For her ordinary care, like other children, she needs her GP, district nurse and health visitor. For her hydrocephalus she needs paediatric neurosurgery. For her complex epilepsy she needs paediatric neurology. She needs physiotherapy because of the cerebral palsy and cramps. She needs speech and language therapy to help her learn to swallow efficiently and occupational therapists who help her to manipulate her communication device through which she communicates with her family who love her dearly and want to do the best for her.
That is one example and we have hundreds of children in our country who need integrated co-ordinated care. Perhaps Emily was lucky because she got the interventions that she needed and they were brought together. But, we also have a lot of children, as referred to in this debate, who are being missed on the way through because they do not have such clear-cut presentations. That is why, unless we use this as an opportunity to really change the way that we look after our children in health and social care in the broader context, we will be failing them.
Baroness Thornton
My Lords, this is a very important debate and the first opportunity we have had to look at the proposals affecting children. The Government’s plan is that public health services for children under the age of five, including health visiting and the family-nurse partnership, will initially be commissioned by the NHS Commissioning Board. To facilitate its plans to increase the health visiting workforce by 4,200 over a four-year period from 2011, the intention is that eventually this responsibility will pass to local authorities, which from the outset commissioned services for children between the ages of five and 19, including the Healthy Child Programme for school-age children. Maternity care meanwhile will now be undertaken by CCGs, although it was originally intended that this would be undertaken by the NHS Commissioning Board. The board will still be responsible for specialist neonatal services.
In the very helpful public health report recently published by the House of Commons Health Committee, Councillor Rogers of the LGG told the committee that the initial split of commissioning children’s public health services,
“doesn’t make sense. There is obviously a serious risk of a gap developing around the age of five, and it doesn’t make sense for school nursing to be in one place and health visiting to be in another”.
The Government’s response to the Health Select Committee was that,
“we believe that the commitment to raise the number of health visitors by 2015 is best achieved through NHS commissioning and thus will retain our existing proposal that the NHS Commission Board should lead commissioning in this area in the short-term”.
Earl Howe
My Lords, noble Lords who tabled amendments in this group have drawn attention to the particular needs of children. I am in total sympathy with their wish to highlight the importance of children's health in all its facets. The noble Baroness, Lady Wilkins, mentioned Sir Ian Kennedy's report, Getting it Right for Children and Young People, published last year. Sir Ian emphasised that the NHS does not always get everything right for children. He gave us some hard-hitting messages. I say again what I said in my letter after Second Reading: we are determined to build in children's health explicitly and clearly throughout the new system. The NHS reforms are designed to put firm foundations in place to secure improvements, and the Health and Social Care Bill contains sufficient levers to ensure that the new NHS will work better for children.
I thank the noble Lord, Lord Ramsbotham, for his very compelling contributions today and at Second Reading, when he raised questions on speech and language therapy. I commend his work as chair of the All Party Parliamentary Group on Speech and Language Difficulties. I also thank the noble Baroness, Lady Wilkins, for her extremely constructive remarks. I share the commitment of the noble Baroness and the noble Lord to ensuring the early identification of speech, language and communication needs among pre-school children. What can we do about this? One thing that we can do and are committed to doing is beefing up community health resources targeted at the well-being of children and families. In that context, I reassure noble Lords who spoke to these amendments that we are committed to increasing the health visitor workforce by 4,200 by 2015.
We are equally committed to improved delivery of the healthy child programme, which includes a development review at the age of two to two-and-a-half. That provides a huge opportunity, and we are clear that it has to be seized. Everything that has been said by noble Lords about child development in the early years is absolutely to the point. The noble Baroness, Lady Armstrong, rightly referred to the family nurse partnership programme, which has done a tremendous amount, as she explained to us, to address the needs of what were traditionally considered hard-to-reach families.
In his absence, I would also like to thank the noble Lord, Lord Northbourne, for his earlier remarks. I will take the opportunity to address his specific concerns. The Bill as drafted would already allow the Secretary of State or local authorities to provide services to parents or prospective parents where that was a step whose primary purpose was improving health. We recognise that the health and well-being of women before, during and after pregnancy is a critical factor in giving children a healthy start in life and laying the groundwork for good health and well-being in later life.
How can we do this better? The Health and Social Care Bill will, we believe, provide the basis for better collaboration and partnership working across local government and the NHS at all levels. The drivers of the integration in the NHS will be the CCGs and the NHS Commissioning Board. Both have new duties to promote integrated working by taking specific action where beneficial to patients. In addition, the Bill gives each health and well-being board a duty to encourage integrated working between health and care commissioners to advance the health and well-being of the people in its area. That would include children and young people.
The key NHS and public health contributions to speech, language and communication needs are these: first, early identification of pregnant women who may themselves have had the same kinds of difficulties and who would benefit from enhanced support in preparation for parenthood; secondly, building the capacity of universal services working with young children to provide the support required in the early stages, enabling speech and language therapists to focus their support where it is most needed; thirdly, early identification of children with speech, language and communication needs, where enhanced health visitor capacity and better delivery of early years reviews at the age of two to two-and-a-half will be a focus; fourthly, local planning and commissioning for speech and language therapy services through clinical commissioning groups; and, fifthly, consideration of how high-cost and low-volume provision should be commissioned in the new system.
The Government are also committed to tackling obesity and to the continuation of the national child measurement programme. Now in its seventh year, this is a trusted source of world-class data, providing annual information on levels of overweight and obesity in primary school children in their reception year and in year 6. The government amendments in this group amend the powers of the Secretary of State in paragraph 7B of Schedule 1 to the NHS Act 2006 so that he can make regulations about the processing of the full data set of information relevant to this programme. This would include both information resulting directly from the weighing and measuring activity and other relevant data held by local authorities. The amendments also ensure that he can require persons exercising functions in relation to the programme to have regard to guidance about the processing of that information. Our proposals aim to ensure that this important programme can continue to operate in full effect once it transitions to local authorities, along with other public health functions, from April 2013. I hope that the Committee will support the amendments.
I have discussed the vital importance of a focus on children’s needs throughout the NHS, but in our view it would not be appropriate to anticipate priorities in future mandates by enshrining in legislation the inclusion of objectives relating to particular sections of the population—a point I made earlier to the noble Lord, Lord Northbourne, while he was in his place—nor would it be appropriate to impose requirements on CCGs to exercise their functions with reference to specific patient groups or treatments. What you do not emphasise, you can serve to downplay.
CCGs are already under a duty to exercise their functions with a view to procuring that health services are provided in an integrated way for all patients where they consider this will improve the quality of health services and outcomes and reduce inequalities in outcomes and access. The duty also applies in relation to the integration of health services with the provision of health-related and social care services. Where education and children’s services are health or social care-related, they would therefore already be covered by this duty.
The noble Baroness, Lady Wilkins, and the noble Lord, Lord Ramsbotham, tabled a series of amendments concerning the role of health and well-being boards. I fully support the need to ensure the effective assessment of need and access to professional advice on education and children’s services. However, although extremely well intentioned, the amendments are unnecessary and also run counter to the principle of local areas being best placed to assess local need and to access appropriate local expertise. I hope that noble Lords will not press those amendments.
On Amendment 91A, on our second day in Committee we discussed a group of amendments on the topic of integration. There were numerous extremely valuable contributions from many noble Lords that ensured that we had a very informative debate. However, it may be helpful to the noble Lord, Lord Ramsbotham, and the noble Baroness, Lady Wilkins, if I briefly mention that the requirement the Bill places on the board and the clinical commissioning groups to promote integration when commissioning services is very germane in this context. Clauses 20 and 23 contain new Sections 13M and 14Y which create duties for national and local commissioners to promote integration across health and social care. I am thoroughly supportive of the intention behind this amendment. Better integration of services will undoubtedly lead to high quality and better care for patients, and that is why we have asked the NHS Future Forum to consider in more detail how we can ensure that our reforms lead to better integrated services. I am very much looking forward to receiving its recommendations which will be published before the end of the year. I hope that the noble Lord and the noble Baroness will feel reassured by that.
I think the tenor of the question from the noble Baroness, Lady Thornton, was about whether all children’s public health services should be commissioned at a local level from the outset in 2013 to avoid fragmenting the delivery of programmes and care pathways. We believe that the commitment to secure a 50 per cent increase in the number of health visitors and thereby ensure associated improvements in support for families is best achieved through NHS commissioning, and we have therefore retained our original proposal that the NHS Commissioning Board should lead commissioning in this area in the short term. However, we wish to engage further on the detail of the proposals, particularly in respect of transition arrangements and the best way to begin to involve local authorities in local commissioning of these services in partnership with the NHS.
The noble Baroness also referred to the important issue of safeguarding children. Local authorities will continue to lead on safeguarding children arrangements under the Children Act 2004. The board and CCGs will be members of local safeguarding children boards. I have already spoken about the national child measurement programme, and I hope that I covered the noble Baroness’s questions adequately on that topic.
The noble Baroness asked why the government amendment allowed any other information to be prescribed. The amendment will maintain the Secretary of State’s powers to regulate the processing of child measurement data after local authorities undertake the measurement programme, in the same way that PCTs currently deliver the programme. It would not be appropriate to set out the full national child measurement programme data set in primary legislation, as she will understand. The power also gives flexibility to make changes to the data collection that will be needed going forward, and that will allow the Government to ensure that the national child measurement programme remains fit for purpose. Of course, the introduction of any new data would need to be set out in regulations, subject to public consultation and the negative parliamentary procedure.
I hope that that covers the ground adequately. Once again, I thank noble Lords for their contributions. I can now see that the noble Baroness, Lady Whitaker, wishes to ask me a question.
Baroness Whitaker
It is the same question. In the noble Earl’s very comprehensive answer, did I miss whether speech, language and communication problems were within public health? I do not recall hearing him answer that question.
Baroness Thornton
While the noble Earl is collecting questions that we feel were not answered, I asked specifically about the risk register, whether it is 100 per cent of children and where the weighing and measuring is taking place.
Earl Howe
My Lords, I will have to write to the noble Baroness on that question, and indeed some of the other questions that she posed in her speech. I hope she will allow that. As regards speech and language therapy, rather than give the noble Baroness an answer that may turn out to be incorrect, I may have to drop her a note. I will write to her.
Lord Ramsbotham
My Lords, I thank the Minister for his habitually thorough and sympathetic summing up. I think we can look forward to further work on this subject. I also thank all those who have taken part in this debate, and particularly the noble Baroness, Lady Wilkins, for her words. I must apologise to the House for saying that it was district nurses who did the work; of course, it is health visitors.
I have two concerns, one of which the noble Baroness, Lady Whitaker, has just mentioned, which is the question of confirmation that this is a public health issue. My second concern is, in the words of the Minister, that this should be left to be a local issue. I am concerned about the number of issues that are being devolved to local government for it to have to decide differing priorities. That is an unfair burden in this particular issue, which I do not believe should ever be left to be a postcode lottery for the children of this country. In that spirit and bearing in mind that I shall look very carefully at what the Minister said, I beg leave to withdraw the amendment.
Lord Rooker
“( ) promoting co-operation between each of the authority’s relevant partners”
Lord Rooker
My Lords, I return briefly to the point that I made as an aside on an earlier amendment regarding the effect of local government. As this clause is drafted, it is absolutely clear that not all local authorities in England are public health authorities. It is quite clear that in the areas in England with two-tier local government, the powers and duties apply to the county councils and not the district councils. The county councils are in the same position as unitary authorities: they will be under the new statutory duty to improve the health of people living in their area; they will receive the new ring-fenced public health grant; they will be eligible to earn the new health premium; they will jointly appoint, with Public Health England, the director of public health; they will provide a place in each organisation for the director of public health; and they will operate the new health and well-being board. However, where the county councils differ from unitary authorities is that they do not have the environmental health workforce. That is with the district councils.
This significant difference to the backbone of the public health workforce, which is directly controlled by local authorities, comes from the environmental health cadre. In England, there are 27 shire counties and 201 shire districts within those counties. There are 56 unitary authorities, 36 metropolitan districts, and 33 London boroughs, which of course includes the City of London. This amendment proposes that the Secretary of State and the public health authority shall promote co-operation between each of the authority’s relevant public health partners, which are listed in Amendment 75.
The department is relying on localism. When I was in the other place, one of my boasts, rather than apologies, was that I was never a local government councillor. I love local government. It is independent and it makes a massive contribution to local democracy. But to be honest, I have never put it on an altar as a service deliverer or as a bastion of democracy. Localism, as defined and discussed, and some key issues such as public health and food safety do not go together. I have had agreement to this, even from LACORS. You are relying too much for public protection on the vagaries of all the pressures on local government. Localism and some of these issues do not go together. It is no good kidding ourselves that they will, because they will not. The noble Lord, Lord Ramsbotham, touched on that point and I am glad to reinforce it.
The department is relying on localism to argue that the county and district councils will work together to make the appropriate arrangements for the delivery of public health services. Of course, it is right; there should be flexibility. Not all the areas of England are the same. There has to be co-operation. I repeat what I said earlier on: one size does not fit all. However, a statutory duty to co-operate does not dictate that councils should design their services—it just ensures that they co-operate in doing so. It is not always the case that different levels of local government are willing to co-operate. I have to say, regretfully, that it can sometimes depend on the personalities of the political leaders of the councils. People’s services should not depend on the personalities of the individuals in charge.
There is no option available to local authorities not to co-operate with each other under this amendment. They have to work together to ensure this—but really they should be forced to co-operate. It must be in the Bill to protect those areas where personalities may intervene. The amendment is not limited to the relationship between county and district councils. It requires the public health authorities to co-operate with all the relevant public health partners, which are listed. That helps to embed the department’s requirement that local authorities should develop integrated services with other partners such as adult social services and voluntary and not-for-profit organisations.
There are precedents in recent legislation for such a duty to co-operate. I have been advised, which I freely admit, by the Chartered Institute for Environmental Health. For example, in the case of safeguarding children, the relevant partners are required to co-operate with the children’s services. Again, in the civil contingencies legislation, category 1 responders are duty bound to co-operate with and support all other category 1 responders.
This issue will not be dealt with today but we need to know the Government’s view in respect of this lacuna, almost, of treating England as though it is all a happy band of brothers and sisters and as though everyone gets on with each other in local government. Unfortunately, the two-tier mix is not planned. If England had a two-tier mix by design we might be able to have a better system, but it does not. It is almost an accident. My view is that it should be single tier, which I have probably implied. In Wales and Scotland in particular, the benefit of single-tier local government is clear for those Administrations. One way or another, Ministers will have to address this problem because it will not go away. I beg to move.
Lord Greaves
My Lords, I shall turn to Amendment 75ZA in my name in a minute. First, I congratulate the noble Lord, Lord Rooker, on putting his finger on the extremely important issue of the role of district councils where there is a two-tier local government system. I do not agree with everything that he said about local government but I agree with a great deal of what he said about the problems that we have. This legislation is designed for unitary authorities—metropolitan districts, London boroughs and the unitaries in the rest of England. The Government do not seem to have thought out exactly how it will work in two-tier areas. This is not an issue of principle or challenge to the Government. It is an attempt to make this system work better in practice when it comes in.
My amendment would remove the provision in the Bill that deletes shire districts from the definition of local authorities in new Section 2B to be inserted in the 2006 Act under Clause 9. I would argue the case for that but the noble Lord, Lord Rooker, suggests that co-operation and partnership is the way forward. My noble friend Lady Tyler has put forward an interesting amendment about the role of CCGs in local government functions and how that might work. There are other ways of looking at it. I sincerely ask the Government if we can have discussions between now and Report to thrash this issue out properly. In a sense, it is a technical matter but it may not work. In replying to a previous amendment, my noble friend Lady Northover said that we have to join up all the different areas that affect public health. The crucial word is “affect” because there is no doubt that a great deal of what district councils do affects health.
Like the noble Lord, Lord Beecham, I am sadly old enough to have been on a local authority committee, which was a municipal borough, in Colne before 1974. It was the housing and health committee, which received regular reports from the medical officer of health. The public health authorities at that time were the lower-tier authorities. While they have problems of resources and the ability to do things, again in the words of my noble friend Lady Northover, they have local insight and expertise, which has to be tapped into.
District councils carry out some duties. The Labour Front Bench amendment, which refers to retaining existing duties for districts, is important but it is an absolutely minimalist approach. A huge amount of what district councils now do are things that they do not have a duty to do but which they have taken on because there were problems and things that needed doing. They do it because they have powers but not necessarily duties.
Housing is crucial and there are still many council houses. If you are looking at listing the two or three main public health improvements which have taken place in this country in the past 100 years, the massive provision of council housing for 50 years of that time must be near the top of the list. They provided people with decent homes, decent environments and decent estates when previously they had lived in appalling slums. This has been a huge achievement, yet it was not a public health achievement; it was a housing achievement. Even now, they have their strategic role as housing authorities, which is very important even if they have pushed away their council housing to other organisations. Over the past 100 years the improvements in public health are down to improved housing conditions. Even poor housing conditions nowadays are usually immeasurably better than they were 100 years ago. This is all down to the work of local authorities. A huge amount of work still has to be done, particularly with the bottom end of the private rented sector—the sort of areas I know too well in my own ward.
All this kind of work is lower-tier local authority work. It encompasses the whole environmental health regime, which noble Lords have talked about, from food inspections to dealing with pollution and air quality. A huge improvement in public health was led by the introduction of the Clean Air Acts, which have made air breathable when, as many of us remember, it was hardly breathable. So local authorities tackled air pollution and air quality. Indeed, they are responsible for all sorts of things, such as contaminated land and pest control licensing. Of course, the lower-tier authorities are also responsible for enforcing the legislation on the prohibition of smoking in enclosed public spaces and for the whole operation of street cleansing and refuse collection—litter, dog fouling and tackling graffiti. You might think, “What has graffiti got to do with public health?” If you live in a neighbourhood that has been allowed to become run down, people are allowed to spray graffiti where they want and the whole place is rotten, the effect on people’s quality of life and their mental health is huge.
The whole of planning is about public health in many ways—the built environment, the nature of the built environment, the provision of facilities and the regeneration of areas. Leisure services and facilities, playgrounds, parks and the whole of the public realm have a huge effect. If people enjoy living in a town, a village, a suburb, a neighbourhood or wherever they live, if it is a pleasant place to live in and enhances their quality of life, their basic health will improve. The council may provide parks, playgrounds, sport and recreation activities, sports development activities, indeed the whole leisure field. However, a great deal of what local authorities do is discretionary.
In recent years, district councils particularly have taken on a lot of work on behalf of other authorities. They have been funded by PCTs and other parts of the health service, by central government and by other sources. I will briefly mention some of the projects that are going on in my own area of Lancashire at the moment: living and eating well schemes, run by the leisure trust; stop-smoking schemes; healthy workplace schemes; suicide prevention; intensive family support schemes; and schemes to reduce infant mortality by encouraging young women having children who otherwise would not go to prenatal classes to attend them and by putting them in touch with professionals. Things such as the provision of cycle racks may not appear to have anything to do with public health but, when you think of it, it is obvious that these are practical local schemes. Many such schemes are not very expensive but they are being funded at the moment through the PCTs, the health service and other bodies, and it is crucial that these kind of schemes continue.
I repeat the point I raised earlier about resource allocation. If this new system results in the district councils—the lower-tier authorities in two-tier areas—losing their funding, a lot of these schemes will not exist. What we need in all these areas is an audit of existing resources, an audit of what goes on at the moment and some kind of duty on the upper-tier authorities that will receive a lot of this money to pass the money to the district councils for appropriate schemes in appropriate places.
I do not know the best way of writing district councils’ roles and opportunities into the Bill, but I am absolutely clear that they have to be there. The present situation, in which all the Bill does is to strike them out and say they are not here in relation to public health, is not acceptable. So I ask the Minister whether we can have some discussions between now and Report stage to get this sorted out, as it is very important.
Baroness Tyler of Enfield
My Lords, I wish to speak to Amendment 79A, to which my name is attached, which is about integration in the broadest sense, including those services delivered by local authorities.
The main purpose of the amendment is to probe whether clinical commissioning groups will be expected to demonstrate a real understanding of the wider social determinants of health and to commission broader support services that improve health and well-being. It is a statement of the obvious that improvements in health are not always achieved by clinical interventions alone; they are dependent on wider determinants of health, such as housing, which is a point that has just been made most powerfully by my noble friend Lord Greaves. Therefore, housing and housing-related support deliver very important health interventions and it is important that that is recognised by the clinical commissioning groups.
I believe that there is a big opportunity here to realise efficiency savings and to improve health outcomes through better use and integration of community support. Therefore, including housing and community support, transport, education, employment support, access to sports and leisure facilities and the like, alongside clinical services, will help CCGs to prioritise early intervention that prevents more serious health problems arising for a wide range of older and vulnerable people.
Noble Lords may wonder why I put the emphasis on education and employment services, but I think that they are particularly important for those with mental health problems. They will help such people to manage their conditions and prevent them from worsening and they will help those people experiencing serious social exclusion, a point that was made very powerfully by the noble Lord, Lord Rooker, earlier. It is undoubtedly the case that truly joined-up commissioning of services can and does happen, but it is also patchy. Therefore, provisions in the Bill should make sure that the best current practice is taken forward everywhere in a way that meets local needs.
Research published by the National Housing Federation has recently shown that only 20 out of 152 primary care trusts scored highly on the previous collaborative working competency. Clearly, there is more to do here. The Marmot review, Fair Society, Healthy Lives, noted:
“This link between social conditions and health is not a footnote to the ‘real’ concerns with health—health care and unhealthy behaviours—it should become the main focus”.
I also mention the very important role that housing associations and support providers deliver in terms of preventive services and intervening early to prevent more serious problems arising. Housing-related support has been shown to be cost effective and good value for money. An independent national evaluation estimated that investing £1.6 billion annually in housing-related support services can generate savings of £3.4 billion to the public purse by avoiding more costly acute services. That included avoiding costs of £315 million in direct health costs.
Housing support services can often effectively reach out to those with little or no access to statutory services. I mention particularly homeless people who are estimated to consume eight times more hospital in-patient services than the general population of similar age and to make five times more accident and emergency visits.
I conclude by giving one short case study of a specialist provider of homes, sheltered housing and services for older people in this area. Willow Housing and Care developed a support service to help older people kept in hospital for too long because they lacked appropriate housing. The service was for patients who were ready to leave hospital, but who were not able to return home because that no longer suited their needs. The scheme diverts people away from residential care placements, saves social services delayed discharge fines and helps to free hospital beds. A support worker works with the patient and their family in hospital for two to three weeks, helping them to make choices about returning home or going to alternative accommodation, including arranging things like aids and adaptations, cleaning and ongoing care and support. The Department of Health’s own evaluation of the service has shown that, for a £40,000 investment, the service has saved £400,000 in health and social care expenditure through reducing admissions to residential care and readmissions to hospital.
I believe that this powerfully underlines the need for clinical commissioning groups to commission broader support services, both to improve health outcomes and to achieve better value for money.
Baroness Hollins
My Lords, I shall speak to Amendments 203C and 215A. Although the Bill places a duty on each clinical commissioning group to,
“obtain advice appropriate for enabling it effectively to discharge its functions from persons who (taken together) have a broad range of professional expertise in … the protection or improvement of public health”,
it places no duty on clinical commissioning groups to act at all times with a view to the improvement of public health. Such an omission will render the delivery of public health outcomes significantly less likely, with clinical commissioning groups free to act without regard to the wider public health needs of the populations they serve.
The Government’s intention to leave public health—and therefore public mental health—entirely to local authorities could mean that the opportunity will be lost for clinical commissioning groups, local authorities and national agencies to work in consort to achieve better outcomes. There is a fundamental relationship between mental health and well-being and almost all other aspects of individual and public health. Handing responsibility for public mental health solely to local authorities could have deleterious consequences for achieving good outcomes in public health more generally unless precautions are taken.
The purpose of these two amendments is to try to mitigate the consequences of this decision. They would ensure that clinical commissioning groups are required to act in such a way that they contribute to the improvement of public health—and public mental health—and are required to demonstrate in what ways their actions fulfil such an obligation.
I should also like to add my support to the amendment of the noble Baroness, Lady Tyler. I was unable to participate in the discussion about the previous group— where perhaps the comments I am going to make might have been more relevant—because of a commitment to speak at the same time to an amendment in Grand Committee to the Welfare Reform Bill, due to the rather unfortunate timetabling of that Bill.
The point that is relevant here as well is that public health relies on the relationship between so many different agencies, and I am thinking here particularly about the contribution made by education. The example I want to give is about the health of the next generation, which relies so much on the way in which children are parented. Education and support for future parents seems such a worthwhile investment. I want to give just as an example the work of the charity Teens and Toddlers. It does not work by telling teenagers to change their behaviour, because that does not work; it offers them a holistic and transformative experience which has a much greater effect. It really is a health intervention as well as an educational one. The programme allows teenagers to spend two hours a week for 15 weeks looking after a toddler in a nursery. They also spend time talking through what that experience has taught them. What is so extraordinary is the effect of the programme, which is now available in 12 London boroughs and 13 other areas of the UK. Some 97 per cent of those who graduated from the programme have not become pregnant before the age of 20, and 92 per cent have continued in employment, further education or training. I am sure that the Minister will agree that public health is so much more than the responsibility of only the local authority and the NHS.
Baroness Barker
My Lords, I want to address briefly the question that Clause 15 should stand part of the Bill raised by the noble Baroness, Lady Thornton, and her colleague on the Front Bench. At this stage I do not intend to go over the points which have already been made so expertly. I simply want to ask a simple question. Clause 15 sets out the functions and the shared duties of local authorities and the Secretary of State to improve public health. What is not clear is which duty falls to the Secretary of State and which to local authorities at any one time. What would be the trigger for an intervention by the Secretary of State? It is quite important that noble Lords should understand this as we go ahead. Would I be right or wrong to assume that it would be exceptional, rather than the norm, for the Secretary of State to intervene? Is that what the department thinks? If it were exceptional, can the Minister set out under what circumstances it is envisaged that the Secretary of State would intervene?
For example, if a local authority unilaterally decided to cut its entire funding of sexual health services, would that be regarded as something which would cause the Secretary of State to intervene? If a local authority came up with a good argument for why it should not fund such services, or there was a major outbreak of an environmental nature, would the Secretary of State intervene under additional powers? I can understand the logic of this in that both the Secretary of State and local authorities need to have powers, and those powers should be shared, but I would welcome further clarification on how these powers will be exercised both jointly and separately.
Lord Beecham
My Lords, public health started in local government some 160 years ago—and as many of us have previously remarked, it started in Birmingham or Liverpool or Newcastle, depending on who you believe. But in all events it owes its origins to local government, and as many noble Lords have already made clear, local government has made enormous strides in promoting the welfare of the community and indeed the individual through the exercise of public health functions—notably, of course, in the realm of housing.
It is because, as my noble friend Lord Rooker has pointed out, so many responsibilities still rest with district councils that his amendment, to which I have subscribed, clearly makes the case for ensuring that while we have a two-tier system in parts of the country, district councils should be involved. They have manifold responsibilities that have been exhaustively, not to say exhaustingly, adumbrated by the noble Lord, Lord Greaves, in his long list of their functions. I spotted two that for some reason he overlooked. One is noise abatement, which I am afraid is a significant health issue in many places, and the other is, perhaps more generally, community safety, which again can be a district council function. All these matters suggest that there ought to be a clear role for district councils in two-tier areas, certainly in relation to public health and, as perhaps we shall discuss at a later stage, in respect of other aspects as well. For that reason I hope the Minister will acknowledge that the amendments dealing with the role of district councils, including the amendment in my name which seeks to reaffirm that whatever else happens, the current duties relating to public health which apply to district councils should remain in place, should be accepted so that nothing in the Bill would dilute those responsibilities.
The noble Baroness, Lady Hollins, has made a good case in Amendment 203C for clinical commissioning groups to promote public health. I do not purport to understand the groupings here. This is no reflection on the noble Baroness, but it seems to me that the other amendment would have been better placed in the debate around clinical commissioning groups rather than here. The words “public health” have registered, so the amendment seems to have been plonked here, it might be thought somewhat inappropriately. Her argument, of course, is absolutely valid, but it is perhaps slightly unfortunate that that amendment has been placed in this group.
I have to say much the same about Amendment 79A, tabled by the noble Baroness, Lady Tyler. There are, if I may say so, two things wrong with the amendment. First, it really talks about providing commissioning consortiums—or, as they are now called, clinical commissioning groups—with responsibilities. That, again, is in the wrong place, but even if it were in the right place I would find myself in difficulties supporting it, because it seems to set up a parallel system with local government. It would invest in clinical commissioning groups the possibility of commissioning a range of services:
“housing or housing related support … education and employment … transport and leisure services, and … other health-related services”.
That last item I can understand, but the other three are primarily local government responsibilities. The implication is that either they would effectively take over or jointly commission services, in addition to local government. That is misconceived and likely to blur the position very significantly. So if the amendment were likely to be pressed to a vote, I could not find myself in the same Lobby as the noble Baroness. However, I apprehend that she will not be pressing it to a vote.
The noble Baroness, Lady Barker, raises interesting points under the clause stand part debate, and they are ones that should be considered. However, at this time I propose to stand apart from clause stand part. She is right to raise these matters and perhaps they can be taken further in discussion, as can other of the suggestions in amendments that we have heard tonight. On Report, one hopes that the Government will have reflected on the points made, and particularly on the position of district councils as referred to by my noble friend Lord Rooker and the noble Lord, Lord Greaves, so that we can ensure that the position of such councils and the duty to co-operate, which is so essential, is embodied in the Bill and not left to chance. It is not universally the case, I am sorry to say, that the relationship between county and district councils is all that amicable. There have been cases in parts of the country where it has been very far from the case. It should be made clear to both groups that there is a duty to co-operate, particularly to the county authorities that they have to reflect the interests of the district councils, because of the importance of the functions that they exercise.
Baroness Northover
My Lords, with Amendments 73 and 75, the noble Lord, Lord Rooker, has correctly identified the importance to public health of collaboration and co-operation between agencies. The noble Lords, Lord Rooker and Lord Greaves, come from somewhat different perspectives with regard to local government, perhaps based on their relevant or not relevant experience in this regard. I am, as ever, very grateful when my noble friend Lord Greaves offers me help, and we certainly can have discussions. Noble Lords, as these debates have shown, can offer experience across a wide area of knowledge and we would be remiss not to tap into that.
Lord Greaves
I thank my noble friend very much indeed for that. While the noble Lord, Lord Rooker, and I may come from different ends of the spectrum, we end up in the middle agreeing on a way forward.
Baroness Northover
Well, there we are—at this time of day, just before a recess, we have cross-party consensus. Shall we just adjourn?
The noble Lord, Lord Greaves, correctly identifies the areas in which local authorities have done so much to improve public health. I made reference earlier, as others have made reference, to the 19th century, because the sanitary reform then was a local authority achievement, and it did more than the invention of antibiotics to save and extend lives. The devolution of public health to local authority-level aims to link up all those areas across people’s lives, a point emphasised by the noble Baroness, Lady Tyler.
The noble Baroness graphically shows how health is related to wider social and economic factors, a point that the noble Baroness, Lady Hollins, has demonstrated in her account as well. I know from DfID how investing in girls’ education in developing countries results in later pregnancy. Why should it not be true here as well?
Baroness Northover
I am reassured that she is slightly clarified. This has been yet another important exploration of how the new arrangements might work. I realise that there will no doubt be further discussion; nevertheless, I hope that in the light of what I have said the noble Lord will be prepared to withdraw his amendment.
Lord Rooker
My Lords, I am grateful to the Minister and for the support for the fact that we need to address this issue. I am not asking for any more reassurances but I should like to believe that between now and Report there will be deeper discussions with local government, probably even addressing the machinery of government.
I cannot believe that the existing silos of Whitehall will work when the Bill is implemented. There is now a cross-over between health and local government which has not existed in this country for many decades. Therefore, there is going to be a cross-over and a different kind of working relationship between the Department for Communities and Local Government and the Department of Health. That seems to me eminently sensible for reasons of both accountability and delivering a seamless service to the public. After all, that is what it is about. The public do not care where the service comes from; they want to know that the service is there.
I appreciate the constraints that the noble Baroness is under, but I think that it was well worth while giving this issue a run-out. I have no doubt that we will return to it on Report, but basically I hope that there is more of an impetus and that Ministers’ officials will say, “Well, we do need to have a little bit more discussion to lock this thing down”. The Government cannot afford to get this wrong with this legislation, as the Minister has realised. I think that, with a bit of extra thought, consultation and discussion within government and with local government, a satisfactory solution can probably be found. I beg leave to withdraw the amendment.
Lord Hunt of Kings Heath
Lord Hunt of Kings Heath
My Lords, I shall also speak to Amendment 86. This is very much a probing amendment designed to elicit from the Minister the Government’s intention with regard to high security services.
My reading of the Bill is that there is a responsibility on the national Commissioning Board to arrange for the provision of high security psychiatric services but that whoever provides such services is none the less subject to direction by the Secretary of State. Equally the board can also be given directions by the Secretary of State. The noble Earl would be right in thinking that I have no problem whatever about directions by the Secretary of State. I assume that this power of direction is because of the evident importance of sensitivity and risk in relation to high security services. I would be grateful for clarity on that.
However, I also want to ask about oversight and scrutiny. If high security services are commissioned by the NHS Commissioning Board, who will have oversight of that? Presumably the Secretary of State will take an interest in how well it is done. That must be implied from the direction duty. Will Monitor or the Care Quality Commission come to this as well? Will the CQC be looking at quality and standards? Will that involve the whole question of whether the NCB is commissioning those services effectively? Those questions might also apply to prison healthcare, which also falls to the NHS Commissioning Board—again with no obvious oversight in relation to that commissioning.
Although the issue of mental health services is the subject of my amendment and I was going to ask the noble Earl to clarify, in many ways our earlier debate—many hours ago—on the comprehensive responsibilities for commissioning services by CCGs covered that matter. But if he had a word or two or would write to me about mental health services, I would be grateful. The real issue on mental health services is the GPs’ own approach. There is patchiness in relation to how well GPs are prepared to either treat people with mental health issues or to provide support. The question arises as to whether we are confident that clinical commissioning groups will take mental health services sufficiently seriously. He might want to comment on that. In the main, we need clarity on who monitors the national Commissioning Board when it is commissioning high-security psychiatric services. I beg to move.
Earl Howe
My Lords, the noble Lord, Lord Hunt, has introduced these two amendments which deal with the important issue of mental health, high-secure mental health services in particular. Amendment 85 would reinstate the Secretary of State’s duty to provide high-secure services. I want to reassure the Committee that while this duty has been removed, the Bill is clear that the Commissioning Board must arrange provision of these services. But I recognise the concern and I agree that we must ensure these services are provided and that the Secretary of State continues to be involved. High-secure mental health services are highly specialised and have close links to the criminal justice system. They deliver high-quality clinical care and public protection. We have, therefore, set out in the Bill powers of direction over the NHS Commissioning Board in relation to its commissioning of high-secure services and over high-secure providers in relation to the actual provision of high-secure services. To give a couple of practical examples of the Secretary of State’s accountability, he needs to ensure that there is sufficient capacity in the high-secure system so that when the Secretary of State for Justice directs an offender to a high-secure hospital, there will be a place. Secondly, the Secretary of State for Health also needs to ensure that the high-secure system is safe and secure so that the Secretary of State for Justice is confident that when offenders are directed there, public protection will be upheld. The Bill also requires the Secretary of State to authorise high-secure providers. I am confident that these measures together ensure that these services will be properly commissioned by the NHS Commissioning Board, while retaining appropriate levels of intervention by the Secretary of State. I therefore hope the noble Lord will feel comfortable in withdrawing his amendment. He asked about oversight of secure mental health services. The commissioning of those services, as I have said, will be overseen by the Secretary of State. CQC and Monitor will oversee the provision of secure mental health services.
Amendment 86 would introduce a direction-making power in relation to the NHS Commissioning Board’s commissioning of mental health services in general. The noble Lord did not speak at length to that amendment. I explained just now that it is appropriate for the Secretary of State to have direction-making powers over the board in relation to the commissioning of high-secure mental health services. That is because of the specialised nature of those services and the links to public protection. But the noble Lord will not be surprised to hear me say that the introduction of a direction-making power in relation to the board’s commissioning of mental health services in general is not consistent with the approach in the rest of the Bill. As the noble Lord knows, mental health encompasses a huge range of conditions and services and individual needs and we believe local commissioning by clinical commissioning groups will be the best solution to meet most mental health needs with some commissioning by the NHS Commissioning Board for more specialised areas of care.
The noble Lord expressed doubts about the extent to which CCGs will have the necessary focus on mental health. Here we come back to the role of the board in issuing commissioning guidance to CCGs, underpinned by the quality standards that NICE will produce. We should remember, too, that CCGs will be consistently held to account against the outcome domains of the commissioning outcomes framework. Part of the holding to account will embrace mental health outcomes.
We demonstrated our commitment to mental health with the early publication of the cross-government mental health strategy. We had a lengthy debate about that important area earlier in the Committee's proceedings. I have no doubt that there is more to say, but I hope that, after those few remarks, the noble Lord will feel able to withdraw his amendment.
Lord Hunt of Kings Heath
My Lords, I am grateful to the noble Earl. On the role of the board in commissioning services, I will make a general point: clearly the national Commissioning Board will be very important. How it works should be scrutinised. I suspect that this will lead us on to the question of the mandate, which we will debate next week. At this stage, I beg leave to withdraw the amendment.
(i) ”
(ii) after “paragraph 7A” insert “and of any other prescribed information relating to the (c) in sub-paragraph (2) after “such weighing or measuring” insert “or in relation to information prescribed under sub-paragraph (1)””
(1A) Such regulations shall”
Lord Hennessy of Nympsfield
My Lords, in the unavoidable absence of my noble friend Lady Williams of Crosby and the noble Lord, Lord Marks of Henley-on-Thames, who send their apologies, I will speak to this amendment, which has my wholehearted support. I attempted to add my name to it, but it was already replete with noble Lords by the time I arrived.
The core purpose of the amendment is to make it a requirement for the Secretary of State to make regulations under Clause 17 and to ensure that they are kept up to date and reviewed regularly. The Bill is heavily laden throughout with powers for the Secretary of State to lay down regulations, not least for the huge matter of the functions and powers of the national Commissioning Board, of Monitor and of the CCGs—and even for the special health authorities that have not been set up.
Throughout our debate, many noble Lords expressed deep concern about the character and ethos of the health service that will be sculpted by the Bill. Therefore, scrutiny of the regulations is a matter of profound importance. My noble friend Lady Williams and I have often discussed the degree to which accountability for secondary legislation will become scarcely visible in the case of the negative procedure for statutory instruments, and only slightly more visible in the case of affirmative resolutions. There is a third procedure called super-affirmation, but it is rarely used. In effect, secondary legislation slips through Parliament scarcely scrutinised.
However, there have been some improvements lately in terms of committees. In addition to your Lordships’ Statutory Instruments Select Committee and its sister, the Joint Committee on Statutory Instruments, which have considered the vires of secondary legislation, there has been a very welcome Merits of Statutory Instruments Committee since 2003, but that, too, does not establish a sufficiently robust scrutiny procedure.
Health is a particularly difficult and complicated issue, as this Bill displays in neon lights. We have a duty to our people to make sure we get it right. In the all-party House of Commons Health Select Committee, we have a tried, tested and knowledgeable body, which has produced a stream of fine and well received reports. In the view of my noble friends and myself, that committee should have all the regulations placed before it in plenty of time to offer its wisdom as to whether or not they should be agreed to. The Health Select Committee already carries a considerable responsibility for advising on health policy and should not be overburdened. Therefore, my noble friends and I would suggest to the Government that the committee should be given the resources to employ an extra clerk and an adviser to select those regulations which in their view would have a substantial impact on the capacity of the health service to meet the needs of all its patients in England and the needs of society as a whole.
This amendment also fits with the Minister’s very welcome campaign of reassurance on the constitutional front, to which he has devoted so much time and effort since Second Reading, and for which I am truly grateful. I hope, therefore, that he will be able to accept the spirit, the detail and the practical value of this amendment. I beg to move.
Lord Lucas
My Lords, I have Amendment 92 in this group. I have a long speech on this, but my noble friend has written to the Campaign for Freedom of Information, saying among other things:
“Where possible, we will push to ensure that where functions are transferring to other bodies, the coverage of FOIA is maintained”.
Perhaps I had better listen to him first and then make the speech afterwards.
Lord Hunt of Kings Heath
My Lords, that is an invitation to which I am sure the noble Earl was looking forward. The amendments are clearly concerned with the regulations to be made in exercise of the functions by the board or the clinical commissioning groups, to be known as standing rules. The very words, standing rules, give a clue as to the importance of this part of the Bill.
My Amendment 92ZA concerns the consultation process. New Section 6E(6) of the National Health Service Act 2006, proposed by Clause 17(1), currently states that,
“regulations may require the Board to consult prescribed persons”.
My amendment would replace “may” with “shall”. Given the importance of these matters, there should certainly be a prescribed consultation process.
The noble Earl could perhaps clear up one point about the consultation provisions in this part of the Bill. My reading is that they appear to be confined to an exercise of its functions, by virtue of new Section 6E(4)(b) and new Section 6E(5), which are concerned with the draft terms and conditions and the draft model commissioning contracts. I am sure it is right to consult on these, but I wondered why the consultation appears to be confined just to those. What about the standing rules themselves? Perhaps I have misread Clause 17, or perhaps it is covered by wider consultation requirements elsewhere, but if he were able to reassure me on that I would be grateful.
Amendment 93 is a probing amendment. Under new Section 6E(8), the board,
“may not impose a requirement on only one clinical commissioning group”.
Are there no circumstances in which it would be appropriate for the board to put a requirement on a single clinical commissioning group? I did not understand that, and, again, if the noble Earl could clarify that, it would be helpful. I can reassure him that, like the noble Lord, Lord Lucas, I will not make a long speech on that matter.
I will return to the point raised by the noble Lord, Lord Hennessy. My Amendment 94 would require regulations made under Clause 17 to be affirmative. This Bill is packed with regulating powers. You can hardly move for the regulating powers that have been given to the Secretary of State. The Department of Health is not very fond of affirmative regulations—it has very few affirmative regulations in its legislation compared with other departments—but I think it might have allowed us a few more affirmatives than is currently allowed for. It seems to me that standing rules shape the way the board and clinical commissioning groups go about their business. Given that the intent is to hand over much more authority from the Secretary of State to the board and clinical commissioning groups, I do not think it is unreasonable that matters to do with the standing rules should be subject to the affirmative procedure. I hope that the noble Earl will be able to give some comfort on that matter.
Baroness Barker
My Lords, I cannot remember which legislation it was, but I know for a fact that I was sitting on the other side of the House and that the Minister was the noble Lord, Lord Hunt of Kings Heath. If I could go back and trawl through Hansard, I would find the reference to the speech in which I started by saying that I feared that one day we would have a piece of primary legislation that consisted solely of regulations and that we were perilously close to it. I point out to the noble Lord, Lord Hunt of Kings Heath, that whatever he may think about this legislation, he has form on this.
Lord Hunt of Kings Heath
There is one very big difference. In the legislation I was bringing forward, we retained the clear accountability of the Secretary of State to Parliament which had clear direction powers over the National Health Service. Therefore, it was much more appropriate that regulations did not have to be affirmative because Parliament could demand the accountability of the Secretary of State. We are moving into a new situation where the Secretary of State is taking a much more hands-off approach, so the argument that the regulations be affirmative is much more persuasive. There is a real degree of difference between then and now.
Baroness Barker
That might have been the case, but I recall that under the Government of which he was a member, a fair amount of Henry VIII powers went through at the same time so, although his basic thesis might be different, I am not sure that Parliament was that much more able to question the intention of the Secretary of State at the point at which primary legislation was being debated in this House.
I want to speak up partly in support of the amendment moved so eloquently by the noble Lord, Lord Hennessey. I would perhaps differ slightly. I think that in this House there is a great deal of very high quality scrutiny of delegated powers and secondary legislation. It is one of the things that this House does extremely well. The additional point in the proposal he has made is to bring to the process of scrutiny of secondary legislation the involvement of people on the Health Select Committee in the House of Commons who, by dint of their membership of that committee, have a detailed and ongoing knowledge of the workings of the National Health Service in its entirety. I understand what he is trying to do, and I have a great deal of sympathy with it. My only reservation about that is that I think the power of the Health Select Committee is that it sets its own agenda and holds the Government to account. I would not like an inadvertent effect of what the noble Lord, Lord Hennessey, is proposing to be to trammel the independence and power of that very important committee to scrutinise what the Government are doing. However having made that criticism, I have a great deal of sympathy with what he is trying to do, but I hesitantly suggest that perhaps this problem is not quite as new as some noble Lords might suggest.
Lord Hunt of Kings Heath
My Lords, perhaps I might just come back to the noble Baroness. Would she agree that this is a point that deserves greater consideration when we come to the mandate itself? At the moment the Government are proposing to simply lay the mandate before Parliament before the start of each financial year. Would she agree that the mandate itself might be subject to more scrutiny by Parliament?
Baroness Barker
My Lords, I do not want to get into that debate, which I think we have not yet come to, but I thank the noble Lord—sorry, I am so tired tonight, I was about to call him “the noble Lord the Minister”; I am going back in time—
Baroness Barker
I thank the noble Lord, Lord Hunt, for drawing attention to a very important point that I think has been missed and in some cases distorted, which is that our debates so far have been about the powers of the Secretary of State and we have ignored a number of other elements that have a direct bearing on that, such as the mandate. That appears to have passed by people like 38 Degrees completely. I thank him for drawing it to our attention but I will resist the temptation to get into the detail of that this evening.
Baroness Wilkins
My Lords, Amendment 92A is tabled in my name and those of the noble Baroness, Lady Hollins, and the noble Lords, Lord Rix and Lord Wigley. It would make explicit the responsibility of the NHS Commissioning Board and clinical commissioning groups to be compliant with the public sector equality duty, as set out in Section 149 of the Equality Act 2010.
Section 149 states that a public authority should,
“take steps to meet the needs of persons who share a relevant protected characteristic that are different from the needs of persons who do not share it”,
as part of the duty on it to advance equality of opportunity. This essentially makes provision for such public authorities to be subject to making reasonable adjustments for individuals who may have specific or different needs as a result of factors such as age, disability and religion or belief. In the context of this amendment, the healthcare bodies concerned and the healthcare professionals who work in them would be required to take the necessary steps so as to offer appropriate care to people with these protected characteristics.
In particular, I am speaking about the provision of reasonable adjustments for disabled people, particularly those with a learning disability. People with a learning disability will often have particularly complex healthcare needs and therefore require specialist interventions in order to have them appropriately met. These interventions are about health professionals adopting a change of attitude towards disabled patients and not making assumptions as to their quality of care which would not be made towards non-disabled patients. For example, the use of hospital passports can help to provide key personal information about an individual’s medical details and, as importantly, details about how they communicate so that health professionals can better understand the patient’s individual needs and communication requirements. Additionally, learning disability liaison nurses can help to provide specialist support and guidance to medical professionals when treating someone with complex needs.
These measures are more often than not achievable, reasonable and proportionate, and help to ensure that health professionals are treating disabled patients with the dignity and respect they are entitled to. Whether this is for planned or non-planned admissions, it is necessary for the NHS to make adequate provision for patients with disabilities. This can be achieved through better disability and learning disability awareness training for all staff so that they can better understand the needs of such individuals who may be in their care.
A 2009 poll conducted by ICM on behalf of Mencap found that a third of healthcare professionals have not been trained in how to make reasonable adjustments for a patient with a learning disability.
At this point, Baroness Northover continued the speech for Baroness Wilkins.
This can lead to poor treatment and can exacerbate existing healthcare inequalities. The same ICM poll indicated that almost half of doctors and a third of nurses said that people with a learning disability receive a poorer standard of healthcare than the rest of the population. The Mencap report Death by Indifference in 2007 also revealed the premature and avoidable deaths, in the NHS, of six patients with a learning disability. Since then, a further 60 families have been in contact with Mencap with similar experiences to this. It is therefore particularly important for the NHS Commissioning Board and clinical commissioning groups to be fully aware as to their responsibilities and obligations under the public sector equality duty.
It is very important that disabled patients and their families can be expected to be treated in the NHS without being the victims of prejudice and discrimination. The amendment tabled in my name and others’ sets out specifically the requirements on these bodies to adhere to the public sector equality duty. They would safeguard disabled patients against malpractice, mistreatment and neglect in the NHS.
Baroness Hollins
My Lords, I am delighted to have this opportunity to support the amendment of the noble Baroness, Lady Wilkins. The noble Baroness has eloquently put forward the case for reasonable adjustments and has given good examples of reasonable adjustments that people need and why they are so important for people with a learning disability. I fully endorse her sentiments on this issue. I am also speaking for my noble friend Lord Rix, who was unfortunately unable to stay this evening.
It is vital, under the new arrangements, that health professionals and the various health bodies that will be created are fully aware of their legal responsibilities when treating disabled patients. As the noble Baroness said, this is particularly relevant for people with a learning disability who continue to experience large health inequalities and who are at a disproportionate risk of experiencing epilepsy, mental health problems and premature death. Not only do people with a learning disability experience poorer health outcomes, but they also receive fewer routine immunisations and blood pressure checks and have poorer access to cervical and breast cancer screening programmes.
In response to an earlier group of amendments to this Bill, tabled in the name of the noble Lord, Lord Rix, on day 3 in Committee, the Minister gave many assurances as to why it was not necessary to mention disability or learning disability specifically in the Bill. He cited NICE quality standards, Monitor, the NHS outcomes framework, Clause 12 of this Bill, clinical advisory groups, the duty of clinical commissioning groups to involve and consult people “appropriately”, the annual report by the Secretary of State and, above all, the public sector equality duty.
My noble friend Lord Rix and I are both extremely grateful to have heard all of these assurances, put forward by a Minister who is both sympathetic and determined to be as helpful as possible. But we cannot imagine patients with a disability, especially those with a learning disability, being conversant with all these facts, and perhaps even having to visit their GP or local hospital with a vast compendium of their entitlements tucked under their arms to place in front of the health professional—who, as we know, may have been inadequately educated in their responsibilities with respect to the requirement to make reasonable adjustments—before they receive adequate and correct treatment.
The amendment of the noble Baroness, in one simple and effective move, would bring together all of the Government’s good intentions in this area and remove any ambiguity or uncertainty, by making it 100 per cent clear as to the importance of public bodies in the NHS meeting their obligations under the public sector equality duty, not just for disabled people, but for all of the protected characteristics.
The Minister stated in reply to earlier amendments by my noble friend Lord Rix that the Government’s starting point,
“is that people with a learning disability are people first”.—[Official Report, 7/11/11; col. 18.]
He will not be surprised to hear that my noble friend and I fully concur with that view.
Earl Howe
My Lords, the standing rules will set the ongoing legal requirements for both the NHS Commissioning Board and the clinical commissioning groups. We intend to use the standing rules to replicate core elements of the current system, setting out the ongoing requirements, which will predominantly replace existing directions from the Secretary of State. As the standing rules will set out system-wide generic requirements, they will not apply to individual CCGs. While the rules will be kept under review, we do not expect to update them annually.
Clause 17 confers powers to make standing rules in a number of specified areas. The powers will be used to maintain the existing arrangements for NHS continuing healthcare—that is, care arranged and funded solely by the NHS for individuals outside hospital who have ongoing healthcare needs. They will also set out the mandatory terms to be included in commissioning contracts, set requirements around the provision of information and provide the legal basis for certain patient rights in the NHS constitution.
In addition to the particular areas specified in the clause, the Secretary of State will have a backstop power to make standing rules in other areas, under subsection (7)(c) of new Section 6E. He can require the board and clinical commissioning groups to do other things which he considers necessary for the purposes of the health service. The power simply provides a prudent degree of system flexibility to take account of changing circumstances in the NHS.
Noble Lords have tabled a number of amendments regarding the scrutiny that the regulations will receive, both through consultations and by Parliament. The noble Lord, Lord Hennessy, spoke with great force and persuasiveness on this theme. There are two elements to the scrutiny question—public consultation and parliamentary scrutiny. I can assure the Committee that in line with good practice across government, we fully intend to consult publicly on any new proposals for standing rules. The Health Select Committee would have the opportunity to examine proposals, and Ministers and the department would of course engage constructively with the Committee on any inquiry. However, I do not think that it is usual practice for legislation to set expectations on how the Government should work with Select Committees or on which areas the committees should focus.
Questions have also been raised about whether the board should be required to consult interested parties, such as representatives of CCGs and providers, before it drafts standard contract terms. We believe that regulations should be flexible on that point and minor changes will not always require consultation. Therefore, the regulations should be able to provide for this flexibility where necessary.
As to questions of parliamentary scrutiny, the standing rules will be subject to the negative resolution procedure, with the affirmative procedure used if the Government exercised the backstop power to make standing rules to require the board and clinical commissioning groups to do other things that the Secretary of State considers necessary for the purposes of the health service. The Delegated Powers and Regulatory Reform Committee of your Lordships’ House was satisfied with these arrangements, as set out in its recent report on the Bill, which I was pleased to note.
The noble Lord, Lord Hunt, asked why the standing rules are not subject to the affirmative procedure. The rules will replicate current provisions in existing legislation, so we believe that the negative procedure provides for adequate scrutiny of these provisions. However, we agree that the affirmative procedure is important in other cases, which is why the broader power to allow the Secretary of State to make regulations which require the board or CCGs to do such other things as the Secretary of State considers necessary for the purposes of the health service—under subsection (7)(c) of new Section 6E, to be inserted into the NHS Act under Clause 17, which is a very generalised provision—will be subject to the affirmative procedure, which we think is the right balance.
Incidentally, the noble Lord remarked that, in his view, one cannot move in this Bill for delegated powers. I disagree with that. I think that this Bill represents a very significant transfer of power from the Executive to Parliament through placing far more detail in primary legislation as to the structures and workings of the health service than we have ever had before. For example, this Bill enshrines a process for the tariff, which is currently nowhere to be found in legislation.
The noble Lord asked about consultation on the standing rules themselves. The consultation to which the noble Lord referred is consultation by the board on standard contract terms with interested parties. Consultation on the standing rules themselves will be consultation by the Secretary of State. We intend to consult on these in line with good practice, as I have indicated.
Noble Lords also raised concerns about integration. We have discussed this topic at some length already, so I will be fairly brief. I can reassure noble Lords that the board and CCGs will be subject to the public sector equality duty set out in Section 149 of the Equality Act 2010—I am looking here particularly at the noble Baroness, Lady Wilkins, whose points I fully took. This is in addition to the duties set out by this Bill that require the board and CCGs to have regard to the need to reduce inequalities in outcomes and access to services when exercising their functions. I agree with the noble Baroness that awareness, training and understanding of the particular needs of people with disabilities are absolutely vital for all health bodies if they are to ensure that the improvement in outcomes that is needed in this area can be realised. We keep coming back to the outcomes framework. We should not forget it. It is not necessary to put it in the Bill but it does overarch the Bill, and we believe that the Bill creates the framework for the NHS to improve through the combination of clinically led commissioning and strengthened joint working.
Turning to the concerns raised by my noble friend Lord Lucas in his amendment, I draw the Committee’s attention to the provision that enables the standing rules to set out the mandatory terms to be included in the commissioning contracts. We expect that contracts will include, as now, provision to ensure that private providers are required to assist and co-operate with commissioners to enable them to comply with their disclosure obligations under the Freedom of Information Act. The underpinning of this is that, where a provider is not a public authority—that is, not an NHS trust or an NHS foundation trust—there is a provision in the current contracts for private providers to do exactly as I have indicated. I can tell my noble friend that we intend to use the standing rules to continue this provision, and I hope he will feel that that is entirely in keeping with, and goes with the grain of, his Amendment 92.
I also want to touch on the provisions that relate to EU obligations. These should be read alongside Clause 16, which allows the Secretary of State to delegate EU functions to the board and clinical commissioning groups. It sets out two types of direction-making power: one to direct about the exercise of delegated EU functions and the other to direct about any functions to ensure that we can respond quickly to potential breaches of EU law. Where there are ongoing, predictable requirements that derive from EU obligations but that do not relate to functions delegated under Clause 16, the power in the standing rules will be appropriate. We think that it is preferable to put such requirements in regulations rather than directions as this allows for parliamentary scrutiny and certainty for the NHS.
In the light of the details that I have set out, I hope that noble Lords who have spoken will feel able to withdraw their amendments.
Lord Lucas
Does my noble friend want my 15-minute speech now or will he promise me a meeting before Report stage? Given judgments that have already been made in parallel cases in other parts of freedom of information law, I do not believe that the solution he offers will work and achieve what he has promised. I shall be very happy to swap him a meeting before Report stage for a 15-minute speech now.
Lord Hennessy of Nympsfield
I am very grateful to the Minister for his, as always, very thoughtful reply. I am grateful, too, to the noble Baroness, Lady Barker, for her point, which I fully accept, about the collective gift of this Chamber when it comes to detailed scrutiny. Quite naturally, I also note her point about the sovereignty of Select Committees in the other place. In some ways it sounds an innovative suggestion that the Health Select Committee should take on this scrutiny regulatory task, but there are some precedents—remedial orders under the Human Rights Act, following declarations of incompatibility, and orders under the Legislative and Regulatory Reform Act 2006, are all made only after scrutiny in draft by the relevant Select Committees.
I think that this matter is too important to the accountability question as a whole for it to be abandoned at this stage. Therefore, I am confident that several noble Lords will wish it to be re-examined once more on Report. In the mean time, I beg leave to withdraw the amendment.
Baroness Barker
“(5A) Regulations must also secure procedures for the Board to require clinical commissioning groups not to appoint to the Board or a sub-committee of a clinical commissioning group any person who is an employee or a share-holder of a commissioning support organisation.”
Baroness Barker
My Lords, I spoke to this amendment on Monday. The noble Earl, Lord Howe, replied in the depths of the evening, and at the conclusion of that debate I did not have a chance to say that I believe that this is an extremely important and fundamental matter. It concerns CCGs not being able to appoint shareholders or staff of CSOs to their decision-making committee. I signal my intention to bring this matter back on Report. I hope that it might be possible for the Minister to meet me on that. I would have raised that point the other night, but it was very late.