(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.