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 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.
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.
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.
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.
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 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.
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.
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.
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 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.
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) ”
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.