House of Lords
Corporate Governance
Lord Lea of Crondall
To ask Her Majesty’s Government whether they will initiate a review of the structure of corporate governance in large United Kingdom companies, in the light of wider public and social interests in boardroom decisions.
The Parliamentary Under-Secretary of State, Department for Business, Innovation and Skills (Baroness Wilcox)
My Lords, the Government are examining the responses to a recent discussion paper on corporate reporting, which includes proposals for clearer reporting of corporate social responsibility issues and on executive remuneration. Professor John Kay is due to publish his recommendations for encouraging more long-term behaviour in equity markets in the summer of 2012. In February this year, the Government welcomed the publication of proposals by the noble Lord, Lord Davies of Abersoch, for increasing the number of women on boards, and that work continues.
Lord Lea of Crondall
I thank the Minister for that reply, and I apologise for sounding like a frog—I do not mean one of those Frogs, or a Kraut. Do I get more time for all these interruptions?
I welcome the commitment by the Deputy Prime Minister at the weekend to curb the excesses of top boards of directors, whose pay is spiralling up as everyone else's spirals down. Will the Minister accept that the key option to restore confidence in the workforce and the wider society is—in Mr Clegg's words—to break open the closed shop of board remuneration by adding an employee representative? Secondly, does she agree that this test will be missed not by appointing a hand-picked favourite, which would make the whole exercise cosmetic, but by some mechanism whereby the person—he or she—self-evidently has the confidence of the whole workforce?
Baroness Wilcox
Some have said that remuneration committee membership as a whole does not come from a wide enough talent pool, that it stifles innovation and that the closed shop of boards and board committees needs to change. We know that diverse boards that bring a range of experience are more effective. The idea of introducing employee representatives may be one way of encouraging more challenge on pay. As I said, we have three consultations out at the moment, all of which report at various times leading up to the spring, so I hope that we will be able to give the noble Lord answers that he will find favourable at that time.
Lord Taverne
My Lords, there is in all quarters deep concern about the inequalities of pay in industry, which have increased dramatically in recent years. The Government could do something practical about that in this House. Will they seriously consider looking again at the schedule and the timetable for the Second Reading of the Bill of the noble Lord, Lord Gavron, which would give us an early opportunity to debate it? Will they also give it a fair wind, so that this Bill, in one form or another, can find early expression in the law and make quite a difference to the present situation?
Baroness Wilcox
I am sure that the usual channels will discuss the matter and we will come back to the noble Lord.
Baroness Howe of Idlicote
My Lords, given the mention of the Davies report and given a recent report which I read, which showed that women's contribution had increased UK GDP by a considerable percentage, can the Minister give us a clear idea of what steps she and the Government intend to take to speed up the process of implementing the Davies report?
Baroness Wilcox
The implementation of the Davies report is going ahead and things are improving, but we want to see what results can be achieved through a voluntary approach, and we are taking a very close interest in how much progress is being made. We want to encourage talent, but we want to avoid tokenism. I think that 89 per cent of the women whom the noble Lord, Lord Davies, spoke to said that they were not in favour of quotas, so we are trying to avoid getting to that stage if we can. There is no one-size-fits-all answer—companies need to be flexible in their operations. I should like to think that the women who are chosen to go on those boards are chosen because they are the right people for the job.
Lord Monks
My Lords, does the noble Baroness accept that there are many lessons to be learnt from our neighbours across the North Sea in terms of rebalancing the economy, which is an objective of all of us? It seems to me that the Government have not yet accepted that one component of the success of these economies is that workers and other stakeholders have an influence at board level. What plans do the Government have to move in the direction of our successful North Sea neighbours?
Baroness Wilcox
So why do we not let employees have a say on pay? Some have said that remuneration committee membership as a whole—
Baroness Wilcox
On boards and pay, I shall refer back to my notes because we have three reviews going on at the moment. There are no noes on anything. At the moment we are keen to listen to everybody’s views and to look at progress anywhere else in the world. The UK has a strong corporate governance framework and we are committed to strengthening it further, as we should do. As it happens, this country has a good reputation in the world for running boards, although of course we will have to wait to see what Professor Kay says in his review.
Lord McFall of Alcluith
My Lords, does the noble Baroness accept that there will be no long-term future for companies if there is not adequate shareholder engagement? To date, the level of that engagement has been shameful, allowing ownerless corporations to dictate and a managerial class to prevail. Does the Minister not agree that the Government should do something to ensure that we get both short-term and long-term engagement with shareholders, which is crucial for the long-term health of a company?
Baroness Wilcox
There is no doubt that shareholder engagement should—and, I hope, will—be improved. After all, it is shareholders who can, as is only right and proper, hold the company’s feet to the fire on the day they are asked to put up the salary of the chairman and the chief executive. They are not doing their job well, particularly the very big shareholders—the big pension funds and so on. I myself have sat on boards and have experienced these big shareholders not turning up at the shareholders’ meeting, instead having another meeting at another time. Usually, small shareholders turn up and make very good suggestions, but then in come the proxy votes—and there are millions of them. We are doing everything we can to see whether we can get shareholders to take the responsibility and the power that they have to put this right.
Baroness O'Cathain
My Lords, can the Minister go a little further on shareholders and their involvement with boards? As we all know, the major shareholdings are held by big institutional investors—namely, pension funds—and the problem with that is that they never have taken their responsibility seriously enough. Instead of hammering on about worker representation and women’s representation, they ought to get right down to the bottom of the issue and find out what the responsibilities of these pension funds are.
Baroness Wilcox
My noble friend has expressed it extremely well. We would like to think that this will happen voluntarily, but in the mean time the Kay review is examining proposals for tackling potentially damaging short-term economic behaviour in the markets. We will also be looking at the actions of the shareholders and seeing what recommendations are made there.
Immigration
(13 years ago)
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Lord Roberts of Conwy
To ask Her Majesty’s Government what steps they are taking to reduce net immigration.
The Minister of State, Home Office (Lord Henley)
My Lords, we are committed to reducing net migration to tens of thousands, not hundreds of thousands, by the end of this Parliament. We have already introduced an annual limit on the number of non-EU workers, overhauled the student visa route and increased enforcement activity. Our next steps are to break the link between temporary and permanent migration by restricting settlement rights and to reform family migration.
Lord Roberts of Conwy
I am glad to hear that very positive response. With immigration in the last calendar year running at 591,000, and in this year to March at only 9,000 fewer, is it not imperative that we do all that we can to reduce immigration for the sake of everyone already here and relying on our hard-pressed services, and to keep the total population from reaching the projected high of 70 million about 16 years from now?
Lord Henley
My Lords, we are trying to reduce the net migration figures—that is, the difference between immigration and emigration. I stress that we believe that immigration enriches the country and we owe a lot to all those who have come and who will come to this country. However, there must be limits, and it must be sustainable. We have seen a smallish drop in net migration, but it is not as small as it should be. That is partly because emigration seems to have gone down very dramatically. There could be a number of reasons for this; I cannot speculate on that. I suspect it is not for the reason that the noble Lord, Lord Tomlinson, is trying to give from a sedentary position. Emigration has probably come down because there is no longer a Labour Government in power and people want to stay in this country.
Lord Anderson of Swansea
Will the noble Lord confirm that many of those hard-pressed services, including our health service, are in fact provided by immigrants? Will he also say how robust are the efforts to ensure that marriages apparently properly entered into subsist at the end of the relevant period?
Lord Henley
My Lords, the noble Lord, Lord Anderson, is right to point out that we owe a lot to immigrants, particularly in those so-called hard-pressed services. However, there are a great many employed people in this country. As he will remember, a previous Prime Minister, Mr Gordon Brown, made a point of wanting British jobs for British people. Those jobs could be done by people here if they were able to take them up. Regarding the noble Lord’s substantive point about the genuineness of marriage, that is something we want to address and are addressing.
Baroness Hamwee
My Lords, the Office for Budget Responsibility has drawn attention to the link between migration and growth. Its July report on fiscal sustainability mentioned that immigrants are more likely to be of working age than the general population. Will the Minister acknowledge the importance of this factor, given our generally ageing, and therefore less economically productive, society?
Lord Henley
My noble friend makes a very valuable point about the demographic changes we are facing. People have fewer children, we are an ageing population and we live longer. I welcome and acknowledge what she says. However, there is a limit to the number of people we can get into the country and we want to make sure that the net migration figure is sustainable in the long run.
Baroness Prashar
My Lords, does the Minister agree that overseas students are not immigrants and should therefore not be included in the net migration figures?
Lord Henley
The noble Baroness makes a very good point. The changes we are making for overseas students are intended to make sure that they can come here to study and can possible stay on, but we do not want them to bring their families where that is not necessary or to stay on as permanent residents afterwards if that is not appropriate.
Lord Peston
Will the Minister enlighten us on the economics of all this? A great many of his noble friends in this House and his honourable and right honourable friends in the other place claim to be great supporters of free trade and the free market. Will he explain how that is compatible with denying employers and other institutions the right to buy labour services, wherever they might come from, that can be used profitably? Surely supporting the free market means allowing precisely that, and not limiting immigration?
Lord Henley
My Lords, I could, if I had the time—but I do not have the time—give the noble Lord a long lecture on the economics of this.
Lord Henley
Perhaps the noble Lord and I could have a discussion about this at another time and in another place. The simple fact is that some control has to be brought in because the numbers are unsustainable in the long run. The noble Lord does not agree with me; we will have to remain not agreeing on this subject. However, there are limits to the number of people we can fit into the country.
Lord Willoughby de Broke
My Lords, if the aim is to reduce net immigration, will the noble Lord say whether he is going to repatriate the power over immigration from the EU? It would surely help to reduce net immigration if we controlled immigration from the EU.
Lord Hunt of Kings Heath
My Lords, on the economics of immigration, is the absurdity of the Government’s position not shown by what has happened in relation to the students whom he mentioned? Already, universities are reporting a downturn in the number of international students coming to this country, causing grave disadvantage to the UK. What does he say to the House when other countries have opened their doors with open arms to such students?
Lord Henley
My Lords, I am not going to take lessons from the noble Lord on the absurdity of our position when the party opposite, when in government, did absolutely nothing to control immigration—nothing whatever. It is right to control the numbers and we will continue to try to do so. It is also right to control the number of students, particularly the number of bogus students coming to bogus colleges who should not be coming in at all.
Culture and Arts: Funding
Baroness Jones of Whitchurch
To ask Her Majesty’s Government what steps they are taking to minimise the impact on arts and cultural activities of local authority cuts.
Baroness Rawlings
My Lords, this Government believe that the arts should look for funding from as many different sources as possible. It is for each local authority to decide how and to whom it distributes its funds. Central government will provide over £800 million to the arts, museums and heritage through grant in aid in this financial year. We are also working with bodies in this area to improve their fundraising capabilities.
Baroness Jones of Whitchurch
I thank the Minister for that reply. Given the scale of the cutbacks in local authority funding, is she concerned that councils are disproportionately cutting local arts projects to protect other essential services? Does she recognise the large disparities that are developing in arts activities between one council and another, with some areas in effect becoming cultural deserts? As the noble Baroness knows, some councils are proposing cuts of up to 100 per cent. Is this the time for the Government to consider imposing a statutory duty on councils to fund local arts provision?
Baroness Rawlings
My Lords, the noble Baroness, Lady Jones, raised several important points. I will try to answer them all. Her Majesty's Government appreciate that local authorities have had to make difficult decisions on spending. The noble Baroness is absolutely right that it is harder for smaller, regional bodies to cope with the changes. However, we are glad that some enlightened councils have recognised not only the economic contribution that the arts can make to an area but the way they enhance the environment in which we live. Her last point was about imposing a statutory duty, but this would only add to the burdens placed on local government at a time when deregulation is a priority. It is right to give responsibility to local communities and local authorities to take the decisions that are most appropriate to their areas.
Lord Storey
My Lords, the Minister will be aware—as the noble Baroness opposite said—that many local authorities have made disproportionate cuts when making savings, including local authorities that are run by her party. Will the Minister assure us that the Government will do all in their power to ensure that young people, particularly those from disadvantaged backgrounds, will be able to access the arts?
Baroness Rawlings
My Lords, my noble friend is absolutely right that some local authorities have cut more than others. He is also right that we should encourage the private sector into sponsorship. This is exactly what the coalition Government announced yesterday in the draft clauses of the 2012 Finance Bill. There will be legislative provision for a new cultural gifts scheme.
The Earl of Clancarty
My Lords, is the Minister aware of the recent Museums Association report that shows that cuts to local authority funding are already having a direct and drastic effect on many local and regional museums, with cuts to staff, opening hours and events, and the risk of closure. Bolton museums are selling off numerous art works to pay for other services. Will the Minister admit that there is no realistic alternative to proper public funding of local authority museums?
Baroness Rawlings
My Lords, the noble Earl makes several important points, and the Museums Association’s cuts survey in June 2011, which he mentioned, showed that many local authorities are still finding it possible to maintain museum services.
The Lord Bishop of Exeter
My Lords, I invite the noble Baroness to join me in welcoming the reopening next week, after a £24 million refurbishment, of the Royal Albert Memorial Museum and Art Gallery in Exeter. We in Exeter are enormously proud of this flagship project, because it has been driven by an understanding of the wide contribution of the museum to the city’s quality of life. That includes cultural provision, community cohesion, individual well-being, civic identity, economic attractiveness and destination tourism. Will the Minister affirm the importance of ensuring that this broader impact of culture is embedded in a wide spectrum of cross-cutting policy-making, and will she say what Government can do proactively to secure this at both the national and the local level?
Baroness Rawlings
I congratulate the right reverend Prelate on what has been happening in Exeter and the reopening of the museum. I totally agree with him that quality of life will be enhanced by all that. I would like to stress what the Chancellor of the Exchequer announced in his autumn Statement: that the overall annual budget for the acceptance in lieu scheme will now be £30 million, an increase of 50 per cent, which will have an effect in Exeter as well.
Lord Howarth of Newport
My Lords, while there is all too little that the DCMS can do directly to assist local authorities faced with the devastation of their finances to carry out their cultural responsibilities, will Ministers at the department do everything in its power to support the Arts Council in its efforts to mitigate the effects of this, and will it also encourage national institutions that the department funds to emulate the excellent example of the British Museum and its programme of partnership with museums across the country?
Baroness Rawlings
My Lords, the noble Lord, Lord Howarth, makes an important point. I could not agree with him more in his praise for the British Museum and for its director, Mr Neil MacGregor, for all his excellent work in the area. I can reassure him that each of the national museums that the DCMS sponsors has a specific obligation to work in partnership with regional museums. We will give every support to the Arts Council and to Dame Liz Forgan. The noble Lord is right to be concerned—we are all concerned—and I know she is talking across the board with local authorities and that they are interested in fostering their cultural enterprises.
Lord Stevenson of Balmacara
My Lords, when the Minister for Culture, Ed Vaizey, gave oral evidence recently to the Culture Select Committee, he admitted that while the department cannot dictate to local authorities what spending decisions they make, he hoped that the signal from us to support the arts will be taken on board. Can the Minister share with us what signals have actually been sent recently to local authorities, and what the reaction has been?
Baroness Rawlings
My Lords, the biggest signal of all, which we just made yesterday, is the philanthropic legislation that is coming through. I am sure the noble Lord will agree that with the acceptance in lieu, lifetime giving and acquisitions, this is one of the biggest supports for all arts bodies. I am very pleased that he asked that.
Economy: Government Policies
(13 years ago)
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Lord Clinton-Davis
To ask Her Majesty’s Government what is their response to the report of the Institute for Fiscal Studies on the Chancellor of the Exchequer’s latest economic measures.
The Commercial Secretary to the Treasury (Lord Sassoon)
My Lords, the Government took decisive action at the Autumn Statement to ensure sustainable public finances and to meet the fiscal targets set at Budget 2010.
Lord Clinton-Davis
The Institute for Fiscal Studies has referred to higher inflation, unprecedented cuts, the longest wage stagnation in history and plunging incomes. Is it not appropriate in the light of this respected organisation’s report that the Government should change their economic course, to avoid a major shipwreck before it is too late?
Lord Sassoon
No, my Lords, that is precisely not the conclusion from the IFS report. What the IFS report also pointed out was that Labour’s plans—the plans of Mr Alistair Darling in his March 2010 Budget—
“would, if [they] had been implemented, now of course have implied even higher debt levels over this parliament than those we will in fact see. That would have left an even bigger job to do in the next parliament”.
There would have been £100 billion of additional debt if we had followed Labour’s plans, and that was under Mr Darling. Mr Ed Balls has so far announced unfunded commitments of £91 billion a year—£326 billion of unfunded expenditure. Mr Ed Balls wishes to pave the road to Rome, if not to Athens.
Lord Christopher
My Lords, did not the Conservative Party embrace Labour’s spending plans?
Lord Sassoon
My Lords, what my right honourable friend the Chancellor said we would do is to stick precisely to the spending plans that he set out in the March Budget and the subsequent spending review. That is what we will do, and that is what will keep our interest rates low.
Lord Vinson
My Lords, as part of their measures to see what can help this poor old country out of its troubles, would the Government look at our huge imbalance of trade—currently running at about £30 billion a year plus? I am not suggesting for one moment that all those jobs could be done in this country, but it is the equivalent of about 1 million jobs that we are shipping overseas. There are some areas of our economy that could be done here. For instance, why do we need to import so much cement, which we can make in this country just as well as importing it from other countries? Could we not look at a sensible policy of import substitution to try to create jobs in this country that are being created unnecessarily in other countries, when we could do the jobs perfectly well ourselves?
Lord Sassoon
My Lords, our exporters are leading the growth in this country and indeed, although it is early days, there are some signs from the figures over the past 18 months that at last, after a decade of a declining share of world trade, the UK’s share is increasing. It is a modest increase and it is early days but our exporters are performing very strongly.
Lord Barnett
I would like to welcome one part of the Statement from the Chancellor, when he said that he had negotiated £20 billion of funds from pension funds for infrastructure investment. That is very welcome. However, could the noble Lord tell us how exactly it is to be financed with the pension funds? Is it a PFI deal, or what rate of interest are they going to be paid?
Lord Sassoon
I am grateful to the noble Lord, Lord Barnett, for welcoming this important initiative. In fact it is a case of the pension funds coming to us. That particular group of pension funds has £800 billion under management. So it will be funds that they already have under management, and they wish to allocate a greater share to the infrastructure sector. It does not hit the public sector in any way.
Lord Newby
On that exact point, my Lords, the IFS says that the £20 billion of additional funds from the pension funds looks to be,
“more of an ambition than a done deal”.
It adds that they,
“have little clarity as to what the nature of this potential additional spending might be”.
Is the Minister able to tell us, first, what priorities the Government have assigned to that potential additional expenditure; and secondly, when he hopes the benefits of that additional funding might come through?
Lord Sassoon
My Lords, to repeat, the pension funds and also the insurance companies have come to Government and asked for our help. We have signed a memorandum of understanding to help them set up their vehicle as quickly as possible, because clearly they want to find an investment home for their money.
Lord Davies of Oldham
My Lords, does the Minister accept that the best deficit reduction strategy is in fact a growing economy? Why are the Government pursuing policies that have already reduced growth, and are destined to do so for several years?
Lord Sassoon
I do not accept that at all. Of course we all wish to see a strongly growing economy. The latest forecasts from the OBR are that the private sector will generate 1.7 million jobs over the forecast period. That is strong growth in the private sector.
Baroness Wheatcroft
My Lords, while cutting the deficit is essential, it will undoubtedly leave many people facing financial hardship. In the light of that, does the Minister have any comment on the stories this morning about the forecast growth in what is known as payday loans and the interest rates—some might say extortionate interest rates—charged on them?
Lord Sassoon
I completely agree with my noble friend that it is very concerning that people on low incomes should be exploited. Therefore, it is important that this issue is fully debated. However, I would also point out that the latest forecast from the IFS shows that real household disposable income will stabilise in 2012 and sharply rise in 2013.
Airports (Amendment) Bill [HL]
Accession (Immigration and Worker Authorisation) (Amendment) Regulations 2011
(13 years ago)
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Lord Strathclyde
That the draft Orders and Regulations be referred to a Grand Committee.
Health and Social Care Bill
(13 years ago)
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16:35 - Division on Baroness Thornton's amendment - Ayes: 195 / Noes: 248 - Amendment disagreed.
Baroness Thornton
At end to insert “but that this House regrets the Government’s appeal against the Information Commissioner’s ruling that the Government should release the Transition Risk Register; notes that the Information Commissioner says that disclosure would aid public understanding and debate on crucial aspects of the Bill; and requests that the Secretary of State reconsider his decision to withhold the information in order that this House can have the information in time to be considered during the passage of the Bill.”
Baroness Thornton
My Lords, I move the amendment, which is for a Motion of Regret, in my name on the Order Paper. This is the third time that I have asked for the indulgence of the House to bring this important matter before it and I hope that this will be the last. My amendment is not a fatal Motion. It does not intend to stop the progress of the consideration of the Bill, much as the doctors, the BMA and others might desire it. The battles to change the Bill are for later today and in the new year. This is a broader issue.
This amendment will allow the House to express its dismay, should it so wish, that the Government are denying the Committee currently considering the Bill information that may be pertinent to its deliberations. Noble Lords may recall that my right honourable friend John Healey MP and the Evening Standard both submitted freedom of information requests in November 2010 to have the register of risks relevant to the Bill released. They went through the procedures of review and appeal with the Department of Health.
On Friday 2 November, the Information Commissioner ruled that, given the particular circumstances—that is, the passage of primary legislation through Parliament—the register of risks should be released. I raised the matter in the House on 14 and 16 November, asking for the information to be made available. On 28 November, the Minister informed the House that the Department of Health was appealing the decision of the Information Commissioner. He was unable to inform the House of how long the appeal process might take and whether the risk register might ever or eventually be made available to the House in time to be considered during proceedings on the Bill.
The Minister also said that some information might be made available. However, he said:
“I cannot share the detailed breakdown of the information recorded in the risk register, or the wording”.—[Official Report, 28/11/11; col. 16.]
The noble Baroness, Lady Williams, supported the need to make this information available to the House, for which I for one am very grateful. It underlines the fact that this is not a party-political issue and is not for point-scoring. It is about the proper functioning of this Chamber doing the best job it can with all the information available to enable us to do so. The pros and cons of releasing the information have been thoroughly explored by the Information Commissioner in his ruling, including addressing the concern about precedent-setting expressed by the noble Lord, Lord Butler, on 28 November. The Information Commissioner argues with great clarity in his ruling that the particular circumstances of the Bill mean that the information is directly relevant and should be released. He said in his ruling of 2 November that:
“The Commissioner finds that there is a very strong public interest in disclosure of the information, given the significant change to the structure of the health service the government’s policies on the modernisation will bring”.
In this ruling the commissioner goes on to say that he,
“considers that disclosure would go somewhat further in helping the public to better understand the risks associated with the modernisation of the NHS than any information that has previously been published”.
This is the information that we have been refused. Today we start day 11 in the Committee on this huge and complex Bill, with its implications for our NHS. We have been considering this Bill for over 60 hours, and by my reckoning we have about another 25 or so to go before we embark on the next stage in the new year. We do so ignorant of this information.
As well as regretting the decision taken by the Government, the amendment asks the Minister to reconsider the decision to appeal the Information Commissioner’s ruling. I appreciate that the decision about this matter may be above the Minister’s pay grade, and I sympathise with his position. It seems to me that a clear expression of the House’s dismay and regret may strengthen the Minister’s hand when he discusses this further in the department.
There are two final matters which I ask the House to consider. The first is that the last Government, under similar circumstances, and indeed after a year of resisting, released the third Heathrow runway risk register to Justine Greening MP. It did not create a rush to request risk registers. Secondly, it has also emerged, as was published in the Evening Standard, that NHS London publishes quarterly on its website a risk register for health services in the capital, including how they could be affected by the Government’s reforms. NHS London’s frankness can only add to the case for publication. I understand that one other NHS region is also considering this course of action. I ask the Minister if he is aware of this, and does it not rather undermine the argument the Government are using to appeal this decision? Indeed, does his department intend to stop NHS London?
I hope the House will regard this as a very serious matter. I hope that noble Lords will consider supporting this Motion of Regret if there is no change in the Government’s position. Like all noble Lords here, I hold the noble Earl, Lord Howe, in great respect and esteem, and I have come to the decision to proceed only after much reflection. It is because this House is a body of revision and scrutiny. It has without doubt a worldwide and distinguished record of scrutiny, which includes, after consideration of evidence and facts, telling Governments that they need to change legislation. This House has a reputation for standing up to Governments when it believes that rights and liberties are in jeopardy, and having access to the information allows us to reach considered decisions. I suggest that we are being denied the ability to do our job. A GP sent me a message this morning:
“Glenys Thornton, how can you debate a Bill without knowing the risks?”.
He is right.
Baroness Williams of Crosby
My Lords, it is important to spend a moment or two explaining the purpose of a risk register. One of the difficulties that has arisen over recent years is that risk registers have been used in the planning of long-term substantial projects by both the last Labour Government and the present coalition Government. When a risk register is produced, the effort is to consider all the contingencies—some of them highly unlikely—which might arise in relation to that project. There will certainly be some information in that category that would enable the discussion of any Bill of sufficient significance passing through Parliament to be treated with better knowledge than might otherwise be the case. It is also true that under the terms of the relevant legislation, particularly under Section 35(1)(a), there is an exemption category which allows those registers that directly affect policy formulation to claim an exemption from the output and effect of information legislation.
What we now know happened in this case is that when the Information Commissioner considered the point put to him by the original seeker after information, he had to weigh up on the one side the exemption argument and on the other side the argument of the public interest. He himself indicated in his original findings in early November this year that it was a very narrow balance, but that he believed, as the noble Baroness has said, that the issue was sufficiently in the public interest for him to overrule the exemption. There is a legislative right to appeal, of course, and that right to appeal was taken up by the Department of Health on the grounds that this is to do with policy formulation and therefore falls within the exemption. It asked the commissioner to overrule the application. The commissioner decided to uphold the application on the balance of considerations both ways, and the Department of Health then decided to use its right to appeal and it is that appeal which is now about to come before the tribunal. My understanding is that both sides in this argument, the complainant and the defendant, have asked for more time in order to prepare their cases. Only after that will the tribunal be able to make a ruling.
Along with the noble Baroness, I am of the view that it would be helpful to the Report stage of this Bill to have as much information as can possibly be made available. However, the proper way to do that is to allow the tribunal to reach a judgment. My understanding is that if both parties to the tribunal were to request a decision to be made as quickly as possible after the cases have been prepared, the tribunal might be agreeable to a rapid decision. That is very important because nothing can happen before such a decision and it would be unfortunate for the House if the result was not known well before the Bill reaches Report.
I ask the Minister whether he could consider such a joint approach to the tribunal, recognising fully that the two sides must be able to prepare their cases, to see whether it could not act much more quickly than is its usual practice in order to allow the House to have the information if, indeed, the tribunal decides not to uphold the appeal. If it does uphold the appeal, it will then of course be a different case and there will not be any further argument about it. I put that to the Minister because I believe it is very important to settle this issue quickly. I fear that it may hang like a dark shadow over the whole of the Report stage. It must be decided one way or another either before or very soon after the Report stage begins when the House resumes in the new year.
Lord Pannick
My Lords, I understand the wish of the Government to appeal against the decision of the commissioner because of the general issues of importance raised under the freedom of information legislation, but the issue raised today by the amendment does not depend on the proper answer to the question that was before the commissioner and which will be before the tribunal. That is because the issue before the commissioner and the tribunal was the proper balance of interests—a very difficult balance of interests, as the noble Baroness, Lady Williams, has said—between the public interest in having this information and the very real need to ensure that risk registers in general are not disclosed. But the issue before the House is different. It is the issue of whether the Members of this House should be given information that the commissioner in his judgment, having seen that information, has said will be of considerable importance in enabling the Members of this House to perform our scrutiny function in relation to this vital Bill.
I cannot share the opinion of the noble Baroness, Lady Williams, that this is the same issue as will be before the commissioner. It is a matter for the judgment of this House how best we perform our scrutiny function. Whatever the balance may be, in general, between the public interest in disclosure and the very real interest in not disclosing confidential information that is on a risk register, the balance is surely very different in principle when we have before the House a Bill that we are scrutinising and considering. It would, I think, require an overwhelmingly strong argument to justify non-disclosure to this House of information that is relevant to our scrutiny function. I therefore hope that the Minister will be able to say today that he is prepared to disclose to this House at least the substance of the information that is contained in the risk register, so that we may fully perform our scrutiny function in relation to this vital Bill.
Lord Clement-Jones
My Lords, I am very interested in the argument of the noble Lord, Lord Pannick. He seemed to be setting a rather different standard, well above that imposed by the Freedom of Information Act 2000. I have no doubt that the Minister will deal with that argument when he comes to it. However, I believe that the question for the House today is whether we support the Department of Health’s right to appeal against the Information Commissioner’s decision. This has been a much more finely balanced decision than I believe the noble Baroness, Lady Thornton, is prepared to credit, which I find somewhat surprising given her recent role in government. In this kind of situation, with a qualified exemption under the Freedom of Information Act, it is all about whether the balance of public interest is served by disclosure or non-disclosure. The arguments put forward to the commissioner were in relation to two essential aspects. First, there is the “safe space” argument: the importance of government having the freedom to debate policy and make decisions,
“without being hindered by external comment”.
Secondly, there is the “chilling effect” that disclosing information relating to a particular policy, while that policy is still being formulated or developed, could have on,
“the frankness and candour with which relevant parties make future contributions to that particular policy debate”.
These are perfectly respectable arguments and that is why the commissioner found that the factors are finely balanced, as my noble friend Lady Williams said. In the light of the particularly strongly held views of the department—and I believe that these are genuinely held—it seems that it is entirely valid for the department to appeal to the First-tier Tribunal.
However, I agree very strongly with my noble friend that time is of the essence in this case. There is little point on a decision on appeal not being made until March or April; because, as my noble friend has pointed out, the Bill will probably have passed through this House entirely by then. To mitigate the possibility of that kind of delay, my noble friend’s suggestion is entirely right and sensible. The Department of Health and the complainants should apply to the First-tier Tribunal for an expedited hearing. This is well within the tribunal’s case-management powers under paragraph 5 of the procedural rules, which were last set out in 2009. Of course, this is a discretionary power, but I believe that any tribunal would recognise the need to resolve these matters quickly, particularly in the light of the debates we have had in this House. I believe it would be extremely helpful in the circumstances if the Minister indicated the department’s willingness to proceed along these lines. I hope that my noble friend can give a positive response today, even if further time is needed to prepare the case on both sides.
Lord Turnbull
My Lords, I was not involved in the earlier exchanges in this House on this issue. Coming to it new, my view is that first, there is a very important issue of public policy here; and secondly, the FOI process, still less the procedural devices in the course of this Bill, is not an effective way of resolving the issue.
The issue is this: in what way should public authorities report on risk ex ante and account for their management of it ex post? A ruling on a request for a specific document from a specific department is, in my view, incapable of addressing that issue adequately.
Let me declare an interest: I am a director of Prudential plc. This, in the jargon, is a SIFI—a significant financial institution—and, as such, it is now required to have a separate risk committee. In the rest of the plc world, risk is still dealt with as the work of the audit committee. I am a member of that risk committee. Looking at its experience, one can identify three categories of material. First, there is a definition in the annual report of the risk universe and the organisation’s risk appetite: capital risk, liquidity risk, credit risk, operational risk, and so on. In addition there is a definition of the organisation’s appetite for risk.
Secondly, the annual report has material on how risk is managed—the so-called three lines of defence: front-line managers, the risk function at the centre, and internal audit. There is then a third category of information. It might be about the risk of falling below a particular level of capital, or the danger of not finding enough liquidity at a crucial time, or the danger that the key supplier might fail or that IT systems might be interrupted. There are also watch lists: what banks or counterparties does one not want to increase one’s exposure to? This is often set out in the diagrams with which many Members of this House will be familiar, in red, amber and green, showing impact, likelihood, a combined score and then the mitigants.
Very little of this category of information is disclosed, for a very good reason. Discussing it can risk making it more difficult to manage the case in question and in some circumstances might crystallise the very event one is trying to avoid. The same should apply to public bodies. Mention has been made of the chilling effect—that is, officials being reluctant to give candid advice more or less in real time. There is also something that has not really been covered by the Act, which I call the “crystallisation effect”. Managers might be reluctant to be frank in public about operational difficulties if that would undermine their ability to make contingency plans or could trigger an event before their plans are ready.
In my view this is the wrong way to resolve this issue. Where the line should be drawn, what is reported and what is withheld should not be decided on a case-by-case basis. The Information Commissioner—indeed, the whole of the FOI Act, in my opinion—is afflicted by the fallacy of composition. Because something is desirable in case A, it will also be desirable in all cases, if all cases alike are treated in the same way. However, if I stand up to get a better view of a football match, I will improve my view; if we all stand up, none of us will. The fact that one cannot take cases in isolation is perfectly illustrated in this case. The Information Commissioner issued a decision on 2 December on a request from the risk register on the NHS reform programme. Yet only the day before, he issued a decision on a different request, I think from a different complainant, on the strategic risk register. It is fanciful to think that those things could be decided independently or that they could be isolated from what happens in the rest of the public sector.
How, therefore, should this issue be dealt with? Not, as I say, by requiring the release of a particular document originally written for a different audience. It would be better if the Information Commissioner had recommended that the Government should set in hand work involving the man known as HOTGAS—the head of the Government accountancy services—and the NAO, to create a framework of best practice on what should be provided in departmental reports, and what operationally should be withheld. It is normally the case that public accounting standards in the private sector have developed over time and the public sectors usually follow with a lag. The reporting of risk and of risk management is in my view the next area for improvement in the public sector accounts, and the role of the CAG should then be to police whether those principles are being followed. In the case of this Bill, I hope that the Minister can be as forthcoming as possible on what the risks are without creating any of the perils that I have indicated.
The Information Commissioner has made a decision so it goes to the tribunal, and the Government’s case would be greatly improved if they were able to indicate that they supported the kind of initiative that I have suggested. Meanwhile, I hope that the noble Baroness, in the light of any assurances and further information from the Minister, will not press her amendment, but if she does I hope that the House will support the Government, on the understanding that the reporting of risk is the next issue to be advanced across public bodies as a whole.
Baroness Scotland of Asthal
My Lords, I think we need to be clear that my noble friend Lady Thornton’s Motion is simply for this House to express its regret. It is not a fatal Motion but an opportunity to express a view.
I have to say, and this is rare, that I disagree with the noble Baroness, Lady Williams; indeed, this may be one of the first times I have done so when not sitting where the noble Earl, Lord Howe, now sits. The whole purpose of the Information Commissioner is that he is charged with looking at the most delicate and difficult issues and seeking to come to a balanced view on whether the public interest points in one direction or another. It is clear that both parties have an opportunity to appeal if they disagree with him, but I hope that Members of this House, if they have had an opportunity to read the commissioner’s decision, will have found it sound, well argued and balanced. So we have a well argued, balanced view from the Information Commissioner that he believes, having had the advantage of looking at the documents, that the risk register would enable this House to better scrutinise the Bill to the effect of helping us to make a better Bill for the people of our country.
I agree with those who say that this opportunity has to be sparingly used, and it is clear that the commissioner agrees. This will not open the floodgates, which it sounded as if the noble Lord, Lord Turnbull, was suggesting would happen if we agreed to this Motion of Regret. It is clear that the National Health Service is dearer to the people of our country than almost any other institution, so this touches every single citizen. Be they a baby or a person in their third age, it is of equal importance. If we compare it to the importance of the third runway at Heathrow, I hope that the House will think the NHS is a tad more important. Notwithstanding the difference in importance and, as my noble friend Lady Thornton made clear, the great reluctance from my own Government—it took over a year—we gave way, because it was right and proper to do so and there appeared to be an overwhelming public interest. If there was an overwhelming public interest in that case, how much more is there an overwhelming interest in this?
I suggest to the House that the noble Lord, Lord Pannick, is right that this goes to our power and ability to properly scrutinise the Bill. I therefore invite your Lordships to join my noble friend in gently saying to the much beloved noble Earl, Lord Howe, that this is may be a moment when he has to take a message back to his department and say, “Can this not be released?”. If it is as cogent, sound and well placed as the Government believe it is, surely that will only persuade those of us who have anxieties and assist in our scrutiny.
Lord Warner
My Lords, I hesitate to intervene but it is a Motion of Regret, and one element of the regret the House would express would be regret for the position the noble Earl has been put in. Much of our debate so far on this Bill has been on the basis of how it would work in practice and how things would happen on the ground. I suspect there is a lot of information about how things would work in practice in the risk register. My concern is that the noble Earl is being put in a very difficult position and at risk of misleading the House—I am not saying he has; I am not saying he has not—as he has been put in a position where, because he is unable to use that information, he may be forced to hedge his bets to reassure the House on some of the practical issues. I hope that is not the case and he has not been put in that position, but we need to be sure and I hope he can give us some reassurances.
Lord Mackay of Clashfern
My Lords, the decision of the commissioner is certainly well argued, but under the existing system it is subject to appeal to the tribunal and the Department of Health intends to exercise the right to appeal. In that situation, in my submission, the Minister is entitled to give this House the best information he has. There is no question of failure to release this report in any way leading to the noble Earl, Lord Howe, misleading this House. I do not believe that is at all likely.
The noble Lord, Lord Pannick, developed a cogent argument, but the question he raises in relation to what is to happen here today is a different question from that which arises on the appeal. Unfortunately, although it is a different question, it is very closely related because, if the document is to be released now, the question of an appeal to the tribunal is evacuated because the document will already have become public, which is the issue in the appeal. Therefore, I believe that my noble friend Lady Williams of Crosby has suggested the best way out of this business: the Government and the other parties to the appeal should do what they can to have the appeal expedited. I do not believe that the tribunal is in any worse position than a court of law in getting on with the job quickly and that is the best course because if the tribunal endorsed the commissioner’s decision then that solves the matter.
Lord Pannick
Would the noble and learned Lord agree that if the tribunal dismisses the appeal it would then be open to the Government to take the matter to the Court of Appeal?
Lord Mackay of Clashfern
Certainly. The Court of Appeal has a very great record in dealing with matters quickly.
Lord Mackay of Clashfern
Delay is something that the courts can control. That is one of the functions they have to try to do expeditiously when an expeditious judgment is required. I believe the solution proposed by my noble friend is the best one: namely, that an expedited decision should be sought from the tribunal.
Lord Richard
I want to ask the noble and learned Lord a question. If there is an expedited appeal and it is going to run its course, does the noble and learned Lord think we should continue with this Committee stage or wait until we see the result of the appeal?
Lord Mackay of Clashfern
I assume that if the decision was available in time for the Report stage, the House would have ample opportunity to consider its relevance to the matters in issue in the Bill.
Lord Richard
What would happen if it were not available at the beginning of Report stage?
Lord Mackay of Clashfern
I hope that it would be possible for the decision to be available at the beginning of Report stage.
Lord Martin of Springburn
My Lords, I have listened carefully to what all noble Lords have said. I was interested in what the noble Lord, Lord Pannick, had to say. He often advises me on legal matters, so perhaps he can advise me further. If the information comes to us as an open House, it will be public information. Therefore, to say that it comes before noble Lords means that it becomes available to everyone.
Lord Martin of Springburn
That is fine. I am learning every moment. The amendment states that,
“this House regrets the Government’s appeal against the Information Commissioner’s ruling”.
It makes no criticism of the Minister; there is nothing personal here. I am a trade unionist but I was formerly a full-time trade union official and also a lay magistrate for a very short time. My training taught me not to worry about the decisions that I made, whether they were judicial or semi-judicial, as there was an appeals procedure. The Government are exercising an appeals procedure. We go down a dangerous road if we criticise anyone—whether it be the Government or a private individual—for exercising an appeals procedure. An appeals procedure is a good, safe mechanism for everyone concerned. The wording of the amendment worries me because an appeals procedure is there to be used. The only thing I ask of the Minister is to say that it is being used as a mechanism for achieving clarity with regard to the Information Commissioner’s decision rather than as a stalling mechanism to prevent the Opposition getting the information. If the appeals procedure were being used as a stalling mechanism, I would feel aggrieved as that would be the wrong thing to do.
I do not think that anyone can brag about the Heathrow decision. It took a year to release the information so there is nothing to brag about. The Government have greatly encouraged the appealing of information commissioners’ decisions on other occasions and there were many occasions when the previous Government did not want to abide by an information commissioner’s decision. I do not know much about the risk reports that are being discussed but I understand that they constitute officials’ information given privately to the Minister concerned. If I am wrong, noble Lords will correct me. I was never a Minister but former Cabinet Ministers are present and the noble Baroness who moved the amendment is a former Minister. I would be deeply concerned if officials were unable to give information or advice in writing in the privacy of a Minister’s office in case it was deemed to constitute data which had to be produced in the public domain. If that were the case, officials would not provide that information. I worry about that.
I know how important the National Health Service is. Like many others in this House, I was brought up in a household where I was taught to appreciate the National Health Service. However, this has implications for advice given by officials to Ministers. As I say, I am worried about the implications for that advice.
The amendment uses the word “regrets”. It is a serious matter to me to express regret and to put it in terms of a Motion before the House. Let us not kid ourselves about the Information Commissioner doing a nice balancing act, looking at both sides and weighing up the public interest and the Government’s interest. All too often, the Information Commissioner has said that it is in the legislation and therefore it is going into the public domain no matter what the consequences are. If there had been a wee bit more work put into the legislation years ago, we might not be standing here today concerning ourselves with an Information Commissioner’s decision.
Lord Campbell-Savours
My Lords, a number of Members of the House have suggested alternative ways forward. The best suggestion came from my noble friend Lord Richard. He made the perfectly reasonable suggestion that the Report stage be deferred until we get a ruling on the appeal. I am a mere mortal Back-Bencher, making the offer on behalf of colleagues, but I would imagine that my own Front Bench would support that proposition. Why do we not simply defer it? It is a perfectly reasonable suggestion. The Government will get their way and we will get our way in the sense that we will then be informed when we get to the Report stage of the Bill.
In reality, what is happening today is that the Government are simply using an appeal procedure to delay, knowing this will ensure that certain issues, which should be freely discussed on the Floor of the House during the course of consideration of the Bill, are not going to be discussed. It may be worth noting the comments of Justine Greening when she experienced similar problems under, regrettably, the previous Labour Government. These are her words:
“The DfT’s refusal to release the register until ordered by the Commissioner”—
which we subsequently did, of course—
“shows that Ministers have truly lost all integrity on being open with the public they are there to serve”.
If that was the attitude taken by the noble Earl’s colleagues at that time, why should it not be our attitude today? Perhaps in the light of Justine Greening’s comments at that time, he may wish to reconsider his own position on these matters.
Lord Richard
My Lords, I am very grateful to my noble friend Lord Campbell-Savours for supporting my earlier remarks. Perhaps I may expand on them briefly. This is a very strange situation. It is not one that I have ever come across quite in this way before. There is evidence which is, at least prima facie, relevant. Everyone seems to agree that it is relevant to consideration of the Bill. Indeed, as far as the Information Commissioner is concerned, it is not only relevant but disclosable. That is a fairly strong basis on which to start our consideration of what we do about the Bill. If there is a chunk of evidence which is relevant to the Bill, and if that evidence is prima facie disclosable, it is somewhat wrong for the Government to crack ahead with the whole thing while the issue of disclosure of that piece of evidence remains up in the air. If one could expedite the appeals—I am bound to say, as a former practising barrister, that it does not always happen that appeals are expedited in the way one hopes—and therefore get the appeals procedure out of the way before Report stage starts, that would be a sensible way of proceeding.
On the other hand, if you do not get the appeals procedure out of the way, you have to look at the other side of the balance, which is that if the appeals procedure is not out of the way and this issue remains live, the Report stage should not start until after the appeals have been determined and after there has been a firm judicial decision, one way or the other, as to whether or not the Information Commissioner’s opinion on disclosure of this evidence is right. It is a strange position, but the evidence is clearly relevant and, according to the Information Commissioner, prima facie, disclosable. There are also precedents that this type of information should be disclosed. Therefore, it seems to me that it would be wrong just to crack ahead with the Bill as if this issue did not exist.
Baroness Finlay of Llandaff
My Lords, I hesitated over whether to intervene, but I feel that I should comment as a clinician. There is enormous concern out there in the clinical services, particularly over transition as the changes come through. There are all types of risk registers and many of them deal with financial and livelihood matters, but the problem is that this issue relates not to livelihoods but lives. People are really concerned that they will not be able to treat critically ill patients in the way that they know, and in the way that the evidence informs them, if we do not get the transitional arrangements correct. That is why there is so much strength of feeling behind the need for access and the need to know where the major risks that have been identified are. Assurance needs to be given through this House to the public at large that action has been taken to deal with the major risks that may be exposed in the risk register.
This is a Motion of Regret. It is nothing more than that. It does not alter the course of the law, and many suggestions have already been made to the noble Earl. I should emphasise that this debate in no way undermines the confidence of either this House or the profession outside in the integrity of the noble Earl, Lord Howe. That is completely intact and not under question. The anxiety relates to what is not being disclosed and what is not being dealt with and, therefore, who is actually being put at risk.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, as the House will recall, I have made clear on earlier occasions why the Government do not believe that it is appropriate to reveal the details of my department’s risk registers. This decision was made not solely in consideration of the current Bill but in the wider context of government. It is important for me to emphasise that.
However, in addressing the noble Baroness’s Motion, it may be helpful to put the issues that she has raised into the broader context of the Freedom of Information Act. The overriding aim of the Act is to maintain a balance between openness and confidentiality in the interests of good government. Openness is an intrinsic part of good government and is a principle that I and my fellow Ministers firmly believe is important. At the same time, it is equally important to acknowledge the need for a safe space when formulating policy and the associated risks. Those noble Lords who took part in the debates on the FOI Bill will recall the clear position taken by Ministers of the day about where that balance should be struck in relation to the workings of government. It was made clear that the Act was not intended to change the way that the Government conduct their business by requiring all their deliberations to be made in public. Some element of confidentiality must remain for the proper and effective conduct of that business.
Ministers and civil servants need the space to be able to consider the worst risks—even to broach quite unlikely risks—and to do so openly and frankly, without the threat of disclosure. Without this safe space for open and frank risk assessment, the registers would be in serious danger of becoming anodyne documents and their purpose would thereby be significantly diluted. That is why information relating to the formulation or development of government policy is explicitly exempt from disclosure under the Act. There is also an explicit exemption for information that would inhibit, or be likely to inhibit, the free and frank exchange of views for the purposes of deliberation.
It is my department’s very clear view, and the view of other government departments, that departmental risk registers of this type and nature should be treated as being exempt from disclosure. That was also the view taken on several occasions by health Ministers in the previous Government. I say to the noble Lords, Lord Pannick and Lord Martin—I was grateful to the noble Lord, Lord Martin, for his remarks—that the Government have no wish to be discourteous or obstructive to this House. Quite the opposite.
We are absolutely not using the right of appeal as a delaying mechanism. The department has published and discussed its proposals for reform at every stage of the process; we have debated them at length in both Houses; it has released some detail about the associated risks and what it is doing to address them in its impact assessments. In response to the noble Baroness, I myself have provided the broad issues covered by the risk register in my Statement of 28 November. Incidentally, that Statement was meant to be complete. I assure the House that in taking forward the Bill, no further risks are identified on the register that would fall outside the list of broad issues that I provided. I am therefore satisfied that I have not misled the House as a result of the Government's decision to appeal.
I am very grateful to my noble friend Lady Williams for her suggestion that the case should be expedited. I am as keen as anyone to see the matter speedily resolved. As my noble friend knows, she and I discussed this yesterday privately and I have since pursued the matter actively with my officials. I should say, however, to place my noble friend's suggestion in context, that since we met, the solicitor acting for the Information Commissioner has requested an extension of time to file the commissioner’s response to our appeal notice and has indicated that the appeal raises issues of considerable importance that will require the tribunal's normal target time for listing an appeal hearing in order for the case to be properly prepared.
I should also make clear a further point. For our part, as the House knows, we take the view that this case raises an important matter of principle for the Government as a whole. We took the decision that we have taken after very careful thought and discussion. Now, the burden is on us as appellants to provide accurate and pertinent evidence to the court to support our case. In preparing that case, we need to consider and consult across various parts of government, as indeed we consulted about our decision to appeal. It is obviously important that we have the necessary time to prepare and carry out those consultations. We have not asked for more time, but I suggest that we need enough time.
I completely understand and sympathise with the desire of my noble friends to see the matter resolved, and I undertake to use my best endeavours to pursue the suggestion so helpfully made by my noble friends Lady Williams and Lord Clement-Jones. The decision to appeal the Information Commissioner's ruling has not been taken lightly, but we have taken it because we believe that the commissioner has not given sufficient weight—
Baroness Thornton
Can the Minister give us some times here? How long is it going to take? When does he expect to have the tribunal sit? He keeps saying that it will take time to prepare and to do this, but I think that we need to know how long that will be.
Earl Howe
Having anticipated that question before this debate, I made a point of asking but I am afraid that I do not have a definite answer to give the noble Baroness at this stage. As soon as I am able, I would be delighted to do so.
Our appeal is based on the belief that the commissioner has not given sufficient weight in his judgment to the considerations embodied in the relevant provisions of the relevant FOI Act. As the noble Lord, Lord Butler, made clear on 28 November, the ruling has serious implications across government in the precedent it sets for all risk registers.
Lord Campbell-Savours
The noble Earl said that he could not give us an idea of the timetable, but he does have something under his control: he has control of the timing of Report. He could say, “We will defer Report stage until the appeal result”. Why does he not just do that?
Earl Howe
The noble Lord knows that that is a matter for the House and the usual channels and not for me. However, I have no doubt that his suggestion will be registered in the appropriate places and will be considered. He must understand that it is not solely in my gift to order the business of this House.
I am of course acutely aware of the concerns of noble Lords on this issue. However, I would just ask those noble Lords who may at first blush be inclined to side with the noble Baroness in her amendment to recognise that there is room for an honestly held difference of view on this matter, that the principle involved is very important for the workings of government and that the Government have acted both properly and reasonably in asking the Information Tribunal to reconsider the merits of the case.
Baroness Thornton
My Lords, I thank noble Lords for this very illuminating and important debate, and I feel the weight of that importance. I think that the Minister would admit that over the past four weeks we have been very measured in our approach to this issue. We have not rushed at it; we have not sought to delay the Bill; and we have been very measured and patient in trying to work out the best way forward.
I thank the noble Lord, Lord Pannick, my noble and learned friend Lady Scotland and my noble friend Lord Richard and others for their support on this. I also thank my noble friend Lord Richard for crystallising the point that we should not proceed to the next stage of the Bill until we have the results of the appeal, and perhaps that would concentrate minds. In that context, I think that my amendment, which is a regret Motion, will help.
The noble Lord, Lord Clement-Jones, spoke about a chilling effect. I found the remarks of the representative of our former Permanent Secretaries in the House, the noble Lord, Lord Turnbull, interesting but possibly not to the point. The Freedom of Information Act may need reforming but that is not the point of my regret Motion. Particularly in response to the noble Lords, Lord Clement-Jones and Lord Turnbull, I should like to quote to the Committee from “Yes Minister”. This is from episode one of the first series and is about open government. Bernard, who noble Lords will all remember is the Private Secretary, says:
“But surely the citizens of a democracy have a right to know”.
Sir Humphrey—or maybe we should call him “Sir Andrew”—says:
“No. They have a right to be ignorant. Knowledge only means complicity in guilt; ignorance has a certain dignity”,
although it is not dignity that I would particularly welcome.
I confess that I am disappointed by my colleagues on the Liberal Democrat Benches. I was here with them in the Chamber fighting for the Freedom of Information Act all those years ago, and I know that they would have liked my Government to have gone even further than we did. Therefore, it is a matter of regret and disappointment that they are not joining with us in saying that the commissioner’s ruling is a good and measured ruling, that it takes account of all those issues and that this information should be made available to the public and, indeed, to the House.
Finally, the question is very simple. It is not about the appeals tribunal, and the noble Lord, Lord Pannick, was right. It is about how this House amends legislation to make it good legislation, and it is an amendment to regret the fact that we are not being given the information that we need to help us in that job. It is a very mild rebuke—it is an amendment expressing regret. It is a regret that we cannot do that job because we need this information. My view on that has not changed as a result of this debate. I feel enlightened by this debate to a certain extent and think that we may see a way forward. However, we need to regret the fact that we do not have this risk register, and I wish to test the opinion of the Committee.
Lord Warner
Lord Warner
My Lords, in moving Amendment 240, I shall also speak to Amendment 242 in this group in my name and that of the noble Lord, Lord Patel.
Amendment 240 inserts the words “cost and” before “effectiveness” regarding the exercise of functions by various bodies that the Secretary of State must keep under review. The NHS faces an unprecedentedly long period of having to survive on short financial rations. This is now likely to extend at least two years after the 2015 election, if we are to believe the Chancellor’s utterances last week on the public finances and deficit reduction. The NHS has never delivered in any one year of its history the productivity and cost-saving requirements set by the £20 billion Nicholson challenge, which is to be produced at least four years on the trot. Most informed commentators expect a financial crisis of some kind in the NHS in the next few years, so the reality is that the Health Secretary will have to keep under close review the expenditure and costs of all the bodies listed in Clause 49. The Government should face up to this reality, in my view, as the Chancellor seems to want us to, by adding the words in Amendment 240 to the Bill.
Amendment 242 is another part of that reality checking of the NHS in the Bill. On earlier amendments I raised my concern about keeping in check the overheads and management costs of the national Commissioning Board and clinical commissioning groups, and was duly told that these were not necessary. I acknowledged then that my amendments were probably not framed as they should be. However, I am returning to this issue with Amendment 242, which requires the Secretary of State to report annually to Parliament the administrative costs of the bodies listed in Clause 49, together with the percentage of the NHS budget they represent and their percentage increase over the previous year. If the Secretary of State is doing his or her job properly, they should have this information available to them and be monitoring it closely, especially in the financial climate the NHS faces over the coming years.
We know from history how, left to their own devices, bureaucracies can expand their remits and resource consumption. Ministers never like to own up to this happening on their watch. To improve the prospects of keeping Ministers and, if I may put it this way, these big NHS beasts on the financial straight and narrow, it would be extremely helpful if the Bill required the reporting of administrative costs and their movement over time to Parliament once a year. I hope the Minister can be constructive about accepting such an amendment as it in no way challenges the Government’s reforms. I beg to move.
Baroness Cumberlege
My Lords, I have two amendments in this grouping and, lest I be drummed out of the Brownies, I would like to explain that there is a typo in the Marshalled List. It should read not “detailed merits” but “detailed remits”. As noble Lords will appreciate, there is a great difference, and I do not need any persuasion as to the merits of this Bill.
The purpose of my two amendments is to be probing; I am really just seeking clarification. The Future Forum was very widely welcomed by most people, but it further complicated the new proposals in the Bill regarding how we are to organise and manage the NHS. After years of being dictated to and micromanaged, there is a real risk of paralysis, and this at a time when commissioners need to reach decisions and be truly radical.
As I understand the proposed structure, the national Commissioning Board and clinical commissioning groups will be supported by clinical networks, clinical senates, commissioning support organisations and health and well-being boards, which will work in partnership with them. In addition, we have a new public health system, which we debated last Monday, with the creation of Public Health England and the establishment of HealthWatch England and Local HealthWatch to try to improve patient and public involvement. This has the potential to cause confusion and duplication if the Government are not clear about the accountabilities, roles and responsibilities of these different organisations. I would like to take a very serious example: it is still unclear who will take the lead on the commissioning of specialist doctors and nurses responsible for safeguarding children within the NHS.
At a national level, the movement from a single department of state to a more dispersed range of organisations, including the national Commissioning Board, Public Health England, HealthWatch England, Monitor and the Care Quality Commission, could have a similar effect. The danger is that the NHS could find itself in paralysis at just the moment that it needs to make key decisions that are crucial for the sustainability of parts of the service. In particular, some of the important decisions on potential service reconfigurations are urgent if the NHS is to meet the Nicholson challenge and at the same time fulfil its commitment to high quality and safe services to patients.
It is still unclear to me, and I know that it is to some others, how the respective responsibilities and accountabilities of commissioners, providers and regulators for quality are intended to work together. We also need to ensure that additional complexity does not result in an increased administrative burden or financial cost, as the noble Lord, Lord Warner, has said, falling on healthcare organisations. I think that my noble friend gave an undertaking on that on Monday but further clarification would be welcome.
Because of these concerns about the complexity of the new structure, I am asking the Minister if he could look seriously at this issue; go beyond the organograms and design detailed remits and powers for all those in the system to minimise confusion, gaps and duplication; and be as clear as possible at the outset as the reforms are implemented, while at the same time keep under review and address any confusion, gaps and duplication between the components in the system. Change is always a challenge. The more we can reduce muddle and confusion from the outset, the more successful these reforms will be.
Lord Hunt of Kings Heath
My Lords, I have a number of amendments in this group which concern the duty of the Secretary of State to keep health service functions under review. This is an important provision. I note that on what will probably be the last day in Committee, we have Amendment 354, which relates to a requirement on the Secretary of State to publish a report which can then be debated by Parliament. Although it is not grouped with this amendment, it is highly relevant to it.
It would be helpful to know from the Minister just how these matters are going to be monitored and how adjustments can be made in the light of experience. As my noble friend Lord Warner suggested, although we are not going to be allowed to see the risk register—I am very doubtful that we will see it before the Bill has passed through your Lordships' House—we know that considerable risks will come with these changes. The noble Baroness, Lady Cumberlege, spelled out some of the key issues that we face. The last thing that the health service needs is a massive reorganisation. Clearly, there are risks and it is right that there should be a regular review by the Secretary of State.
It is also right that the Secretary of State, when reviewing the operation of the changes, reviews all parts of it. I am extremely puzzled by Clause 49 concerning the duty to keep under review. The Bill sets out the bodies to be reviewed. They are the NHS Commissioning Board, Monitor, the Care Quality Commission, the National Institute for Health and Clinical Excellence, the Health and Social Care Information Centre and special health authorities. There is no mention of the plethora of bodies that will exist in the new system. There is no mention of clinical senates, the local field forces of the NHS Commissioning Board or health and well-being boards. Quite remarkably, there is nothing about clinical commissioning groups. Perhaps the noble Earl could tell me why the effectiveness of the CCGs is not to be kept under review?
Perhaps I have misread the Bill and this will be done in some other way. But I find it remarkable that this Bill is built around GPs and clinical commissioning groups, which are untried and untested, yet they are not to be kept under review. Looking at the architecture of this Bill, one begins to see very tight control of most of the health service but when it comes to clinical commissioning groups, issues of corporate governance, conflicts of interest or any of the other matters, it is incredibly light touch. It is as if we are to believe that, somehow, this part of the reforms is believed by the Secretary of State to be so remarkably able to carry out its duties that very little monitoring, performance management or review is to be undertaken. I would be grateful to know why clinical commissioning groups in particular have been left out of this list.
Amendment 243A concerns the annual report. In Clause 50 we see a requirement on the Secretary of State to publish an annual report on the performance of the whole service in England, which must be laid before Parliament. That, of course, is welcome. But my amendment asks that the report should include a statement on progress towards reducing relevant inequalities, on integration of services, on waiting time performance, and on health outcome performance. No doubt the noble Earl will argue that it is a list, and that the Secretary of State’s annual report is bound to cover these matters.
However, we are in new territory when it comes to specifying matters in the Bill. We are told that the Secretary of State is stepping back from involvement in the National Health Service, and that we should not worry about that, because there will be a mandate, and a constitution. All will be well. Those of us with some experience in these matters are rather doubtful as to whether that is sufficient in terms of accountability. In that context, it is right for Parliament to set out some details which we would expect the Secretary of State to report annually. Of course, there may well be other matters which one would wish the Secretary of State to report on, but my four areas cover some of the main points.
Amendment 245B relates to the intervention orders under the 2006 Act. I would be grateful if the noble Earl would confirm whether those intervention orders apply to the NHS Commissioning Board and clinical commissioning groups. If they do not, perhaps he could explain why not?
Amendment 245C deals with liabilities and the Secretary of State’s responsibility in relation to NHS organisations. Again, could the Minister confirm whether this duty applies to the NHS Commissioning Board and to clinical commissioning groups?
Amendment 245ZA relates to the general power of the Secretary of State. In page 289, line 30, the Government seek to dissipate the general power of the Secretary of State, as is currently set out in Section 2 of the 2006 Act. I realise that this takes us back to the crucial debate we had on day 1 about the powers and duties of the Secretary of State. The Explanatory Note which relates to this says that the reason for changing the wording is because there is no longer a duty on the Secretary of State to provide services. Given that those matters have been, in a sense, put to one side, is this part of the package that is being looked at, because it does relate to the general powers of the Secretary of State?
My noble friend Lord Warner made some very apposite points which I certainly support, and I was very interested in the remarks of the noble Baroness, Lady Cumberlege. I had been agonising about her amendments, and she has very helpfully clarified a point for all of us. She has really put her finger on it. I am disappointed that she did not take part in our debate at our last sitting ,when we discussed the complexity of the new arrangements.
We were promised a streamlined approach. What we have got instead is a highly complex set of arrangements. The NHS Confederation has expressed its concern about their complexity. I therefore like the amendment of the noble Baroness, Lady Cumberlege, that asks the Government to try to clarify for us who on earth is responsible for what in the new system.
When it comes to the key issues of the reconfiguration of specialist services and of funding, someone out there is going to have to hold the reins. Some agency or body is going to have to sort the problems out. It ain’t going to be the clinical commissioning groups. They are too small and they will not be able to do it, so someone else will have to. Is it going to be the clinical senates, or are we going to have to rely on the local government health and well-being boards, or will it actually be the local offices of the NHS Commissioning Board? I know that it will be the local offices of the NHS Commissioning Board. If that is so, we come back to the fact that that is patently going to be where the power is, and surely they ought to be made accountable. That is why I had an amendment down on our last day in Committee to turn them into statutory bodies. I detected a modicum of sympathy around the Committee, but not much more than that. However, the noble Baroness, Lady Cumberlege, as a distinguished former regional health authority chairman, knows that when we had the RHAs it was they that, in the end, had to intervene and sort problems out. There needs to be some sort of agency to do that in the future, and I think we should be told.
Baroness Murphy
My Lords, I had not intended to intervene but I have been stimulated to do so by the noble Lord, Lord Hunt of Kings Heath. The model being described of the Commissioning Board and its regional offices—the outposts—is very similar to the model that functions rather well for universities. There is the Higher Education Funding Council for England, which is centralised but also corporate with all its regional offices. The vice-chancellors, who you might say are the chief executives of the local organisations, relate directly to HEFCE. However, the regional executive officers are there to act as a moral support and a conduit. They do not necessarily sort out problems, but at least they are aware of them and know which areas the central body ought to be looking at. That is not so different from the way the regional officers from the Department of Health worked during the time of the district health authorities, between 1983 and 1990. If it is well done, and it has certainly functioned well for the duration of HEFCE, then it seems to me that it is a model which can be built on and developed. Is not that the way the problems the noble Lord is talking about will be resolved?
Lord Hunt of Kings Heath
I am grateful to the noble Baroness for her helpful intervention and I fully accept what she says. I want to make two points. First, we need an acknowledgment by the Government that there is going to be a kind of intermediate tier that, in the end, they can turn to when there are problems—if CCGs cannot work out a strategic approach or if reconfiguration is not taking place, as well as all the things that arise in the health service generally. My second argument is that I believe the health service is somewhat different from HEFCE in that it touches everybody, and the kind of issues that this intermediate tier will intervene on are likely to concern the public much more. There is then a case for making the intermediate tier a statutory body. Essentially there are two points here. I certainly agree with the noble Baroness about the importance of a helpful enabling intermediate tier which occasionally needs to intervene.
Earl Howe
My Lords, as I have observed on earlier occasions, I believe that this Bill increases Ministers’ accountability for the health service through a range of mechanisms. However, perhaps I may begin by saying to the noble Lord, Lord Hunt, that I agree that the Secretary of State’s annual report is an important mechanism through which he will account for the system. I am sympathetic to the objective behind Amendments 243 and 243A, which seek to specify areas for inclusion in the Secretary of State’s annual report, but I can reassure noble Lords that I expect to see mention of areas such as the reduction of inequalities set out in the report, as these issues are the foundation of a high-performing health service.
The Bill also sets out extensive powers of intervention in the case of failure, which are essential if Ministers are to be able to retain ultimate accountability for the health service. The intervention powers in the Bill are specific to the organisations to which they apply, which is the issue covered by Amendments 245B and 245C. With that point in mind, I believe that the powers set out by the Bill strike the right balance, enabling appropriate freedom for NHS bodies while ensuring that the Secretary of State can intervene in the event of their failure.
The Secretary of State’s duty of keeping performance under review only applies to national arm’s-length bodies. It does not refer to CCGs. The noble Lord, Lord Hunt, questioned why that was. We think that is right; however, the CCGs will very definitely be kept under review. The Bill sets out a robust process for the board to hold CCGs to account and sets out extensive powers for the board to keep the performance of CCGs under review and to step in where they are not performing.
The noble Lord also queried why there was no mention of a range of other bodies, such as senates and field forces. The answer is that they are part of the NHS Commissioning Board, which is specifically mentioned. As regards health and well-being boards, as the noble Lord will know, we intend them to be part of local government. I do not think local authorities would take very kindly to the Secretary of State for Health keeping them under review.
There are also a number of amendments in this group that are concerned with the transparency and accountability of arm’s-length bodies, such as the amendments of the noble Lord, Lord Warner. Much like the Secretary of State’s annual report, each arm’s-length body’s annual report and accounts must be laid before Parliament. I simply remind the Committee that all ALBs are under a duty to exercise their functions effectively, efficiently and economically, and the Secretary of State is required to keep under review how effectively they are exercising their duties and functions.
Finally, I turn to co-operation between the bodies in the system. The Bill sets out a formal duty on each organisation to co-operate, and the department will hold organisations to account for the way they work with each other, not just how they perform their own functions. As regards Amendments 240A, 243ZA, 350 and 351, I hope I can reassure noble Lords that, through these two routes, the department will work to ensure that duplication is prevented and gaps do not emerge. If the Secretary of State believes that the duties of co-operation are being breached or are at significant risk of being breached, he will be able to write formally and publicly to the organisations. If the breach is significant, sustained and having a detrimental effect on the NHS, the Secretary of State will have a further ability to lay an order specifying that the organisation should take certain actions only with the approval of another specified body, other than the Secretary of State himself.
Amendment 245ZA looks to reinstate a power at Section 2 of the National Health Service Act 2006, which would enable the Secretary of State to provide services. We believe that the role of the Secretary of State should be one of oversight, direction-setting and intervention when organisations are failing. We have had many hours of valuable discussion on this topic; so while I fully understand the various concerns raised by noble Lords, I remind the Committee that all sides of this House have agreed to a process of engagement and discussion on this subject. The noble Lord, Lord Hunt, asked specifically in relation to this amendment whether this issue was covered by that process. The Clauses 1 and 4 process, as I call it, is considering the issue of the Secretary of State’s accountability for the NHS in the round rather than specific clauses in the Bill; so, yes, this would be covered by that process.
I hope that I have provided enough detail on these clauses to enable the noble Lord to withdraw this amendment.
Lord Warner
I wonder if the noble Earl could enlighten me, and indeed the House, on the story that is trailed in the Times today that the Secretary of State is going to have 60 benchmarks or indicators—which some of us would think looked like 60 targets. Are they going to be a key part of his process of keeping performance under review? Will he give the House a little more flavour of what that is going to mean?
Earl Howe
My Lords, that story in the press was about the outcomes that the Secretary of State is proposing should form the basis on which the health service is held to account. It is likely that the outcomes framework will form part of the annual mandate. These are proposals which we are hoping for comment upon. Therefore the answer to the question of the noble Lord is that the health service—I am not talking about the ALBs other than the board, but the National Health Service Commissioning Board—will be held to account against those outcome measures.
Lord Warner
My Lords, I have listened very carefully to the Minister. I am disappointed that he cannot agree to put something more specific in the Bill about administrative costs. I am concerned about those getting out of control, when the NHS faces a very difficult set of financial challenges. However, I hear what he says. We may want to come back to this at a later stage, but in the mean time I withdraw the amendment.
Lord Warner
As I said in our recent debate on the Dilnot commission report, secured by my noble friend Lady Pitkeathley, we need to consider whether this Bill is a suitable vehicle for progressing implementation of that report. Here I should declare my interest as a member of the Dilnot commission. First, I shall make some remarks on the growing crisis, if I may put it that way, in social care and the implications of that crisis for the NHS and patients, particularly as, despite the extra money the Government have provided for social care in the spending review—I commend the Government on that—we still face a £1.2 billion shortfall by 2014, according to the King’s Fund.
The NHS and social care are in a symbiotic relationship with each other, in that what happens in one sector can have a profound effect on the other. That is what is happening now. The current problems have their roots in the past. Both sectors face the challenge of a service response to an ageing population. The fact that we live longer is, of course, something to celebrate, but it does have consequences for health and social care. By 2030 there are expected to be £2.5 million more people aged 75 or over. The current 1.5 million over 85 will double in the same period. The number living with dementia in the UK is expected to reach 1.4 million by 2040. We have nearly 18 million people living with long-term conditions that require treatment and care, but not necessarily in hospital. Getting the balance right in the resourcing, co-operation and delivery of services between the NHS and social care is critical to the quality of care and quality of life for this ageing population and for the cost to the taxpayer of those two services.
What is clear is that doing nothing and letting the current system carry on is not really an option. For example, the King’s Fund has shown that even if we do nothing to the current inadequate adult social care system, its cost will rise from £6.7 billion in 2011 to £12.1 billion in 2026. In that situation, the eligibility criteria for social care will get tighter and tighter, despite the extra expenditure, and the pressures on the NHS will increase as social care is unable to cope. Both systems need rebalancing and improved integration between the two.
However, they do not start from the same position. Since 2003-04, spending on social care has increased by 19 per cent in real terms, which is half the rate of increase in NHS spending in England over the same period. Despite this increase in spending on social care, access to state-funded services has reduced. In 2005-06, 60 per cent of local authorities restricted their service eligibility threshold to those whose needs were substantial or critical, leaving those with low or moderate needs to fend for themselves. By 2010-11, that 60 per cent had risen to 82 per cent of local authorities. As local authorities try to balance their budgets, they have cut the price they pay to providers, with a consequential impact on the quality unless they can persuade a growing number of self-funders to subsidise the care of those who are funded by the state. The impact has meant increasing burdens on informal carers, whose health is often not of the best, and rising costs in the NHS. Perversely, we can now end up with the taxpayer spending £3,000 a week to care for an 85 year-old in the medical ward of an acute hospital when they would be better off in a medically supervised £1,000-a-week single room in a nursing home.
At the heart of this problem is that social care simply does not have the standing of the NHS. If we are to improve social care and its integration with the NHS for the benefit of service users, we have to improve that public and political standing and realign the financial balance between the NHS and social care. I suggest that a good starting point for that would be the statutory duty placed on the Secretary of State. Leaving aside our current dispute over the precise wording of Clause 1, the Bill as it stands gives the Secretary of State the clear duty, which he has had for a long time, to promote a comprehensive health service designed to improve the physical and mental health of people and the prevention, diagnosis and treatment of illness. There is nothing equivalent to that duty in relation to the NHS for adult social care.
In subsection (1) of my new clause in Amendment 260DA, I have tried to even things up a bit by placing a clear duty on the Secretary of State to secure continuous improvement in the quality of social care services. This would mean that, when considering his priorities in relation to health and social care, the Secretary of State would have to consider securing a proper balance between both sectors. I suggest that both will face similar demographic challenges and careful consideration would then have to be given to how to allocate resources and priorities between the NHS and adult social care.
The rest of Amendment 260DA is intended, if I may put it this way, as a helpful encouragement to the Government to use the Bill to secure the legislative framework to implement the ideas in the Dilnot commission’s report but without the Government, at this stage, committing themselves to the precise financial figures in our report or the timing of implementation. The Government would be able to consider the responses to the consultative process that closed last Friday and prepare their White Paper in the spring as they are proposing to do. The amendment would remove the need to worry about whether they would have a piece of legislation on this subject in the next Session. I have to say that a number of us, both inside the House and outside, have a fair degree of scepticism about whether that Bill will actually happen.
There is widespread support for the direction of travel pointed to by the Dilnot report, with widespread consensus among stakeholders that this is the road we should tread if the finances of adult social care are to be placed on a more secure footing over time. It is no purpose of mine today to go into the detailed merits of the Dilnot commission’s report. However, I would like to hear, especially from the Liberal Democrats who have been supportive in this area, whether they support moving forward swiftly as many of us do. What I should make clear is that I regard subsection (1) of Amendment 260DA as standing on its own merits irrespective of the Government’s attitude to using this Bill to create a legislative framework for implementing Dilnot. I cannot say that my optimism on that aspect is all that great. However, I hope we can secure support across the House for inserting something in the Bill along the lines of subsection (1) so that when the Bill leaves this House there is a bit more equilibrium between the duty placed on the Secretary of State in relation to the NHS and that placed on him in relation to adult social care. I am not wedded to the precise wording of my amendment but I hope we can actually secure some cross-party consensus on the need to put something that follows the spirit and thrust of that subsection into the Bill before it leaves your Lordships’ House.
Amendment 244 simply requires the Secretary of State, when he publishes his annual report on the NHS, also to report on the health service’s integrated working with adult social care. This is such an important part of how the NHS will work in the future, particularly with the financial challenges that are faced, that I believe we should make specific reference to it in the Bill. I hope the Government agree. I beg to move.
Baroness Pitkeathley
My Lords, my name is attached to Amendments 244 and 260DA. I want to emphasise how vital integrated working is from the point of view of the patient. Most patients, especially older ones or those with a long-term condition, do not experience either health or social care but some kind of combination of both—combinations that fluctuate according to variations in their condition.
This, as we have been reminded, is a Health and Social Care Bill yet the Committee debates thus far have not reflected the experience of patients and their families but have been very focused on acute care and the role of hospitals. I am delighted that consideration of these amendments gives the Committee the opportunity to focus more acutely—no pun intended—on the social care aspect of the proposed legislation. I strongly support the call for social care provision to be subject to annual review. I remind the Committee of the multifaceted nature of social care—residential care, home care, respite care and increasingly tele-care—and of the range of providers such as private, voluntary and social enterprises. Many of these services are facing huge challenges because of increased demand and reduced resources so it is clearly vital that a review is carried out regularly and I can see no reason why the Government should not agree to this amendment.
Baroness Murphy
My Lords, I have added my name to the amendment because we are considering a Bill under which we are trying to improve the efficiency, effectiveness, productivity and quality of the NHS. Yet we know that that is completely impossible without improving the social care system.
When I first picked up a copy of the Bill from the Printed Paper Office and read it through, I thought that there must be a third part that would address social care. I therefore rang up the department and spoke to the relevant David—they are all called David—and asked, “Where is it, David? Where are the social care bits that should go with it to make it a Health and Social Care Bill?”. He just said, “Oh, that comes later”. The reality is that many medical specialties simply cannot function effectively without social care services. Those specialities include general practice and my own in geriatric psychiatry. Much of that work involves people with long-term conditions, mental health problems, learning disabilities, all care of the elderly, all primary care and community services. I spent some years of my life trying to transfer money—rather successfully in Lewisham—out of the NHS and into social care, in order to be able to perform my job.
We are not getting the best use of the specialities in the National Health Service for wide tracts of the population simply because we have inadequate domestic personal care, inadequate assessments under social care, inadequate provision of support for carers and those vital bits that make real life work. We know that 40 per cent of the increase in demand for NHS services is entirely dependent on the change in the demographic over the past 20 years. We know from the predictions of McKinsey and others that that increase will continue unless we do something about it.
I used to do a lot of work in the Italian health service, where social care, because it has been so dependent on church organisations, is not organised in the same way that we are. The Italians began to be seriously worried, and they still are, because of the horrendous bed-blocking and poor health services for older people. I hate the term bed-blocking; it really means an inappropriate service to an older person. Who cares whether the bed is blocked? I personally did not care about that as regards my patients. The important thing is that the patients were not getting the appropriate services they needed in the community.
Unless we get a government response on how social care is to be funded in the community and in residential and nursing care that is doable, feasible and affordable, we will not make much progress in the health service because we will be constantly coming back to this problem. It is for this reason that I have added my name to the amendment. I do not know if it is the right amendment. I saw it as a way of kicking the Government a bit further to get a move on about the social care response. The Bill will not work for the NHS of the future unless we have an appropriate social care service response.
Lord Turnberg
My Lords, there is little doubt that one of the key elements in the delivery of a system of care which improves on what we have now—and we certainly need to improve the current position—is the need to integrate care between the NHS and social care. It is in that light that I have found the Nuffield Trust report, Towards Integrated Care in Trafford, which I am sure that many noble Lords have read, so helpful. A number of things of value come out of the report. First, it needs local buy-in, the involvement of clinicians, managers, patients, local authorities and the public. It also needs good data-sharing, good leadership and time. It does not happen overnight. It took them two years, despite having all the enthusiasm and conditions in the area, for it to get off the ground.
Of course, all that needs the will of those who are paying for the services—the commissioners—if they are to pay for integrated care across the divide, which has proved so difficult. All those local changes depend on funding. If we believe that improvements in this area are critical—and I am sure we do—surely it should find a stronger place in the Bill, in particular in the Secretary of State’s annual report. Amendment 244 states that we should insert the words,
“and its integrated working with adult social care services”,
in the report. That seems to me entirely appropriate and I hope that the noble Earl will consider that as a useful amendment to take forward.
Baroness Cumberlege
I just ask the supporters of the two amendments a question—the noble Lord, Lord Warner, may be the appropriate one, having been a director of social services. The amendment talks about breaking down the barriers. We are all at one with that. I was very interested in what the noble Baroness, Lady Pitkeathley, said about the Dilnot report; the noble Lord, Lord Warner, was a distinguished member of that committee, of course. Having listened to the amendment’s promoter, I thought it was very persuasive and one could see a real future there.
One of the blocks that has not been addressed in this debate is the difference in accountability in terms of the democratically elected councillors who are responsible for social care. I wonder whether the Lord, Lord Warner, had thought about ways to try to harness that to get that integration. To try to bring together two very different accountabilities is a real challenge.
Lord Warner
I shall briefly respond to that. We should never forget that the lion's share of the money that goes on state-funded adult social care comes from central government and is passed through local authorities to be spent on that group through the commissioning of various domiciliary, residential and even nursing home care. Although what I have crafted is a duty on the Secretary of State, a lot of this comes back to where the balance is struck between the NHS and adult social care in terms of priority and funding in Richmond House. They are all under the same departmental expenditure limit at department level.
The sense I had as a Minister was that it is a bit like the Army: you have to put a musician in the canteen. A former director of social services is kept well away from social care in Richmond House. I saw a reluctance in the NHS culture in Richmond House—which, thankfully, has changed with the arrival of David Behan —to fight for social care at the time of expenditure reviews. That is a real and serious issue. The big guns of the acute sector are alive and well in Richmond House when the expenditure review comes around. My noble friend Lord Hunt is nodding—I think enthusiastically, given his current job as chairman of a foundation trust. This is a real issue. We need a bit more balance in the statutory duty on the Secretary of State in order to align the money going into social care vis-à-vis the NHS.
There is a perfectly good point to be made at the local level. You want to see priority being given to adult social care at the local level, and you want to see openness on the part of local government—which, if I am honest, has not always been there—in working across the boundaries with people in primary care and in the NHS. That is absolutely an issue. However, if in local government you have only enough money to deal with people with substantial or critical needs, then your ability to help people with moderate needs and stop them getting worse will be restricted by the amount of resources available. It will then be extremely difficult to work across that boundary. We know that many local authorities have reprioritised their services, taking money away from other services and putting it into adult social care, but a very clear finding from the Dilnot commission was that the adult social care pot is simply not big enough. It is no good for us to keep uttering that there is a need for integration if there is not enough money at the local level for adult social care to work across the boundaries.
Baroness Greengross
My Lords, I strongly support the amendment and the remarks of the noble Lord, Lord Warner, and the other noble Lords who have spoken. Over the past 50 years we have seen a huge rise in longevity. In this century and at the end of the last century, that rise in longevity has been largely due to medical success in taming many acute and terrible diseases that once we could hardly even talk about. Now, many cancers can be lived with for a long time. However, the big and difficult condition to be dealt with now is dementia. This is a long-term illness and it is terminal in various forms, yet the care for people with dementia is funded largely through social care. This, in itself, is an enormous anomaly. One in four patients in hospital who are elderly and a huge number of people in the community have dementia, but that illness is treated as being due for social care, not NHS care, although the borders do blend to some extent.
We need to celebrate that huge medical success but we cannot do so if we go on as we are with the funding of, and attitude towards, social care, which remains very much as the Cinderella between the NHS and the community. Many people now say that this differential means that in reality we should close 20 per cent of acute hospital beds and transfer those patients to a different sort of care—perhaps hospitals transformed into community hospitals. It is not a case of killing them off; they should be transformed into care centres where people with these long-term conditions can be properly treated. We really must work towards that and accept the truth of it. If we do that, there will be an obvious need to integrate health and social care quite differently from the way that we have done it in the past. What is needed is not a transfer of resources but integration. We must get this right.
I have recently been involved in the EHRC’s inquiry into the care of older people in the community. We found that while a quarter of a million people are happy with the social care they receive in their homes, another quarter of a million are not—and understandably so because some of the ways in which they are looked after are, frankly, appalling. This is partly because of the huge diversity and differential in the allocation of resources, as well as the status and training of staff in dealing with the most difficult issues and problems. I am not going to go through everything I learnt from that inquiry. The report has been published, and I hope it will be helpful to many people in policy-making and in practice.
If we get this right and we keep people in the community for longer, we will save an enormous amount of money. At the moment, adult social services directors have no choice but to give money to the people in the most acute need, which means that the social care needs of all these other people are therefore not being met. If I were one of those directors and I had to choose where my money was going to go, that is what I would do. That needs to change because of the necessity of resource integration. We must find a way to intervene earlier, for dementia for example, with drugs, early diagnosis, and treatment in the community. People will then be able to live in the community for much longer and many will die in the community. An enormous amount of money will be saved. Care for people with dementia, in particular, in hospital is really unsuitable. It is bad for them and it is extremely bad for other patients. It really must change.
One reason that community care goes wrong is annual budgeting. If, like local authorities, one has to have an annual budget, one can do no preventive work. At least a four-year cycle is needed. It is like starting a business, investing in it, and expecting the return within a year—it cannot be done. One must wait a few years for the return. However, local authorities cannot wait because they lose their central government grants; we need to change that. The well-being boards need to be given the resources to integrate care properly so we can get rid of this imbalance.
Further, the Dilnot recommendations—and I congratulate the noble Lord, Lord Warner, on the distinguished role he played in this—are the first realistic proposals which bring together all sectors—public, private and voluntary—to get it right, with what seems to be a political consensus. This is such an opportunity, and we really cannot afford to lose it. Older people will suffer the most. There is still an enormous amount of discrimination. The social care we offer to younger disabled adults and to people with physical or learning disabilities is totally different; the attitude, and the range of resources and skills available to younger adults are quite different. This is direct and really damaging discrimination. The only way to change this is by integrating resources through the well-being boards. We need to make Dilnot a reality so that in the longer term all of us know enough to save for our pensions and our care. This amendment is essential if we are to get some action now. I support it very strongly.
Baroness Emerton
My Lords, I support the amendments, first, because I totally agree with them. The second reason takes me back in history—I think it was 1976 or 1978—to when the Government had a Bill proposing that learning disability clients should be taken out of mental handicap hospitals and placed in the community. I had the privilege and lovely responsibility —this is when old age comes into experience—of managing that project. I worked with the noble Lord, Lord Warner, who was then director of social services. I also worked with Lambeth, Lewisham, Southwark and all the London boroughs, which were absolutely against having patients transferred to the community.
If there is something in the Bill and it is government policy, everybody will work towards it and understand that there must be integration. We have mentioned the word “culture”. I found this issue absolutely fundamental. It runs through the whole issue. The noble Baroness, Lady Cumberlege, was also part of this exercise. She was in Brighton at the time and some clients went to Brighton. It was extremely difficult to get local authorities to understand the needs of some of these clients. Some had special needs and difficult behavioural problems. However, we got there because we had target dates by which we had to do it and also because we had trained staff. We have not yet spoken about the workforce, except in terms of carers and social care. We need to have a workforce that will be able to supply the level and standards of care that will be required.
My noble friend Lady Greengross has just mentioned the fact that dementia care in hospitals is not good. That is probably very true, although it is good in some places. We must look at training needs for social care as well as for transferring patients to secondary care. The culture issues are important and once they are included in the Bill, one can get to work on them.
Baroness Barker
My Lords, I will speak briefly in support of the amendment and answer the point made by the noble Lord, Lord Warner. Since 1948, we have had a system whereby there has been an agreed national settlement on a person's entitlement to healthcare. It is delivered to national criteria and demand is managed largely by waiting times. Running in parallel is social care, where there is no national entitlement and demand is managed by eligibility criteria. The two systems are administered in parallel by completely different people, side by side. Successive reports have set out for us all the different ways in which the two systems do not work together. People have analysed the reasons why the systems do not work together.
The most telling thing for me is that we have known for a very long time, because we have evidence to prove it, that if older people are discharged from hospital and are supported through the period of discharge, the likelihood of them being readmitted to hospital is very low. We also know, because of that, that the cost to the NHS decreases. I am afraid to say that those of us who work in the charitable sector also know how impossible it is to get the NHS to run a hospital discharge system. The noble Baroness, Lady Emerton, is absolutely right. I do not want to throw blame about, but it leads to my point about why I think the amendment is important. The biggest single thing that will make an impact on the NHS is cultural change. There are a lot of barriers in the NHS to that change. We have heard the point echoed in our debates over the past few weeks. Some of our most eminent clinicians have made the point very glibly that there is very little evidence about what works in social care. That is true; social care has some way to go in developing an evidence base. However, we have some evidence and it still gets ignored because social care is not up there with healthcare.
Noble Lords have talked throughout our debates about specialist nurses and how important they are. I have come to the conclusion that the greatest asset of a specialist nurse is that they know their way around social care and can explain it to people in the NHS. I do not wish to denigrate specialist nurses in any way; they do a fantastic job. However, part of me thinks that if they are the only ones who understand the system, are they letting the rest of the NHS off the hook? The biggest single thing that will make the Bill work or not work is whether everyone in the NHS sees it as their responsibility to understand and work with social care.
The amendment of the noble Lord, Lord Warner, is cleverly worded. I congratulate him on that. It is based on Dilnot and the Law Commission, although he has crafted it using general terms so that it is not specific to those two reports. I commend him for that. On balance, the most important part of the amendment is proposed new subsection (2)(b), which reflects the Law Commission report. Until we get nationally agreed standards of eligibility, assessment and charging policies, it will be impossible for anyone who works in the NHS to know what it is they are supposed to be integrating with. That is the key point. I understand that Dilnot is important in terms of funding, but the Law Commission report is the important one.
I listened very carefully to what the noble Lord, Lord Turnberg, said. I always do. It is a very good report; I agree with that. However, he said that all these local developments in integrated care depend on funding. He is right, but there is a huge amount of wastage of resources throughout the health service. I pick up on this at local level. It comes down to two things: data are not shared and there is no understanding of common assessment of needs. Those two things cost the NHS and social care a fortune. Proposed new subsection (2)(b) of the amendment is so important because it covers the key area on which we have to work.
Perhaps noble Lords have been slightly pessimistic about the Bill. The existence of health and well-being boards is important. It will be possible, locally if not nationally, to begin to work on these issues. It will be possible for some areas to do highly innovative stuff. Noble Lords have talked about the work done in Torbay. When my colleagues were in charge of the borough of Islington, they had a very interesting approach. Social services took responsibility for everything that was to do with children and the NHS took responsibility for everything that was to do with older people, which included social care. I would like to see more of that and I hope that health and well-being boards will bring it about.
Presumably the noble Lord, Lord Warner, was told to have a go at the Liberal Democrats today. I was surprised that he asked about our attitude to the Dilnot report and the Law Commission report. At our conference in September we passed a resolution to the effect that we welcomed the reports and wished to see the Government implement them quickly. We have not come up with a series of bureaucratic provisions to hold up implementation. I pay tribute to Paul Burstow. He came into government when the previous Labour Government had not resolved the issue in 13 years. He found extra funding for social care and went out of his way to make sure that the Dilnot review was set up. He laid down a challenge to us that I pass on to noble Lords. He challenged us to campaign on social care with all the passion and vigour that we do on the NHS. I challenge noble Lords to do that. Actually, I would like to challenge 38 Degrees and everybody else to do that, because there are an awful lot of people who are willing to be as vociferous as you like on the NHS but are suddenly silent when it comes to social care. Some of us have had enough of that. I commend the noble Lord’s amendment.
Lord Warner
I was not doubting the enthusiasm on the Liberal Democrat Benches regarding this area. I just wanted to provoke the noble Baroness into giving the kind of excellent speech that she has given. I was hoping that we would hear from her. I also join her in paying tribute to Paul Burstow, and indeed Norman Lamb, for the very supportive way in which they have approached this issue.
Baroness Thornton
My Lords, we have had a very interesting debate on this imaginative amendment from my noble friend Lord Warner. Today’s debate might well be the only debate on social care in the whole life of this Bill, including in the Commons. I would like to talk about some real people, with real conditions and real problems, because it is only by testing this Bill against those that we will know whether it is going to work, and whether the issues that are being raised by noble Lords across the House are going to be taken into account.
I would like to pick up where the noble Baroness, Lady Greengross, left off, and talk a bit about dementia, partly because I have a very close friend whose wife has dementia and I have been following the path of this for the last seven or eight years, but also because this is an issue that affects hundreds of thousands of people. The Alzheimer’s Society reckons that: there will be 1 million people with dementia by 2025; dementia costs the country £20 billion now; one in three people over 65 will die with dementia; only 40 per cent of those have a formal diagnosis—that figure varies enormously across the UK; and, of course, which is the reason why they are important to this debate, people with dementia are very significant users of health and social care services. We know that people over 65 with dementia are currently using up one-quarter of hospital beds at any one time. The current system of charging for care, such as help with eating, hits people with dementia hardest, as the noble Baroness, Lady Greengross, has said, and amounts to what the Alzheimer’s Society calls a “dementia tax”.
We know all of this. The All-Party Parliamentary Group on Dementia, the National Audit Office and the Alzheimer’s Society have identified that significant resources are wasted on poor-quality care—for example, through crisis admissions into hospital or long-term care. There are opportunities to save money in dementia care across a wide range of settings; for example, by investing in early intervention and prevention services. In a way, those matters are the test of this Bill. Can we save the money and deal with the people who have got dementia? How can we promote a shift of NHS resources away from acute hospitals into community-based services, as recommended by the NHS Future Forum and the recent inquiry by the All-Party Parliamentary Group on Dementia?
I know that the Government recognise that a sustainable NHS in the future requires a new long-term settlement on social care to ensure quality for people facing disability and long-term illness. We think that this amendment will help with that. When I was looking at this amendment, I remembered that I myself was given a speaking note that said, “Of course, health covers social care, too”. That is not good enough any more; it is not good enough to say that by writing health into the Bill and giving the Secretary of State responsibility for it, we are somehow covering social care. Apart from anything else, it has not worked. We know it has not, and we are where we are. There are some very serious issues.
Earl Howe
My Lords, with Amendments 244 and 260DA, the noble Lord, Lord Warner, has taken us to the important matter of the relationship between the NHS and social care, and I agree with him that this relationship is in a real sense symbiotic. The noble Lord presented us with some sobering facts and messages about the increasing pressures that are likely to arise in our health and social care services over the next two decades, and it is in large part because of those looming pressures that the Government have brought forward their proposals for health service reform. The noble Lord deserves to be listened to with close attention, and I again pay tribute to his work as a member of the Dilnot commission.
Looking first at Amendment 244, we strongly agree that integrated services are important. The noble Baroness, Lady Greengross, brought home that message compellingly. This is why, throughout the Bill, there are duties to promote and encourage the commissioning and provision of integrated services. It is a vital principle. However, sympathetic as I am to the spirit of the amendment, I feel that the Bill’s current wording already provides for what it seeks to achieve. I would already confidently expect the annual report to cover aspects of service integration, and that is because integrating services, both between different parts of the NHS and between the NHS and other public services, would be essential to providing a seamless and high-performing health service. The change of culture that the noble Baroness, Lady Emerton, and my noble friend Lady Barker spoke of will not happen overnight, but it can be encouraged and promoted by shining a bright light on how well or badly the NHS is performing in this area.
Turning to Amendment 260DA, the Government are absolutely clear that a key objective of social care reform must be to improve outcomes for individuals and their families and carers using social care. Again, I completely understand why the noble Lord has brought forward this proposal, and I recognise that the amendment has been carefully crafted. In explaining the amendment, the noble Lord expressed worry about whether the Government are serious about pressing ahead with reform. The Government have committed to setting out proposals for the reform of social care in a White Paper and a progress report on funding reform to be published in spring of next year, with legislation to follow at the earliest opportunity. I can confirm to my noble friend Lady Barker that this will include our response not only to Dilnot, but also to the report published earlier this year by the Law Commission.
We agree that reform of the system is urgent and we debated these very issues recently and in some depth in a debate led by the noble Baroness, Lady Pitkeathley. If the Committee will forgive me, I will not repeat what I said on that occasion. However, on 15 September, the Government launched Caring for Our Future: Shared Ambitions for Care and Support, which was an engagement seeking views about the priorities for improving care and support. This focused period of engagement has been welcomed by stakeholders and, although it officially concluded on 2 December, we will continue to work closely with the social care sector as we formulate our proposals for reform.
Lord Warner
My Lords, I have listened carefully to what the Minister has said. I am not totally astounded to hear his remarks and I am grateful for the generous way in which he made them. However, I also listened carefully to other people in this House, in particular, the noble Baroness, Lady Barker. I certainly cannot see why the Government cannot move on Amendment 244. It does not pre-empt in any way their decision-making on the Law Commission, Dilnot or anything else they want to write about in terms of their White Paper in the spring.
The flavour of this debate is that we need to give some particular attention in this Bill to integration between health and social care. Requiring the Secretary of State specifically to deal with that issue in his annual report is a very good signal to be given to the outside world and, particularly, to the NHS. A number of people who have spoken today have suggested that that signal needs to be given.
I was not expecting to get a lot of progress on Dilnot but I want to come back briefly to subsection (1) of the new clause to be inserted in the Bill under Amendment 260DA. I feel strongly that we need a duty of this kind on the Secretary of State to balance the equation with the NHS. I shall take advice from a lot of people outside this House on whether we should come back to this issue on Report. At the moment, my instincts are that we will want to but I want to hear what people outside this House in the sector have to say. But I certainly reserve the right to come back on that issue, which I am happy to discuss with the noble Earl further if he wishes to do so. In the mean time, I beg leave to withdraw the amendment.
“(hb) a subsidiary of a company which is formed under that section and wholly owned by the Secretary of State,”
Earl Howe
My Lords, this set of amendments is predominantly made up of a series of minor government amendments to Schedules 4 and 5. Many of them make minor or technical changes to these schedules to correct errors, ensure the Bill’s provisions work as they are intended to do and make minor consequential amendments to the NHS Act 2006. They correct a couple of errors in cross-references and the placement of consequential repeal; add references to the Bill’s provisions on transfer schemes to Sections 216 and 220 of the NHS Act, which relate to the transfer of property held on trust by the NHS, such as charitable property; and remove a reference to Section 2 of the Local Democracy, Economic Development and Construction Act 2009, which is being repealed by the Localism Bill.
The amendments also amend the definition of “qualifying company” in Clause 294, so that under the Bill we will be able to transfer property to a subsidiary of a company wholly owned by the Secretary of State, not just to companies owned directly by the Secretary of State. They also amend Schedule 4 to allow such subsidiary companies to be members of the statutory risk-pooling schemes for meeting liabilities of NHS bodies.
This group also includes one other amendment on Schedule 5, tabled by my noble friend Lord Lucas. Amendment 254 amends the Freedom of Information Act 2007 so that the criminal offence of taking certain actions to prevent disclosure of information held by a public authority is expanded to include information held by service providers. I can reassure my noble friend that the Government are committed to extending the scope of the Freedom of Information Act to increase transparency. To do this effectively, we need to spend time properly considering the issues raised. It would not be appropriate to rush through changes that have not received proper scrutiny.
As part of this work, the Freedom of Information Act will be subject to post-legislative scrutiny and the Cabinet Office has recently concluded a public consultation on an open data strategy, which is aimed at establishing how we ensure a greater culture of openness and transparency in the delivery of public services. I understand that my noble friend has already met with officials to discuss his concerns around freedom of information and this Bill, which I hope reassured him. If he has additional concerns following this debate, I would be more than happy to write or to meet him to discuss this further. I hope that that will enable him not to press his amendment when we reach it.
I also hope that I have satisfied noble Lords that this set of government amendments should be made and that my noble friend will feel equally content.
Baroness Thornton
My Lords, I should like to ask one question and to make one remark. Even the Minister smiled when he used the words “openness” and “scrutiny”. Given our previous conversations about the information that the House has not received, I do not intend to rehearse that again but I would look at colleagues in the Liberal Democrat Party and say just how shocked and amazed I am by their lack of willingness to want proper openness and scrutiny on this Bill.
My question concerns the strategy risk-pooling schemes. I understand what those are, but I would like to know who the pooling would be shared with.
( ) in sub-paragraph (5), omit “in its area””
“In section 216 (application of trust property: further provisions), in subsection (3), after “or 214” insert “of this Act or section 294 or 296 of the Health and Social Care Act 2011”.”
“In section 220 (trust property previously held for general hospital purposes), in subsection (2), after “or 214” insert “of this Act or section 294 or 296 of the Health and Social Care Act 2011”.”
(a) omit paragraph 49 of Schedule 2 to the National Health Service Reform and Health Care Professions Act 2002, and(b) ”
Lord Warner
“( ) On the abolition of the Health Protection Agency, the Secretary of State will allocate their functions and any others he or she considers appropriate to an Executive Agency with its own chief executive as accounting officer with a management board with an independent chairman and at least three non-Executive Directors with expertise in its functions selected by the Department’s Chief Scientific Adviser.
( ) In allocating these functions the Secretary of State shall ensure that staff of the Executive Agency should have freedom to secure and discharge external research contracts.”
Lord Warner
My Lords, we come now to Clause 53 and the proposed abolition of the Health Protection Agency. I shall speak to Amendment 257ZA in this group, but in doing so I should make clear that I do not support the abolition of the Health Protection Agency, and I have every sympathy with the Front-Bench amendment that Clause 53 should not stand part of the Bill. I should not be unhappy if I lost my amendment because the clause itself was removed.
However, if the Government are going to proceed with this casual vandalism against an internationally respected organisation, I would hope that we could secure some damage limitation, which is what this amendment attempts to do. I will leave it to my co-signatories of this amendment, who have much more scientific and clinical expertise than me, to explain why we need to protect the independent scientific and research expertise of the Health Protection Agency in any new organisational form that there is for it.
As the Minister who helped to shape the Health Protection Agency in its present form by bringing together a wider range of scientists in one organisation, I want to put on record that it has acknowledged the importance of that and the improvement in the cross-fertilisation of ideas that has come about because we brought a wider range of scientists into the organisation.
I should also make clear that when confronted with crises involving areas of great public concern—I cite as examples the great concern in 2003 and 2004 about the growth in healthcare-acquired infections, and, later on, the Litvinenko affair and the concerns about polonium-210—the independent scientific advice from the arm’s-length Health Protection Agency was absolutely vital to giving the public confidence in how we were moving forward and dealing with those issues. It was the people from the Health Protection Agency, particularly during the Litvinenko affair, who were able to stand up in public and give scientific reassurance in that area. It is that independence of scientific expertise that I am very anxious we should preserve in the move to abolish the Health Protection Agency.
Amendment 257ZA would ensure that if the functions of the Health Protection Agency are to be transferred to the Secretary of State and the Department of Health, there should be a distinct executive agency with its own chief executive as accounting officer, and a management board with an independent chairman and at least three non-executives with expertise in its functions, selected by the department’s chief scientific adviser. The amendment would also ensure that staff had the freedom to secure and discharge external research contracts.
These changes will help to retain high calibre staff over time, and indeed the scientific reputation of what is currently the Health Protection Agency, in its new guise. I believe that they have the support of the staff of the HPA and reassure them about scientific independence and the ability to carry on seeking research contracts.
We need this reassurance in the Bill, not just warm words, however well intentioned the Minister is. I beg to move.
Lord Turnberg
My Lords, my name is also attached to Amendment 257ZA. I also do not like the idea that the HPA is to be abolished, so I hope my amendment is not necessary, which it will not be if the proposal that the clause should not stand part of the Bill is agreed.
I have, of course, extolled the virtues of the HPA on a number of occasions in your Lordships’ House. You could say that I would do that, wouldn’t I?, having been the chairman of the predecessor of the HPA, the Public Health Laboratory Service, but it is certainly true to say that it is the envy of the world, and I am not the only one who says that. The Centers for Disease Control and Prevention in Atlanta, in the United States, are a very well funded counterpart with which we collaborated very strongly, and even they recognised this excellence and envied the fact that we, unlike them, had a network of laboratories across the country primed and ready to detect outbreaks of infection wherever they occurred. Those laboratories were linked into a central laboratory at Colindale, where highly specialised tests could be carried out when needed for unusual infections and where epidemiologists could link up outbreaks in one area of the country with outbreaks in another, so that it was possible to track the speed and spread of infections and prevent them developing into epidemics.
The fact that the HPA is hardly ever in the news is testament to its success in protecting the population. If your Lordships think that because it is so good there is now less need for such surveillance, let me point to the fact that just one set of infections—those responsible for food poisoning—remain a considerable health hazard, and gives rise to about 1 million cases per annum in the UK. Although it is usually fairly mild and often not reported, some cases, such as those due to E. coli, can be very severe indeed, and in the particularly vulnerable can be fatal. Food poisoning is, unfortunately, not showing any signs of decreasing, so the need for constant vigilance is high and the role of the HPA remains absolutely vital.
The amendment sets out two of the planks needed for the agency to contribute to its key roles. The first is the degree of independence that it needs to be able to give advice not only to those out in the field who need to act but very specifically to the Secretary of State and the Government. The HPA must not be seen to be simply the mouthpiece of government. It must have the independence that is so necessary to its credibility. It has stood it in good stead over the years. Its advice is respected and accepted, and we should not lose that now.
The other element of the amendment is the need to be able to undertake research. If the agency is to keep ahead of ever-changing bacteria and viruses, which seem to mutate every week, and to be able to develop new ways of rapid detection, it needs access to research funds. For example, it has excellent high quality researchers, two of whom have recently been elected to the fellowship of the Academy of Medical Sciences, which is a demonstration of their esteem. Over the years it has been fortunate to have access to research funds from the Department of Health, and I understand that that will continue. That, of course, has been of enormous value, but the agency has also attracted research funds in fairly large amounts from external grant funders, and this is funding won in open competition. There is a fear that as an authority that is rather more closely identified with the Department of Health, access to those external funds will be denied to it.
The amendment makes the clear case that the agency must continue to have access to these funds in order for it to function at the highest level. I hope that the Minister will accept the case and look sympathetically at the amendment.
Lord Patel
My Lords, my name has been added to Amendment 257ZA and I have tabled Amendment 260 in my own name. I shall try to explain why I have added Amendment 260 to this group. There has been some advice to degroup it, and I have been tempted, but I have left it where it is. First, I agree absolutely with what my two friends, the noble Lords, Lord Warner and Lord Turnberg, have said in relation to independence in research and in the expert advice that Public Health England will be giving, and I shall support that by giving some details.
First, however, I shall refer to the funding issue. I do not understand why it has been suggested that Public Health England should not be allowed to bid for external research funding. I cannot see what the threat would be. I have no doubt that it was the Minister who suggested it, and maybe he was given advice, but I wonder why he was given it. I shall give some examples. The current running costs of the HPA covered by government funds are £145 million. On top of that, the agency receives some capital expenditure and depreciation funding. But the agency itself obtains another £150 million from external sources: funding for research and funding from the services of the HPA which are contracted to other agencies and sectors. These include laboratory services, and nuclear and chemical decontamination services. If I was running a university department and I got £150 million-worth of external funding, I would regard that as pretty good—in fact, as excellent. Most of our universities would struggle to get that kind of research funding.
Where does it come from? The largest source of external research funding comes from the National Institutes of Health in the United States for high containment work on infectious diseases. Both the noble Lord, Lord Turnberg, and I know from experience that to get a grant from the NIH is very tough. The agency also receives external research funding for vaccine evaluation, as well as from the recent licensing of one of HPA’s research-generated products by the Food and Drug Administration in the United States. The agency has a product called Erwinase that is used to treat childhood leukaemias, which clearly demonstrates the commercial benefit of its ongoing research and income-generating potential. That sets out the picture as far as research income is concerned, and I repeat that I do not understand why the agency should not be allowed to bid for it.
The second issue is that of publication. The agency must be independent enough to be able to publish evidence and offer expert advice on all topics in which it has expertise, regardless of government policy. For the public to have confidence in their public health agency, it must have the independence to publish. The Government may not take the advice they are given, but the agency must have the independence needed to be able to publish it, so again I cannot understand why it might not be allowed to do so. Nor can I understand why it cannot publish in any journal it wishes on any of its research or advice. To achieve all this, it is important that it has an independent board with an independently elected chairman. That is one of the crucial amendments I wish to see if we are going to go ahead with Public Health England as an executive agency of the department. That is also why I have tabled Amendment 260, which offers the belt and braces needed if, as the Government intend, Public Health England is established as an executive agency. If it is not given independence in terms of research, advice and its board, what we would then need to do is set up a non-departmental public body. That is the purpose of Amendment 260.
Lord Walton of Detchant
My Lords, I too support this amendment, although like the noble Lords, Lord Warner and Lord Turnberg, I would much prefer to see Clause 53 deleted from the Bill. Throughout my professional career I have been familiar with the expertise of the former Public Health Laboratory Service. It conducted research, carried out microbiological surveillance, protected the population of this country from epidemics and so on, looked after the safety of our water supplies, and indeed undertook a huge number of other activities. The noble Lord, Lord Turnberg, chaired that body with great ability and distinction.
I just do not understand the purpose of the Government in abolishing its successor, the Health Protection Agency, which has continued to follow that pattern and to supervise the work of laboratories across the country which were formerly part of the Public Health Laboratory Service. Again, it is difficult to understand what the purpose is of abolishing a body that has proved to be so effective, which continues to give excellent service and which, as other speakers have said, attracts external research funding. If it were to be absorbed into the Government under the Secretary of State, I believe that it would be less able to fulfil its functions and to carry out the distinguished research in which it has been involved over many years. For that reason, while I strongly support the proposal that Clause 53 should no longer stand part of the Bill, if—for the reasons that I hope can be explained by the noble Earl—the Government decide that that clause should remain, it is crucial that we have an amendment such as the one before us in order to preserve the activities of such a vital scientific institution.
Baroness Finlay of Llandaff
My Lords, I have added my name to Amendment 260, but I should like also to talk about the problem of abolishing the Health Protection Agency. I must declare an interest because at the moment my daughter is on a placement there and is most impressed by the work that she has seen. There will be a very specific problem for the Health Protection Agency if it is not completely independent, and that relates to Medical Research Council research funding. If the agency is part of the Department of Health, it will find it more difficult to secure MRC funding. That may also apply to Wellcome funding, but the problem will be particularly acute with regard to funding from the MRC, which is the highest rated funding that the agency can get.
Also, as has already been said, the agency is internationally renowned and recognised for the excellence of its work and looks set to bring in more work to the UK. It is now working with the World Health Organisation on disaster planning. In planning for new disasters that might take place, it is important that countries know what other countries are going to be doing. We have sea borders, but if there is a massive disaster in another country we cannot go to its assistance if we do not know how its systems work. The Health Protection Agency is the leading body in this work on behalf of the UK. It seems very short-sighted to do anything that would destabilise this organisation.
Baroness Masham of Ilton
My Lords, I, too, would like to support what has been said about the HPA. It is so well thought of across the world, and infections spread across the world. Infections are getting much more complicated, with drug resistance, and we need the HPA more than ever. I ask the Minister one question: whatever happens to it, will it have an independent chairman?
Baroness Cumberlege
My Lords, I speak to Amendment 260, in the name of the noble Lord, Lord Patel. It is probably not the time to go around memory lane, but I want to draw on some experiences that I have had. I was the hapless Minister responsible for the Health Education Authority. Some people may remember the Health Education Authority. It was largely independent and its funding came through the department. I should not speak ill of the dead, but it really was a nightmare. One of my lasting memories of my modest ministerial career was when we had a Starred Question in this House, asking why government money and very scarce resources should be spent on a leaflet, produced by the Health Education Authority, entitled, I think, 69 Ways for Better Sex. It was the first that I or the department had ever heard of it. Perhaps one of the interesting things was the number of noble Lords who said they could not take part in the debate unless they had seen a copy of the leaflet.
The HEA went completely off the rails. It was only when we were reading or listening to the media that we found out what it was up to. In the end, it not only alienated the Department of Health and the Government, it alienated local health authorities, with their responsibilities for public health. It was they in the end who asked us to close it down. Well, we did. Listening to the current proposal for Public Health England to be an agency, I think that is a good idea, although I know it is very unpopular with the Faculty of Public Health and others. An executive agency, although not totally independent, will operate with a degree of autonomy from Ministers on a day-to-day basis. While not as independent perhaps as a health authority, it will be recognisable as an entity and have its own identity.
The only model that we have got in health of an executive agency is the MHRA. Its chairman, noble Lords will know, is Professor Sir Alasdair Breckenridge, who has been the chair since its inception. Sir Alasdair is a very strong individual and somebody people really respect highly. In the vernacular, he is the sort of person you do not mess with because you know you will not win; you do not even try because he is somebody with enormous integrity and presence, and runs a very good organisation. It seems a good idea to look at the MHRA model and see how it is organised. Sir Alasdair tells me that there are eight non-executives on the agency board, who form the majority and are the board. They have a very good chief executive who is a civil servant but the non-executives are not. They are drawn from right across the country with different experiences and, again, they are people of huge distinction who are very much respected.
Here is an example or model that actually works. It has been tried and tested, and is a model we could certainly adapt for Public Health England. However, I suggest to my noble friend that the important thing is to keep the public health constituency with us on this. It is important that it has a real involvement in choosing the chairman of this new agency. If it is involved, that will go someway to ensuring the agency will be a success. It should also be involved in the recruitment and appointment of the non-executive members. We have a highly credible organisation here that could be a very good model for Public Health England and I hope my noble friend will consider those points about the appointment of the chairman and the non-executives, and the formation of that board.
Lord Warner
I was the Minister responsible for the MHRA and very much share the noble Baroness’s views on this. There are some slight differences, one of which is that a lot of the funding for the MHRA, in effect, comes from the pharmaceutical industry, in terms of licence fees. However, I was well aware of the MHRA experience, and my own experience of it, in trying to craft Amendment 257ZA, which does bear some resemblance to that. I certainly would not argue with the idea that the number of non-executives under my amendment should be larger than three—it does say “at least three”. I will certainly go along with her that some outside expertise, in quite substantial numbers among the non-executives, is an extremely good model.
Lord Beecham
My Lords, I am tempted to open by invoking, if not the Health Protection Agency, then perhaps the protection of the local environmental health department, because conditions in this Chamber, at this temperature, are hardly conducive to anyone’s good health. However, that is a matter perhaps for the House authorities to look at.
I rise to express the view that Clause 53 should not stand part of this Bill and to support my noble friend Lord Warner’s Amendment 260. I do the latter on the basis that that would be a fallback position, because I entirely concur with the view expressed in particular by the noble Lords, Lord Turnberg, Lord Patel and Lord Walton, and the noble Baroness, Lady Finlay, who have of course such a distinguished history as leading clinicians in these and other medical fields. Part of the thrust of the argument is the need to maintain not only a functioning organisation which has, as we have heard, an international reputation, but also to ensure that any such organisation has the requisite degree of independence from Government—that is, the right and in fact the duty, as the noble Lord, Lord Turnberg, made clear, to advise the Secretary of State and the Government generally without fear or favour.
Amendment 260 would create an executive agency for the Health Protection Agency. It is arguable that executive agency status would not of itself lead to the required or desired degree of independence whereas perhaps a special health authority would conceivably achieve that. There is a difference of view from the Government about the status of a special health authority. Their preference for Public Health England is that it should be an executive agency. They argue that a special health authority would not be appropriate. They point to analogous situations of agencies created for the Medicines and Healthcare products Regulatory Agency and curiously, by way of analogy, the Met Office, as organisations which are deemed to have sufficient independent status, albeit operating as executive agencies of their respective departments.
Neither of those arguments can be sustained. The role of Public Health England is a much wider one than either of the two bodies to which their document published earlier this year refers. A regulatory agency is not the same as an organisation which has to advocate and oversee a wide range of services, such as Public Health England would be required to do, and the Met Office is hardly an organisation which is required to be independent of Government in preparing its weather forecast. The analogy is somewhat ludicrous.
There is also, of course, the very important point made by noble Lords about the need for independent status in order to attract some of the funding, both charitable and contractual, on which in particular the Health Protection Agency is critically dependent and which might be endangered by its absorption into Public Health England in a way which would make it clear that it is no longer independent. That is not to say that the creation of Public Health England in the form of a special health authority would not of itself be desirable. The bringing together of a range of functions under the auspices of Public Health England, although not, I would argue, the Health Protection Agency, would be welcome.
A number of professional bodies have commended the principle but clearly have reservations about how the new structure would work. The Association of Directors of Public Health, for example, makes it clear that Public Health England should include health protection and emergency planning, health improvement and health services in its main areas of work and, in addition, provide an independent science base and advice to the Government and the devolved Governments. One of the arguments against creating a special health authority was that it would not be able to deal with devolved Governments. I would have thought that that is something that the Government could deal with relatively easily.
The role of Public Health England should also support the national Commissioning Board and provide support for local directors of public health. However, the association expressed concerns about the role and status of directors of public health. We recently discussed some of those in Committee. It also had concerns about the input into the national Commissioning Board and the lines of accountability. We will have Public Health England, the clinical commissioning groups, the directors of public health and various other functioning arms of the National Health Service, and it is not clear how the relationship would work and, in particular, what the role of Public Health England would be. The association has argued strongly for consolidating public health capacity into Public Health England with overall responsibility for improvement, protection and promotion of health care, and for public health intelligence and analysis.
Baroness Northover
My Lords, the noble Lord, Lord Warner, is right about the international status of the HPA. In many ways, the proposals for Public Health England take its development a step further by building on its successes and bringing other organisations into the new Public Health England. Independence of scientific expertise, as he and other noble Lords have said, is indeed crucial. The noble Lord, Lord Turnberg, is right that the HPA has an outstanding international reputation, and the intention is to build upon that. I am glad that the noble Lord, Lord Beecham, welcomes at least some of these proposals, even if he is concerned in other areas.
When we discussed the provisions in Clause 8 that set out the Secretary of State’s health protection functions, we touched on Public Health England and the abolition of the Health Protection Agency. Public Health England will be the national component of the new public health system and will be established as an executive agency as part of the Department of Health. It will bring together activity currently spread across a range of bodies, including the Health Protection Agency, into a new unified body directly accountable to the Secretary of State. It is important to emphasise that the agency is just one component of a system that is currently fragmented, opaque and spread across central government, local government, the NHS and other arm’s-length bodies such as the Food Standards Agency and the National Treatment Agency. We want to replace all that with a clearly defined and much more unified system for protecting and improving the nation’s health. Public Health England will be able to build on the recognised expertise within our public health system from a range of organisations.
We understand that there have been some concerns about the status of Public Health England. I hope that I can reassure noble Lords that further amendments in this area are not necessary; I hear what they say about those concerns but I hope that we can address them. As an executive agency, Public Health England will have a distinct identity and a chief executive with clear accountability for carrying out its functions. Its status will underline its responsibility for offering scientifically rigorous and impartial advice. As we design Public Health England, we will work closely with stakeholders to ensure that it offers support for directors of public health and their partners in the local system. We talked more about the local side of that the other day.
Many noble Lords have expressed concerns about the independence of Public Health England and the need to ensure that it has appropriate corporate governance. We have listened to what people have said. I can say for the first time that we can commit today that the chief executive of Public Health England will chair a board. This will include at least three non-executive members who will provide independent advice and support. We expect the non-executive members to have relevant experience in the public health field, local government or the voluntary and community or private sector in order to provide a broad range of experience and challenge and advise on how the organisation can maximise its income generation abilities. In addition, we will be looking to one of these non-executive directors to have the necessary skills to chair Public Health England’s audit and risk committee, which will provide assurance on risk management, governance and internal control for Public Health England.
Lord Turnberg
Am I correct in hearing that the chairman will be the chief executive appointed by the Secretary of State?
Baroness Northover
It is proposed that the chief executive, who will be appointed in an open competition, will chair the board. Does that answer the noble Lord’s question? No.
Baroness Cumberlege
My Lords, that is great opportunity lost. If we are going to have an executive agency on the lines of the MHRA, that organisation has an independent chairman, not a civil servant. What we really want is an independent chairman. The majority on the NHS Commissioning Board are non-executives. I am very grateful to the Government for going some way, but a little stride further would be very welcome.
Lord Patel
I agree with the noble Baroness, Lady Cumberlege. Why does the Minister not think that there needs to be an independent chair?
Baroness Northover
I thought that noble Lords would be delighted to hear my announcement, but I hear that they are less than thrilled. I will take that back and consider carefully what my noble friend has said about striding further forward, and see how best people’s concerns can be addressed.
My noble friend Lady Cumberlege asked whether the public health community would be involved in selecting the chair and non-execs of Public Health England. We will give very serious consideration to how the chief executive and the non-executive directors are appointed although in the case of the chief executive the final decision must of course be with the Secretary of State.
Some noble Lords have suggested that a special health authority model might be appropriate and Amendment 260 would have that effect. The key issue here, as the noble Lord, Lord Beecham, correctly identified, is that Public Health England will exercise functions that are wider than just the health service in England. In particular, Public Health England will have UK-wide responsibilities. I heard what he said about believing the devolved Administrations could somehow or other be sorted out but I am not so certain. Public Health England will have responsibilities for highly specialised health protection functions such as radiation protection and will therefore need an organisational form that can operate across the whole of the United Kingdom, and a special health authority is normally established in relation to England only. It cannot be established under secondary legislation to exercise UK-wide functions that relate to reserved matters or in relation to functions in England that do not relate to the health service—that obviously would be a challenge.
On the points raised about Amendment 257ZA, I hope I can reassure noble Lords that the chief executive of Public Health England would be appointed through an open and fair competition and would be solely responsible for its day-to-day operation. Ministers will agree the business objectives for Public Health England and the chief executive will be responsible for putting in place the management structure and using the budget appropriately to deliver these. This operational freedom will be supported by a framework agreement between the Department of Health and Public Health England which will set out the roles and responsibilities of both organisations.
During an earlier debate the noble Lord, Lord Turnberg, raised the question—it has been raised again today particularly by the noble Lord, Lord Patel—about the ability of Public Health England to receive research grants. Public Health England will be able to receive research funding from most, if not all, of the sources from which the Health Protection Agency currently receives research income. In the light of the concerns that the noble Lord, Lord Turnberg, flagged up last time, I asked for an analysis of where the HPA currently got its research funding from, in terms of proportions, organisations, amounts and so on. I then asked what would happen in each case. I was reassured to see exactly how Public Health England would be eligible, right across the board it seemed to me, for the kind of grants that currently exist. I am very happy to discuss this further with the noble Lord if he wishes.
In particular, there was concern about what money could be received from the EU and it is very clear that, in terms of the funding rules on intergovernmental organisations such as the EU, the executive agency would no doubt work in conjunction with an academic or analogous institution, as is the case now, to apply for that kind of funding. I appreciate noble Lords’ concern about that and how important it is that this is got right. I therefore hope that they will have a really good look at how this would carry across.
Clearly it is extremely important for Public Health England to have scientists who are not only independent but also able to publish—it is important for their own future careers as well as the work they are doing within Public Health England—and to continue to be able to publish. Public Health England would have a very important role in filling evidence gaps and building on the evidence base to improve and protect public health. That is a critical part of what it would be doing, so that would continue. I am not quite sure where the noble Lord, Lord Patel, got some of his concerns from but he is right to probe and to make sure that this is going to work in the future.
Lord Warner
I am slightly bemused by what the noble Baroness has said on research. I would certainly like to know in writing, rather than poring through Department of Health files, what the risk assessment is of Public Health England losing research grants out of the total of £150 million that the noble Lord, Lord Patel, mentioned and in particular, whether it is at risk of losing the MRC grants that the noble Baroness, Lady Finlay, mentioned. We need something clear in writing and not just vague assurances. We also need some guarantees from the Minister about the right of people who are doing research in Public Health England to publish peer-reviewed articles without any censorship from the Department of Health and Ministers.
Baroness Northover
I am sorry if I am being at all opaque. As noble Lords have said, the HPA generates income and conducts research which it is in effect selling out. There is some commercially sensitive information in what I have here: I am sure that we can clarify it but I am a little bit concerned not to say something that is commercially sensitive. As I said, I looked all the way through here and have seen organisations such as the Wellcome Trust. In fact, I have just been passed a note with large writing saying, “A lot of this information is commercially sensitive but we will write saying what we can”.
Lord Warner
I do not wish to have any commercial-in-confidence information and I am sure my friends do not either. We want to know what is at risk out of the £150 million the Health Protection Agency is getting now under the new arrangements. If you can guarantee, in writing, that Public Health England is not at risk of losing any of that money I think we will be much more confident. We do not want the details of the commercially sensitive stuff we just want the global figure and the assurances of what it is at risk of losing.
Baroness Finlay of Llandaff
Can we also have the assurance that it will be eligible in the future to apply for a broad range of funding even if currently it does not hold a grant from a particular grant-giving body? I think that that applies to the MRC.
Baroness Northover
I hope the cameras are not shining down on this piece of paper of mine so I can try to give you some of the information that may be less commercially sensitive: there are organisations such as the Wellcome Trust and Research Councils UK. Noble Lords should be very reassured as to how this will work, but as a very junior Minister I have to be extremely careful.
The noble Lord, Lord Turnberg, flagged this up, I took it back and asked for a breakdown of the funding the Health Protection Agency gets. I asked in every instance what would happen in the future and I have a comprehensive answer because I thought it was extremely important. I hope noble Lords will be reassured both by my probing and these answers, even if I dare not reveal them all. I hope we can therefore write and reassure noble Lords that those working for Public Health England will indeed have access to the same kind of grants that they have at the moment.
Amendments 257A and 257B are minor and technical government amendments to Clause 54. These amendments would allow the Secretary of State or the Northern Ireland department acting alone to exercise functions in relation to biological substances for the whole of the United Kingdom. I was asked about sub-national structures. Indeed, Public Health England will have hubs. The precise details of these arrangements will be published shortly. As stated in Healthy Lives, Healthy People, we will provide further detail on the operating model for Public Health England.
I was also asked about emergencies. As I mentioned on the previous occasion when we debated public health, Public Health England will act on behalf of the Secretary of State as a category 1 responder. It will also be able to offer support or leadership in dealing with local incidents short of a full-blown emergency.
Reference was made to one or two other areas. If noble Lords will forgive me, I will write to them to sweep up what needs to be covered. I hope that noble Lords are reassured by what I have said. It is extremely important to the Government and to both Ministers in the Lords concerned with this matter that Public Health England is very strong and has the necessary independence. As the noble Lord, Lord Turnberg, put it, it should not be the mouthpiece of the Government. It needs to be able to conduct expert research. I hope that I have reassured noble Lords who have raised these very important points that all this is built into the Bill, and that the noble Lord will withdraw the amendment.
Lord Warner
My Lords, my reaction is, “C+: Must work harder”. The noble Baroness has given some reassurances but they are certainly not sufficient. She should have a lengthy chat with her noble friend Lady Cumberlege on the MHRA. I would be happy to join them as it is an interesting model and has a lot to offer. The noble Baroness, Lady Northover, may remember the Cadbury inquiry’s report on the governance of companies in which it advised that there should be a separate chairman and chief executive. Therefore, the principle of promoting good governance through having a separate chairman and chief executive is well established in both the public and the private sector. She might think about that a bit more.
I do not know about other noble Lords but I was not swept off my feet by the assurances on research. We would like some good assurances in writing, particularly with regard to the ability of the new body to compete for MRC research funds. I continue to have concerns about the ability of any body in this position to publish peer-reviewed articles and findings from research that are uncensored. The road to hell is paved with good intentions. Once a body is inside the Civil Service code, the ability to publish independent utterances and research tends to become a bit more circumscribed. Therefore, we want further assurances in that regard.
I will want to discuss with my colleagues whether we will come back to this issue on Report. In the mean time, I beg leave to withdraw the amendment.
“( ) Any function conferred on the appropriate authority by this section may be performed by either the Secretary of State or the Department of Health, Social Services and Public Safety in Northern Ireland acting alone or both of them acting jointly (and references in this section to the appropriate authority are to be construed accordingly).”
Arrangement of Business
(13 years ago)
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Earl Attlee
My Lords, before we start the Question for Short Debate, I am pleased to announce that due to changes in the speakers list, we now have six minutes per Back-Bench speaker.
Teaching School-Age Sport
Lord Addington
To ask Her Majesty’s Government what proposals they have to ensure that the quality of teaching of school-age sport increases the levels of participation in sport in later life.
Lord Addington
My Lords, I thank everybody who has found time in their schedules to speak in this debate. I pass on the apologies of my noble friend Lord Storey, who is unable to join us due to an illness in his family. I hope that he will catch up next time round.
When I tabled this Question a long time ago, I used the words “school-age sport” because I am rather wary of talking exclusively about school sport as it has never encompassed everything that is required in the education of sportsmen, particularly at amateur level. Indeed, most of my speech concerns amateur sportsmen. We have never had a system within schools that has reached out to everybody and provided them with a basis for the rest of their sporting life. When you are considering embarking on the next stage of your sporting career, you usually have to join a club at some point, certainly if you are an enthusiastic amateur. One of the great fault-lines in our sports participation is the high drop-out rates at the ages of 16, 18 and 21. At those ages our education process changes and work can intervene. We should aim to achieve a balance whereby people continue their participation in sport throughout their lives, or at least make a lasting commitment to it. If one is a very fit and healthy 16 year-old but becomes an unhealthy, paunchy 30 year-old, what was the point of bothering to be fit and healthy at 16? Although the picture of a trophy that you won at an under-15s event which hangs on your wall may help to incentivise you, exercise should be treated as the wonder drug in terms of gaining health benefits from sport. The Health and Social Care Bill should be ringing in our ears in that respect. If you are fit and healthy, virtually everything else that you do will become easier. Your school reports will announce that you are studying better. You are also better able to interact and less liable to catch some of the more debilitating diseases. Obesity will rarely be a part of your life.
What I am trying to get at is how we encourage sports participation throughout life. Schools alone have never achieved this. In the past few years many initiatives have come forward, many from government, on what we should try to do to integrate the state and the private sectors in this regard. There was a great deal of consensus on how you should reach out to both sectors, certainly until fairly recently. I have complained at times that there were so many initiatives on the part of various sports that you felt that the same kids were turning up to the same events and swapping tennis rackets for rugby balls, cricket bats or footballs, with a couple of other smaller sports thrown in. The same people tended to turn up for the different sports, but that was possibly a personal impression. I have asked my next question before, but have we ever established which of those schemes was the best in retaining participation in sport through to adulthood? That is the real test. I do not think that we have found that out. Once we have established that, we can build on it. To go back to the amateur sports clubs, something like 22 per cent of our volunteers are involved in them and 2 million people take part in them. They are the big society writ large. In this country that sector is largely self-generating and self-funding. We have a tradition of owning our own sports clubs as regards some of our major sports. That is not the case for all sports but it is for many of them. The funding is provided by the individuals taking part in the various sports and by activities such as running a bar. They have taken on a huge amount of sporting activity which, in other nations, is provided by the state at local government level. These people should be supported, and the main way we can do this is to make sure they have a steady supply of recruits.
When I tried to plan what I was going to say, I used the phrase “elephant in the room” about the School Sports Partnership, something which has led to a degree of controversy in sport which those of us who looked at it a few months ago were not used to. Ofsted praises the project very highly. I have not heard too much against it, but since its demise I have heard some people say “The one I met was not that great”. Its objective was to make links between club and sport and to make use of the expertise and enthusiasm of the club, an environment you are in because you actually love the sport—or at least like it. I do not care what you call the scheme or how you do it, it is the enthusiasm that is the important bit. In times of austerity, it might look like something that was ripe for the picking—particularly to someone who was not tuned into this process.
What have we learnt from this process? What is the best way to achieve our aims? The particular individual scheme does not matter, in the end, nor does its name. What matters is how we take the benefit that was created in the good examples and go on with them. We can talk long and hard about what we actually think should be in this process of transferring from school-age sport to adult sport but we can be absolutely sure that, unless we have input from the top down that encourages this, we will miss out on a lot of youngsters who want to get involved. The social benefits—the value of the company of adults who are not your parents but who are interested in you and supportive—cannot be underestimated.
Some parents become a taxi service that runs the child everywhere to get on with their sporting life—the ones who say, “If it is summer it must be cricket”, or “If it is winter it must be football”, and “Oh, we have basketball in between”; I quote one of my neighbours as he helped me change a tyre the other day. We need to reach the group that do not have that support, or at least make it easier for them to access it. If we can do this then we are achieving and expanding our base in one of the most valuable community activities we have.
The world will not change if local team X manages to get a couple more trophies. It will change if we can encourage people to take part in that sport, right down to the third team. If we can encourage people who do not play at the highest level to take part—even if it is just a social activity—we are achieving most of our aims: the regular exercise, the social interaction, the bonding that goes on. If we can encourage people to come into that process early enough we can build on it and do what we can with it.
The political class has put a great deal of effort into encouraging this. We will be making a mistake if we allow doctrinaire activity to get in the way of school-age participation. I have heard quite a lot of worrying things from the Government about the importance of competitive sport. I do not know what uncompetitive sport is: exercise and training? I promised, a while ago, not to use the example of the football match in the film “Kes” again, but I am coming back to it. Those who are familiar with it will remember bored, cold people kicking each other and the ball, half of them not taking part at all. For too many, that is the experience of sport. If, in order to have a competitive match you go down to lower ability groups who are not interested and not tuned in, you can go back to that kind of situation. I hope the Minister can tell me that the importance of good education and connections with outside sporting bodies will be given priority; and that, although we want people to be involved in sport, we will not sacrifice the chance of an enjoyable experience for the sake of simply saying, “You are competing”.
Baroness Heyhoe Flint
My Lords, within the understanding and appreciation of the debate proposed by my noble friend Lord Addington, who I thank greatly, there has to be a key assumption that the quality and quantity of teaching of school-age sport is such that both factors are perfect: in other words, enough weekly hours of sports tuition and of a high enough standard to enthuse youngsters at school so that they wish to continue with such activities when they leave full-time education.
Let us look on the bright side and assume that both these key factors of school sport—quality and quantity—are answered in the positive. Both the current Government and the previous Administration have made efforts to increase the hours devoted to school sport and to improve the qualifications of the tutors and coaches in schools. Even in these difficult economic times, it is therefore very good news that the Department for Education announced £65 million of funding for school years 2011 to 2013 to release secondary school physical education teachers to organise competitive sports and train primary school teachers. Additionally, Sport England announced £35.5 million of lottery funding up to 2014-15 to support the new school games initiative inspired by the values and profile of the soon to be upon us 2012 Olympic and Paralympics.
Common sense decrees that if school sport is an enjoyable and uplifting experience, and if the encouragement is there from the PE staff, youngsters may wish to seek similar happy sporting experiences when they leave school. However, there are many negatives looming that can be erased only by a higher level of investment, and therein lies a drawback—a lack of facilities and organisers for casual sport and recreation and lack of ability to unlock the doors of sports venues in community schools to enable community sport and recreation activities to take place. Just drive around your own city, town or village and observe how many facilities are barred and shuttered after school hours. How many amateur sports clubs have expired through lack of funding to enable them regularly to hire costly indoor sports arenas or artificial turf pitches and the use of floodlights, which help when it is dark? The desire to take up sport after leaving school may be thwarted by lack of local organisations.
However, all is not doom and gloom. Data from the Taking Part survey—a national survey of culture and sport by the DCMS—show that a higher number of adults who currently play sport definitely played sport while at school. Perhaps I could indulge in an initiative promoted and actioned by the England and Wales Cricket Board, again, and show how a governing body of sport—and there are 320 such organisations recognised in the UK—can grasp the nettle and mirror the ECB, which has invested focused resources into increasing participation and growth in the adult game through its adult participation strategy as part of its Whole Sport Plan programme.
Cricket has established strong links between school sport and the club game through the Chance to Shine programme. Chance to Shine is a charity that aims to establish by 2015 regular coaching and competitive cricket opportunities to 5,200 primary schools and 1,500 secondary schools. Last year, more than 1 million boys and girls took part in the schools cricket programme —44 per cent were girls, I am pleased to say—but the most heartening factor, which is perfectly in tune with the theme of this debate, is that more than 29,000 children, 30 per cent of whom were girls, migrated from Chance to Shine schools to local clubs, thus demonstrating the success of the programme in getting more people to play sport once they leave school.
This is just a small case study that shows how the responsibility and drive of just one national governing body has solved a funding problem by working with partners to introduce more opportunities to schools and colleges to reduce barriers, such as extra time commitments and travel, in order to support the retention of young people in sport at the traditional drop-off age of 16. The ECB has also put increased resources into volunteering in sport, which means that young people can be organised, coached and umpired by their peers—not by us noble Lords, I hasten to add—rather than by teachers, who may not have the time or facilities to hand to be of value. Through the adult participation strategy, the ECB is ensuring that cricket is delivered to the 16-plus age group as a continuation of its previous involvement. The ECB is also increasing its investment in colleges of further education and universities.
Maintaining participation in sport, once youngsters leave school, is the biggest challenge facing policy-makers, and we all know the inherent benefits of a fit and healthy nation. Looking to London 2012, the DCMS has developed programmes for school leavers to embrace sporting activities—in particular in Places People Play, which is a £135 million initiative that is being delivered by Sport England in partnership with the BOA and the British Paralympic Association.
Government must continue to take up the responsibility of helping to provide the sporting pathway for school leavers to journey into an adult sporting environment and at least help to provide the opportunity and facilities. After all, you can take a horse to water, but unless that trough is filled, the poor old horse will go very thirsty.
Baroness Howells of St Davids
My Lords, I, too, thank the noble Lord, Lord Addington, for raising this debate. His opening speech and that of the noble Baroness, Lady Heyhoe Flint, were enlightening. What I am about to say about the merits of sport in schools will take a different turn.
On Monday night, I attended an awards evening hosted by Tessa Sanderson’s foundation. Tessa is a gold medallist. The foundation, in collaboration with Newham College, seeks out talent, trains and gives much support to those who, because of poverty or ill health, may have missed the opportunity to get involved in sport. Many recipients of the awards paid tribute to the help that they received and talked of how their lives had been turned around. Most of the audience were so moved that there was hardly a dry eye in the room.
One awardee, sitting in his wheelchair, told his story. He left his school at 16 after the break-up of his parents’ marriage. He got into drugs, gangs, stealing and so on, and became a “no-good person”—those are his words—until one night, he decided to steal a motorbike, which he drove into a wall. He broke his back and lay in a hospital bed for some considerable time, contemplating suicide. He said he blamed no one, and said that it was his fault and that he needed no sympathy. That was until his mentor came into his life. His mentor introduced him to sport and he has been the recipient of many medals. He is hoping to go for gold in the 2012 Olympic Games. His mentor says that he has a good chance of raising the union jack with pride. His one regret is that he was not introduced to the buzz of sport during his school days. He is now financially secure, enjoying life and would like to influence others.
For most young British black males, sport of one sort or another has been the only means of upward mobility. The have used their talents across as many athletic fields as they have been exposed to. There are too many names to list them here, but noble Lords will have heard those names, Saturday after Saturday. I ask the Minister to consider new ways to improve the quality of teaching sport in schools.
I should also like to introduce the Minister to a programme that I have been involved with through my trusteeship of the Windward Islands Research and Education Foundation. With the enormous support of St George’s University, we launched in 2010 a programme called “Sport for Health” in the primary schools on the island of Grenada. In one year, this project has taken off so well that we are hoping for a gold medal in 2012. The prospective gold medallist is a champion for the project. Also, many footballers of Caribbean origin are working with us. Our patron is Garth Crooks, and he is very much a working patron.
There is considerable evidence of the adverse effects of non-communicable disorders on the quality of life. Those disorders should not be an inevitable burden on society, given that it would cost so little to attach sport to school programmes on healthy diets. Already, those pupils in Grenada are using sport to reduce obesity and other non-communicable diseases. Let us shift the paradigm through healthy eating—which we already encourage in schools—and add sport for health. There is no disgrace in dying healthily. Let us go for gold in our schools.
Baroness Grey-Thompson
My Lords, I thank the noble Lord, Lord Addington, for raising this debate and asking some very important questions about what it is that works in sport so that we can improve on it.
It is incredibly important to think about school sport at this time while we all become obsessed with the Olympics and Paralympics. With 233 days until the start of the Olympics and 266 until the Paralympics, we have a unique chance to inspire people to be healthier. I admit to having mixed views on attaching participation rates to the Games. I do not believe that this is the right way to measure the success of the Games, but we have no better time to target people.
I declare interests as a board member of UK Athletics and the London Marathon, as a trustee of Laureus Sport for Good Foundation, and as chair of the Commission on the Future of Women's Sport. As a Paralympian, although I have a background in competitive sport, these days I am learning a lot more about participation, which just means that I get slower every year. However, I am passionate about what school sport can encourage, and not just because I was successful. Actually, I was not that great as a child. I spent a long time doing physical activity before I became good at sport, and I had the opportunity to be okay for a long time.
In sport we need role models, whether they are the gold medal-winning athlete or an amazing PE teacher. Like others in your Lordships' House, I do not believe that what we have is right. Perhaps instead of asking questions, I shall make some suggestions for change. Girls leave school half as likely as boys to meet recommended activity levels. Competitive sport is great for some people. I loved it. It works for sporty girls, but it is important not to forget the rest. Girls are missing out on the health and personal development benefits that participating in sport can bring.
Head teachers and governors should be doing all that they can, and in my opinion a lot more, to ensure that PE and sport is provided in such a way that girls find engaging and establish healthy activities and habits for the rest of their lives. If I could wave a magic wand and be just a little radical, I would extend the school day and have PE every single day of the week, to encourage that habit. It would not be something that girls did twice a week; they would do it five days a week. The schools that give more choice on the type of activities in which girls become involved, and where PE teachers pay attention not just to the talented girls, will achieve far higher participation rates.
So, for once, I am asking the Government not for more money for this area but to encourage schools to do more and be more creative, because 80 per cent of women do not currently do enough exercise to be healthy. I do not forget that parents have a role to play in their children's lives and I do not want to negate their responsibility, but it is a challenge for some parents. If you are a mum around my age, you probably had a fairly miserable time in PE in schools. You will have been sent out on cross-country runs and to play hockey wearing gym knickers and not allowed to wear gloves. I speak to so many women whose expression, when I mention sport to them, just turns cold. Because their experience is negative, they do not understand some of the benefits that they can pass on to their children by encouraging them to do sport.
I also understand that sports development is really hard. I did it as a job for two years—my first job on graduation. I understand that that cultural change will not happen on its own. British sport will be better for more girls taking part at school. As the noble Lord, Lord Addington, said, I do not really mind what it is called, but we have to do something to encourage change. If more girls do sport in school, more will carry on afterwards, more will get involved in coaching, volunteering and administration. If the Government want to change representation of women at all levels of society, what better place to start than school sport?
Journalist Liz Jones wrote recently what I would describe as an “interesting article” about women in sport. She was right in some aspects, saying that some girls do not like competitive sport, but we should not throw the baby out with the bath-water. I disagree with her comments about women with sinewy arms not looking attractive and that they should not be involved in competitive sport. I prefer to think about a woman looking strong. We have to encourage girls and women to think differently about what is attractive and what being a strong woman really means for them. In January next year, the Women's Sports and Fitness Foundation is releasing a report on girls’ attitudes to sport and physical activity, and I think that this will provide valuable insight into how we can make improvements. I will take the liberty of personally delivering it into every noble Lord’s pigeon hole.
Having travelled around the world with the Sport for Good Foundation, I have seen some amazing examples of good practice—projects that have recognised how hard it is to engage girls, and so have worked with their mums. I would love more of this. What better way to encourage daughters and mums than to do sport together?
Just this afternoon, I visited a wonderful school: Highbury Grove in Islington. Yes, it is on a new site, which has the most amazing sports facilities. It has a 200 metre track; it has a swimming pool; it is absolutely stunning. Through sport and music the school has turned around attendance and improved academic grades. Credit should be given to the head and the staff, who see the importance of physical activity. They also work with the local community. Like the noble Baroness, Lady Heyhoe Flint, my plea is for more of that. School sites that are open to a wider community can help change the patterns of participation.
My second favourite topic around school sport is young disabled people being active. There is so much more to do in this area, and I know of many positive changes through Sport England and the other home country sports councils. I do not see enough disabled people being active enough, whether at school or beyond. I am pleased that there have been some positive moves in the direction of more clearly being able to measure participation of disabled people—it is a real challenge. So many reasons are given for the barriers to participation, but I have never believed that something being a challenge is a reason to not try.
This is where schools can make a massive difference to young disabled people, because, if we want a more inclusive society, what better way to do it than through sport? It is even more important that disabled children, very young children, are encouraged to play and be active, because those benefits carry on for the rest of their lives. I also believe that, if we have more disabled people active, that contributes to wider government targets of helping to get more disabled people into work. What I would love to see in this area is better teacher training so that there is far greater understanding of adaptive PE. Where I probably am very radical is that I think we need specialist PE teaching at primary level. I know that there is a cost to that, but I would love general teachers at primary level to have much greater understanding of working with everybody in their class. Finally, teachers need to understand what talent is in disabled pupils so that they encourage and give realistic goals, not tell them they are brilliant just because they are disabled and are having a go. There is a big difference between participation and elite sport.
I do not believe that it is all doom and gloom, but neither do I think that we have it right. If this were a school report, it would read “Could do better”, and our young people deserve much better than the provision they currently receive.
Lord Smith of Finsbury
My Lords, it is a privilege to follow the noble Baroness, Lady Grey-Thompson, and a pleasure to be taking part in this very short but important debate. I thank the noble Lord, Lord Addington, for tabling the subject. I want to make three brief points about why school-age sport—that means sport in schools, sports associated with schools but outside school hours and sport completely separate from school—is so important. It is important because it can and should be preparation for sporting endeavour and even sporting excellence in later life. The quality of the teaching, of the facilities and of the enthusiasm that is communicated to youngsters at school are crucial in helping the transfer from school age to later life. It can be life-changing. I know that because I first found informal sport—through hillwalking and mountaineering—at school. It became a very important part of my life subsequently. As an aside, I say that I hope very strongly that we can rediscover a spirit of adventure for young people, the ability to take risks in engaging in informal recreation in the outdoors, because we have lost a lot of that in recent years and we need to find it again.
In both informal and formal sport, sport at a young age can lead to riches later in life. Secondly, sport can enhance the educational original experience and overall quality of a school. Sports, both competitive and non-competitive, can make a huge contribution to the atmosphere and culture of a school and the ability of pupils to engage with academic subjects, as well as with their sport. That is why, when I was Secretary of State at DCMS, I encouraged Sport England to come forward with a substantial programme of funding for school sports co-ordinators. That is why we endeavoured, with a modest degree of success, to prevent the selling off of school playing fields. It is why the school partnership programme was a valuable attempt to link the enthusiasm of sporting clubs and societies with the engagement of pupils in schools. These things are not just important for sport; they are so important for the quality of the education as a whole that pupils receive.
My third point links a little to what the noble Baroness, Lady Howells, said. We do not need to read the recent report, Reading the Riots, about what happened back in the summer to understand why some young people get into trouble, hang about on street corners, join gangs and smash windows. It is not just because of poverty of circumstance—housing, environment and upbringing. It is because of all those things and more, but often it is because of poverty of aspiration. The starting point for any process of regeneration, either physical or social, has to be giving young people a chance to find self-esteem, to find something that they can be proud of themselves for having done, something to give them a sense of real achievement. Sports can give them that.
I would say the same about music, drama, dance and the arts in general as well, but the chance to play sport and to become part of a team, part of a league, to endeavour to excel—the chance to do all those things that sports can be to young people in an exciting and enthusiastic way—can be life-changing. Let us make sure that more of our young people get that opportunity.
Lord Lexden
My Lords, we are all indebted to my noble friend Lord Addington for bringing to our attention once more the twin and linked issues of sport in our schools and in adult life. This topic of course grows steadily in importance and preoccupies public attention to an ever greater extent as we get closer to next year’s Olympic Games. However, the Olympic Games concern the world’s sporting elite. It is the rank and file amateur sporting associations and schools across the country with which this debate has rightly been mainly concerned.
If the state of school sport in the United Kingdom were all that we would like it to be today, with the majority of children being classified as having demonstrated “exceptional performance” under the national curriculum level descriptors on leaving school, we would all be confident that they would be likely to flock with enthusiasm of their own accord to the plethora of amateur associations and clubs that operate in every corner of our kingdom. Sadly, however, in many of our state schools sporting performance leaves much to be desired. Departmental figures for 2010 reveal the depressing statistic that only one in five state schools regularly played in competitions with other schools and that only two children in five regularly played competitive sport, even within their own school, and all this despite more than £2 billion having been spent in attempts to rectify the position.
The independent sector, on the other hand, continues to provide many centres of excellence, as shown by Millfield School, for example, with its outstanding sporting record. At school level, partnerships between the state and independent sectors—a point that as a former general-secretary of the Independent Schools Council I always stress wherever appropriate—offer an immensely important way forward, as I think more and more people have come to appreciate over recent years.
Although the report is some years old, the Institute of Youth Sport at Loughborough University has analysed sporting partnerships between the independent and state sectors. The report mentions numerous benefits to the pupils involved, including increased self-esteem, motivation expectations, new chances to try sports that had not previously been available, the establishment of new links between schools and local clubs, and the dispelling of misplaced preconceptions that the pupils in the two sectors had about each other. As many speakers in this debate have stressed, schools must be opened as fully as possible to the wider community. Such great gains—to individuals and to society as a whole—should be extended as widely as possible. School partnerships between the two sectors must be conducted on an equal basis, bringing enjoyment and satisfaction on both sides. For my part, I continue to regret that as soon as possible I fled from the rugby field and the cricket pitch for the tranquillity of the school library.
What should be our overall aim? If we could work towards ensuring continuity for pupils, we could end the distinction between school sport and sport in later life, and the two would become merely different points along the same spectrum, as my noble friend Lord Addington stressed at the outset. My noble friend Lady Heyhoe Flint also lent strong support for that view. I believe that this is what we should be trying to do, especially if we are to avoid squandering that increased enthusiasm and participation created by the Olympic Games for which everyone hopes. In too many previous Games in other countries, participation has soared in the immediate aftermath, only to tail off sharply over a longer period. If Britain’s Games serve as a catalyst for the mixing of schools and local sports clubs, its legacy will last longer than the stadium’s own steel.
Success in this venture will spring from partnerships between sports organisations and the nation’s schools, underpinned by a high degree of volunteering. Apart from areas where government agencies such as Sport England could help to facilitate such partnerships, progress should proceed as far as possible without heavy-handed bureaucratic intervention. Perhaps more responsibility for the initiatives that are undertaken could rest primarily with school heads, although of course the local clubs themselves would be equally important partners.
Finally, and most importantly, such a strategy would go a long way towards improving the health of scores of children and encourage the virtues of sportsmanship that are just as important off the field as they are on it. It was Cicero who taught us that:
“It is exercise alone that supports the spirits, and keeps the mind in vigour”.
Baroness Billingham
My Lords, we do indeed thank the noble Lord, Lord Addington, for this interesting Question. I shall just repeat it to remind the House what it says:
“To ask Her Majesty’s Government what proposals they have to ensure that the quality of teaching of school-age sport increases the levels of participation in sport in later life”.
Well, my straightforward and brief answer to that is, “None whatever”. I have to say that I am outraged, as are thousands of others, that the actions taken by the coalition so far have destroyed the hard-won foundation for sport laid by the previous Government. I can tell noble Lords that it was not easy. Successive Labour Sports Ministers, supported by the health and educational lobbies, battled to increase the reality of PE in schools and to open up the reality of sporting extracurricular activities, which other noble Lords have mentioned. They succeeded, and when the coalition took over, it had the potential to improve not only the health of the nation but to bring about a fair and broad introduction to sport at grass-roots level. Within that framework, school partnerships had offered expert, well trained staff and the network of school sport partnerships that held the prospect of high-level professional input into schools, which had been lacking in the past and which we had all bemoaned.
So let us fast-forward to the arrival of Michael Gove, Secretary of State for Education for the coalition Government. He promptly announced a cut of more than £160 million of funding for sport in schools. He did this by removing the ring-fencing of that money, allowing heads to decide where the extra money should be spent. When league tables of academic achievement dominate the priorities of heads, the likelihood of that money being spent on academic subjects becomes, for them, irresistible. That decision, taken by the Secretary of State without any public consultation or discussion within the schools themselves and, I understand, without even any discussion in Cabinet, will have the most profound and devastating effect on the sporting lives of future generations.
To take away basic school sport is to wreck grass-roots sport—the vehicle by which individuals may later choose a specialist sport to provide a lifelong interest and involvement in that sport. The Secretary of State ignored at a stroke all arguments about the benefits of sport across the nation, as others have mentioned—health, well-being and educational advantage. It is clear that Michael Gove is sport-phobic, even philistine, and it is even more astounding when viewed against the promises of sporting legacy to be achieved against the background of the 2012 Olympics.
All promises are broken. As the Times wrote just last week:
“2012 legacy plan for a fitter Britain is quietly scrapped”.
So much for the promises which helped London to win the Games, and so much for the vision of the noble Lord, Lord Coe, of a healthier sporting nation. Even the Prime Minister is a very keen sportsman. However, they all find themselves well and truly rumbled. The coalition fails to understand the crucial role of schools, both secondary and primary, where well taught sport can be embedded as the foundation for children’s future sporting lives. Instead, the DCMS, the Secretary of State and the Sports Minister show their total lack of understanding of the nature of a sporting heritage. Grass-roots sport is the key to success. Their belief that competitive sport is the answer—that Olympic-style competition might be the spur—completely misses the point. As has been said, for a small minority of very talented individuals that may be the case. For the vast majority, however, it will prove disastrous.
All the evidence shows that Labour’s investment in sport was having a rich return. Our ambition of 2 million more people becoming physically active by 2012 and for 60 per cent of young people to be doing at least five hours of sport per week became a reality. This is now on the scrapheap of coalition dogma. That is why I am so angry. For the first time, students in state schools—93 per cent of the school population—were provided with a well funded framework for a sporting legacy. The statistics of the outcome of the Labour investment of £1.5 billion from 2003-08—specialist school colleges, as have been mentioned, school sport co-ordinators, school and club links, and a host of other initiatives—showed a 10 per cent increase in active participation across the community. By his draconian action, Michael Gove has put paid to this, with only government support for competitive sport to hide his nakedness.
But noble Lords can relax. Public schools, which educate just 7 per cent of our children, know better. Their comprehensive programme of expensively funded school sports continues unabated. They provide a full range of sport, competitive and non-competitive, and they will be richly rewarded. In future, even more privately educated athletes will hold aloft the winning trophies and wear the gold medals around their necks. The rest—the 93 per cent—will look on to a world that has been ruthlessly denied them.
Finally, to put the tin lid on it, the Government have announced an additional £41 million for the Olympic opening ceremony, presumably for hundreds of synchronised maypole dancers. What a total lack of judgment. That money should have gone back into schools and grass-roots sport. It is most dispiriting. The coalition has lost its way.
Baroness Garden of Frognal
My Lords, I thank my noble friend for calling this debate, the importance of which is exemplified by the calibre and the expertise of those who have spoken this evening and the quality of their contributions. It is not often that we get the chance to debate the quality of teaching of PE and sport and the positive impact it can have on lifelong participation, and I am very pleased that we have been able to do so today.
Ofsted’s report, Physical Education in Schools 2005/2008, published in April 2009, found that the overall quality of teaching in physical education was good or better in two-thirds of the schools it visited, although it was more variable in primary schools. The previous Government’s PE and Sport Survey 2009/10 found that 84 per cent of pupils aged five to 16 participated in at least two hours of physical education per week in curriculum time. However, the survey also found disappointingly low take-up of regular competitive sport by young people, with only around two in five pupils taking part in regular competitive sport within school, and only around one in five in regular competitive sport against other schools. That is hardly a good platform on which to base lifelong participation in sport. I rather share with the noble Baroness, Lady Grey-Thompson, some memories of those miserable days on cross-country runs and foggy sports pitches. For those like me who were not in any way built for sport, this did nothing to enhance self-esteem.
However, noble Lords throughout this debate have spoken of the very wide-ranging benefits of sport which of course start with a good teaching experience. The noble Baroness, Lady Howells, the noble Baroness, Lady Grey-Thompson, the noble Lord, Lord Smith, and others indicated the importance of enthusiastic and motivated teachers at school to ensure that young people regard sport as fun. This is really important if we are to encourage young people to continue sport after school and into their adult life. We know that there are ages and stages when participation drops. As my noble friend Lord Addington indicated, 16, 18 and 21 are the key ages at which participation drops. There are particular concerns about cohorts, including girls and young women, and indeed young people with disabilities who are not encouraged to continue in sport, as might serve them well. We heard from the noble Baroness, Lady Howells, about the life-changing effects of sport, the inspiring programme in Grenada, and the event she attended recently at Newham College.
I will pick up one or two of the references to particular sports. My noble friend Lord Addington asked for examples of the best schemes targeting community participation. We have an example from England Netball, which developed the Back to Netball programme aimed at tempting women who have dropped out of the sport to return through a fun and flexible offer. This approach is driven by a network of netball development officers around the country, appointed by England Netball. The success of the programme is evaluated and monitored in the partnerships which are created locally to deliver and provide the necessary support and exit routes to sustain women’s participation beyond their initial engagement. England Athletics also developed a programme, and my noble friend Lady Heyhoe Flint talked about the Chance to Shine cricket programme, which has been so successful in increasing participation, and in appealing to women to take part in cricket. If only we could read more in the media about the success of women’s sport and teams, that would help to enhance sport across the board for girls and women.
As part of delivering a legacy from the London 2012 Olympic and Paralympic Games, the Secretary of State for Culture, Media and Sport has stated that he wants to create a culture of people playing sport for life and has already written to all the national governing bodies of sport saying that they will be required to focus more on youth from 2013—specifically the 14 to 25 year-old age group. He will be making an announcement in January about a new strategy for participation which will include better links between schools and sports clubs in the community. Contrary to what the noble Baroness, Lady Billingham, was saying, we are not walking away from increasing participation. Every sports governing body will have individual targets in their 2013-17 sports plans that they will have to reach.
The ambition is for every secondary school club to be linked to a multi-sport club in their area and for sport governing bodies to have much stronger relationships with schools. As we have heard today, young people who join a sports club are far more likely to continue playing sport when they leave school. By providing the right coaching or activity at the right time and in the right place, we can bridge the gap between school and community sport through satellite clubs and sports hubs. Sport England is working with 34 national governing bodies of sport to increase the number of five to 19 year-olds taking part in club sport or taking on leadership and volunteering roles within sport. Those roles are also extremely significant in involving and enthusing people.
Places People Play, Sport England’s £136 million lottery-funded mass participation legacy programme—which was mentioned by my noble friend Lady Heyhoe Flint—includes Sportivate, a £32 million programme that gives 14 to 25 year-olds access to six-week courses in a range of sports including judo, golf, tennis, wakeboarding, athletics, and parkour—or free running. That programme is aimed at those who do not currently choose to take part in sport in their own time, or who do so for a very limited amount of time, and will support them to continue playing sport in their community after the six weeks is up. There is also the Sports Makers programme, which is recruiting tens of thousands of new sports volunteers, aged 16 and over, to organise and lead community sporting activities across the country.
My noble friend Lord Addington and the noble Baroness, Lady Billingham, have berated us once again on the School Sports Partnerships front. The noble Baroness is quite right that my right honourable friend the Secretary of State for Education announced in October last year that ring-fenced funding would not continue beyond the summer term 2011. On average, each of these partnerships costs £250,000 to run, and while many were successful in generating interest and increasing participation, this was not true of all of them.
We will build on the good work already being done by schools to encourage more pupils to play competitive sport both in their school and against other schools. I stress that we are not trying to dismantle school sport partnerships. We are happy for schools to continue to work in partnership with other schools if they wish to do so. We are simply not requiring them to and instead entrusting partnerships to schools for them to continue to fund them from within their school budgets if they want to.
There are all sorts of partnerships. My noble friend Lord Lexden spoke of the very successful schools partnerships between state and independent schools, which enhance the prospects of a range of children and young people who would not otherwise have access to particular facilities. We are encouraged by the fact that more than 10,000 schools have signed up to be part of an exciting new competition, mentioned by my noble friend Lady Heyhoe Flint, which will harness the power of the London 2012 Olympic and Paralympic Games to inspire a generation of young people to take part in competitive sport, and will culminate in a national finals competition. The first of these will take place in May next year at the Olympic Park. In response to the noble Baroness, Lady Grey-Thompson, I say that more than 30 sports are involved in this, so there should be something for everyone to participate in. We hope that all young people—boys, girls, young men and young women, the disabled and the fully able—will find something that will be interesting and fun to participate in.
The noble Baroness, Lady Grey-Thompson, mentioned the difficulty of engaging girls and women in sport. It was great to hear that England's netball team recently became 2011 world series champions. Following the World Championships this year, we have 12 world champions in Olympic sport, of whom six are women; and 18 world champions in Paralympic sport, of whom eight are women. The participation figures for women’s sport do not make great reading. The Government will be much tougher at holding sports to account and encouraging them to ensure that girls enjoy sport as much as boys.
My noble friend Lady Heyhoe Flint also mentioned the community use of school sports facilities. The Government are encouraging more community use of school sports facilities through extended schools programmes. We hope that they will remain open for more people to enjoy.
The noble Lord, Lord Smith, talked about sport giving young people self-esteem, and about how life-enhancing that is in all sorts of ways that range far wider than sport. Significant evidence shows that sport can have a positive impact on behaviour. When it is used as part of a wider development programme of education and support, it can certainly lead to reduced offending and better social and educational outcomes. A great scheme called StreetGames works with six NGBs to build a sporting infrastructure in deprived areas and has had great success in recruiting and training coaches, community sports leaders and volunteers.
The contributions to this short debate have focused very much on the wider impact of sport on life-enhancing skills. We have heard about a sense of achievement. My noble friend Lord Lexden spoke of the virtues of sportsmanship and my noble friend Lord Addington of the social benefits and of a wide range of other activities that add to them.
I am conscious of the time. I end by thanking all noble Lords who took part in this stimulating debate, and give special thanks to my noble friend Lord Addington for raising this important issue. We are all shaped by our experiences. No doubt the shape of many of us here reflects the amount and quality of PE and sport we experienced and enjoyed at school, and the extent to which we took that participation with us into adulthood. As we count down to the Olympic and Paralympic Games we can be excited and proud of all that is going on in school and community sport. The Government will continue to work hard to ensure that sport remains a key part of our national life.
Health and Social Care Bill
(13 years ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
“The Health Research Authority
(1) There shall be a body corporate called the Health Research Authority (referred to as “the HRA”).
(2) The Secretary of State shall make all necessary regulations to establish the HRA within 12 months of the Act receiving Royal Assent.
(3) The HRA shall manage a co-ordinated process for all aspects of the approval of health research involving human participants or their data, including—
(a) the provision of ethics committee opinions and other approvals,(b) with the National Institute for Health Research and NHS trusts, delivering a consistent, efficient process for obtaining permission for research carried out under the scope of the Research Governance Framework for Health and Social Care (referred to as “NHS R&D permissions”),(c) with the Medicines and Healthcare Products Regulatory Authority, improving the regulation of clinical trials of medicinal products, and(d) other such functions as may be specified in regulations including those currently being undertaken by organisations which will cease to function following the implementation of future legislation.(4) The HRA shall have the following general functions—
(a) providing general oversight and guidance as it considers appropriate in relation to activities within its remit,(b) publishing annual metrics and indicators on all research approvals within its remit, (c) working with relevant bodies across England, Wales, Scotland and Northern Ireland to address differences in practice and legislation, and providing supporting guidance or codes of practice that apply across the UK,(d) superintending compliance with requirements imposed by legislation relevant to its remit,(e) monitoring developments relating to activities within its remit, and(f) facilitating and promoting health research involving human participants or their data.(5) The HRA must carry out its functions effectively, efficiently and economically.
(6) In carrying out its functions, the HRA must, so far as relevant, have regard to the principles of best regulatory practice (including the principles under which regulatory activities should be transparent, accountable, proportionate, consistent and targeted only at cases in which action is needed).
(7) The Special Health Authority known as the Health Research Agency is abolished and its functions transferred to the HRA.”
Lord Willis of Knaresborough
My Lords, I beg to move, at last, Amendment 258 and will speak to Amendments 260A, 260B and 260C, which stand in my name and those of other noble Lords. I put on record my thanks to noble Lords across the Chamber for the way in which they have supported a series of proposals and amendments concerning research. This has been a non-party political area of the Bill and I am deeply grateful to them.
On Monday, the Prime Minister launched a new strategy for UK life sciences with all the hype that he could muster—quite right too, as it is an outstanding document and contribution to life sciences. Our research is world beating, our National Health Service has a patient database unrivalled anywhere in the world and we are putting together a research and governance framework that will make the UK the place to do health and medical research. It is UK patients who will benefit by having novel and ground-breaking treatment literally years earlier than could have been hoped for five years ago when the noble Lords, Lord Darzi and Lord Sainsbury, set out with a very similar message. There is no difference between either side of the House on that issue.
By coincidence, the amendments before us today will help deliver that strategy—and deliver it earlier. At the heart of the delivery platform for the strategy for improved outcomes for patients is the Health Research Authority, established not as a creature of Government but as a full NDPB. In essence, the amendments in this group would put in the Bill the commitments that the Prime Minister gave this week, and that the Secretary of State gave when he accepted the proposals made by the Academy of Medical Sciences in its ground-breaking report, A New Pathway for the Regulation and Governance of Health Research.
To date, establishing the Health Research Authority via the Bill has not been the Government’s preferred option; I think I am safe in saying that to the Minister. Instead, the usual cautious Civil Service-driven approach of creating a temporary vehicle meant that a special health authority was set up on 1 December to carry out many of the functions of a future NDPB. However, much of the confusion, duplication, delay and obfuscation outlined in Sir Mike Rawlins’s report will continue to exist, as we wait for another Bill that may or may not come in the next Session of this Parliament. If a single Member of this House actually believes that any Government would be enthusiastic about bringing in a new Bill, having sat through this particular Bill—which is by no means finished—then, quite frankly, they are on a different planet.
The Minister argues that the special health authority will do almost everything that such a Health Research Authority will do, but is this really the case? Will it really have the authority or the power to change much at all? The research community welcomed, as I did, the transfer of the National Research Ethics Service to the special health authority, but what about the plethora of other regulatory bodies? Ethical approvals, including the storage of tissue, from the HTA, and embryo project licences from the HFEA will still be required. Ethics and Confidentiality Committee approval will still be needed for exemptions to common-law confidentiality. Permissions from the Administration of Radioactive Substances Advisory Committee will be needed if research clinicians wish to administer radioactive substances. All the powers of the Medicines and Healthcare products Regulatory Agency will remain exactly where they are.
As a special health authority, the Health Research Authority has absolutely no authority to deal with the different legislative regulatory arrangements across the devolved nations. It was quite interesting that with Amendment 260, tabled by the noble Lord, Lord Patel, the Government prayed against creating a special health authority because it would be able to deal only with England; it would not be able to deal with the rest of the United Kingdom. This is exactly the sort of organisation that has been set up to deal with this crucial area of health research.
Crucially, there will still be the vexing issue of individual National Health Service research and development approvals. Unless the HRA is set up as an NDPB in this Bill, approval processes, which are often taken sequentially rather than in parallel, with often conflicting advice from different bodies, will continue to cause confusion, delays and frustration, and the UK will continue to see research programmes haemorrhage away to international competitors as clinical trials persist in being problematic—exactly the opposite of what A New Pathway for the Regulation and Governance of Health Research is preaching to us this week.
Amendment 258 would establish the Health Research Authority in primary legislation—now—as an NDPB and set out the HRA’s role in co-ordinating the approval and regulation of health research. Subsection (3) provides for the transfer to and the management of,
“all aspects of the approvals of health research”.
Subsection (3)(a) covers the transfer of functions of the National Research Ethics Service to the HRA when it is established as a full NDPB, but the wording is broad enough to cover other research approvals that could be transferred—for example, those of the Human Fertilisation and Embryology Authority, the Human Tissue Authority, the Ethics and Confidentiality Committee and the Administration of Radioactive Substances Advisory Committee—all without the need for further legislation. This could all be done through secondary legislation in an orderly time and allowing for full consultation.
Subsection (3)(b) covers the HRA’s role in providing NHS R&D permissions, which it would undertake jointly with NHS trusts. Amendment 260C, which I will come to in a minute, allows for a more detailed exploration of the exact role of the HRA in NHS R&D permissions. Subsection (3)(c) covers the HRA’s role in supporting the MHRA in the regulation of clinical trials.
Subsection (4) explores the general functions of the HRA. At the moment, some regulatory organisations are very good at providing advice and support; others, quite frankly, are not. High-quality guidance is needed in some areas, and where this is currently absent or confusing—for example, in the use of patient data in research, which is an absolute minefield—subsection (4)(a) would ensure that researchers apply appropriate standards consistently across all studies, with the HRA becoming an authoritative source of guidance both to support researchers and NHS trusts and to build patient confidence in research.
Subsection (4)(b) would support the HRA’s quality remit, as it would be required to publish,
“annual metrics and indicators on all research approvals”,
while subsection (4)(c) addresses the important area of UK-wide research frameworks. The regulation and governance pathway is currently fragmented across the whole of the United Kingdom. Some research approvals, such as those of the HFEA, apply to the whole of the UK; some apply to England and Wales, with different arrangements in Scotland, as happens with the HTA and the ECC; and some are managed separately in each Administration, as happens with the NHS R&D permissions in individual healthcare trusts. The complexity of the system can create additional barriers for researchers, which is a huge barrier to the UK being the prime destination in terms of research.
Subsection (4)(f),
“facilitating and promoting health research involving human participants or their data”,
is a massive issue, which again, if it were on the face of the Bill, could be dealt with in secondary legislation.
Put simply, Amendment 258 would allow the Health Research Authority to be set up with a minimum of detail, allowing the details to be worked out in consultation with the broad community, and indeed with public consultation, but it would mean that any future government would have to work on putting it into action, rather than waiting for some legislation, which may or may not come down the track. The real issue is that if we are left with a special health authority, we will be left with it in four, five, or perhaps even 10 years’ time. We will have lost the opportunity to move forward. It is that serious.
Amendment 260A is a probing amendment, which sets out the specific health research functions that should be transferred to the Health Research Authority. What we are saying is that, in addition to the National Research Ethics Service, it would be easy in this piece of legislation, which the Government may or may not take forward—and this is entirely a probing amendment—to bring in, in addition to the Ethics and Confidentiality Committee, the research functions of the Human Tissue Authority, the Human Fertilisation and Embryology Authority and the Administration of Radioactive Substances Advisory Committee. It does not require a new Bill to do that. It could simply be done on the back of this Bill.
Amendment 260B is again a probing amendment, which seeks to strengthen the link between the Medicines and Healthcare products Regulatory Agency, the MHRA, and the proposed Health Research Authority. In effect, it would establish a duty of co-operation between the two organisations. It is expected that the new Health Research Authority will take on most aspects of the regulation of health research, except for the regulation of clinical trials of investigational and advanced therapy medicinal products, which will continue to be regulated by the MHRA. This simple amendment seeks clarity from the Government around their expectations for the relationship between the Health Research Authority and the MHRA.
Finally, Amendment 260C is the crucially important probing amendment because what it would do is establish an organisation called the “National Research Governance Service”. This is hugely important because one of the biggest barriers to effective development of clinical trials at the moment is getting NHS R&D permissions. It took one hospital five weeks to get the necessary permissions for a kidney research clinical trial; in another it took 29 weeks. Getting a stroke programme up and running took one week on one site and 35 weeks on another. The average time it takes to get a cancer trial up and running is something like 80 weeks. It is absolute nonsense, and how the Minister can turn to this House and say we have an opportunity to do something about that and not take it is something only the Minister can respond to—which I am pretty sure he will do very strongly and very supportively of these amendments in the near future.
NHS R&D permissions are currently the greatest barrier in the regulation and governance of health research, with multiple, duplicative checks undertaken at every NHS site. The Academy of Medical Sciences recommended creating a national research governance service—this comes directly from the AMS report—within the HRA to centralise as many of these checks as possible to avoid duplication. The Government have ignored this recommendation and instead introduced standard operating procedures and incentives to make improvements to the current system. Only a civil servant could have done that, when in fact what we want is action.
Lord Walton of Detchant
My Lords, I give very warm support to these amendments, which were so expertly introduced by the noble Lord, Lord Willis. As he said, the report of the Academy of Medical Sciences, after a long period of study and a committee chaired by Sir Michael Rawlins, made a number of important proposals, which the Government, in principle, accepted.
This takes the matter very much further. Following last night’s very exciting and far-sighted Statement by the Government about the developments in research and their sponsorship of translational research, the need to translate the discoveries of basic medical science into practical developments in patient care, the crucial importance of making access available to the NHS database to enable clinical trials to be carried out, and the crucial importance of more rapid access to new medicines and so on through the NHS, it is crucial to recognise that all those proposals are very important. These amendments would carry that forward.
It is also important that the Health Research Agency, which has already been established, is as yet an inadequate vehicle to further the developments to which the noble Lord, Lord Willis, referred in great detail. It is essential to recognise that to carry forward the developments envisaged in the Government’s Statement last night on translational research on the governance of clinical trials and the overall governance of research as a whole in the NHS, something like these amendments must be put in the Bill.
I want to comment briefly on the proposals set out in one of the amendments, to the effect that it would be sensible to remove from the Human Tissue Authority and the Human Fertilisation and Embryology Authority their research components and that these would much more happily settle in the newly defined Health Research Authority. There is a lot of sense in that, because the research carried out by these organisations is important, and it is research that is in many ways crucial to the development envisaged in these amendments.
However, it is important to recognise too that the Human Tissue Authority in its present existence has a major responsibility for regulation—regulating the departments, for instance, in which anatomical work is carried out, and regulating departments of pathology and other teaching functions which are absolutely vital. Similarly, the Human Fertilisation and Embryology Authority is not primarily concerned with research but also has major licensing functions, in licensing organisations in which work under the Human Fertilisation and Embryology Act can be carried out.
I understand that there has been a proposal by the Government that the functions of the HTA and the HFEA might be transferred to the Care Quality Commission. I would only comment, as John McEnroe said, that you cannot be serious. The Government cannot really be serious. This is not an organisation which is set up to handle that type of information. It is crucial to recognise that the Care Quality Commission has very specific responsibilities. It has taken on the responsibilities of three previous bodies, which were involved in looking at healthcare, social care and psychiatric care. It is carrying a major load—
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
Will the noble Lord give way? I am sure the noble Lord will know that through this Bill we cannot transfer the functions of either the HTA or the HFEA to any body at all. Indeed, that was the substance of my undertakings to this House under the Public Bodies Bill debate—that we would defer consideration of those matters until a later Bill. This Bill simply covers the reform of the health service, obviously, and my noble friend has sought to introduce an amendment to set up the Health Research Authority as a statutory body. But I gave an undertaking to this House that I take very seriously: that the consultation process on the transfer of functions from the HTA and the HFEA has to take place. It would be premature for this Bill to cover that matter. For that reason alone, I urge noble Lords to be very cautious about my noble friend’s amendment, about which, nevertheless, I will say some warm words.
I wanted to specifically cover that matter, as I notice the noble Baroness, Lady Warwick, looks as if she wants to rise to her feet. I can understand why, because it is important for the Committee to understand that the matters to which the noble Lord has just referred are matters which we will reach in due course, rather than today.
Lord Walton of Detchant
I am very grateful to the noble Earl for clarifying the position, but it is important that in the longer term we shall have to learn more about the future of those two very important authorities. In the mean time, the crucial importance of these amendments is to clarify in the Bill the responsibilities of this new organisation which is going to be responsible for regulating research in the UK, and which will streamline and improve the present mechanisms for research approval in many different situations. Therefore, I strongly support these amendments.
Lord Patel
My Lords, I hesitated to rise last time because I saw the Minister getting up, and I thought he was about to make a pronouncement to stop the debate because he had a solution to it all, but I realise now that was not the case.
I strongly support the amendment of the noble Lord, Lord Willis. I have my name attached to it. It is crucial that we hear more than just the setting up of the authority, as the Government have announced a few days ago, to take charge of the National Research Ethics Service. I was part of that organisation until I finished my time in the National Patient Safety Agency and was responsible for setting up much of its work, so I take the blame for its shortcomings, if there were any.
The issue we are discussing is why there is a need to set up the Health Research Authority with wider functions than those of NRES. The report produced by the Academy of Medical Sciences identifies serious issues which are important if we are going to deliver on the life sciences strategy announced yesterday and on which I have highly commended the Government; it is excellent. But if we are to deliver on it, we need to streamline the regulatory processes that currently are so cumbersome. For instance, an NHS research and development permission is required at every NHS site where the research is to take place, and the review by the Academy of Medical Sciences confirms that this is perceived to be by far the greatest barrier within the regulation and governance framework. The current process for obtaining research permissions across multiple NHS sites is inefficient and inconsistent. Local negotiation about research contracts and costings is a further source of delay, together with a lack of agreed timelines within which approval decisions are made. Governance arrangements are therefore very important, and the noble Lord, Lord Willis, told us that the report has highlighted that there should be a governance board as part of the Health Research Authority.
The noble Lord gave some examples of delays which had been highlighted by respondents, including in kidney research, stroke research and multiple clinical trials involved in heart research. The solution is to set up an authority which can provide a national research governance service as a part of it. Clinical trials are another example. The noble Lord mentioned how our global share of clinical trials has fallen dramatically. This is particularly related to the fact that it is cumbersome to conduct clinical trials in the UK. To address the challenges identified around clinical trials, improvements are clearly necessary at both the European and the UK level. I know that discussions are going on and that the department is involved in a revision of UK clinical trials, and I hope that they will come to some fruition. The noble Lord also said that the relationship between the new Health Research Agency and the Medicines and Healthcare Regulatory Agency will be crucial in improving the current system. That is an important point, because it was the relationship between the MHRA and clinical trials that at times caused problems.
The problem is that the existing regulation and governance pathways, which evolved in a piecemeal manner over several years, have now become dysfunctional. Although new regulatory bodies and checks have been introduced with good intentions, the sum effect is a fragmented process characterised by multiple layers of bureaucracy and uncertainty in the interpretation of individual pieces of legislation and guidance. This has produced a lack of trust in the system along with duplication and overlap of responsibilities. There is no evidence that these measures have enhanced the safety and well-being of either patients or the public, so the answer lies in now creating a Health Research Authority with multiple functions in order to go forward.
Baroness Warwick of Undercliffe
My Lords, I declare an interest as chair of the Human Tissue Authority, whose work is affected by the review of arm’s-length bodies and is referred to in one of the amendments. The desire to streamline the governance and regulation arrangements to support high-quality research underlies both the Government’s intentions and the amendments relating to the new Health Research Authority. These are laudable aims which I certainly support and which the HTA also supports wholeheartedly. Researchers want to get on with their research, and from their perspective what is important is that they see a seamless end-to-end and proportionate process for regulation and governance. The HTA has always striven to do exactly that within its focused regulatory remit relating to research while ensuring that the interests of the public are protected. But transferring the HTA’s work in research to the new body, as Amendment 260A proposes, may undermine these aims. I want to focus my brief remarks on that point.
The Department of Health clearly has favoured an option to keep all the HTA’s functions together, including research, and will consult on that basis shortly. I believe this is to a large extent because of the HTA’s track record of collaborative working to ensure that the regulatory burden on researchers is minimised. I would be happy to provide a range of examples dealing with NRES, the MHRA, the HFEA, tissue banks and clinical pathology accreditation, but in the interests of brevity I certainly will not iterate them now. Suffice it to say that, in the absence of detail at this stage about how the HRA will operate, it would be premature to make decisions now in haste that we may live to regret later. However, I will briefly set out three reasons why I believe that the HTA’s research functions should not be part of the Health Research Authority.
Lord Turnberg
My Lords, I had a previous bite of this cherry when I spoke at some length in my prayer to take note of the statutory instrument to set up the Health Research Agency a few weeks ago, so I will not be long and will not repeat what I said on that occasion about the need for a research regulatory authority that was more than simply a home for the national research ethics committee. Highly important though that is, my message was that it was essential but not sufficient. If we are to get over the barriers to research posed by the regulatory processes that delay research approval, we must include more functions.
I was very taken by the Statement that the noble Earl repeated yesterday on the life sciences. It was a marvellous demonstration of the Government’s commitment to research and innovation—I could not have said more myself in many of its aspirations. However, if you were looking for a reason for us to have a fully functioning research regulatory authority, as set out in this group of amendments, you need look no further than that Statement. It points out quite clearly where the barriers to innovation lie—with excessive regulation, access to patient data and delays in taking up innovation into practice.
On regulation, the Statement says:
“Excessive regulation can mean that the uptake of new treatments and technology is slow. That is a challenge felt acutely by an industry that sometimes feels that the return is not there quickly enough to satisfy investors. It is felt even more acutely by patients”.—[Official Report, 6/12/11; col. 685.]
There it is; we need a more strongly established research regulatory authority. Let me give one example of where we are in danger of losing out. The NIHR—the National Institute for Health Research—sponsored the North West Exemplar programme to see whether it could engage both the pharmaceutical industry and the NHS in trying to get approval for multicentre clinical trials in a reasonably short time. This involved getting the strategic health authority in the north-west to convince the various hospital trusts in its area to approve the research as efficiently as possible. It has worked—their rate of research and development committee approvals are rapid and compare very favourably with the rest of Europe. They are certainly better than the rest of the UK.
However, there is a danger of that being lost when we lose the strategic health authorities. The driving force of the strategic health authorities will disappear shortly. That is another reason for a research regulatory authority to take on this leadership role: to drive this exemplar forward and spread its message more widely. We need it, therefore, not only for the National Research Ethics Service and the ethics committee on the use of data—a separate ethics committee—but for many of the other functions described so forcefully by the noble Lord, Lord Willis.
I heard exactly what the Minister said about the HTA and the HFEA, and what my noble friend Lady Warwick of Undercliffe said about the HTA. I accept that that should be looked at as a separate set of items. These amendments would allow that; I do not think that they are obviated. However, we need this critical role if we are to take advantage of our excellence in research and if we are to fulfil the Government’s ambitions, as set out yesterday in the Statement. The dangers are evident already, as we see the pharmaceutical industry withdrawing and moving elsewhere. If we are to draw it back, we must have something in the Bill that sets up a full—and fully empowered—health research authority. I hope that the amendment has some sympathy in the Government.
Lord Warner
My Lords, my name is on Amendment 258. I speak as a former Minister responsible for NHS R&D in the pharmaceutical industry in 2003 and 2004. We were having exactly the same discussions then. Since that time, the National Institute for Health Research has been set up, we have had the Cooksey review, OSCA has been set up, and we have had the review by the Academy of Medical Sciences. All these cases come back to the issue of a faster, smoother regulatory approval system. The same blockages that are being talked about now were being talked about five, six, seven years ago.
In that time the UK has lost large numbers of clinical trials. We continue to lose trials and we are going to lose more to south-east Asia. UK plc suffers while we continue with these present arrangements. I understand the Minister’s anxieties about this. However, at the end of the day it is difficult to see that a new authority would be in place, even with a very smooth passage, until at least a year later than if we went along with the amendment. We need to move faster on this.
I end with one question to the Minister. Have the Government actually talked to the big beasts in science research in this area—to the Wellcome Trust, the MRC, the Academy of Medical Sciences? Have they asked them directly whether they would you sooner have the Willis amendments or wait for a Bill in the next Session. I would like to know what their straight answer to the Minister would be on that particular question.
Baroness Finlay of Llandaff
I have my name on the amendments about setting up the authority. In his response to the questions posed, I hope that the Minister will address how exactly we are going to streamline the process, as has been outlined so eloquently, and whether mechanisms such as commencement orders could be used so that we do not delay the process of speeding up research, because some parts, such as the Human Tissue Authority and the HFEA, are not yet clarified. It would be very sad to go at the slowest pace rather than storm ahead. This Government have demonstrated an understanding of research as an important economic driver to the UK as a whole, but that infrastructure, as suggested in these amendments, has to be in place and cannot wait. I hope, therefore, that the Minister will also address the timetabling in detail when he replies.
Lord Beecham
My Lords, I come to this debate unencumbered by any particular knowledge or experience of the issues addressed by the amendment, but it is apparent that today’s debate is but the latest instalment in a long-running saga, which in a sense reached its peak almost exactly seven months ago on Report of the Public Bodies Bill; many of the arguments that we have heard today were rehearsed on that occasion. It is not without significance that the noble Baroness, Lady Deech, complained at that time that no full and impartial public review of the risks and benefits, including the financial risks, of the proposed abolition of the HTA and the HFEA had actually been undertaken. Members of this Committee are clearly of the same mind as most noble Lords have been.
At that time, the Minister set out his reflections on the points that had been made in that debate. He pointed out that there was a common theme: a desire for greater clarity on where the Government intended to transfer the functions of the HFEA and HTA, and concern that the dispersal of functions across a range of bodies would risk fragmenting regulation. Clearly, those matters are still in the air. The Minister said that he intended to consult in the late summer on the options for where certain functions would be most appropriately transferred, and intended to proceed on the basis that the preferred option was for the HFEA and HTA functions to be transferred to Care Quality Commission, except for certain research-related functions that would transfer to the health research regulatory agency. Consultation would therefore take place. It is now seven months since all that was said. The main justification for not proceeding with what was sought then, and indeed still is now, was that:
“We do not want to add to what is already a substantial Bill”.—[Official Report, 9/5/11; col. 699.]
It might be thought that there were matters of less importance in the Bill, and certainly matters that in many respects were more controversial, than the topic that we are addressing today.
Having said that, I have listened with interest to my noble friend Lady Warwick, who takes a somewhat different view of this. Without the in-depth knowledge that other noble Lords have exhibited on this I hesitate to disagree with her, but for my own part I am persuaded by the force of the arguments made by the noble Lord, Lord Willis, and those distinguished noble Lords who have supported him. It is not good enough, particularly in the light of the Government’s clearly confirmed intention to press on with giving greater emphasis to the role of research, specifically in this field, that we should be told, as I anticipate—perhaps wrongly—that further consultations will take place and at some time there will be a conclusion and then a Bill. Given that legislation must already be piling up for the next Session, which, presumably, unless the rules have changed again, will be a year long, it is unlikely, with pressure from other departments, that this department will obtain the space for a Bill of this kind, so the uncertainty will continue. Uncertainty is almost the worst feature of the present situation; it cannot be good for anyone concerned with the problems of research, from the point of view of either pure research or, more particularly, its development into industry and production. Equally, the ethical side clearly cannot be allowed to drift.
I hope the Minister will, if he cannot commit tonight to reviewing the position, undertake seriously to discuss matters again with the noble Lord, Lord Willis, and those who have supported him tonight, with a view to seeing whether, even at this stage, the Government can change their position and deal once and for all with a significant issue around which there seems to be a considerable degree of consensus in this Committee and in your Lordships’ House.
Earl Howe
My Lords, the amendments in this group aim to create a Health Research Authority. My noble friend has explained the rationale for the authority very succinctly and I want to make it clear at the outset that I am on precisely the same page as him as to what he is seeking to achieve for health research. We announced in the Plan For Growth in the Budget in March that we would create a body to combine and streamline the approvals for health research, which are at present scattered across many organisations. We also said that wherever we can achieve this simplification without primary legislation, we will. We have already laid legislation to establish the Health Research Authority, which started its work on 1 December 2011 as a special health authority, as was reported in Monday’s Statement on our strategy for UK life sciences. In that form it will take on a number of key functions and I will come to those in a moment.
Looking ahead, as I mentioned earlier, we will be consulting on the future of the HFEA and the HTA. That consultation, as the noble Lord, Lord Beecham, has pointed out, has been delayed but we are still very much intent on launching it and hope to do so shortly. We look forward to stakeholders’ views on the option of passing the research-related functions of the HFEA to the HRA as proposed in the AMS report. In that regard, where primary legislation is required to consolidate functions, we intend to subject it to pre-legislative scrutiny during the next Session and to introduce it as soon as parliamentary time allows.
It may interest my noble friend to know that I am upbeat. I am advisedly upbeat and want to stress to him and other noble Lords that contrary to the apprehensions that have been expressed, the Health Research Authority will have substantive functions as a special health authority. It will combine and streamline approvals for health research through unification of functions and processes wherever that is possible without additional legislation and through co-ordination where it is not. I say to my noble friend without any hesitation that we can achieve a very high proportion of what we wish to achieve with the HRA in this form as a special health authority. It will bring together functions relating to research ethics committees currently performed by the Secretary of State, the National Patient Safety Agency and strategic health authorities. It will operate a single system for researchers to apply for approval to research ethics committees, NHS trusts, the Medicines and Healthcare products Regulatory Agency, the National Information Governance Board and the Administration of Radioactive Substances Advisory Committee.
By April 2013, it is intended also to bring in functions currently performed by the Secretary of State on the advice of the National Information Governance Board’s ethics and confidentiality committee. The Health Research Authority will also work closely with the bodies I have just mentioned, as well as the Care Quality Commission, the Human Fertilisation and Embryology Authority, the Human Tissue Authority and the National Institute for Health Research to co-ordinate relevant functions, processes and standards. That is why, despite my noble friend’s understandable desire to see an NDPB established as soon as possible, I suggest to him that for practical purposes, setting aside the HFEA issue for one moment, the amendment is unnecessary.
However, there is another reason why it would not be right to establish the agency in this Bill—it would not be for the good of research in this country. I say that for the following reasons: it would weaken parliamentary scrutiny by stopping Parliament being able to debate primary legislation on the functions of the agency because it would consign much of the detail to secondary legislation—I do not think that is something that in the past your Lordships’ House has been keen on. It would pre-empt public consultation; for example, on the future of the HTA and the HFEA, and in my view it would put haste ahead of getting it right by dealing with a complex issue without due discussion and consideration.
Lord Willis of Knaresborough
I am listening carefully to what my noble friend is saying. However, Amendment 258 would not compromise in any way the consultations which he has rightly promised on the HTA and the HFEA. The proposed new subsection (3)(a) in Amendment 258 refers to,
“the provision of ethics committee opinions and other approvals”.
It does not state what those other approvals are. Therefore, if the amendment were passed, the Minister could consult in a year’s time or in two years’ time and come to a decision without compromising those approvals.
Earl Howe
I hear what my noble friend says but I cannot agree that his approach is the best for research in this country. Very real risks would accompany trying to shoehorn a very important and complex issue into this Bill in what I have to say to my noble friend is an inappropriate legislative form. The noble Lord, Lord Warner, asked about the view of the Academy of Medical Sciences on this matter. The last time that I spoke to staff at that body, which was not very long ago, they were dead set against my noble friend’s approach. They believe that the approach the Government are taking, which is a step-by-step approach, is exactly right. They recognise that the Special Health Authority can achieve a very great deal, we do not need to rush into primary legislation and we would do very much better to take our time over that process.
My noble friend mentioned the devolved Administrations. We have also directed the Health Research Authority to collaborate with the devolved Administrations in the exercise of its functions. We expect it to maintain effective communications with the UK health departments on the practical implications of implementing legislation, policy and guidance, building on the success of the national research ethics service at developing a single UK-wide system for research ethics committee review. Therefore, I do not regard that problem as at all insurmountable.
We agree with the intention behind Amendment 260C of improving the consistency and efficiency of reviews of the bodies carrying out research. We consider the National Institute for Health Research to be a more appropriate mechanism than the Health Research Authority for taking action to achieve outcome improvements, such as those called for in the Academy of Medical Sciences report. My noble friend may wish things were otherwise but noble Lords need to remember that NHS trusts are autonomous bodies. It is important that there is a clear division between the responsibilities accepted by them when planning and conducting research and the responsibilities of the body that regulates their practice. In this environment, the NIHR is in a strong position to support and influence them. The NIHR has already introduced mechanisms to achieve the effect of Amendment 260C through its co-ordinated system for gaining NHS permissions, its research support services framework of standard operating procedures and good practice guidance and its research passport scheme. It is also introducing benchmarks for NHS trusts’ performance in the initiation and delivery of research. NIHR funding will become conditional on meeting such benchmarks, so there is a direct incentive for NHS organisations to comply with those benchmarks.
As regards the Health Research Authority monitoring developments relating to activities within its remit, I thank my noble friend for raising the horizon-scanning point. I will gladly consider that further to see what can be done.
In sum, I do not see this amendment as appropriate. I appreciate that my noble friend intended it as a probing amendment, but I hope that I have set out clearly why I do not think that this would be the right way to go. Noble Lords can be relaxed that we are already embarked on a course which should deliver major improvements in all the areas where we want to see improvements as regards the clinical trials process in this country. As I say, I am optimistic that we are embarked on the road to the sunlit uplands in this sense. We will in due course—I hope that that will be sooner rather than later—come to a point where we can embody these things in primary legislation. However, I urge noble Lords to consider the need to take our time and to consider those matters very carefully.
Lord Willis of Knaresborough
My Lords, I thank the Minister, as always, for his courteous and passionate reply to this debate. He has used the words upbeat, relaxed and enthusiastic about the amendments and the aim behind them and I appreciate what he said. He made the point—and has made it often—that the Special Health Authority, which was set up on 1 December, will be able to take on, over a short period of time, many of the functions which I have outlined in Amendment 258. I would be grateful if the Minister would put in writing the timetable for delivering all those elements. It would be hugely advantageous to know just how they would fit and dovetail in.
My noble friend Lord Warner—well, he is a friend—commented on the views of the Wellcome Trust and the Academy of Medical Sciences; the Minister said that the Academy of Medical Sciences was against the Willis amendment. In fact, the last time that we met the Academy of Medical Sciences—the noble Lord, Lord Turnberg, and I were on the same platform with it about a month ago—the academy made it clear that, while it did not want to have any detail in the Bill because that would compromise the detailed discussions, it was happy to see the architecture in the Bill. This is something which the Wellcome Trust supported; in fact, I was helped by both the trust and the Academy of Medical Sciences in drafting these amendments. The Association of Medical Research Charities, which I chair, was also incredibly helpful. There are, perhaps, some crossed wires here.
On Amendment 260C, I hear what the Minister says about bringing those two issues together, particularly for the R&D functions of NHS trusts. I said that there is a real issue about autonomous organisations. Why has the NIHR not actually done it? If this is the biggest obstacle to getting clinical trials developed quickly in the UK, why has it not already forged those relationships, and what confidence do we have that it will be able to do so over the next year or so?
This has been a good debate and I am incredibly grateful to noble Lords throughout the House for their support for these amendments. I still believe that the proposals in Amendment 258 could be in the Bill but given the Minister’s assurances and his willingness to debate these issues further, I beg leave to withdraw the amendment.
Lord Fowler
“Charges to overseas visitors
(1) The National Health Service (Charges to Overseas Visitors) Regulations 2011 (S.I. 2011/1556) is amended as follows.
(2) In regulation 6 (services exempted from charges) for paragraph (e) substitute—
“(e) the diagnostic test for evidence of infection with the Human Immunodeficiency Virus (HIV) and counselling associated with that test and its result;(ea) all other services for the treatment of HIV provided to an overseas visitor who has been present in the United Kingdom for a period of not less than six months preceding the time when services are provided;(eb) treatment for sexually transmitted infections other than HIV;”.”
Lord Fowler
My Lords, I will be brief. The amendment aims to remove an anomaly in the law which is both absurd and damaging. As the Select Committee on HIV and Aids said in its report, the priority with HIV should be prevention. For every case we prevent we save, in financial terms, about £300,000 in a lifetime’s treatment, as well as the human cost of that lifetime’s treatment. Antiretroviral drugs preserve life, and thank God for that, but they do not cure. The vast majority of National Health Service treatment for HIV is free, but the present law charges for treatment for a small group of people in this country, which has obvious and, frankly, baleful, effects.
First, if the charges result in no treatment, it is dangerous to the individual and endangers his own life. Secondly, it means that the man or woman affected is likely to spread the disease to others and add to the casualty list, although effective treatment reduces onward transmission by something like 96 per cent. Thirdly, such a charging law acts as an obvious deterrent to people coming forward for treatment and testing, which is the whole aim of policy, and negates it. Therefore, the effect of the present law is against all the policy aims of public health—a point very strongly put by the National AIDS Trust, to which I pay tribute.
Lord Davies of Stamford
This is a very difficult situation and I am very much in sympathy with the noble Lord’s amendment, but I wonder whether he would address the one reservation and concern on which I imagine I may not be alone: if we cease to charge for HIV treatment and diagnosis, as the noble Lord suggests, that could constitute an incentive for people to come to this country to exploit that possibility, given what he has already said about the expense and difficulty of receiving that treatment. Indeed, it could be an incentive for people to deliberately overstay their visa or become illegal immigrants to this country.
Lord Fowler
I will obviously deal with that issue, because it is crucial. If the noble Lord would be as patient as I have been in waiting for the opportunity of this debate, then all will be revealed to him.
It is probably the black African population who are most affected by the current policy, yet it is here that the Government’s policy of prevention has been most concentrated. We need to remember that late diagnosis of HIV, leading to the late start of treatment, is one of the major causes of serious ill health and early death. Yet, here we are, pursuing a policy that deters treatment and testing, from which the only logical result can be that late diagnosis. If you want a monetary argument, you have to add the additional costs of treatment for that individual plus the cost of those who may be further infected. On the face of it, it is not a prudent financial policy.
Why do we therefore pursue such an apparently reactionary and foolish policy? Here I come to the noble Lord’s point. Only one argument has ever been put forward. It is that if the rule were to be lifted there would be a danger of “health tourism”. This is an argument based entirely on assertion. As far as I can see, there is no evidence whatever for it. My Select Committee looked at this point, as the noble Lord will know because he has read the committee’s report on this matter. The same rule is not applied in Scotland, Wales or Northern Ireland—either as policy or in practice. Has there been an influx of those suffering with HIV to Edinburgh, Cardiff or Belfast? Of course not. My Select Committee could find absolutely no evidence in this respect. If there is such evidence, I invite the Minister to give it or any other evidence that she may have on health tourism, because, so far, it has never been put.
The crucial point against the law in England is that it is not enforced in any event. It is incapable of being enforced. The patients are usually destitute. A hospital gives the treatment. Then it pursues the charges. Then it finds out that the patient cannot pay and it writes off the whole amount. As one of our witnesses said, it is a constant circle of nonsense. That is the position that is being defended at present.
I have not yet heard any sensible defence of the present position. As a matter of principle, Parliament should not pass laws which cannot be enforced; and as a matter of practice, Parliament should not pass laws which add to the problems of public health and do not reduce them. If the Government are serious about their intent to put prevention first, this law should be repealed. I beg to move.
Baroness Gould of Potternewton
My Lords, I am very pleased to support the amendment. I was also very pleased to see that, in the response to the HIV Select Committee report, the Government are reviewing their current policy, which excludes some people from HIV treatment. The HIV Select Committee was absolutely right to say that it is wrong to charge anyone with HIV treatment and care.
For me, it is not only a question of health, it is a question of humanity. I find it incredible that this position survives. I have to say this with great regret, because I spent a long time trying to persuade my Government that something should be done about this, with little success. The argument was made very much in the way that my noble friend said about health tourism. I hope, although I am not clear from the words of the Minister in replying to the debate in December, whether that is still in their thinking. She said,
“we must avoid creating any incentive for people to come to the UK for the purpose of free HIV treatment”.—[Official Report, 1/12/11; col. 492.]
As my noble friend Lord Fowler said, there is no evidence to support the claims of HIV health tourism if the charging is ended. In 2008, the National Aids Trust produced a report on the myth of HIV tourism, demonstrating that such claims are wholly unfounded. Data from the Health Protection Agency show that the average time between a migrant arriving in the UK and an HIV diagnosis is almost five years. That is an awfully long time for someone coming on the basis of health tourism. For me, it is the absolute clincher as to why this is all such nonsense. Further, government reports have suggested that asylum seekers have no prior detailed knowledge of the UK's asylum policies, welfare benefits or entitlement to treatment. That would apply equally to HIV.
HIV charges, as the noble Lord, Lord Fowler, said, are not applied in Scotland, Wales or Northern Ireland. We would have seen some movement from London or anywhere in England to those nations if people wanted to access free treatment. If individuals do not move from London to Edinburgh to access free treatment, it is difficult to believe that they move from, say, Harare to London, for that reason. Another reason makes that claim somewhat ludicrous. A report published yesterday by the HPA shows that 5.9 per cent of TB patients are HIV-infected. TB treatment is free for those people; but the HIV treatment is charged. I do not know how one differentiates between those treatment costs, and, again, it just shows how stupid the position is.
In addition, since 2004, when the charges for HIV treatment were first implemented in England, there has been a 13-fold increase in access to anti-retroviral treatment in low and middle-income countries around the world, with sub-Saharan Africa seeing the greatest increase in the absolute numbers of people receiving treatment. ART coverage of all those who need it now stands at nearly 50 per cent in those regions and continues to increase. It is most unlikely that those able to purchase a flight to the UK will be unable to purchase ART in their own country. Having HIV does not in itself prevent removal from this country if a person is in breach of the Immigration Rules, as was established at the European Court of Human Rights in the case of N. Therefore, there is no reason for someone who knows they have HIV to migrate to the UK believing that their HIV-positive status will secure settled residence and ongoing access to treatment.
However, there is another criterion which, again, I had not appreciated until yesterday. A situation arises from the new Immigration Rules that have just come into force which further entrenches the way that HIV treatment charges deter African men and women in particular from finding out about their HIV status or going for treatment. Now, anyone with an unpaid NHS debt of over £1,000 will routinely have further immigration-related applications, whether to remain or for re-entry, refused. In the past, it was possible to encourage people coming forward for testing and treatment on the basis that it would have no impact on their immigration status. That is no longer possible as, if you are not entitled to free HIV treatment, your immigration status can be affected. As the noble Lord, Lord Fowler, said, these people are destitute and do not have the money. As a consequence of this change, they could now be removed from this country, which is something that never happened before.
There is also the whole question of costs. It seems to me that not removing charging continues to increase the cost to the NHS arising from HIV treatment charges. Ending charges for HIV treatment will actually save the NHS money by preventing new HIV infections and by identifying HIV early, when it can be effectively treated, so reducing the need for hospitalisation and other costly care when people with HIV become seriously ill. Reducing the level of undiagnosed HIV and increasing the proportion of people with HIV on effective ART will reduce the number of HIV transmissions occurring in the UK. I think that the noble Lord, Lord Fowler, said that preventing one onward transmission of HIV saves between £280,000 and £360,000 in treatment costs over a lifetime. People who are diagnosed late or who do not access treatment become seriously ill and will often require expensive in-patient care—a week’s stay costing between £15,000 and £25,000, and there may be many repeat visits to hospital. Surely it is cheaper to provide no deterrents to early testing and treatment.
It is sound common sense to remove this costly and inhumane restriction from the NHS (Charges to Overseas Visitors) Regulations. I hope that perhaps, not today but when the review is over, we will hear sound common sense from the Government.
The Lord Bishop of Newcastle
My Lords, I strongly support the amendment, and I shall be very brief. I believe that it is high time to put an end to the singling out of HIV as the only infectious disease which is subject to treatment charges. I believe that exempting HIV from charges is necessary to save lives, to protect public health and to safeguard NHS resources. Ensuring that everybody who needs treatment receives it is the key point. Charges deter people from accessing treatment and from testing for HIV. Why is it that HIV is the only serious communicable disease for which treatment is not provided free of charge? It is inconsistent and confusing, and undermines efforts to prevent further infection. Removing the charges will prevent many premature deaths in the United Kingdom, and will reduce long-term costs and transmission of HIV. This is why I hope the Minister will look very kindly on this amendment.
Lord Hunt of Kings Heath
My Lords, I congratulate the noble Lord, Lord Fowler, and my noble friend Lady Gould, on their perseverance. I think they have been waiting for about three days for this amendment. Clearly, they have pointed out the anomaly in the law and the perverse incentive under the current situation; in particular, the fact that if charges result in no treatment, there is danger to the individual and risk of spreading the disease, and that knowledge of charging prevents people from coming forward for testing and treatment. As my noble friend Lady Gould has just said, the contrast with other infectious diseases such as TB clearly points this out as an anomaly.
I too was interested in the answer to the question about health tourism. We have been given a pretty convincing response. The experience of Scotland, Wales and Northern Ireland is very clear. I also found very interesting the question of cost against benefit. It appears that very little money is raised by the charge, but that it is a disincentive for people to come forward. If they do not come forward, the cost to the system in the end is much greater. It seems to me a pretty convincing argument. I know there is a review, but we encourage the noble Baroness to anticipate that review and give good news to your Lordships tonight.
Baroness Northover
My Lords, I am very grateful to my noble friend Lord Fowler for the constructive way in which he has raised this amendment and I pay credit, as others have to done, to his continuing, enormous commitment to improving HIV services for all. I also pay tribute to other noble Lords who contributed to this debate and to this long battle over many years. I will commit to having considered by Report the arguments and proposals set out by my noble friend.
The Department of Health is indeed currently concluding an internal review of the current policy to charge some people for HIV treatment. We will be concluding this review by the new year, including any discussions with the other government departments which will have an interest. The review has considered many of the issues raised by noble Lords today. These include the increasing evidence of the public health benefits of early diagnosis and the role of HIV treatment in reducing onward transmission of HIV.
In the UK, around 25 per cent of people with HIV are unaware of their infection, which means they are unable to benefit from effective treatment and risk transmitting HIV to others. Promoting HIV testing to reduce undiagnosed HIV and late diagnosis remain important priorities for HIV prevention. We would be very concerned if our current policy were to deter people from testing for HIV, even though testing has always been free of charge to all. Those already entitled to free HIV treatment and care include asylum seekers and, from 1 August this year, failed asylum seekers receiving specific support packages from the UK Border Agency. Further, failed asylum seekers who are already receiving HIV treatment when their asylum application and any appeal fails continue to receive free HIV treatment up to the point that they leave the country, regardless of whether or not they receive the UK Border Agency support.
However, I acknowledge that a small number of vulnerable people will not be covered by the current exemptions and they may be deterred from accessing HIV testing services because they cannot afford treatment or are confused about the entitlement to free NHS treatment.
The world has made huge progress against the HIV epidemic in the 30 years since AIDS was first identified. Globally, new infections have fallen, and nearly 7 million people are on ARV treatment. While there is currently no significant evidence of health tourism in relation to HIV, in considering any changes to our current policy we must make sure we that we do not create an incentive for people to come to the UK for the purpose of free HIV treatment, without compromising our overriding responsibility for public health. I stress again that our overriding responsibility is to public health. As my noble friend Lord Fowler said, the Select Committee on HIV examined the issue of health tourism.
In conclusion, the department's review identified and considered many of the issues raised today. We are now looking urgently at how these can best be addressed. I assure my noble friend that we will provide a clear position in time for Report. I hope that in the light of this he will feel able to withdraw his amendment.
Lord Fowler
My Lords, I thank the Minister for that very sympathetic and understanding reply. We obviously understand that a review is taking place and take comfort from the fact that it will be complete by Report. She will have noticed that support has come from all parts of the House. I think that it would have come from the Liberal Democrats; I know that they share this view. Therefore, every party, including the Bishops' Bench—for which I am very grateful—is represented. Perhaps I may say that the House has left its visiting card on the issue. We look forward to Report and to the statement of policy that I am sure will come by then. Given the Minister’s assurance, I beg leave to withdraw the amendment.