17:24 - Division on Amendment 76 - Ayes: 185 / Noes: 282 - Amendment 76 disagreed.
Lord Hunt of Kings Heath
My Lords, this is an important debate. I want the noble Earl, Lord Howe, to make it absolutely clear in relation to Amendment 71 that the intervention of the Secretary of State will follow if the Secretary of State considers it to be in the interests of the health service when one of these bodies is failing to discharge a function properly. The wording of this amendment means, in effect, that if issues are raised in Parliament about NHS performance on which the Secretary of State, quite naturally and properly, wished to intervene, the Secretary of State can indeed do that. In the end, only the Secretary of State can, in those circumstances, consider what is in the interests of the health service. It is absolutely right and proper for the Secretary of State to be in that position.
The second set of amendments starts with Amendment 294. The noble Baroness, Lady Murphy, is absolutely right to point out the problem of conflict between the CQC and Monitor, which is almost built in intentionally. The second report of the Francis inquiry into the Mid-Staffordshire trust may have some points to make about that. However, we are also adding to the architecture of the national Commissioning Board, and there is inevitably going to be tension between those three bodies. For instance, the national Commissioning Board and Monitor are to be given roles relating to the tariff, and it is clear that there is confusion over the roles in respect of quality issues. Monitor is now involved in making some inquiries of foundation trusts relating to quality, which is no doubt a defensive reaction to the criticism that will flow from the Francis inquiry. The national Commissioning Board is so powerful in the new structure that there are bound to be some issues about its relationship with the quality and economic regulators. We would like to hear from the noble Earl, Lord Howe, that the Secretary of State will not hesitate to intervene and knock heads together if the natural—and probably useful—tension goes beyond that and becomes a problem.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, this group consists of amendments to the Secretary of State and the Commissioning Board’s powers of intervention over health bodies and to the Secretary of State’s powers in the case of breaches of duty to co-operate. First, I should like to discuss the amendments relating to the powers of intervention. In doing so, I thank my noble friend Lord Marks for tabling the amendments and presenting them to the House so ably. He committed a great deal of time and effort to developing these amendments and I believe that they will make this a better Bill.
As noble Lords will be aware, the amendments sit within the package of amendments relating to ministerial accountability that was agreed through a process of cross-party negotiation and consensus-building. They address concerns from several Peers that, in the words of my noble friend Lord Marks,
“the bar may be set too high against the Secretary of State’s intervention”.—[Official Report, 11/10/11; col. 1572.]
I hope they provide reassurance to the House that this will not be the case. I support the amendments and hope that other noble Lords will follow me in doing so.
In answer to the noble Lord, Lord Hunt, my noble friend’s amendments clarify that the Secretary of State can intervene where he considers that a national body is failing to discharge its functions consistently with what he considers to be the interests of the health service, provided that he considers that the failure is significant. They also clarify the same point for the Commissioning Board’s intervention powers over CCGs and, in addition, where a national body may have functions beyond the remit of the health service, these amendments clarify that the Secretary of State can intervene where the body significantly fails to exercise the function consistently with the purpose for which it was conferred. I hope that that explains fully the point of the amendments and answers the noble Lord’s question.
Lord Hunt of Kings Heath
I thought that there was a question to the Minister as to whether he would consider the matter between now and Third Reading. Am I not right?
Lord Hunt of Kings Heath
Does that mean that the matter can be brought back at Third Reading? I think that is the point here.
Earl Howe
My Lords, if there is a common theme to these amendments, I suggest it might be the fear of falling through the cracks, and I hope I can demonstrate that there are no cracks to fall through. However, there is a lot to cover and I apologise in advance if I speak for longer than normal.
First, perhaps I may say how wholeheartedly I agree with my noble friend Lady Williams as to the crucial role that CCGs will play in meeting the health needs of their entire population. In preparation for today’s debate I reacquainted myself with the requirements in the Bill to ensure that this happens. The requirements are robust and I can confirm that CCGs must exercise their responsibilities so that services are commissioned to meet the reasonable requirements of all their patients. My noble friend Lady Williams can be absolutely assured that every person registered with a GP practice or usually resident in England—that is the term—will be the responsibility of a CCG and the board must ensure that the whole of England is covered. This means that Amendments 75 and 94 are unnecessary.
I was asked by my noble friend Lord Newton about charges for patients. Noble Lords need to understand that as regards issues of entitlement to access to the NHS, the Bill does not change the status quo. I listened with care to my noble friend Lady Tyler, and I would like to thank her for spotting the inconsistencies in the Commissioning Board and CCG duties. As she quite rightly says, the inequality duties, if the government amendments on the annual reports are agreed, would be in the unusual position of being specifically referred to in the annual report provisions but with no similar reference in the provisions on the annual plans of CCG performance assessments. I therefore undertake to bring forward amendments at Third Reading to rectify that.
Amendments 95, 108 and 111, which are similar in effect, would require CCGs to have regard to the advice of local healthwatch and HealthWatch England, or in the case of Amendment 111 would require local healthwatch’s involvement in developing or revising commissioning plans. HealthWatch England will not advise CCGs directly. Instead its advice will inform the board’s commissioning guidance for CCGs. Certainly at the local level, we would expect CCGs to be taking account of local healthwatch; and, to reassure my noble friend, under Clause 182 CCGs already have to have regard to the views made known by local healthwatch when exercising functions relating to healthcare services. As my noble friend said, local healthwatch will also have a key role to play via the health and wellbeing board in assessing local population need—preparing the joint strategy and influencing the commissioning plans of CCGs. Taken together, this represents a robust set of arrangements for the views of patients and the public to feed into local commissioning.
The noble Lord, Lord Hunt, painted a doomsday-like picture of what he sees as the consequences of the arrangements that we have set out in respect of CCG governance. The noble Lord suggests that by not having the more traditional arrangements, as per his amendments, the CCGs will be more likely to run into financial distress, not properly meet their statutory duties, commit fraud or even commission unsafe care. Simply put, I cannot agree with that gloomy outlook, because it overlooks completely the arrangements that are already in place and what would happen if a CCG was to face the risk of running into any of these difficulties.
Let us take financial management, which he focused on. A CCG must have an accountable officer who is responsible for ensuring that the CCG meets all its financial obligations. The appointment must be agreed with the NHS Commissioning Board. A CCG must keep and publish proper accounts, which must be audited in accordance with the Audit Commission Act 1998 and must be sent to the NHS Commissioning Board by a date specified by the board. If the board requests specific information relating to a CCG’s accounts, or to its income, expenditure or use of resources, the CCG must provide it. Each CCG must have a constitution that sets out the CCG’s arrangements for decision-making. Each CCG must have a governing body, which must meet in public, except when it feels that it is a confidential matter and so not in the public interest.
The governing body must have an audit committee chaired by a lay person who must have the skills, knowledge and experience to assess and confirm that the CCG has appropriate arrangements for all aspects of governance, including financial and risk management. The governing body must ensure that the CCG adheres to such generally accepted principles of good governance as the Nolan principles, which are foremost among these—indeed, the Commissioning Board Authority has been clear that it expects CCGs to adhere to them. Furthermore, if the CCG is at risk of failing, is failing or has failed to exercise its functions, including those in relation to financial management, the board can intervene with a range of powers, from directing remedial action to be taken, removing the accountable officer, to dissolution—although we would expect that to be very much a last resort.
I absolutely agree with the noble Lord that it is essential for CCGs to have strong governance—there is no difference between us on that. This is a topic on which we listened to the Future Forum and made a number of significant amendments last year. We remain open to suggestions that would improve the Bill in this regard, I hasten to say, but I cannot agree that the noble Lord has suggested the right mechanism to achieve that end. To agree to either of his Amendments 76 or 77 would not only fail to meet his stated objective of improving a CCG’s governance but would risk introducing additional bureaucracy and confusion with the wide range of existing ways that CCGs are held to a high standard of good governance.
Given the role of the board in scrutinising arrangements and ensuring that governing bodies are effective, I do not accept the need for an additional centralised process of independent appointments to governing bodies, as proposed by Amendment 76, or for asking both Houses of Parliament to approve each CCG constitution. It cannot be reasonable or proportionate to require both Houses of Parliament to scrutinise the constitutions of several hundred local bodies. The board can publish guidance on the form and content of constitutions, and take a view of local circumstances, which Parliament, with the greatest respect, could not do.
Amendment 77 would require a majority of non-GPs on the governing body. This overlooks some important points about CCGs: that they are rooted in general practice and build on the central relationship between GPs and patients. It is GPs who look at patients’ needs in the round, making sure that they have access to the services that will best meet their needs and keep them healthy. Our rationale for having governing bodies with non-GP membership was not to put GPs in the minority but to make sure that there are other voices and perspectives alongside those of GPs so that decisions are made in an open, accountable and transparent way. The NHS Future Forum supported that vision. Requiring non-GP members to outnumber the GP membership on a CCG’s governing body would not make that governing body any more effective in ensuring adherence to principles of good governance, or in ensuring that the CCG was effective, efficient and economical. As we discussed on Monday, there is extensive provision for managing conflicts of interest.
On the quality payment, the debate today, as in Committee, centred on two questions: what the quality premium should reward and what the premium should be spent on. The payment would incentivise and reward improvements in quality and outcomes and reductions in health inequalities. It is not there to encourage a focus on financial management, and it is not—to answer a question posed by the noble Lord, Lord Hunt, in Committee—a way to reward demand management.
Our intention is that the quality premium will reward performance against the commissioning outcomes framework. The starting point would be the five domains of the overall outcomes framework and could contain measures such as reductions in mortality rates for cardiovascular disease, cancer survival rates, the management of diabetes, stroke and mental health and reductions in the number of cases of healthcare-associated infections. Those are only a few examples. If CCGs commission services in such a way that they achieve excellent outcomes in areas such as those, it is only right that the NHS Commissioning Board should be able to reward them for doing so.
The noble Lord, Lord Patel, has put across a persuasive case that the payment should be restricted to being spent on improving services. I have given that proposal significant thought but on this occasion I am unable to agree with the noble Lord’s amendment. We all want to see quality and outcomes improving and inequalities falling, and we are aware of the scale of the challenge. I want the quality premium to be as an effective incentive as it can be in order to best drive those improvements.
Indeed, I was pleased to see last week that this view was shared by Age UK and the National Osteoporosis Society in their report on falls and fracture services, which called for a greater role for financial incentives in the commissioning and provision of services. The report said that,
“the introduction of a Quality Premium payment for commissioners in return for improving health and wellbeing outcomes among patients could reduce falls and fracture rates”.
That is a very good example.
There are any number of ways in which a CCG may wish to use such payments. It might wish to spend the money on a new service for patients; to reward provider organisations that have played a major part in helping achieve the improvements; and, yes, it might wish to reward GP practices that are members of the CCG if they have played an instrumental part in improving quality of services and outcomes—for instance, through their work on service redesign. It would be wrong in principle to rule out any one of those options in the Bill.
However, I hope to reassure the noble Lord on his central concern. I agree that great care needs to be taken in designing the mechanics of the payment. We will use secondary legislation to make detailed provisions as to how CCGs can use these payments, including the circumstances in which they may be able to distribute the whole or part of a payment to individual member practices. That is very important and provides flexibility to adapt any rules or principles governing payments in the light of experience.
We have started discussing the potential contents of these regulations with stakeholders and I can confirm that we will extend these discussions to include a broad spectrum of views, including the NHS, patient groups and professional bodies. I hope I have reassured noble Lords sufficiently to enable them to not press their amendments.
Amendment 96 relates to an area with myriad terms that have a slightly different meaning, and I shall set out the crucial differences. Very rare conditions, which often require highly specialised services, will be commissioned by the NHS Commissioning Board. Rare or less common conditions will by and large be commissioned by CCGs, but they will be supported in doing so by the board, clinical senates, networks and the ability of CCGs to work together to pool skills and expertise.
Baroness Finlay of Llandaff
Can the noble Lord clarify whether the guidance will also cover the commissioning of services that are currently going to fall within the responsibility of a local authority, at the interface between health and social care, for the long-term maintenance of patients with very severe disability?
I accept the Minister’s comments on this amendment and the onus on clinical commissioning groups, and those made by my noble friend Lady Murphy, that the commissioning board may be the central focal point, as was outlined in the amendment that was not accepted, Amendment 63A. However, my second question is whether the Minister would be prepared to meet me to see whether there is a need for a review of the wording to clarify completely that there are no gaps for these patients, who may be large in number but very disparate and heterogeneous, with a very broad range of views. In that event, perhaps we could return to the matter at the last point, at Third Reading.
There are two distinct questions there on which I would appreciate clarification.
Earl Howe
On the first question from the noble Baroness, we fully anticipate that NICE will provide quality standards and guidance on services commissioned by CCGs and local authorities jointly. Typically, those are the kinds of service that the noble Baroness has spoken of, some of them in relation to less common and more complex conditions. Therefore, the commissioning guidance would reflect the NICE advice, and I hope that I can reassure her on that point.
Of course, I am willing to meet the noble Baroness between now and Third Reading, although I am not necessarily giving her the green light to bring this amendment back at Third Reading. I have explained that the Bill adequately covers the points of concern. Furthermore, I think that the amendment is flawed. We can achieve what she seeks through provisions already in the Bill and those that are not in the Bill that I have described.
Baroness Williams of Crosby
In moving the amendment, I asked the Minister for an unqualified assurance that all people resident in England would be covered by a clinical commissioning group, and I have to say that I think he gave me that assurance. However, I simply ask that between now and Third Reading, if any Member of this House comes forward with evidence of the exclusion from clinical commissioning groups of anyone resident in England, the Minister will give that careful consideration. I am sure he will. He has won the trust of this House and I take the assurance on the basis of that trust, but if there is a dispute over whether there is any exclusion I hope he will permit me to suggest that his door might be as ever open if any Member of this House wants reassurance on the basis of evidence brought before him. I beg leave to withdraw the amendment.
“Seal and evidence(1) The application of a clinical commissioning group’s seal must be authenticated by the signature of any person who has been authorised (generally or specially) for that purpose.
(2) Any instrument which, if executed by an individual, would not need to be under seal may be executed on behalf of a clinical commissioning group by any person who has been authorised (generally or specially) for that purpose.
(3) A document purporting to be duly executed under a clinical commissioning group’s seal or to be signed on its behalf must be received in evidence and, unless the contrary is proven, taken to be so executed or signed.”
(a) the prevention or diagnosis of illness in the patients, or(b) their care or treatment.”
Baroness Thornton
My Lords, I intend to make only two remarks. We have a great deal to get through tonight, so I shall exercise great self-discipline. I think that I will come in at under a minute and a half.
The noble Earl needs to be commended for his determination and hard work in this area. We think that it is an important issue. This is a growing problem and the noble Earl makes very reasonable requests, for which he has widespread support. I agree with the noble Baroness, Lady Masham, in that I fear this problem may get worse before it gets better, but I hope that the Minister will have good news for us about it.
Earl Howe
My Lords, we return to an issue of enormous significance for the individuals and families affected. I refer of course to those suffering from addiction, or withdrawal from addiction, to certain prescribed drugs. I am grateful to the noble Earl, Lord Sandwich, for his amendment, which would put in primary legislation a requirement for clinical commissioning groups to provide a specific service and, in so doing, to co-operate with and take account of the good practice of specialised agencies.
I think that the desire for good practice and for improving practice is common ground between us. The noble Earl will know that local areas are currently responsible for the design and provision of treatment and support services. We think that that is right. Having said that, it is clear that we need to do all we can to prevent dependence occurring in the first place. I am fully with him on that. For those who do develop dependence, it is important that they have access to the services they need to help them to recover, rebuild their lives and contribute productively to society. By placing the funding and responsibility for commissioning services to support people to recover from dependence with the local authorities, the Bill will provide local areas with opportunities to improve integration of commissioning and provide more effective joined-up services to meet local needs.
The Earl of Sandwich
My Lords, as the noble Baroness, Lady Thornton, implied, we are moving to the fast-track of this Bill, and I do not want to hang around for too long. I thank my noble friend Lady Masham for bringing to our attention the issue of early death, and my noble friend Lord Williamson, who has a lot of experience, for his support. My noble friend Lady Finlay made the important point that the responsibility falls within primary care, and I am encouraged by what she said about guidance. However, the Minister did not even pick that up. One might have thought that he could have just said, “Yes, we are going to do something in the guidance”, but I do not know whether he actually heard the point.
Earl Howe
I am happy to pick that up, because it was a point that arose in connection with an intervention from the noble Baroness, Lady Finlay, in the previous group of amendments. Of course, we will be relying on the NHS Commissioning Board to issue guidance in a number of clinical areas. Again, when the noble Earl and I meet, I will update him to the extent that I am able to on the thinking in that regard. The point of such guidance—which will relate to numerous areas of care and services—is that it should inform joined-up commissioning in local services, so that we really do get a step change in the quality of commissioning in local areas.
The Earl of Sandwich
It is quite true that the CCGs are going to be overwhelmed with guidance from all directions, but I maintain that this is an important aspect.
I thank my noble friend Lady Hollins for the very important point that she made. I did not even talk about prescribing today but I hope to come back and talk about it later—the whole question of training and what young doctors are being told. “Rational prescribing” is a phrase that I will now be able to repeat.
I know that the Minister accepts the arguments, and of course there are many things that we have in common—good practice and the use of the voluntary sector. I take the point about the duty that falls on local authorities, but I still maintain that we have to separate this out from the mainstream of drug addiction and alcohol treatment. It is the kind of treatment that only the very careful, experienced volunteers can describe. I do not think that I can begin to describe the actual treatment. However, the NHS will soon get to grips with what is happening. I welcome the chance of having a meeting. I will of course come to talk, and I hear that there is to be a range of experts. I feel that the Minister has given a little bit of a Civil Service answer, because there are only but one or two people who follow this subject in the department. I do not mind talking only to two people—it will be a very good opportunity to take this further. Meanwhile, I beg leave perhaps to consider this again at a later stage of the Bill, and to withdraw the amendment.
“section 14XA,”
Baroness Northover
Baroness Northover
My Lords, in Committee we had a number of excellent debates about the role of local authorities in public health. A number of noble Lords raised concerns, and I hope that this debate will show that the Government listened very carefully. As a result, we propose to make a number of important changes.
I will begin with Amendments 120, 127 and 129, which are minor and technical amendments to Clauses 29, 30 and 31. These contain lists of local authority functions, including references to,
“functions by virtue of section 6C of the NHS Act 2006”.
The amendments change the reference to functions by virtue of Section 6C(1) and 6C(3). The reference to Section 6C(2) is unnecessary as it provides a power to impose requirements for how local authorities should exercise their functions, rather than a power to confer those functions. I look forward to an interesting debate on the other, more fundamental amendments in the group. I beg to move.
Lord Patel
My Lords, I will speak to Amendments 121, 122, 123, 125 and 126 in my name. I will also comment on the Government’s Amendment 124.
Amendment 121 covers the appointment of a public health specialist. It states:
“The individual so appointed must be a registered public health specialist who has a broad range of professional expertise in public health”.
When we debated this in Committee I made it clear that doctors—public health specialists who are trained in medicine—not only do medical training at undergraduate level but do several more years of training in public health before they are given a certificate of completion of training that allows them to be registered on a GMC register of public health specialists. The situation is similar for public health dentists; they go through similar training.
The problem is that non-medical public health specialists—of whom there are many—do not go through any specific training. Registration is voluntary. We will come to registration issues at a later date. The amendment states that those appointed must be registered public health specialists with a broad range of professional expertise in public health, which they must demonstrate at the time of appointment. I hope that the noble Baroness, Lady Northover, will comment on that.
The noble Baroness was absolutely right to say in her opening speech that the Government had listened. I am grateful to both the noble Earl and the noble Baroness for the time they took to meet me, and to meet representatives of the Faculty of Public Health. I declare an interest as an honorary fellow of that faculty. As a result, the Government have brought forward amendments and produced a document, which I will refer to at a later stage, that is very helpful in identifying the role of public health doctors in a local authority.
Amendment 125 is linked to this issue. It concerns the appointment of directors of public health. It states:
“Any registered public health specialist or other person who is employed in the exercise of public health functions by a local authority or is an executive agency of the Department of Health shall be employed on terms and conditions of service no less favourable than those of persons in equivalent employment in the National Health Service”.
If we are to appoint directors and consultants of public health in local authorities and attract high-calibre individuals, we will have to make sure that they are not disadvantaged by taking a job in a local authority. The amendment merely alludes to that. Currently all specialists in the NHS, be they physicians, surgeons, obstetricians, paediatricians or other specialists, are appointed by an advisory appointments committee. The constitution of that committee is statutorily determined. The committee includes a representative from the appropriate college faculty. In this case it would be the Faculty of Public Health.
Lord Beecham
My Lords, two shows in the West End have taken the theatre-loving population of London by storm in the past year. One of them was “Noises Off”, a farce that might be thought of as an apt metaphor for some of the relations on the government Benches; the other was “One Man, Two Guvnors”, which is perhaps relevant to the position of directors of public health. I am very glad, therefore, that the amendments proposed by the noble Lord, Lord Patel, and some of those which the noble Baroness will propose, reinforce the position and status of directors of public health. It is crucial that they are independent and are employed on conditions that are comparable to those of fellow clinicians in other parts of the health service. Therefore, the Opposition support the amendments of the noble Lord, Lord Patel, particularly in relation to Clause 30 and disease control.
I perhaps have reservations about the requirement for the Secretary of State to consent to the dismissal of a director; it is right that it should be in the form of consultation. It would be a foolhardy authority that ignored the strong views expressed by the Secretary of State. Given the relationship between central and local government, it is right that it should be a question of consultation rather than consent.
I endorse the views of the noble Lord, Lord Turnberg, about the relationship with Public Health England, which is another example of that dual relationship which directors must have. I equally endorse the observations of the noble Lord, Lord Brooke, who seeks to ensure that the responsibilities cover the entire population, resident or working, of the appropriate area.
The Government have moved significantly on some of their amendments. We are on the right track. I hope that they will look sympathetically at the amendments of the noble Lord, Lord Patel, and strengthen further that crucially independent role of the director, who should certainly be a chief officer of an authority and be accountable to the chief executive. It is an important safeguard, which I commend to the Government.
Baroness Murphy
I strongly support the stance that the noble Lord, Lord Beecham, has taken on the amendments of the noble Lord, Lord Patel, but I was expecting him to speak to Amendment 163A. I am very disappointed that he has not because it is such a brilliant idea and I was hoping that the Government might listen to it.
Baroness Northover
My Lords, I thank the noble Lord, Lord Patel, and other noble Lords for their contributions. No doubt I shall do so again in a minute.
Lord Wolfson of Sunningdale
My Lords, the noble Lord, Lord Beecham, said that the wording used in Amendment 125 was that rewards and salaries should be “comparable”. In fact the actual wording is “no less favourable”. The two are entirely different: which wording is being proposed?
Lord Beecham
I shall go along with the amendment. I do not see a distinction of the kind to which the noble Lord refers.
Baroness Northover
I once again thank the noble Lord, Lord Patel, and other noble Lords for their extremely constructive engagement in this important area. I further thank the noble Lord, Lord Patel, for expressing his gratitude to the Government for the changes that have been brought forward.
Noble Lords have welcomed the moving of public health to a more centre stage. The Government have listened hard and have worked to address a number of the issues that have been raised about how this would work. We have brought forward a number of proposals, and I hope that noble Lords will be reassured that the objectives they seek can be achieved by these means.
We agree completely with the noble Lord, Lord Patel, about the need for high-quality, appropriately qualified public health staff, and it remains the case that appointments of directors of public health must be made jointly with the Secretary of State, who will be able to veto unsuitable candidates. To build on that, the Chief Medical Officer and the Local Government Association have written to local authorities on this issue and given advice covering the run-up to April 2013. This advice makes clear that external professional involvement in the recruitment process is the best way of assuring the necessary professional skills and that it should remain a central component of senior public health appointments.
My noble friend Lady Jolly raised questions about guidance, and she and other noble Lords may find the recent letter from the Department of Health and the Local Government Association reassuring. If they read through that letter they will see that on appointing to vacant posts it states:
“External professional assessment and advice provided by the Faculty of Public Health is a central component of senior public health appointments”.
It further states:
“The Faculty of Public Health provides essential advice on the draft job description, draft advert and person specification and we recommend you”—
local authorities—
“contact them at an early stage to benefit from this”.
There are a number of other points in the letter which I hope noble Lords will find reassuring.
Amendment 124 states that a local authority must have regard to any guidance given by the Secretary of State in relation to its director of public health, including guidance on appointment, termination of appointment and terms and conditions of management. The Local Government Association agrees that there should be a direct line of accountability between a director of public health and the chief executive. This issue was of extreme importance to noble Lords, who flagged it up in Committee, and we are taking it forward. It was also mentioned that the director should have access to elected members. We intend to produce guidance that reflects that, and it has already been spelt out in the letter to which I have referred.
In response to the concerns raised here, the Government have announced their intention to require non-medical public health specialists to be subject to regulation by the Health Professions Council. We will discuss the implementation timetable with interested parties and expect that the necessary changes will be made under the powers in Section 60 of the Health Act 1999.
During the helpful debates in Committee on the role of the director of public health we discussed how to ensure that directors have appropriately senior status. This is a vital new role—it provides local leadership on health improvement and protection as well as advising the local NHS on public health—and, in reaction to concerns raised, we have brought forward Amendment 152 to add directors of public health to the list of statutory chief officers in the Local Government and Housing Act 1989. This, combined with statutory guidance, aligns them with other chief officers, including directors of adult social services and children services. We hope that that reassures noble Lords and is what they were seeking. Furthermore, Amendment 128 is intended to give the Secretary of State the power to issue guidance on other local authority public health staff. I hope that that will further reassure my noble friend Lady Cumberlege.
The issue of appointment panels was raised and I can confirm that Public Health England, on behalf of the Secretary of State, will be represented on all appointment panels. Further guidance will be issued on the matter but, again, if noble Lords look at the letter to which I have referred I trust they will find it reassuring.
The noble Lord, Lord Patel, and others raised the issue of the requirements for dismissing a director of public health, and I welcome what the noble Lord, Lord Beecham, said about the need for the right balance of responsibilities. Directors will, of course, have the protection of employment law, and local authorities must consult the Secretary of State before dismissal. This will encourage them to ensure that their case is solid and to deter impulsive action. The Secretary of State will now also be able to issue guidance, to which local authorities must have regard, on how the dismissal process works.
Ultimately, of course, it cannot be in anyone’s interest for the local authority to be required to continue employing an individual if it believes that it has good grounds for dismissal. The Secretary of State can express his views clearly and robustly, but it is the authority that has the employment relationship with the director and that therefore must make the final decision. However, having regard to what the Secretary of State has to say is obviously an extremely important safeguard. The local authority will need to have very strong evidence to demonstrate why they wish to dismiss a director if they are to carry through their duty properly.
I was asked an important point about an external person on the appointments panel and I have referred to the involvement of the Faculty of Public Health generally. We are actively pursuing the idea of an external person and obviously we will be extremely happy to continue to work with the faculty over this and other issues.
The noble Lord, Lord Patel, and other noble Lords raised the issue of emergency planning and whether there would be an improvement on what exists now. Certainly, in our view, the new arrangements will be a significant improvement on the current ones. For example, in a new pandemic, joint plans will be in place between Public Health England and the NHS Commissioning Board for the important testing and data-gathering that is essential to understand the nature of a new disease in the early stages. The noble Baroness, Lady Finlay, is absolutely right that lines of communication need to be extremely clear and that working out exactly how this is to be done is extremely important. The department is well aware of that and the matter is being taken forward.
The NHS, Public Health England and local authorities will have joint plans in place to establish anti-viral collection points, for example, if needed. Public Health England, as an executive agency, will be able to provide scientific and technical advice and the NHS will have clearly understood mobilisation plans to respond to additional pressures on hospitals and primary care services. Throughout an emergency, the Chief Medical Officer, with Public Health England, will provide the Secretary of State with consolidated scientific advice to inform response and resolution. I trust noble Lords will be reassured by that.
Lord Patel
I am not actually that reassured. The point I was trying to make is that the current arrangements, as specified in the document so far, are flawed. They do not identify a lead person with the local authority who will respond to Public Health England’s advice and who also has plans in place not just for a pandemic or national emergency but for a local emergency. I gave two examples. The main problem is the lack of a lead person in charge locally. It might not be solved today but I hope the noble Baroness accepts that there is an issue here.
Baroness Northover
The director of public health has responsibility for what happens locally. One of the important issues here is the nature of the epidemic. The response to deal with that will be determined at the appropriate level—that is the key element in this. However, if the noble Lord and the Faculty of Public Health would like to engage further in discussions on this, I am extremely happy to offer that, knowing full well that my noble friend the Minister always has his door open. We look forward to further discussions to make sure that, where we feel it is working well but noble Lords need reassurance, we can address their concerns.
The noble Lord, Lord Walton, brought me back to my history of medicine when he spoke about the history of public health. He emphasised the importance of training and the noble Lord, Lord Turnberg, emphasised education, training and research. I assure noble Lords that all training contracts will be honoured. We are exploring at the moment how public health trainee contracts will be managed in future and are engaging with those who are concerned in these areas. We will set up a stakeholder group of professional bodies, Department of Health policy groups, deaneries, employers and trade unions to develop a framework for supporting public health trainees. I trust that will reassure noble Lords.
I completely agree with the noble Lord that the question of whether directors of public health will hold honorary NHS consultant status is very important and one that we are well aware of. We will shortly publish for consultation a public health workforce strategy to inform decisions on matters such as this.
The noble Lord, Lord Turnberg, asked how directors of public health and Public Health England would work together. Public Health England will have local units to encourage collaboration that will be partners in local planning for public health and will help to join up the system. Public Health England will directly support the public health directors with evidence, guidance and best practice.
I have addressed the senior status of public health directors and the manner of appointments, potential dismissals and emergencies. The noble Lord, Lord Beecham, includes the health premium in his amendment. I realise that he wanted to be extremely brief, so I will be extremely brief in reply and emphasise to him that we intend this premium to support the narrowing of health inequalities. I know—or at least assume—that his amendment is to probe and to find out how we view this. There will be a number of indicators to try to narrow those health inequalities.
We do not want to see anyone disadvantaged by our proposals for conditions of service, and employment law will apply to staff who transfer. Last November, in partnership with employers and unions, we published best practice guidance for staff transfers, followed by further guidance agreed with the Local Government Association. Shortly, we will publish a wider workforce strategy for consultation.
“( ) A local authority must have regard to any guidance given by the Secretary of State in relation to its director of public health, including guidance as to appointment and termination of appointment, terms and conditions and management.”
Baroness Northover
I thank noble Lords for that extremely brief and consensual approach to this issue. We debated this in detail in Committee, and I commend all noble Lords for their work in this area.
We certainly agree that the rates of tooth decay in children and adults is an important public health measure. I point noble Lords to the public health outcomes framework, which my noble friend Lord Colwyn might like to have a look at, which is a document to which local authorities will have to have regard.
The noble Lord, Lord Hunt, asked whether, in terms of the public health funding allocation to local authorities, if a local authority has a fluoridation scheme, whether it will be covered within the budget. I can assure him, as I did in the meeting that we had earlier, that indeed it will be covered in the budget, which will look at the public health needs of the area—and that will be reflected in the grant. Those are the current schemes. The noble Lord asked about future schemes. Public health funding is ring-fenced, and the Government look at the needs of the area. However, local authorities will be deciding how they prioritise various issues, so it would not be appropriate for us to say that they must address this issue through a fluoridation scheme. They might be looking at all sorts of other public health issues and seeking to address their responsibilities in terms of dental health in some other way. However, I point out something that I did not know before—and I do not think that the noble Lord knew before—which is that just about all fluoridation schemes currently in place have been initiated by local authorities over their history.
I recognise the commitment of noble Lords to dental health. I appreciate it and realise that noble Lords want to speed it along. I hope that reassurances about the level of funding for current schemes will reassure the noble Lord, Lord Hunt, so that he feels able to withdraw his amendment. We continue to be very keen to engage in this area.
Lord Hunt of Kings Heath
My Lords, I should have declared in moving my amendment that I am president of the British Fluoridation Society. The noble Baroness, Lady Gardner, reminded me by making her own declaration. I am most grateful to the Minister and beg leave to withdraw my amendment.
“( ) The duty in subsection (3) does not apply in relation to the proposal if the Secretary of State so directs by an instrument in writing.”
Baroness Tyler of Enfield
My Lords, I support this important amendment. The whole basis of the Health and Social Care Bill is to place great emphasis on delivering integrated care as part of the needed reforms, and I am sure that we all support that. As the noble Lord, Lord Adebowale, has just said, though, Clause 36 in its current form will remove one of the few examples of genuinely joined-up service provision between local health and social services. A joint duty on aftercare services for these people, some of the most vulnerable in society, is crucial if they are not to have further lapses and become more and more marginalised. We talked earlier about people falling between the cracks, and that is the danger that we are in.
Baroness Northover
My Lords, I realise that noble Lords want to move on to other debates, so it might be opportune if I intervene now. We have always expressed sympathy for what the noble Lord intended in his original amendment. We listened carefully to the points put by the noble Lords when they came to see us, even if it seemed that we were not very responsive to what they were saying. We note the considerable emphasis that they place on retaining the duty of co-operation with the voluntary sector that is set out in Section 117. We realise that the clause removes the duty that is currently there, and that is clearly causing concern.
We do not feel that there is anything in the clauses that will bring in charging for any NHS or social care services that are currently provided free under Section 117, and the Government have no plans to bring in measures that would change the position on charging for Section 117 services. However, sometimes tidying up causes concerns. We are all used to dealing with the section as it currently stands and could continue to do so. We are nothing if not a listening team. The Government have therefore decided, and I hope that the noble Lord, Lord Patel, will be pleased, that we will not oppose his amendment. In the light of this, if your Lordships’ House agrees and wishes to accept his amendment, the Government will need to bring forward a few technical amendments at Third Reading to make a few consequential changes to the Bill to ensure that the amendment works properly in the amended 1983 Act. I hope that the noble Lord will be pleased that indeed we heard what he and his noble friend were saying.
“( ) Subsection (1) does not apply to any function of the Secretary of State of making an order or regulations.”