Health and Social Care Bill

Baroness Gould of Potternewton Excerpts

Tuesday 11th October 2011 Lords Chamber

[Baroness Gould of Potternewton]

My Lords, I, too, want to raise the question of public health, but I want to talk much more about the structures and whether it is possible, with the structures that we have, to meet the Government’s commitment to focus on public health. I hope these are not just fine words and that there is a real commitment to public health. I agreed with the Minister when he said this morning that public health had received little coverage to date. For me, it is absolutely key. To quote a senior physician: “Healthcare is vital to all of us some of the time, but public health is vital to us all of the time”. That is something that we should bear in mind constantly.

I support the decision that public health should return to its origins in local government for many of the reasons that other noble Lords have indicated. The local authority is best placed to influence the factors that have the biggest impact on a person’s health. I genuinely want the new structure to succeed, which is why I want to raise some of my concerns about the present position. I am concerned about the fragmentation of the services, for instance the proposed split of sexual health services when integration is essential. That applies to many other services, too. I am concerned about the lack of clarity in lines of accountability and access between Public Health England, commissioning groups, the NHS, the health and well-being boards and the directors of public health. I am concerned about the lack of a definition of what constitutes public health, how it will relate to all the other key functions of local government and, not least, the inadequacy of the designated funding. It might be ring-fenced but, without a definition of what it covers, ring-fencing is meaningless. We have the concepts but not the detail, and it is the detail that we should look for in Committee.

Public Health England, an executive agency within the Department of Health and under the direct control of the Secretary of State, will oversee the operation of the public health system and manage national issues such as flu pandemics, as well as incorporating the Health Protection Agency and the National Treatment Agency for Substance Misuse. That for me raises a serious question about the independence of the staff of those two bodies, for without independence it seems impossible that they are going to be able to carry out their job in surveillance and monitoring. We really have to look seriously at whether that is the right position.

Crucial to public health are the directors of public health. They are appointed by the local authority, but in contrast to the protection afforded to other key local authority staff they have no significant protection of tenure. A local authority may terminate the appointment of the director of public health only after consultation with the Secretary of State. I would like to know what the role of the Secretary of State is. Can he overturn the decision of the local authority?

Also diminishing the role of the DPH is the lack of provisions guaranteeing the necessary resources, staffing and status to allow him or her to carry out their important responsibilities. To be effective, they have to be senior officers who, I believe, report directly to the chief executive of the council. The Government reject the argument that DPHs and other public health officials have to be registered with an appropriate statutory body, ignoring expert advice such as that from the Royal College of Physicians, which says:

“An expert and influential Director of Public Health will be essential if a more localised system of public health is to be effective”.

The Faculty of Public Health regards statutory registration as essential to ensuring the quality of the senior public health workforce and to protecting the public, as did the Future Forum and the House of Lords Select Committee on HIV and Aids. As a consequence of the Government’s proposal for a voluntary system, an employer can appoint untrained and unqualified applicants to vital positions, including that of director of public health. An example of what might happen is that a voluntary registered public health specialist is on call when an emergency happens, requiring an instant decision that could be one of life or death. Surely that person must have the required expertise to take that decision and not be in a position where they might put people’s lives at risk.

Key to the scrutiny of commissioning decisions as well as to the voice of the people are the health and well-being boards, which have been mentioned. At this stage, I have only one question for the Minister. Does he believe that the Bill gives these boards sufficient power to ensure that service delivery matches local needs and to take on the responsibility for producing the joint strategic needs assessment, ensuring that this is taken into account in developing commissioning plans? “Having regard”, as the Bill says, does not necessarily mean acceptance or implementation.

A further point relating to the localisation of public health is the question of the national tariff. An amendment moved by the Health Minister, Simon Burns, makes it clear that unlike services commissioned by the CCGs, national tariffs will not apply to local authority or public health services. This is a particular problem for sexual health. The return to a system of block contracts will threaten the open access nature of all sexual health services and potentially restrict those able to attend services according to age or place of residence.

The London Specialised Commissioning Group has shown that commissioning on a broader basis provides efficiencies, economies of scale and uniform standards of treatment, so providing the best service for the patient and bringing it in line with the Government’s stated aim of the future being patient-centred. I ask the Minister quite sincerely to examine this proposal. It is essential that there is flexibility in the tariff system.

No one would argue that the NHS does not need reform, or that there is no place for conditions in commissioning, or that the focus should not be beyond the patient, but I see no case for this distortion of the NHS on which this Bill is allegedly based. There is no democratic mandate, and no consensus for these dramatic changes, and I find it very difficult to understand how the Government can ignore the volume of concern that has been expressed about this Bill from all quarters of the health service and the public.

I must also ask the Minister about the ethics of the Government starting such a major reorganisation before the legislation is complete. It seems to be an attempt to override the parliamentary process. Both concepts of “national” and “service” are being dismantled. Those ideals are clearly of less importance than the unevidenced rationale to break up the NHS and provide incentives for the private sector. It may be that we can hear a little more in the Minister’s reply about the question of competition, which we did not hear about this morning.

I ask the Government to genuinely listen, to put the NHS first and to give it the stability it needs, rather than just continuing with the dangerous limbo in which the NHS is at present. I shall support the amendments of my noble friend Lord Rea and the noble Lord, Lord Owen. There is so much to rethink. There are so many questions to answer and so many things to put right in the Bill. Supporting both or either of the amendments gives us the opportunity to do that, and I hope that we will have that opportunity.