Health and Social Care Bill

Baroness Northover Excerpts

Wednesday 29th February 2012 Lords Chamber

Moved by

[Baroness Northover]

120: Clause 29, page 56, line 8, after “6C” insert “(1) or (3)”

[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.

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[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 Northover]

My Lords—

[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.

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[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.

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[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.

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[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.

[A noble Baroness]

Now you have to go over and give her a kiss.