EU: Healthcare

Baroness Northover Excerpts

Wednesday 11th January 2012 Lords Chamber

[Lord Kakkar]

My Lords, I am very grateful for the opportunity to introduce this Question for Short Debate on the impact of the European Union on the delivery of healthcare in the United Kingdom—a subject on which I have spoken in your Lordships' House on a number of previous occasions. In doing so, I wish to draw noble Lords’ attention to my entry in the register of interests as a practising surgeon, professor of surgery at University College and active biomedical researcher. I would also like to take this opportunity to thank those noble Lords who have kindly added their names to the speakers list and who will make a contribution to this short, time-limited debate.

The impact of European Union directives and regulation on the delivery of healthcare in our country is an important issue. It is not primarily an issue of politics but of the well-being and safety of patients in our healthcare system. If there have been unintended consequences of the adoption of regulation and directives into domestic legislation, it is important for Governments to recognise this and ensure that appropriate measures are taken to overcome them.

We can consider the impact of legislation from Europe on the delivery of healthcare in our country in three broad areas. The first is directives and regulation that have already been incorporated into the laws of our country. The second concerns how directives and regulation that are under consideration should be incorporated into domestic legislation. The third covers areas of broader concern connected with potential consequences, particularly with regard to European Union competition law and the intended purpose of the Health and Social Care Bill.

As regards the first category, it is well recognised that the European working time regulation has had a detrimental impact on the training of our young doctors, particularly those who are training to pursue careers ultimately as independent practitioners at consultant level in the craft specialties, such as my own of general surgery. A restriction to 48 hours’ working per week has resulted in trainees feeling that they have insufficient experience at the end of their training to be certain that they can perform independent consultant practice in the way that it is envisaged in our country rather than models for the delivery of clinical practice in other European countries, to the extent that there is genuine concern that we may be producing generations of consultants less able to deliver the rigorous and demanding practice that we have always expected and have been fortunate enough to receive in our country.

There is also the question of the additional cost of providing locum cover to ensure that rotas are compliant with a 48-hour working week. In an important piece of work published last year, the Royal College of Surgeons identified an additional £200 million a year cost in providing locums to ensure that rotas were 48-hour compliant after the first year of the introduction of the final European working time regulation.

There has also been considerable concern about the problem of language and competence testing. I think most noble Lords would agree that the same standard should apply to every doctor and healthcare practitioner working in our country with regard to their ability to speak the English language and be able to communicate appropriately with patients. There is no doubt that the ability to communicate is a hugely important part of the delivery of healthcare. Equally, it is only right that patients in our healthcare systems are able to expect that all doctors and other healthcare professionals who have the privilege of treating them in our hospitals and other healthcare environments practise to the same level of competence. At the moment it is impossible for the national regulatory bodies in our country to ensure that doctors who are registered elsewhere in the European Union meet the same standards as we expect of our own graduates or graduates from elsewhere in the world.

There are real concerns that the first year after qualification from medical school—formerly known as the house job year, now known as foundation year 1 —which is an essential part of completing the process for full registration with the General Medical Council, has now been opened up to competition from medical graduates across Europe as part of the free mobility of labour in the European Union. However, this first year of clinical practice remains an important element of ensuring that our young medical graduates can complete their training and can ultimately register to practise in our country. The issue is very simple: if they are unable to take that year, they are unable to fully register and will not be able to practise in our country. This is a huge waste because these talented graduates should remain in our country and serve our nation, ensuring that the debt they have is repaid through practice in the National Health Service. In this year’s round of appointment to that first foundation year, some 52 potential graduates have not been given a foundation year 1 post and some 113 practitioners from the European Union have taken places on those foundation year 1 schemes. How do Her Majesty’s Government propose to ensure that this problem does not result in our graduates being unable to complete that essential first year after they have qualified from medical school?

There are also important concerns about the impact of the European clinical trials directive in terms of reducing the competitiveness of the biomedical science and research science output of our country. It is estimated that in the year 2000, 6 per cent of all patients who entered clinical trials around the world came from our country. Soon after that, in 2003, the clinical trials directive was incorporated into our domestic legislation, and the problems associated with its bureaucracy have resulted in a reduction in this country to just 2 per cent in 2006 and 1.4 per cent in 2010 of the number of patients included in clinical trials around the world.

These are all well proven areas where Her Majesty's Government need to develop a strategy to address the problems that have been experienced. However, there are also important matters relating to directives that are currently being considered by the Department of Health for inclusion in domestic legislation. There is a directive on transplantation which, if incorporated, will add bureaucracy to the delivery of transplantation services in our country, resulting in added cost. Those responsible for the delivery of these services believe that our standards that are highly regarded throughout the world are of sufficient quality and that any potential European directive must not be gold-plated and undermine an already successful service.

With regard to energy efficiency, a directive that is currently under regulation has caused considerable concern to the NHS Federation. This directive requires the building stock of all public bodies, including the National Health Service, to be improved on an annual basis, and for 3 per cent of floor space to be addressed each year. This will cost some £70 million a year, and the NHS, given the severe financial constraints it is facing, can hardly afford this.

Then there is the ongoing concern that European competition law may inadvertently be applied and in some way affect the proposals of Her Majesty's Government in the Health and Social Care Bill. Clinical commissioning groups, in wishing to take forward the development of new services to improve the clinical outcomes and care of our patients, could be disrupted in doing that through the application of European competition law.

In October last year, the Prime Minister indicated that all government departments should look at European regulation to determine how it might be adversely impacting on the work of those departments and the life of our country. There is no doubt that in the area of healthcare, the training of our young doctors, the innovation and delivery of biomedical research, and the delivery of healthcare itself have been detrimentally affected. It is absolutely essential that Her Majesty's Government are sensitive to the concerns—repeated on several occasions by those with responsibility for the delivery of healthcare in our country—and act as a matter of priority.

[Baroness Northover]

I remind noble Lords that this is a time-limited debate and that all speakers, except for the Minister, have two minutes. When the clock displays two minutes, noble Lords have had their two minutes. I note that we are without at least one speaker in this debate.

Health and Social Care Bill

Baroness Northover Excerpts

Monday 19th December 2011 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, I, too, pay tribute to the noble Baroness, Lady Emerton, for her perseverance and determination in this very important area. Rather like the noble Lord, Lord Alderdice, I am clear that the role of healthcare assistants has to be seen in the context of a much more general debate about nursing care, including the compassion that he talked so eloquently about.

As the noble Baroness said to us rather earlier this afternoon, we had an excellent debate on nursing on 1 December, and we are presented with something of a paradox: on the one hand, we should not ignore the huge advances in the nursing profession over the past 20 years. There has been the move to a graduate profession and nurses have taken on much greater responsibility, including for complex care and specialist care, and I think that, overall, the public have welcomed that increased responsibility. At the same time, there has been real and mounting concern about basic standards of care and issues to do with hygiene, feeding of patients, nutrition, dignity and even face-to-face contact—the kind of compassion that the noble Lord, Lord Alderdice, has just spoken about. We have seen the reports from unannounced visits of various bodies. Recently, the CQC has undertaken important visits to many of our hospitals. There seems to be real evidence and concern about a falling of standards of basic care.

The reasons for that are not clear. It is possible that nurse training is now too focused on academic performance rather than on practical nurse training. It is also at least possible that the drive for specialist nurses and modern matrons has taken from the ward the many experienced nurses who, in retrospect, might be better placed in leading their ward as ward manager or senior sister. What is not in doubt is the need for serious thinking about how we can enhance the overall quality in standards of basic care that nurses give.

That brings us to the role of healthcare assistants. Again, in our debate on 1 December, the noble Earl, Lord Howe, in responding, referred to the concerns that had been expressed about nursing in the acute sector in particular. He said he felt that that,

“related to inappropriate delegation by nurses to healthcare”,

assistants. He continued:

“Wherever there is a multidisciplinary team of regulated professionals and unregulated healthcare workers, appropriate delegation and supervision is vitally important. This is an area ripe for formal review”.

He also said that the Government welcomed,

“the NMC’s plans to update its guidance on delegation”,

and that they have,

“asked Skills for Health and Skills for Care to accelerate production of a code of conduct”.—[Official Report, 1/12/11; col. 419.]

I am sure that those actions by the Government are very generally welcomed. The question before us is whether they are sufficient. From what the noble Baroness, Lady Emerton, has said, it is clear that she does not think that they are. Powerful support for that argument has been received from the Nursing and Midwifery Council, which argues that a system of regulation for healthcare support workers should contain provisions for consistent UK-wide standards of training and practice that would assure the public and employers that they have the knowledge and skills to practice safely. It further suggests a mandatory register to ensure that workers who have been struck off the nursing and midwifery register are not re-employed in a healthcare support role, which has been the subject of some concerns. It is also notable that the House of Commons Health Committee supports mandatory statutory regulation of healthcare assistants, which it believes is the only approach that would maximise public protection.

However, we have heard from my noble friend Lady Pitkeathley, chair of the Council for Healthcare Regulatory Excellence, who has put a different view. It will be interesting to hear the response of the noble Baroness, Lady Emerton, on why she thinks that a voluntary register for healthcare assistants is the way forward. I should like to ask her whether she would support NHS bodies which require healthcare assistants to be voluntarily registered as a condition of employment. If that were the case, what safeguards does she think could be put in place as regards a worker who was dismissed because of poor conduct towards a patient? How could we ensure that in those circumstances that person could not then work in another part of the care sector? That seems to me to go to the heart of the issue of whether a voluntary register could work.

I have no doubt that NHS employers could be encouraged to make it mandatory but the problem with that is that too many people could slip through the net. I would also ask the noble Baroness to respond to my noble friend Lord Warner. I share his view that, clearly, we are crying out for a fundamental review of these issues around nursing quality and care, compassion, and dignity of care being given to patients, and that relationship to healthcare assistants. If the Government are not prepared to move on this and on the point about only going as far as a voluntary register, can they at least give some comfort and assurance that they recognise that this matter needs close attention?

I am not a great believer in royal commissions—I think it was Harold Wilson who said that they could be established in a minute but take years—but there is a strong case for a fundamental review of the nursing profession, embracing healthcare assistants. Would the Government be prepared to give us some comfort on this?

[Baroness Northover]

My Lords, these amendments seek to extend compulsory statutory regulation to healthcare support workers. I thank noble Lords for the amendments because they raise important issues about the ways in which we assure the quality and safety of those who work in support of our regulated health professionals. The Government are publishing a fact sheet on this issue that will contain further details about their proposals, which I hope will be helpful to noble Lords.

There are more than 200,000 nursing assistants and approximately a further 1 million people working in similar jobs in adult social care in England alone. The majority of support workers give the highest quality of care. However, a minority let patients down. This is rightly a cause for concern, although as a former historian I have to say that I do not fully recognise the notion of everything having been perfect in earlier periods but everything breaking down at this point. One needs only to look at what has been said from Florence Nightingale onwards about what happened during the interwar periods, during times of war and so on. This has always been more varied than perhaps noble Lords are allowing for. Nevertheless, it is extremely important that we try to drive up quality and ensure that quality holds good right across the health service and social care. It is right that there is discussion and debate about the best way of ensuring that high standards of care are delivered at all times.

As the noble Baroness, Lady Pitkeathley, pointed out, there are already existing tiers of regulation that protect patients and service users. Professionals struck off by their regulator or sacked by an employer who pose a risk to vulnerable adults or children should be referred to the Independent Safeguarding Authority, which has been very clear that it expects this to happen. In the same way, employers should make referrals about individuals from unregulated groups where they pose a risk of harm to vulnerable adults or children. Providers and employers also play a key role in ensuring safe, high quality care that patients and service users can be confident in, being both responsible and accountable for the staff they employ. Under the registration requirements of the Care Quality Commission, providers must take steps to ensure that at all times there are sufficient numbers of suitably qualified, skilled and experienced persons employed for the purpose of carrying on any regulated activity.

An individual being on a list does not alter this and would not remove employers’ responsibility to undertake a range of checks on the suitability of any persons who they appoint, including qualifications, relevant registrations, employment history and reference checks to ensure that an individual is competent for a specific role. Equally, appropriate delegation and supervision is a necessity within teams made up of both regulated and unregulated professionals and workers. Guidance by the Nursing and Midwifery Council is being updated so that nursing staff know how to delegate appropriately and safely.

We are not ruling out compulsory statutory regulation for healthcare support workers, but our view is that the case has not yet been made for imposing further compulsory statutory regulation, given the tiers of existing regulation and the duties on regulated professionals. There is no solid evidence that demonstrates that healthcare support workers and adult social care workers should be subject to compulsory statutory regulation. Research by King’s College London concluded that little evidence could be deployed to show that regulation of healthcare support workers would reduce the risk to the public, although it was clear that some healthcare workers were undertaking roles that had traditionally been done by nurses. The point is that quality is not always what is delivered. Therefore, we have to try to tackle that concern and not simply assume that regulation will deal with it. As the noble Baroness, Lady Pitkeathley, mentioned, there are regulated professions which are in some instances letting us down. We must focus on the real problem and figure out ways of tackling it.

The Government’s view is that high standards for healthcare support workers and other professional occupational groups can be assured without imposing compulsory statutory regulation. That is why, in the wider context of supporting providers, we are creating through the Bill a system of external quality assurance for voluntary registers. To pick up the point made by the noble Lord, Lord MacKenzie, there are various examples of voluntary registration for groups of professionals. We are proposing a quality-assured voluntary approach, looking at how those registers are set up and operated and what training is offered and so on. A quality-assured voluntary register will set standards for training, conduct, competence and ethics that all registrants must meet.

[Lord Hunt of Kings Heath]

My Lords, if the Government are putting so much faith in the quality-assured voluntary register, surely the evidence from King’s College would show that that was not necessary. They cannot have it both ways. Either regulation, and what comes with it, provides advantages or it does not.

[Baroness Northover]

Regulation and training are often put as two words in one sentence. Regulation may indeed include training; assured voluntary registers may also include training. The noble Baroness, Lady Emerton, talked about that. Perhaps I may come on to it, because it is potentially relevant here.

I am particularly grateful to the noble Baroness for her contribution to this debate, not only today but throughout her time in the House of Lords. We agree that common standards of training are needed for those working in both health and social care, as well as more role-specific training, and that this will lead to a more capable and flexible group of support workers. As we seek to integrate health and social care more effectively, this area deserves a lot of scrutiny.

We expect work on the standards to begin by April 2012 in terms of training, and for them to be agreed ahead of the establishment of voluntary registers for healthcare support workers and adult social care workers, which could be operational from 2013. This will allow unregulated workers to demonstrate that they meet a set of minimum standards for training and are committed to a code of conduct.

[Lord Hunt of Kings Heath]

My Lords, I still do not understand this. If it is so important that the voluntary registers are established, for the reasons that the Minister has given, why on earth not go the full hog and make registration compulsory? If the Government do not think that it is important, they would not be pursuing the voluntary register approach. However, by taking that approach, they will leave lots of people outside the net.

[Baroness Northover]

As the noble Baroness, Lady Pitkeathley, and others have indicated, one has to be proportionate about this and not think that simply going down the route of regulation is going to crack it. Nevertheless, training and making sure that people are well prepared for the work that they are doing is clearly of great importance. We would expect a voluntary register, quality assured in the way that I have described, to provide a way for employers to assure what they are offering in terms of staff. There will therefore be greater take-up. Those who are on the quality-assured register will find themselves more employable, which will move things forward. Meanwhile, if, as we continue to debate this, voluntary registration does not seem sufficient and regulation seems the route to go down, the Government do not rule that out. However, it is extremely important to focus on the end point, which is to try to drive up quality, and not simply be deflected by thinking that this would crack it.

I assure noble Lords that we will keep this issue under constant review. We are well aware of people’s concerns and that standards need to be driven up in a much more even way across the board. As I say, we are developing the education and training which I hope will go some way towards this.

[Lord Patel]

I wish to pick up on one point. Can the noble Baroness reassure us on what it is she will keep under constant review? I understood her to say that the Government will rely on employers to ensure that these support workers have some kind of training. There will be no national training standards and, once the employers are satisfied that these people have some kind of training, they will be entitled to go on a voluntary register. As I understand it, the logical thing here is first to establish a national standard of training; then to ensure that those national standards are implemented; and then to allow people to register. If they register, the next step would be regulation. The first step is not immediate regulation but national standards of training and assessment that those standards are being met, before people can go through any kind of registration. What is the noble Baroness agreeing to keep under review?

[Baroness Northover]

I should perhaps explain that more precisely. This issue will be constantly under review so that if there are concerns in this area they will be flagged up. The Government will of course continually consider how best to respond and make sure that standards are of the quality that we need. The noble Lord is right: national standards of training are indeed the start. Then people are admitted to a register and so on. A voluntary-assured register would demand that kind of national level of standards in training. I hope that in that regard I can at least reassure the noble Lord.

[Lord Warner]

One question has puzzled me more and more as the noble Baroness has progressed. My noble friend Lady Pitkeathley laid great stress on the position of the regulated nurses and the fact that they will have to ensure that people working in the healthcare assistant type of roles under their supervision do not take on roles that they are not competent to fulfil. Going back to my description of the way the NHS works in reality, particularly in acute hospitals, there is a constant flow of different people on these wards—regulated and registered staff, agency or bank staff, are there particularly in the evenings, for unsocial hours and at weekends. We have heard a lot about employers. I am still puzzled about how the statutory regulated nurses satisfy themselves about the competence of the healthcare assistants working under their direction. They seem to be the people most exposed—at least theoretically—to cop it from their regulatory body if they have not made extensive inquiries about the competence of these healthcare assistants. How does the noble Baroness square that particular circle if we do not have much knowledge of the training of these people and they have not even registered on a voluntary basis?

[Baroness Northover]

The noble Lord will be familiar with being on wards at changeover time and when there is a pooling of information about who is on the ward and what the problems are. Issues are flagged up and one team passes information on to the next.

[Lord Warner]

I have seen changeovers at weekends, when visiting relatives. It is not a pretty sight.

--- Later in debate ---

[Baroness Northover]

I have seen many, many changeovers. The proposal is being brought forward so that registered, regulated nurses have a better idea of when and how to delegate, and that is extremely important for the reasons that the noble Lord has just indicated. As I have indicated, the training and national standards of healthcare workers, to which the noble Lord, Lord Patel, referred, are also important—as is taking that forward so that the registered nurses are aware of the kind of training that those healthcare workers have had. I want to pick up on the case that the noble Baroness, Lady Emerton, mentioned about the healthcare worker who was taking a patient’s blood pressure but did not know what the reading meant. Surely, it was for the person to whom that was reported to take action on the significance of that. That information was to be passed on to somebody else to read, understand and interpret.

[Lord MacKenzie of Culkein]

But if that healthcare assistant does not have the basic training or an understanding of the reading that she or he has just taken, they may not see the importance of reporting it to another nurse.

[Baroness Northover]

I am not suggesting that they would. What I am suggesting is that the registered nurse might go and check the chart.

[Baroness Emerton]

My Lords, perhaps I could be helpful at this stage. I am grateful to noble Lords who have contributed to this debate. A large number of issues have been brought forward; I shall start with the title “nurse”. As noble Lords have mentioned, a person who is nursed—and feels that they have been nursed—experiences care, compassion, respect and dignity. There has been a lot of discussion among the public, and indeed in this House, about registered nurses becoming graduates and whether they will be too posh to wash, to put it colloquially. To me, a nurse who is a graduate would be only too grateful to be able to attend to the basic needs of patients, because that is part of holistic care. When you do various intimate things for patients, you learn a great deal about their condition.

The point that has been raised about the nurse is very important. We talk about support workers but we cannot talk about support nurses, because the term “nurse” is completely left for the statutory requirement of a regulated nurse. We are looking for a support worker who is able to do tasks which they understand, with the skills of the graduate nurse—because by 2013, we will be producing all-graduate nurses—within holistic care. That is the point I was trying to make this morning: it is the holistic care we are looking for in the delivery of care. However, it is not only holistic care in the acute sector; we are looking at the holistic care which is integrated with social care, because we are now looking at patients going into the community. Indeed, people working in the acute sector need to understand that the patients they are discharging are going into the community, which is a different scene and which may require not only a nurse but social care support. Therefore, somewhere in our education we need to bring together a basic core of understanding healthcare, nursing care and social care.

The point that the noble Lord, Lord Warner, made is very important. We need to conduct this review. On the other hand, the research evidence shows us that as regards highly qualified registered staff, the higher the proportion, the less likely it is that patients will have a longer stay in hospital. They will have a better clinical outcome. I hope that the Government are not going to ignore that research. If possible, we should carry out a truly safe cost-benefit analysis into increasing the number of trained staff, seeing where they are needed, rather than having a higher proportion of support workers.

The Royal College of Nursing has been resolute in putting forward the regulation of healthcare support workers because it feels that that is the way to ensure that they are answerable to a registered nurse. We talk about employers but I am not sure who the employers are going to be—social workers, managers or the nursing profession. This whole issue needs to be taken away and looked at, and perhaps we could return to it. I do not know whether these comments are helpful but I feel strongly about this issue, as noble Lords may have gathered. I pass it back to the Minister.

[Baroness Northover]

I hear what the noble Baroness says. She is extremely well informed, as ever, and I hope that she will continue to engage as we take this forward, as she has done up to now. However, at this point I hope that she will withdraw her amendment.

[Baroness Emerton]

My Lords, I am prepared to withdraw but we will probably come back to this on Report. I beg leave to withdraw the amendment.

--- Later in debate ---

[Lord MacKenzie of Culkein]

My Lords, I support this group of amendments. I want to make just a couple of points, as I think that most of the others have already been covered.

I am looking at some information sent in an open letter from the Registration Council for Clinical Physiologists to Anne Milton, the Parliamentary Under-Secretary of State in another place. Interestingly, in that open letter the registration council, which operates a voluntary register, takes the view that the council is rather toothless. It says that the professions covered by clinical physiologists will continue to be,

“saddled with a toothless system of voluntary registration, in which those managing the registers are exposed to unacceptable legal risk when attempting to enforce the meagre sanctions at their disposal and maintain professional standards”.

It says it is evident that those administering the current inadequate voluntary registration process are being threatened with civil action by those whom they are forced to reprimand. It is a pretty poor state of affairs when those who are trying to enforce professional standards are themselves threatened with legal action.

I know from talking to people involved with the registration council that people leave the register when disciplinary issues come to the fore. I gather that in one instance a person left the register when faced with discipline, emigrated to Australia, continued to practise and got in trouble there. As I understand it, the Australian statutory body that exists for clinical physiologists was astonished to discover that there was no statutory regulation in force in this country.

I do not think that we can continue with this so-called voluntary system and light touch. We need to do what other countries do and have statutory responsibilities and statutory training and registration for these very important groups of staff.

[Baroness Northover]

My Lords, these amendments seek to extend compulsory statutory regulation to physicians’ assistants in anaesthesia and clinical physiologists and to make changes to legislation to further provide for the compulsory statutory regulation of clinical physiologists.

I make it clear at the start that healthcare scientists such as clinical physiologists play an important and highly valued role as part of clinical teams, and this is also true of physicians’ assistants. It is a testament to their professionalism that the Department of Health is not aware of any general concerns about the standards of practice of either group. Furthermore, we need to be absolutely clear that the purpose of regulation is to protect the public, not to support the development of a profession.

Given the wider systems of assurance in place such as the Care Quality Commission’s registration requirements, and the vetting and barring scheme, the Government do not consider that the case for compulsory statutory regulation of these groups of healthcare scientists not already subject to regulation, and physicians’ assistants, has been made. However, we agree that there need to be processes to ensure high standards of care, and assured voluntary registration overseen by the Professional Standards Authority for Health and Social Care has the potential to provide this. It will ensure that there are robust standards of conduct and training. It will be open to employers and commissioners to insist on only recruiting staff on voluntary registers. Those doing so would secure many of the benefits of compulsory regulation. Both healthcare scientists and physicians’ assistants already have established voluntary registers and would be well placed to seek accreditation from the authority.

The noble Baroness, Lady Thornton, asked why we were not taking forward the regulation of clinical physiologists as recommended by the Health Professions Council. The recommendations of the Health Professions Council were not based on an assessment of the risk presented by a profession, but rather on whether that profession had already developed processes of assurance which prepared them for professional regulation. There is therefore no evidence that compulsory statutory regulation is necessary to mitigate the risks posed by the professions recommended for such regulation by the Health Professions Council. This is probably why the previous Government did not decide to regulate, although this is an issue that has been flagged up for a number of years. The professions recommended by the Health Professions Council for compulsory statutory regulation will be well placed to join the system of assured voluntary registration that we are proposing.

The noble Baroness, Lady Thornton, asked about research in terms of regulating clinical physiologists. We are not planning on commissioning research into the case for regulating them, but we will review the case for introducing compulsory statutory regulation for clinical physiologists and, obviously, others in the light of experience of assured voluntary registration, and the evidence about risks available.

[Baroness Thornton]

Perhaps the Minister could tell us what sort of timescale she envisages for this, or whether it will have to wait until an accident happens like the noble Baroness, Lady Finlay, recorded and then the Government will deal with it.

[Baroness Northover]

The noble Baroness will be fully aware, because she was a health Minister, that if there is no evidence of there being a risk then you do not choose to regulate. That is presumably why the previous Government chose not to.

The noble Baroness, Lady Finlay, flagged up the position of anaesthetists’ assistants. I had interesting discussions yesterday with an anaesthetist and an anaesthetist’s assistant, and it was very enlightening. As the noble Baroness will know, the anaesthetist is of course ultimately responsible. Assistants must always be supervised by a consultant who needs to be available within two minutes. The issue that the noble Baroness raises is one of quality assurance. As she knows, the Royal College of Anaesthetists runs the training and the registration for those assistants. After they have done a science degree, generally it is 27 months of practice. If the Royal College of Anaesthetists judges that that is inadequate, on the basis of the kind of concerns that the noble Baroness raises, then it is clearly for it to say that there are risks, it has encountered risks, and that needs to be addressed. If this system comes under the quality assurance system that I mentioned earlier, there will be another body looking at whether that kind of training, assurance and registration is adequate. However, there have not been cases flagged up as causing concern. I also point out that there are few anaesthetists’ assistants. They are more generally used in other countries, I gather, but not so much in the United Kingdom. The noble Lord, Lord Alderdice, asked why there is not more statutory regulation. In some ways I think I have addressed that. Although compulsory statutory regulation is sometimes necessary, one has to look at the risks and at what is proportionate.

[Baroness Thornton]

The health Minister Anne Milton said that those professions in which a patient safety case can be made, including that of clinical physiologists, will be considered for statutory regulation subject to a cost-benefit risk analysis. Will the Government carry out that analysis and, if so, when and in what time? I do not particularly want an answer about what my Government may or may not have done or may or may not have decided. The noble Baroness’s own Minister has pronounced on this matter since the general election so it seems to me that she needs to answer the question: when will they do the risk analysis?

[Baroness Northover]

I have already mentioned to the noble Baroness—she is probably totally familiar with this—that the Department of Health does not have evidence of there being a risk in this regard. Clearly, as I mentioned on the earlier group, these issues will always be kept under review. If the concerns that she has flagged up and if the association, which is particularly encouraging the regulation of clinical physiologists—that is fine; it is all part of professionalisation—flags up particular concerns that emerge from other evidence, then of course the department will take that very seriously. However, things need to be proportionate.

[Baroness Finlay of Llandaff]

I have listened very carefully to what has been said about the assistants relating to anaesthesia, but I also used the more catch-all phrase about the clinical perfusion scientists. I would be grateful if, after this debate, the noble Baroness would write to me and explain why coroner recommendations in relation to clinical perfusion scientists are not considered to be enough of a risk to take action. If one is trying to assess this on a risk spectrum, it would be helpful to understand why a coroner's decision to recommend that this small, contained group of clinical perfusion scientists should be regulated does not constitute enough of a risk to go down that route to regulate them and to have them on a statutory register.

[Baroness Northover]

I am very happy to take away what the noble Baroness has said and to discuss the situation further with her.

We expect the assured voluntary registration to be up and running by 2012. Therefore, afterwards that would need to be assessed to see whether anything further is required, as noble Lords have figured might be the case. We are hoping to see how it all works.

The noble Lord, Lord Walton, flagged up various groups which were regulated and he could not quite see why others were not. Given that I used to bump into the noble Lord, Lord Walton, in the Wellcome Library for the History and Understanding of Medicine, I think he will fully understand that the way in which regulation has grown up has not necessarily been logical or consistent. Therefore, I flag up the 2005 Hampton review on regulation which says that it should be proportionate to the risks that it seeks to mitigate and various other provisions. That is what we are seeking to do. Of course, we shall keep under review what we are doing to see whether it is adequate. In the mean time, I hope that the noble Baroness will be willing to withdraw the amendment.

[Baroness Thornton]

My Lords, I thank the Minister, but this is not yet a satisfactory situation. We might be moving towards one but we are not there by any means. If I were on the register of clinical physiologists I would find it slightly offensive for the Minister to suggest that I was asking for statutory regulation as a kind of professional development of the organisation. Physiologists are very clear in all of their briefings that they think that this is important for patient safety. That is why they want statutory regulation and that is why we need to listen to them very carefully.

[Baroness Northover]

I am extremely happy to acknowledge that.

[Baroness Thornton]

I thank the noble Baroness for that. The noble Baroness, Lady Finlay, made a graphic and powerful case. I thank my noble friend Lord Rea, the noble Baroness, Lady Masham, and the noble Lord, Lord Walton, for their support for the amendment. My noble friend Lady Pitkeathley and the Minister are coming at it from a different point of view. It is entirely possible that an arbitrary decision was taken, quite possibly by my Government, that there was enough statutory regulation. It is possible that this Government need to think that that was an arbitrary decision in the history of regulation and that exceptions need to be made.

There are questions about the limits of assured voluntary registration. Do clinical physiologists carry out invasive procedures that could harm patients? Yes, they do. Are clinical physiologists incentivised to join the voluntary register? No, they are not. A small number of NHS and private employers notionally require applicants to be on their register but there is no mandatory requirement for this. Are professionals incentivised to maintain the voluntary register? No, their activities are carried out on a voluntary basis by the chair and other officers. Does the voluntary register empower patients to make formal complaints? No. While the Health Professions Council operates a system whereby anyone can make a complaint about the fitness to practise of a professional on its register, in most instances members of the public are not aware of the existence of voluntary registers. Finally, does the voluntary register have any powers of enforcement? No, it does not. The RCCP operates a disciplinary code and procedure but it cannot protect patients from continuing to be treated by practitioners who have not been registered and who are potentially unfit to practise. I beg leave to withdraw the amendment.

Health: Cancer

Baroness Northover Excerpts

Tuesday 13th December 2011 Lords Chamber

[Baroness Royall of Blaisdon]

To ask Her Majesty’s Government what action they will take in response to the findings of Professor Colin Pritchard’s study published recently in the British Journal of Cancer.

[Baroness Northover]

My Lords, this study concerns mortality. We have a good track record on reducing cancer mortality. However, because mortality rates are linked to incidence rates, mortality on its own is not a useful measurement of NHS performance. Survival rates are much more effective as they show how good the NHS is at diagnosing and treating people with cancer. We know that our cancer survival rates lag behind the best performing countries, and our ambition is to improve survival rates and save 5,000 additional lives per year by 2014-15.

[Baroness Royall of Blaisdon]

My Lords, I recognise what the noble Baroness says about survival rates, but does she agree that the report demonstrates that in the past 10 years cancer services in the UK have improved dramatically? While England and Wales spend less on health than most other countries—9.3 per cent of GDP compared with 10.7 per cent in Germany and 15 per cent in the USA—they achieved the biggest overall annual fall in cancer deaths, and cancer deaths are important to people in this country as well as cancer survival rates.

[Baroness Northover]

The noble Baroness is right; there has been that decline. Of course mortality is extremely important, but you have to look at incidence, survival and mortality together. She will also be aware that much of that decrease in mortality is because of the decrease in men smoking. Men took up smoking in larger numbers than did women. The numbers of men smoking started to decline in the 1950s, and that has had an effect on the decline in the number of cancer deaths.

[Lord Aberdare]

My Lords, pancreatic cancer is one of the deadliest cancers, accounting for about 5 per cent of all cancer deaths. A recent report by Pancreatic Cancer UK found that survival rates for pancreatic cancer patients in the UK—only 3 per cent are expected to live for five years or more—are worse than in most comparable countries and have not improved in 40 years. What assurances can the Minister give that the NHS will continue to work to improve results in all forms of cancer and that pancreatic cancer sufferers will not just be written off as a lost cause?

[Baroness Northover]

Pancreatic cancer is an extremely difficult cancer to diagnose. As the noble Lord knows, when it is picked up it is often very advanced and survival rates are very poor indeed. The Government are well aware of the problems here. My honourable friend Paul Burstow in the other place is meeting Pancreatic Cancer UK shortly. I hope that the noble Lord will feed into that. If he has an association with that organisation, can he put his questions to it so that they can be fed to Paul Burstow, or alternatively to me?

[Baroness Gardner of Parkes]

My Lords, is it not a fact that the great improvement in cancer treatment is due to early detection? It is important to keep people trained in that, particularly for the rare cancers that I am always talking about. Do the Government not feel that we owe a great deal to the cancer and research charities that are continuing to do very useful work in alerting people to the need for early detection?

[Baroness Northover]

My noble friend is absolutely right. We owe a huge amount to the organisations in the United Kingdom, not least Cancer Research UK, which is a major player internationally. She is also right about early diagnosis. That is how you start to bring deaths down; you make sure that you diagnose early enough so that you can intervene in a way that is going to be much more effective. Noble Lords might like to know that there will be a first ever national cancer campaign on bowel cancer to flag up the symptoms to people in the hope that they seek diagnosis at a much earlier stage, because if it is caught early it is completely curable.

[Lord Winston]

My Lords, the complex paper by Professor Pritchard also looks at the costs of delivering cancer care. One of the points made very clearly in that paper is that the cost of drugs delivered under the NHS is considerably less. We pay far less for the excellent results that we get than Germany, Spain, Italy and France do—as much as 40 per cent less, in some cases. Given that, and given that independent assessments of the health service show that the British health service has some of the best value for money in the world, why did the Prime Minister say that we cannot go on as we are and introduce the current Health and Social Care Bill?

[Baroness Northover]

I fully agree that the National Health Service is very cost-effective and that it has been an extraordinary service. However, we have many challenges coming down the track, as the noble Lord will be acutely aware—not least our ageing population, which needs to be supported, particularly at home and in the community where appropriate, and not immediately taken into hospitals, where interventionist care may not be in the best interests of those patients. Therefore it is extremely important that there is more clinical judgment on the best interests of each patient and how these things are organised, and that they are not simply driven forward by the way in which provision is organised at the moment, which is very much focused on secondary institutions.

[Lord Sharkey]

My Lords, the biggest cause of cancer deaths in the country is still lung cancer. It kills more people every year than breast cancer and prostate cancer combined, yet lung cancer attracts only 5 per cent of cancer research funding. The Minister has said that this is unsatisfactory and thinks that it is largely due to the lack of first-class research proposals. Does the Minister agree with me that we should not let this situation continue, with the biggest killer getting the least research? Will the Minister consider urgently sponsoring a meeting of all interested parties to see how we might intervene to generate many more fundable first-class cancer research proposals?

[Baroness Northover]

My noble friend raised this with my other noble friend Lord Howe, who has taken a slight break in the health Bill at the moment. I was struck by his answer, which was on the paucity of cancer research funding for lung cancer. I therefore have more information for my noble friend, which is that the amount spent on lung cancer between 2006 and 2010 in fact doubled in comparison with a 28 per cent increase for overall cancer research spending. The National Institute for Health Research, for example, is currently hosting 62 studies on lung cancer that are being set up or are just beginning to recruit patients. I hope, therefore, that my noble friend will be encouraged that there appears to be a shift. However, if my noble friend would like to write to my other noble friend the Minister with detail about the meeting that he would like, the Minister would be delighted to receive that letter.

Health and Social Care Bill

Baroness Northover Excerpts

Monday 5th December 2011 Lords Chamber

[Baroness Northover]

My Lords, I think that, one way or another, I am going to disappoint: I am going to disappoint the noble Lord, Lord Beecham, that the response is not coming from my noble friend Lord Howe, whom he is so fond of, or—

[Lord Beecham]

I am quite prepared to be made fond of the noble Baroness.

[Baroness Northover]

I am absolutely delighted.

In answer to the noble Lord, Lord Warner, it may be that the version of my noble friend Lord Howe that he is seeing now is slightly different from the one that he usually sees, but I am surprised at his comment about my noble friend having made little movement. The noble Lord will know—

[Lord Warner]

I thank the noble Baroness for giving way. I encourage her to reflect on what she might experience in terms of surprise on Report if we do not see a little more flexibility.

[Baroness Northover]

As a former Minister, the noble Lord, Lord Warner, will be familiar with how—much more familiar than I was when I came into this position—change is discussed and then moves forward. I can assure him that the Government are very much listening and discussing the issues that have come up in your Lordships’ House. As he will know well, it is usually in Committee that noble Lords probe issues and flag up concerns, and usually on Report that shifts occur. I hope that the noble Lord understands that we are indeed listening. Perhaps noble Lords will bear in mind the fact that there has already been much discussion of issues such as ministerial accountability, education and training, research, HealthWatch England and patient involvement, among other issues. Public health is undoubtedly one such issue. I can assure him that that is the case. As the Bill moves along there will undoubtedly be open discussion. I have certainly seen that from the inside.

As noble Lords will know, we previously discussed the high-level provisions relating to the public health powers and duties of local authorities and those of the Secretary of State. We are now focusing on the process of local engagement whereby health improvement responsibilities will return to local authorities. When discussing Clauses 8 and 9 I briefly referred to the role of the director of public health, but I should like to take this opportunity to highlight the importance that the Government attach to the role of director of public health and local government within the new system.

The director of public health will be ideally placed to embed public health across the work of the local authority, acting corporately but exercising the appropriate professional autonomy where necessary, to advocate for the health of the local population. As the noble Lord, Lord Patel, put it, he or she indeed needs to be the strategic leader on public health in the local authority. Other noble Lords echoed that view. We understand that there are a number of concerns about the status of the director of public health but I hope that I can reassure noble Lords on the points they have raised. We are indeed seeking the kind of status that they referred to.

Amendments 228, 229, 232, 233 and 233A relate to the status of the director of public health. As my noble friend Lady Cumberlege noted, given the importance of their leadership position, we would expect a director of public health to be of chief officer status with direct accountability to the chief executive. We hear what noble Lords say about the importance of that.

We have progressed this important issue—the noble Baroness, Lady Cumberlege, wanted an update—and we expect to make a formal announcement in the new year about how we will ensure the senior status of the directors of public health. We are committed to addressing that further. I hope that noble Lords will be reassured by what I have said.

Amendments 229, 231, 233 and 233A relate in particular to the qualifications and experience of the director of public health. The director of public health will be jointly appointed by the Secretary of State, who will be able to ensure that only appropriately qualified individuals are appointed. The fact that the Secretary of State, in the shape of Public Health England, will play an active part in directors’ appointments will help to bind the system together and help to ensure consistency of approach to the role without infringing unduly on local authorities’ independence.

In the National Health Service, some standardisation is imposed by the NHS (Appointment of Consultants) Regulations. The joint appointments process for directors of public health would allow the Secretary of State and local authorities to agree similar standards for local government.

Amendment 225 would require the Secretary of State to agree the appointment. I can reassure the Lord, Lord Patel, that the joint appointment process would already involve the agreement and active participation of the Secretary of State. The local authority and the Secretary of State could not properly imply with their duties and conduct a fair appointment process unless the individual chosen was suitably qualified with appropriate professional expertise. The joint appointment gives the Secretary of State more involvement in the Bill as it stands than under the amendment, which would limit his role to approval.

Amendments 234 and 234A would require the local authority to obtain the agreement of the Secretary of State before dismissing a director of public health. Under new Section 27(2) of the 2006 Act, the director of public health is an employee of the local authority, although any local authority wishing to dismiss its director of public health would have to consult the Secretary of State. Directors of public health will also have the full protection of employment law. Given that their employment relationship is with the local authority, we believe that this provides an appropriate level of protection.

I thank the noble Lord, Lord Patel, for Amendment 236. The amendment would allow the Secretary of State to issue guidance to which local authorities must have regard in relation to the appointment and termination of the director of public health. My noble friend Lord Howe and I will commit to considering this further.

Amendment 339 inserts a new clause which would require the Health Professions Council to establish a register for currently unregulated public health specialists. This links to Amendments 229 and 230, which would require that all directors of public health are on a register. I share the desire to assure the quality of all public health specialists in a way that is robust and effective.

The consultation on Healthy Lives, Healthy People and the NHS Future Forum identified a number of options for assuring the decision-making of public health specialists, including assured voluntary registration and compulsory statutory regulation, and we have sought further evidence from the public health profession to demonstrate whether compulsory statutory regulation is needed. We want to assess this evidence carefully before making final proposals. I assure noble Lords that we are listening.

I also reassure noble Lords that if compulsory statutory regulation of all public health specialists is introduced, we would seek to ensure that the bodies responsible for regulation would be subject to oversight by the Council for Healthcare Regulatory Excellence, which is renamed the Professional Standards Authority for Health and Social Care in the Bill.

Amendment 259 would place in the Bill requirements in relation to the terms and conditions of public health staff working in Public Health England and local authorities. I reassure the noble Lord, Lord Patel, that employees who are compulsorily transferring with their current work function from the NHS to a local authority or Public Health England will—by virtue of either the Transfer of Undertakings (Protection of Employment) Regulations, TUPE, or a statutory transfer scheme under Clause 294, where the Cabinet Office statement of practice on staff transfers in the public sector, COSOP, applies—have their pay, terms and conditions protected.

The Government are currently working with stakeholders to develop a public health workforce strategy, and a formal consultation will be published in due course. We are now beginning the detailed work of developing a new set of terms and conditions for Public Health England and we have started work with trade union colleagues to negotiate a package on that.

The noble Lord, Lord Walton, asked about health inequalities. This is an issue that we covered when we talked previously about public health. I reiterate that we intend to encourage local authorities, through the conditions that we attach to their new funding, to consider the need to reduce inequalities when they discharge their public health functions. The noble Lord also asked whether the CCGs and the board will have duties to obtain appropriate advice. Again, this is an issue that has come up before. They will explicitly need to do that. He also asked whether they should be on these boards. We intend to require local authorities to have a core offer of public health advice to the NHS and we will publish more information about that shortly.

Coming back to the question of local authority terms and conditions of transfer, work is currently under way on a concordat, which will provide principles and standards relating to the transfer, selection and appointment processes affecting public health staff moving to local authorities. This is expected to be published shortly.

Various noble Lords made reference to emergencies. As the noble Lord, Lord Beecham, said, we will be talking about that when we come to a later group of amendments, so perhaps we can postpone consideration of that subject until then, when I can answer any questions that have come up.

In conclusion, I commend noble Lords for their great expertise in this area—expertise in public health and right across the domain, and also, as the noble Lord, Lord Beecham, showed, in local government. It is very important that this is put together effectively. Many have welcomed the move of public health to local authorities, and this should, as noble Lords have previously noted, present many very useful opportunities to put public health centre stage. We hear the concerns that noble Lords have flagged up as these changes take effect but I hope that they will note that we are taking back many of the issues for consideration. I see scepticism on the face of the noble Baroness, Lady Thornton, but I hope that noble Lords will have listened to what I have said in the key areas that they have flagged up. On that basis, I hope that the noble Lord will be prepared to withdraw his amendment and that noble Lords will continue their constructive engagement with the department in this area.

[Lord Warner]

Can the noble Baroness write to us about central government approval of people who are employees of the local authority? There are three areas where I should certainly like to be a lot clearer. The first is what the position with medical officers for health was in the past. My memory is that they were approved by the then Health Secretary. The second is the position of directors of social services. In the past, as I recall, they used to be approved by central government and were employees of the local authority. The third is the current position of chief constables. As I recall, they certainly had to be approved by the Home Secretary and I think may technically—although I am not sure—be employees of the local authority. It would help us to understand the Government’s position on this if we could have more clarity—certainly on those three examples.

[Baroness Northover]

I am more than happy to write to the noble Lord about those areas.

[Lord Beecham]

Perhaps the Minister, if not today then subsequently, could address her mind to the significant issue that I raised about the positions of directors of public health and district councils. Her assumption, which is fair enough at the present stage of the Bill, is that to all intents and purposes Public Health England and the Secretary of State are one. It is a political version of the theological concept of consubstantiation. I understand that, but that assumes that Amendment 260, which calls for Public Health England to be a special health authority, will not be approved. If it were approved, what would the Government’s position be on the question of joint appointments and consents that under the Bill at the moment would lie in the hands of the Secretary of State? At that point, Public Health England would not be the special health authority. I am not asking for an immediate answer, but if the amendment were to be approved—and I certainly hope it will be approved in due course—would it be Public Health England in those circumstances or would it be the separate Secretary of State’s role to adjudicate on those matters?

[Baroness Cumberlege]

I thought we were going to debate Amendment 260 later today and I would like to take part in that debate when we come to it in the groupings.

[Baroness Northover]

I thank noble Lords for being so willing to receive letters about the areas that they are concerned about. I found myself retrieving what I learnt in my history degree, and I suppose this then becomes the Reformation. I will ensure that we write to noble Lords about these areas.

[Lord Patel]

I thank the Minister for her detailed answer. I know that this is a complicated group of amendments, each one referring to different aspects of public health. As I said in my opening remarks, it is extremely important that we realise that if we want a strong, reliable, effective, qualified, properly trained and accountable public health workforce, we need to address their accountability, employment status, registration and regulation. I did not put these amendments down lightly. They in no way seek to change the policy or structures of the Bill; they merely seek to strengthen the role of public health directors and public health consultants.

I do not know whether the noble Baroness passed the Warner test, but I listened carefully and I know she said a couple of times that the Government were looking at it and will produce a plan in early January. We will look at that carefully and carefully read what she said. I am very willing to engage with her because the public health faculty out there has great concerns. It is not concerned because it wants to be difficult; it is concerned that it will be asked to deliver something while its hands are tied behind its back. It would much rather come out into the open, to be told its status and to have that status put into the Bill so that it can begin to do the work that it is being asked to do. On that basis, I beg leave to withdraw the amendment.

--- Later in debate ---

[Lord Beecham]

My Lords, again I have a great deal of sympathy with the amendment moved by the noble Lord, Lord Patel, and the amendments in the name of the noble Baroness, Lady Williams. It seems to me that there is the potential for confusion over the differing roles that arise in situations such as an outbreak of disease or other public emergencies. The Bill variously imposes duties on the director of public health, although not specifically on the local authority, to act in such cases, bearing in mind that the documents are to be issued by the Secretary of State. Quite what documents would be issued in an emergency is not clear.

Amendments 227 and 235 in the name of the noble Lord, Lord Patel, accord better with the situation which might arise. They clearly make the point of local authority involvement and do not simply rely on the provisions of Clauses 43 and 44, which confer duties on the board and clinical commissioning groups. Incidentally, the fact that such duties are imposed on clinical commissioning groups surely enhances the need for the director of public health to be a member of, or to be represented on, such groups. But that is a matter to which we will no doubt return when we come to the governance arrangements for clinical commissioning groups.

Clause 43 makes it the responsibility of the board to ensure that all providers designate an individual to be responsible for the relevant emergency. Again, it is not quite clear what is meant by providers in that context. The board is also required to secure that it and the clinical commissioning groups in the health service—but, specifically, not local authorities—are prepared for emergencies. There seems to be some fragmentation in the distribution of responsibilities for this situation. That matter is also reflected in the general position in relation to resilience and emergencies generally. At the moment, there is a strong regional structure and if there is a problem, the regional director of public health can intervene and can require steps to be taken. There is always the facility for someone to be directed to act in the case of an emergency; as it were, someone will always be on call. It is not clear that that will survive the new structures.

It is essential in these cases also to recognise the important role that the voluntary sector plays in a public emergency. The Red Cross and other organisations of course are very often the first on the scene. I know that the noble Baroness, Lady Emerton, will address this issue when she speaks to her amendment. In advance of her doing so, I want to indicate support for the involvement of that sector as a consultee in the question of appointing directors of public health but, more widely, for the contribution of that sector to be recognised.

This issue of fragmentation of responsibility and the lack of a regional structure, which will follow if the Bill is passed in its present form, is a matter that attracted the attention of the Health Select Committee. That committee’s report indicated that there is a lack of confidence in the structures that would replace the regional structures under the provisions of the Bill:

“We are concerned at the lack of clear plans for Public Health England to be established at the regional level. The idea of “sub-national hubs”, in some—as yet undefined—alignment with the sub-national structures of the NHS Commissioning Board and the Department for Communities and Local Government does not seem to us adequate”.

Public Health England needs clear strategic and regional accountability, and although we are not yet debating Public Health England, nevertheless there is clearly in the mind of that committee—and I share that view—considerable doubt about whether the structure, with perhaps four sub-national hubs and a number of groupings around the Health Protection Agency when it is now combined with and taken into Public Health England, will in fact be sufficient. Although Clause 44 gives the Secretary of State powers of direction, the absence of regional arrangements clearly could, in the minds of that committee, create considerable difficulties. So there are issues which are partly reflected in the concerns of members of the Faculty of Public Health to which I referred in the debate on the previous amendments, and the role of the Health Protection Agency in the new structure will bear materially upon that issue.

I think the amendments tabled by the noble Lord, Lord Patel, actually take us in the right direction. We need a stronger structure to cope with problems of disease, immunisation and particularly emergencies, and again I draw attention to the fact that local authorities that would be involved in emergencies are not necessarily the principal authorities with which a director of public health would be involved. Again I raise the issue of how district councils in shire county areas will be involved in those situations. Without necessarily seeking a response today, I hope that is a matter that the noble Baroness the Minister would take away and consider. I am afraid it is becoming a bit of a recurrent theme, but for that very reason it seems to me that we need to address it properly so that the entirety of the local government family is involved in preparing for and dealing with emergencies as they arise, given in particular that district health authorities have very significant responsibilities in some areas. The noble and learned Lord, Lord Mackay of Clashfern, referred to E. coli, and food safety is the function of district council authorities and clearly part of the agenda which has to be addressed when looking at public health as a whole.

I hope that on this occasion the Minister will be somewhat more sympathetic than she proved to be last time to the amendments that have been tabled by the noble Lord.

[Baroness Northover]

My Lords, we are always sympathetic to all sorts of amendments, and the fact that we take away amendments and consider them further should, I hope, reassure noble Lords—

[Baroness Emerton]

I apologise to the Minister; I was waiting to speak to my Amendment 236ZA. The issue of voluntary sector involvement is important because the changes proposed in the Bill have significant relevance to it and in particular to the voluntary aid societies. The British Red Cross and St John Ambulance provide emergency response and are recognised respondents under the regulations of the Civil Contingencies Act. I declare an interest as a member of St John Ambulance for 66 years.

The history of the status of these two organisations goes back to the Geneva Convention. Because they have a specific responsibility for providing emergency services, there needs to be clarity about the lines of accountability within local authorities. Both organisations are recognised in the humanitarian field and for first aid and for looking after civil or military emergency situations. That is their responsibility. The auxiliary status is enshrined both in the royal charter for the Red Cross and in the Geneva Convention. The Women's Royal Voluntary Service used to be included, but it has withdrawn from voluntary aid society status. Nevertheless, all voluntary organisations are important in that they are present and they will need to know how to be organised under these new arrangements. They want to be assured that they will be commissioned, as they are now under the Civil Contingencies Act. Prior to this Bill, they were commissioned by the PCTs through local authorities and these changes have significance for them in how they will be managed and how the chains of communication will work.

The community-based presence of both organisations means that they are involved in vital emergency responses. They are first-responders and deal with civil emergencies. They hold, for example, a large number of ambulances with four-wheel drive. Indeed, the London Ambulance Service says that it cannot possibly cope in an emergency without the backup of the volunteer ambulances, particularly in bad weather. I speak to this amendment because voluntary organisations need to be involved and need clarification of their communication with local authorities.

--- Later in debate ---

[Baroness Northover]

My Lords, these amendments address the response to emergencies. We agree entirely that dealing quickly, decisively and in a co-ordinated way with sudden threats to public health must be a priority for the new system. We believe that the establishment of the position of director of public health within local authorities will strengthen considerably their capacity to respond to emergencies. However, the overall response will depend on the precise nature of the threat, as my noble friend Lord Ribeiro has indicated, and it is very likely to involve the NHS and other agencies, such as Public Health England, as well as local authorities. Therefore we want to allow for local flexibility in deciding who is best qualified to lead the response to a particular incident. Nevertheless, we must also ensure, when incidents occur, that all the responders are prepared and fully understand the parts that they play. We agree that the duty for local authorities, which we intend to prescribe in regulations, must be strong enough to ensure that the right arrangements are in place, not just a document that describes those arrangements.

We believe that the Bill already provides for the kind of coverage that is required. Clause 27 sets out a number of responsibilities for directors of public health and is already clear that these include the local authorities’ functions in planning for and dealing with public health emergencies. This, we think, fully matches the intention behind Amendment 227.

We agree with the spirit of the noble Lord’s Amendment 235. Clause 15 gives the Secretary of State the power to specify in regulations certain steps that local authorities must take under their new public health duties. The regulations will be subject to the affirmative procedure in Parliament, but I can assure the noble Lord that we expect that the steps the Secretary of State prescribes will include ensuring that robust and agreed local plans are in place for dealing with threats to public health, even if they are not full-blown emergencies.

Amendment 236ZA, tabled by the noble Baroness, Lady Emerton, and other noble Lords, recognises the invaluable role that the voluntary aid societies, such as St John Ambulance, can play in dealing with emergencies. We certainly have no difference with the noble Lords on that, and hope—and expect—that local authorities will involve St John Ambulance and other agencies, such as the British Red Cross, when they ensure that plans are in place for tackling threats to health. We will consider how to address this issue in the regulations that we intend to make. On that basis, I hope the noble Baroness will be willing to withdraw her amendment.

I come now to the amendments in the name of my noble friend Lady Williams of Crosby. My noble friend Earl Howe said that at this point I should simply concede because they were in the Bill anyway, but I will address the substance of her amendments. She seeks to enhance the readiness for emergencies by conferring additional duties on the Secretary of State. I assure noble Lords that the Secretary of State already has the clear duty to protect health not only by virtue of Clauses 8 and 44 but under the Civil Contingencies Act 2004. Both the NHS Commissioning Board and the Secretary of State will be category 1 responders. As such, they will have a duty to assess, plan and respond before and during an emergency. This is made clear in Schedule 7 of the Bill. There might have been a slight misunderstanding over this.

The words at the start of Clause 43 that will replace the current cross-heading preceding Section 253 of the 2006 NHS Act that reads simply “Emergency powers”, are:

“Emergencies: role of the Secretary of State, the Board and clinical commissioning groups”.

New Section 252A then deals with the role of the board and CCGs, and Section 253 deals with the Secretary of State. We are not removing the Secretary of State’s role. The Secretary of State retains his role, exercising his powers as indicated in Section 2 of the 2006 Act and under the Public Health (Control of Disease) Act 1984, as well as his duties under the Civil Contingencies Act 2004. I hope that my noble friend will be reassured in this regard.

Amendment 238, tabled by my noble friend Lord Marks, would require the NHS Commissioning Board to consult a Secretary of State before it takes steps to facilitate a response to an emergency that requires co-operation between different parts of the health system. These are operational decisions that are often taken at a local level where speed is very important. For example, hospital operations in one part of the country may need to be suspended because blood supplies are needed elsewhere. The amendment could inadvertently introduce additional delays into the decision-making process in a response to emergencies.

The clauses as currently written allow the health service to respond to emergencies directly and effectively and give the Secretary of State the power to intervene. We will consider what noble Lords have said but, in the mean time, I hope that they will not press their amendments.

The noble Lord, Lord Ribeiro, asked for a definition of emergency. I am assured that emergency has its ordinary meaning. I will write to him with the full definition rather than take noble Lords’ time. On the basis of what I have said, I hope that the noble Lord will be willing not to press his amendment.

[Baroness Emerton]

I thank the Minister and look forward to seeing the regulations.

--- Later in debate ---

[Lord Walton of Detchant]

Before the Minister writes to the noble Lord, Lord Ribeiro, with a definition of emergency, could she clarify whether we are talking in this Bill about medical emergencies, such as serious epidemics, or whether we are also talking about terrorist attacks, floods and natural disasters, all of which may require the deployment of medical resources? It is important that that should be clarified.

[Baroness Northover]

My Lords, I will write to noble Lords if it is not that wide a definition, but my assumption is that it is the wider definition that needs to be covered.

As a brief response to the noble Lord, Lord Patel, I can say that much of this will be in regulations. I know that the previous Government had problems when they said that they would put something in regulations. The House would say that it wanted to know while it passed a Bill exactly what it would be, but a distinction needs to be drawn between the kind of things that you want in the Bill, where there needs to be an architecture and structure that gives flexibility, and the kind of precision and more detailed explanation that you have in regulations. The noble Lord will be familiar with that. If we can take anything further and outline what sort of things might be in the regulations, as the previous Government also sought to do, I am sure that we will.

[Lord Patel]

I beg leave to withdraw the amendment.

--- Later in debate ---

[Lord Colwyn]

My Lords, my noble friend Lady Gardner reminds me of how I used to practise. It is not a lot of fun to pull a load of teeth out for a child under general anaesthetic. We are in great danger of getting into a pro and anti-fluoride debate, which I do not want to do. However, I want to support the noble Lord, Lord Hunt, who is a patron, or vice-president, of the British Fluoridation Society, as am I.

As it stands, Clause 32 will mean that after 1 April 2013 the money currently spent on the existing NHS schemes will pass to local authorities, which do not have a dental budget. They would have to pass it on to the Secretary of State via Public Health England to pay the continuing bills. Would it not be more efficient and quicker if the current NHS spend on fluoridation went directly to the Secretary of State—that is, Public Health England? It would mean that the organisation that pays the bills has the money in its account and is not reliant on transfers from local authorities.

As the Bill stands, when any new schemes are agreed by local authorities after they take charge of consultations on fluoridation, the Secretary of State will look to them to pay for those schemes. However, local authorities are not responsible for dentistry and have no dental health budget. The amendment of the noble Lord, Lord Hunt, means that although local authorities will be the decision-making bodies in future, the money for any fluoridation schemes that they support will come from the dental health services budget of the NHS Commissioning Board—the body that stands to benefit from the reduced treatment costs that would inevitably follow. The NHS Commissioning Board would transfer funds to the Secretary of State, who would pay the bills submitted by the water companies. Does the amendment of the noble Lord, Lord Hunt, not simplify the process?

[Baroness Northover]

My Lords, let me first set out the Government’s position on fluoridation. The Government’s policy is that decisions on fluoridation should be taken locally. That is why we have transferred the responsibility for conducting consultations and determining their outcome to local authorities. More than 5 million people, mainly in the West Midlands and the north-east of England, receive a water supply in which the fluoride content has been topped up to a level of one part per million. Worldwide, some 200 million people now receive fluoridated water in the United States and 11 million more in Australia. There are also fluoridation schemes in Ireland, Canada and Hong Kong.

I hear what the noble Earl, Lord Baldwin, said about evidence. A report, A Systematic Review of Public Water Fluoridation, commissioned by the department of health at the University of York, was published in September 2000. It concluded that water fluoridation increased the proportion of children without tooth decay by 15 per cent and that children in fluoridated areas had, on average, 2.25 fewer teeth affected by decay than children in non-fluoridated areas. However, as the debate has shown, there is a great range of views on this matter. That is why we feel that decisions must be taken at a local level following extensive consultation.

Our view is that the responsibility for proposing fluoridation schemes and for conducting consultations on such schemes should transfer to local authorities, while the responsibility for contracting for fluoridation schemes should transfer to the Secretary of State. In practice, the Secretary of State’s functions would be carried out by Public Health England. Making local authorities responsible for consultations on fluoridation schemes fits well with their responsibilities for public health. We anticipate that proposals for fluoridation schemes will derive from the joint strategic needs assessments that local authorities and health bodies will make of their populations.

The noble Lord, Lord Hunt, raised the question of whether local authorities would neglect dental health. Dental ill-health would seem to have wider repercussions. The great difficulty, particularly among older people whose teeth have decayed, certainly bears out the necessity of preserving teeth in younger life. It is not simply a matter of looking at children’s teeth and the impact on them but of seeing dental health as lifelong. Health and well-being boards would therefore have a responsibility to consider dental health because of that significance.

More than one authority might be involved in any scheme that is put forward because water distribution systems are generally larger than the area of an individual local authority. The Bill sets out a number of initial steps that the lead or proposing local authority must take, including consulting relevant water undertakers and the Secretary of State to ensure that a proposed scheme is operable and efficient. Unless only a single authority is affected, or the other affected authorities do not wish to participate in the process, the Bill requires local authorities to arrange for a joint committee to carry out the consultation process and make subsequent decisions in relation to the proposal. From 2013-14, the department intends to allocate a ring-fenced public health grant to local authorities. The ongoing costs of fluoridation schemes will be reflected within the grant to those local authorities.

The noble Earl, Lord Baldwin, asked about neutral information. This is an area where we should proceed on the basis of evidence. Public Health England might well be the right body to assess such evidence. The noble Earl also asked about schemes going ahead only with the support of the local population. The provisions in the Bill transfer responsibility for consultations to local authorities and include powers for the Secretary of State to specify the steps that local authorities must take in relation to consultation. We expect that the evidence base will still determine a decision to consult. However, putting local authorities in charge of consultations would make decisions on fluoridation more democratically accountable. We intend to consult on the detail of the regulations, including the process that local authorities must follow when ascertaining public opinion.

My noble friend Lady Eaton asked whether people would be able to reject local fluoridation. Of course, consultation needs to be meaningful. The decision to consult and whether to fluoridate will be for local authorities, not the Secretary of State, to take. We expect them to take account of the scientific evidence as well as public opinion.

I acknowledge that these provisions and the whole area are complex. Much of the technical detail will be included in regulations. No doubt we will have further profound discussions of this. We intend to consult on the policy proposals for the regulations that we will make under the powers in this clause in a consultation document that we will publish in due course. In the light of this, I hope that noble Lords will be content not to move their amendments, and that the noble Lord, Lord Hunt, will be happy for the clause to stand part of the Bill.

Health and Social Care Bill

Baroness Northover Excerpts

Monday 5th December 2011 Lords Chamber

[Baroness Thornton]

My Lords, what links the two parts of this debate are the unintended consequences and the need for second and third thoughts about things. My noble friend Lord Patel, the noble Lord, Lord Adebowale, and the noble Baroness, Lady Hollins, expressed concern about this clause. That is frankly good enough for me. It has been suggested elsewhere in the way of things that some enthusiastic civil servants, in the process of tidying up this Bill, have actually brought about what could be serious unintended consequences. The noble Baronesses, Lady Murphy and Lady Barker, also have some important points to make about the amendment in the name of the noble Baroness, Lady Barker. This House spent many hours constructing the architecture through the Mental Capacity Act and the Mental Health Acts, not all of it right. I do, however, remember the duty of co-operation being an important part of those Acts; those rights, protections and duties are very important and we need to check that we have not damaged them through the construct of this Bill.

On Clause 51 stand part, we on these Benches are pleased to support the important amendment put down by the noble Baroness, Lady Finlay, about the problems that might occur when the responsibilities of primary care trusts for the certification of deaths are transferred to local authorities. I do not intend to read out the whole of this note because the noble Baroness, Lady Jolly, has referred to most of it, but we are very concerned that these proposals will mean delay and an increase in cost when people are at their most vulnerable and least able to withstand that. I do not think that anybody in this House would want that to happen. I suspect that the Government would not want to place in jeopardy the trust and confidence in the system as it is, and I think there is a danger that Clause 51 does that. We on these Benches support the amendments in this group.

[Baroness Northover]

My Lords, noble Lords have spoken passionately about the need to support patients who are particularly vulnerable. These are complicated areas, and I am happy to write to noble Lords to clarify what is intended in the Bill and to address their specific questions if I do not answer them in what I say here.

The Bill makes a number of essentially consequential amendments to the Mental Health Act 1983. The Government are also taking the opportunity to remove a few redundant powers and to make a small number of changes to that Act. That is the intention. This is not a major shift; these are meant to be tidying-up changes. However, if they have unintended consequences, it is important that they are flagged up, and I hear what the noble Lord and other noble Lords said.

The principal changes are the change in the responsibility for commissioning independent mental health advocates from the NHS to local authorities and the change in the requirement that a second opinion must be given even where patients on supervised community treatment consent to their treatment. This condition does not apply to patients who are detained in hospital and is contributing to the major difficulties that the Care Quality Commission is experiencing in managing the second opinion appointed doctors service.

The Government are also taking the opportunity afforded by the Bill to make a number of changes to the Section 117 of the 1983 Act. The first amendment in this group, which was tabled by the noble Lord, Lord Patel of Bradford, addresses that. The main change is to transfer the duty on primary care trusts to commissioning consortia, but the clause also takes the opportunity to align the duty in Section 117 more closely with mainstream NHS legislation. That is the intention. For example, it gives the Secretary of State the power to make regulations that say which consortium is to be responsible in any given case. That will allow us to end the current anomaly that sees some PCTs responsible for Section 117 aftercare for patients whose other needs are the responsibility of a different PCT.

Regulations could also say that, in particular circumstances, the NHS Commissioning Board is responsible rather than the consortium. That would allow us to prevent consortia ending up having to commission services that are normally commissioned by the board just because the patient happens to qualify under Section 117. The noble Lord, Lord Patel, spoke very persuasively about the need to avoid this clause having unintended side effects, and I can confirm that that is certainly not the Government’s intention. I am very happy to meet the noble Lord to discuss these issues further.

On co-operation with the voluntary sector, we need to consider consistency with other services that CCGs will commission in order not to give in some way a distorted picture of when CCGs should work closely with the voluntary sector. Nevertheless, I am happy to have further discussions on this point.

On charging, which is clearly a significant concern of the noble Lord, the Bill does not change the current situation. Patients will not have to pay for any care under Section 117. I hope that I can reassure the noble Lord on that point.

The second amendment in this group was tabled by my noble friend Lord Marks and is about access for children who come under the 1983 Act to the services of an independent mental health advocate. Section 130C of the Mental Health Act 1983 already gives the same right of access to such an advocate to all qualifying patients, including children. Making special provision for minors might give the impression that other qualifying patients should have lower priority for access to such services. Our aim is that every vulnerable person who comes under the major provisions of the 1983 Act and wants the support of an advocate should have one. That should, of course, include every child and young person, but it should also include everyone else as well. The current law not only supports the aim of this amendment in respect to children but does so for all vulnerable people of all ages.

--- Later in debate ---

[Baroness Barker]

I understand entirely my noble friend’s response to my amendment. I am very pleased with that. No doubt I and other noble Lords will spend at least part of 2012 making sure that we hold the Government’s hand to the flame on that review. I wanted to respond to what she said about the amendment in the name of the noble Lord, Lord Patel of Bradford, which I very much support. The first scenario that the Law Society and others were trying to probe in that amendment was one where it was unclear whether or not a patient came under the auspices of a CCG. The second was what would happen if a CCG decided not to commission a particular type of service—for example, some kind of psychological therapy—and it did so independently and not in discussion with the social services authority. I was not clear from the noble Baroness’s answer whether in her discussions with the noble Lord, Lord Patel, she would be covering both those eventualities.

[Baroness Northover]

My Lords, I am happy to cover both those eventualities in the discussions. Moving on to Clause 51 concerning death certification reforms, this amendment to the Coroners and Justice Act 2009 places responsibility for the appointment of medical examiners and related activities on local authorities in England instead of the PCTs. The Government are committed to implementing the reforms of the process of death certification set out in the Coroners and Justice Act 2009. These are important and long overdue reforms, which will involve a medical examiner providing an independent and proportionate scrutiny of cause of death in all cases not investigated by a coroner. The reforms will improve the quality of information on cause of death, increase transparency for bereaved families, and strengthen local clinical governance and public health surveillance arrangements. As your Lordships will be aware, these reforms form part of the response to the recommendations of the Shipman inquiry and, of course, the noble Baroness played a key role in taking these changes through.

The clause moves responsibility for the appointment of medical examiners from PCTs to local authorities and makes similar changes to the arrangements for performance managing and funding the medical examiner service. This change is needed because of other provisions in the Bill which will abolish PCTs from April 2013, despite the quote that was made earlier. Establishing the medical examiner service in local authorities should enhance the availability and accessibility of important public health information and intelligence. It will also align the service with other existing local authority responsibilities, including coroner and registration services.

I now turn to the fee payable for death certification, which, clearly, is a very difficult and immensely sensitive issue. Many people, including my noble friend Lady Jolly, have questioned whether there should be a fee at all and whether the state should pay for certification of death. It is the Government’s policy in line with the proposals set out by the previous Government in 2009 that the medical examiner’s independent scrutiny and confirmation of cause of death stated on the certification should not result in an increase in costs. It is also important to remember that the payment of the fee is already the case as regards the 70 per cent of people who are cremated, with this fee forming part of undertakers’ fees.

The current economic situation means hard choices are inevitable and the need to ensure that certification of death is cost neutral is one of those challenges. With regard to how the fee is paid by individuals, I am aware of the problems. Let me make it clear: it is neither the Government’s desire, nor intention, that this fee should be paid upfront. We would like to come to a solution that fully recognises how difficult a time this is for families and we do not want to add to the heavy burden which is felt at such a time.

As such, we have already started discussing with stakeholders and others how to arrive at an appropriate method for payment of fees. We will be consulting fully on this topic and want to hear the full range of views before making a decision. Given the sensitivities, if any Member of the Committee would like to discuss these issues further with me or officials, we would be very happy to take that forward. In due course, I will move that this provision stands part of the Bill.

[Lord Patel of Bradford]

I am very grateful to the noble Baroness for her response. I am particularly grateful to noble Lords who have contributed on the amendment standing in my name. We have had the benefit of the huge expertise and experience not only of the voluntary sector but of eminent psychiatrists who understand what happens to patients detained under the Mental Health Act. We should not simply ignore those views or brush them under the carpet. My problem is that we have heard a number of times in this Committee that, “Such-and-such is not an intention of the Bill, and the new arrangements will ensure that quality and outcomes are the prime drivers in decision-making rather than cost or expediency”. No doubt that is what is intended, but as we all know, the road to hell is paved with good intentions.

This is not a technical issue, or an issue that can be left alone in the hope that matters will resolve themselves and things will work out. This is about a fundamental principle of law that seeks to protect the vulnerable. The noble Lord, Lord Adebowale, gave a perfect example of what happens to real patients. If we cannot act now in the best interests of those who cannot speak for themselves by virtue of being detained under the Mental Health Act, who are by definition vulnerable and dependent on the state to make the right choices for them, then I do not know what we are doing here today.

The amendment tabled by the noble Baroness, Lady Barker, exemplifies why we have to be very careful about decisions that we make for this group of patients—the unintended consequences could be enormous. It is wonderful that the Minister said that the Government will review this next year. That is welcome. However, how many more lives will be ruined in the next 12 months? We have made mistakes in the past and we continue to make them. In terms of this amendment and Section 117, the danger with simply moving forward and saying, “This will be okay—that is not what we intend”, does not sit comfortably at all.

My amendment is very simple: it will ensure that CCGs and social services authorities continue to have a joint duty. I cannot see why we should not insist that CCGs and local authorities should have a joint duty in relation to this very vulnerable group of people. It will ensure that the joint duty includes maintaining co-operation with relevant voluntary agencies. We are asking the voluntary sector, “Please take over services and help us deliver”, and all the rest of it. Why can we not maintain the co-operation that exists?

The amendment will also ensure that the duty remains free-standing, as was the clear intention of the Appellate Committee of this House, so that aftercare services are not limited to other provisions but can actually meet the patient’s needs. By doing so it ensures that patients who have been detained under the Mental Health Act and require aftercare services do not find themselves having to pay for those services.

The noble Baroness said that there is no intention regarding payment. However, I think that I gave enough examples in my speech to show why I think that will be challenged. I am not a lawyer or an expert on these things but I did look at the judgment. What is interesting about the judgment that was given way back in 1999—when we did not have austerity measures and there were plenty of resources—was that, on three occasions, three local councils tried to force four people detained under the Act to pay for aftercare services. They had three different appeals. By the time they got to the fourth appeal in this place, one of the patients had died. That emphasises my point about how long people have to wait. If they were trying to charge then, what is going to happen now when we are desperate for resources in health and social care? People are really going to be pushing this.

I am afraid that that does not hold water for me at all. I tabled this amendment in good faith but I am concerned that clauses in this Bill will clearly have unintended and detrimental consequences. We chose not to reject this Bill out of hand under the rightly justified position that it is the proper place of this House to amend and improve legislation through a robust process of scrutiny. I believe that my amendment is the right and proper way to correct the Bill and to prevent significant harm arising.

[Baroness Northover]

I did not directly address the Stennett case and I must do so. The Stennett case indeed makes clear that such services have to be provided free of charge and the Bill in no way overturns that. It does not challenge that. What comes under Section 117 remains as it was—what is provided by it is still free of charge. This does not in any way challenge the Stennett conclusion.

[Lord Patel of Bradford]

The clause actually says—again, I am not a lawyer; I am looking at this in layman’s terms—that you do not need to have this consultation. As the noble Lord, Lord Adebowale, said, Mr Bloggs could then leave hospital and receive some accommodation, daycare and counselling through the health service, but the local authority could then decide unilaterally to say—as it can—“Right, the daycare and the accommodation have gone. We are not going to pay for them”. It does not even consult the patient or the CCG. It can do that. The legislation states that. The clause says that local authorities can do that now. It is okay.

We are being foolish if we think that local authorities or CCGs are not going to opt out of this where they can. They will opt out of providing bits of services. The voluntary sector will be lumbered with them. It will be told to pick up the tab, but organisations such as Turning Point do not have the resources to pick up the tab.

[Baroness Northover]

I repeat my invitation. The noble Lord makes a cogent case. I invite him to come into the department and make that case. I am saying that his worries are ill founded, but if he is right and there are things that need to be done to ensure that the case that I am making is indeed watertight, please will he help us to do that?

[Lord Patel of Bradford]

The noble Baroness is almost as persuasive as the noble Earl. I gratefully accept the invitation, and I am sure that the noble Lord, Lord Adebowale, will also be very happy to sit with officials. Like I say, I do not think for one second that the department is being malicious. There are some unintended consequences that are worth exploring further to see if we can make this legislation better. I beg leave to withdraw the amendment.

International Development Policy

Baroness Northover Excerpts

Thursday 1st December 2011 Lords Chamber

[Baroness Northover]

My Lords, I, too, thank the noble Earl, Lord Sandwich, for securing this debate and for introducing it, as ever, so cogently. As others have also said, he has an outstanding record of work in this area. Once again, the depth of experience among noble Lords has shone through. I was struck by the very wise maiden speech of the noble Lord, Lord Singh of Wimbledon, which I thoroughly enjoyed. I am sure that we all look forward very much indeed to his future contributions.

This debate—in its title, at least—spans all that the Department for International Development does and has an especial and additional focus on Dalits. In some ways, their plight serves to show up all that we should be doing: if we are not addressing the needs of the most marginal people, then what is our purpose? Underlying all this is fairness. Across the world, too many people live in conditions that are anything but fair. In sub-Saharan Africa, one child in seven does not live to see their fifth birthday simply because of unsanitary conditions and dirty water. Every year, more than 1 million children lose their mothers simply because those women did not receive adequate care during pregnancy and childbirth. Each day, 69 million children do not have the chance to go to school.

As the right reverend Prelate the Bishop of Ripon and Leeds said, we know that what we are doing to help people out of poverty is right, but we also know that it is in everyone’s interest. The noble Lord, Lord Hannay, played his part in the UN high-level panel, which made very clear that particular link. If we fail to tackle the root causes of the global challenges that face us, whether they be economic instability, conflict and insecurity, climate change or migration, then we will all suffer the consequences. That is why I am very pleased that, despite our economic situation, the coalition has kept to its commitment to spend 0.7 per cent of GNI on aid from 2013. I thank noble Lords for the welcome that they have given to that commitment, as well as for the very kind words that have been expressed to me by noble Lords.

I can also assure noble Lords that, as well as meeting their promise on the quantity of British aid, the Government are determined to ensure the quality of British aid. We are doing what we can to encourage other countries to meet their promises. It is in extremely difficult circumstances that this is the case, as noble Lords will appreciate, and we are also, as referred to by the noble Lord, Lord Hannay, trying to bring in the BRIC countries. My right honourable friend the Secretary of State received a positive response when he was in China and I look forward to hearing more from him on this issue.

On the quality of aid, the coalition Government undertook the bilateral and multilateral reviews referred to by noble Lords. The noble Earl, Lord Sandwich, in particular, asked about specifics, particularly in relation to the bilateral review. All DfID’s programmes were assessed against need, effectiveness and other factors, including what was being done by other donors. DfID concluded that British aid should in future be focused on 27 countries, which together account for three-quarters of global maternal mortality, nearly three-quarters of global malaria deaths and almost two-thirds of children out of school. This tighter focus will ensure that we concentrate our efforts where the need is the greatest, increase our impact on fragile or conflict-affected states and deliver in the places where most poor people live. Aid to Russia and China has been stopped, while another 14 countries will see their existing aid programmes closed by 2016.

The noble Earl, Lord Sandwich, asked about Kosovo. I can assure him that DfID’s graduation from Kosovo will be a phased process, honouring existing commitments and exiting responsibly. After 2012, the British embassy will continue to support Kosovo and UK funding will continue through the EU and other multilateral agencies. The noble Earl will no doubt note how well the EU came out of the multilateral review, and we are very glad that the UK can continue its strong funding through that, which will support Kosovo.

In the multilateral aid review, DfID assessed 43 international funds and organisations to which the UK contributes. Nine organisations, including UNICEF and GAVI, were assessed as providing very good value for money and therefore we are increasing their funding. The noble Earl asked whether there was a particular proportion that would go between bilateral and multilateral countries. There is not a fixed proportion. In the multilateral review, four organisations were deemed to be underperforming and have been placed on special measures. We are pressing for UNESCO, the Food and Agriculture Organisation, the Commonwealth Secretariat and the International Organisation for Migration to improve their performance. Should we see no improvement when these organisations are re-assessed in 2013, the UK will reconsider its support.

I hear very much what the noble Lord, Lord Hannay, said about UNESCO, which we did indeed discuss at Question Time the other day. I have written to him on that subject and I hope that he will receive that letter shortly. We bear in mind the balance between the challenges facing UNESCO in this regard and its need to make sure that it delivers more effectively than thus far.

These are extremely difficult times for the United Kingdom. Therefore, it is even more important that people can see that the aid that they are supporting through their taxes is targeted, focused on the poorest, and makes a difference. The noble Earl is quite right that there is great public support for aid.

The noble Lord, Lord Judd, is right to flag up whether the emphasis on results puts the longer-term programmes under some question. The answer is that we are acutely aware that development is a long-term process. We are fully committed to that. The concentration on education, health, girls’ education and so on underlies that commitment, but it is also important that people can see the end-result of their aid giving so that we can ensure that we can maintain the percentage to which we have committed this Government.

No other Government thus far have managed to achieve that. I bear in mind what the noble Baroness, Lady Kinnock, said about there not being as much money available, even when we meet the 0.7 per cent, as if we had a really flourishing economy. That is enormously to be regretted, but I note what other noble Lords said about the achievement of reaching even 0.7 per cent. I pay tribute to the previous Government for helping us on that way, but this coalition Government are committed to that.

Just as DfID has scrutinised multilateral donors, it is offering itself for scrutiny because that is very important in people understanding where this money is going—hence the new Independent Commission for Aid Impact, ICAI, which published its reports recently, and DfID’s new aid transparency guarantee. The focus on results does not mean that we do not understand how development is a long-term effort.

We also know that the concentration on fragile states will not easily produce instant results, but we are acutely aware that conflict breeds poverty. No low-income, fragile country has yet achieved a single millennium development goal. I hope that I can assure the noble Baroness, Lady Kinnock, that we are making plans for after 2015. Although at the moment there is tremendous focus on trying to ensure that as many elements of those MDGs as possible can be delivered, we are looking beyond that.

We are increasing the level of funding for fragile states to 30 per cent of development aid by 2014-15, while the building stability overseas unit, which is based jointly with DfID, the Foreign Office and the Ministry of Defence, is focusing on upstream prevention. Some of the lessons learnt from the lack of development awareness in the early days in Afghanistan, for example, must surely be applied in the future, as well as some of the lessons from Iraq. For example, not destroying the infrastructure needed to support the civilian population once the initial conflict was over is one lesson that was carried through, with the building stability overseas unit emphasising that that was to be the way that things were approached in Libya.

I know that noble Lords will understand and commend DfID’s focus on women and girls, recognising that daughters, mothers and wives tend to reinvest gains in their own families and communities, completing a virtuous cycle of development. We will also invest in girls’ education. One extra year of schooling can increase a girl’s wages by 10 to 20 per cent, helping to end the transition of poverty from one generation to the next. We will maintain a particular focus on maternal health, saving the lives of 50,000 women in pregnancy and childbirth.

I hope that the noble Viscount, Lord Craigavon, will welcome the fact, as he seems to have done, that we will also give at least 10 million more girls and women access to family planning. Contraception costs less than £1 a year. The noble Viscount noted that the global population figure now stands at 7 billion, which shows how important the policy is. That cannot be overstated.

More generally, we are seeking to provide people with the means to pull themselves out of poverty. Wealth creation is the engine of long-term growth, as we have seen in parts of Asia, and so we are putting in place the conditions—land reform, better transport links, fairer legal systems and improved internet access—that we hope will encourage that development. Within DfID, a new private sector department is helping to promote this. We will redouble our efforts to open global market opportunities to developing countries, pressing the EU to do all that it can to make sure that poor countries benefit. We will continue to lobby G20 countries to provide 100 per cent duty free, quota free, market access for the least developed countries.

Where British companies invest in developing countries we will make sure that they do so in an open, transparent and accountable manner. The new Bribery Act helps to reinforce that. We strongly encourage businesses to respect human rights and the environment and we provide support for international standards, such as the OECD guidelines for multinational enterprises.

I was asked about the extractive industries. UK support for that has contributed to 11 countries reaching compliance status and 22 other candidate countries going through the validation process by September 2011. The right reverend Prelate is absolutely right that it is extremely important to look at the economic development of these countries and to make sure that that is occurring in a way that assists the population at every level, down to the bottom billion to which reference has been made, and not simply to those at the top, and that we do not concentrate simply on aid.

Good health is a basic starting point for people who are trying to lift themselves out of poverty. That, too, is an area on which we very much focus. At the moment, there is a strong emphasis on malaria in all our country programmes with a view to helping halve malaria deaths in the 10 worst affected countries. On this World AIDS Day, the British Government remain at the forefront of global efforts to tackle HIV/AIDS, on which I note that I have another debate immediately after this. Although we have made huge progress, there are still more than 34 million people living each day with HIV. Our main focus is on women and Africa where there is the highest incidence and the greatest vulnerability.

Alongside all our proactive work on governance, health, education and economic growth, we will continue to respond to humanitarian emergencies. As noble Lords know, more than 13 million people are experiencing the worst effects of the drought that has spread across the Horn of Africa. UK aid is providing much-needed support, including food, vaccinations and clear water and sanitation. Our response to humanitarian crises has also been reviewed by my noble friend Lord Ashdown—a review that has been widely welcomed internationally. The incidence and severity of natural disasters is likely to increase due to climate change. We know that the poorest and most marginal will be hit the hardest and worst. The noble Lord, Lord Judd, is absolutely right about that and it is a major focus of DfID.

Time is running short, and I want to turn now to the Dalits. Noble Lords have rightly made the point that members of the Dalit caste suffer from the most severe forms of poverty, deprivation and exclusion. Often living apart from the rest of society they routinely face discrimination in accessing basic services and are barred from undertaking certain occupations. The case of the Dalit girl mentioned by my noble friend Lord Avebury brings that graphically home to us. We have heard much about their plight from noble Lords—in particular, the noble and right reverend Prelate, Lord Harries of Pentregarth, and my noble friend Lord Avebury, who have been doughty champions of Dalits in this House in terms of those overseas and those in the United Kingdom.

Britain is committed to helping India to eradicate caste discrimination. Indeed, as noble Lords know, discrimination on the grounds of caste was abolished by the constitution of India in 1950, but we recognise that there is a long way to go. The UK regularly raises such issues with the Government of India, about which the noble Earl, Lord Sandwich, asked. It was last discussed in September on a ministerial visit by my noble friend Lady Warsi.

DfID’s development programme is specifically designed to benefit the poorest and most excluded, including Dalit women and girls. We are seeking to increase the number of Dalit children, especially girls, enrolled in school. My right honourable friend the Secretary of State for International Development is due to visit India shortly and plans to meet Dalit girls while he is there and seek to address how we can ensure that more of them are in school and able to see school through.

At a strategic level we are supporting civil society programmes, such as the poorest areas civil society programme and the international partnerships programme. Both are aimed at tackling discrimination, and together the two programmes should help more than 25 million excluded people.

DfID is also working with Dalit groups in Bangladesh and Nepal to help them access basic services, such as health and education. DfID Nepal is working with the Dalit NGO Federation and my honourable friend in the other place, Lynne Featherstone, visited Nepal in June this year in her capacity as champion on violence against women, and engaged with Dalit women there. The noble Earl, Lord Sandwich will remember that when we were in Nepal a few years ago through DfID, we also met Dalit groups and I certainly found that extremely informative.

I am aware that I am running out of time and have numerous questions from right across the House. My best strategy is to write to noble Lords in answer to the numerous questions raised. To conclude, as ever this has been an extremely stimulating, wide-ranging and constructive debate, which has amply demonstrated the House’s understanding of the many complex challenges which we face in our efforts to alleviate poverty and suffering across the world. We know there are major challenges facing all of us, we know we are all inter-linked and the noble Lord, Lord Singh, put that beautifully. Something happening in one area of the world will have an impact elsewhere. We know it is a challenge maintaining aid when we are in the midst of our own economic problems. We also know that, whatever those problems are, those who are the most vulnerable are those who are already at the margins—the poorest and especially the women and children among them. I know that view is shared right across the House.

HIV and AIDS in the UK

Baroness Northover Excerpts

Thursday 1st December 2011 Lords Chamber

[Baroness Northover]

My Lords, I congratulate my noble friend Lord Fowler on securing this important debate today, World AIDS Day. He has an outstanding record as the person who very much shocked us into an awareness of AIDS. He also deserves plaudits for his continuing interest in HIV and AIDS nationally and internationally, an interest that has done much to raise awareness inside and outside Parliament. As we know all too well, in issues such as this awareness is a significant part of the battle.

The report by the House of Lords Select Committee on HIV and AIDS in the United Kingdom, No vaccine, No Cure: HIV and AIDS in the United Kingdom, was most timely, given that it was 25 years ago when my noble friend led the Government’s response to HIV and AIDS. I commend the outstanding membership of this Select Committee, many of whom have a long record of work in this area, as I know from when I was an officer of the All-Party Parliamentary Group on HIV and AIDS. This report will help to inform the Department of Health’s new sexual health policy framework planned for next year.

In October, we published the Government’s response to the report and made clear that we agreed with many of the Committee’s recommendations on combating HIV and AIDS. World AIDS Day provides an excellent opportunity to reflect on the progress that we have made. Globally, there has been progress. The epidemic has stabilised in many regions. New infections have fallen by 21 per cent since 1997. Nearly 7 million people are on antiretroviral treatment—a more than tenfold increase over five years.

Today is also an opportunity to recognise the continuing challenges presented by HIV, both globally and at home. More than 34 million people are living with HIV and, as noble Lords have noted, there is no cure or vaccine in sight. Around 10 million people in need of treatment are not getting it. There are more than 7,400 new HIV infections every day, which is two for every person who begins receiving treatment. To compound the problem, HIV funding is flatlining, about which we can read more in today’s papers.

While the scale of the epidemic is very different in countries such as the UK, as my noble friend Lord Fowler pointed out, we are not unaffected by the global picture. Effective treatment from the NHS can transform the lives of those living with HIV or AIDS, but there is no cure or sign of a vaccine and HIV still attracts considerable stigma, which is a huge challenge.

The Government’s early response all those years back, led by my noble friend Lord Fowler, has helped to make sure that the UK has remained a relatively low prevalence country for HIV, particularly compared with some of our European neighbours. The early introduction of needle exchange and harm minimisation programmes, for example, has meant that we have very low rates of HIV in drug users who inject, unlike in other countries, as my noble friend pointed out.

Earlier this week, the Health Protection Agency published its annual HIV report for 2010. There are now around 91,500 people living with HIV, of whom around a quarter are unaware of their infection. This means that they are unable to benefit from highly effective treatment and risk unwittingly transmitting HIV infection to others. The HPA also reported that in 2010, new diagnoses in men who have sex with men—MSM—reached a peak of 3,000, and MSM remain the group most at risk of HIV transmission in the UK.

That is why I very much welcome the report’s focus on the importance of HIV prevention. The Government agree that we need to be more effective in supporting responsible sexual behaviour. HIV prevention makes good economic sense too, as noble Lords have pointed out. The HPA estimated that preventing the estimated 3,800 HIV infections acquired in the UK in 2010 would have saved over £32 million annually, or £1.2 billion over a lifetime, in costs.

This year, the department has invested £2.9 million in a national programme of HIV prevention for men who have sex with men and for African communities, delivered by the Terrence Higgins Trust and African Health Policy Network. On top of that, the NHS provides many HIV prevention services, some funded separately and some funded as part of mainstream services such as testing and distributing information and condoms. The Department of Health is currently considering how national HIV prevention programmes might be taken forward when the current programmes end. The Committee’s comments will help to inform what happens.

Of course, effective prevention requires effective testing. Late diagnosis is the most important factor associated with HIV-related morbidity and mortality in the UK. We agree with the Committee that HIV testing should be offered more widely and in various healthcare settings, particularly in areas of high prevalence. In September 2011, the HPA published its final report on pilots which the department funded in 2009-10 to help to reduce late diagnoses of HIV. The findings were encouraging and patients responded to being offered HIV tests. We are also funding the Medical Foundation for AIDS and Sexual Health to develop ways of helping GPs and primary care staff to offer HIV tests more routinely.

It is vital that the public health system is versatile and proactive enough to deal with HIV and AIDS. Reference has been made to how this is going to be structured in the future. Ring-fenced public health funding is central to our NHS and public health plans. This will allow us to plan spending on prevention without the money being raided for other projects. In today’s restrictive financial climate, this is a very noteworthy commitment in this area.

Finally, I turn to the concerns raised by noble Lords about the current policy to charge some people for HIV treatment. As we made clear in our formal response to the Committee, we are concluding an internal review of our current policy—I know that review does not please the noble Lord, Lord May, but I hope he will be encouraged in the end—and expect this review to be completed by the new year, including any discussions with the other government departments that have an interest. The review is considering many of the issues raised today. These include the increasing evidence on the public health benefits of early diagnosis and the significant role of HIV treatment in reducing the onward transmission of HIV.

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 was to deter people from being tested for HIV, even though testing has always remained free of charge to all. I acknowledge that a small number of vulnerable people will not be covered by the current exemptions and that they may be deterred from accessing HIV testing services because they cannot afford treatment or are confused about the entitlement to free NHS treatment. In considering any changes to our current policy we must avoid creating 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 hear the powerful case made by the right reverend Prelate the Bishop of Wakefield in this regard. The department’s review has considered many of the issues raised today and we will conclude it by the new year.

I turn to some of the questions that noble Lords have put to me. The noble Lord, Lord Fowler, asked about supporting more HIV testing in general practice. I have made reference to the funding that we have provided to the Medical Foundation for AIDS and Sexual Health, which is working on a three-year project to try to support GPs and primary care staff in offering HIV testing. The noble Baroness, Lady Gould, also referred to that.

The noble Lord, Lord Fowler, and the noble Baroness, Lady Masham, asked about prisoner health. As they know, we do not routinely screen people in prison for HIV just because they are prisoners—rather, we have an active case-finding programme which encourages both prisoners and staff to consider whether their behaviour, current or previous, may have put them at risk of infection with HIV and provides them with an opportunity for testing. We respect the rights of prisoners to accept or refuse testing if they so choose, which reflects normal practice in the wider community.

The Department of Health offender health team has worked with the HPA to improve disease surveillance in prisons. We aim in the new year to disaggregate data on diagnosis made on people in prison. Condoms are routinely provided in prisons to prevent the transmission of STIs. NICE evaluated the evidence of effectiveness of needle-exchange programmes in prisons and stated that there was a need for more research on the added value. It felt that the condom programme was useful.

The noble Lord, Lord Fowler, and other noble Lords, including the noble Baroness, Lady Healy, spoke of the need for a new prevention campaign. The awareness campaigns of the 1980s, which targeted the whole population, were effective in raising the public’s awareness of a serious public health threat at a time when we did not know how HIV would develop or the main routes of transmission. By the mid-1990s, it was clear that men who have sex with men and people from sub-Saharan African countries were disproportionately affected by HIV. That is why, since 1996-97, the Department of Health funded programmes that focused on those communities. This approach is supported by community organisations and others including the HPA. The previous Government also subscribed to this. I hear what noble Lords have said and this will no doubt continue to be assessed on an evidence-based approach.

The noble Lord, Lord Fowler, asked about home-testing kits, to which I think I made reference in my speech. We are reviewing our policy on banning the sale of home HIV tests. We recognise anyway that the current ban is probably not sustainable given that home-testing kits are already available from overseas on the internet. It is essential if there is any change that home-testing kits are quality-assured, including the provision of clear patient information on following up positive or unclear results. It is extremely important that those kits are reliable if they are going to be used at home.

The noble Lord, Lord Fowler, asked about national procurement of ARV drugs, as did others. The Department of Health is keeping this under wider review. We are very keen to ensure that we have clinical collaboration in ensuring there is leverage on price and that experience from procurements on a local and regional basis will be used in evaluating the ability to take this forward on a multi-regional or national basis. It will be under review.

Various noble Lords, including the noble Lords, Lord Lexden and Lord Black, and the noble Baroness, Lady Gould, spoke about stigma. It is of course very much the case still that stigma is an enemy to progress. TB was a stigma in the 19th century and cancer in the 20th century and we have a problem here also when people are unwilling to come forward because HIV has the power to define a person in a way that an illness simply should not. Too many people with HIV still experience shame and isolation because of their diagnosis and that can manifest itself, as we have heard, in discrimination in all sorts of places.

The Department of Health’s new sexual health policy framework planned for next year will consider how key partners involved in HIV care work and others can work together to reduce and challenge HIV stigma. The national HIV prevention programme for African communities, funded by the Department of Health, has contributed to toolkits for faith leaders and communities in this area and we want to develop this further; that is a very important message that comes out of this report.

The noble Baroness, Lady Gould, asked whether the Department of Health would consider the HPA’s Time to Test for HIV report. The answer is yes and this will help to inform our forthcoming sexual health policy framework. She also asked about the public outcomes framework; we are considering responses to this, including a proposal on an indicator on late HIV diagnoses and we will publish that framework very soon. The noble Baroness also asked about tariffs on sexual health; as she probably knows there is ongoing work on tariffs and I will write to her in more detail about this.

My noble friend Lady Tonge expressed her reservations about our plans in general and this issue in particular. I can reassure her, at least in one or two areas. The £2.9 million on prevention that was flagged up as being inadequate excludes work done on prevention by the NHS, for example testing, condom distribution and local health promotion. There is more there than she might have felt. I will no doubt address many of her concerns on the health Bill more widely outside this Chamber, otherwise I am sure we will be here again until at least midnight.

My noble friend Lady Tonge, and the noble Baronesses, Lady Healy and Lady Massey, spoke about PSHE in school; I assure noble Lords that we recognise that children benefit enormously from high-quality PSHE which helps them make safe and informed choices. There is a slimming down of the statutory curriculum to give schools more freedom and space to teach a curriculum which engages pupils; however, we have launched a review of PSHE to identify the core body of knowledge pupils need and ways of improving the quality of teaching. I emphasise that we welcome representations, including evidence and examples of good practice, and I strongly urge noble Lords to feed into that process. As a result of the review we will be drawing up proposals, based on the evidence, and consulting on them.

The noble Baroness, Lady Masham, asked about the future of the HPA; we will be having further discussions about this in the health Bill. In fact, we almost came to it last night but I think it will now be discussed on Monday. As she knows, the HPA, along with a number of other organisations, will be brought together into Public Health England, which will be free to carry out research; it is an executive agency of the Department of Health that will be established in April 2013—always assuming your Lordships pass the health Bill. It can carry out research, it must give advice to the Government—it has that independence; those working will be able to apply for grants and so on. We will work to maintain the excellent quality of the HPA’s current HIV surveillance programme when it transfers to Public Health England.

The noble Lord, Lord Lexden, referred to Northern Ireland, and it was extraordinary to hear of the difficulties that he perceived there. It shows how in many areas, not only geographically but by community, some communities can be particularly difficult and harder to reach than others. Nevertheless, I assure him that the Department of Health works with the devolved Administrations to discuss issues that are common across the UK, such as increased testing, and to share good practice on prevention and care.

There was some concern about possible fragmentation because of local authorities being much more involved now in public health and also the NHS Commissioning Board. Again, we will no doubt return to these issues in the Bill, but the Department of Health is already working, and will be working over the coming year, with key stakeholders to map out the integrated sexual health pathway that will address the concerns raised today. This debate will no doubt feed into those concerns to ensure that work on the issue is joined up.

I have referred to the HIV home testing kits, which the noble Lord, Lord May, flagged up. The noble Lord, Lord Black, and other noble Lords spoke about HIV awareness in the general population being very low. Although we wish to seek improvement in all kinds of areas, it is quite interesting to note that, according to NAT’s Ipsos MORI poll, four out of five adults in the communities that are most at risk were aware that HIV can be passed on by having sex without a condom. In other words, the targeting of information, at least to those groups, is having an effect. I am pleased that that is the case.

The noble Baroness, Lady Massey, the noble Lord, Lord Gardiner, and others asked about the sexual health policy framework. We are seeking to take a life course approach—that sounds like a course that we are offering through PSHE—to sexual health needs, for young people through to old people, including people aging with HIV, and we are working with the Sexual Health Forum to agree this framework. That work is being undertaken at the moment.

The noble Lord, Lord Gardiner, asked about introducing HIV testing and learning from antenatal HIV testing. We have asked the UK National Screening Committee to consider the evidence on making HIV testing more routine. We await its response.

I hope that I have covered most of the points raised. If there are points that I have not answered, I will write to noble Lords. Clearly we have a tremendous amount to think about as a result of this report and there is still more to do. We all have a part to play in keeping HIV high on the agenda, and debates such as this and the coverage today in the media all help to raise the profile of the disease. I welcome the report and the extremely important cajoling from noble Lords today. I am aware that we shall return to some of these areas in the discussions on the health Bill. I look forward to being further cajoled and I hope that we can make progress in at least some of the areas that have been flagged up in this important debate.

International Development

Baroness Northover Excerpts

Monday 21st November 2011 Lords Chamber

[Lord Sheikh]

To ask Her Majesty’s Government what steps they are taking to ensure that funds allocated to international development are spent in accordance with their objectives.

[Baroness Northover]

My Lords, the Government are focusing on delivering specific results and better value for money through our programmes. DfID is measuring the results and making them transparent so that the Government can be held to account. The Secretary of State for International Development has also established the Independent Commission for Aid Impact to provide independent assurance that UK aid is being spent properly and is achieving the desired impacts. The commission reports directly to Parliament through the International Development Select Committee.

[Lord Sheikh]

My Lords, I thank the Minister for that response. The Public Accounts Committee in another place found recently that DfID had no systematic or comprehensive approach to quantifying the extent of foreign corruption and was unable to provide an estimate of the scale of leakage. Does the Minister agree that this is not acceptable, and what action are the Government taking to put this right to ensure that they secure value for money?

[Baroness Northover]

My Lords, it certainly would be unacceptable if this were the case. The report very much reflects the position of the past and takes little account, it seems to me, of the changes made by the coalition. For example, in 2009-10 about 43 per cent of known losses were recovered, whereas over the past year that has risen to 92 per cent. We have also transformed the way in which the department manages its finances so that spending is attached to tangible results, which are being rigorously scrutinised by the new independent aid watchdog that I referred to just now.

[Lord McConnell of Glenscorrodale]

My Lords, will the Minister comment on the current position on the budget aid to Malawi? Six months ago the Secretary of State suspended budget support to Malawi but gave us assurances that funds would be redirected by other means to be spent in that country for those in need. Is it possible to give an estimate at this stage of all the money that will be spent in this financial year, and are we now on target to achieve the objectives set out in our own Government’s development plan to support Malawi this year?

[Baroness Northover]

I realise that the noble Lord has a great interest in Malawi from his work in the Scottish Parliament. I will write to him so that he has the most up-to-date details on that. His question reflects the difficulty, which we all recognise, of working in some of the most complex countries around the world. It is extremely important that we balance the needs of the poorest people in these countries with the difficulty of working through some of their Governments.

[Lord Hannay of Chiswick]

My Lords, will the Minister confirm that, as the press reports, the Secretary of State for International Development has today, or recently, written warning the FAO and UNESCO for the last time that their aid from us may be at risk? Will she say whether the Secretary of State intends, in the light of the 20 per cent or more cut in UNESCO’s budget, for reasons that have nothing whatever to do with its efficiency, and for reasons that I imagine the Government do not sympathise with, to take that into account when considering that particular case?

--- Later in debate ---

[Baroness Northover]

I hear what the noble Lord says. In the initial part of his question, he is referring to the multilateral aid review that took four organisations out of those that DfID would support and put four into, as it were, special measures, to be reviewed. UNESCO’s current problems are very significant. He is referring to UNESCO deciding to recognise the Palestinian Authority and the withdrawal of United States support as a result. I will write to him with the latest information on that.

[Lord Roberts of Llandudno]

My Lords, especially at this time of heavy youth unemployment, could we ask the Government to encourage organisations such as Voluntary Service Overseas to expand their activities and to give jobs to as many as, say, 20,000 young people in developing these projects? It would give work to those who have no work, and it would give hope to those who have little hope.

[Baroness Northover]

My Lords, we are currently piloting the International Citizen Service, which is giving more than 1,000 young people from all backgrounds the opportunity to spend three months doing voluntary work overseas. This will make a real difference to some of the world’s poorest people, while developing skills that will be invaluable as they seek employment in the future. Our intention is to scale up this programme so that 7,000 young people will benefit over the next three years.

[Lord Turnberg]

My Lords, is the Minister aware that in the Palestinian West Bank territories many textbooks contain all sorts of anti-Semitic and anti-Christian remarks and incitements to violence? Is that not something that DfID should pay attention to in its funding arrangements?

[Baroness Northover]

The noble Lord is right that some of these textbooks include things that we would certainly not wish to see within them. There is no doubt about that. With his work in the area, he knows how difficult it is to bring together groups that come from opposing positions. Sometimes it is extremely important to try to take forward the bigger picture and ensure that the Israeli side has security and that the Palestinian side has some kind of hope. That has to be the focus of DfID in supporting those who are in poverty in whatever situation they may be living.

[Baroness Kinnock of Holyhead]

Does the Minister share my concern that the Development Assistance Committee of the OECD has reported that international donors have met only one of the 13 targets that they set themselves on aid effectiveness and that, in addition, aid is now fragmented, unpredictable and poorly co-ordinated and lacks transparency? Will she give an assurance that the Government will raise these issues as a major concern at the Busan high-level forum on aid effectiveness later this month?

[Baroness Northover]

The noble Baroness is right that as more organisations and countries have become involved in aid, which itself is welcome, there is a lot of fragmentation. Previous meetings such as those in Paris and Accra have tried to take this forward, and Busan is trying to do that too. She is absolutely right that this is something that DfID will be emphasising, to try to ensure that aid is effective and targeted, and that countries and organisations should work closely together. In this regard, it is extremely important to bring in some of the BRIC countries, which up to now have not played such a large part in this area and may play a major role in the future.

Health and Social Care Bill

Baroness Northover Excerpts

Wednesday 16th November 2011 Lords Chamber

[Baroness Northover]

My Lords, given that my hard-working noble friend Lord Howe deserves at least a short break, I shall be addressing these amendments. If I do not cover them sufficiently comprehensively, given the time, I shall be very happy to write to noble Lords.

This is a very large group of amendments covering Clauses 8, 9, 14 and 19, which together set out the fundamental legislative basis for the new public health system. I thank noble Lords for their general welcome of these provisions, which of course put public health very much front and centre in the new system.

The Public Health White Paper sets out the Government’s commitment to protecting the population from serious health threats, helping people to live longer and to enjoy healthier and more fulfilling lives, and to improving the health of the poorest the fastest. At a national level, there is a clear rationale for accountability for health protection to rest with the Secretary of State. The nature of various threats to health are not, of course, always amenable to individual or local action. They require a clear line of sight from the Secretary of State down to local services.

Clause 8 inserts new Section 2A and gives the Secretary of State a new duty to take steps to protect the health of the public in England. In practice, Public Health England, the national component of the new public health system, will play a key role in health protection, bringing together a fragmented system and strengthening the national response on emergency preparedness. It is our intention that it will be an executive agency of the Department of Health. Public Health England as an executive agency will have an operational distinctiveness that will allow it to build and maintain its own identity. Agency status will support the ability of scientists in Public Health England to give expert, objective and impartial scientific advice, which noble Lords have called for, to both the Secretary of State and more widely. I entirely share the view of the noble Lord, Lord Warner, that we must make use of the best scientific and other evidence available. We intend to set out clear proposals shortly on how the Secretary of State and Public Health England will receive professional advice. I am confident that those proposals will at least match the intention of the noble Lord’s amendment.

[Lord Warner]

I hesitate to interrupt the noble Baroness on her debut at this point, but does she understand that by its very nature an executive agency is within a government department and does not have the same level of independence as a non-departmental public body? We are seeing played out in the public arena at present some of the consequences when there is disagreement between people in an executive agency and a Minister. That concerning the Home Office is currently being played out on the front pages of our newspapers. Does she agree with me and, I think, my noble friend Lord Turnberg, that having scientists in an executive agency fetters their freedom compared with in a non-departmental public body?

[Baroness Northover]

The noble Lord flags up a concern that has been expressed about the independence of the new organisation. I would point out the example of the Met Office, which is arranged in a similar way. What it does on climate change may not always go down well with the Government of the day, yet it has no reluctance in coming forward with the evidence that it has.

It is extremely important that it should have that expert advisory position. That is why it was moved out of the Department of Health, which was the original proposal. The noble Lord will know that it was going to be within the Department of Health, but the Future Forum flagged up that concern and the decision was taken that it be arranged in this way, to address the points that the noble Lord has raised.

Coming back to what I was saying about the Health Protection Agency, I remind noble Lords that Clause 53 abolishes that agency and repeals the Health Protection Agency Act 2004. That is central to the Government’s plans for unifying national health protection activity and creating a more transparent and accountable service under the Secretary of State. In so many ways the Health Protection Agency has done an outstanding job, and we certainly pay tribute to those who have worked within it. It has established an outstanding international reputation, as the noble Lord, Lord Turnberg, pointed out. Public Health England will be able to build on that recognised expertise not only from the Health Protection Agency but from other organisations that we can draw into our public health system. There was talk about whether this should be a special health authority. The noble Lord, Lord Beecham, said that he wished to address this later on, so no doubt we will come back to this and to the points the noble Lord, Lord Warner, made about independence and why we are not proposing to do things in quite that way.

--- Later in debate ---

[Baroness Finlay of Llandaff]

I am grateful for the reassurance that the noble Baroness does not see any way of uncoupling diagnosis from treatment. I am not terribly comfortable with the furniture analogy. Pieces of furniture are not as complex and integrated as human bodies.

[Baroness Northover]

I have a feeling that carpenters might disagree. Nevertheless, I take on board what the noble Baroness says, and I hope that I have reassured her.

Where was I? I think that I have covered the points spelled out by various noble Lords on research and evidence. Research and evidence would rightly run right the way through these arrangements, and I would have expected noble Lords to flag this up. It is absolutely crucial that evidence underpins the work that is done. I heard what was said about nudging, and so on. The Select Committee itself said that it welcomed the exploration of new ways of doing things, provided that they do not dislodge other ways of assessing things. It is extremely important that, in all these areas, you assess what the impact of something is. I hope that noble Lords will be reassured. We will come on to this in a minute.

[Lord Warner]

I suggest the noble Baroness reads the report of the inquiry chaired by the noble Baroness, Lady Neuberger, which makes it very clear that the scientific evidence to back up nudge as a way forward is extremely weak.

[Baroness Northover]

I hear what the noble Lord says. To judge so quickly something which has only exploded on to the agenda relatively recently does not seem to me to be terribly scientific. As a former social scientist, I do not think that that is giving quite enough time to assess it. However, the Government absolutely hear what the noble Lord says. We need a range of ways of exploring things. If people suggest ways of probing and investigating areas, then all those areas need to be assessed properly, and given due time to take effect.

I was about to come on to the point that, in this Bill—noble Lords have flagged this up—there is provision for continuing to measure children even though that public health responsibility has gone over to local authorities. It underpins our understanding of the extent to which we have obesity among children. It is extremely important that it is carried forward, and I think that that bears out the Government’s commitment to continued research.

I have covered patient records. The noble Lord, Lord Turnberg, asked about child services. I know that my noble friend will be coming back into full view in a minute, and will address some of these areas, so maybe that is best covered then. We are extremely concerned to make sure that, across all areas, these matters are properly co-ordinated.

I have addressed the point raised about the separate annual reports. The Secretary of State is reporting generally, across all these areas. I hope that I have not missed out any key areas. There was a question from the noble Lord, Lord Turnberg, about Public Health England. It will indeed be able to receive research funding from the majority of sources from which the HPA is currently receiving research income. This was a key point that was flagged up by noble Lords last night, and it has been confirmed. Research is clearly vital for the specialist expertise required in Public Health England.

I appreciate noble Lords’ probing on all these important areas, but I hope that at this stage the noble Lord will be happy to withdraw the amendment.

[Lord Beecham]

My Lords, I am grateful to the Minister for her reply, although I shall resist the temptation to follow her into the realm of rearranging the furniture or even the deckchairs on the NHS “Titanic”. She rather missed the point of Amendment 69ZA, which adds to the provision in the Bill that will require each local authority to,

“take such steps as it considers appropriate for improving the health of the people in its area”,

the duty to take such steps as are appropriate to tackle the problems of health inequalities. That is the point that the amendment seeks to enshrine in the Bill. It is a duty that will lie on the Secretary of State for national purposes, but not for local purposes.

[Baroness Northover]

I am sorry that the noble Lord feels that I did not adequately deal with that. The point I made is that moving public health to local authorities will join up a lot of the other factors—housing, the environment and so on—for which they have responsibilities. As the Marmot review highlighted, that should help to address some of those areas.

It is also worth bearing in mind that the Equality Act introduced by the previous Government is relevant across all these areas and in terms of the groups with protected characteristics. Many of those who suffer from particularly bad health would be covered by that.

[Lord Beecham]

My Lords, it is surely clearer to have in one place the responsibility for reducing health inequalities. The amendment simply adds to the Bill:

“and shall, in doing so, take such steps as are appropriate to reduce health inequalities”.

That is the right place to have it when one is delegating that responsibility. The noble Baroness referred to the ring-fenced grant, which will, of course, apply to the public health function but, as she has just said, the public health function is not confined to what might be described as health expenditure. This duty to reduce health inequalities as part of local government’s new responsibilities should be embodied in statute, to ensure it in the consideration of the rest of local authorities’ functions and budgets.

I noted the remarks of the noble Baroness, Lady Williams, who is not in her place. She seemed to think that the Government have given independence to public health bodies. I hope she is right in her inference, but I am not so sure. We will return to this matter when we discuss Public Health England and other aspects of the Bill, including the role of public health specialists and directors of public health within local government. There are amendments that reinforce the independence of such postholders which are necessary additions to the Bill. I accept that the Government’s aspirations may be in line with that, but it seems to me that the Bill does not go far enough in providing them.

I want to return briefly to my amendment, which I do not think the Minister referred to, which is based on the recommendations of the Select Committee report on the public health impact of budget changes for the national level of public health, which affects Public Health England and the local authorities. I refer to the observations of the Select Committee:

“The Department of Health must also make clear how the actual level of funding for public health will relate to the historic baseline. We seek reassurance from the Department that, in setting the public health budget, it will take account of objective measures of need. This must apply in respect of both the national budget and allocations to local authorities”.

The next paragraph says:

“Although the Department of Health states that, in the current reduction of NHS management and administration costs, frontline public health services are being protected, we have heard evidence to the contrary. Furthermore, the Department has failed to give a convincing account of its distinction between frontline and non-frontline spending in public health services. Unless it can do so, the suspicion will remain that it is an arbitrary distinction and that public health services are suffering, and will suffer, in consequence of the cuts that are being made”.

In relation to the health premium, which as yet we have barely explored, the committee said:

“We are concerned about the proposed introduction of the Health Premium. We believe there is a significant risk that, by targeting resources away from the areas with the most significant continuing problems, it will undermine their ability to intervene effectively and thereby further widen health inequalities. Although many witnesses welcomed the proposed ring-fencing of public health budgets … and the Committee understands the short-term attractions of this approach, it does not believe it represents a desirable long term development”.

After further analysis, the committee said that,

“the ring-fenced public health budget should operate for no more than three years”.

[Baroness Northover]

I am sorry that the noble Lord thought I did not cover the first point. I did not make myself clear. With regard to the total figure for the health premium, which I mentioned briefly—and the Department of Health will be publishing something shortly—there is consultation on that. There is always controversy over how best to do that. I recognise what the Health Select Committee says about not wanting to have an inadvertent removal of money from where it is most needed to an area that might need it less, which appears to have done better and so on. These things are clearly very complex, as the noble Lord will know, and there is consultation on how best that should be taken forward so that it is most effective and does not have that unintended consequence.

[Lord Beecham]

Of course there is consultation going on. It has been going on for an inordinate amount of time and we need to see the outcome of that—as indeed does local government—during the passage of this Bill, I hope. These are critically important matters which at the moment remain opaque, to put it mildly. Of course there will be a report in due course, but the financial aspects of that report must be consistent with the thrust of the policy, and on that we are clearly not in a position to make a judgment. This is a matter to which we will clearly have to return, possibly in conjunction with the Bill, possibly separately. If local authorities are to undertake these increased responsibilities, there will have to be a satisfactory system to make possible the operation of the machinery that the Bill is creating.

Having said that, I acknowledge that these are all probing amendments. I hope that the Government will look at some of them with a view to possibly adopting them in future. On that basis, I beg leave to withdraw the amendment.

--- Later in debate ---

[Baroness Hollins]

My Lords, I shall speak briefly about the importance of information in an early diagnosis. I have two areas to focus on. First, people with learning disabilities often get a late diagnosis and suffer terribly because of it, with an earlier death as a consequence for many. Often that is because of a lack of accessible information. I speak as the executive chair of a social enterprise, called Beyond Words, which designs pictorial information to try to bring health and social care information to people who cannot read. Any public health information campaigns need to remember that not everybody can read information easily; it has to be designed to be inclusive.

Secondly, I have a question about how the accessibility of information about the bureaucratic structures of the NHS will help with early diagnosis. This is to do with the current “choose and book” system. Something that has happened to a close relative of mind in the past few weeks made me realise that I do not know how the Bill is addressing the whole issue of better choice for patients. I will briefly tell noble Lords the story. It is about somebody who needs an early diagnosis for what seems like a serious, rare, long-term condition and who has been referred through the choose and book system to four different hospitals to see four different specialists in different areas, where those specialists cannot easily communicate with each other because their hospital systems do not speak to each other. The person concerned chose the hospitals that offered the earliest appointments, which is what most people do and what choose and book offers you. You take the first appointment because you are worried, but the hospital consultant is unable to refer to a consultant in the same hospital with whom they would be able to consult. The patient has to go back to the GP and back through the choose and book system. It is not working.

There is something about information and early diagnosis here as well. I could not see where, apart from under information, I could raise this issue. I look forward to hearing a response from the Minister.

[Baroness Northover]

My Lords, Amendments 65A, 71ZA, 97A and 133A seek to raise the priority within the Bill of public health information advice designed to encourage the early diagnosis of serious conditions. Improving early diagnosis is an important objective across the whole health system, which includes the new public health system. I am very grateful to noble Lords for raising such a significant issue.

I completely agree with my noble friend Lord Sharkey as to the important role of information advice campaigns. I hope that I can reassure him that the changes to public health will not see the end of such campaigns. Where such campaigns work, we want to see more of them. We know how important early diagnosis is in treating cancer, for example. Thus, people coming forward for bowel cancer screening can be diagnosed at a stage where the disease is totally curable.

The noble Baronesses, Lady Masham and Lady Gould, emphasised other areas in which treatment is more effective earlier but also where there is a risk of infection, such as HIV, TB, hepatitis and meningitis. The noble Lord, Lord Davies, flagged up other STDs, among other issues. We are well aware of the importance of these areas. This is also where local authorities’ involvement in public health should assist rather than detract. The noble Baroness, Lady Gould, rightly flagged up this issue in relation to HIV/AIDS. No doubt we will return specifically to the points that she has raised when we debate HIV/AIDS on 1 December, World AIDS day, a debate to which I am responding. I look forward very much to our discussions then.

We will no doubt come back later to wider discussions of Public Heath England and the directors of public health, to which the noble Lord, Lord Davies, referred. Perhaps his notions can be revisited then when attached to the appropriate amendments.

As I outlined in the debate on the previous group of amendments, Clause 8 sets out the Secretary of State’s new duty to take steps to protect public health. It illustrates this duty with a list of steps that would be appropriate for the Secretary of State to take. That list includes the provision of information and advice. Amendment 65A would amplify that to specify that this could include information in campaigns around early diagnosis. I should explain that the list in Clause 8 is neither prescriptive nor exhaustive. The amendment would not therefore either require or give the Secretary of State a new power to do anything that the clause does not already accommodate.

Similarly, Amendment 71ZA would have the equivalent effect on a list of steps that local authorities may take under their new duty to improve public health. As we have already said, local authorities’ new responsibility will include behavioural and lifestyle campaigns to prevent serious illness and they will be funded accordingly. The Department of Health is also working with stakeholders from the NHS, local government and voluntary and community sectors to finalise the operational design of the new public health system. We expect to publish proposals shortly and they will set out how we expect to promote early diagnosis through the system.

Of course, the NHS will continue to play an important part in public health, a point emphasised by the noble Baroness, Lady Finlay, earlier. The Bill allows the Secretary of State to mandate or agree particular services that will be the responsibility of the NHS Commissioning Board. Amendment 97A seeks to ensure that he will consider early diagnosis campaigns when he does so. I hope that the noble Lord, Lord Sharkey, will be reassured that this is something which we are already considering. I can also reassure noble Lords that the objective of Amendment 133A is already met by the clause as drafted. Where the Commissioning Board is engaged in early diagnosis campaigns, then the duty to promote the integration of services would automatically apply to those campaigns just as they would to any other health, or health-related, services.

I emphasise that we especially expect advice and information to continue to play a major role in early diagnosis and local authorities will be able to contribute to that. Meanwhile, Public Health England, too, will be able to manage and support effective national campaigns. We will be publishing further detail shortly on how the different levels of the system will work.

In short, I believe that we are in total agreement with noble Lords about the principles underlying their amendments and with what noble Lords have said in the debate. We share their desire for improvement in this area. We all know what huge potential early diagnosis offers and the vital importance in this of public health campaigns. The Bill as drafted offers all the necessary support for that ambition. I therefore hope that the noble Lord will accept that and withdraw his amendment.

[Lord Beecham]

My Lords, as we are in Committee, I can repair my omission in failing to anticipate the Minister’s response to what has been a very good debate. I congratulate the noble Lord, Lord Sharkey, on tabling these amendments. I take issue with him slightly over one matter he mentioned: the relative performance of this country in terms of cancer survival rates. Recent reports make clear that they have improved substantially and are now beginning to outstrip those of other comparable health services. However, that does not detract at all from the thrust of the amendments.

The Minister referred to bowel cancer screening. That is but one example of the importance of early diagnosis, and public information can certainly assist in that context. As some of your Lordships may recall, I have some personal experience of this because my wife died of colon cancer last year. Her symptom was constipation, which is not a predominant symptom. Relatively speaking it is a less frequent symptom, but even now it is not something that some of the literature and material produced by cancer charities refers to. That is an illustration of the need for clear information to be given. There has been a very successful campaign about stroke, which was temporarily halted and then resumed. There is clearly a role for that kind of campaign. I should have thought that the Government could accede to the request for these duties and responsibilities to be included in the Bill.

Although I certainly strongly support the amendments, there are perhaps two riders that I might add. The first is that information, which of course can be in many forms, is not of itself necessarily enough. For example, information in labelling on food does not convey very much to people. This is an example of nudging not being enough. In some cases what is needed, apart from information, is action, and I hope that, as part of their public health agenda, the Government will take a rather firmer line in making requirements of the food industry and others concerning what goes into the nation’s diet.

The other rider relates to the efficacy of some kinds of campaigning. This does need to be measured. Some campaigns—noble Lords have referred to them—have been extremely effective; others, less so. The rather dramatic advertising about HIV and AIDS in the early days was not thought to have been particularly effective. It seems to me that in the interests of effectiveness and efficiency—that is, in terms of the expenditure involved—we need to evaluate what sort of campaigning and publicity works.

With all those qualifications, such as they are, I strongly support the noble Lord’s amendments. I hope that the Government will take another look at whether sending a very clear signal by having these kinds of amendments made to the Bill would assist what we all agree across the House is a prime responsibility and a prime opportunity for the Government to advance the public health agenda.

[Baroness Northover]

My Lords, my apologies if I leapt up far too soon. I caught the noble Lord’s colleague’s eye and it looked as though no one would be speaking from that side of the Chamber. However, I am incredibly glad to hear what is in fact cross-party support for this kind of campaign. The noble Lord is absolutely right: the part that charities play and have played in many of these campaigns is absolutely critical, not the least of which is Cancer Research UK and its various campaigns. Therefore, I thank the noble Lord for his contribution.

[Lord Sharkey]

I thank all noble Lords who have spoken to the amendments and I thank the Minister for her response. I should also like to register the propensity of all Governments to make sudden cuts to public information campaigns. Last year, the Government announced a freeze on their £540 million annual publicity budget. On 29 May this year, they announced a partial thaw, with expenditure of £44 million on four campaigns in England. This followed the publication of a Department of Health report called Changing Behaviour, Improving Outcomes, which found that, for example, after the cessation of campaigns, calls to the Change4Life information line fell by 90 per cent, calls to the FRANK drugs line fell by 22 per cent and visits to the NHS Smokefree website fell by 50 per cent.

All that illustrates my continuing concern that it is too easy to cut public health information campaigns and that it might be even easier in devolved organisations. Therefore, notwithstanding the Minister’s helpful response, I continue to believe that we need safeguards against such cuts written into the Bill. I look forward to discussing this again on Report. I beg leave to withdraw the amendment.

--- Later in debate ---

[Baroness Gould of Potternewton]

My Lords, it is interesting that there is not a universally accepted definition of public health. There are, however, broad domains of public health, be they health improvement, health protection or health services. The Faculty of Public Health defines public health as:

“the science and art of promoting and protecting health and wellbeing, preventing ill-health and prolonging life through the organised efforts of society”.

That is a very broad definition. It could almost include every range of local government services. It seems to me that there is a need for some guidance on what aspects should be included in the ring-fenced budget. We have previously been told that there will be no breakdown of the budget within that ring-fencing, which makes it even more important that some guidelines are laid down. The frequent reply from the Minister has been that we leave it to each local authority to determine what public health is. But while I appreciate that there will be a variation in needs between different authorities in different areas, some guidance and priorities might be useful to them.

I am delighted that my noble friend has highlighted sexual health as being important because there is a great deal of concern that sexual health will not be a favoured issue for many local authorities. Furthermore, as regards HIV for instance, there is no understanding that there is all too often a relationship between the required long-term care and other aspects of local government services. There is also concern that, unless it is highlighted, there will be a lack of understanding by local authorities of the divide within the commissioning arrangements for HIV and contraceptive services between the National Commissioning Board’s responsibilities and their own—for prevention and testing in the case of HIV and for the establishment of clinics for special cases in the case of contraception. Guidance would give local authorities greater clarity of their roles and responsibilities and the fact that they are a key player in this process of integration. I am sorry to refer again to the response to the Select Committee report on HIV and AIDS, but it is so topical. The Government identify that integration where possible—whatever that means—will be by the NHS Commissioning Board, clinical commissioning groups and health and well-being boards. That will apply to all health services so there is no need to have a special duty applying to the integration of specific services, such as sexual health and HIV. However, I think that is a misjudgment. Having some identification priorities would give guidance as to which areas require special duties.

At Second Reading, the Minister referred to the Advisory Committee on Resource Allocation, which is an independent expert committee that has been asked to advise on a public health formula to inform the distribution of the public health grant across local authorities, saying that it intends to publish further detail later this year. So I appreciate that we are not going to get the detail for which I would have asked on the distribution of that grant. If we could get some detail, that would be very helpful, but perhaps I may remind the Minister that there is only two months left this year and I hope that we will get that response before the end of it. The calculation of spend on public health, including sexual health services, must be based on robust and accurate data, so can the Minister identify how that can be achieved without a specific definition of what it should include? I appreciate that the Minister has so far always rejected the idea of coming up with a definition and he certainly might not agree with the list that is before him. Nevertheless, I would be grateful if he could rethink this. There needs to be some principle laid down to make sure that local authorities understand what public health actually means.

[Baroness Northover]

My Lords, Amendment 66 would add alcohol services to the list of examples that the Secretary of State may take under his new duty to protect health and Amendment 74B would add a number of steps, including one on alcohol, to the equivalent list of steps for local authorities to take up under their new duty. I appreciate the decision by the noble Baroness, Lady Finlay, to regroup and we will discuss her amendments a little later. However, the noble Baroness, Lady Thornton, followed by the noble Baroness, Lady Gould, decided that the group should stay in place.

Adding to the Bill's list of steps that may be taken may highlight an issue but would not materially alter the situation. The noble Baroness, Lady Thornton, with her governmental background, is clearly extremely familiar with the function served by these indicative lists. I appreciate her indication that she is probing on this. Obviously it is extremely important in these different areas.

I also note the definition of public health that the noble Baroness, Lady Gould, quoted. I scribbled down the part about the science and art of promoting health and well-being through the organised efforts of society. That illustrates that this is an evolving and moving area. We hope that it will evolve and move because public health has now been put with local authorities. By joining up all the different areas we wish to join up, we hope that the field of public health will move along. Therefore, it is not appropriate to put in the Bill such a definition, which is set at a particular time, because of the evolution that I hope will expand in a way that the noble Baroness—who clearly is not satisfied—will be happy with.

[Baroness Gould of Potternewton]

We are talking about a ring-fenced budget; we are not talking about a general local government budget. Therefore, there must be some guidance on what should go into that budget. I do not mind whether it is a definition in the Bill or guidance, but something must be done to make sure that we know what is in the ring-fenced budget.

[Baroness Northover]

The noble Baroness is absolutely right. This is not simply philosophy. Therefore, regulations will provide that guidance. In the mean time, I say that this is an issue on which we have spent considerable time working. She is probably aware of the July 2011 update to the public health White Paper. If she is not, I suggest that she looks at it. Paragraph A.10 on page 27 contains a list of the areas in which we expect local authorities to engage. I am sure that the noble Baroness, Lady Thornton, will be pleased that the list starts with tobacco control. The noble Baroness, Lady Finlay, may note that the second item is alcohol and drug-misuse services. Other issues that noble Lords have mentioned are also listed, such as obesity and community nutrition initiatives. The list is long.

[Baroness Thornton]

The Minister is giving a list—and there are at least two further lists in Clauses 8 and 9. I cannot see why my list should not be in there, too.

[Baroness Northover]

I can see the temptation. The list in the Bill is indicative. These lists are always subject to much debate about what goes in and what stays out. I fully understand why the noble Baroness wishes to add her list. However, we would resist adding to the list in the Bill, which is, as she knows, indicative. We appreciate people's contributions to what needs to be covered in these areas. I point out to her that the list—no doubt we will spend many hours debating the regulations—includes all sorts of things, such as mental health services and dental public health services. I will not read out the whole list. If noble Lords think that something is on it that should not be there, or that other things that are not on it should be, I am sure that we will consider those points as we debate the regulations.

I noted a response to the noble Baroness, Lady Hollins, but I think that I may be referring to a previous debate. She is absolutely right to emphasise that we have to make sure that everything we do is patient-centred. All the changes must focus on that. It is a challenge for everybody. Perhaps people have tried to do it before. No doubt we will have problems trying to do it ourselves, now and in the future, but that has to be the focus. Therefore, we have to remember the diversity of the patients that we are talking about. I am sorry; that answer belonged in an earlier debate.

I know that we will return later to debate alcohol. I hope that noble Lords will not press the amendments in this group.

[Baroness Finlay of Llandaff]

I beg leave to withdraw the amendment.

--- Later in debate ---

[Lord Beecham]

My Lords, in my youth—your Lordships might think it a rather sad youth—I was, at age 25, opposition spokesman on Newcastle City Council on a pre-Seebohm health committee, which had two remarkably effective and powerful chief officers. One was the medical officer of health, and the other was the chief public health officer. That was the designation of what I suspect we would now call environmental health officers. They were a very powerful combination and very influential within the council. But the point is that they were working together, which is precisely what my noble friend’s amendment seeks to achieve at national level. In later debates we will undoubtedly discuss the role at local level. It is absolutely right to identify this as a core function.

The noble Lord, Lord Rea, referred to one aspect of the role of such officers in environmental issues affecting public health. Perhaps I may revert for a moment to the previous debate and my noble friend Lady Thornton’s proposal to list some matters for inclusion as public health issues in the scope of the duties of local authorities and the Government. Several of those—including nutrition, air and water quality, adequate housing standards, fuel poverty, and possibly even occupational health—will fall within the domain precisely of this kind of appointment. It therefore seems to me that working alongside the chief medical officer of health, or reporting to him—a position of the kind covered by my noble friend’s amendment— would be entirely appropriate and effective. That binary combination or approach would ensure that, across the range of public health issues, there would be the best leadership and the best advice would be available to Ministers at national level and, similarly, at the local level. If it were to be matched, as I hope it would be, that advice would be available to local authorities.

The noble Lord, Lord Northbourne, referred to variations in the practice of local authorities in terms of the resources they devote to this topic. That was undoubtedly true in the past and will no doubt be true in the future, but it is also true at present. The practice of primary care trusts in terms of the way that they allocate budgets is by no means uniform, although I am not necessarily suggesting that it should be. But that is precisely one of the difficulties that I suspect we will encounter when the Government are forced to determine how much is currently being spent, how much perhaps should be spent and how much is to be allocated through any formula-based system under the ring-fencing scheme to be pronounced.

Individual authorities will have different ways of applying core funding, but that does not represent a substantive change from what we have now. Indeed, I would hope that, given greater public accountability, we will have a better outcome than we have had in the existing pattern. I warmly endorse my noble friend’s amendment.

[Baroness Northover]

My Lords, I thank the noble Lord, Lord Rooker, for giving me the opportunity to highlight the outstanding work that environmental health officers carry out in district councils as well as in the private and voluntary sectors. The Chartered Institute of Environmental Health, to which he referred, also does an excellent job in presenting the issues nationally and in liaising with central government. They will all continue to play a crucial and developing role in public health.

The noble Lord has long been a doughty fighter on environmental issues. I remember my astonishment when, as a Minister, he granted an amendment which I had tabled that he had been refused permission to grant. I therefore feel very mean in suggesting that I will not be reciprocating today. However, when the noble Baroness, Lady Finlay, raised her points, I was rather glad that, when acting on the Energy Bill in relation to the point for which she fought on preventing carbon monoxide poisoning, I was at least able to grant something there, although I know that that was more limited than what is being sought now.

I should stress that environmental health officers, along with other local authority staff, will be very much inside the group of professionals and practitioners in local government who will form part of the wider public health workforce. Consequently, we expect many opportunities for them in the future to contribute to and to shape local plans and priorities. Surely that will help transform this area, because public health, as I indicated, needs to be defined widely. In its new location it will change in order to have the effects that we wish to see. The noble Lords, Lord Beecham and Lord Rea, are right to urge working together, especially given the history of these officers.

At the national level, the Chief Medical Officer will have a central role in providing impartial and objective advice on public health to the Secretary of State for Health and to the Government as a whole. She will be the leading advocate for public health within, across and beyond the Government, advocating the design of policies that improve health and well-being. We are clear that this role includes advising on environmental health issues as well, and that the Chief Medical Officer will in turn continue to be able to seek such advice on environmental health and other issues whenever necessary just as she can do now. The Government believe that, as valuable as environmental health expertise is, this makes the post of chief environmental health officer unnecessary.

The noble Lord is of course right to urge discussion across devolved areas in all fields, as we can learn from each other. He might be reassured that the Chief Medical Officers of the various Administrations meet regularly, and that Public Health England, like the Health Protection Agency, will in some ways have a remit that extends beyond England and thus offer the chance to learn from the experience of others. We remain confident that Ministers will receive high-quality advice from the CMO on environmental health. I stress that we also need to look internationally and draw on research and experience very widely in this field. We can learn a lot from that.

The noble Lord’s amendment calls for the Secretary of State to,

“report to Parliament annually on the work of the Chief Environmental Health Officer”.

We agree on the need for transparency and believe that the Secretary of State’s accountability for public health at the national level is a major strength of the new system. This is why Clause 50 of this Bill requires the Secretary of State to publish an annual report to Parliament on the working of the comprehensive health service as a whole, which will include his and local authorities’ new public health functions.

The noble Lord, Lord Whitty, asked what the Government are going to do about ring-fencing the budget. Some of the issues that he raised were discussed in the first grouping on public health. I do not know whether he was in his place at the time. If he was not, he should be reassured that his noble friend Lord Warner intends to flag up some of the concerns that he raised in a later grouping, and we have various other groupings in which his concerns will no doubt be flagged up. I point out in relation to our discussion on the previous group that we will be using regulations to set out what essential services local authorities have to provide. Noble Lords can also see what is in the White Paper.

I want to clarify what will be covered in regulations so that if I was not clear in the last grouping, I can be clear now. Essential services that we think need to be delivered consistently across the country—for example, dealing with local emergencies—will be included in regulations. We will use publications like the updated White Paper, which I quoted earlier, to set expectations about the totality of services to be covered by the public health ring-fence. I hope that that provides clarification.

My noble friend Lord Greaves talked about the co-operation between different councils—county councils, district councils and so on. District councils have local insight and expertise. In many cases they will have the lead on key services affecting health and well-being, such as housing and environmental health. Health and well-being boards will play a big part in local health improvement activity and must find themselves able to involve local councils so that they work most effectively.

The noble Lord, Lord Northbourne—sorry to startle the noble Lord—wondered what would happen if local authorities do not carry out their duties. The Secretary of State does not have a conventional performance management role with local government—I am sure that those in local government will be pleased to know. However, he does have the power to intervene and ensure that particular services are provided if a local authority fails to do so. Local authorities will also have to account for their use of their ring-fenced grants, and the power exists to recoup money if the conditions attached to the grant are not met. I hope that that reassures the noble Lord.

In summary, it is very clear that environmental health is and will continue to be a very important component of the public health system, which will be led locally by directors of public health. I hope that the noble Lord is prepared to withdraw his amendment.

[Lord Rooker]

My Lords, I am grateful to the Minister for her reply, and particularly for reminding me about the favour that I did her. It proves that Ministers can make policy at the Dispatch Box. I accepted her amendment against advice; I used the excuse that there would have been a government defeat if I had not. She cannot use that tonight because I shall not press the amendment anyway, but I am very grateful that she remembered that.

I do not want to make a long speech. The Minister said that the work of environmental health officers is absolutely fundamental. They are the unsung heroes of policing a system in this country for our citizens on a whole range of issues, whether food, air quality or other matters. The public are aware of them only when things go wrong. I am reluctant to go down this route, but I declare an interest of chairing the board of the Food Standards Agency, which is a government department, and that is why I do not speak on it in this House. Environmental officers are unsung heroes and they deserve our support. They provide a 24/7 operation and they go into areas where, by and large, police officers would go in only pairs. Late at night they visit takeaway enterprises and so on. They do an enormous amount of work.

I also hear what the Minister said in answer to the point about discussion between the four Governments in the UK. If the only link between the four UK Governments on the respect agenda is between the four Chief Medical Officers, we are in dead trouble. Although that is important, it is more important that Ministers in the four Governments who have similar responsibilities talk to each other. Devolution means that things will be done differently—we are not looking for a one-size-fits-all situation—but it is crucial that there is co-operation, consultation and information. Major changes take place without any contact whatever with other Governments and it is the same in this area. There is no doubt that that causes problems. I am sure that we will turn in more detail to the issues relating to local government in regard to other amendments and we may or may not come back to this on Report. In the mean time, I beg leave to withdraw the amendment.

--- Later in debate ---

[Baroness Thornton]

My Lords, I rise to comment on these excellent amendments, and to support my noble friend Lord Beecham who has his name against Amendment 71. Amendment 71 is one of those very small amendments that changes “may” to “must” but it is actually at the heart of this discussion. What we are talking about here is how national campaigns will be linked to local action, and how they will be funded.

I start by reminding the Committee of some of the key components of this Government’s health policy on the harmful use of alcohol: banning the sale of alcohol below cost price; reviewing alcohol taxation and pricing to ensure that it tackles binge drinking without unfairly penalising responsible drinkers, pubs and important local industries; overhauling the Licensing Act; local authorities having more powers to remove licences and refuse grants that are causing problems; allowing councils and police to shut down establishments; doubling the fines for underage alcohol sales; and local councils being able to charge more for late-night licences.

My noble friend Lord Brooke put his finger on it, as did my noble friend Lord Turnberg, when he expressed scepticism as to the efficacy of these when you link them to the responsibility deal pledges on labelling. As part of the public health responsibility deal agreed with the Government in March 2011, UK alcohol beverage companies have pledged—that is an interesting word to use in this context—to implement a health labelling scheme to better inform consumers about responsible drinking. This pledge is in line with the industry’s response to the Department of Health’s consultation in May 2010 on options for improving information on the labels of alcoholic drinks to support consumers in making healthier choices in the UK. I do not think this is going to work.

Will the Government be reviewing their national campaign on alcohol and the misuse of alcohol in the light of this Bill? We have a national policy and a campaign, presumably run and directed by the Secretary of State for Health through the public health agency within the department. We have to look at what will actually happen on the ground and indeed address the dangers or risks that are posed by this Bill. A key question is the distinction between primary prevention and secondary prevention, which is complex in relation to the prevention of alcohol misuse. It is a concern when interventions cannot be clearly delineated as primary and secondary prevention. It seems that the reforms being proposed here will make that worse, not better.

Multiple commissions across one therapy, such as alcohol misuse, may cause uncertainty over who is responsible for funding services considered for both primary and secondary prevention. The worst case scenario is that neither the directors of public health nor the GP consortia commission secondary prevention services because the directors of public health are focused on primary prevention, awareness and information, the GPs are focused on treating the physical complications and harms relating to alcohol, and the hospitals are mopping up the people who turn up needing treatment for alcohol abuse.

If we are to tackle the fact that the number of hospital admissions was over a million in the last year, and that it is estimated to cost the NHS £2.7 billion a year—almost twice the equivalent figure for 2001, with the costs to society being even greater—there has to be co-ordination between national and local, and some direction about how these programmes will be carried through at local level. On these Benches we are therefore very sympathetic to what we see as a series of rather modest and focused amendments. We hope that the Minister will be able to look upon them with some sympathy.

[Baroness Northover]

My Lords, Amendments 71, 71A, 72, 74A, 202, 328, 329 and 331, make alternations to local authorities’ new duty for public health. In introducing this group, the noble Baroness, Lady Finlay, has made a very powerful case, as one would expect from somebody who has campaigned for a very long time in this area. Clearly, the harm caused by alcohol is unacceptably high, and everyone has to play a role in reducing its harmful use. She is absolutely right in her campaign on this. As she says, 1.1 million hospital admissions were alcohol-related, out of a total of 14 million admissions, at a cost of £2.7 billion. It is of course extremely striking that 13 per cent of 11 to 15 year-olds reported drinking in the last week. I am acutely aware of the particular vulnerabilities of children and young people in this regard. The British Crime Survey suggests that alcohol is linked to half of all violent crime, so you can see the significance of what we are talking about here.

Can I assure the noble Baroness, Lady Masham, that indeed, we are very acutely aware of how many prisoners have alcohol problems, as well as drug and mental health problems? As a Whip in the Ministry of Justice, I can assure the noble Baroness that we regard this as extremely important and that we are seeking to tackle it.

Local directors of public health in local authorities will have a key role in tackling alcohol harm. Can I assure the noble Baroness, Lady Finlay, that this will need to be addressed at every level of the health service and public health? That is why it receives such prominence in the paper that I referred to earlier. Again, I refer to the fact that public health, itself in the past very much a Cinderella service, is now at the front and centre of these changes. We hope that the involvement in local authorities will help to change this.

There are a number of steps that need to be taken; I would like to flag up some that the Government are taking at the moment. The noble Baroness, Lady Thornton, made reference to a number of these, and we are fully aware that this is a range of things, and that neither this Government nor the previous one, in all the range of things that we have undertaken so far, have made a dent in this problem. We recognise that this problem is driven by economic and social change, and it needs to be addressed in that regard, and understood very fully. In terms of relevant things which are happening, local directors of public health and local authorities will have a key role in tackling alcohol harm. We know that engaging with those drinking above the lower risk guidelines early on, and providing advice or referral for treatment for those who need it, does work, and that that is helpful.

While the health services have made improvements, much more needs to be done to identify consistently early signs of drinking above the lower risk guidelines, and to offer advice whenever and wherever the opportunity arises. I know how difficult this is with teenage children.

The coalition’s programme for Government, to which the noble Baroness, Lady Thornton, referred, committed to a ban on the sale of alcohol below cost. It also committed to review alcohol taxation and pricing to ensure that it tackles binge drinking. The Treasury published its review of taxation on 30 November 2010 and set out changes to duty on beer.

I hope that the noble Lord, Lord Turnberg, will be reassured that we will bring together the Government’s approach in an alcohol strategy, which is to be published towards the end of this year. We are reforming the Licensing Act via the Police Reform and Social Responsibility Act to enable local communities to ensure responsible retailing of alcohol. Also mentioned was the consultation on the public health outcomes framework.

[Lord Turnberg]

In the review that the Government are undertaking, will they take note of the publication on alcohol by the Academy of Medical Sciences, produced by Sir Michael Marmot two or three years ago? It recommended a whole series of things to do. Unfortunately, the Government of the day sexed it down and we were not able to move much further with it. I hope that this Government will take it into account.

[Baroness Northover]

I note what the noble Lord has said in regard to his Government. I would be astonished if those working on this strategy were not bearing that in mind, but I will check. I can assure the noble Lord that, in the unlikely event that they are not, I will bring the review to their attention so that they can factor it in.

The noble Lord, Lord Rea, asked whether the current spending on alcohol is included in local authorities’ funding for public health. I can assure him that that is the case and that what is being spent by PCTs on commissioning alcohol services will be reflected in the resources transferred to local authorities.

Amendments 66 and 72 would add,

“providing services for the prevention and treatment of harmful drinking and alcohol dependence”,

to the list of steps that the Secretary of State and local authorities may take under new Sections 2A and 2B. However, the Bill already gives the Secretary of State and local authorities the ability to take appropriate steps to address harmful drinking. The new public health responsibilities in this Bill give local authorities a ring-fenced grant to ensure that local authorities have the resources to deliver their public health responsibilities, including alcohol misuse services. Obviously, there was discussion of that ring-fence grant previously. I think it is a move forward that, instead of public health being part of the overall NHS and subject to being raided, there will be a ring-fenced grant.

Clinical commissioning groups are already under a duty—under Section 3 of the NHS Act, as amended by Clause 10, and under new Section 3A—to commission services as they consider appropriate as part of the health service or to secure improvement in the physical and mental health of their population. Given the scale of the problem, it would be astonishing if that was not part of how they see their responsibility.

I can further reassure your Lordships’ House that the importance of services which reduce alcohol-related harm will not be overlooked. The Secretary of State will set the strategic direction of the NHS through the mandate to the NHS Commissioning Board. This should be the route for highlighting priorities for the health service and I have no doubt that debates in Parliament, such as this, and in the wider sphere will help to influence that.

Amendments 328 and 329 would require joint strategic needs assessments to include an assessment of alcoholism in the local population and the involvement of representatives from alcohol services in the preparation of the joint health and well-being strategy. While we fully support the principle that the joint strategic needs assessments need to be comprehensive, we do not feel that it is necessary to include this amendment in the Bill. The scope of this assessment will naturally include the needs related to harm from alcohol. However, we have retained the power for the Secretary of State to issue guidance on the preparation of the joint strategic needs assessment. We will ensure that it covers the need to consider alcoholism, which I hope will reassure noble Lords.

Amendment 329 would require local authorities and clinical commissioning groups to,

“involve representatives from alcohol services”,

in the preparation of the joint health and well-being strategy. While there is no representative of alcohol services in the local area on the health and well-being board, it would still be able to involve experts as appropriate or invite them to be members of the board. On Amendment 331, which would require health and well-being boards to include,

“a representative from alcohol and drugs service”,

the same point applies: they could be a member of the board or their advice could be sought. The legislation sets out a minimum membership for these boards—

[Baroness Thornton]

I am slightly disturbed that so far the Minister has given us lots of coulds and maybes and “there is no reason why they should not”. Given the scale of this problem, I think that the Government need to look carefully at what goes on the face of this Bill and what is put in regulations about the problem of alcohol abuse.

[Baroness Northover]

I think that that point comes through loud and clear from this debate. I note what the noble Baroness said about what goes into the Bill or in regulation. She will know, from her experience of government, that generally speaking you do not put this sort of thing into the Bill. However, I take on board very much what she said about regulation, and I will take that back to the department.

The noble Baroness rightly focused on the joint strategic needs assessment and analysis of the current and future health and social care needs of an area. This would include the health and social care needs that are alcohol-harm related. Health and well-being boards would be able to involve people as necessary. As I said, noble Lords have made a very strong case for tackling alcohol abuse, which is very much economically and socially driven by the changes that underlie why this has come about. I have no doubt whatever that this issue will continue to dominate our debates, whether over regulation or over the Secretary of State’s mandate. This is a difficult area to tackle, as we know and as the previous Government knew, and it is best tackled as a cross-party attempt.

If only putting such matters into the Bill was a panacea. However, I am sure that the noble Baroness recognises that that is not the case. We realise that a range of measures must be taken, and I can assure the noble Baroness, Lady Thornton, that we constantly review the effectiveness of what we do. If we did not, I am sure that noble Lords would ensure that we did. I hope, therefore, that the noble Baroness will agree to withdraw her amendment.

[The Archbishop of York]

As the Minister resumes her seat, I would ask: if the matter is so serious, what is the problem with changing the word from “may” to “must”? What difficulty does that bring? Seeing the seriousness of the matter, why do the Government continue to say, “We will watch this”, “We will do this”, or “There will be a review of this”? This is a very simple amendment. I would have thought that they could, for once, admit and accept that the amendment be inserted, instead of postponing for some future thing. What is the real problem? I have not heard an answer to why “may” must remain and “must” must not be inserted.

--- Later in debate ---

[Lord Beecham]

My Lords, public health started in local government some 160 years ago—and as many of us have previously remarked, it started in Birmingham or Liverpool or Newcastle, depending on who you believe. But in all events it owes its origins to local government, and as many noble Lords have already made clear, local government has made enormous strides in promoting the welfare of the community and indeed the individual through the exercise of public health functions—notably, of course, in the realm of housing.

It is because, as my noble friend Lord Rooker has pointed out, so many responsibilities still rest with district councils that his amendment, to which I have subscribed, clearly makes the case for ensuring that while we have a two-tier system in parts of the country, district councils should be involved. They have manifold responsibilities that have been exhaustively, not to say exhaustingly, adumbrated by the noble Lord, Lord Greaves, in his long list of their functions. I spotted two that for some reason he overlooked. One is noise abatement, which I am afraid is a significant health issue in many places, and the other is, perhaps more generally, community safety, which again can be a district council function. All these matters suggest that there ought to be a clear role for district councils in two-tier areas, certainly in relation to public health and, as perhaps we shall discuss at a later stage, in respect of other aspects as well. For that reason I hope the Minister will acknowledge that the amendments dealing with the role of district councils, including the amendment in my name which seeks to reaffirm that whatever else happens, the current duties relating to public health which apply to district councils should remain in place, should be accepted so that nothing in the Bill would dilute those responsibilities.

The noble Baroness, Lady Hollins, has made a good case in Amendment 203C for clinical commissioning groups to promote public health. I do not purport to understand the groupings here. This is no reflection on the noble Baroness, but it seems to me that the other amendment would have been better placed in the debate around clinical commissioning groups rather than here. The words “public health” have registered, so the amendment seems to have been plonked here, it might be thought somewhat inappropriately. Her argument, of course, is absolutely valid, but it is perhaps slightly unfortunate that that amendment has been placed in this group.

I have to say much the same about Amendment 79A, tabled by the noble Baroness, Lady Tyler. There are, if I may say so, two things wrong with the amendment. First, it really talks about providing commissioning consortiums—or, as they are now called, clinical commissioning groups—with responsibilities. That, again, is in the wrong place, but even if it were in the right place I would find myself in difficulties supporting it, because it seems to set up a parallel system with local government. It would invest in clinical commissioning groups the possibility of commissioning a range of services:

“housing or housing related support … education and employment … transport and leisure services, and … other health-related services”.

That last item I can understand, but the other three are primarily local government responsibilities. The implication is that either they would effectively take over or jointly commission services, in addition to local government. That is misconceived and likely to blur the position very significantly. So if the amendment were likely to be pressed to a vote, I could not find myself in the same Lobby as the noble Baroness. However, I apprehend that she will not be pressing it to a vote.

The noble Baroness, Lady Barker, raises interesting points under the clause stand part debate, and they are ones that should be considered. However, at this time I propose to stand apart from clause stand part. She is right to raise these matters and perhaps they can be taken further in discussion, as can other of the suggestions in amendments that we have heard tonight. On Report, one hopes that the Government will have reflected on the points made, and particularly on the position of district councils as referred to by my noble friend Lord Rooker and the noble Lord, Lord Greaves, so that we can ensure that the position of such councils and the duty to co-operate, which is so essential, is embodied in the Bill and not left to chance. It is not universally the case, I am sorry to say, that the relationship between county and district councils is all that amicable. There have been cases in parts of the country where it has been very far from the case. It should be made clear to both groups that there is a duty to co-operate, particularly to the county authorities that they have to reflect the interests of the district councils, because of the importance of the functions that they exercise.

[Baroness Northover]

My Lords, with Amendments 73 and 75, the noble Lord, Lord Rooker, has correctly identified the importance to public health of collaboration and co-operation between agencies. The noble Lords, Lord Rooker and Lord Greaves, come from somewhat different perspectives with regard to local government, perhaps based on their relevant or not relevant experience in this regard. I am, as ever, very grateful when my noble friend Lord Greaves offers me help, and we certainly can have discussions. Noble Lords, as these debates have shown, can offer experience across a wide area of knowledge and we would be remiss not to tap into that.

[Lord Greaves]

I thank my noble friend very much indeed for that. While the noble Lord, Lord Rooker, and I may come from different ends of the spectrum, we end up in the middle agreeing on a way forward.

[Lord Beecham]

And so do I.

[Baroness Northover]

Well, there we are—at this time of day, just before a recess, we have cross-party consensus. Shall we just adjourn?

The noble Lord, Lord Greaves, correctly identifies the areas in which local authorities have done so much to improve public health. I made reference earlier, as others have made reference, to the 19th century, because the sanitary reform then was a local authority achievement, and it did more than the invention of antibiotics to save and extend lives. The devolution of public health to local authority-level aims to link up all those areas across people’s lives, a point emphasised by the noble Baroness, Lady Tyler.

The noble Baroness graphically shows how health is related to wider social and economic factors, a point that the noble Baroness, Lady Hollins, has demonstrated in her account as well. I know from DfID how investing in girls’ education in developing countries results in later pregnancy. Why should it not be true here as well?

--- Later in debate ---

[Baroness Tyler of Enfield]

Slightly but not tremendously.

[Baroness Northover]

I am reassured that she is slightly clarified. This has been yet another important exploration of how the new arrangements might work. I realise that there will no doubt be further discussion; nevertheless, I hope that in the light of what I have said the noble Lord will be prepared to withdraw his amendment.

[Lord Rooker]

My Lords, I am grateful to the Minister and for the support for the fact that we need to address this issue. I am not asking for any more reassurances but I should like to believe that between now and Report there will be deeper discussions with local government, probably even addressing the machinery of government.

I cannot believe that the existing silos of Whitehall will work when the Bill is implemented. There is now a cross-over between health and local government which has not existed in this country for many decades. Therefore, there is going to be a cross-over and a different kind of working relationship between the Department for Communities and Local Government and the Department of Health. That seems to me eminently sensible for reasons of both accountability and delivering a seamless service to the public. After all, that is what it is about. The public do not care where the service comes from; they want to know that the service is there.

I appreciate the constraints that the noble Baroness is under, but I think that it was well worth while giving this issue a run-out. I have no doubt that we will return to it on Report, but basically I hope that there is more of an impetus and that Ministers’ officials will say, “Well, we do need to have a little bit more discussion to lock this thing down”. The Government cannot afford to get this wrong with this legislation, as the Minister has realised. I think that, with a bit of extra thought, consultation and discussion within government and with local government, a satisfactory solution can probably be found. I beg leave to withdraw the amendment.

Middle East: Water

Baroness Northover Excerpts

Thursday 27th October 2011 Lords Chamber

[Baroness Northover]

My Lords, I thank my noble friend Lord Alderdice for bringing this interesting and challenging report to the attention of the House. I know that he works tirelessly on the issues of peace and reconciliation, and he is to be commended for this work. Given his profound experience in Northern Ireland and elsewhere, it surely behoves us to listen to him closely. I thank all noble Lords for their contributions to this debate—contributions that are clearly borne out of deep experience. I especially congratulate the noble Lord, Lord Williams of Baglan, on his excellent maiden speech. His detailed knowledge of the region shows the profound challenges that the region faces and how important it is that we listen to those with possible routes through. I look forward very much indeed to his future contributions. I know that we will all benefit from his engagement here.

This report presents us with an innovative and striking proposition. We are all aware that factors such as resource scarcity—including that of water—climate change and population growth may increase the potential for conflict. The noble Lord, Lord Triesman, rightly emphasised the key importance of population growth in the region. On water, the facts seem to bear out the potential for conflict. By 2025, more than 2.8 billion people in 48 countries may face water scarcity. Meanwhile, the International Water Management Institute has estimated that demand for water for agriculture alone could increase by over 30 per cent by 2030. My noble friend Lady Falkner flagged up the great significance of climate change in all this.

However, this report puts forward the premise that water should become an instrument of co-operation rather than conflict. As the report notes, water sources and rivers are no respecters of national boundaries. As my noble friend Lord Alderdice and others have so eloquently explained, water could become a theme of dialogue and co-operation between nations. All in a particular region must, of necessity, have an interest in resolving the challenges posed. This could then assist in other areas. As he said, this may not be achieved in a day or a week. The true resolution of conflict is a long-term challenge.

From noble Lords’ accounts, we can see how deep are the problems in terms of conflict, simply over water—not that there is yet even an agreed set of data, as my noble friend Lady Falkner pointed out. Set that against some of the political problems, as laid out, for example, by the noble Lord, Lord Williams, and my noble friend Lady Falkner, and one can see the depth of the challenge. However, as my noble friend said, doing nothing is no longer an option.

The Government place high value on innovative approaches such as those that look at how to use issues of mutual concern, such as shared and scarce resources to reduce conflict. Seeking to reduce conflict is a key element of our foreign and development policy. We have committed to spend 30 per cent of development aid in fragile and conflict-affected states by 2014-15. The Building Stability Overseas strategy published in July of this year, which spans the FCO, the MoD and DfID, sets out the UK Government’s overarching approach to try to prevent conflict and tackle instability through a strong integrated approach, bringing together all these areas of development, diplomacy and defence. A key pillar of this strategy is to invest in upstream prevention to tackle the underlying drivers of conflict and build capacity to manage tensions within and between nations constructively.

The type of approach suggested in this report on using water management as a source of regional co-operation rather than conflict has been seen to work well in some areas of the world that share scarce water resources. The Department for International Development is currently supporting regional initiatives, mainly in Africa and Asia, which have shown that water resource management can serve as an entry point for co-operative development. These include the water initiative under the Southern African Development Community, the Nile Basin initiative, and the South Asia Water Initiative.

The initiatives have already helped to build trust and stronger relationships between countries, and this improves the management of water within and between countries for the benefit of all. These approaches have worked well where initiatives were effectively co-ordinated and avoided duplication of effort.

Another lesson, which the report supports, is that, while distribution and management of water is highly political, it is sometimes better to treat co-operation on water as a technical, rather than a political, issue and hence to encourage practical co-operation between experts rather than politicians. We have heard from both the noble Baroness, Lady Deech, and the noble Lord, Lord Palmer, details of some of the university and other collaboration which is currently under way. That is very encouraging.

The noble Baroness, Lady Deech, rightly emphasises the importance of co-operation in science and technology and noble Lords will be no doubt be interested in the UK Government’s recent initiatives in this field. Tonight, my right honourable friend the Chancellor of the Exchequer will travel to Israel and the occupied Palestinian territories; during his visit he will launch the new UK-Israel high-tech hub and give political profile to the importance of co-operation in this field.

The report we are discussing today specifically focuses on the Middle East, where the fair and effective distribution of shared water resources is an absolutely key issue. Jordan, Lebanon, Syria, Turkey, Iraq, Israel and the occupied Palestinian territories are its main focus. The report, however, is cognisant of the enormous political difficulties, including those between Israel and its Arab neighbours, and therefore presents a road map for action which begins with efficient internal management, storage and distribution. It also proposes the interesting idea of establishing a co-operation council for water resources for Iraq, Jordan, Lebanon, Syria and Turkey and, separately, a confidence-building initiative between Israel and the Palestinian Authority. We pay tribute to the authors and the sponsors for exploring and raising these ideas.

Noble Lords will be very well aware of the dramatic changes that have affected the region and the challenges and opportunities that they bring. The report was, of course, published before the remarkable events of the Arab spring, to which the noble Lord, Lord Alderdice, and the noble Lord, Lord Williams, have referred. Many states are undergoing rapid transition and leaders in those countries have pressing issues to deal with so that they can respond to the legitimate demands of their population. The Government are committed to working through the Arab Partnership with the international community to support the democratic transitions that we hope are under way. However, we are aware that each of these countries will face a great range of challenges, not least in resource allocation. The noble Lord, Lord Alderdice, is surely right to say that, as we focus on what is happening in the Arab spring, we should not forget the other challenges that these countries will face.

In the region, the UK funds the Global Water Partnership, which has supported a regional water partnership for the Mediterranean. Partners have included Israel, Jordan, Lebanon, Syria and Turkey, among others. These independent regional groups have promoted the concept and implementation of integrated water resources management as a vital approach to managing this area’s resources.

Water is, as we have heard, one of several important subjects for negotiations between Israelis and the Palestinians. Noble Lords have shown how acutely aware they are of this problem. UK officials regularly raise concerns over water issues with Israeli counterparts and we have brought the Foresight report to the attention of the EU donor and co-chair of the water sector working group with the Palestinian Authority. I reiterate that our immediate focus remains to bring the parties back to peace negotiations. However, my noble friend Lord Palmer urges us not to wait for the political process before advocating co-operation on water.

My noble friends Lord Alderdice and Lord Palmer emphasised how much Israel can contribute through its technological expertise—a point also emphasised by the noble Baroness, Lady Deech. I agree that the use of technological solutions may well be one of the key ways to address water shortages. Individual, practical and immediate water management measures should not need to wait for political negotiations to be completed.

The noble Lord, Lord Triesman, posed a series of challenges, which showed his very deep knowledge of this area. I hope that the authors of the report respond to those challenges, and I should be extremely interested in knowing what those responses are.

My noble friend Lady Falkner wondered whether DfID would consider working in waste water management in West Bank territories. There are currently 30 donors, NGOs and agencies working on water issues in the West Bank, and DfID has therefore decided not to focus on water issues because of this good coverage. However, as I said, UK officials have brought the report to the attention of these groups. Nevertheless, we would be happy to host a round table meeting on the challenges of conflict over water in the region and all noble Lords will be encouraged to feed into this.

In conclusion, I again thank noble Lords for their participation in this very important debate. It has highlighted the issues of water and conflict, and the need to identify innovative and new approaches to address some of the challenges that they will increasingly pose in the future. We have a shared interest in preventing conflict, promoting constructive dialogue between nations to manage scarce resources and ensuring a sustainable supply of water to all populations. We therefore very much commend those who are working to develop ideas on how best to achieve this.

House adjourned at 5.47 pm.