NHS Commissioning Board: Mandate

Baroness Northover Excerpts

Tuesday 13th November 2012 Lords Chamber

[Earl Howe]

My Lords, I am grateful to the noble Lord for the welcome he was able to give to aspects of the mandate, not least in the area of mental health where, as he will have noted, the original version of the mandate has been considerably strengthened in a number of places to emphasise the parity of mental health with physical health in a number of ways. I am glad he thinks that that is a positive step and I agree that it is a necessary one if we are to achieve the higher standards in the care of those with mental health problems which we all want to see.

The noble Lord also welcomed the focus on outcomes and the fact that the mandate has been restructured around the five domains of the outcomes framework. We thought it was logical and sensible to hold the board to account for objectives which related directly to indicators within the outcomes framework. That has been warmly welcomed by the board itself.

The noble Lord asked a number of specific questions. First, on personal budgets in mental health, I can tell him that, subject to the results of the current trials in personal health budgets which we expect to announce very soon, we expect that mental health will be one of the areas where patients will be able to exercise direct control over the services they receive. As the noble Lord well knows, patient empowerment in the area of mental health is, in itself, therapeutic. If we can encourage that, we should.

The noble Lord also mentioned mental health in the workplace and I completely agree with what he said about that. I recently mentioned, in your Lordships’ House, the network which Dame Carol Black and I chair in the department looking at health in the workplace and the pledges that have been devised and which businesses can sign up to. One of those pledges indeed relates to mental health. We hope that we can recruit willing enthusiasts from among the business community to sign up to as many of those pledges as they can.

The noble Lord referred to public health, and I agree with him that it is not a matter simply for the department; all government departments need to engage in it. I should say to him that the creation of Public Health England will provide an immediate opportunity for that body to work with other government departments, but also much more widely to ensure that we genuinely have a joined-up approach to public health objectives. He will know that the public health outcomes framework, which has been drawn up to align itself as far as possible with the NHS outcomes framework, will be a powerful driver for improvement across the field of public health.

The noble Lord characterised the mandate as an uncosted wish list. I can tell him that it has been costed, and the NHS Commissioning Board itself was fully consulted before the mandate was drawn up, because it would clearly not be in anyone’s interests to task the board with delivering the unachievable. The board is aware that it will receive real-terms increases in the budget for the NHS—increases the NHS has received during every year of this Parliament. He referred to cuts. I want to emphasise to him that while we are aware that there are significant constraints at a local level, particularly at provider level, the overall budget to the NHS is not being cut; it is increasing, year by year.

The redundancy payments that unfortunately have been necessary of course represent ongoing annual savings from now on. It is always painful to make people redundant, but we deemed that it was absolutely necessary if we were to retain a sustainable health service. Every pound that we save will go straight back into front-line care.

The noble Lord mentioned the performance of the previous Government, and I am the first to pay tribute to the improvement in the health service that took place under that Administration—not least in waiting times. It is why we have explicitly said in the mandate that waiting times continue to matter. They matter to patients, they are clinically a valid measure of patient experience, and we have no intention of abandoning that metric.

The noble Lord also spoke about enforced competition. I should correct him on that because, as he will know from our debates on the Health and Social Care Bill, we believe that competition can sometimes be a tool for commissioners. We do not believe that it should be shoved down anybody’s throat. Competition, as Sir David Nicholson pointed out the other day, should be regarded as a rifle shot, rather than a carpet-bombing exercise. It should be used only where it is in the interests of patients, which is why the first duty of Monitor, the economic regulator of the health service, is to serve the interests of patients.

The noble Lord referred to partnership working, and I was absolutely in agreement with him that there needs to be partnership, not only at a local level between GPs, social care, secondary care providers, but at the level of the arm’s-length bodies. Chapter 7.3 of the mandate covers the latter aspect comprehensively. However, in Chapter 2, we also place great stress on integration of services, which was the subject of a number of debates in your Lordships’ House during the passage of the Bill. Primary care is covered in Chapter 9.2, which is one of the main areas that the board will be commissioning.

The noble Lord asked me about networks, which we debated a few days ago. They can take various forms. The strategic clinical networks, about which he asked me in his Oral Question the other day, embrace, as he knows, four major clinical areas where we believe that considerable change is required if we are to see services improved to the extent that they should be. However, that does not preclude other networks forming at a local level—for example, at provider level—to ensure that services are joined up. I am sure that we shall encourage those networks, wherever they are appropriate, but we are not mandating them.

The noble Lord asked me about measurable progress. Today, we are publishing an updated version of the NHS outcomes framework, which includes an appendix that sets out the detailed definitions for the majority of indicators. We will have robust metrics which we shall be able to use to measure health outcomes. Over the past few months, the Health and Social Care Information Centre has been publishing many of the data as they have become available. Publishing data for the indicators will, in itself, show whether outcomes are improving. In order to interpret progress, we will work with the NHS Commissioning Board and experts to develop a methodology for measuring progress. There is time enough to do that and I will happily keep the noble Lord informed as that work rolls forward.

[Baroness Northover]

My Lords, perhaps I may remind noble Lords that contributions and questions should be brief so that as many noble Lords as possible can participate. I also remind noble Lords that contributions will come from around the House so Members other than those in the Labour Party need to speak now. Maybe we could hear from the Cross Benches.

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[Baroness Northover]

My Lords, it is the turn of the Conservatives.

[Lord Hunt of Kings Heath]

My Lords, there was an agreement between the usual channels that it is the Government Benches, then the Opposition and then the Cross Benches. The noble Baroness is seeking to reinterpret what has already been agreed.

[Baroness Northover]

It is the turn of the Conservatives.

[Baroness Cumberlege]

My Lords, I, too, congratulate the Government on the mandate. When we were debating the Bill, I requested that the mandate should be short, precise and well-focused, and it is all of those things. I particularly welcome the focus on the importance given to improving standards in maternity services. The mother’s experience and the start of life are very important and have a huge impact on the long-term well-being of children.

I wish to link the outcomes framework with the mandate. On the outcomes framework, at page 11 under “Trauma” we are told that this is an area for further improvement. It states:

“As part of the development of the placeholder ...‘improving recovery from injuries and trauma’ the indicator has now been defined as ‘Proportion of people who recover from major trauma’”.

That links very much with what my noble friend was saying earlier about expertise. The point I want to make on the mandate is that we are told that the objectives in the mandate can be realised only through local empowerment. The board’s role in the new system will require it to consider how best to balance different ways of enabling local and national delivery. These may include the duties and capabilities for engaging and mobilising patients, professionals and communities in the shaping of local services.

My concern is on A&E and the emergency services. With the NHS Commissioning Board having now appointed Tim Kelsey to look at communications, how can we get public leadership to understand that expertise in certain areas is very important for survival? The footballer Fabrice Muamba collapsed on the football field and passed several A&E departments to get to the one that saved his life because the expertise was there. Is there a requirement in the mandate that there should be a mobilising and further education of the community so that it understands what expertise is needed in order to save lives?

Winterbourne View

Baroness Northover Excerpts

Tuesday 30th October 2012 Lords Chamber

[Baroness Northover]

My Lords, I remind noble Lords of the Companion, which says that Statements are a time for brief comments and questions, not for immediate debate. If noble Lords are brief as many as possible will be able to contribute.

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[Baroness Emerton]

My Lords—

[Baroness Northover]

My Lords, I have been keeping a tally and it is the turn of the Labour Party and then the Cross-Benchers.

[Baroness Donaghy]

Is the Minister satisfied that not a single senior manager or owner went to jail as a result of the Winterbourne View scandal? Given that, how on earth is a culture change going to be promoted in these organisations? Can he assure the House that the responsibility and any judicial changes will be considered as part of any review?

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[Viscount Tenby]

My Lords—

[Baroness Northover]

I think it is the turn of the Liberal Democrats and then maybe the Cross-Benchers after that.

[Lord Cotter]

My Lords, I very much welcome the mention of training once again today. It is so important that support workers are trained. One issue that has come to my notice quite frequently is that through a lack of training, support workers question the trained professionals an awful lot. The management also need to be trained to back up the professionals who are trained in their job as a vocation, so that the less well trained support workers respect their decisions.

Care and Support

Baroness Northover Excerpts

Wednesday 11th July 2012 Lords Chamber

[Earl Howe]

My Lords, I thank the noble Baroness for her comments and questions. While she levelled a number of criticisms at the Government, I was glad to hear her positive comments—although I would characterise her speech as a glass half empty speech rather than the opposite. Nevertheless, I am grateful to her for recognising that this package of proposals represents progress. In many areas it is progress that her party and mine fully sign up to. However, she said at the start of her remarks that there was a lack of vision and strategy in these proposals. I was sorry about that because I do not share her view. The White Paper and the draft care and support Bill undoubtedly form the most comprehensive overhaul of care and support since 1948. They respond directly to the concerns that people have raised with us time and again.

I hope that when the noble Baroness reads the White Paper she will agree that the whole flavour is about creating a system that keeps people independent and well. There are many major commitments in the White Paper, including more support and equality for carers, housing investment, better information and personal budgets. Those things all combine to set out a new vision that tailors care around people’s well-being, rather than expecting people to conform to a system, which is what we have at the moment.

The noble Baroness criticised the Government for delay. I gently point out that more than 13 years ago there was a royal commission chaired by the noble Lord, Lord Sutherland. The previous Administration had 13 years to respond to it but did not do so. Nevertheless, progress was made in certain areas. We have gladly picked up on some of the areas of progress that the previous Administration put in place, not least in the area of carers. However, it is not true that since the present Government came to office we have seen no action. One of the first decisions that we made was to protect care and support in the spending review through an additional £7.2 billion over four years. That was an explicit recognition of the strains that local authorities were expected to come under. I announced through the Statement today further funding in recognition of those strains at local level.

It is true that some of the changes will take longer than others, but progress will be made within 12 months. It will include introducing quality profiles for every provider so that people have comparative information on the quality of different organisations, investing £200 million over the next five years to develop specialised housing, publishing a code of conduct and minimum training standards for care workers, and launching a new national information website at nhs.uk. I hope that the noble Baroness will welcome those innovations.

On the deferred payment scheme, there is a lot of discussion to be had. Our proposals are that deferred payments will be available in all local authorities. Currently they are available in some but not all. As the noble Baroness knows, the social care means test requires people to use their housing wealth when they go into residential care. We are announcing that we will allow people to pay later, giving them more time to sell their home at their convenience or even for it to be sold after their death. We are not confirming now exactly who will be eligible or the rate of interest that will be attached, but we have said we will consult on these issues with the care sector.

As regards the cross-party talks, I should like to put it on the record that we fully intend to continue to engage with Her Majesty’s Opposition and with the sector on options for implementing the Dilnot model as well as with Mr Dilnot himself. At this stage, we are open-minded as to what form that engagement should take. As has been the case to date, discussions on funding reform will be led by the Department of Health on behalf of wider government. We wish to continue what I believe has been a very constructive series of discussions, with the Opposition in particular. The disagreements and criticisms that blew up over the weekend were regrettable and we wish to draw a line under that. I hope the noble Baroness will appreciate from the correspondence that has flowed between our two lead spokesmen that that is indeed the intent.

The noble Baroness is not correct as regards the NHS underspend. It was not lost to the NHS. The overall year-end surplus of £1.6 billion for PCTs and SHAs last year will be carried forward and made available in 2012-13. That represents a 3% increase in funding available to the NHS relative to last year. As I mentioned earlier, we are allocating further funding on top of the £7.2 billion that we previously announced in support of local authorities.

There are many questions to answer in this package. I do not hide from that, but it is right that we take time to work through this, including engaging with all stakeholders to ensure that any reform is sustainable and fair.

[Baroness Northover]

My Lords, before we get into the session where all Peers can contribute, I remind noble Lords that the Companion states that ministerial Statements are made for the information of the House and that, although brief comments and questions are allowed, Statements should not be made the occasion for immediate debate. Perhaps I may emphasise brevity and therefore the courtesy of allowing as many noble Lords as possible to contribute.

Health and Social Care Bill

Baroness Northover Excerpts

Tuesday 13th March 2012 Lords Chamber

[Lord Patel]

My Lords, Amendment 249 is related to statutory registration. We have been talking about voluntary or statutory registration for the past three hours. I shall be happy if at any time the noble Earl interrupts to stop me trying to make a case for statutory registration for public health specialists because he has already made up his mind that he is likely to accept if not this amendment then statutory registration. I believe that the noble Baroness, Lady Northover, is trying to intervene.

[Baroness Northover]

My Lords, a great deal of attention has been paid to public health in this House and we very much welcome that and the efforts by the noble Lord, Lord Patel, and others. We recognise that public health specialists play a critical leadership role in protecting the public from harm. The Government recognise the strong support for a compulsory statutory regulation system for all public health specialists. I think that that is what the noble Lord was going to say. We agree that it is absolutely essential that all public health specialists, including those not currently subject to compulsory statutory regulation—

[The Deputy Chairman of Committees (Baroness Gibson of Market Rasen)]

The noble Lord has not moved the amendment.

[Baroness Northover]

The noble Lord may withdraw it in a moment.

[The Deputy Chairman of Committees]

The noble Lord must move the amendment. Does the noble Lord wish to move the amendment?

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[Lord Patel]

I should like the noble Baroness to finish her sentence, because I think she was leading on to say professions other than in medicine or dentistry.

[Baroness Northover]

If noble Lords are happy, I will continue. I will be happy to answer any questions. All public health specialists, including those not currently subject—

[Lord Hunt of Kings Heath]

I think that the noble Lord, Lord Patel, wanted an early indication as to whether the noble Baroness was going to accept the amendment and then allow the debate. He is not looking for a winding-up speech at this point.

[Baroness Northover]

Noble Lords will know that the Government have already announced their intention to regulate all public health specialists so that we address the anomaly whereby some were regulated and others were not. If that is the answer that the noble Lord was looking for, put briefly, I hope that he will welcome it.

[Lord Patel]

I welcome those comments. As I understand it, the noble Baroness, Lady Northover, is saying that the Government intend through secondary legislation to establish statutory regulation of all public health specialists, including those not in medicine and dentistry. I am grateful for that. I beg leave to withdraw the amendment.

Health and Social Care Bill

Baroness Northover Excerpts

Thursday 8th March 2012 Lords Chamber

[Baroness Williams of Crosby]

Before the Minister concludes, perhaps I may press him on what is implicit in Amendment 220B, although I shall not move it. If, for example, the governors were to oppose a figure of more than 5 per cent, and the figure were greater than appears to be proper in the light of health services, what steps would be available to ensure that health services are protected?

[Baroness Northover]

As we are on Report, perhaps noble Lords will allow the Minister to develop his argument and then put brief questions in the light of what he said—otherwise he will lose his train of thought.

[Lord Hunt of Kings Heath]

My Lords, I hesitate to take issue with the noble Baroness because clearly she is in a position to help the House. However, interventions on Report are quite allowed. I am very puzzled that the Government are trying to seek to rule that Report stage procedure should change so that we simply listen to the Minister. That is not Report.

[Baroness Northover]

My Lords, I am not saying that short questions cannot be put. However, it might be beneficial to the House if the Minister were able to develop his argument. Then, if noble Lords had questions that he had not addressed, that would be the relevant time to put them.

[Noble Lords]

Hear, hear!

[Baroness Northover]

That is what the noble Lord, Lord Hunt, preferred when he was a Minister. I hear from around the House some sympathy for the point. If the suggestion does not work, no doubt we can take the matter to the Procedure Committee and look at a different way of doing things.

[Lord Hunt of Kings Heath]

My Lords, the noble Baroness is not in a position to dictate to the House that it should change its procedure on Report. Surely the beauty of debate lies in interventions, and responses by Ministers. When I was a Minister for 10 years at the Dispatch Box, I always took interventions and welcomed effective and proper debate. I am on my feet—

[Baroness Northover]

For clarification, perhaps I may remind the noble Lord that the Companion sets out that a Member shall not speak after the Minister on Report,

“except for short questions of elucidation to the minister”.

I realise that noble Lords are putting short questions of elucidation. The Minister made it clear that he wishes to make progress and that at the moment he does not wish to take interventions so that he can develop his argument.

[Noble Lords]

No!

[Baroness Northover]

He certainly did to me. Perhaps the Minister would like to make it clear—if he wishes to be interrupted many times and not develop his argument, so be it. Perhaps my noble friend would like to clarify—

[Lord Campbell-Savours]

I object to the procedures of the House of Lords being changed by a junior Minister.

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[Lord Phillips of Sudbury]

I did not want to leap on the noble Lord, Lord Warner, because that would do him an injury, but I wanted to assure him that the amendment does not affect his trotting off to the chap down at Waterloo station. He can buy whatever private patient care he likes, wherever and whenever he likes—

[Baroness Northover]

I remind my noble friend that he can reply on his amendment at the end. I am sorry to keep on intervening on my noble friends in defence of the noble Lord, Lord Warner, who wanted to continue his argument, as he did. My noble friend has the opportunity to respond at the end.

[Baroness Murphy]

I have concerns similar to those of the noble Lord, Lord Warner, but this amendment is different from those that I have seen floating around from the noble Lord, Lord Phillips. I also have questions, but we must be very clear about what we mean by “queue-jumping”. If an NHS patient goes to an ordinary NHS hospital consultant and is told that they need an operation, it is completely legitimate for them then to ask to go privately and pay for the operation. That is, as the noble Lord, Lord Warner, said, enshrined in the NHS Act of 1948, and completely legitimate. Queue-jumping is when a patient sees a private consultant who then inserts the patient into the NHS list ahead of other NHS patients. That is what we want to avoid, and it is already completely illegal and highly frowned on. Most hospitals do what they can to exclude it, but I take the point made by the noble Lord, Lord Phillips, that it goes on, and we know that it does. It is an unpleasant practice and should be stamped out, but I do not know whether this amendment does that.

As the noble Lord, Lord Kakkar, reminded us, the conundrum of private units in NHS hospitals must be borne in mind. That may be the most constructive way in which to ensure that NHS consultants are available to NHS patients when they need to be, as the noble Baroness, Lady Finlay, said. But often private patients have operations that go wrong—and then, if there are two patients in need of an NHS intensive care bed, the patient who takes priority is the person with the clinical need. It is very much the same as someone on a battlefield. It does not matter whether it is an enemy soldier or a domestic soldier.

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[Baroness Wheeler]

My Lords, with an additional 68 government amendments tabled at the end of last week on the issue of HealthWatch England and the now much altered healthwatch organisations, it is somewhat of a challenge to work out exactly what the Government want from HealthWatch England and local healthwatch organisations. Why has not the Government’s time since Committee stage been spent on trying to address the issues and concerns raised by noble Lords which would ensure that HealthWatch England and local healthwatch organisations have the real status and authority to do the job that we all recognise is required of them? Instead they have concentrated on compiling one of the most confusing additional sets of amendments that we have seen on this Bill, which will seriously undermine the ability of both the national and local organisations to act as an effective and robust watchdog for patients and the public.

The new local arrangements for healthwatch organisations provide a plethora of contradictions and confusions and we shall discuss those under a later group. Sadly, none of that addresses the continuing concern across the House and among key patients’ groups and organisations about the HealthWatch-CQC relationship. Fortunately, Amendment 223A, from the noble Lord, Lord Patel, my noble friends Lord Harris, Lord Whitty and myself does. Those noble Lords have all made a coherent and powerful case for the amendment and for ensuring that HealthWatch England is independent. The amendment provides for a body corporate, with clear primary duties to represent the interests of patients and users of the National Health Service and of social care services, independent of any provider or regulator of those services. As well as powers to provide information and advice on the views of patients and standards of quality of care, the amendment provides HealthWatch England with powers to investigate complaints made by or on behalf of a patient or user of a local healthwatch organisation and to raise and investigate complaints relating to wider issues affecting patients or users in general.

The Government have said that they want to see HealthWatch England with genuine operational independence from CQC. However, attempts to do that by, for example, providing the majority membership of HealthWatch members on the HealthWatch board, or reassurances after the last debate in Committee in terms of HealthWatch England being able to speak out publicly in certain circumstances, even if their views conflict with its host body or government, miss the point. None of these small steps gives the unequivocal reassurance of independence that a robust patients’ watchdog, acting in the interests of patients, must have. In the new market-dominated system that we will soon have, independence and a collective voice for patients is more vital than ever. In the end, it will come back to how the proposed measures will play out in practice and how conflicts of interest between HealthWatch England and the CQC, or indeed healthwatch organisations in the local authority, will be dealt with.

Most important of all is the issue of public perception, understanding and confidence in the independence of HealthWatch. It is important that HealthWatch is seen to be credible and truly independent, able to challenge and to scrutinise the work and decisions of the regulators, both CQC and Monitor. The niceties of whether there is a majority of HealthWatch members on the board, whether they can combine or exchange data and whether they are part of an organisation that the Secretary of State keeps under review will escape a patient, carer or representative who, for example, makes a complaint about how CQC has investigated care in a residential home, only to find that the body investigating the complaint or championing improved quality of care on behalf of patients is a committee of the CQC itself.

I hope that the noble Baroness will address these concerns: in particular, points that were repeatedly made about how the culture clash between healthwatch and the CQC will be addressed and managed; how we will stop CQC—in the words of the noble Lord, Lord Patel—“suffocating” HealthWatch England; how the potential serious conflict of interest will be dealt with; and how public faith, trust and confidence in healthwatch can be achieved under the relationship with the CQC, particularly in light of that body’s major organisation and resource problems so starkly highlighted in the Department of Health’s recent CQC performance and capability review.

In the debate on the duty of candour, the Minister referred to the CQC as an organisation that was remote from patients. We need an independent HealthWatch England and we need local healthwatch bodies that everyone can rely on to be genuine patient representatives. I am afraid that the Bill gives us neither.

[Baroness Northover]

My Lords, this has been another excellent debate. I listened very carefully—as I did before—to the views expressed. Overall, there is clearly complete agreement on all sides of the House that the voice of patients and the public should be at the heart of the NHS. As the noble Lords, Lord Patel and Lord Harris, and the noble Baroness, Lady Masham, and others indicated, the history of how previous Governments tried to implement this is tortuous. The recent past has borne witness to a number of attempts to do it, and noble Lords referred to some of the problems. No attempt—not even Community Health Councils—managed to fulfil the worthy intentions of its architects, and we went from one to another.

As the noble Lord, Lord Patel, recognised—I appreciate his words—we seek here to take the strengths from past attempts, build on them and ameliorate the weaknesses as we develop our proposals for HealthWatch England. In the light of the comments of the noble Lord, Lord Harris, and as the noble Baroness, Lady Murphy, emphasised, it is worth remembering one of these previous attempts: the Commission for Patient and Public Involvement in Health. It was established in July 2003 and operated nationally and regionally, following regional government boundaries. Within five years it had been abolished after being seen to lack clout, to be too bureaucratic and too top-down for the public and those on the ground. Perhaps I may again remind the House of the judgment from the Health Select Committee’s 2007 Report into Patient and Public Involvement in the NHS, which stated:

“The evidence we received was overwhelmingly critical of the Commission”.

We are convinced that trying to recreate the commission is not the best way forward, and instead propose that HealthWatch England should be a statutory committee hosted—that was a very good description from the noble Lord, Lord Patel—by the CQC, which is a far more viable option.

I am well aware that this proposal has met with concern.

[Lord Harris of Haringey]

My Lords—

[Baroness Northover]

I will finish and then I will respond to the noble Lord if I need to. I am well aware that this proposal has met with concern from some quarters. I will explain why we are proposing this arrangement and why we do not feel that the case for having a separate body is stronger.

HealthWatch England will have clout. It will have a seat at the top table, taking centre stage in providing advice on patient and public views to the CQC, Monitor, English local authorities and the Secretary of State for Health. Noble Lords were right to say that Healthwatch England must influence all these bodies; that will be its responsibility. My noble friend Lady Jolly, too, made that clear. Each of these persons or bodies will have a duty to respond to the advice. Through local healthwatch, HealthWatch England will be closely linked to the views of people expressing views about the services that most directly impact on their lives. Our proposals for HealthWatch England will place it at the heart of the system—not at the top, divorced from the views of local people, as CPPIH turned out to be.

As a committee of CQC, HealthWatch England will be able to draw on the best of CQC’s evidence base on quality and standards of care. The enthusiasm with which CQC wishes to learn via healthwatch is instructive. It will be helpful to CQC to have information coming from local healthwatch and HealthWatch England to CQC to alert it to problems such as those at Winterbourne View. This will give HealthWatch England a prominent position within a CQC that will have a strengthened role in assuring the safety and quality of health and adult social care services, and a strengthened focus on the concerns of health and social care consumers. This will ensure that from the outset HealthWatch England will have a greater presence and ability to influence than would a body established from scratch.

The Bill already contains significant safeguards to ensure that HealthWatch England will be able to operate effectively in that situation. For example, it will provide advice to a wide range of organisations. I have just mentioned central national organisations and local authorities. However, we listened carefully to concerns expressed in Committee about possible conflicts of interest between the CQC and HealthWatch England. This issue was raised again today. We therefore welcome Amendment 228, tabled by my noble friends Lady Cumberlege and Lady Jolly. It places duties on CQC and HealthWatch England to have regard to guidance from the Secretary of State about managing conflicts between these bodies. This is a sensible suggestion, and we are happy to support the amendment.

While acting independently, HealthWatch England must of course be accountable. Government Amendment 229 places a duty on it to send all local healthwatch organisations a copy of its annual report. It was the noble Lord, Lord Harris, who thought that this was a good idea and tabled an amendment to this effect in Committee. We agreed that it would help to secure the intended wide transparency and communication between HealthWatch England and local healthwatch. I am grateful to the noble Lord for flagging that up and suggesting the idea.

It is also important that local healthwatch—

[Lord Harris of Haringey]

My Lords—

[Baroness Northover]

No, I am going to continue, and if there are things that need to be dealt with at the end, I shall deal with them. It is also important that local healthwatch is able not only to provide information to HealthWatch England but to influence HealthWatch England’s actions on matters raised locally that may have national importance. Various noble Lords made that point and they were quite right. We therefore welcome, and will support, the amendments of my noble friend Lady Tyler.

[Lord Warner]

Are we allowed under the Standing Orders to hear the question of the noble Lord, Lord Harris? I would very much like to know what his point is.

[Baroness Northover]

If I wish to continue with the thrust of my argument—as the noble Lord, Lord Warner, said in the previous debate—I can do so. At the moment it is better if I lay out my argument. If there are points of clarification that noble Lords want an answer on, I will be very happy to give way when I have completed my argument.

We welcome and support—

[Baroness Jay of Paddington]

My Lords, I was not present when the noble Baroness had an exchange with the noble Lord, Lord Warner, on this matter. However, I have been in the House for 20 years and it is my widespread experience that of course the Minister is right to say that she must complete her argument. However, she has spoken for some minutes since the first intervention by the noble Lord, Lord Harris, and her argument has been well made.

[Baroness Northover]

The noble Lord, Lord Warner, wished to continue his argument against my noble friend Lord Phillips, and he did continue his argument.

Government Amendment 226ZG will enable HealthWatch England—

[Lord Warner]

May I just correct the noble Baroness? I actually anticipated that the noble Lord, Lord Phillips, was going to jump up. I did not stop him jumping up. He chose to withdraw.

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[Baroness Rawlings]

I shall just read from the Companion:

“A member of the House who is speaking may be interrupted with a brief question for clarification. Giving way accords with the traditions and customary courtesy of the House. It is, however, recognised that a member may justifiably refuse to give way, for instance, in the middle of an argument, or to repeated interruption, or in time-limited proceedings when time is short. Lengthy or frequent interventions should not be made, even with the consent of the member speaking”.

[Baroness Northover]

My Lords, it may help the House if I continue, but I am very happy to give way to noble Lords who wish to ask questions once I have gone through the various elements.

Government Amendment 226ZG will enable HealthWatch England to make recommendations of a general nature to local authorities about the making of arrangements for local healthwatch organisations and, where HealthWatch England is of the opinion that local healthwatch organisations’ activities are not being carried out properly, to draw this to the attention of the local authority.

Amendment 226A, tabled by my noble friend Lady Cumberlege, would place a duty—I see Companions spinning all around the House, so while noble Lords are studying that—

[Lord Harris of Haringey]

I want to ask a question, and I think the Minister has moved on to another point.

[Baroness Northover]

I am very happy to take noble Lords’ questions completely out of order, if need be, at the end if I have not addressed them.

Amendment 226A would place a duty on local healthwatch organisations to have regard to any advice or assistance provided by HealthWatch England under new Section 45A(2). We believe that this is too prescriptive. While we anticipate that local healthwatch organisations will welcome advice and assistance from HealthWatch England, a blanket requirement to have regard to the advice and assistance does not seem appropriate.

The Government very much agree that it is very important to get the membership of HealthWatch England right, the better to ensure its independence, and I thank noble Lords for their contributions on this issue. The Bill already gives the Secretary of State the power to make regulations about the appointment of members, and it is a power that we intend to use. In Committee, we said that we would take away and consider the suggestions put forward by noble Lords. We have heard what was said and have undertaken a public consultation on these regulations. Noble Lords have flagged up that a number of noble Lords are interested in local elections from local healthwatch organisations to HealthWatch England, and that is one of the issues flagged up in that consultation.

The consultation closed on 2 March, and the responses are now being analysed. Government Amendments 225 and 226—I thank my noble friend Lady Cumberlege for adding her name to Amendment 226—would ensure that regulations are able to make adequate and appropriate provision about HealthWatch England’s membership, including procedures for appointing members. It would also ensure that the regulations must require that the majority of members cannot be members of the CQC.

I now turn to aspects of the amendments relating to specific functions of HealthWatch England. It is interesting that some of these have not been flagged in the debate. Amendment 223A includes elements on patients’ complaints, and I think it is important for noble Lords to be aware of some of the elements in it. I would point out that statutory mechanisms have been in place for the investigation of NHS and adult social care complaints for a number of years, and a great deal has recently been done to improve these arrangements.

In 2009, the previous Government—and I give credit to them—following considerable public consultation, introduced new complaints arrangements for the NHS and adult social care. These reforms placed a greater focus on the outcome of the complaint and on speeding up the process. Importantly, they placed emphasis on resolving complaints at local level with recourse to the independent Health Service Ombudsman, if appropriate, so that organisations were better able to learn from their mistakes and to use the information to improve future service delivery. While there is room for improvement in the local handling of complaints, we support the reforms put in place by the previous Government, and it remains this Government’s view that complaints are best dealt with initially at local level. We wish to build upon these solid foundations. However, it is extremely important that the information that can be gathered from people’s experience is fed in and that an individual complaint is taken forward in a largely satisfactory way.

The relevant part of Amendment 223A, which deals with complaints, could, we believe, fundamentally change the nature of HealthWatch, compromise its primary role of consumer champion, lead to confusion among service users, duplicate current arrangements and impact adversely upon the role of the Health Service Ombudsman.

The noble Lord, Lord Patel, laid out extremely clearly what HealthWatch England needs to do. It is extremely important that it is recognised as a very important body in the new structure and that it has input from practical experience. The noble Lord is quite right that information needs to come up from local level to national level and that it needs to feed in at every point of the new architecture. HealthWatch England needs to be part of what drives up standards, and it is different from the regulator. Many noble Lords emphasised that. It is indeed the voice of the people. All, including the Secretary of State, have to listen to HealthWatch England, so it has a huge and important job. The noble Lord is quite right. It will not be buried in the CQC. Hosting is a very good way of describing its situation. It does not have to spend time and effort on back-office functions as CPPIH had to.

How Healthwatch England will be made up, its relationship to local HealthWatch and elections will be dealt with through regulations that will be informed by the consultation to which I have referred.

I now turn to the noble Lord, Lord Harris—

[Lord Goldsmith]

When will we know when the noble Baroness has reached the end of the argument so that we can hear the question that the noble Lord, Lord Harris, wants to ask? I am worried that the noble Baroness thinks that argument means speech. That has never been my interpretation or my practice at the Dispatch Box.

[Baroness Northover]

I am very happy to indicate when I think I have finished. I now come to answer some of the points made by the noble Lord, Lord Harris, or to address them at least. He may feel that I have not adequately answered them and, after that, he might like to hop up.

[Lord Harris of Haringey]

That is not my style.

[Baroness Northover]

I bear in mind a long history with the noble Lord, Lord Harris, that goes back quite a way and includes his very complimentary remarks when I gave my maiden speech in your Lordships’ House. Noble Lords might want to look at them.

Both HealthWatch England and local healthwatch have statutory forms—perhaps the noble Lord, Lord Harris, might wish to hear this.

[Lord Harris of Haringey]

I am multitasking; it is all right.

[Baroness Northover]

I am so glad. Both have statutory forms and functions so they cannot simply disappear in the way that he fears. I pay credit to him for all his work in this area over many years.

It was a shame that the noble Lord, Lord Harris, was not at the meeting yesterday to which the noble Baroness, Lady Murphy, has referred. With his formidable local government experience, I am quite surprised that he does not welcome the local authority involvement in the arrangements that we are putting forward. Had he been there yesterday, he would have heard the enthusiasm of the LGA, the chief executive of East Sussex County Council and others for their new involvement in health services. They are extremely keen to be best informed by flourishing local healthwatches. As they take on their new task, they see having that information as very important.

The noble Lord, Lord Harris, asked about the funding formula. Funding for local healthwatch will continue in a very similar fashion to LINks. It will be allocated primarily through the formula-based grant. Like LINks, this funding will not be ring-fenced, but each local authority’s allocation through the formula-based grants will be publicly available. I hope that that is of help to him. In addition, local healthwatch will receive additional funding through the DH learning disabilities and NHS reform grant.

I have various other responses to various other people, but perhaps the noble Lord wishes to put a question to me.

[Lord Harris of Haringey]

I am enormously grateful to the noble Baroness. She has answered some of the questions that I put. However, the question I wanted to ask related to her remarks about 15 minutes ago, when her argument seemed to be that this amendment recreated the former Commission for Patient and Public Involvement in Health. Does she acknowledge that this is a completely different structure, because it would be derived from the bottom up, with the support of local healthwatch organisations? What is more, it would not have to be encumbered by the bureaucracy that the Department of Health formerly imposed on that commission. It is a completely different structure.

[Baroness Northover]

I hear what the noble Lord says, but if he remembers the relationship and the aims of CPPIH, a lot of them echo the arguments that he has been making about such a structure. We may simply have to differ. The Government are very keen to have a structure that is up and running immediately, linking to, plugged into and influencing the national bodies that it needs to, and that it is not spending its time on its central structure. That is why this arrangement has been sought and that is the philosophy behind it.

The noble Baroness, Lady Masham, raised a number of issues, some of which will be considered in the next grouping. Perhaps I could come back to them then so that I do not take too long. I am astonished and delighted to see so many noble Lords who are interested in what I have to say on this.

My noble friend Lady Jolly asked about information-gathering, and she is absolutely right. In many ways this bears out how the CQC is very useful in this regard. By being hosted within the CQC, HealthWatch England will gain support from CQC expertise on the best methods of gathering and making the most of intelligence from local healthwatch. As part of HealthWatch England’s set-up plan, the CQC has dedicated resources to identify and develop the system that will support information flow between HealthWatch England and local healthwatch. I take on board very strongly what she said about the need for that information to be produced in a form that can be generalised and applied nationally, and that there are not lots of disparate bits of information that cannot be put together.

The noble Lord, Lord Warner, asked again about campaigning. I said in Committee that HealthWatch England and local healthwatch can campaign. I followed that up with a letter confirming that, which I hope he got—but perhaps he did not—and I reiterate it here. I hope that that is of help to the noble Lord.

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[Baroness Northover]

In response to the noble and learned Baroness, if I was in any way discourteous, I apologise but I hope that I gave the opportunity at the end for anybody who had further questions please to put them to me.

[Lord Patel]

My Lords, I thank the noble Baroness for her response. I think that the conversation, or lack of it, was unfortunate because not only did it not allow people to put their questions at the correct time, it probably interrupted the noble Baroness’s flow of speech and thoughts. Having said that, I am flattered by her compliments on what I had to say. However, she did not address the fundamental point when I speak for those who are concerned about public and patient involvement. She has said that the statute provides that HealthWatch England will be a committee. That is quite different from a statute which provides that HealthWatch England will be independent. Again, there is a vast difference. Also, in terms of its functions, there is nothing in the statute that says that HealthWatch England will have the power to ask for or demand information in the interests of patients and the public in order to demonstrate that the quality of care provided is not adequate. Although the statute recognises that HealthWatch England will have strong relationships with Monitor, the Commissioning Board and so on, it will not have the power in statute to demand that independently. It has the power in statute to work through the CQC to ask for that. That is what concerns people outside. Indeed, while listening to the debate I was getting e-mails saying, “This is not what we asked for and it is not what we want. This does not give us confidence that we will have the necessary authority to respond”.

The one lone voice in the wilderness, although it might have been loud, came from the noble Baroness, Lady Murphy. She suggested that this is ideal because of one very good chief executive in mid-Sussex. I wish we could clone her. For every one that is successful there will be 10 failures, and it is those failures which a good, powerful and independent HealthWatch England would be able to address when a local healthwatch organisation fails because the chief executive is not being supportive.

There are many issues here. If we are serious about giving the public and patients a strong voice, the Government must recognise that they need strong support and that they need it for a long time. Although I have not been associated with patient and public organisations in England, I have been involved with them on three different occasions. In fact, I set up one of them. I should say to the Minister that I thought I did a brilliant job. I gave it all the powers one could possibly give in terms of setting standards, inspecting hospitals, writing reports and criticising every service. It worked well, but it fell down because its strong support was withdrawn. It is important to recognise that if we are serious about giving patients and the public a strong voice, we need to give them status. We should not treat them like juveniles who do not understand the issues. They should be treated with the respect they deserve and be given strong support.

Unless the Minister is about to tell me that suddenly she is hearing a different message and that we can have a further conversation and another opportunity to look at this, I am afraid that, for those outside who are concerned about this, I will have to seek the opinion of the House.

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[Baroness Northover]

My Lords, we have great sympathy with Amendments 227 and 233. It is indeed vital that the voice of children is sought throughout the system and we agree that HealthWatch has a key role to play in this at both national and local levels. I thank the noble Baroness, Lady Massey, for the important points to which she and others drew attention. As we know, the noble Baroness has a long record of promoting the rights of children.

We are aware that some LINks have, as the noble Baronesses, Lady Massey and Lady Finlay, said, struggled to engage fully with children and certain groups of adults. It is very important that local healthwatch learns from that and is clear about the importance of engaging with children and young people. However, we do not feel that we should specify particular sections of the population in the Bill, although local healthwatch and HealthWatch England need to seek out views, especially of those who are hard to reach.

The noble Baroness, Lady Massey, spoke about guidance on engagement with children for local healthwatch. I can assure her that professionals and service users’ representatives are, through the Children and Young People’s Health Outcomes Forum, currently working with the Department of Health to develop a children and young people’s health outcomes strategy and to ensure that detailed design and development work is done with children and young people in mind. This includes HealthWatch. I can confirm that five local healthwatch pathfinders include a focus on children and young people. We hope to learn from that and that other local healthwatch organisations will learn from their experience. HealthWatch England will be able to use the work of the children and young people’s health outcomes strategy, the experience of the pathfinders and wider development work to develop advice and assistance to local healthwatch organisations on effective engagement with children, young people and their families.

The noble Baroness, Lady Massey, also suggested that we conduct a review of how HealthWatch England and local healthwatch involve children in their work. That is a very valuable idea. We fully agree that we should look at reviewing this, perhaps after three years of operation, to see how effectively HealthWatch England and local healthwatch have involved children and other hard-to-reach groups in their work.

The noble Baroness also suggested having a champion for children within HealthWatch England to drive forward children’s engagement. I hope I have reassured her that involving children will be a priority for HealthWatch England and local healthwatch. However, we believe that it would not be appropriate to have a children’s champion or, indeed, a specific representative for any patient group.

In the next group of amendments we will look at a definition of “people” that came from my noble friend Lady Jolly. That rather bears out what many noble Lords have said about making sure that we do not have just a narrow focus but recognise that we must not overlook groups such as children or hard-to-reach adults which have not necessarily had their voices heard in the past.

I was asked by the noble Baroness, Lady Finlay, whether HealthWatch will have the resources to involve children fully. Yes, it will. Representing people of all ages will be a core function of HealthWatch and will be resourced at a level to ensure that it can fulfil its duties and functions. The noble Baroness, Lady Masham, spoke strongly about how important it is to involve children and young adults, as did the noble Baroness, Lady Finlay, and others. I very much agree and feel that HealthWatch offers great potential to improve involvement in this area. Throughout everything that we are doing we are seeking to join up and integrate in the important way that she flagged up in her comments.

Although I cannot take forward the idea of the champion, nevertheless we understand and take on board the other suggestions that the noble Baroness, Lady Massey, has made. We are keen that HealthWatch England and local healthwatch groups reach out to a number of groups whose voices have not necessarily been heard in the past. Even if the noble Baroness is slightly disappointed with that response, I hope that with these other reassurances she will feel able to withdraw the amendment.

[Baroness Finlay of Llandaff]

Before the noble Baroness sits down, does she recognise that the legal status of children differs from that of adults? That is why they do not fall into the same category as many other vulnerable groups. Children do not reach the age of majority until they are 18, although they can consent to some things at 16. Therefore, they are always dependent on a responsible adult to speak for them or to open the door for them, as it were. They cannot form a group in the way that others in the population can to speak up for their rights and what they need. Will the noble Baroness reassure us that the Government recognise that the legal status of children differs from that of adults, and that if these amendments are not to be accepted, careful consideration will be given as to how that can be made explicit in the Bill before it completes its passage?

[Baroness Northover]

The noble Baroness made a poignant case for why children need to be listened to. I hope I can reassure her that HealthWatch England and local healthwatch have a responsibility to hear the voices of everyone, whatever their age. I accept what she says about the legal status of children. However, as she made very obvious, that does not mean to say that we cannot hear their voices and take very seriously their perception of how they can best be treated.

[Baroness Massey of Darwen]

My Lords, I thank all noble Lords who have taken part in the debate on this amendment. I am aware that there is a very powerful lobby in this House which supports the voice of the child in all matters and supports children’s welfare generally. There is also a very powerful lobby outside of children’s organisations that are dedicated to providing children with what they need.

I thank the noble Baroness for the reassurances that she has given. However, I stress that the research I quoted contains clear evidence that the voice of the child is often overlooked. We must be vigilant that it is not overlooked in the future. One of my three queries to the Government concerned disseminating guidance. I fully accept that there will be a health outcomes strategy for children. However, we have to keep an eye on that and see what happens in relation to the contribution of children’s voices to carrying out that strategy.

The noble Baroness said that there would be a review of how HealthWatch England and local healthwatch involved children. I suggest that two years after commencement is a sufficiently long period. I am disappointed about the champion issue because without advocacy some vulnerable groups will be neglected, which is never a good thing. I will follow up these issues with the Government. In the mean time, I beg leave to withdraw the amendment.

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Moved by

[Baroness Northover]

231B: Clause 181, leave out Clause 181

[Baroness Northover]

I shall speak also to the other government amendments in this group relating to local healthwatch. Local healthwatch goes to the heart of the Government’s ambition for a health and care service that is centred around patients and users. In the consultation paper Liberating the NHS: Local Democratic Legitimacy in Health, published in July 2010, the Government stated:

“Local authorities have a vital role in commissioning HealthWatch arrangements that serve their local populations well … In the event of under-performance, a local authority should intervene; and ultimately re-tender the contract where that is in the best interests of its local population”.

Local healthwatch will go further than just gathering views; it will be there to support individuals by providing information and advice about access to services and choice. We firmly believe that this will enable people to take more control of their own health, treatment and care, and understand and use the increased choices available to them. I am sure noble Lords will agree that this kind of support will be invaluable.

As a corporate body with a statutory function of carrying out statutory activities, local healthwatch will gather information about people’s views and experiences of the health and social care system. This will enable the voice of people to reach commissioners and providers of health and social care services, a link that has been lacking in the past.

Local healthwatch will have a seat on every statutory health and well-being board which will prepare statutory joint strategic needs assessments and joint health and well-being strategies, which will inform local commissioning plans. Through local healthwatch the patient voice will influence and inform the work of the health and well-being board. I hope that noble Lords will agree that this will give local healthwatch much more influence at the decision-making table and will help hardwire public engagement into the strategic planning of health and care services from the start.

The evidence and insight gathered by local healthwatch will also inform HealthWatch England and enable it to advise on the national picture—for example, where it sees a pattern across a number of local concerns—which will ensure that local views will be able to influence national policy, advice and guidance. This role will be strengthened following the amendments of the noble Baroness, Lady Tyler, which we accepted earlier when debating HealthWatch England.

We have always envisaged that local authorities, which will be responsible for commissioning local healthwatch, will have flexibility about its organisational form. This will enable them to take account of local needs and circumstances. We are pleased that senior voices within local government support the Government’s policy intentions and are willing to use their leadership role to help support local authorities to drive effective commissioning and implementation at local level. This approach to local healthwatch aligns with the Government’s localism agenda. However, on reflection we realised that greater flexibility was needed over the organisational form of local healthwatch, and for this reason we tabled the amendments in this group. We do not now think that prescribing from the centre that local healthwatch must be a statutory body corporate with an exact form is the best way forward.

Before listening to the views of noble Lords, perhaps I may address some concerns around the Government’s approach to local healthwatches. The first relates to their status as statutory bodies with statutory functions. One issue that LINks have faced is the model itself. As they are inherently loose networks, they require a host to provide administrative and other support, which has caused difficulties in some areas. By establishing local healthwatch as a body corporate we will avoid the difficulties of this, as the local healthwatch will be able to employ staff as well as involving volunteers.

It is important that local healthwatch organisations will be corporate bodies with statutory functions setting out their powers and duties. We agree with the assertion of the National Association for Voluntary and Community Action that,

“a network of vibrant community led organisations, answerable to local people, will have far more bite than over 150 unaccountable quangos”.

If we were to set out the more rigid requirements that statutory corporate bodies would have, this would be more likely to lend itself to the creation of such quangos.

Secondly, a number of noble Lords are concerned that there is a risk that a local authority will not wholeheartedly embrace entering into a contract with a body that will then criticise it. It is not new for local authorities to commission bodies, partly or fully, which then make their views known in feedback or reporting arrangements, with the net result of improving services locally. Examples include citizens advice bureaux, tenant organisations, legal advice centres and advocacy support. I assure noble Lords that these groups tend not to be afraid to come forward, and that most local authorities welcome such insight—as we heard yesterday from the LGA and others at the meeting to which noble Lords referred. It follows that there should be no problem were a local healthwatch organisation to share differing views or constructively criticise a local authority’s commissioning or provision of care services. It will be useful for local authorities to hear that feedback.

The needs of local communities should play a part in who is contracted to become the local healthwatch. We want to ensure that the expertise that exists in the community has the opportunity to contribute to local healthwatch. For example, a local authority could commission a community interest company, charity or other form of social enterprise that meets the prescribed criteria. Local authorities will be best placed to make such decisions, based on their knowledge of their local area, and it will be right to allow each to commission a local healthwatch that is right for them.

Thirdly, a key failing of many LINks is their inability to involve a wide range of people and different sections of the community. We discussed this when debating the previous group of amendments. The result is that they lack diversity in their membership, which makes them unrepresentative of their local population. These issues are being addressed by healthwatch. There is a duty on healthwatch to be representative, in the sense of the population demographics of an individual local community, when carrying out its functions. In order for local healthwatch to be truly representative across the individual local community, the ambition is that it will be part of a system rooted in local experience, harnessing the expertise of the public, community and voluntary sectors and others at the local level, particularly those working with people and groups who have a difficult time getting their voices heard. I beg to move.

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[Baroness Wheeler]

My Lords, on behalf of these Benches, I want to express our concern and exasperation at these cobbled-together, last-minute changes to the status and organisational arrangements for local healthwatch. We are utterly opposed to depriving local healthwatch of its statutory status. It is hard to see the logic behind the new approach, even for those of us who are supportive of the local development of social enterprises.

The noble Baroness has not explained why this last-minute change is taking place 14 months into the consideration of the Bill. Why was this new approach and dramatic change not spelt out and included in the consultation that the Government have conducted since Committee stage on healthwatch membership? Why such a fundamental change of direction at this late stage?

The Government’s argument is that the new arrangements will provide local authorities with the flexibility that they need in establishing healthwatch organisations and facilitating their networking with other local community organisations. In practice, this means that not only will each local healthwatch be very different, and it will take more than the proposed national kite mark to provide them with any joined-up coherence, but they will all develop at a very different pace as local authorities take time to decide on the form of structure, and then draw up and implement their commissioning arrangements, or further subcontracting arrangements, if they want to make things really confusing, and so on. This is hardly the smooth transition from LINks organisations to the proper and coherent structure of patient representation at local level that we need. Like so much in this Bill, what could be simple and straightforward is made fragmented and complicated and requires detailed explanation. The Government also make strong play of local healthwatch organisations having a statutory function through a seat on health and well-being boards, through making a contribution on that board and the statutory joint strategic needs assessments and the joint health and well-being strategy. healthwatch will also have statutory status through the statutory health and well-being boards’ ability to refer back to the NHS Commissioning Board plans that do not meet the needs of the local communities. So we have a second-hand, reflected statutory authority by participating in bodies that have statutory status.

It is interesting, too, that with clinical commissioning groups the Government have repeatedly argued that the Bill was needed to enable CCGs to be statutory bodies in their own right. Now we see exactly the opposite argument when it comes to patient representation.

Finally, there is the relationship of local healthwatch with the local authority, where there is again huge potential for conflict of interest, and concern that even the well intentioned authorities facing severe budget cuts could struggle to find the required funding for healthwatch organisations. Government amendments to address this and potential conflicts of interest by requiring local authorities to,

“have regard to ... any Secretary of State guidance on this matter”,

do not provide the safeguards that would be needed to ensure that patients, their carers or representatives should be able to expect if they are concerned that their complaint about a social services department is channelled through a non-statutory body funded and linked to the local authority itself.

As with the rest of the Bill, these are complicated structures understood and supported by no one, with details fleshed out at the last minute and sprung upon the House, in effect, only three working days before we are due to consider them, and with no opportunity for consultation on such fundamental change. Arguably most important of all is that it is impossible to see, among all these amendments, how these local organisations will relate to national healthwatch. Perhaps the kite marks are designed more to help HealthWatch England recognise who it has under its umbrellas than to assist local organisations networking with each other.

I hope that even at this late stage the Minister will acknowledge the concern, confusion and demoralisation, particularly among key patient organisations and groups, at the last-minute decision to change the status of local healthwatch organisations. I hope that she will agree to withdraw these amendments and instead restore statutory status to local healthwatch, enabling them to be organisations that everyone can rely on to be genuine patient representatives, fully trusted and supported by patients and the public.

[Baroness Northover]

Again, my Lords, what shines through is a great commitment to public and patient involvement at a local level; the only dispute is over the form of that. Again, noble Lords are familiar with the fact that various models have been tried, and I emphasise once again that we are seeking to build on the strengths of what has worked and mitigate some of the problems that have been encountered.

My noble friend Lady Jolly has tabled Amendments 234 and 235, the result of which would be to replace references to “people” with “local people” in Section 221 of the 2007 Act and insert the definition of “local people”. We talked about the difficulty of organisations— LINks in particular—reaching groups that were defined as hard to reach. The definition in my noble friend’s amendment says that when carrying out its functions, local healthwatch has to be representative of people who live in the area, service users and people who are representative of the local community. That applies to people of all ages and emphasises the need for local healthwatch to champion the views of the whole breadth of the local community. I am therefore grateful to my noble friend for this contribution, and I am happy to support her amendments.

Although I am sympathetic to the sentiment behind my noble friend Lady Cumberlege’s Amendments 232, 236 and 237, I hope I can reassure noble Lords that, as corporate bodies, local healthwatches will have the flexibilities to make their own arrangements for securing staff, accommodation and so on, so the local authority should not have to make such arrangements on their behalf. There is no need for express provision on payment of expenditure because the legislation requires local authorities to make arrangements to ensure that the relevant activities can be carried on in their area. Necessarily, that means providing adequate funding to enable the functions to be carried out. This is an important point that I hope reassures noble Lords: the statutory functions must be delivered, and that is a protection of these bodies.

My noble friend Lady Cumberlege is quite right about local healthwatches working out their own priorities and work, and they will no doubt be doing that in conjunction with what is found to be good practice around the country, information coming from HealthWatch England and so on. I assure my noble friend that staff are there to help to facilitate such work, not to dominate it. My noble friend Lady Jolly is right: local healthwatch is a partner with local authorities—the eyes and ears, as the noble Baroness, Lady Murphy, and others have said.

My noble friend Lady Cumberlege was concerned that government amendments would damage local healthwatch’s independence. I do not agree: the amendments do not dilute in any way the statutory functions of local healthwatch, including the ability to give advice to local authorities among others. In response to concerns that local authorities may try to suppress local healthwatch, we specifically brought forward Amendment 236E giving the Secretary of State the ability to publish conflicts of interest guidance that both local authorities and local healthwatch would have to have regard to.

The noble Lord, Lord Harris, raised a number of issues. He regretted the fact that yesterday he was not at the seminar that I mentioned. I regret that he was not there. It was interrupted by a couple of votes, but I am sure that he would have engaged with those who were speaking there. That would have helped to inform everybody. All Peers were invited and some from his group attended. I see a few shaking heads.

[Lord Hunt of Kings Heath]

My Lords, the seminar was held during the regular meeting of Labour Peers which has occurred at 5 pm on Wednesday evenings since time began.

[Baroness Northover]

I am very sorry if there was a conflict of timing. Obviously it is difficult to schedule all the various meetings. My noble friend Lord Howe has had 100 meetings on this Bill.

[Baroness Thornton]

This has happened all the way through.

[Baroness Northover]

I am very sorry if that was the case. If it was the case all the way through, as the noble Baroness, Lady Thornton, indicates, perhaps it might have been an idea to feed that in.

[Baroness Thornton]

The noble Baroness might like to check with the Box. I informed the noble Earl’s office of the times of our group meetings at the beginning of proceedings. Meetings and seminars have clashed all the way through.

[Baroness Northover]

I am very sorry if that is the case. I would hope that we would be able to have other such meetings. As these arrangements are taken forward, it would be extremely useful to have people’s engagement. I was extremely glad that, even in such a clash, the noble Baroness, Lady Wheeler, and her noble friend were there.

The noble Lord, Lord Harris, should have received the letter about the amendments, but I gather that he thought he had not. A letter and briefing notes were sent to all Peers when the amendments were tabled and a full narrative of local healthwatch policy has been published on the Department of Health website. If the noble Lord has not seen the letter then I will feed that into the department to make sure that he receives this information so that he has it at his fingertips when he is contacted late at night by people who email him with concerns.

As I have mentioned before, it is very important that the local healthwatch seeks out views right across the area. It is an important factor in this arrangement that the local healthwatch will have a seat on the health and well-being board. I hope that that will help to reassure people of the influence of local healthwatch.

The noble Lord, Lord Harris, talked about privatisation by so-called social enterprises, or he flagged that up as a concern. I emphasise that the Government are huge fans of social enterprises, which perform a range of roles across the NHS. Social enterprises such as Turning Point are, of course, extremely valuable. This is not about privatisation or competition, as I feel we have made very clear.

The noble Lord, Lord Harris, also referred to my noble friend Lord Howe. My noble friend’s concern in 2007 was that local LINks should have at least a basic structure of governance. That is precisely the concern that has led us to propose that local healthwatches should be social enterprises. The question of governance is quite separate from the question of whether or not an organisation should be statutory. Perhaps the noble Lord, Lord Harris, can enter dialogue with my noble friend Lord Howe on all of that in due course.

The noble Lord, Lord Harris, also asked about the possibility of there being more than one local healthwatch. Only one local healthwatch will be permitted for each local authority area. Each local authority will be able to make only one contract. If the local healthwatch wishes to subcontract some of its functions it can do so if the local authority permits, but the functions would still remain the responsibility of the local healthwatch. I hope that that clarifies the position.

[Lord Harris of Haringey]

I was trying to establish whether it would be possible, under these amendments, to segment the various functions of local healthwatch and contract them separately. I think the noble Baroness has just confirmed that. Am I right?

[Baroness Northover]

The key fact is that there is one local healthwatch for any local authority area. If it decides that it wants to subcontract something to best achieve what it needs, that is up to that local healthwatch. The noble Lord might want to bear in mind the statutory functions of local healthwatch and its responsibilities as eyes and ears. If it was not working, I am sure that noble Lords such as he would flag that up. Local healthwatch would then have to justify what it was doing and might need to move away from it.

I realise that time is pressing and it is a Thursday afternoon. I have listened to the concerns expressed about the need for local healthwatch to have strong lay involvement. I completely agree. This will be vital to the success of local healthwatch. Therefore, I confirm to the House today that we will use the power of the Secretary of State to specify criteria, which local healthwatch must satisfy, to include strong involvement by volunteers and lay members, including in its governance and leadership. This will have the effect that a local authority cannot award a local healthwatch contract to a social enterprise unless this condition is satisfied. I hope that that provides reassurance to noble Lords. My noble friend Lady Jolly also flagged this up.

The noble Lord, Lord Low, the noble Baroness, Lady Wheeler, and others raised the issue of funding for local healthwatch. It is important that local authorities can manage local priorities, since they are best placed to respond to their local communities. Therefore, local healthwatch will remain within local authority funding mechanisms, as I mentioned earlier. This view was supported by the NHS Future Forum, which made clear in its Patient Involvement and Public Accountability report that it did,

“not agree that budgets for local Healthwatch should be ring fenced”.

However, to reassure noble Lords, I point out that statutory functions must be delivered. This helps to protect what local healthwatch is there to do.

I believe that there is consensus over our ambition for local healthwatch. We do not disagree about what we want it to do for people or to accomplish in order to raise the quality of care. I hope that I have reassured noble Lords that it is right for local healthwatch to be delivered at a local level by organisations that are accountable locally. To embed healthwatch in localism will not only enable the organisational form of local healthwatch to best meet the needs of the local population but better enable local healthwatch to play an effective role in feeding back people’s views and promoting their involvement in the scrutiny and provision of local care services. I refer again to the positive reaction of several different local authorities and councillors who are very pleased that they will now be involved in many elements of the healthcare services, as they are in public health.

[Lord Harris of Haringey]

Could the noble Baroness tell us how many LINks have been in touch with the department to say that they welcome these changes?

[Baroness Northover]

Like the noble Lord, I recognise that the organisations which are in place when change occurs are always concerned. LINks have rightly expressed concern about whether what they know works well in what they do will be taken forward. They are very open about the challenges that they faced and some of the areas in which they have not done as well as intended. I pay tribute to the then Government for trying to make the system work when it was set up. It was a reaction to what had been done before and a looser model. Everybody in the system wanted that to work as a model. However, I think that the noble Lord has admitted that it has not worked universally. It is therefore understandable that the relevant organisations expressed concerns. I hope that they will become involved in the new system and that what they have contributed—the volunteers among them have made an effective contribution in many areas—will feed into local healthwatch. With that, I hope that noble Lords will accept the Government’s amendments.

Health and Social Care Bill

Baroness Northover Excerpts

Tuesday 6th March 2012 Lords Chamber

[Lord Beecham]

My Lords, we certainly support these amendments. I am particularly pleased by the reference in Amendment 171A to the transfer of information between child and adult social care authorities, which picks up a point that was raised in an earlier debate. These are sensible amendments, although there is an error in Amendment 238G, which refers to health and welfare boards, instead of health and well-being boards. On that not untypically pedantic note, I support the amendments and trust that the Minister will give them a favourable response.

[Baroness Northover]

My Lords, there is a clear consensus on the importance of further integration and more services being joined up around patients’ needs. The Bill seeks to encourage and enable the delivery of integrated services and contains strong provisions to ensure that this takes place. We are placing a duty of integration on all bodies, including clinical commissioning groups and health and well-being boards, to ensure more joined-up provision of services for patients, social care service users and carers. Furthermore, all NHS bodies and private and third sector providers supplying NHS services are required by the Health Act 2009 to take account of the NHS constitution in their decisions and actions. This includes the principle that the NHS works across organisational boundaries and in partnership with other organisations in the interests of patients, local communities and the wider population.

The Bill takes this further by making it clear that, in exercising any of their functions, commissioners must act with a view to securing that services are provided in a way that promotes the NHS constitution; and with a view to securing continuous improvement in outcomes, including effectiveness, safety and quality of patient experience. Commissioners must also exercise their functions with a view to securing that health services are provided in an integrated way where this would improve the quality of those services, including outcomes, and/or reduce inequalities in access to services and outcomes. The intention is, therefore, that it would be for commissioners to drive integration and co-operation between providers in the light of local circumstances and needs, and to enforce this through legally binding contracts. This would apply equally, and perhaps all the more importantly, in relation to the provision of services for long-term conditions where multidisciplinary care is required.

Health and Social Care Bill

Baroness Northover Excerpts

Wednesday 29th February 2012 Lords Chamber

[Baroness Thornton]

My Lords, perhaps I may just say that when I was a Minister this was one of the few battles that I had and lost in the department. I shall be very glad if the noble Earl has had the battle and won—congratulations. I also say well done to all those who have been campaigning on this issue, particularly my noble friend Lady Gould.

[Baroness Northover]

My Lords, I am the lucky one who has drawn the long straw on this issue and I am very grateful to my noble friend Lord Howe for allowing me to have that long—rather than a short—straw. I am especially grateful to my noble friend Lord Fowler for bringing back this important issue. Again, I pay tribute to his enormous commitment in improving HIV services for all and, of course, to the outstanding work he did to protect the public from infection.

As I advised in Committee, the Department of Health has now concluded its review of the current policy, under which some overseas visitors are excluded from free HIV treatment. The review considered many issues, including the public health and economic arguments for providing free treatment. We also noted the recommendation and findings on this in the No Vaccine, no Cure report, published last year by the House of Lords Select Committee on HIV and AIDS in the United Kingdom, chaired by my noble friend Lord Fowler.

Since the debate in Committee we have also taken account of the views of other government departments with an interest in this issue and I am pleased to report that the Government have agreed to support the change that this amendment proposes. The evidence on the public health benefits of HIV treatment is compelling. Research published last year, and subsequently reviewed and endorsed by our own Chief Medical Officer’s expert group, shows that treatment reduces infectivity and onward transmission by up to 96 per cent. Reducing transmission will reduce the risk of new infections in the wider UK population and, as noble Lords have said, reduce the NHS costs associated with treating late diagnosis of HIV. Around half of new HIV diagnoses in the UK are diagnosed late; that is, after HIV treatment is clinically recommended. As the noble Baroness, Lady Masham, said, late diagnosis results in increased mortality and morbidity and more expensive treatment.

As my noble friend Lord Fowler said, it is estimated that there are 91,000 people living with HIV in the UK, of which one-quarter are unaware they are infected, which means they can continue to transmit HIV to others. Without access to treatment upon diagnosis there are no or few incentives for testing. Amending these regulations will remove this barrier. It is also worth noting that the knock-on effect of improved public health protection for HIV is that reduced onward transmission will itself reduce the number of new cases within the overall population. The noble Baroness, Lady Gould, made reference to the importance of all of this. Earlier diagnosis, resulting from the testing of those previously put off by the prospect of charges, will reduce the number of late cases with more complex emergency healthcare needs. Together these benefits should reduce overall NHS costs significantly over the longer term.

Therefore, we agree that where clinically necessary we must provide HIV treatment, free of charge, to all who are present in the country, irrespective of their residency status. In doing so, this actually does no more than to bring HIV treatment in line, as others have said, with that for all other major communicable diseases, such as TB and hepatitis, and for all other sexually transmitted infections for which treatment is free without a qualification period. However, my noble friend’s amendment as drafted proposes to include a residency qualification period of six months for HIV treatment. I understand why he put that provision in. Our view is that such a limitation could compromise our primary public health objective and that therefore there should be no such exclusion. However, I recognise that my noble friend had included this limitation to address wider concerns about attracting others to come here for treatment. We share those concerns.

The NHS is, and must remain, a national not an international health service. While it should also provide for the emergency and humanitarian needs of others, we are clear that in implementing this change we must avoid creating an incentive for people to travel to the UK solely for the purpose of free HIV treatment. In fact, they should not have to; there has been huge progress globally on increasing access to free or subsidised HIV treatment. Some African countries have achieved universal treatment coverage. Average treatment coverage in Africa has increased to almost 50 per cent, with even higher treatment coverage in eastern and southern African. While the different models of healthcare systems in other countries make direct comparisons difficult, research suggests that free HIV treatment is available, regardless of a person’s residency status, in France, Spain, Holland, Italy and Portugal. The noble Lord mentioned the situation in the rest of the United Kingdom.

The Department of Health is already in the process of drafting, with HIV clinicians and others, new clinical guidance to support implementation in a fair and consistent manner. This will limit the extent of immediate access to drugs after a person is diagnosed and allow for continued review of the duration of any drug supplies before another visit is required. So it simply will not be the case that tourists can get off the plane and access immediate long-term supplies of drugs. If clinicians identify a person who is in the country just to receive free treatment, the NHS will not provide it unless there are exceptional circumstances, such as extreme infectiousness or pregnancy. Treatment for any conditions other than HIV itself remains chargeable.

Furthermore, we will continue to monitor any change in new HIV diagnoses in the UK of HIV infections acquired abroad. We will strengthen our current monitoring and collect additional anonymised data on residency status that will help to identify any abuse. In addition, we will maintain existing stringent procedures to check for fraudulent registrations at GUM clinics. It will also remain the case that receiving HIV treatment will not be sufficient to overturn an immigration requirement to leave the country and there are no provisions under the Immigration Rules for a person to travel into the UK in order to access the NHS.

To conclude, I am very grateful for the opportunity to discuss this important issue again and I am very grateful to noble Lords around the House for all their work over a number of years. I pay tribute also to the noble Baroness, Lady Thornton. This is a very sensitive issue and I appreciate the constructive way that people have dealt with it. There is a compelling public health case in support of this amendment which we cannot ignore. However, while safeguarding our overriding responsibility for public health, we are clear that the change this amendment proposes should not be seen as an incentive for travel to the UK for the purposes of obtaining free HIV treatment. We will therefore be introducing strong safeguards in our front-line procedures in clinics to address this.

Having said that, the Government support the change that this amendment proposes but I am asking my noble friend to withdraw it for now, for three reasons. First, on a technical point, the proposed change is to secondary regulations. It is not normal procedure to amend such regulations through a primary Act. Secondly, as I have indicated, the amendment includes a six-month exclusion period that we do not support. Thirdly, the department needs some time to finalise the clinical procedural safeguards and monitoring processes that I have set out.

However, in seeking withdrawal, I offer on behalf of the Government an absolute commitment that the department will introduce a statutory instrument to amend the current exemption, so that the exemption from charges for treatment of sexually transmitted infections will include HIV. The change would be effective from October this year, and we would anticipate laying the amending SI before the Summer Recess to achieve that effective date. As my noble friend Lord Fowler said, this makes economic and human sense. I hope that my noble friend will understand and agree to the process that I have proposed as the most effective way of delivering the mutually desired outcome of his amendment, for which he and others have long campaigned.

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[Baroness Finlay of Llandaff]

My Lords, I also did not put my name on this amendment because there was not enough space for more than four names.

I have a concern that the Health Protection Agency itself may have been a bit like a prophet in its own land and that it was not recognised fully until now, when we see its disappearance, just how important the work is that it has been doing, both nationally and internationally. Apart from already earning money for the UK, its potential to carry on doing so in the emerging large economies in other parts of the world and expanding its scientific input is enormous. It has the role not only of public health but of anticipating what threats may emerge in the future, particularly in the range of toxins that it looks at and studies.

These amendments seem to solve a problem that we have all heard about. We have all been at meetings; we have all met with the relevant people. I really hope that we will not just get told that this cannot happen for a variety of reasons. The amendments seem to be solving a problem that has only been created as a result of these changes. I cannot see that there is anything to lose, except that if the amendments are not accepted we might lose the capacity to earn international research funds in the future.

[Baroness Northover]

My Lords, noble Lords have raised a number of issues regarding Public Health England, many of which we discussed in Committee. Both then and today, we heard serious points very cogently argued, which we greatly appreciate. We have considered all these issues very carefully. Since Committee stage, the department has published more detail on the new public health system, including its operating model for Public Health England. The views expressed in Committee influenced the tone of those documents, and I hope that I can now reassure noble Lords that our proposals will give the agency the operational independence that it needs to become the leading organisation of its kind in the world.

The first point I want to stress is that Public Health England will function openly and transparently. Its operational freedom will be formalised in a clear and published framework agreement between it and the department. My noble friend’s amendment proposes that the PHE board must have a non-executive chair and a majority of non-executive members. We have considered this at length and understand what the amendment aims to achieve, but we do not agree that this is the best option.

The Public Body Review was clear that Ministers should take more responsibility for arm’s-length bodies. Cabinet Office guidance is also clear that nothing should undermine the direct accountability of an agency chief executive to the relevant Minister. We believe that there are sound and pragmatic reasons underlying that position, which could be put at risk by a governance structure dominated by non-executive representatives.

The public will look to the Secretary of State for leadership and accountability in protecting the nation from threats to health and they will be right to do so. The buck must be seen to stop with him. In the past, public health has too often been pushed to the fringe, which has been recognised by noble Lords. This arrangement brings public health centre stage. Instead of the NHS simply being a treatment service, public health in its widest sense will be central to the new arrangements.

[Lord Hunt of Kings Heath]

Does the noble Baroness not recall the reason why the Food Standards Agency was set up? The agency was given complete independence because the public had lost confidence in the role of Defra in relation to food safety. On public health issues, surely she can see that when she simply says that it should be a Minister who responds, the risk is that people will lose their faith in the fact that public health advice will not be impartial and independent. The Government are really putting at risk the integrity of the public health advice that is received.

--- Later in debate ---

[Baroness Northover]

I have heard what the noble Lord and other noble Lords have said in that regard. There have been very interesting debates over the role of the Secretary of State in the whole of the NHS. Public health is one part of that. It is interesting to see that in some areas noble Lords would like the Secretary of State to be closer.

[Lord Hunt of Kings Heath]

Perhaps I may come back on that. Surely, it is very different. In relation to the National Health Service, we have been arguing that because of the need for parliamentary accountability, it is absolutely right that the Secretary of State should have the responsibilities that are now in Clause 1. But here we are talking about critical issues around public health where the need for independence is very important. Having professional advice on issues such as public health is very different from there being direction over the operation of the NHS.

[Baroness Northover]

As I have outlined, there is independence. It is key to the changes that we hope to put in place in terms of public health that it moves to the centre stage and that the Secretary of State has a much more direct line of sight in terms of promoting public health and the protection of the public. The Secretary of State will lead and have direct accountability for public health, which many people have welcomed.

Inserting an independent chair and board between him and the individual charge for the day-to-day running of Public Health England could blur those clear lines of accountability and undermine the chief executive without enhancing the agency’s flexibility, responsiveness and effectiveness in dealing with threats. This is not to say that the chief executive should not face independent challenge from the board. On the contrary, the board will include at least four independent—

[Lord Warner]

My Lords—

[Baroness Northover]

This is the Report stage so I hope that the noble Lord has a simple question for clarification.

[Lord Warner]

My query is a point of fact. The Minister is putting great emphasis on the role of the chief executive. Could she tell the House whether the chief executive has a scientific background which is relevant to public health?

[Baroness Northover]

Since the chief executive has not been appointed yet, I cannot give the noble Lord an answer. Perhaps I might be able to continue, especially as it is almost 10.30.

As I have said, the board will include at least four independent non-executive members of the highest calibre, bringing experience of public health, local government, the voluntary sector and business. The challenge they provide will be real and impossible to ignore. Public Health England will also have scientific committees set up to provide rigorous and impartial advice. Executive agencies are normally established administratively, without legislation, and that remains our intention in this case. I realise that my noble friend Lady Cumberlege may want to fix Public Health England’s status in legislation to protect it from undue interference. Of course this is a valid objective, but I hope she will accept that the openness with which Public Health England will operate, and the nature of the Secretary of State’s duty to protect health, would deter him from clipping Public Health England’s wings. He would simply be limiting his own ability to fulfil his statutory duties. I also hope that my noble friend will consider whether the model that her amendment suggests is really in the best interests of public health. A significant advantage of the agency option is its flexibility, allowing Public Health England to adapt and stay fit for purpose without amending primary legislation.

The second part of the amendment focuses on research, to which a number of noble Lords have referred. We recognise the value of the research that the Health Protection Agency undertakes now, and the importance of it continuing. The Bill as drafted provides for the Secretary of State to conduct and commission research and Public Health England will exercise those powers. Noble Lords have expressed concern over Public Health England’s ability to secure health protection research funding. We are satisfied that there is no point of principle preventing Public Health England applying for health protection research funding from external national and international partners, including charities and income generation from commercial contracts. I hope that I can reassure the noble Lord, Lord Patel, that Public Health England can also bid for EU funding, subject to Treasury rules. I hope also that I can reassure other noble Lords that there is no reason why these changes should jeopardise the outstanding reputation that the HPA has had in research.

More specifically, I am happy to be able to confirm that funding from the National Institute for Health Research for research into health protection will continue at its current level and that this autumn we will launch a NIHR research call to be awarded to Public Health England and academic institutions in partnership. Publishing public health research will be not only possible under the Bill as drafted but critical, as noble Lords have indicated, in ensuring that the public health community as a whole learns and progresses. It is also worth mentioning that we expect Public Health England’s published data to be subject to the relevant code of practice on official statistics, which imposes strict limits on Ministers’ access to certain information before it is released.

I am afraid that the amendments tabled by the noble Lord, Lord Beecham, while seeking to enhance Public Health England’s independence, would blur the lines of accountability still further. Executive agency status, we believe, provides by far the most appropriate blend of operational independence and clear accountability. When we debated the special health authority model during the Committee stage, I did indeed, as the noble Lord said, refer to its impracticality. Special health authorities are established to exercise functions in relation to the health service in England, whereas Public Health England needs to exercise functions, such as radiological protection functions, in respect of Scotland, Wales and Northern Ireland. I should also point out that the NHS Commissioning Board will not, in the future, be a special health authority.

--- Later in debate ---

[Lord Beecham]

My Lords, I thank the noble Baroness for her reply to my amendment. The noble Baroness, Lady Cumberlege, will no doubt speak in relation to hers. I am afraid that I do not find the response convincing in a number of respects. In the first place, on the status of Public Health England as an executive agency, she did not really deal with the Cabinet Office guidelines, which I remind your Lordships state that an executive agency should be a clearly designated unit responsible for undertaking executive functions of the department that established it as distinct from giving policy advice. If, as I apprehend, it is the intention that Public Health England should give policy advice, it should not be an executive agency. If on the other hand the Government’s position is that it should not give policy advice, it is a significant departure from what we have hitherto understood the role of Public Health England to be and certainly from the current arrangements. That would not be acceptable to this side and, I suspect, to other Members of your Lordships’ House.

In anticipation of the Minister’s reply, I raised the question of income. She referred to the possibility of raising income but did not set out in any detail the proposals which we had anticipated being forthcoming in light of the Government’s previous statement that they would explain clearly how the income-raising capacity of the organisation would be maintained.

[Baroness Northover]

I thought that I had said clearly that there is no point of principle preventing Public Health England applying for research funding from external national and international partners, including charities, commercial companies, the EU, DH, UK research councils et cetera. There is no reason why this new organisation should not be as eligible as the previous one to apply for that research funding.

[Lord Beecham]

That evades the question of why the Government said they would be bringing forward proposals in that respect. If it was axiomatic that revenues could be raised in that way, presumably that would have been stated at the outset.

In any event, the further point I anticipated the noble Baroness would raise relates to the devolved Administrations. She referred to the 2006 Act as if that were immutable—which, of course, it is not. If it was thought that the position of the devolved Administrations was in some way a barrier to creating the agency because of the provisions of the 2006 Act, then this legislation could have amended that Act. Again there has been no indication in response to my question about whether this issue has been discussed with the devolved Administrations. As I say, I cannot imagine there would be any disadvantage to them in establishing Public Health England as a special health authority.

I regret that the thrust of my amendment has not adequately been dealt with. In the circumstances, I cannot do more than withdraw my amendment to the noble Baroness’s amendment. I do not know whether she is content with the offer of talks. If I were in her position, I would be asking for a little more than only an offer of talks: I would be asking for some assurance that the Minister will take the matter away and consider it with a view to something happening at Third Reading. Without that assurance I fear that we will get no further forward than we are now—and that is not a satisfactory position for outside organisations such as the Faculty of Public Health, others in the professions or many Members of your Lordships’ House. However, in the circumstances, I beg leave to withdraw Amendment 162A.

--- Later in debate ---

[Baroness Cumberlege]

Perhaps I may address that in one minute’s time.

I appreciate the commitment of my noble friend Lady Northover to this matter. I understand that the Government are anxious to build on public health, as the noble Lord, Lord Patel, said, and that they take this area with all due seriousness.

[Baroness Northover]

I assure my noble friend that we do indeed take this area very seriously. We are looking forward to the discussions that will happen with the Secretary of State, my noble friend and others.

[Baroness Cumberlege]

I thank my noble friend for that. I must say I am not reassured. What noble Lords were saying about credibility in the public mind is very important. There is a perception, whether we like it or not, that departments within Government tend to be closed—not secretive perhaps, but not very accessible to the general public. They have an image, and that perception is a reality in the public mind. Although there is an intention that they should be open and transparent, I am not sure the public see it like that.

On the question of trust, it was interesting that the Office for National Statistics at one time lacked a degree of credibility. People did not trust the figures that were coming out and so the Government of the day reconstituted it with the UK Statistics Authority and set it up in very much the way that we are trying to set up Public Health England. There is another model there. The Food Standards Agency, NICE and a lot of the new organisations—indeed the NHS Commissioning Board—are all being set up with non-executives and independent chairs. It seems really strange that here we have one of the most important new ideas coming forward with the establishment of Public Health England, trying to do something totally different.

I have never taken an amendment to Third Reading, nor have I tested the opinion of the House against the wishes of the Government whom I support. However, I have to say that I feel so strongly about this issue. I very much welcome the talks that have been promised but that does not rule out the possibility—I hope it will not become a reality—of taking this to Third Reading. I hope, if we meet the Secretary of State and our House of Lords Ministers as has been promised, that we will come to some accommodation. This is just too important to be left as it is and we need to take it further. I very much want to reach agreement in the future. It would not be a good idea to test the opinion of the House right now, because we would have a very small vote, but I do want to give notice that I feel strongly and will bring it back at Third Reading. However, as we cannot reach an accommodation at this time, I beg leave to withdraw the amendment.

Health and Social Care Bill

Baroness Northover Excerpts

Wednesday 29th February 2012 Lords Chamber

Moved by

[Baroness Northover]

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

[Baroness Northover]

My Lords, in Committee we had a number of excellent debates about the role of local authorities in public health. A number of noble Lords raised concerns, and I hope that this debate will show that the Government listened very carefully. As a result, we propose to make a number of important changes.

I will begin with Amendments 120, 127 and 129, which are minor and technical amendments to Clauses 29, 30 and 31. These contain lists of local authority functions, including references to,

“functions by virtue of section 6C of the NHS Act 2006”.

The amendments change the reference to functions by virtue of Section 6C(1) and 6C(3). The reference to Section 6C(2) is unnecessary as it provides a power to impose requirements for how local authorities should exercise their functions, rather than a power to confer those functions. I look forward to an interesting debate on the other, more fundamental amendments in the group. I beg to move.

[Lord Patel]

My Lords, I will speak to Amendments 121, 122, 123, 125 and 126 in my name. I will also comment on the Government’s Amendment 124.

Amendment 121 covers the appointment of a public health specialist. It states:

“The individual so appointed must be a registered public health specialist who has a broad range of professional expertise in public health”.

When we debated this in Committee I made it clear that doctors—public health specialists who are trained in medicine—not only do medical training at undergraduate level but do several more years of training in public health before they are given a certificate of completion of training that allows them to be registered on a GMC register of public health specialists. The situation is similar for public health dentists; they go through similar training.

The problem is that non-medical public health specialists—of whom there are many—do not go through any specific training. Registration is voluntary. We will come to registration issues at a later date. The amendment states that those appointed must be registered public health specialists with a broad range of professional expertise in public health, which they must demonstrate at the time of appointment. I hope that the noble Baroness, Lady Northover, will comment on that.

The noble Baroness was absolutely right to say in her opening speech that the Government had listened. I am grateful to both the noble Earl and the noble Baroness for the time they took to meet me, and to meet representatives of the Faculty of Public Health. I declare an interest as an honorary fellow of that faculty. As a result, the Government have brought forward amendments and produced a document, which I will refer to at a later stage, that is very helpful in identifying the role of public health doctors in a local authority.

Amendment 125 is linked to this issue. It concerns the appointment of directors of public health. It states:

“Any registered public health specialist or other person who is employed in the exercise of public health functions by a local authority or is an executive agency of the Department of Health shall be employed on terms and conditions of service no less favourable than those of persons in equivalent employment in the National Health Service”.

If we are to appoint directors and consultants of public health in local authorities and attract high-calibre individuals, we will have to make sure that they are not disadvantaged by taking a job in a local authority. The amendment merely alludes to that. Currently all specialists in the NHS, be they physicians, surgeons, obstetricians, paediatricians or other specialists, are appointed by an advisory appointments committee. The constitution of that committee is statutorily determined. The committee includes a representative from the appropriate college faculty. In this case it would be the Faculty of Public Health.

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[Lord Beecham]

My Lords, two shows in the West End have taken the theatre-loving population of London by storm in the past year. One of them was “Noises Off”, a farce that might be thought of as an apt metaphor for some of the relations on the government Benches; the other was “One Man, Two Guvnors”, which is perhaps relevant to the position of directors of public health. I am very glad, therefore, that the amendments proposed by the noble Lord, Lord Patel, and some of those which the noble Baroness will propose, reinforce the position and status of directors of public health. It is crucial that they are independent and are employed on conditions that are comparable to those of fellow clinicians in other parts of the health service. Therefore, the Opposition support the amendments of the noble Lord, Lord Patel, particularly in relation to Clause 30 and disease control.

I perhaps have reservations about the requirement for the Secretary of State to consent to the dismissal of a director; it is right that it should be in the form of consultation. It would be a foolhardy authority that ignored the strong views expressed by the Secretary of State. Given the relationship between central and local government, it is right that it should be a question of consultation rather than consent.

I endorse the views of the noble Lord, Lord Turnberg, about the relationship with Public Health England, which is another example of that dual relationship which directors must have. I equally endorse the observations of the noble Lord, Lord Brooke, who seeks to ensure that the responsibilities cover the entire population, resident or working, of the appropriate area.

The Government have moved significantly on some of their amendments. We are on the right track. I hope that they will look sympathetically at the amendments of the noble Lord, Lord Patel, and strengthen further that crucially independent role of the director, who should certainly be a chief officer of an authority and be accountable to the chief executive. It is an important safeguard, which I commend to the Government.

[Baroness Northover]

My Lords—

[Baroness Murphy]

I strongly support the stance that the noble Lord, Lord Beecham, has taken on the amendments of the noble Lord, Lord Patel, but I was expecting him to speak to Amendment 163A. I am very disappointed that he has not because it is such a brilliant idea and I was hoping that the Government might listen to it.

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[Baroness Northover]

My Lords, I thank the noble Lord, Lord Patel, and other noble Lords for their contributions. No doubt I shall do so again in a minute.

[Lord Wolfson of Sunningdale]

My Lords, the noble Lord, Lord Beecham, said that the wording used in Amendment 125 was that rewards and salaries should be “comparable”. In fact the actual wording is “no less favourable”. The two are entirely different: which wording is being proposed?

[Lord Beecham]

I shall go along with the amendment. I do not see a distinction of the kind to which the noble Lord refers.

[Baroness Northover]

I once again thank the noble Lord, Lord Patel, and other noble Lords for their extremely constructive engagement in this important area. I further thank the noble Lord, Lord Patel, for expressing his gratitude to the Government for the changes that have been brought forward.

Noble Lords have welcomed the moving of public health to a more centre stage. The Government have listened hard and have worked to address a number of the issues that have been raised about how this would work. We have brought forward a number of proposals, and I hope that noble Lords will be reassured that the objectives they seek can be achieved by these means.

We agree completely with the noble Lord, Lord Patel, about the need for high-quality, appropriately qualified public health staff, and it remains the case that appointments of directors of public health must be made jointly with the Secretary of State, who will be able to veto unsuitable candidates. To build on that, the Chief Medical Officer and the Local Government Association have written to local authorities on this issue and given advice covering the run-up to April 2013. This advice makes clear that external professional involvement in the recruitment process is the best way of assuring the necessary professional skills and that it should remain a central component of senior public health appointments.

My noble friend Lady Jolly raised questions about guidance, and she and other noble Lords may find the recent letter from the Department of Health and the Local Government Association reassuring. If they read through that letter they will see that on appointing to vacant posts it states:

“External professional assessment and advice provided by the Faculty of Public Health is a central component of senior public health appointments”.

It further states:

“The Faculty of Public Health provides essential advice on the draft job description, draft advert and person specification and we recommend you”—

local authorities—

“contact them at an early stage to benefit from this”.

There are a number of other points in the letter which I hope noble Lords will find reassuring.

Amendment 124 states that a local authority must have regard to any guidance given by the Secretary of State in relation to its director of public health, including guidance on appointment, termination of appointment and terms and conditions of management. The Local Government Association agrees that there should be a direct line of accountability between a director of public health and the chief executive. This issue was of extreme importance to noble Lords, who flagged it up in Committee, and we are taking it forward. It was also mentioned that the director should have access to elected members. We intend to produce guidance that reflects that, and it has already been spelt out in the letter to which I have referred.

In response to the concerns raised here, the Government have announced their intention to require non-medical public health specialists to be subject to regulation by the Health Professions Council. We will discuss the implementation timetable with interested parties and expect that the necessary changes will be made under the powers in Section 60 of the Health Act 1999.

During the helpful debates in Committee on the role of the director of public health we discussed how to ensure that directors have appropriately senior status. This is a vital new role—it provides local leadership on health improvement and protection as well as advising the local NHS on public health—and, in reaction to concerns raised, we have brought forward Amendment 152 to add directors of public health to the list of statutory chief officers in the Local Government and Housing Act 1989. This, combined with statutory guidance, aligns them with other chief officers, including directors of adult social services and children services. We hope that that reassures noble Lords and is what they were seeking. Furthermore, Amendment 128 is intended to give the Secretary of State the power to issue guidance on other local authority public health staff. I hope that that will further reassure my noble friend Lady Cumberlege.

The issue of appointment panels was raised and I can confirm that Public Health England, on behalf of the Secretary of State, will be represented on all appointment panels. Further guidance will be issued on the matter but, again, if noble Lords look at the letter to which I have referred I trust they will find it reassuring.

The noble Lord, Lord Patel, and others raised the issue of the requirements for dismissing a director of public health, and I welcome what the noble Lord, Lord Beecham, said about the need for the right balance of responsibilities. Directors will, of course, have the protection of employment law, and local authorities must consult the Secretary of State before dismissal. This will encourage them to ensure that their case is solid and to deter impulsive action. The Secretary of State will now also be able to issue guidance, to which local authorities must have regard, on how the dismissal process works.

Ultimately, of course, it cannot be in anyone’s interest for the local authority to be required to continue employing an individual if it believes that it has good grounds for dismissal. The Secretary of State can express his views clearly and robustly, but it is the authority that has the employment relationship with the director and that therefore must make the final decision. However, having regard to what the Secretary of State has to say is obviously an extremely important safeguard. The local authority will need to have very strong evidence to demonstrate why they wish to dismiss a director if they are to carry through their duty properly.

I was asked an important point about an external person on the appointments panel and I have referred to the involvement of the Faculty of Public Health generally. We are actively pursuing the idea of an external person and obviously we will be extremely happy to continue to work with the faculty over this and other issues.

The noble Lord, Lord Patel, and other noble Lords raised the issue of emergency planning and whether there would be an improvement on what exists now. Certainly, in our view, the new arrangements will be a significant improvement on the current ones. For example, in a new pandemic, joint plans will be in place between Public Health England and the NHS Commissioning Board for the important testing and data-gathering that is essential to understand the nature of a new disease in the early stages. The noble Baroness, Lady Finlay, is absolutely right that lines of communication need to be extremely clear and that working out exactly how this is to be done is extremely important. The department is well aware of that and the matter is being taken forward.

The NHS, Public Health England and local authorities will have joint plans in place to establish anti-viral collection points, for example, if needed. Public Health England, as an executive agency, will be able to provide scientific and technical advice and the NHS will have clearly understood mobilisation plans to respond to additional pressures on hospitals and primary care services. Throughout an emergency, the Chief Medical Officer, with Public Health England, will provide the Secretary of State with consolidated scientific advice to inform response and resolution. I trust noble Lords will be reassured by that.

[Lord Patel]

I am not actually that reassured. The point I was trying to make is that the current arrangements, as specified in the document so far, are flawed. They do not identify a lead person with the local authority who will respond to Public Health England’s advice and who also has plans in place not just for a pandemic or national emergency but for a local emergency. I gave two examples. The main problem is the lack of a lead person in charge locally. It might not be solved today but I hope the noble Baroness accepts that there is an issue here.

[Baroness Northover]

The director of public health has responsibility for what happens locally. One of the important issues here is the nature of the epidemic. The response to deal with that will be determined at the appropriate level—that is the key element in this. However, if the noble Lord and the Faculty of Public Health would like to engage further in discussions on this, I am extremely happy to offer that, knowing full well that my noble friend the Minister always has his door open. We look forward to further discussions to make sure that, where we feel it is working well but noble Lords need reassurance, we can address their concerns.

The noble Lord, Lord Walton, brought me back to my history of medicine when he spoke about the history of public health. He emphasised the importance of training and the noble Lord, Lord Turnberg, emphasised education, training and research. I assure noble Lords that all training contracts will be honoured. We are exploring at the moment how public health trainee contracts will be managed in future and are engaging with those who are concerned in these areas. We will set up a stakeholder group of professional bodies, Department of Health policy groups, deaneries, employers and trade unions to develop a framework for supporting public health trainees. I trust that will reassure noble Lords.

I completely agree with the noble Lord that the question of whether directors of public health will hold honorary NHS consultant status is very important and one that we are well aware of. We will shortly publish for consultation a public health workforce strategy to inform decisions on matters such as this.

The noble Lord, Lord Turnberg, asked how directors of public health and Public Health England would work together. Public Health England will have local units to encourage collaboration that will be partners in local planning for public health and will help to join up the system. Public Health England will directly support the public health directors with evidence, guidance and best practice.

I have addressed the senior status of public health directors and the manner of appointments, potential dismissals and emergencies. The noble Lord, Lord Beecham, includes the health premium in his amendment. I realise that he wanted to be extremely brief, so I will be extremely brief in reply and emphasise to him that we intend this premium to support the narrowing of health inequalities. I know—or at least assume—that his amendment is to probe and to find out how we view this. There will be a number of indicators to try to narrow those health inequalities.

We do not want to see anyone disadvantaged by our proposals for conditions of service, and employment law will apply to staff who transfer. Last November, in partnership with employers and unions, we published best practice guidance for staff transfers, followed by further guidance agreed with the Local Government Association. Shortly, we will publish a wider workforce strategy for consultation.

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[Baroness Northover]

I thank noble Lords for that extremely brief and consensual approach to this issue. We debated this in detail in Committee, and I commend all noble Lords for their work in this area.

We certainly agree that the rates of tooth decay in children and adults is an important public health measure. I point noble Lords to the public health outcomes framework, which my noble friend Lord Colwyn might like to have a look at, which is a document to which local authorities will have to have regard.

The noble Lord, Lord Hunt, asked whether, in terms of the public health funding allocation to local authorities, if a local authority has a fluoridation scheme, whether it will be covered within the budget. I can assure him, as I did in the meeting that we had earlier, that indeed it will be covered in the budget, which will look at the public health needs of the area—and that will be reflected in the grant. Those are the current schemes. The noble Lord asked about future schemes. Public health funding is ring-fenced, and the Government look at the needs of the area. However, local authorities will be deciding how they prioritise various issues, so it would not be appropriate for us to say that they must address this issue through a fluoridation scheme. They might be looking at all sorts of other public health issues and seeking to address their responsibilities in terms of dental health in some other way. However, I point out something that I did not know before—and I do not think that the noble Lord knew before—which is that just about all fluoridation schemes currently in place have been initiated by local authorities over their history.

I recognise the commitment of noble Lords to dental health. I appreciate it and realise that noble Lords want to speed it along. I hope that reassurances about the level of funding for current schemes will reassure the noble Lord, Lord Hunt, so that he feels able to withdraw his amendment. We continue to be very keen to engage in this area.

[Lord Hunt of Kings Heath]

My Lords, I should have declared in moving my amendment that I am president of the British Fluoridation Society. The noble Baroness, Lady Gardner, reminded me by making her own declaration. I am most grateful to the Minister and beg leave to withdraw my amendment.

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[Baroness Tyler of Enfield]

My Lords, I support this important amendment. The whole basis of the Health and Social Care Bill is to place great emphasis on delivering integrated care as part of the needed reforms, and I am sure that we all support that. As the noble Lord, Lord Adebowale, has just said, though, Clause 36 in its current form will remove one of the few examples of genuinely joined-up service provision between local health and social services. A joint duty on aftercare services for these people, some of the most vulnerable in society, is crucial if they are not to have further lapses and become more and more marginalised. We talked earlier about people falling between the cracks, and that is the danger that we are in.

[Baroness Northover]

My Lords, I realise that noble Lords want to move on to other debates, so it might be opportune if I intervene now. We have always expressed sympathy for what the noble Lord intended in his original amendment. We listened carefully to the points put by the noble Lords when they came to see us, even if it seemed that we were not very responsive to what they were saying. We note the considerable emphasis that they place on retaining the duty of co-operation with the voluntary sector that is set out in Section 117. We realise that the clause removes the duty that is currently there, and that is clearly causing concern.

We do not feel that there is anything in the clauses that will bring in charging for any NHS or social care services that are currently provided free under Section 117, and the Government have no plans to bring in measures that would change the position on charging for Section 117 services. However, sometimes tidying up causes concerns. We are all used to dealing with the section as it currently stands and could continue to do so. We are nothing if not a listening team. The Government have therefore decided, and I hope that the noble Lord, Lord Patel, will be pleased, that we will not oppose his amendment. In the light of this, if your Lordships’ House agrees and wishes to accept his amendment, the Government will need to bring forward a few technical amendments at Third Reading to make a few consequential changes to the Bill to ensure that the amendment works properly in the amended 1983 Act. I hope that the noble Lord will be pleased that indeed we heard what he and his noble friend were saying.

[A noble Baroness]

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

Health and Social Care Bill

Baroness Northover Excerpts

Monday 27th February 2012 Lords Chamber

[Lord Warner]

Before the noble Lord sits down, perhaps I may ask him and his noble friend behind him whether they have seen Amendment 161A, which would introduce a new clause on standards of adult social care.

[Baroness Northover]

My Lords, perhaps I may remind noble Lords that we are at Report stage. According to my note, only the mover of an amendment or the Lord in charge of the Bill can interrupt with short questions.

[Lord Warner]

I am the mover of the amendment and I was interrupting with a short question to the noble Lords, who seem to be unaware of a part of the Bill which addresses their concern. Before I was interrupted, I was going to ask them whether they had seen Amendment 161A, which says that the duty would enable the Secretary of State to address the issue of reducing,

“barriers to the delivery of integrated health and adult social care”,

and give him powers to produce regulations to deal with that. Therefore, we will be coming to an amendment which, if agreed, will enable their concerns to be addressed.

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[Baroness Northover]

My Lords, the Minister has sat down, so it is for the mover of the amendment to respond.

[Lord Winston]

I am sure that the Minister will want to answer my question because it is not aggressive or political; it is really to find out how this Bill will work. When somebody goes to casualty after a month with a broken nose and complains, “Look, my main problem is the pain in my sinuses which I have had for a long time”, and is told by the doctor when they had already waited six hours, “I’m afraid the sinuses are a different department. You’ll have to make another appointment”, that is a problem with integration. How does the Minister think we might accomplish better integration with this Bill?

Health and Social Care Bill

Baroness Northover Excerpts

Monday 13th February 2012 Lords Chamber

[Lord Rea]

My Lords, I do not know if it is a slight slip on the part of those who drafted the Bill that the word “promotion” is not already in the clause. The coalition agreement on public health states:

“The Government believe that we need action to promote public health, and encourage behaviour change to help people live healthier lives … harnesses innovative techniques to help people take responsibility for their own health”.

That is a bit unfair on people because lifestyles are very much dependent on life chances. People who come from a rotten background may indulge in practices which are not particularly good for their health, but you cannot really ask them to change. We need to take into account a lot of the things which my noble friend Lord Beecham has just gone through because they are relevant to the practice of public health. The word “promotion” should definitely be included at the beginning of this clause.

[Baroness Northover]

My Lords, in Committee noble Lords made a number of helpful and constructive comments on public health. We have carefully considered this feedback, and as noble Lords will see in later clauses, we have made some significant changes to the public health provisions. Amendments 24 and 28 both relate to the Secretary of State’s accountability and his role in the promotion and improvement of health. The Secretary of State is under a duty to protect the health of the public in England. We are clear that the primary legal responsibility for health improvement should lie with local government, although the Secretary of State will have the power to act on health improvement when appropriate. We welcomed what the noble Lord, Lord Beecham, said in Committee about a renewed involvement of local government in public health, and he has reiterated that today. It is extremely important that local government, which is often best placed to take this forward, sees its prime legal responsibility and that there is no duplication of duties. Therefore, in drafting Clauses 10 and 11, we have taken care to avoid duplicating duties and to keep roles and responsibilities clear. We do not believe that additional amendments to the Bill are needed and I hope that noble Lords will understand why we have drafted these provisions in this way.

Amendment 26 takes the list of steps that the Secretary of State may take as part of his health protection duty and turns it into a set of fixed duties. I hope that I can reassure noble Lords that the Secretary of State cannot simply ignore the steps even though we have used the word “may” and not “must”. He must give proper consideration to what steps are appropriate to protect or improve health. Although the duty does not necessarily require the Secretary of State to take all the steps listed under new Section 2A, if after proper analysis he considers that a particular step is appropriate, he must take it. However, we take the view that the Secretary of State needs the flexibility to decide what steps are appropriate. The Bill outlines the areas in which the Secretary of State might take action. It fleshes out the ways in which the Secretary of State must take steps to protect the public. To prescribe these exemplars in statute runs the risk of inflexibility. One duty in the list, for example, is to make available the services of any person or any facilities. What would that mean if it was made a “must”?

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[Baroness Finlay of Llandaff]

Will the Minister clarify what the sanctions are when there is a failure to co-operate? Examples of failure to co-operate are emerging already. While there is an outline duty in the Bill, what are the sanctions when that is not happening?

[Baroness Northover]

Local authorities have a statutory responsibility for public health. If the noble Baroness looks at the outcomes framework, she will see where different authorities have different responsibilities. In order to discharge those responsibilities, those authorities will have to work together, otherwise they will not be able to deliver those outcomes.

In response to Amendment 25, we entirely share the view that we must make use of the best scientific and other evidence available. However, we do not think that an amendment to the Bill is necessary to do this. If the Secretary of State is to carry out his duty effectively, he must necessarily obtain and use such advice.

I heard how the noble Lord, Lord Beecham, read out the amendment. It is clear that evidence must be sought without it being skewed in any way by any special interests. However, the way in which the amendment is drafted implies that the Secretary of State might not be able to consult legitimate professional organisations or stakeholder groups that may have relevant expertise and experience. I made that point in Committee. We agree, clearly, that the inappropriate influence of special interests would not be right, but that is not quite how the amendment is drafted.

The Government’s Chief Medical Officer will continue to provide independent advice to the Secretary of State on the population’s health. She will be supported in this role by a public health advisory forum that will bring together expert professionals and leading partners to assist her in providing advice and challenge on public health policy and implementation. I hope the noble Lord will be reassured about that. The use of evidence underpins all this and there is no intention whatever that it should be skewed in any way. I trust that that reassures noble Lords and that they will not press their amendments.

[Lord Beecham]

My Lords, given the number of issues on which there are serious disagreements around the House, certainly between the Opposition and the Government, this is a shame. On an issue on which we basically agree in principle, the Government have been entirely negative about suggestions made not merely by the Opposition—heaven forfend—but by the Health Select Committee, which is less prone to charges of any sort of political bias.

I find it almost risible that the Minister should single out one line in the amendment that deals with the Secretary of State's duties in the clause by transforming an option,

“making available the services of any person or any facilities”,

into a mandatory requirement. I agree that perhaps we could have taken that particular line out, but the principle of getting stuff properly into the Bill remains important. All the other items ought to be part of the Secretary of State’s mandated responsibilities.

The Minister referred repeatedly to frameworks, but frameworks are not statute and not something that is immediately accessible to the public or others. Statute should set out a fairly comprehensive picture of what the Government intend, and there has been a failure to take the opportunity to do that, whether in promoting public health or in any of these other matters. It is perfectly true that government Amendment 144 will give the Secretary of State the responsibility of reporting back on how he has exercised his responsibilities, but he is not responsible for what is being delegated to local government. He may undertake to report back on what local government is doing, but there is no obligation on him to do so, as I read the Bill. Yet the whole issue of local authority responsibility in relation to the public health agenda, and in particular to inequalities, after—I remind your Lordships—a very strong recommendation from the Health Select Committee, could be ignored in practice. That cannot be satisfactory.

With all due respect to the Minister, I cannot say that I found her replies at all convincing or helpful, and it is a pity that in an area in which we could have worked together to improve the Bill there seems to be no inclination to do so, since the Government are simply standing pat on their original proposals, with a few very minor amendments. If that is how the Bill is going forward, I think they are missing an opportunity, but that is their responsibility. In the circumstances, since there is clearly no evidence of any intention to be flexible on the part of the Government, I reluctantly beg leave to withdraw the amendment.

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[Baroness Thornton]

My Lords, briefly, we support these amendments and commend the noble Lord, Lord Ramsbotham, and my noble friend for tabling them again because they are indeed important. I got quite excited when I saw the original spelling which was out there because I was thinking, “Is this about TB or HIV? This is a new one on me”. Nevertheless, this is a very important group of amendments because, as the noble Lord, Lord Ramsbotham, and other Members of the House have pointed out over many years, if you do not deal with the communication, speech and language problems of children at an early stage, you are storing up problems for the future. Indeed, Jean Gross’s report on front-line speech therapy for children is a cause for great concern, because it is quite clear that significant gaps are already appearing because of the cuts that have been made to provision.

I point out to the House that the allied health professionals have expressed their very grave concern about these issues by saying that they would like the Bill not to proceed. They are among the many thousands of health workers who, in this case, have been saying that for some extremely good reasons. Perhaps the noble Baroness would like to explain to the House what she is doing to persuade the allied health professionals and the speech and language therapists why the Bill will help them do their job any better, when it is quite clear that the services to children with speech and language therapies are already suffering.

[Baroness Northover]

My Lords, we are very sympathetic to the points that the noble Baronesses, Lady Hollins, Lady Whitaker and Lady Thornton, have just made. The noble Baroness, Lady Hollins, is quite right about the importance of communication skills—or even “communization skills”; my dyslexic son latched on to that one. We are acutely aware that addressing these kinds of areas is critical to the reduction of inequalities.

The noble Baronesses, Lady Hollins and Lady Whitaker, were concerned to ensure that we had flagged up this area. My noble friend Lord Howe sent a letter to the noble Lord, Lord Ramsbotham, who has worked tirelessly in this area. I emphasise that the Healthy Child programme, from pregnancy to five years, is the overarching NHS framework for providing prevention and early intervention for children and their families, and consists of a programme of screening, immunisation and health and development reviews. It is led and delivered by health visitors. It provides regular opportunities after birth for the parents and the health visitor to review together a child’s development, health and well-being, including any concerns about speech and language skills. We are working to improve the coverage of the HCP by delivering the Government’s commitment to increasing the health visitor workforce by 4,200, full-time equivalent, by 2015.

As part of the HCP’s schedule, the review at two to two and a half years includes a focus on speech and language development and is a key opportunity for health visitors to identify any problem and to take appropriate steps to refer a child to speech and language therapy if required. Following the commitment in the July 2011 publication Supporting Families in the Foundation Years, the Department of Health and the Department for Education are working together to develop the two to two and a half year review to become an integrated review, covering both health and education. The Department of Health is also leading a piece of work to develop a population measure—

[Baroness Thornton]

How does the Minister reconcile what she has just been telling us about referring children to that service after review at two and a half years with the fact that 70 local authorities have lost their NHS funding, 25 have lost cash from the LEA and those speech and language therapists are actually not going to be there?

--- Later in debate ---

[Baroness Northover]

I would refer the noble Baroness to the public health outcomes framework and the way that this will be included in that. The framework is very widely drawn and I hope that the Opposition will generally welcome that. It builds on the work that they themselves did and I hope that they recognise that.

I think that I have covered most of the issues that were flagged up. I reiterate that we appreciate enormously the commitment that noble Lords have paid to this area. We know how important it is; it sets the foundation for what happens later for many of these children. On the basis of that, I hope that the noble Baroness will be willing to withdraw the amendment.

[Baroness Hollins]

My Lords, I know that my noble friend was extremely grateful for the letter from the noble Earl, Lord Howe, on this matter. Communication is fundamental and screening is critical. We know that early intervention is effective. I am disappointed that the Minister did not confirm whether there would be a halt to the reduction of speech and language therapists. I beg leave to withdraw the amendment.

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[Baroness Northover]

My Lords, we discussed environmental health in Committee. It is clearly an important area that indeed interlinks with public health, but I hope to reassure noble Lords that we are taking action in this area through non-legislative means. The noble Baroness, Lady Finlay, is absolutely right to say that a narrow definition of public health is inadequate and it seems to me that this is the strength of moving the responsibility for public health to local government.

We need to emphasise the interlinkages in this area and I refer again to the public health outcomes framework. I am looking here at the domain “Improving wider determinants of health”, which includes indicators such as,

“Children in poverty … Pupil absence … First-time entrants to the youth justice system … Killed or seriously injured casualties on England’s road … Domestic abuse … Violent crime … Reoffending … Statutory homelessness … Fuel poverty”,

and many others. The point is that there are wide determinants of public health and it is necessary to link all these areas under the leadership of a director of public health who is drawing them together, rather than identifying an area as being the only one that links in. Directors of public health will need to link up with many other areas, nationally and locally, if that much wider definition of public health is to be accepted and become reality.

It is imperative that we continue to work with all our partners to achieve our ambitions for better public health, better care and better value for all. The Chartered Institute of Environmental Health indeed does an excellent job in presenting the issues nationally and liaising with central government. The environment within which people live, work and play, the housing they live in, the green spaces around them and their opportunities for work and leisure are all crucial to their health and well-being. For example, poor air quality is a significant public health issue and the current burden of particulate air pollution in the UK is estimated, on 2008 figures, to be equivalent to nearly 29,000 deaths at typical ages and an associated loss of 340,000 life-years in the population.

There is no doubt about the significance of that, but I should like to put it in the wider context of all the other areas with which the new director of public health will link up. Every day of the year, local councils have direct contact with many of their residents, and a fully integrated public health function in local government at strategic and delivery levels offers extremely important opportunities to make every contact count for health and well-being. I mentioned the public health outcomes framework and the way that it broadly defines things. It includes four indicators of direct relevance to environmental health professionals, and noble Lords have picked up on a number of those.

At a 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 and the Government as a whole. We are clear that this role includes advising on environmental health issues. The Chief Medical Officer will, in turn, continue to be able to seek advice on environmental health and other issues whenever necessary, just as she can now. A public health advisory forum will support the Chief Medical Officer in this role. This will bring together expert professionals and leading partners to assist the Chief Medical Officer in providing quality advice and challenge on public health policy and implementation, including areas such as the public health outcomes framework.

The amendment also calls on the Secretary of State to report annually to Parliament on the work of the chief environmental health officer. As discussed in Committee, we agree on the need for transparency and believe that the Secretary of State’s accountability for public health at national level is a major strength of the new system, which is why Clause 52 requires the Secretary of State to publish an annual report on the working of the comprehensive health service as a whole. That will include his and local authorities’ new public health functions.

I understand the arguments that noble Lords are making. We will come on later to issues relating to directors of public health and their leadership role. There clearly needs to be co-operation there, but across other areas too. Noble Lords who have worked in this area for some time have very effectively been arguing the case for this wider definition of public health and what affects it. In the light of that and the reassurances that I have given, I hope that the noble Lord will be willing to withdraw the amendment.

[Lord Harris of Haringey]

Before the noble Baroness sits down, will she clarify whether she sees the chief public health officer as being essentially the head of profession for environmental health officers around the country?

[Baroness Northover]

This being Report, and as I am not sure that that was a brief question for elucidation—

[Lord Harris of Haringey]

It was exactly that. I asked specifically for an answer to the question I put earlier. That is entirely consistent with Standing Orders at Report.

[Baroness Northover]

Okay. I think the noble Lord has a fairly good idea of what the structure looks like. Therefore, you do not muddle it up with a multitude of different people with different responsibilities at the same level. I think that he can therefore see clearly the answer to his question. Meanwhile—one I prepared earlier—I will also write to the noble Lord in case that is not quite right.

[Lord Beecham]

My Lords, I have a vision of meetings in the health world now starting with, instead of prayers, as we have in your Lordships’ House, a brief recitation from the outcomes framework. That seems to be the noble Baroness’s prescription for everything. However, it does not meet the case. We are not seeking to supplant the role of the Chief Medical Officer; we are seeking to augment the resources available to the Chief Medical Officer and the Government as a whole by the appointment of someone senior with the relevant experience across a range of issues mentioned by Members on both sides of the Chamber in this debate which impinge on the health of the nation, communities and individuals.

It is lamentable that the Government fail to take sufficient regard to the potential that this has to reinforce the common agenda. It is not a question of in any way diminishing the role of the Chief Medical Officer. I do not know whether the noble Baroness has considered the situation in Wales; I am sure that the noble Baroness, Lady Finlay, would enlighten her and, perhaps, all of us about how effective that post has been. It looks to me as though another opportunity to work together to promote the common agenda is being ignored.

Therefore, I regret that I will have to beg leave to withdraw the amendment. We will have to return to the point in future. When, in due course, we have the Secretary of State’s review of what is happening in public health, perhaps we can look particularly at the role of environmental health and how it might best be deployed within the department and across government. That may be an opportunity to do something, not necessarily within the statutory framework—I am sure that an appointment can be made outside the statutory framework—but it is an issue to which we shall have to return.