Health and Social Care Bill
Lord Beecham Excerpts(13 years ago)
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Lord Beecham
Lord Beecham
My Lords, we now come to the important area of public health. This is the time for your Lordships’ House to dip its collective spoon in the good part of this curate’s egg of a Bill. I have to say that, of course, in the context of this Bill, “good” is a relative term, but I very much welcome the reversal of the 1973 reorganisations—the splitting off of public health from local government—and the recognition, implicit and indeed explicit in the Bill, of the need for the closest possible relationship between public health services and the wide range of local government services which contribute to the promotion and improvement of the public health of individuals and whole communities.
In this context, of course, it is critically important to recognise the need for a high degree of professionalism, and in particular to ensure that public health specialists are thoroughly engaged at a senior level within local government and that they have a considerable measure of independence, both at national and at local level. There are amendments that we will be discussing—not necessarily in this group but as we go through the Bill—that address those particular issues.
One amendment in this group that I will not be moving or speaking to today is Amendment 94A, which relates to the making of Public Health England into a special health authority. By the vagaries of grouping, Amendment 267, in the name of the noble Lord, Lord Patel, relates to a later part of the Bill, although it could have been grouped with my amendment. It would be discourteous of me to anticipate that debate, given that the noble Lord’s amendment is down for future discussion. In general, we need to examine the role of government and their capacity either directly or through any of the other bodies created by the Bill to deal with the broader issues of public health at the local and national level.
Amendment 60B is the first amendment in my name. It simply incorporates the concept of promotion of public health as well as protection and improvement of public health in the rubric to Clause 8. It strikes me as a more positive and perhaps wider responsibility, which is echoed in some of the amendments we will discuss in this group about promotion through information, publicity and the like. It also perhaps has slightly less of a strictly medical connotation than the original rubric contains.
More significantly, Amendments 67A and 75ZZA relate to the proposed requirements on the Secretary of State to produce annual reports in dealing with the public health impact of budget changes and, as regards Amendment 75ZZA, in respect of finance generally. As ever, there is a significant issue around finance, which cannot be dealt with in terms of the context of the Bill. But it is critical that the reform is carried through with a workable system of financing the new arrangements. Considerable concerns about that have been voiced in response to the consultation documentation about funding the public health service from a number of quarters, including local authorities, the Faculty of Public Health and other organisations.
The difficulties of course are that at the moment public health is funded through the PCTs. It is by no means clear what the total quantum will be defined as in terms of the money to be redistributed direct to local authorities—ring-fenced, as we know it will be—let alone how that quantum will be distributed by way of formula. In addition, there is the new concept of the public health premium which will be used to reward those authorities which achieve an improvement in the public health of their area.
These are difficult matters. The Select Committee suggested that the public health impact of financial changes should be the subject of report. Both amendments simply follow the recommendations of the Health Select Committee of the House of Commons. I hope that the Minister will be able to agree them or at least agree to consider them and come back on Report.
I have been looking into this issue with the Local Government Association and this morning I received some advice stating:
“We are no nearer an announcement on the distribution formula or quantum after the third trawl for data. We remain concerned that it may be dealt with in isolation from wider issues about the design of the wider systems and the role and cost of Public Health England”.
Clearly, the finance will not be dealt with in the Bill but we need to know as we go through the Bill and approve—I hope improve—the proposed structures, how the financial system would work. Perhaps in reply the Minister could give an indication of when it would be expected that the financial framework will be explained and judgments might then be made about the adequacy or otherwise of those arrangements because they will impinge heavily on the eventual outcomes that we are all seeking.
Amendment 69ZA will extend to local authorities the duty to have regard to and promote the health equalities agenda, which we have discussed previously in relation to the national Commissioning Board and the national players, as it were. It seems to me sensible that there should be a matching requirement for local authorities to have particular regard to that issue.
Lord Beecham
My Lords, I am grateful to the Minister for her reply, although I shall resist the temptation to follow her into the realm of rearranging the furniture or even the deckchairs on the NHS “Titanic”. She rather missed the point of Amendment 69ZA, which adds to the provision in the Bill that will require each local authority to,
“take such steps as it considers appropriate for improving the health of the people in its area”,
the duty to take such steps as are appropriate to tackle the problems of health inequalities. That is the point that the amendment seeks to enshrine in the Bill. It is a duty that will lie on the Secretary of State for national purposes, but not for local purposes.
Baroness Northover
I am sorry that the noble Lord feels that I did not adequately deal with that. The point I made is that moving public health to local authorities will join up a lot of the other factors—housing, the environment and so on—for which they have responsibilities. As the Marmot review highlighted, that should help to address some of those areas.
It is also worth bearing in mind that the Equality Act introduced by the previous Government is relevant across all these areas and in terms of the groups with protected characteristics. Many of those who suffer from particularly bad health would be covered by that.
Lord Beecham
My Lords, it is surely clearer to have in one place the responsibility for reducing health inequalities. The amendment simply adds to the Bill:
“and shall, in doing so, take such steps as are appropriate to reduce health inequalities”.
That is the right place to have it when one is delegating that responsibility. The noble Baroness referred to the ring-fenced grant, which will, of course, apply to the public health function but, as she has just said, the public health function is not confined to what might be described as health expenditure. This duty to reduce health inequalities as part of local government’s new responsibilities should be embodied in statute, to ensure it in the consideration of the rest of local authorities’ functions and budgets.
I noted the remarks of the noble Baroness, Lady Williams, who is not in her place. She seemed to think that the Government have given independence to public health bodies. I hope she is right in her inference, but I am not so sure. We will return to this matter when we discuss Public Health England and other aspects of the Bill, including the role of public health specialists and directors of public health within local government. There are amendments that reinforce the independence of such postholders which are necessary additions to the Bill. I accept that the Government’s aspirations may be in line with that, but it seems to me that the Bill does not go far enough in providing them.
I want to return briefly to my amendment, which I do not think the Minister referred to, which is based on the recommendations of the Select Committee report on the public health impact of budget changes for the national level of public health, which affects Public Health England and the local authorities. I refer to the observations of the Select Committee:
“The Department of Health must also make clear how the actual level of funding for public health will relate to the historic baseline. We seek reassurance from the Department that, in setting the public health budget, it will take account of objective measures of need. This must apply in respect of both the national budget and allocations to local authorities”.
The next paragraph says:
“Although the Department of Health states that, in the current reduction of NHS management and administration costs, frontline public health services are being protected, we have heard evidence to the contrary. Furthermore, the Department has failed to give a convincing account of its distinction between frontline and non-frontline spending in public health services. Unless it can do so, the suspicion will remain that it is an arbitrary distinction and that public health services are suffering, and will suffer, in consequence of the cuts that are being made”.
In relation to the health premium, which as yet we have barely explored, the committee said:
“We are concerned about the proposed introduction of the Health Premium. We believe there is a significant risk that, by targeting resources away from the areas with the most significant continuing problems, it will undermine their ability to intervene effectively and thereby further widen health inequalities. Although many witnesses welcomed the proposed ring-fencing of public health budgets … and the Committee understands the short-term attractions of this approach, it does not believe it represents a desirable long term development”.
After further analysis, the committee said that,
“the ring-fenced public health budget should operate for no more than three years”.
Baroness Northover
I am sorry that the noble Lord thought I did not cover the first point. I did not make myself clear. With regard to the total figure for the health premium, which I mentioned briefly—and the Department of Health will be publishing something shortly—there is consultation on that. There is always controversy over how best to do that. I recognise what the Health Select Committee says about not wanting to have an inadvertent removal of money from where it is most needed to an area that might need it less, which appears to have done better and so on. These things are clearly very complex, as the noble Lord will know, and there is consultation on how best that should be taken forward so that it is most effective and does not have that unintended consequence.
Lord Beecham
Of course there is consultation going on. It has been going on for an inordinate amount of time and we need to see the outcome of that—as indeed does local government—during the passage of this Bill, I hope. These are critically important matters which at the moment remain opaque, to put it mildly. Of course there will be a report in due course, but the financial aspects of that report must be consistent with the thrust of the policy, and on that we are clearly not in a position to make a judgment. This is a matter to which we will clearly have to return, possibly in conjunction with the Bill, possibly separately. If local authorities are to undertake these increased responsibilities, there will have to be a satisfactory system to make possible the operation of the machinery that the Bill is creating.
Having said that, I acknowledge that these are all probing amendments. I hope that the Government will look at some of them with a view to possibly adopting them in future. On that basis, I beg leave to withdraw the amendment.
Baroness Northover
My Lords, Amendments 65A, 71ZA, 97A and 133A seek to raise the priority within the Bill of public health information advice designed to encourage the early diagnosis of serious conditions. Improving early diagnosis is an important objective across the whole health system, which includes the new public health system. I am very grateful to noble Lords for raising such a significant issue.
I completely agree with my noble friend Lord Sharkey as to the important role of information advice campaigns. I hope that I can reassure him that the changes to public health will not see the end of such campaigns. Where such campaigns work, we want to see more of them. We know how important early diagnosis is in treating cancer, for example. Thus, people coming forward for bowel cancer screening can be diagnosed at a stage where the disease is totally curable.
The noble Baronesses, Lady Masham and Lady Gould, emphasised other areas in which treatment is more effective earlier but also where there is a risk of infection, such as HIV, TB, hepatitis and meningitis. The noble Lord, Lord Davies, flagged up other STDs, among other issues. We are well aware of the importance of these areas. This is also where local authorities’ involvement in public health should assist rather than detract. The noble Baroness, Lady Gould, rightly flagged up this issue in relation to HIV/AIDS. No doubt we will return specifically to the points that she has raised when we debate HIV/AIDS on 1 December, World AIDS day, a debate to which I am responding. I look forward very much to our discussions then.
We will no doubt come back later to wider discussions of Public Heath England and the directors of public health, to which the noble Lord, Lord Davies, referred. Perhaps his notions can be revisited then when attached to the appropriate amendments.
As I outlined in the debate on the previous group of amendments, Clause 8 sets out the Secretary of State’s new duty to take steps to protect public health. It illustrates this duty with a list of steps that would be appropriate for the Secretary of State to take. That list includes the provision of information and advice. Amendment 65A would amplify that to specify that this could include information in campaigns around early diagnosis. I should explain that the list in Clause 8 is neither prescriptive nor exhaustive. The amendment would not therefore either require or give the Secretary of State a new power to do anything that the clause does not already accommodate.
Similarly, Amendment 71ZA would have the equivalent effect on a list of steps that local authorities may take under their new duty to improve public health. As we have already said, local authorities’ new responsibility will include behavioural and lifestyle campaigns to prevent serious illness and they will be funded accordingly. The Department of Health is also working with stakeholders from the NHS, local government and voluntary and community sectors to finalise the operational design of the new public health system. We expect to publish proposals shortly and they will set out how we expect to promote early diagnosis through the system.
Of course, the NHS will continue to play an important part in public health, a point emphasised by the noble Baroness, Lady Finlay, earlier. The Bill allows the Secretary of State to mandate or agree particular services that will be the responsibility of the NHS Commissioning Board. Amendment 97A seeks to ensure that he will consider early diagnosis campaigns when he does so. I hope that the noble Lord, Lord Sharkey, will be reassured that this is something which we are already considering. I can also reassure noble Lords that the objective of Amendment 133A is already met by the clause as drafted. Where the Commissioning Board is engaged in early diagnosis campaigns, then the duty to promote the integration of services would automatically apply to those campaigns just as they would to any other health, or health-related, services.
I emphasise that we especially expect advice and information to continue to play a major role in early diagnosis and local authorities will be able to contribute to that. Meanwhile, Public Health England, too, will be able to manage and support effective national campaigns. We will be publishing further detail shortly on how the different levels of the system will work.
In short, I believe that we are in total agreement with noble Lords about the principles underlying their amendments and with what noble Lords have said in the debate. We share their desire for improvement in this area. We all know what huge potential early diagnosis offers and the vital importance in this of public health campaigns. The Bill as drafted offers all the necessary support for that ambition. I therefore hope that the noble Lord will accept that and withdraw his amendment.
Lord Beecham
My Lords, as we are in Committee, I can repair my omission in failing to anticipate the Minister’s response to what has been a very good debate. I congratulate the noble Lord, Lord Sharkey, on tabling these amendments. I take issue with him slightly over one matter he mentioned: the relative performance of this country in terms of cancer survival rates. Recent reports make clear that they have improved substantially and are now beginning to outstrip those of other comparable health services. However, that does not detract at all from the thrust of the amendments.
The Minister referred to bowel cancer screening. That is but one example of the importance of early diagnosis, and public information can certainly assist in that context. As some of your Lordships may recall, I have some personal experience of this because my wife died of colon cancer last year. Her symptom was constipation, which is not a predominant symptom. Relatively speaking it is a less frequent symptom, but even now it is not something that some of the literature and material produced by cancer charities refers to. That is an illustration of the need for clear information to be given. There has been a very successful campaign about stroke, which was temporarily halted and then resumed. There is clearly a role for that kind of campaign. I should have thought that the Government could accede to the request for these duties and responsibilities to be included in the Bill.
Although I certainly strongly support the amendments, there are perhaps two riders that I might add. The first is that information, which of course can be in many forms, is not of itself necessarily enough. For example, information in labelling on food does not convey very much to people. This is an example of nudging not being enough. In some cases what is needed, apart from information, is action, and I hope that, as part of their public health agenda, the Government will take a rather firmer line in making requirements of the food industry and others concerning what goes into the nation’s diet.
The other rider relates to the efficacy of some kinds of campaigning. This does need to be measured. Some campaigns—noble Lords have referred to them—have been extremely effective; others, less so. The rather dramatic advertising about HIV and AIDS in the early days was not thought to have been particularly effective. It seems to me that in the interests of effectiveness and efficiency—that is, in terms of the expenditure involved—we need to evaluate what sort of campaigning and publicity works.
With all those qualifications, such as they are, I strongly support the noble Lord’s amendments. I hope that the Government will take another look at whether sending a very clear signal by having these kinds of amendments made to the Bill would assist what we all agree across the House is a prime responsibility and a prime opportunity for the Government to advance the public health agenda.
Baroness Northover
My Lords, my apologies if I leapt up far too soon. I caught the noble Lord’s colleague’s eye and it looked as though no one would be speaking from that side of the Chamber. However, I am incredibly glad to hear what is in fact cross-party support for this kind of campaign. The noble Lord is absolutely right: the part that charities play and have played in many of these campaigns is absolutely critical, not the least of which is Cancer Research UK and its various campaigns. Therefore, I thank the noble Lord for his contribution.
Lord Beecham
My Lords, in my youth—your Lordships might think it a rather sad youth—I was, at age 25, opposition spokesman on Newcastle City Council on a pre-Seebohm health committee, which had two remarkably effective and powerful chief officers. One was the medical officer of health, and the other was the chief public health officer. That was the designation of what I suspect we would now call environmental health officers. They were a very powerful combination and very influential within the council. But the point is that they were working together, which is precisely what my noble friend’s amendment seeks to achieve at national level. In later debates we will undoubtedly discuss the role at local level. It is absolutely right to identify this as a core function.
The noble Lord, Lord Rea, referred to one aspect of the role of such officers in environmental issues affecting public health. Perhaps I may revert for a moment to the previous debate and my noble friend Lady Thornton’s proposal to list some matters for inclusion as public health issues in the scope of the duties of local authorities and the Government. Several of those—including nutrition, air and water quality, adequate housing standards, fuel poverty, and possibly even occupational health—will fall within the domain precisely of this kind of appointment. It therefore seems to me that working alongside the chief medical officer of health, or reporting to him—a position of the kind covered by my noble friend’s amendment— would be entirely appropriate and effective. That binary combination or approach would ensure that, across the range of public health issues, there would be the best leadership and the best advice would be available to Ministers at national level and, similarly, at the local level. If it were to be matched, as I hope it would be, that advice would be available to local authorities.
The noble Lord, Lord Northbourne, referred to variations in the practice of local authorities in terms of the resources they devote to this topic. That was undoubtedly true in the past and will no doubt be true in the future, but it is also true at present. The practice of primary care trusts in terms of the way that they allocate budgets is by no means uniform, although I am not necessarily suggesting that it should be. But that is precisely one of the difficulties that I suspect we will encounter when the Government are forced to determine how much is currently being spent, how much perhaps should be spent and how much is to be allocated through any formula-based system under the ring-fencing scheme to be pronounced.
Individual authorities will have different ways of applying core funding, but that does not represent a substantive change from what we have now. Indeed, I would hope that, given greater public accountability, we will have a better outcome than we have had in the existing pattern. I warmly endorse my noble friend’s amendment.
Baroness Northover
My Lords, I thank the noble Lord, Lord Rooker, for giving me the opportunity to highlight the outstanding work that environmental health officers carry out in district councils as well as in the private and voluntary sectors. The Chartered Institute of Environmental Health, to which he referred, also does an excellent job in presenting the issues nationally and in liaising with central government. They will all continue to play a crucial and developing role in public health.
The noble Lord has long been a doughty fighter on environmental issues. I remember my astonishment when, as a Minister, he granted an amendment which I had tabled that he had been refused permission to grant. I therefore feel very mean in suggesting that I will not be reciprocating today. However, when the noble Baroness, Lady Finlay, raised her points, I was rather glad that, when acting on the Energy Bill in relation to the point for which she fought on preventing carbon monoxide poisoning, I was at least able to grant something there, although I know that that was more limited than what is being sought now.
I should stress that environmental health officers, along with other local authority staff, will be very much inside the group of professionals and practitioners in local government who will form part of the wider public health workforce. Consequently, we expect many opportunities for them in the future to contribute to and to shape local plans and priorities. Surely that will help transform this area, because public health, as I indicated, needs to be defined widely. In its new location it will change in order to have the effects that we wish to see. The noble Lords, Lord Beecham and Lord Rea, are right to urge working together, especially given the history of these officers.
At the national level, the Chief Medical Officer will have a central role in providing impartial and objective advice on public health to the Secretary of State for Health and to the Government as a whole. She will be the leading advocate for public health within, across and beyond the Government, advocating the design of policies that improve health and well-being. We are clear that this role includes advising on environmental health issues as well, and that the Chief Medical Officer will in turn continue to be able to seek such advice on environmental health and other issues whenever necessary just as she can do now. The Government believe that, as valuable as environmental health expertise is, this makes the post of chief environmental health officer unnecessary.
The noble Lord is of course right to urge discussion across devolved areas in all fields, as we can learn from each other. He might be reassured that the Chief Medical Officers of the various Administrations meet regularly, and that Public Health England, like the Health Protection Agency, will in some ways have a remit that extends beyond England and thus offer the chance to learn from the experience of others. We remain confident that Ministers will receive high-quality advice from the CMO on environmental health. I stress that we also need to look internationally and draw on research and experience very widely in this field. We can learn a lot from that.
The noble Lord’s amendment calls for the Secretary of State to,
“report to Parliament annually on the work of the Chief Environmental Health Officer”.
We agree on the need for transparency and believe that the Secretary of State’s accountability for public health at the national level is a major strength of the new system. This is why Clause 50 of this Bill requires the Secretary of State to publish an annual report to Parliament on the working of the comprehensive health service as a whole, which will include his and local authorities’ new public health functions.
The noble Lord, Lord Whitty, asked what the Government are going to do about ring-fencing the budget. Some of the issues that he raised were discussed in the first grouping on public health. I do not know whether he was in his place at the time. If he was not, he should be reassured that his noble friend Lord Warner intends to flag up some of the concerns that he raised in a later grouping, and we have various other groupings in which his concerns will no doubt be flagged up. I point out in relation to our discussion on the previous group that we will be using regulations to set out what essential services local authorities have to provide. Noble Lords can also see what is in the White Paper.
I want to clarify what will be covered in regulations so that if I was not clear in the last grouping, I can be clear now. Essential services that we think need to be delivered consistently across the country—for example, dealing with local emergencies—will be included in regulations. We will use publications like the updated White Paper, which I quoted earlier, to set expectations about the totality of services to be covered by the public health ring-fence. I hope that that provides clarification.
My noble friend Lord Greaves talked about the co-operation between different councils—county councils, district councils and so on. District councils have local insight and expertise. In many cases they will have the lead on key services affecting health and well-being, such as housing and environmental health. Health and well-being boards will play a big part in local health improvement activity and must find themselves able to involve local councils so that they work most effectively.
The noble Lord, Lord Northbourne—sorry to startle the noble Lord—wondered what would happen if local authorities do not carry out their duties. The Secretary of State does not have a conventional performance management role with local government—I am sure that those in local government will be pleased to know. However, he does have the power to intervene and ensure that particular services are provided if a local authority fails to do so. Local authorities will also have to account for their use of their ring-fenced grants, and the power exists to recoup money if the conditions attached to the grant are not met. I hope that that reassures the noble Lord.
In summary, it is very clear that environmental health is and will continue to be a very important component of the public health system, which will be led locally by directors of public health. I hope that the noble Lord is prepared to withdraw his amendment.
Lord Beecham
My Lords, public health started in local government some 160 years ago—and as many of us have previously remarked, it started in Birmingham or Liverpool or Newcastle, depending on who you believe. But in all events it owes its origins to local government, and as many noble Lords have already made clear, local government has made enormous strides in promoting the welfare of the community and indeed the individual through the exercise of public health functions—notably, of course, in the realm of housing.
It is because, as my noble friend Lord Rooker has pointed out, so many responsibilities still rest with district councils that his amendment, to which I have subscribed, clearly makes the case for ensuring that while we have a two-tier system in parts of the country, district councils should be involved. They have manifold responsibilities that have been exhaustively, not to say exhaustingly, adumbrated by the noble Lord, Lord Greaves, in his long list of their functions. I spotted two that for some reason he overlooked. One is noise abatement, which I am afraid is a significant health issue in many places, and the other is, perhaps more generally, community safety, which again can be a district council function. All these matters suggest that there ought to be a clear role for district councils in two-tier areas, certainly in relation to public health and, as perhaps we shall discuss at a later stage, in respect of other aspects as well. For that reason I hope the Minister will acknowledge that the amendments dealing with the role of district councils, including the amendment in my name which seeks to reaffirm that whatever else happens, the current duties relating to public health which apply to district councils should remain in place, should be accepted so that nothing in the Bill would dilute those responsibilities.
The noble Baroness, Lady Hollins, has made a good case in Amendment 203C for clinical commissioning groups to promote public health. I do not purport to understand the groupings here. This is no reflection on the noble Baroness, but it seems to me that the other amendment would have been better placed in the debate around clinical commissioning groups rather than here. The words “public health” have registered, so the amendment seems to have been plonked here, it might be thought somewhat inappropriately. Her argument, of course, is absolutely valid, but it is perhaps slightly unfortunate that that amendment has been placed in this group.
I have to say much the same about Amendment 79A, tabled by the noble Baroness, Lady Tyler. There are, if I may say so, two things wrong with the amendment. First, it really talks about providing commissioning consortiums—or, as they are now called, clinical commissioning groups—with responsibilities. That, again, is in the wrong place, but even if it were in the right place I would find myself in difficulties supporting it, because it seems to set up a parallel system with local government. It would invest in clinical commissioning groups the possibility of commissioning a range of services:
“housing or housing related support … education and employment … transport and leisure services, and … other health-related services”.
That last item I can understand, but the other three are primarily local government responsibilities. The implication is that either they would effectively take over or jointly commission services, in addition to local government. That is misconceived and likely to blur the position very significantly. So if the amendment were likely to be pressed to a vote, I could not find myself in the same Lobby as the noble Baroness. However, I apprehend that she will not be pressing it to a vote.
The noble Baroness, Lady Barker, raises interesting points under the clause stand part debate, and they are ones that should be considered. However, at this time I propose to stand apart from clause stand part. She is right to raise these matters and perhaps they can be taken further in discussion, as can other of the suggestions in amendments that we have heard tonight. On Report, one hopes that the Government will have reflected on the points made, and particularly on the position of district councils as referred to by my noble friend Lord Rooker and the noble Lord, Lord Greaves, so that we can ensure that the position of such councils and the duty to co-operate, which is so essential, is embodied in the Bill and not left to chance. It is not universally the case, I am sorry to say, that the relationship between county and district councils is all that amicable. There have been cases in parts of the country where it has been very far from the case. It should be made clear to both groups that there is a duty to co-operate, particularly to the county authorities that they have to reflect the interests of the district councils, because of the importance of the functions that they exercise.
Baroness Northover
My Lords, with Amendments 73 and 75, the noble Lord, Lord Rooker, has correctly identified the importance to public health of collaboration and co-operation between agencies. The noble Lords, Lord Rooker and Lord Greaves, come from somewhat different perspectives with regard to local government, perhaps based on their relevant or not relevant experience in this regard. I am, as ever, very grateful when my noble friend Lord Greaves offers me help, and we certainly can have discussions. Noble Lords, as these debates have shown, can offer experience across a wide area of knowledge and we would be remiss not to tap into that.
Lord Greaves
I thank my noble friend very much indeed for that. While the noble Lord, Lord Rooker, and I may come from different ends of the spectrum, we end up in the middle agreeing on a way forward.
Baroness Northover
Well, there we are—at this time of day, just before a recess, we have cross-party consensus. Shall we just adjourn?
The noble Lord, Lord Greaves, correctly identifies the areas in which local authorities have done so much to improve public health. I made reference earlier, as others have made reference, to the 19th century, because the sanitary reform then was a local authority achievement, and it did more than the invention of antibiotics to save and extend lives. The devolution of public health to local authority-level aims to link up all those areas across people’s lives, a point emphasised by the noble Baroness, Lady Tyler.
The noble Baroness graphically shows how health is related to wider social and economic factors, a point that the noble Baroness, Lady Hollins, has demonstrated in her account as well. I know from DfID how investing in girls’ education in developing countries results in later pregnancy. Why should it not be true here as well?
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Baroness Verma
I will reassure my noble friend. We are working against a really difficult economic backdrop, and we will have to make some incredibly difficult choices. Having said that, it is also an opportunity for us to open up to a variety of providers and see if services are then better delivered, with best value incorporated into how those services are delivered. As with personal budgets, delivery will not just be left to one set of providers. What is important is working in partnership—in this case, personal budgets and local government. It is about being able to deliver services far better and with greater choice. Those who have access to personal budgets have said to us in consultations that they feel relieved that they are going to be able to make choices on how their care is delivered.
Lord Beecham
My Lords, is it not ironic on the day that Southern Cross has collapsed—closing 560 residential homes, which account for over 30 per cent of residential care places—that the Government are proclaiming the virtues of diversity? How diverse is a system that allows a single private operator to provide such a high proportion of places, with the results that we can now see? In talking about diversity, how many organisations, particularly voluntary ones, have been contracted on the welfare to work programme? It seems to have been commandeered by a handful of national organisations.
Can the Minister also explain the relevance of the passage in the Statement that talks about,
“open, real-time data on road conditions, speeds and accidents along our motorways”?
Is she suggesting that motorists can then find another supplier of roads on which to travel or is this a question of diversity in the provision of satellite navigation?
More seriously, on the health premium paid to local authorities achieving the greatest improvements in public health, clearly one shares the objective of incentivising the improvement of public health. Is it not going to be difficult for authorities such as my own—the noble Lord, Lord Shipley, is also a member—to improve the very serious and long-standing conditions in public health? There are areas where it will be easier to do that and they will be rewarded for achieving targets while authorities that may need investment to secure improvements will presumably struggle to get it. Will that not have to be reconsidered to ensure that the investment goes in the right place to achieve public health objectives? Those are not in any event entirely under the control of local authorities.
Baroness Verma
My Lords, it is a great disappointment that Southern Cross has had to go down the route that it has gone in. The noble Lord is of course aware that many providers perform excellent work and have greater safeguards in place. We do not want to take one example and judge all private providers on it.
I am not quite sure that the significance of the roads question will be answered as fully as the noble Lord would like. I assume that those data are so that the public—the people who use those roads—are able to question why there is not greater improvement and how greater improvement can be brought about. It is not about avoiding roads but being able to say, “Where judgments are to be made about mapping on those roads, how do we deliver better services? Is it about speed or variable speeds”? I suspect that that is what it is, incorporated into that response.
On health premiums, it is absolutely right that those healthcare providers dealing with very difficult health issues in their areas should be given extra support and rewarded if they deliver better outcomes. It is only right that we work in partnership—sometimes with local authorities or across a range of providers. We must not put a full-stop block on this, so that we are driven by the same service that has gone on for many years and that has not delivered the sort of outcomes that we would like everyone to have—and not because they can buy it. It has to be available for everyone.
Health: Cancer
Lord Beecham Excerpts(14 years ago)
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Lord Beecham
My Lords, I come to this debate two years after my wife was diagnosed with inoperable bowel cancer and with secondaries in her liver and lungs. I therefore hope that your Lordships will bear with me if I speak in a more personal vein than is perhaps usual in debates in your Lordships’ House. My wife was diagnosed after some months of suffering from constipation. Her GP did not refer her to a cancer department—despite there being something of a family history—although in all fairness, as it turns out, it was probably too late in any event. But it is quite significant that constipation is not always recognised, even by some bowel cancer charities, as a significant symptom. It is to be hoped that that matter can be addressed in alerting the public in future to the need to seek advice.
I join most of the speakers who preceded me in paying tribute to the noble Baroness, Lady Finlay, for securing this debate and in particular for her emphasis on the quality of life. My wife was very realistic about her prospects. She did not chase after alternative treatments. She did not seek second opinions. She was determined to make the most of what time was left to her. Within a couple of months of being diagnosed, she made an acclaimed documentary for BBC North East and Cumbria about her condition and about the need for people to seek advice. She even wheeled on a footballer who had previously captained Newcastle United and Scotland to participate in that programme. Indeed, only last week I was approached by somebody quite unknown to me while shopping who had seen that programme and who had, as a result, sought advice and undergone a colonoscopy.
Not only that, my wife subsequently underwent a caecostomy in 2009, which made her a stoma patient. Of course, stoma patients have suffered from a variety of conditions, not just cancer, but together with other stoma patients she went on to make a DVD called “Have Bag, Will Travel”. It was trying to explain to both patients and their friends and, indeed, to practitioners about how to cope with stoma. That is also now being much used. It is available on YouTube and is being used and disseminated in hospitals, universities, medical schools and the like. She had undergone chemotherapy; at first, it seemed to be successful but the tumours began to grow again. She then had a second course of chemotherapy, which did not work; finally, she was treated with cetuximab. She passed the gene test, probably marginally, but alas the treatment did not work. However, NICE did its job. It was an approved treatment and, with some more luck, she might have been able to benefit from that.
However, she went on in her efforts to promote information. As a life coach and counsellor, she then organised a group counselling course for a number of other women who were cancer patients. That has been written up in a booklet called Moving Forward, published by Coping With Cancer. The aim of the booklet is,
“to provide tools to help people who have experienced cancer to reassess their present situation and move forward with their lives”.
That also is now being quite widely disseminated.
In the mean time, she received excellent treatment and support from the new cancer unit at the Freeman Hospital in Newcastle, from her district nurses and from Macmillan nurses. These were all very helpful. In her last weeks, a series of aids and adaptations were installed extremely rapidly. She did not in fact live long enough to gain the benefit from them, but close collaboration between the adult services department of the local authority and the PCT led to those being installed. There are considerable advantages to the close collaboration of those two organisations. Finally, she went to a hospice and received excellent treatment there. As she wished, she was sedated so that her last two or three days were spent without pain.
A number of policy issues arise from this and, of course, from many other similar histories. The first is to promote a better understanding of symptoms, not only among patients but among practitioners. The second is to welcome the improved screening; I am now speaking particularly about bowel cancer. The previous Government instituted tests by faecal smears. The present Government have promoted flexible sigmoidoscopies, although it should be pointed out that my wife had a sigmoidoscopy but it was not able to detect the tumours; the process does not go far enough, as it were, whereas colonoscopies do. I understand it to be the case, certainly in America and maybe in other places too, that more regular colonoscopies are available and are almost treated as routine. That could have a significant effect on detecting cancer early. Although I would not of course expect the Minister to make any kind of commitment, perhaps he would like to comment on the possibility of going beyond the further use of sigmoidoscopies. I would also like the Minister to comment on the provision of stoma nurses because it was apparent, certainly in our area, that there was a limited number of stoma nurses in the community. It would be helpful to have more of them.
A further issue is psychological support, which is the subject of the booklet that I have just mentioned and which again perhaps needs further emphasis. There again, GPs really must be encouraged to have closer contact with cancer patients.
There is also the question of support for the charities that the noble Lord, Lord Howard, so eloquently referred to: Macmillan, Marie Curie and the hospice movement. It is of course wonderful that so many people devote time to, and raise funds for, those hospices, but surely it is time to recognise that perhaps a greater degree of government funding and support is necessary.
Many patients, and my wife was one of them, would like to die at home. It was not possible in her case and perhaps not appropriate, but for many others it would be. I endorse the views of noble Lords who have called for further efforts to ensure that that is available to more patients.