Health and Social Care Bill

Lord Fowler Excerpts

Monday 13th February 2012 Lords Chamber

[Lord Warner]

My Lords, I must congratulate my noble friend. He has obviously had an extremely good weekend and is in very fine fettle. He has done a great service in moving the amendment, because it gives us a chance again to air the continuing concern in many parts of the NHS and the outside world about the cost of the organisational changes that flow from the Bill and the risks of those administrative costs escalating in future.

I recognise that nearly all organisational changes have transitional costs, and I do not doubt the Government's genuine belief that their changes will lead to savings in what they call bureaucratic costs. As the Minister knows, I moved some amendments in Committee to try to cap management costs and their annual increases. He told me in the politest possible way and with his normal, reasonable manner that that was unnecessary.

However, I remain concerned about the Government’s ability to keep under control the costs of the organisational changes that they have set in train with the very large number of new bodies that can play in the NHS game, as my noble friend Lord Hunt made clear. I do not intend to go over them again, but there are a lot more of them than there were before. Whether we call them bodies or ill defined entities, such as the senates, they are still people who will be involved in the administrative processes, and I have never found anyone able to engage in administrative processes who does not incur costs and increase the cost of those services. Some of us have been around the public sector quite a long time. Those bodies can use the age-old arguments to grow their organisations over time. Those growths of organisations are, of course, always in the interests of the public. It is always for the best of purposes that they expand.

I see nothing in the Bill that enables those costs to be contained from escalating in future. It is not just about the start-up costs of the national Commissioning Board or Monitor in the early stages; it is a question of where this whole system will end up in two, three, five or 10 years’ time, when we see, in its full glory, how it works in providing our NHS.

My scepticism rests on how the Government have modified the Bill as it has progressed through Parliament. It would be easier to be more confident about containing those costs if, after the pause and as the Bill has progressed, we had not seen modification, often done with good intentions and often moved in amendments from other parts of the House. However, we have ended up with a model that looks jolly different from the one that we started with when the Bill began its passage through Parliament.

I have also been struck by what I can only describe as the naivety of the language of some of the Government’s supporters, who seem to equate eliminating managers with reducing bureaucracy. As my noble friend said, we badly need managers to make this system work. There is a growing belief that somehow, after all these years, clinicians will suddenly be efficient, cost-cutting commissioners of services and we can forget about the quality of general managers. I am pleased to see the noble Lord, Lord Fowler, in his place because he was, if I may put it this way, the father—or grandfather—of the general management that was introduced into the NHS, and he deserves a lot of credit for that. In the 1980s, the Conservatives decided that what the NHS needed was a good dose of general management, and that is what it had. However, managers suddenly seem to be equated by some of the Government’s supporters with the cause of the problem. They are the people whom we seem to need fewer of while we undergo a massive organisational change and have to save £20 billion over four years. How that is all to be done with a new set of organisations and with many of the most experienced managers being lost to the NHS slightly eludes me.

The Government turned their face against using existing legislation to reduce the number of PCTs significantly, reconstituting them with more members from local authorities and more clinicians. Some of us have reduced the number of PCTs and SHAs and have substantially reduced the number of ambulance trusts without any primary legislation at all. I am still waiting to hear convincing arguments as to why we could not have done some of that under existing legislation without inflicting much of the organisational change relating to commissioning. I support in principle more clinician involvement in commissioning, but why could that not have been done within the existing legislative framework without this plethora of new entities being created? These new bodies will have to learn how to run the NHS and will incur quite a lot of costs while doing so.

In the current public expenditure climate, we cannot afford to have what I would call youth training scheme approaches to managing the NHS. A lot of new people will have to learn on the job. If we do not introduce into the Bill some constraints on these costs, they will escalate out of control. That is why I do not think that my noble friend’s amendment is the perfect solution, although it is an attempt to try to curb costs and stop them running out of control. However, I fear that that is what we shall see when the sets of changes in the Bill are implemented in the real world.

[Lord Fowler]

My Lords, when the noble Lord said that the amendment was not exactly the perfect solution, that was a brilliant understatement of the position, as I think almost everyone would agree. My concern about the amendment is that it is a prime example of declaratory law. Almost no one would disagree with the aim of reducing bureaucracy. I suspect that almost every Government since 1946 have said that that has been their aim, although I am not sure that it takes the argument very much further. I am delighted that the noble Lord, Lord Hunt, is proposing this. He was a former director of the National Association of Health Authorities and Trusts, which I never felt was in the foreground of reducing bureaucracy in the health service, but that is doubtless a very unworthy allegation to make against him. However, going purely on the basis of the wording of the amendment, I think that it is simply impractical to have a,

“minimum level of management tiers” .

What does “minimum” mean? It is a wonderfully generalised statement.

The noble Lord, Lord Hunt, touched on the fact that there is a slight implication—I know that he distanced himself from it—of there being opposition to management inside the health service. Of course I agree with the noble Lord, Lord Warner, that management is absolutely of the essence, and I am delighted to have received praise from him. When I introduced general managers into the National Health Service following the report of the late Roy Griffiths, who, people may remember, did so much and produced a wonderful and exemplary report, it was in the face of opposition from virtually all the health service unions, including, needless to say, the British Medical Association, and most of the people who have been opposing the current Bill. It was also in the face of fierce opposition from the Labour Party—in the Commons at any rate; perhaps it was different in this House. Therefore, if I can make an entirely partisan point, I am delighted that we all agree on this serious point. More than 1 million people are employed in the NHS and there is a vast budget. To believe that you can get through the reorganisation without skilful and good management is completely ridiculous and we need to underline that. We are not talking about administrators—a phrase that is still used far too often. We are talking about managers, and what the health service needs is good managers.

I hope that the noble Lord, Lord Hunt, regards this as simply a good amendment for debate and that he will withdraw it because of its manifest defects. However, he rather criticised the new organisation going down to the local level regarding health promotion. Obviously, if you go down to the local level, you are going to have a number of local authorities. However, I should have thought that one thing on which both sides of the House would agree is that health promotion should be carried out with a ring-fenced budget and with local delivery. I should have thought that most people would want to see that. It contrasts with what the previous Government did and doubtless with what happened before that. Money which went to health promotion—I remember this happening with HIV/AIDS—simply was not used for that purpose; it was used for something else inside the health authority. I think that we are taking a giant step forward with health promotion and I am passionately in favour of that.

The amendment of the noble Lord, Lord Hunt, is interesting. I obviously agree with all the sentiments behind it, as I think most people do. However, as a piece of law, it is, frankly, defective.

[Lord Harris of Haringey]

My Lords, it is an enormous pleasure to follow the noble Lord, Lord Fowler. I was particularly taken with his support for the principle of ring-fenced funding, which I trust the Minister will take into account when, a little later, we come to consider local healthwatch organisations.

Earlier today, we had a Question on the initiatives that had been taken in London on stroke care. I did not get an opportunity to pose this question but I was interested in who, in the absence of NHS London driving the process, would have taken the quite difficult decision to reorganise stroke care in London, given that it was opposed by a lot of the local providers and local organisations. This question also came up during the first day on Report when we looked at who would make decisions on reconfiguring services and who would make decisions when services were not adequate or when there were issues of equality of healthcare to be addressed. At one point, the Minister said:

“The CCGs will be supported in their efforts to improve quality by the NHS Commissioning Board”.—[Official Report, 8/2/12; col. 314.]

Later on, when I probed him on this, he said that “the board”—that is, the NHS Commissioning Board—“will be represented sectorally”. I was not quite sure what he meant, but it being Report stage I could not challenge him. He said:

“There will be field forces in all parts of the country … The majority of its staff will be a field force”.—[Official Report, 8/2/12; col. 316.]

I do not know how a majority can be a field force, but there we are. Later on, he said:

“However, of course, the board will be represented at a local level rather than only centrally, and we expect that the board will be represented in health and well-being boards and in the discussions that take place there”.

When I questioned whether that meant that they would be members, he said:

“It is entirely open to a health and well-being board to invite a member of the Commissioning Board to be a permanent member, but I am not saying that we are prescribing that”.—[Official Report, 8/2/12; col. 340.]

I took that to mean that the NHS Commissioning Board will be sitting at the centre of the National Health Service with its tentacles going out to all parts of the health service. The Minister did not really like that. He said:

“The role of the board is to support local commissioners; it is to be there as a resource to promote guidance, supported by the quality standards that we were debating earlier”.—[Official Report, 8/2/12; col. 352.]

Health and Social Care Bill

Lord Fowler Excerpts

Wednesday 7th December 2011 Lords Chamber

Moved by

[Lord Fowler]

260E: After Clause 57, insert the following new Clause—
“Charges to overseas visitors
(1) The National Health Service (Charges to Overseas Visitors) Regulations 2011 (S.I. 2011/1556) is amended as follows.
(2) In regulation 6 (services exempted from charges) for paragraph (e) substitute—
“(e) the diagnostic test for evidence of infection with the Human Immunodeficiency Virus (HIV) and counselling associated with that test and its result;(ea) all other services for the treatment of HIV provided to an overseas visitor who has been present in the United Kingdom for a period of not less than six months preceding the time when services are provided;(eb) treatment for sexually transmitted infections other than HIV;”.”

[Lord Fowler]

My Lords, I will be brief. The amendment aims to remove an anomaly in the law which is both absurd and damaging. As the Select Committee on HIV and Aids said in its report, the priority with HIV should be prevention. For every case we prevent we save, in financial terms, about £300,000 in a lifetime’s treatment, as well as the human cost of that lifetime’s treatment. Antiretroviral drugs preserve life, and thank God for that, but they do not cure. The vast majority of National Health Service treatment for HIV is free, but the present law charges for treatment for a small group of people in this country, which has obvious and, frankly, baleful, effects.

First, if the charges result in no treatment, it is dangerous to the individual and endangers his own life. Secondly, it means that the man or woman affected is likely to spread the disease to others and add to the casualty list, although effective treatment reduces onward transmission by something like 96 per cent. Thirdly, such a charging law acts as an obvious deterrent to people coming forward for treatment and testing, which is the whole aim of policy, and negates it. Therefore, the effect of the present law is against all the policy aims of public health—a point very strongly put by the National AIDS Trust, to which I pay tribute.

--- Later in debate ---

[Lord Davies of Stamford]

This is a very difficult situation and I am very much in sympathy with the noble Lord’s amendment, but I wonder whether he would address the one reservation and concern on which I imagine I may not be alone: if we cease to charge for HIV treatment and diagnosis, as the noble Lord suggests, that could constitute an incentive for people to come to this country to exploit that possibility, given what he has already said about the expense and difficulty of receiving that treatment. Indeed, it could be an incentive for people to deliberately overstay their visa or become illegal immigrants to this country.

[Lord Fowler]

I will obviously deal with that issue, because it is crucial. If the noble Lord would be as patient as I have been in waiting for the opportunity of this debate, then all will be revealed to him.

It is probably the black African population who are most affected by the current policy, yet it is here that the Government’s policy of prevention has been most concentrated. We need to remember that late diagnosis of HIV, leading to the late start of treatment, is one of the major causes of serious ill health and early death. Yet, here we are, pursuing a policy that deters treatment and testing, from which the only logical result can be that late diagnosis. If you want a monetary argument, you have to add the additional costs of treatment for that individual plus the cost of those who may be further infected. On the face of it, it is not a prudent financial policy.

Why do we therefore pursue such an apparently reactionary and foolish policy? Here I come to the noble Lord’s point. Only one argument has ever been put forward. It is that if the rule were to be lifted there would be a danger of “health tourism”. This is an argument based entirely on assertion. As far as I can see, there is no evidence whatever for it. My Select Committee looked at this point, as the noble Lord will know because he has read the committee’s report on this matter. The same rule is not applied in Scotland, Wales or Northern Ireland—either as policy or in practice. Has there been an influx of those suffering with HIV to Edinburgh, Cardiff or Belfast? Of course not. My Select Committee could find absolutely no evidence in this respect. If there is such evidence, I invite the Minister to give it or any other evidence that she may have on health tourism, because, so far, it has never been put.

The crucial point against the law in England is that it is not enforced in any event. It is incapable of being enforced. The patients are usually destitute. A hospital gives the treatment. Then it pursues the charges. Then it finds out that the patient cannot pay and it writes off the whole amount. As one of our witnesses said, it is a constant circle of nonsense. That is the position that is being defended at present.

I have not yet heard any sensible defence of the present position. As a matter of principle, Parliament should not pass laws which cannot be enforced; and as a matter of practice, Parliament should not pass laws which add to the problems of public health and do not reduce them. If the Government are serious about their intent to put prevention first, this law should be repealed. I beg to move.

[Baroness Gould of Potternewton]

My Lords, I am very pleased to support the amendment. I was also very pleased to see that, in the response to the HIV Select Committee report, the Government are reviewing their current policy, which excludes some people from HIV treatment. The HIV Select Committee was absolutely right to say that it is wrong to charge anyone with HIV treatment and care.

For me, it is not only a question of health, it is a question of humanity. I find it incredible that this position survives. I have to say this with great regret, because I spent a long time trying to persuade my Government that something should be done about this, with little success. The argument was made very much in the way that my noble friend said about health tourism. I hope, although I am not clear from the words of the Minister in replying to the debate in December, whether that is still in their thinking. She said,

“we must avoid creating any incentive for people to come to the UK for the purpose of free HIV treatment”.—[Official Report, 1/12/11; col. 492.]

As my noble friend Lord Fowler said, there is no evidence to support the claims of HIV health tourism if the charging is ended. In 2008, the National Aids Trust produced a report on the myth of HIV tourism, demonstrating that such claims are wholly unfounded. Data from the Health Protection Agency show that the average time between a migrant arriving in the UK and an HIV diagnosis is almost five years. That is an awfully long time for someone coming on the basis of health tourism. For me, it is the absolute clincher as to why this is all such nonsense. Further, government reports have suggested that asylum seekers have no prior detailed knowledge of the UK's asylum policies, welfare benefits or entitlement to treatment. That would apply equally to HIV.

HIV charges, as the noble Lord, Lord Fowler, said, are not applied in Scotland, Wales or Northern Ireland. We would have seen some movement from London or anywhere in England to those nations if people wanted to access free treatment. If individuals do not move from London to Edinburgh to access free treatment, it is difficult to believe that they move from, say, Harare to London, for that reason. Another reason makes that claim somewhat ludicrous. A report published yesterday by the HPA shows that 5.9 per cent of TB patients are HIV-infected. TB treatment is free for those people; but the HIV treatment is charged. I do not know how one differentiates between those treatment costs, and, again, it just shows how stupid the position is.

In addition, since 2004, when the charges for HIV treatment were first implemented in England, there has been a 13-fold increase in access to anti-retroviral treatment in low and middle-income countries around the world, with sub-Saharan Africa seeing the greatest increase in the absolute numbers of people receiving treatment. ART coverage of all those who need it now stands at nearly 50 per cent in those regions and continues to increase. It is most unlikely that those able to purchase a flight to the UK will be unable to purchase ART in their own country. Having HIV does not in itself prevent removal from this country if a person is in breach of the Immigration Rules, as was established at the European Court of Human Rights in the case of N. Therefore, there is no reason for someone who knows they have HIV to migrate to the UK believing that their HIV-positive status will secure settled residence and ongoing access to treatment.

However, there is another criterion which, again, I had not appreciated until yesterday. A situation arises from the new Immigration Rules that have just come into force which further entrenches the way that HIV treatment charges deter African men and women in particular from finding out about their HIV status or going for treatment. Now, anyone with an unpaid NHS debt of over £1,000 will routinely have further immigration-related applications, whether to remain or for re-entry, refused. In the past, it was possible to encourage people coming forward for testing and treatment on the basis that it would have no impact on their immigration status. That is no longer possible as, if you are not entitled to free HIV treatment, your immigration status can be affected. As the noble Lord, Lord Fowler, said, these people are destitute and do not have the money. As a consequence of this change, they could now be removed from this country, which is something that never happened before.

There is also the whole question of costs. It seems to me that not removing charging continues to increase the cost to the NHS arising from HIV treatment charges. Ending charges for HIV treatment will actually save the NHS money by preventing new HIV infections and by identifying HIV early, when it can be effectively treated, so reducing the need for hospitalisation and other costly care when people with HIV become seriously ill. Reducing the level of undiagnosed HIV and increasing the proportion of people with HIV on effective ART will reduce the number of HIV transmissions occurring in the UK. I think that the noble Lord, Lord Fowler, said that preventing one onward transmission of HIV saves between £280,000 and £360,000 in treatment costs over a lifetime. People who are diagnosed late or who do not access treatment become seriously ill and will often require expensive in-patient care—a week’s stay costing between £15,000 and £25,000, and there may be many repeat visits to hospital. Surely it is cheaper to provide no deterrents to early testing and treatment.

It is sound common sense to remove this costly and inhumane restriction from the NHS (Charges to Overseas Visitors) Regulations. I hope that perhaps, not today but when the review is over, we will hear sound common sense from the Government.

--- Later in debate ---

[Baroness Northover]

My Lords, I am very grateful to my noble friend Lord Fowler for the constructive way in which he has raised this amendment and I pay credit, as others have to done, to his continuing, enormous commitment to improving HIV services for all. I also pay tribute to other noble Lords who contributed to this debate and to this long battle over many years. I will commit to having considered by Report the arguments and proposals set out by my noble friend.

The Department of Health is indeed currently concluding an internal review of the current policy to charge some people for HIV treatment. We will be concluding this review by the new year, including any discussions with the other government departments which will have an interest. The review has considered many of the issues raised by noble Lords today. These include the increasing evidence of the public health benefits of early diagnosis and the role of HIV treatment in reducing onward transmission of HIV.

In the UK, around 25 per cent of people with HIV are unaware of their infection, which means they are unable to benefit from effective treatment and risk transmitting HIV to others. Promoting HIV testing to reduce undiagnosed HIV and late diagnosis remain important priorities for HIV prevention. We would be very concerned if our current policy were to deter people from testing for HIV, even though testing has always been free of charge to all. Those already entitled to free HIV treatment and care include asylum seekers and, from 1 August this year, failed asylum seekers receiving specific support packages from the UK Border Agency. Further, failed asylum seekers who are already receiving HIV treatment when their asylum application and any appeal fails continue to receive free HIV treatment up to the point that they leave the country, regardless of whether or not they receive the UK Border Agency support.

However, I acknowledge that a small number of vulnerable people will not be covered by the current exemptions and they may be deterred from accessing HIV testing services because they cannot afford treatment or are confused about the entitlement to free NHS treatment.

The world has made huge progress against the HIV epidemic in the 30 years since AIDS was first identified. Globally, new infections have fallen, and nearly 7 million people are on ARV treatment. While there is currently no significant evidence of health tourism in relation to HIV, in considering any changes to our current policy we must make sure we that we do not create an incentive for people to come to the UK for the purpose of free HIV treatment, without compromising our overriding responsibility for public health. I stress again that our overriding responsibility is to public health. As my noble friend Lord Fowler said, the Select Committee on HIV examined the issue of health tourism.

In conclusion, the department's review identified and considered many of the issues raised today. We are now looking urgently at how these can best be addressed. I assure my noble friend that we will provide a clear position in time for Report. I hope that in the light of this he will feel able to withdraw his amendment.

[Lord Fowler]

My Lords, I thank the Minister for that very sympathetic and understanding reply. We obviously understand that a review is taking place and take comfort from the fact that it will be complete by Report. She will have noticed that support has come from all parts of the House. I think that it would have come from the Liberal Democrats; I know that they share this view. Therefore, every party, including the Bishops' Bench—for which I am very grateful—is represented. Perhaps I may say that the House has left its visiting card on the issue. We look forward to Report and to the statement of policy that I am sure will come by then. Given the Minister’s assurance, I beg leave to withdraw the amendment.

Amendment 260E withdrawn.

Health and Social Care Bill

Lord Fowler Excerpts

Wednesday 12th October 2011 Lords Chamber

[Lord Fowler]

My Lords, as the noble Lord, Lord Beecham, has just said, a constant theme of the debate has been the volume of public and professional objection to parts of the Bill. I do not downplay that, but such protest about change in health policy is hardly unique. The first health debate I took part in was as shadow Health Secretary in 1975, when I came from the peaceful realm of dealing with law and order, crime, police and prisons to the health service, and found the most horrendous row on pay beds taking place. The noble Lord, Lord Owen, will remember that as he was Health Minister at the time.

A few years later I took over as Secretary of State and stayed for six years, which is something of a post-war record. I would like to claim that this was a period of unparalleled peace, but this House has certain standards of honesty and frankness. The lesson I learnt from those years was that any change or reform in the health service almost certainly comes up against the implacable opposition of the BMA and the other health unions—and, very often, of the Opposition. When I introduced general managers, there was a fierce row. When I introduced a manpower policy, there was a fierce row. When I introduced contracting out, it was regarded as the work of the devil; and a proposal to have some very modest partnership between the public and private sector at district level was described by Michael Foot as,

“the most serious attack on the National Health Service since it was originally started”.

The worst attack was when the BMA and the pharmaceutical industry combined to attack my proposals to save on the drugs bill by substituting cheaper, generic drugs for branded sleeping pills and tranquillisers. The BMA said that it was an unacceptable interference in the freedom to prescribe, and the pharmaceutical industry said that I was the worst kind of socialist. Even then, the party opposite voted against me. Perhaps it was the word “socialist” that they did not like. Needless to say, none of the policies has been overturned in the 25 years since. My point is that we should not be amazed at the noise and criticism accompanying any set of changes; that has always been the case. Having said that, I acknowledge that many issues raised in the debate are of genuine concern. Those of us who care about the future of the health service want to see them settled. The question is how that can be done.

What would be entirely unacceptable is for the Bill—by any standards a major government Bill—to be defeated by this House at Second Reading. I was a Member of the other place for 31 years and accountable to the electorate. When I came to your Lordships' House, my position changed. This House has great expertise, as the noble Lord, Lord Winston, has just shown, but it is an unelected House and should not on Second Reading substitute its own view of a major Bill passed by the elected House after an exceptional period of consideration. We were asked yesterday where the mandate was for this legislation. The mandate comes from the elected House—from MPs who are elected and accountable. Frankly I am amazed that the opposition Front Bench supports the amendment of the noble Lord, Lord Rea, because my argument is exactly the kind of argument they used in government on issues that were much less important.

The amendment of the noble Lord, Lord Owen, to which the noble Lord, Lord Hennessy, spoke, is nearer the mark. The question that they raise is not new. In many ways, it is the eternal question of the National Health Service. How, when one has an almost entirely tax-funded service, with an obligation on the Secretary of State to answer to Parliament on how money is being used, does one at the same time achieve maximum devolution for the service to be most effectively managed? I do not deny that there is an important issue here that we should consider. What I doubt is whether we require a special Select Committee to examine the issue. The normal committee processes of the House would be sufficient.

In the time available, I will make three quick points on why I support the Bill. First, any Government have an absolute right and duty to ensure that the enormous resources being devoted to the health service are properly used. We can debate by what percentage health costs go up each year, but we are now spending more than £120 billion a year on the health service. By any standards, that is a vast amount of money. What one wants, particularly in the light of an ageing population and the certainty of new treatments coming on stream, is to see that the service is well managed—and I do mean managed. It serves no purpose to refer to the many excellent managers in the health service as bureaucrats and administrators. We should value their skills in the same way as we value those of the clinicians and doctors.

The second reason I support the Bill is that it explicitly recognises that not everything needs to be run by the health service. Fair competition is not an alien concept but something that applies to every other profession in this country. I do not want to wreck the political careers of the noble Lords, Lord Warner and Lord Darzi, but I agreed absolutely with what they said yesterday about this. Fair competition should ensure the best possible service. Equally, the use of the private sector does not mean that one is privatising the service; that is one of the oldest and dreariest charges. We are committed to a taxpayer-financed service, but making sensible use of the expertise of the private sector is what any modern public service should do.

My third and final reason for supporting the Bill is that it potentially contains—I listened to what the noble Lord, Lord Beecham, said on this—one of the most important steps forward: the creation of Public Health England, with a ring-fenced budget. I have just finished chairing a Select Committee of this House on HIV and AIDS. One of our findings was that at the last count, in 2009-10, the Department of Health spent £762 million on the treatment of HIV—mainly on drugs—and £2.9 million on prevention. The trouble is that people do not march up and down Whitehall or block Westminster Bridge carrying banners saying, “Prevention, prevention”. The public demand treatment. The tragedy is that so much treatment could be avoided, as in the case of one man who wrote to me after our report saying that he was on the verge of suicide when he was diagnosed with HIV, and even today is receiving psychiatric care: a casualty of a failure to prevent an entirely preventable disease.

There has already been a long debate on this Bill. Unless we are careful, we will leave the health service in uncertainty about the future. We will leave it in suspended animation. I do not believe that anyone who is committed to the National Health Service wants to see that. My belief is that this Bill should now be given its Second Reading and that we should proceed to scrutinise it in Committee with the skill and care that this House has always shown.

Health: HIV/AIDS

Lord Fowler Excerpts

Monday 5th September 2011 Lords Chamber

Asked By

[Lord Fowler]

To ask Her Majesty’s Government what steps they are taking to prevent the spread of HIV and AIDS in the United Kingdom.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, the Government fund national HIV health promotion programmes for men who have sex with men and for African communities, the groups most affected by HIV in the UK. This is in addition to harm minimisation programmes for injecting drug users, NHS HIV prevention programmes and open-access testing and treatment services. The White Paper, Healthy Lives, Healthy People, sets out the Government’s strategy for reform of public health in England. This includes sexual health and HIV.

[Lord Fowler]

My Lords, I thank my noble friend for that reply, but does he really think that we are getting the message over on the dangers of HIV? Is it not a fact that the number of people accessing care for HIV has trebled in the past 10 years, that we now have almost 100,000 people with HIV in the United Kingdom and that the cost of treatment and care has now risen to almost £1 billion a year? Given that this is an entirely preventable disease, does not my noble friend agree that we have devoted disgracefully little to HIV prevention programmes over the past decade and that our efforts here should now be urgently increased?

[Earl Howe]

My Lords, may I begin by paying tribute to my noble friend Lord Fowler in his continuing interest in HIV and AIDS, here and internationally? He has done a huge amount to raise the issue’s profile in Parliament and more widely. I agree with much of the thrust of what he said; there is no doubt that over the past 10 or 12 years great progress has been made in a number of areas, but we are still concerned about the increasing incidence of HIV among men who have sex with men and sub-Saharan African communities, which are the groups most affected and vulnerable to HIV in the UK. That is why our prevention campaigns have been targeted primarily at those communities. There is much more work to do. The sexual health framework report that we are publishing later this year will have a separate section on HIV, and I hope that in that document my noble friend will be reassured that our efforts in this area will not let up.

Public Bodies Bill [HL]

Lord Fowler Excerpts

Monday 28th March 2011 Lords Chamber

[Lord Whitty]

My Lords, in moving Amendment 39 I wish to speak also to Amendment 54. Essentially, my question to the Minister is the same as it was in the previous debate: namely, why is Ofcom still included? When we started out on this Bill, almost all the economic regulators were in one schedule or another—Ofgem, Ofwat, the Office of Rail Regulation and, I think, the CAA were all in there. However, only Ofcom remains. When my noble friend Lord Hunt pressed the Government on this earlier, there were references to cost saving and other things, but why does Ofcom appear in Schedules 4 and 5? Instead of a rational approach to the role of economic regulators, we have had departmentally based assessments of their roles, most of which have not yet reached a final decision. Ofgem and Ofwat are being reviewed by their departments but we are not looking in general at the role of economic regulators. We know that some changes are coming along the line to the scope of Ofcom because the Postal Services Bill, which is passing through this House, extends Ofcom’s reach by transferring the work of Postcomm into Ofcom. I support that move but a transfer mechanism or a modification does not need to be included in this Bill because a separate piece of primary legislation exists to achieve that.

Expenditure on Ofcom has already been reduced by the department and the reference in the previous stage to a saving of some £400,000 could be achieved administratively. It is also true that advisory committees to Ofcom can be changed without primary or secondary legislation. Indeed, it seems to me that Ofcom, presumably with the connivance of its parent department, has already removed by stealth the Communications Consumer Panel from effective operation without it being entirely clear where those functions for the protection of consumers in the communications business now lie. Therefore, it is unclear why the Government need additional powers to make savings and streamline Ofcom’s operation.

As regards Ofcom’s inclusion in Schedule 5, we know about the transfer into Ofcom of the Postcomm responsibilities but there is a suspicion that there may be some transfer out of it. Ofcom has responsibility for regulating a whole range of communications industries, many of which are deeply sensitive. I referred just now to its sponsor department but it is sometimes unclear to us who is the sponsor department for Ofcom because, on the media side at least, a significant proportion of Ofcom’s activities now appear to be the responsibility of DCMS rather than BIS. I do not regard that as a particularly healthy move. However, either way, it raises a suspicion that some of its media responsibilities, such as media ownership, broadcasting content and the whole structure of regional broadcasting, may be in line for being curtailed or moved back to the department. It would be alarming if a transfer out involved any of those items.

There are also other responsibilities. Just to show that I am not being partisan, I had a substantial and ongoing row with the previous Government about their provisions in the Digital Economy Bill. Those provisions have been handed over to Ofcom to implement, which is finding some difficult in doing that. There may be some irritation in government about that. Therefore, a lot of Ofcom’s responsibilities could be transferred out.

I should like an assurance that Ofcom’s continued inclusion in Schedule 5 in particular does not mean a reduction in its scope, particularly as regards those responsibilities. Ofcom has, in general, been a pretty good economic regulator in the consumer’s interest, as compared with some other bodies. However, it was and is always up against some powerful telecoms, broadcasting and media companies and their lawyers in almost every move that it makes. I therefore hope that the Government are not envisaging that we should reduce Ofcom’s responsibilities and are not using its inclusion in Schedule 5 to facilitate that reduction without primary legislation. I beg to move.

[Lord Fowler]

My Lords, I agree entirely with the noble Lord, Lord Whitty, that Ofcom is an extremely important body, and I hope that the Government accept that because, in the media area, a body such as Ofcom that is independent and seen to be independent and skilful is of the utmost importance. Certainly, as regards Schedule 3, I should like confirmation that it is not necessarily the case that the proposal means there will be a cut in Ofcom’s budget, although the budget can be modified either way.

I say that because it is difficult these days to debate Ofcom without discussing the role of the BBC Trust, which was set up by the previous Labour Government. The previous Secretary of State rightly changed his view, decided that the trust was an unnecessary body and that the logical way to run the BBC would be for there to be one chairman, a board and the executive, rather than the current extraordinary position, which is unique in the western world, whereby there is at one level the executive and then, in a separate building, the trust, headed by the noble Lord, Lord Patten of Barnes—I am glad to say. However, the noble Lord is able to call himself the chairman of the BBC only as an honorary title. That is ridiculous. He should actually be the chairman of the BBC, and there should be one unitary authority. That is the logical way, and that is why 99.5 per cent of organisations in this country run themselves in that way.

The position that I reach from that is that the responsibilities that are now with the BBC Trust could easily be transferred to Ofcom. That is their logical place and everyone has argued for that. If that happened, one would find that the Lords Communications Committee—no longer under my chairmanship—would consider this matter further. If that is the position, there would clearly be adjustments to funding arrangements and the rest, as set out here. That does not necessarily mean that the funding would be reduced, but that the funding for Ofcom would have to increase.

I ask my noble friend Lady Rawlings—who, I am glad to see, is refreshing herself with water for her reply—whether she will confirm that that is the case. It would be a grave mistake for the Government to accept the argument put by people who have very vested interests that Ofcom is of no particular value and should be downgraded. Everything that has happened in the media world over the past six months confirms the view that the importance of Ofcom should be underlined. That is what I should like to hear from my noble friend now that she has refreshed herself.

[Baroness Jones of Whitchurch]

My Lords, I am grateful to my noble friend Lord Whitty for continuing to champion the organisations that stand out as protecting consumer interests, and for the remarkable good sense that he has shown again this evening in defending Ofcom's independence.

During the passage of the Bill there have been several attempts by Ministers to make reassuring noises about the importance of Ofcom and its central role in the future of media regulation. This may well be the case, but I share my noble friend's concern that the thrust of these changes, far from giving Ofcom greater responsibility, will limit its power to intervene in crucial issues such as media ownership and changes to public broadcasting. Power appears now to be increasingly centralised in the hands of the Secretary of State.

As is the case with many other organisations for which changes are sought in the Bill, one is left to wonder about the cost savings that might occur if the Minister's department is serious about taking on those functions. I concur with the questions of the noble Lord, Lord Fowler, about the proposed savings expected from Ofcom in this context. The Government have trumpeted the increased transparency that will occur, but it remains unclear how we will be able to scrutinise the major decisions that will be taken in the department on issues such as media control. When it comes to transparency, give me Ofcom any day.

My noble friend repeatedly emphasised, in previous debates and today, the special status of the economic regulators and the need to protect their independent function. Again, the Government took steps in the past to reassure the House on this matter. However, like other noble Lords today, I am left wondering why they felt that it was necessary to put the remaining changes to Ofcom in the Bill, and whether this still represents a shift in power and authority away from independent economic regulators and back to the centre. If this is the case, it is a backward step both for the consumer and for the wider public, as well as being a cause for celebration for would-be media barons. I remain unconvinced of the need to change Ofcom's role through the formal mechanism of the Bill, and very much look forward to hearing the Minister’s justification of why it is necessary.

Queen's Speech

Lord Fowler Excerpts

Thursday 3rd June 2010 Lords Chamber

[Lord Fowler]

My Lords, I congratulate the maiden speakers on their contributions, all of which were of a very high standard. I particularly congratulate my noble friend Lord Hill of Oareford on his speech. We worked together in the 1992 election, when we travelled the length of the land with John Major. We braved egg throwers on the south coast and a near riot in Bolton. Some people say that it was a surprise that we won that election and that there must have been a secret ingredient. Modesty prevents me from claiming too much about our effort in that campaign, but my noble friend certainly had a major impact. I say to him sincerely that it is very good to see him in this House. I also congratulate my noble friend Lord Howe on his appointment as a Minister. He did some fantastic work in opposition—no one was more effective—and it is extremely good to see him on the Front Bench.

In the time available for speeches in this debate, there is just the opportunity to leave a visiting card, but my purpose is to emphasise the vast importance of public health policy in fighting disease in this country, an issue that is dealt with in the coalition Government’s priority programme. This country used to have a proud record in this area, but our efforts in recent years have not been so distinguished. That is a vast pity because, if you can prevent disease, not only is that good for the individual but it is also self-evidently valuable for the Exchequer, which can avoid the cost of expensive treatment.

At the weekend, I was listening to Harry Evans, the legendary editor of the Sunday Times. Talking of one his campaigns, he said: “If something bad is preventable, why not prevent it?”. That is not a bad lesson. Let me give just two examples of disease and death that can be prevented. The worldwide toll for HIV/AIDS and for hepatitis B and hepatitis C runs into hundreds of thousands, if not several million. Just in case anyone should believe that this affects exclusively countries overseas, let me give some figures. In the United Kingdom, the number of people living with HIV will soon go through the 100,000 mark. There are somewhere between 250,000 and 460,000 people living with hepatitis C, while the latest estimate is that 326,000 people are living with hepatitis B in the UK. The result, in the case of hepatitis, is that increasing numbers of people are dying from liver cancer and end-stage liver disease as a result of viruses that can be prevented or treated. That is the tragedy.

Unhappily, the crucial link between all these conditions is that they are often undiagnosed. People do not know or find out after the damage has been done. The majority of people affected by hepatitis B are undiagnosed, while half those with HIV are diagnosed late, which means that that they do not get the treatment when it is ideally needed. This also means that the infection can be passed on by people unaware of what they are doing. Taken together, this represents a major public health issue.

In this respect, the position has changed radically since I was doing the health job at the end of the 1980s. For example, HIV need not now be a death sentence—we now have antiretroviral drugs that will preserve life—and the same goes for the other two viruses. It seems to me that the chief priority now must be testing, so that knowledge can lead to action. Self-evidently it is in the interests of the individual concerned to have access to treatment and it is in the interest of public health generally that disease is not spread.

We need to adopt a frank and open policy in warning the public and advising them of the position. We should not be too nervous about putting over a public message. In 1986 and 1987, we tried an entirely open approach with our “Don’t Die of Ignorance” campaign. I do not say that there were not concerns about that public education campaign, which involved advertising on television and posters. I remember a reservation from a very influential figure—none less than the Prime Minister herself. In March 1986, I was sent a minute that said:

“The Prime Minister has emphasised that she still remains against certain parts of the advertisement. She thinks that the anxiety on the part of parents and many teenagers, who would never be in danger from AIDS, would exceed the good which the advertisement might do”.

My private secretary was told:

“Your Secretary of State will now wish to consider how to proceed in the light of the Prime Minster’s firmly held views”.

I think that one can hear the authentic voice of No. 10 coming through. In the event, we went on with the campaign. We formed a special Cabinet committee to oversee it and the result was that we had very few complaints from the public. That is the significant point. The public are sensible and mature on issues of this kind. If they think that there are good public health reasons for a campaign, they will support it.

That is important when considering the issue of migration into this country from countries where, for example, the incidence of hepatitis B may be greater than it is here. I am talking about migration not just from Africa but from Asia and eastern Europe. A group of consultants wrote to the Times at the end of last month proposing the screening of people coming here from high-risk countries. That is an altogether sensible point.

Lastly, there is one other important step that we can take. For hepatitis B, there is a vaccine; it can be prevented. If only that was the case for HIV/AIDS there would be rejoicing throughout the world. Most other countries in the European Union have a policy of 100 per cent vaccination against hepatitis B. We do not. We follow a policy of vaccination of selected groups, which self-evidently is not working. In 2002, the previous Government published a paper entitled Getting Ahead of the Curve. Unfortunately, that did not happen. By 2010, the incidence of hepatitis B has not reduced; it has almost doubled.

There is a challenge here for the new coalition Government, who now have the ability to put some of these things right. It is an opportunity that we should take because a strong policy on public health is capable of delivering immense benefits to this country.