HIV and AIDS: Vaccine

Lord Walton of Detchant Excerpts

Monday 1st December 2014 Lords Chamber

[Baroness Northover]

My noble friend rightly highlights the link between HIV and TB. The IAVI has developed new approaches to HIV vaccine research by focusing on the needs of developing countries and early-stage research. The TB Alliance has four combinations of drugs in late-stage development, and will soon launch a trial of a combination of drugs that are suitable for those who are co-infected with both diseases.

[Lord Walton of Detchant (CB)]

My Lords, does the noble Baroness accept that the major problem in identifying and preparing a vaccine against HIV is that the very term “HIV” stands for “human immunodeficiency virus”, and the consequence is that the virus itself disables the immune system to a very considerable degree? Since the discovery of a vaccine depends on stimulating the immune system to produce a vaccine, this is an exceptionally difficult and challenging scientific problem.

[Baroness Northover]

The noble Lord is absolutely spot on.

Ebola

Lord Walton of Detchant Excerpts

Wednesday 22nd October 2014 Lords Chamber

[Baroness Northover]

There was indeed a report and it had very sensible recommendations. When we finally get past this crisis, which I hope will be relatively soon—but who knows?—it is extremely likely that many lessons will be learnt as to how the international community and nations play their part in dealing with crises like this. We have many lessons to learn.

[Lord Walton of Detchant (CB)]

My Lords, is the Minister aware of any research on the availability of serum derived from blood samples from individuals who have survived the Ebola infection and could such serum be used to confer temporary passive immunity on healthcare workers who have been accidentally exposed to the virus?

Ingram National Park Visitor Centre

Lord Walton of Detchant Excerpts

Wednesday 31st October 2012 Lords Chamber

Asked By

[Lord Walton of Detchant]

To ask Her Majesty’s Government why the Department for Environment, Food and Rural Affairs has decided to close Ingram National Park Visitor Centre in the Breamish Valley in Northumberland.

[Baroness Northover]

My Lords, the Defra grant for the Northumberland National Park Authority this year is £2.9 million. It is for individual parks to decide on their spending priorities. The Northumberland National Park Authority has decided to close this centre as part of a wider review of all its visitor services.

[Lord Walton of Detchant]

My Lords, I thank the Minister for that disappointing reply. Is she aware that this well appointed centre, situated in an area of outstanding natural beauty, provides not only excellent car parking but the only public toilets for miles, a delightful woodland walk and a series of superb displays highlighting the history, geology, flora and fauna of the Cheviot area, displays of great educational value? Will she try to persuade Defra to think again and to try just a little harder to save this invaluable centre?

[Baroness Northover]

My Lords, I remind the noble Lord that it was not Defra that made this decision but the Northumberland National Park. It is of course of great regret to us when such closures take place. The park is working very closely with the Ingram village hall and the displays that the noble Lord mentions will in fact be moved there, as I understand it, so that they are still available to people. The park is also offering additional information points in local businesses such as shops, pubs and community centres. There will also be additional services offered by the park rangers. I would point out that on Hadrian’s Wall the park will have the great advantage of a new centre, The Sill, which is getting Heritage Lottery Fund money. It will become a major centre there and the noble Lord may wish to visit it.

Health and Social Care Bill: HIV/AIDS Programmes

Lord Walton of Detchant Excerpts

Wednesday 21st March 2012 Lords Chamber

[Baroness Northover]

I have been allocated much more time for this Question than my colleague was for the previous one, so I apologise if I am taking too long to answer. The noble Lord will have to wait to see how that transpires.

[Lord Walton of Detchant]

My Lords, does the noble Baroness agree that one of the difficult problems in the area of prevention is the fact that it is not ethically possible to take a blood sample to test an individual for HIV without their informed consent? The problem that arises is that a number of people who are at risk refuse to give consent, even though they continue to have sexual contact, and that is very difficult to overcome.

[Baroness Northover]

The noble Lord is absolutely right. From my other area of international development, I know only too well that that is true world wide. Things have improved enormously in the United Kingdom, where people with HIV are now living normal lives and there is much less discrimination than there used to be. That helps in encouraging people to come forward for testing. However, the noble Lord is absolutely right and it is extremely important that we reduce the stigma so that they are content to do so.

Health: Tropical Diseases

Lord Walton of Detchant Excerpts

Thursday 26th January 2012 Lords Chamber

[Lord Walton of Detchant]

My Lords, now that smallpox has been eradicated from the world and that the same may soon be true of poliomyelitis and that vaccines for malaria and many other neglected tropical diseases are in an advanced stage of development, this development by government is most welcome. Is the Minister satisfied that there are sufficient training opportunities in tropical medicine in this country to enable doctors to be trained who wish to work in the tropics on the eradication of these diseases?

[Baroness Northover]

I thank the noble Lord for his comments. The prospects before us are astonishing. I have just mentioned the United Kingdom universities and their research centres. I know that various noble Lords, including the noble Lord, Lord Crisp, are playing a part in trying to ensure just that.

EU: Healthcare

Lord Walton of Detchant Excerpts

Wednesday 11th January 2012 Lords Chamber

[Lord Walton of Detchant]

My Lords, in the 1970s, when I was chairman of the education committee of the General Medical Council, before I became its president, I was for five years a member of a European advisory committee on medical education, which produced a number of reports on basic and clinical education. It had the effect of improving medical education in many parts of the EU. That remains somewhat uneven. At the same time, we introduced a Professional Linguistic Assessments Board exam for doctors from outside the European Union coming to work in the UK to assess their clinical competence and their ability to understand English. When we tried to do that for European incoming doctors, we were threatened with being taken to the European Court because that was contrary to the Treaty of Rome. At that time, we persuaded the Department of Health that it was essential that it should impose a language test on incoming doctors from the EU as a condition of employment. That has been done very unevenly. What action are the Government taking to improve that situation? Do they propose to try to renegotiate the European working time directive, which has had such an adverse effect on the training of many junior doctors?

Secondly, does the noble Earl think it likely that the Human Tissue Authority will be the competent authority to deal with the transplantation directive in the UK at a time when the Government propose either to abolish or to merge that organisation? Finally, is the European directive on clinical trials being considered by the newly established Research Regulatory Authority?

Health and Social Care Bill

Lord Walton of Detchant Excerpts

Monday 19th December 2011 Lords Chamber

[Lord Walton of Detchant]

My Lords, I should like to ask the Minister to clarify a point of some importance. Many years ago, in the early stages of my neurological career, I was involved in interpreting electroence- phalograms. Subsequently, I was heavily involved in the pursuit of electromyography—a technique for measuring the electrical activity of the muscles in health and disease—and in measuring nerve conduction velocity. I also looked at evoked nerve potentials. A group of individuals grew up in that field originally; it was called the EEG Society. Then there was the Electrophysiological Technologists’ Association—the EPTA—of which I was briefly president. Eventually they came together to form the association of clinical neurophysiologists.

The Health Professions Council regulates 15 health professions, including biomedical scientists and clinical scientists. My understanding is that clinical neurophysiologists, like other clinical physiologists, are not included in or embraced by the term “clinical scientist”. However, I wish to know whether they are covered by the Health Professions Council. If they are not, it is important that they should be regulated. For that reason, if they are not included at present under the terms of the Health Professions Council, I strongly support this amendment.

[Lord Rea]

My Lords, in supporting this amendment I declare an interest. Not only my former patients but I, as a patient, have received skilled help from clinical physiologists. The pacing unit at St Mary’s Hospital, which is run by clinical physiologists, has monitored my pacemaker since it was fitted four and a half years ago. My life has literally been in their hands while they periodically adjust my heartbeat to get the best setting.

The Registration Council for Clinical Physiologists, which has been described, has been trying to persuade the Department of Health to include the profession in the mandatory regulatory framework for health professionals for the best part of a decade. The Health Professions Council recommended in 2004 that clinical physiologists should be included in its regulatory regime, as well as other clinical scientists whose work involves a potential impact on patient safety. The then Secretary of State accepted this recommendation but still no action was taken and has since not been taken despite frequent reminders from me, among others. On my count, 30 parliamentary Questions have been tabled on this issue. It has also been raised in your Lordships' House in a debate on an order to do with the Health Professions Council. I hope that this amendment will serve to speed up the process by focusing the Government’s attention on an overdue step that we feel needs to be taken.

--- Later in debate ---

What requirements help Her Majesty's Government to judge whether a profession has statutory registration or quality-assured voluntary registration? None of the arguments that have been adduced is applied consistently.

[Lord Walton of Detchant]

What is troubling me about this whole exercise is that, under the Health Professions Council, statutory regulation applies to art therapists, biomedical scientists, chiropodists, clinical scientists, dieticians, hearing-aid dispensers, occupational therapists, operating department practitioners, orthoptists, paramedics, physiotherapists, practitioner psychologists —in what way do practitioner psychologists differ from the psychologists to whom the noble Lord referred?—and many others. A lot of these people are already regulated. Where the statutorily regulated bodies end and the voluntarily regulated bodies begin is very unclear.

[Lord Alderdice]

It may seem a little unclear to the noble Lord, but it is not so unclear. Psychologists are qualified as psychologists, not as psychotherapists or as counsellors—they belong to a different professional body and have different qualifications and requirements. Psychologists themselves campaigned for many years for statutory regulation and finally got it through the Health Professions Council. Arts therapists and so on went through the HPC because many of them were occupational therapists, but try as I might—and I have been doing so for well over a decade—I cannot get successive Governments to address the question of psychotherapists and counsellors, despite the fact that they constitute a far larger number of people.

My dilemma with the current set of propositions is that, of the arguments adduced to try to persuade noble Lords that a quality-assured voluntary registration scheme is appropriate because the people referred to—the physiologists, the perfusion scientists and so on—are operating within the health service under supervision, are employed there and are smallish in number, none of them applies to this other group of people, for whom I have had precisely the same reply from the Minister. Therefore, I am keen to hear from the Government what the set of criteria is. Is it simply that this Government are not keen to pursue anything in the way of regulation except at the most modest level? If so, that is a legitimate argument but it needs to be made. If not, then I do not quite see the consistency of the current application.

Health and Social Care Bill

Lord Walton of Detchant Excerpts

Monday 5th December 2011 Lords Chamber

[Lord Patel]

My Lords, while the House settles down, I thought I might tell your Lordships what a hazardous journey I had here today. The temperature difference is only 12 degrees.

The amendments in this group relate mostly to issues concerning public health. It is to be commended that the Bill places a duty on the Secretary of State to take steps to protect the public from diseases and other dangers to health, putting public health at a high level of government responsibility and particularly that Public Health England, once established, will be accountable to the Secretary of State. I look forward to the public health outcomes framework. It is none the less disappointing that, while the Bill places a duty on the Secretary of State to pay regard to reducing inequalities in health, it does not do so for public health. None of my amendments will alter the thrust of the policy in the Bill; nor will they alter the structures for the delivery of public health locally or nationally. I hope that they will be seen as genuine attempts to improve the Bill and improve the chances of the delivery of the public health agenda. I am pleased that the amendments have such widespread support among noble Lords on all sides and I look forward to their contributions.

I will speak to Amendments 225, 226, 229 to 232, 233A, 234, 259 and 339. Amendment 225 deals with the appointment of directors of public health. Amendments 226, 229 and 231 allude to their training and qualifications. Amendment 228 applies to their accountability within the local authority and Amendment 230 concerns registration criteria. Amendment 234 applies to duties regarding the termination of employment of directors of public health and Amendment 259 concerns employment conditions. Amendment 339 deals with the regulation and registration of public health specialists.

As regards Amendments 228, 229, 230 and 231, the director of public health will be the strategic leader for public health in his or her local authority, providing expert public health advice and guidance across health protection, health improvement and health services. In order to provide effective strategic leadership, the director of public health must be able to influence all aspects of the work of the local authority in the wider determinants of health, such as housing, employment, access to services and education. He or she will also work with other organisations, including local health and well-being boards, HealthWatch England and clinical commissioning groups.

The director of public health must be an appropriately qualified and registered public health specialist. He or she must report directly to the accountable officer of the local authority, the chief executive. That is important because if the director of public health is not directly accountable to the chief executive but to some other person and, therefore, is subordinate, their authority will be diluted. The majority of directors of public health are now appointed jointly by the primary care trusts which employ them and local authorities to which they are seconded. Under the new system, all directors of public health will by law be jointly appointed by local authorities and the Secretary of State. That function will be undertaken by Public Health England and they will be located within and employed by local authorities.

As it currently stands, the Bill simply states that a local authority should “appoint an individual” without any specification of the required skills, expertise or stipulation of how these appointments should be carried out. A local authority could, for instance—indeed, there is some evidence that some are actively seeking to do so—tack the public health responsibilities onto, say, the duties of the director of adult social services or even the director of education. Most of them of course are wise and will not do that but it is possible.

Perhaps I may allude to some of the core competences that will be required of directors of public health, although this is not an exhaustive list. They will need to ensure the proper design, development, implementation and utilisation of the major information systems to underpin public health improvement and action for the population across disciplines and organisations. They will need to interpret and advise on highly complex epidemiological and statistical information about the health of populations to the local authority, the NHS and voluntary organisations, and to develop a strategy for reducing health inequalities. As executive directors, they will need to take a leadership role in specified areas with local communities and vulnerable hard-to-reach populations. They will have responsibility for dealing with infectious diseases and threats, including food and water-borne diseases. They will also have responsibility for preparing for emergencies, including pandemic influenza, and for safeguarding the health of the population in relation to communicable diseases, infection control and environmental health, including delivery of immunisation targets.

There are a lot of tasks and they are much more exhaustive than the list I have given the House. Therefore the person appointed as director of public health must have the appropriate qualifications and experience to carry out those tasks. The statutory requirement to have an appointments advisory committee that appoints directors of public health is therefore necessary. When appointing public health specialists, it provides a system which exists in the NHS now for all consultant appointments of monitoring applications for specialist public health posts. Through this system, candidates’ qualifications, training and experience are scrutinised by experts in the field of public health, usually the UK Faculty of Public Health advisers, to ensure that only appropriately qualified and trained people are appointed. Therefore it is important that all directors of public health and consultants in public health are appointed through a statutory appointments committee.

I turn to Amendment 234. Directors of public health will not only have many tasks, but they will have other accountabilities apart from the local authority. While their primary accountability is to the local authority, they will also be accountable to the director of Public Health England and have regional or national responsibilities in the wider public health service and for health protection. Yet while any authority that wishes to dismiss a director of public health will be obliged under statute to consult the Secretary of State, the Secretary of State will not have a veto over any dismissal, although he will be approving the appointment of a director of public health. I believe therefore that it is essential that any local authority wishing to terminate the appointment of its director of public health must be required in statute to have the Secretary of State’s approval and not merely to consult him or her.

In my view, the director of public health’s ability to report independently on the health needs of their community and population is important and critically on how well or not these needs are being met. He or she may be compromised if there is no protection against being sacked at the request of powerful local influences. The need for the Secretary of State’s approval is therefore necessary to reduce this risk. My amendment seeks to address this exceptional—I believe it will be exceptional—but nevertheless quite real possibility where the director of public health’s ability both to define and implement a local health strategy comes into conflict with other strong local interests seeking to dilute the impact of this strategy and compromise the health of the local population.

Amendment 259 will ensure that as public health specialists move out of existing NHS structures into Public Health England and local authorities, they will be guaranteed equivalent national terms and conditions of service to those in the NHS. That is important to ensure continued workforce capacity in public health, cohesiveness and skills and that public health remains an attractive career path. Clarity over the terms and conditions of employment for public health specialists would provide some measure of assurance that the profession will continue to be developed as an attractive one on a par with other medical specialties. The move of public health away from the NHS could potentially make it a less attractive career choice, particularly for young clinicians. That is an important factor. There is a real risk that without national terms and conditions, at parity with existing NHS terms, the public health workforce will become fragmented. As we saw in a report published last week, morale at the moment among the public health workforce is very low because of uncertainties about their role and the employment situation in the future.

Amendment 339 deals with regulation and registration of public health specialists and directors of public health. As Professor Scally concluded in his Review of the Regulation of Public Health Professionals, a review commissioned by the Chief Medical Officer of England and which investigated whether statutory regulation was needed for individuals operating at consultant level in public health,

“public expectation is such that, without the introduction of mandatory regulation of public health consultants and specialists by statutory health professional regulatory bodies, confidence would be lacking in public health professionals engaged at a high level in public health policy, planning and actions”.

Currently, we have a system whereby all medically qualified public health specialists working as consultants or directors of public health must by law be registered either with the General Medical Council or the General Dental Council if they are public health dentists. Specialists with a nursing or midwifery background are regulated through the Nursing and Midwifery Council. However, that is not the case with public health specialists from non-medical backgrounds, even though they will often carry identical responsibilities to their medically trained colleagues. A voluntary system of regulation, operated by the UK Public Health Register, is currently in place for those from backgrounds other than medicine. At the present time, in order to work at consultant or specialist level in public health in the NHS, a person must be on a specialist register such as that held by the GMC or the GDC. Non-medical specialists must be registered on the UK Public Health Register. With the move to local authorities of the majority of the public health workforce, the danger of a two-tier system of regulation or, worse still, no system of regulation could prevail. That is a risk.

Doctors trained as public health specialists have to undergo five years of training as specialist registrars and obtain a certificate of specialist training to be on the specialist register of the General Medical Council. Subsequently, they have to provide evidence of involvement in continuous professional development and be re-evaluated every five years. Similar mechanisms exist for dentists. The role of director of public health in a local authority carries a level of responsibility in relation to the health and well-being of the local population. It requires public confidence and credibility from other organisations. The person who holds such a post should be properly trained and qualified and be on a register. That would be appropriate.

The amendment would establish that all public health specialists not on medical or dental registers should be registered and that the Health Professions Council should establish such a register. I beg to move.

[Lord Walton of Detchant]

My Lords, I warmly support this clutch of amendments relating to the future of the public health service in the UK, so ably proposed by my noble friend Lord Patel. No doubt the Government have taken full account of the House of Commons Health Committee’s detailed report on public health, 12th Report of Session 2010-12, which raises a number of crucially important issues.

There are three principal domains of public health: health protection, which addresses environmental threats to population health; health improvement, tackling health inequalities and lifestyle issues impacting on health and well-being; and healthcare public health, which applies public health expertise to the provision of healthcare services. It is a significant omission in the Bill that it does not include any statutory duty on local authorities to address health inequalities in discharging their public health functions. That is a serious omission in the Government’s plans.

As my noble friend said, all directors of public health will by law be jointly appointed by local authorities and the Secretary of State, with the latter function being exercised through Public Health England, but they would be located within and employed by local authorities. Does this mean that directors of public health who hold medical and dental qualifications will, as at present, hold honorary consultant appointments, with all that that implies, as indeed my noble friend raised in his proposals? I agree entirely with his proposal that the appointment of such individuals should involve an advisory appointments committee accredited by the Faculty of Public Health, as is currently the case in respect of directors of public health within the NHS. Can the Minister confirm that that will be the case?

As my noble friend Lord Patel said, young doctors and dentists training for a career in public health undertake a programme of training for five years as specialist registrars. Who is going to employ them in the future? Will it be Public Health England? Local authorities do not understand what a registrar is, and for that reason it seems extremely difficult to consider that those people training for careers in public health will also fall under the ambit of the local authorities. Perhaps the Government can give us an assurance on that point. I agree with my noble friend Lord Patel that it is crucial that the director of public health be appointed at chief officer level, reporting directly to the council chief executive, and that any local authority wishing to terminate the appointment of its director of public health must be required by statute to have the Secretary of State’s approval.

Another important issue is to recognise the fact that healthcare public health, the third domain, is a core part of the public health service. Its role is to bring public health skills and knowledge to bear on the commissioning of health services, helping to ensure their quality, safety, efficacy, effectiveness, value for money and accessibility. The Government’s initial proposals were seen as downgrading the role of public health in the commissioning of healthcare services, but, happily, it has been clarified. The directors of public health and their teams will provide public health expertise, advice and analysis to commissioning groups, health and well-being boards, and the NHS Commissioning Board. This will be one of the mandated public health services that local authorities must commission or provide. However, this is not enough. Can the noble Earl give us an assurance that the local director of public health will be a member of the board of each clinical commissioning group? There should be a qualified public health professional on the NHS Commissioning Board; and the board should routinely take advice from qualified public health professionals when commissioning decisions are taken. We seek assurances from the Minister on that particular point.

Finally, I support very strongly the comments made by my noble friend Lord Patel about the regulation of public health specialists, including directors of public health who do not hold a medical or dental qualification. Those who are in possession of medical and dental qualifications are of course regulated by the General Medical Council and the General Dental Council. What about the specialists in public health who are not so qualified? Is it the Government’s intention, as Professor Gabriel Scally has indicated, that these individuals should come under the Health Professions Council for their registration? In my opinion and that of many professionals, some form of formal registration rather than voluntary registration is very important and, in fact, absolutely essential. I support these amendments.

[Lord Mackay of Clashfern]

My Lords, I would like to support these amendments generally from the point of view of the tremendous focus that comes on the local public health official when there is an outbreak of ill health—for example, E.coli—which gives people tremendous anxiety. They look for leadership to deal with it; they look to the local official, the local member of the public health team, to do that. The amendments proposed by the noble Lord, Lord Patel, have an important part to play in assuring that the people who are put in that position are adequate to deal with such a situation if it comes along. Fortunately, from time to time there is a quiet spell. Then, all of a sudden, something breaks out that causes tremendous anxiety in the local community. They like to feel that the person who is put into the front line to deal with it has a capacity to know what he is doing and to express himself in a way that enables the community to deal with the thing without excessive scaremongering—but, on the other hand, effectively.

--- Later in debate ---

[Baroness Williams of Crosby]

I thank the Minister. I will spend many happy hours working my way through every possible legal complexity and a number of different Bills. I am grateful for her explanation.

[Lord Walton of Detchant]

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

[Baroness Northover]

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

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

--- Later in debate ---

We are relying on a huge amount of faith in the Government knowing what they are doing. We are relying on that in regard to about £120 billion, give or take, of public money every year. Not surprisingly, coming to the amendments in this group we see that people think there should be some checks. We need to have some safeguards in here, so that if it does go a bit wrong there is some way of salvaging the situation, instead of people assuming that we will keep all the expertise that we currently have in PCTs and SHAs. I know that PCTs and some SHAs have had their problems, but there is also a lot of expertise there. The bits of that expertise which disappear and the bits which remain will, I suggest, be slightly random; it will revolve around a lot of personal choices as much as anything. So we need some checks in this. It is not too late for the Government to be mature and recognise that we need better safeguards. That is why I am very sympathetic to changes which preserve the SHAs, in particular, for a longer period until we have actually got through the financial challenges that the NHS faces.

[Lord Walton of Detchant]

My Lords, I shall speak briefly to Amendments 236AA and 236AAA. As I listened to the noble Lord, Lord Warner, I reflected upon the fact that in the course of my professional career I have been a member of four hospital management committees, an area health authority for teaching, a regional hospital board and a regional health authority. Each one of these had its merits and defects.

On reading them and understanding the intention underlying them, these amendments look absolutely praiseworthy. I do not believe that they would have been necessary if the Government had been clear in what they intend to do about the subnational outreach of the national Commissioning Board. This has been promised to us by the Government and by Sir David Nicholson. It is intended to deal in every respect with the specialised commissioning of highly specialised services with regard to long-term conditions and with the issue, raised in many debates in the course of the last week or two, of the rising problem of rare diseases and their management and the new means of treatment that are being introduced.

Having said that, we hear that the Government are going to have clinical senates at a subnational level. It is intended that at these clinical senates there will be subnational outreaches of the national Commissioning Board that will fulfil the functions set out in Amendment 236AA. If that is right, my concern about supporting Amendment 236AA is that it looks as though it carries the potential danger of introducing yet another tier of management within the NHS. I look back with horror as I remember Keith Joseph’s reorganisation of the NHS in 1974. I was heavily involved at the time as the dean of a medical school. It created regional health authorities, area health authorities and district health authorities. The tiers of management were impossible and the decision-making machinery congealed.

I am very anxious that we do not go down that route. If we could have clarity from the Government about the subnational senates and the outreach organisations of the national Commissioning Board, Amendment 236AA would not be needed and would have the potential danger to which I have referred.

I agree with every word my noble friend Lady Finlay said about the role of the postgraduate medical and dental deans. As I said at Second Reading, and later, it is the financial responsibility of the NHS to provide education and training for all healthcare professionals and to provide training for young doctors and dentists who are being trained for specialities in various branches of the profession. It is absolutely right that that authority and responsibility continue to be imposed upon the postgraduate deans, but surely the right place for them is not only in Health Education England but in these clinical senates—the outreach organisations of the national Commissioning Board to which I have referred. I hope that the Minister can give us assurances about this.

I would hate to say that this amendment, so ably proposed by my noble friend Lady Finlay, is in any sense weak. It is not—it is a strong amendment—but it might not be necessary in the light of the developments to which I have referred at the subnational senate level. I am concerned, too, that if it were accepted it might prejudice the Government’s acceptance and agreement, which the noble Earl gave us quite recently, to the effect that a major government amendment on education and training is to be tabled by him on Report, to which we very much look forward.

The principles underlying these amendments are excellent, but for the reasons that I have mentioned I would find it difficult to support them if they went to a vote.

[Lord Newton of Braintree]

My Lords, I will speak briefly. First, I remind the Committee that when I spoke on a related matter last week, as my noble friend Lord Mawhinney has reminded us, I indicated that I have an interest as my wife is a PCT non-executive. I wish to put that on the record again.

I rise in the same spirit of helpfulness as the noble Lord, Lord Warner, with whose every word I agreed—the Minister needs to know that. I am also conscious, as my noble friend Lord Mawhinney reminded me, of my hurt last week when I was accused of using extravagant language. I will try to do better—well, worse, perhaps—this time. I indicated at that time that when we got to these amendments I thought my noble friend Lord Mawhinney would leave no one in doubt about his views. He has not, and I have not got up in order to disagree with him.

I want to concentrate on two things: the constitutional issue and the conflict of interest issue. The constitutional issue is perhaps arguable, but if you take the view, as my noble friend did, that the Government have in effect—certainly this is how they present it—abolished PCTs before this Bill has even been passed, there is a real question mark. Perhaps it is no more than a question mark because they will say that they have not abolished PCTs and will not do so until an order in two or three years’ time, but that is how it feels, looks and is perceived on the ground, and your Lordships might like to bear that in mind.