European Union (Withdrawal Agreement) Bill

Lord Warner Excerpts

Committee: 1st sitting (Hansard) & Committee stage & Committee: 1st sitting (Hansard): House of Lords
Tuesday 14th January 2020 Lords Chamber

[Lord Hamilton of Epsom (Con)]

My Lords, the Government have done an amazing amount to look after EU citizens in this country. I cast my mind back to the early days of the May Government when there was great pressure to unilaterally make steps to ensure the position of EU citizens living in this country. At that stage, the Government resisted the pressure because they said that this should be part of the negotiations. It should be reciprocated by the EU: it should do the same for our citizens in the EU. As far as I can make out, that has not happened. We have made a generous, unilateral gesture towards EU citizens in this country and there has not been reciprocation from the EU. Does that not mean that the Government have been rather mistaken to make this generous offer? Surely we have an obligation to our citizens in the EU and we should look to it to reciprocate anything that we do in this country. Will my noble friend address this problem when she sums up? As I understand it, British citizens in the EU do not, at the moment, have any freedom of movement between one EU country and another and there are certain problems with EU citizens in this country travelling to and from their country of origin in Europe. This has not been a very satisfactory outcome in the negotiations. Perhaps we would have been better not to have made this extremely generous, unilateral offer.

[Lord Warner (CB)]

My Lords, I support these two amendments. I do so as the roommate of my noble friend Lord Kerslake, who sends his apologies for not being here but has strengthened my arguments for supporting the amendments. I speak as someone who, after the 1997 election—oh glorious days—spent two years in the Home Office and saw every submission of any significance that was made to the then Home Secretary. I always shuddered a little when we got submissions from the immigration part of the department. They sent a quiver through my soul, because of reliability. I remember a former Conservative Home Secretary briefed us shortly after that election. He said to the then Home Secretary: “You have to remember that there are always 500 people in the Home Office who can ruin your political career. The really scary thing is that none of them actually realises that they can do it.” The Windrush exercise demonstrated rather well the wisdom of those remarks.

The important thing about these two amendments is that they do not in any way disturb significantly what the Government want to do. They provide legal certainty, about which I think we will hear more later in Committee. They also provide some very practical stiffening of the arrangements around these new Immigration Rules. I went to one of the Home Office briefings for parliamentarians on the new scheme, at which everybody, MPs, Peers and members of MPs’ offices, made the point to the Home Office that in the real world a lot of people expect someone to produce hard-copy evidence, whether it is the landlord, the GP or whoever. I can speak from personal experience, having helped a number of people get permanent leave to remain here, and not that long ago either. These people had had experiences of having to produce some written documentation that they were entitled to live here.

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[Lord Warner]

I am sorry to interrupt the Minister’s flow, but how many people who have already registered have sought hard copy or physical evidence of their registration and status?

[Baroness Williams of Trafford]

If you apply and are successful for either pre-settled status or settled status, you will receive a letter. That is not in itself proof of your status, because your status is a digital one, but you will receive a letter to confirm the success of your application.

[Lord Warner]

I am sorry, but that is not my point. How many people have applied for a document saying that they have settled status, which they can show to a GP or a landlord?

[Baroness Williams of Trafford]

I do not have the numbers for how many people have applied for a document that confirms settled status, but I can find out. The fact that 2.5 million people have been successful should partly satisfy noble Lords that the system is working well. Also, there have been only five rejections on the system so far. I will come to the point made by the noble Baroness, Lady Ludford, later, but that is quite a decent statistic when you think about the—

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[Baroness Williams of Trafford]

The point I am making is that if you have a physical document which outlines everything, people have access to everything. When people go into banks, they do not necessarily know which documents to bring. Under the digital status, employers and landlords are entitled to see only the data which they need to see.

[Lord Warner]

Before the Minister moves on, sticking with this issue, I am totally confused—more than usual. The Minister said earlier that, if I have been sent my letter from the Home Office describing my status, I can then apply for another document of some kind that I can produce to other people who want the other document. That seems to be an alternative to the code. Will the Minister explain what is the difference between the letter and the other document that I can apply for, which apparently I can use to satisfy someone that I am entitled to something?

[Baroness Ludford]

Before the Minister gets up, I do not think I heard her answer the question about whether the settled status database is going to be available outside the Home Office, within government and to third-parties outside government. Will she answer that very precise point?

[Baroness Williams of Trafford]

I shall start with the point made by the noble Lord, Lord Warner. The letter is confirmation that you have been successful. It is not evidence of your status, but it is there for anyone who wishes to have a physical document to say that they have been successful.

On the digital status—this comes to the point made by the noble Baroness, Lady Ludford—if you want to rent, it could be accessed by the landlord. There is access to the data for people who need to see it for the purposes for which they need to see it.

[Lord Warner]

The second document—

[Lord McNicol of West Kilbride]

There is only one document.

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[Lord Warner]

Regarding the document that I apply for after my first letter—the Minister is saying that there is a second document—why would I apply for something that I already have?

[Baroness Williams of Trafford]

My Lords, you automatically get a letter confirming that you have been successful. There are not two documents. You have online status and you get a letter confirming that you have been successful. There are not two documents.

[Lord Warner]

This is rather a critical issue. Is the Minister saying that the document I have can be used? It apparently cannot be used to satisfy landlords and GPs, so what is the person going to do if the landlord, the GP and everybody else is not satisfied with the Home Office document?

[Baroness Williams of Trafford]

My Lords, the document that the noble Lord refers to is a letter confirming that a person has been successful. Anyone who is successful in obtaining the status could show that letter to a landlord and say, “There. Go and look online to confirm that I have the status”. However, it is not a proof; it is a confirmation. Does that help the noble Lord? I see that it does. Thank goodness.

Gaza

Lord Warner Excerpts

Monday 27th January 2014 Lords Chamber

[Baroness Northover]

My noble friend is right. The UN has described Gaza as being currently in a state of de-development. It does indeed predict that by 2020 the place may be unliveable. The recent blockades and closures of the tunnels have seen the further loss of 20,000 jobs in a dire situation. We strongly support the peace process. Meanwhile we are of course asking Israel to ease the blockade immediately, but in supporting the peace process we hope to see a two-state solution. The aim is to achieve a secure Israel alongside a sovereign and viable Palestinian state, with all issues—borders, Jerusalem, refugees, all of them—addressed.

[Lord Warner (Lab)]

Is the Minister aware that the situation in Gaza has not become intolerable just in the last year or so? It has been intolerable ever since Operation Cast Lead. In the past six months, how many meetings have this Government had with the Israeli Government about lifting this blockade, which is a cause of great humanitarian suffering to the Gaza population, 50% of whom are children?

[Baroness Northover]

I shall write to the noble Lord with the number, but I know from all the Written Answers that I sign off the pressure that we have been seeking to put on the Israeli Government to lift this blockade, recognising that an improved economy in Gaza is essential for the people of Gaza, but also for the security of Israel.

Care Bill [HL]

Lord Warner Excerpts

Wednesday 12th June 2013 Lords Chamber

Moved by

[Lord Warner]

73: Clause 79, page 66, line 13, at end insert—
“( ) a Chief Inspector of Hospitals,“( ) a Chief Primary and Community Care Inspector,”

[Lord Warner]

My Lords, I have put down this amendment to explore briefly the Government’s thinking on the appointments set out in the amendment. As has already been said, I am sure we are all delighted that Professor Sir Mike Richards has been appointed Chief Inspector of Hospitals. I was doubtful about the practicality of this post but if anybody can make a success of it, I think Mike Richards can. Why did the Government not make this a statutory post? Is it because they see it as a time-limited appointment?

The second part of the amendment explores a slightly wider issue. I know that the post of Chief Inspector of Social Care has been advertised but does the Minister think that the post has been too narrowly drawn and represents a bit of a missed opportunity? I know from remarks he has made at events I have been at that the Health Secretary has considered whether there should be a chief inspector of primary care, which I am sure has strengthened his relationship with GPs. For my part, poking around in some of the murkier corners of primary care and trying to strengthen it would be no bad thing.

However, the wider system problem we face in the NHS is the weakness of the combined set of non-hospital services and their integration with social care. That weakness is now leading to moves in some places for acute hospitals to think of themselves as the base for community-based services. I suspect that is a development we will regret in the longer term, particularly if those services end up bearing a disproportionately high amount of the overhead costs of acute hospitals. Can the Minister say a little more about whether the Government are considering appointing a chief inspector of primary care and whether further consideration could be given to widening the brief of the Chief Inspector of Social Care to embrace community health services and possibly primary care? I beg to move.

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[Baroness Northover]

Perhaps I could carry on. I will come back to that in a minute.

Setting these roles as non-statutory clearly gives the CQC important flexibility to design them to fit their method of regulation in the fast-developing field of health and social care, without the constraints of prescribing the functions of the chief inspectors in statute. As these roles are not mentioned in the legislation, it would not be appropriate to require in legislation that they should have a seat on the board. Having said that, discussions with the CQC chair and chief executive showed them to share the view that chief inspectors will have much to offer the board. Their preference, subject to appropriate board approval, is that when practicable these executives should be appointed to the board. Given the intended importance of these roles, we fully agree with that. In advance of the new legislation coming into operation, I can confirm that the Secretary of State would consider using his current powers to appoint the three inspectors to the board if that was requested by the present CQC chair and chief executive.

The noble Lord, Lord Hunt, asked about Health Education England and the HRA. These will be established as unitary boards, which is to say that they consist of both executive and non-executive members. I can clarify that the chief inspectors are accountable to the chief executive and to the CQC’s board. They will speak for the CQC on their findings when they inspect providers. Having clarified these areas and reassured noble Lords about the significance of these roles and the need for flexibility, I hope the noble Lord will be content to withdraw his amendment.

[Lord Warner]

Clearly the noble Baroness has clarified matters, but whether she has reassured me is another question. I think the Government underestimate the profile of the Chief Inspector of Hospitals in particular. There is no doubt that this will be a very powerful and important post with an enormous profile. The idea that this person can be overruled by the chief executive and the board, as this legislation sets out, poses a problem I certainly want to think more about.

I also think that there is a gap here. Community health services are not clearly in anybody’s remit. I am sure my noble friend Lord Hunt would agree that if we were to identify one black hole where there is not a great deal of data on performance and quality, it would be community health services. It is an area that has not been probed well by independent inspection, and as far as I can see the game plan is to have no inspector looking into that area. Given everybody’s concern about integration, it seems a bit of a missed opportunity for there not to be some linking up there.

I want to consider this much further. It would be helpful if Ministers sent the Committee the job description for the three inspectors they propose. In my experience, it is rather difficult to appoint anyone to anything without a job description. It would be very helpful to our deliberations to have that before Report.

[Lord Hunt of Kings Heath]

It seems to me that unless this is sorted out there will be problems in the future, notwithstanding the calibre of the current leadership of the CQC, which I readily acknowledge. If the chief inspector does not have total operational independence when acting as chief inspector, I see a recipe for potential trouble. We will not reach Report until October, so there is plenty of time. My noble friend and I would be very interested to have at least some discussion about how the CQC will avoid the kind of conflicts that clearly we would rather not have, if at all possible.

[Baroness Northover]

I am very happy to take back to the department the request for further descriptions of the jobs in these cases. We should also bear in mind that the aims of these chief inspectors, as part of the CQC, are to maintain safety and effectiveness and drive up quality. They have shared aims; it is not as if they have different ambitions in this regard.

[Lord Warner]

That is extremely helpful, but my noble friend is absolutely right. Bearing in mind our earlier discussion about warning notices and enforcement, in reality what the chief hospital inspector says in many cases is what will determine whether the CQC goes ahead with a warning notice, which might trigger trust special administration. That is a really powerful position in the public arena. I would welcome, with my noble friend, a discussion with Ministers about this, but in the mean time I beg leave to withdraw the amendment.

Amendment 73 withdrawn.

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[Lord Warner]

My Lords, I shall speak to Amendment 77 standing in my name. I have taken a slight different approach from that of my noble friend, but I was out of the traps a little before him. I was trying to do something slightly different, but I am equally happy with his rather more elegant amendment on the duty of candour. Whether I have got the wording of the amendment right is another matter, but I was trying to link the organisational responsibility for a duty of candour to the registration process. Therefore, that right at the outset, as a condition of registration, the organisation had to sign up to the idea of a duty of candour.

When one is in the patient’s position, the duty of candour in relation to the employee becomes very important. The patient sees individual people, not necessarily something called an organisation. On the other hand, for the reasons that the noble Baroness, Lady Finlay, mentioned, one has to provide cover for individuals who operate in that organisation, both to protect them from unreasonable attacks by the victim of the mistakes, but also from attacks by the employer for blowing the whistle on them. In this amendment, I am striving for an obligation on the employer—the provider of the services—to have a duty of candour as part of their registration conditions. At the same time, the employee should be protected against unfair employment practices or unfair criticism. One is then forced along a path—which is not fully explained in my amendment—where the contract of employment between the individual and the employer gives some protection to the employee who blows the whistle.

That is quite complicated stuff and this is a complicated area, but we have to strive not just for organisational candour, but for some protected way for the employee to level with people when things have gone wrong. I think the secret lies somewhere in the contract of employment. We do not want that routed only through doctors. In a care home, for example, it will not be the doctors talking to the residents, their families or whoever. We need to do more work on this. Given that this was such a high-profile issue in the Francis report I, like my noble friend Lord Hunt, find it surprising that we are not trying to deal with it in the Bill, complicated though it is. We need to put some wet towels around our heads to try to find a way of capturing this in the Bill, so it is both fair to the employer and to the employee. That is what I am trying to do. Whether I have succeeded in my simpler version in Amendment 77 I am not sure, but that is the thinking behind it.

[Baroness Jolly]

My Lords, I welcome the debate on the duty of candour. It almost seems as though we are rewinding to 18 months ago, when we had similar debates during the passage of the Health and Social Care Bill. Although I would not have wished the events at Mid Staffordshire Hospital on anybody, I am really pleased that as a result the Francis report recommended a duty of candour. I therefore welcome the Government’s intention to implement that duty. However, as we have seen over the past 20 minutes, nothing is as straightforward as it first seems, so a lot of hot-towel work needs to be done to get this right.

I shall not detain the Committee long, but there are two sets of choices that the Government have made and I am curious why they made them. The first is whether the duty of candour is on the individual or on the organisation. The second, to which the noble Lord, Lord Warner, has just referred, is whether it is going to be in the Bill or in secondary legislation.

The duty of candour will cause a large change in people’s behaviour and it should be a game changer in lots of ways. As an aside, I think that complaints will fall. If somebody turns around and says, “I’m sorry”, people are less likely to complain. Certainly, those of us who have been involved in complaints will know that on many occasions patients just want someone to say that they are sorry and to explain why and how it went wrong, because they do not want it to go wrong in the same way for anybody else. So there might be an unintended consequence there.

When the Minister sums up, I would like to know why the decision was made not to put the duty in the Bill. Is that decision irrevocable?

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[Baroness Northover]

My Lords, I welcome this very interesting debate which has gone in various directions. We have a number of amendments to consider here.

Amendment 73A would transfer the responsibility for the National Reporting and Learning System from NHS England to the Care Quality Commission. We wish to take the opportunity to underline the importance of the data and information available through the NRLS to the work of the Care Quality Commission. Indeed, a key component of the CQC’s new three-year strategy sets out how it will make better use of intelligence to inform inspections. However, I remind noble Lords that it was only on 1 June that responsibility for the National Reporting and Learning System was transferred to NHS England. This transfer puts patient safety at the heart of the NHS—I heard what the noble Lord, Lord Hunt, said, but I think it is extremely important that it is at the heart of the NHS—and will build on the excellent work of the National Patient Safety Agency. NHS England plans to develop a responsive NRLS that will provide a one-stop shop for NHS clinicians, patients and the public.

Additionally, noble Lords may be aware of the Berwick review of safety—reference was made to it—which seeks to learn lessons from the Francis report. It will report in July on a whole system approach to ensure that there is zero tolerance of harm in the NHS. We will, of course, give full consideration to any recommendations that that review might make on the effectiveness of the NRLS. In view of these important developments and reviews, we believe that reallocating this work now would be unnecessarily disruptive.

Amendment 73B introduces a new clause which would require the CQC to have regard to guidance on staffing numbers and skills mix in carrying out all its functions. I fully understand the sentiment behind this. All noble Lords will agree that high-quality care is dependent on the people giving it. We heard from the noble Lord, Lord Campbell-Savours, about the problems that arise when that breaks down. Clearly, the right staffing in terms of numbers and skills is vital for good care. It therefore follows that staffing levels and skills mix are key considerations for the CQC in regulating quality of care. However, as the noble Lord, Lord Campbell-Savours, says, that is not necessarily sufficient. The CQC’s registration requirements place a clear legal duty on providers to have sufficient numbers of suitably qualified, skilled and experienced staff in place for the services provided. It is the responsibility of individual providers to be accountable for staffing levels and the skills mix of staff in their organisations. Where a provider does not meet the staffing registration requirement, the CQC is able to use its enforcement powers to protect patients and service users. However, I note what the noble Baroness, Lady Finlay, said about this being an issue which is not necessarily best placed in primary legislation. The point is to try to achieve quality, safety and efficacy.

The CQC will shortly review and consult on its registration requirements. We intend to amend the requirements so that they will include fundamental standards. These will set the basics below which standards of care must never fall. We can assure noble Lords that the new chief inspectors that we talked about previously, based within the CQC, will have the power to inspect and assess staffing numbers and the skills mix as part of examining the quality of care and will be able to take any necessary action as they consider appropriate. Noble Lords asked whether NICE might become involved in that. We believe that the current legislative arrangements already require the CQC to assess staffing levels. However, we will work with NICE, the CQC, NHS England and other partners to review the use of evidence-based guidance and tools to inform staffing decisions locally.

Amendments 76B and 77 each introduce a stand-alone duty of candour in primary legislation. We had an extremely interesting debate that demonstrated the complexity of the issue. As the noble Lord, Lord Warner, noted, it is a complicated area. The noble Baroness, Lady Finlay, illustrated that, as did my noble friend Lady Jolly and the noble Lord, Lord Campbell-Savours. He noted that there could be unintended consequences such as unwanted litigation. However, my noble friend Lady Jolly said that often all that patients and their families need is clarity and something being admitted to. All these issues show how complicated the area is. The noble Baroness, Lady Finlay, spelt that out.

The Government share the view that providers of health and care must be open in their dealings with patients and service users. Our response to Robert Francis’s report makes a clear commitment to introduce a statutory duty of candour. I therefore wish to reassure noble Lords that we are doing that. In particular, I should like to reassure the noble Baroness, Lady Masham, on that point. That is what we are doing. The route that we are taking is perhaps endorsed by the nature of this debate. We see this as something that is better taken through by secondary legislation. Let me spell that out. The Government intend to introduce an explicit duty of candour on providers as a CQC registration requirement. This will require providers to ensure that staff and clinicians are open with patients and service users where there are failings in care. I hear the warnings voiced by the noble Baroness, Lady Finlay. In the end, the aim has to be to improve the quality, safety and efficacy of care. I note what she said about confidentiality.

As with all requirements for registration with the CQC, the Government intend that the duty of candour should be set in secondary not primary legislation. There are very strong reasons for that. Using secondary legislation will enable us to expedite the introduction of this duty and provide a degree of flexibility to get the design of the duty right. I am sure that the department and my noble friend Lord Howe will welcome noble Lords’ engagement, bringing their own wet towels if they wish to, as we take this forward. Secondary legislation will still allow for full parliamentary scrutiny, given that the changes to the regulations that set CQC registration requirements will be subject to the affirmative procedure in both Houses. The duty itself will have the same legal power in secondary legislation as it would in primary legislation. There is also the additional advantage that in such a new and important area we can refine this new duty over time, if noble Lords’ warnings prove to be significant. That is why I commend the Government’s preferred approach of setting the new statutory duty of candour through secondary legislation.

Amendment 77A has the effect of removing the power to specify the type of information and the type of care provider within scope of the new false or misleading information offence. This is a different but obviously related area. This would mean that we have a criminal sanction that applies to all information required by legal obligation, including under contract, which would be disproportionate. It is important that the offence does not inhibit providers from sharing information voluntarily, but we also need to keep the flexibility to respond to new information or different priorities for information over time.

We appreciate that noble Lords will be interested in understanding more about the types of providers to which this offence will apply. The Government are still considering the scope of the offence and I am absolutely certain that my noble friend Lord Howe will be happy to discuss this further with noble Lords.

We start from the issues raised in the Francis inquiry. We are therefore clear that the offence will apply to providers of NHS secondary care. This includes NHS trusts, foundation trusts and independent sector providers of NHS secondary care. We are giving further thought to whether the offence should also apply to other types of providers. We will consider whether, for example, there is a case for extending the offence to providers of adult social care, general practice and mental health services. We will consider this, working together with our stakeholders, and we will of course keep noble Lords informed as to our thinking as this moves forward.

[Lord Warner]

I am sorry to interrupt the noble Baroness’s flow, but could I just get her to expand a little bit on the approach on the issue I raised about protecting the employer? I was pleased to hear what she was saying about using the registration process to impose the duty of candour on the employer, but there remains the concern, which I think a number of us have, about how the employee who blows the whistle actually gets protected under the arrangements that she is talking about.

[Baroness Northover]

My noble friend says that they have protection under the NHS constitution. I hope that that clarifies it for the noble Lord but, given the time, I am happy, if necessary, to write to cover that further.

There were a number of questions, but I am well aware that time is pressing and that we are almost at the end of this part, so I will just come to one or two of them. In terms of the individual statutory liabilities in Patients First and Foremost, the Government stated that:

“before we introduce criminal sanctions at an individual level…we would want to ensure that this does not unintentionally create a culture of fear”.

The noble Baroness, Lady Finlay, spoke about that. We are, of course, waiting at the moment for the Berwick review, and no doubt we will be addressing this further in the light of it.

The noble Lord, Lord Hunt, asked about various points in relation to Francis. Francis himself made clear that many of his changes can be taken forward within the existing legislative framework and, as the noble Lord, Lord Campbell-Savours, indicated, they are, at heart, about changing behaviours in organisational cultures. The responsibility is therefore with each and every person serving patients to take action to make the changes needed.

However, we have these reviews coming forward, and we will obviously review what else we need to do. This has been an ongoing, long-standing problem, as noble Lords will be aware. I have listened to many debates in your Lordships’ House where these issues have been addressed, and people are endlessly frustrated in terms of trying to make sure that the quality and safety that you see in certain parts of the NHS is replicated in all parts of the NHS.

I am scurrying on through. If there are issues which I have not addressed, I am sure that—

Syria: Refugees

Lord Warner Excerpts

Tuesday 23rd April 2013 Grand Committee

[Lord Warner]

My Lords, I, too, congratulate my noble friend Lady Blackstone on securing this debate and I support everything that she said. I declare my interest as an adviser to the Council for European and Palestinian Relations, under whose auspices our parliamentary delegation recently went to Lebanon. The Syrian conflict is a huge humanitarian disaster with well over 4 million people, and growing, still within Syria’s borders needing humanitarian assistance, in addition to the at least 1.5 million people who have fled to neighbouring countries. The scale of the population displacement caused by this conflict must start to call into question the sustainability of some of the smaller neighbouring states involved, unless there is significant international help over a long period of time.

I want to focus briefly on Lebanon, which has received over 450,000 Syrian refugees across its lengthy border with Syria. That is more than 10% of its population. Let us imagine how we would feel if 6 million people suddenly appeared in the UK, considering the fuss that we have made about a relatively small number of eastern Europeans coming into this country. Around 10% of the people coming across the Lebanon border at the rate of about 7,000 people a day are Palestinian refugees. They are fleeing from their camps in Syria, which have been bombed by Bashar al-Assad’s military. It is very difficult to explain to them why a no-fly zone was appropriate in Libya but is not appropriate in Syria.

The plight of these refugees, especially that of children, is heartbreaking. Most of them are fleeing across the border with little more than the clothes that they are standing up in. Lebanon, which has considerable political and economic problems of its own, as has already been mentioned, is paying a huge political and economic price for keeping its borders open—and, one must say, pretty much welcoming these people into their country in many ways. It is asking its own population for the most part to host these people. They call them guests, not refugees, and there are relatively few refugee camps into which these people are moving and living.

What we saw in Beirut when we visited the city were families of 20 to 30 people living in two or three rooms in bombed buildings that are open to the elements, with little access to water or toilet facilities. They sleep in shifts because there is not enough space for them to sleep at night. They are struggling with exorbitant rents, sometimes $500 a month, which is an enormous sum for these people. It is charged by what I can only describe as racketeering landlords, and there is a lack of food, clean water and medicines. Some have untreated wounds and illnesses. Many are groups of vulnerable women and children with few, if any, accompanying working-age men. Where there are men, they are forbidden by local labour laws from working. Even in the well run volunteer organisation camp that we visited, where the accommodation and facilities are less primitive, dangerous electricity systems and inadequate sanitation present their own hazards on top. The meetings that we had with UNRWA on our visit were less than encouraging. Many of the countries that pledged money at the January Kuwait summit have simply not followed through with the cash.

I do not have time to go further, so I should like to close by posing a couple of questions for the Minister. Are the Government satisfied that all the pledges made at the Kuwait summit are being delivered in terms of hard cash for UN relief agencies to use for Syrian refugees? If not, what action will they take with their international colleagues—with a particular focus, I have to say, on the Gulf states, which do not seem to have delivered on the promises that they made? Do the Government accept that the population displacement caused by the Syrian conflict is likely to prove permanent in many individual cases? What discussions do they contemplate having with international partners on this issue, particularly with regard to Palestinian refugees, many of whom have been subject to multiple displacements? We need to engage with these serious issues in a more strategic manner than we have been doing so far.

West Bank

Lord Warner Excerpts

Tuesday 3rd July 2012 Lords Chamber

[Lord Warner]

My Lords, I congratulate the noble Baroness, Lady Brinton, on securing this debate. I will use my six minutes to speak about the related and linked issue of access to water in Gaza, where there is a very similar situation and lack of water is being used as an oppressive measure. In doing so, I declare my interest as a trustee of the Council for European Palestinian Relations.

I have been to Gaza twice in the past two years and seen at first hand the parlous state of the water and sewerage systems, and the impact on people’s health and on an already totally inadequate healthcare system. More than 90% of water from Gaza’s taps is unfit to drink, according to the World Health Organisation. This is in a population half of whom are children and young people aged under 18.

However, I will not speak from my own experience but will use the recent report by Save the Children and Medical Aid for Palestinians, the launch of which I had the privilege to chair last week. This report reveals some devastating things about water and its pollution in Gaza today. It found that Gaza is not a safe environment for children or adults because its water supply and land are contaminated with pollutants. A September 2010 assessment found that, “1.1 million Gazans”, out of a population of 1.6 million,

“are at high risk of consuming biologically contaminated drinking water from private vendors, the source of water for most Gaza residents”.

Concentrations of chloride and nitrates are as much as 10 times the safe levels established by the World Health Organisation. According to the WHO, ingestion of nitrates in drinking water has been linked to anaemia and some cancers. Some 70% of Gaza’s children are anaemic. The new report states:

“The most recent studies from 1998 and 2002 of infants and children indicated 48% prevalence of nitrate poisoning. Many more children are thought to be at risk today”.

A UNICEF report of March 2011 suggested that in five to 10 years’ time, Gaza’s already depleted aquifer, the sole water source, will stop producing water suitable for human consumption. Seawater has already penetrated the aquifer and the pollution has been compounded by Gaza’s inability to dispose properly of its sewage. Much of the sewerage network has been destroyed or is in a state of acute disrepair. According to the new report, 60 million to 90 million litres of untreated or partially treated sewage have been dumped in the sea every day since 2008. This has an impact not just on Gaza but on neighbouring areas. The report also points out that air strikes in 2011 destroyed $1.3 million- worth of water and sanitation structure, including a new sewage pumping station connecting 130,000 residents of Gaza.

Despite this appalling situation, the new report points out that.

“Sixteen internationally-led projects to address Gaza’s water and sanitation needs, valued at $75 million, continue to await facilitation following the easing of the blockade in June 2010. Only one-fifth of the materials required for these projects have been allowed to enter Gaza, with the remainder sitting in warehouses. No progress has been made on large-scale desalination projects addressing the lack of drinkable water”.

In conclusion, I will mention one of the five key recommendations of the Save the Children and MAP report. It states:

“Given the direct relationship between a supply of clean water and deteriorating water and sanitation systems, on one hand, and child mortality on the other, all planned water and sanitation projects should be implemented immediately, and a clear timetable provided by the Israeli authorities for their completion”.

What action will the Government take, in conjunction with EU partners, to press the Israeli Government vigorously to implement this very sensible recommendation?

Gaza

Lord Warner Excerpts

Wednesday 8th February 2012 Lords Chamber

Asked By

[Lord Warner]

To ask Her Majesty’s Government what contact they have had with the Government of Israel regarding the effect of Israel’s blockade of Gaza on children’s health.

[Baroness Northover]

My Lords, the UK Government are very concerned about the impact of movement and access restrictions on the health of children in Gaza. We regularly press the Israeli authorities on the need to ease restrictions and to address the humanitarian situation. My right honourable friend the Secretary of State for International Development raised these issues during his recent visit.

[Lord Warner]

My Lords, I am grateful to the Minister for her reply. Is she aware that only 5 per cent of the water coming out of Gazan children’s taps is drinkable and the rest is not? Gastroenteritis is endemic among children in Gaza, about 70 per cent of whom are anaemic. Is she also aware that doctors working in the main hospital claim that about 500 people have died as a result of the shortage of basic medication, many of whom are children? Can we not approach the Israeli Government with a greater sense of urgency to secure a change in the situation of these children who are being collectively punished?

Health and Social Care Bill

Lord Warner Excerpts

Monday 19th December 2011 Lords Chamber

[Baroness Pitkeathley]

My Lords, I am very sorry to take issue with the opinions of noble Lords with whom I usually agree most heartily. I remind the Committee of my role as chair of the Council for Healthcare Regulatory Excellence. I should make it clear that I am in no way taking issue with noble Lords' concerns about the practice of healthcare assistants, nor with the emphasis—given particularly by the noble Baroness—on the need for proper training. The only thing I take issue with is whether statutory regulation is the correct solution to the problem.

I am not aware of any body of evidence that demonstrates that the risks of future harm presented by the practice of healthcare assistants could not be successfully managed by the existing processes and governance systems if they were applied effectively. That is the point. Healthcare assistants are already supervised by other staff who have the professional responsibility to supervise them. As we have heard, they almost always work in supervised settings, with supervision usually being the responsibility of staff who are statutorily regulated. Statutorily regulated professionals have a responsibility to ensure that the staff whom they manage offer safe care, conduct themselves professionally and are delegated only tasks that are within their technical competence. For example, the Nursing and Midwifery Council’s code states:

“You must establish that anyone you delegate to is able to carry out your instructions … You must confirm that the outcome of any delegated task meets the required standards … You must make sure that everyone you are responsible for is supervised and supported”.

In other words, we already have in place a governance system to ensure that healthcare assistants work safely and with proper delegation, supervision and support from a statutorily regulated professional. Employers are required to ensure safe systems of work, which will include providing support in delegating and supervising effectively.

Creating a list of people is not in itself an effective safeguard. Effective regulatory conditions are often much closer to home. For example, in an environment that is poorly managed and distant from scrutiny, poor standards of care can become the norm, with staff being drawn into collusion with poor care. We have seen many examples of this recently, particularly of the process of collusion, with people working in a poorly managed environment unable to resist the downward spiral of standards. The most effective way to invert the spiral is by employers properly managing the specific environment, not by establishing another structure.

Winterbourne View was referred to several times in this short debate. Perhaps it is worth reminding noble Lords that registered professionals were involved in delivering poor care there. Statutory regulation did not prevent it. We should always bear that in mind. Regulation is not necessarily the answer. Further, we cannot ignore the fact that statutory regulation would be expensive and cumbersome for a large, low-paid workforce with a high annual turnover. It is not proportionate to the risk, which can be managed by effective training, delegation and supervision.

The recent announcement by the Secretary of State about improving standards of training and the potential to develop a voluntary register of healthcare assistants is encouraging. I also welcome the Nursing and Midwifery Council's announcement that it will fully engage with the project that the Secretary of State announced, and with any further developments around assured voluntary registration for this particularly valuable group in the healthcare workforce. It is important that we make sure that we value this group, who are of such importance in the front line of the nursing and patient care environment.

[Lord Warner]

My Lords, I am speaking because my name is also on this amendment. We need to reflect on several aspects relating to the context of this issue. I do not think that there is much doubt that we have a problem of some significance, or any doubt that the problem has been growing over a long time. I also do not think that it is an easy fix simply to jump to statutory regulation. I went through the process when the whole issue of regulating social workers arose, and that proved extremely difficult to introduce. I do not doubt that we will end up with statutory regulation of some kind, but we might have to go through some processes before we get to that point.

I do not want to duplicate the history that other noble Lords have put forward most expertly. I came into this story as a very young civil servant at the end of the 1960s when the Salmon committee was set up. Some noble Lords may be old enough to remember the Salmon committee—I was assistant secretary to the committee. This was in the days when civil servants could not hold a job for long and were moved on at a tremendous rate. While doing this work we saw how things worked at the ward level. In those good old days of the 1960s and early 1970s there was a ward sister, state-registered staff nurses, nursing auxiliaries and state-enrolled nurses. We also had a set of arrangements in which oversight of cleaning was largely the duty of the ward sister. Furthermore, bank working was not that common.

What has happened since those “good old days” is that hospitals have become used more intensively. Bank working has meant that there is a higher flow of different people moving through the wards, and the profession, with good reason, has wanted to make itself a graduate profession. The context has changed a lot, so the dynamics of those wards has changed quite a lot.

Alongside that we have been growing another industry in the community: in nursing homes, residential care homes and—not quite as fast as one would like, within the health service—a district nursing service. One of the problems in both these areas, whether acute hospitals or the community, is that with the demand of patients for services, and the demography which has gone alongside that shift in time, the qualified and registered nursing profession has inevitably had to look for help from sub-professional groups to help carry the load. In the community there is not a strong management structure to oversee this, so to some extent it is difficult for district nurses to oversee any work done by unqualified personnel. Such oversight might be the theory but in practice it will often be difficult to achieve.

Community services are burgeoning, the hospital service has changed, and we have a problem of a growing need for more people who are not qualified and registered nurses to work alongside such nurses to provide some of the care. We are looking to the Government to produce a comprehensive review that examines the situation that we face now rather than the situation we faced 10 or 15 years ago and which was very different.

I suspect that we will have to move by interim steps towards statutory registration, and perhaps voluntary registration is an interim step. However, I am not convinced that we have a comprehensive set of answers to a continuing and serious problem. The Government need to think about how they will deal with this very serious problem.

[Lord Alderdice]

My Lords, I also have some scepticism about assured voluntary registration, but I will come back to that when we debate the subsequent amendment. I have some sympathy with the noble Baroness’s amendment. I had not intended to speak on this amendment until I heard a number of noble Lords speak, and I take a slightly different lesson from the history of the past number of years in the development of the nursing profession.

Like the noble Lord, Lord Warner, I remember sisters, state registered nurses, state enrolled nurses, nursing auxiliaries and so on, but one of the key things was that all those professionals described themselves as nurses. Indeed, I very well remember as a young doctor that nurses would not say, “I looked after that person”, or “I was on the ward when that patient came in before”, but said, “I nursed that patient”. There was a quality of compassion and relationship that was critical to the profession. I think that not only nursing as a profession, but many other professions went down the wrong road when they took the view that the future was in tighter registration and a graduate profession because that was not fundamentally the need. I heard my right honourable friend in another place being asked questions in the past few days about poor care of patients with dementia, and he made a very important point. He said that you can find two wards beside each other in a hospital with nurses with exactly the same level of training and qualifications but in one of those wards the patients are cared for with compassion and in the other ward they are not. When we move to healthcare support workers, it seems to me that whatever we move to, we do not move to a title that expresses compassion and care for the patients who are being nursed.

My gratitude to the noble Baroness is not for the specific terms of her amendment, and I do not think that they were the burden of her bringing the amendment forward. It is that we engage in a serious, proper debate about this issue, not just for nurses, but for other professions. There are some for whom I believe that statutory registration is the proper way ahead, but there are others for whom it does not seem to be the case that always moving to graduate professions with training and registration is the sole and most important way of dealing with these questions. It is quite clear that making nurses graduates and having registered nurses only has simply opened a door that has had to be filled with other, less qualified and, it has to be said, less expensive employees. Now we have a problem with them not measuring up to the professional standards of compassion that all of those—or at least, almost all of those—who aspired to be nurses at whatever level in the past aspired to in the best sense.

I welcome the fact that the noble Baroness has tabled this amendment; I am not quite sure it is the precise solution, but I hope we find ways to come back to the serious ongoing debate that the noble Lord, Lord Warner, has pointed to because there is a crisis in this area. I remember saying this two, three, four years ago in your Lordships' House and noble Lords who are now on the Benches on the other side thought it was simply a party-political attack. It was not—it was a genuine sense of concern that things were deteriorating. They have continued to do so, and it will not be dealt with solely by registration, training and academic qualifications because a quality of care and compassion and a culture of compassion are necessary. That is not to take away from the question of assured voluntary registration, which I wish to explore in a further amendment.

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[Baroness Northover]

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

[Lord Warner]

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

[Baroness Northover]

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

[Lord Warner]

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

Health and Social Care Bill

Lord Warner Excerpts

Monday 5th December 2011 Lords Chamber

[Baroness Jolly]

My Lords, I rise to underpin much of what has already been said, so I will say it very briefly. The appointment of a DPH to a local authority will be critical. Not only will he or she play a key role in something like an outbreak of E. coli, when that sort of expertise is looked up to and expected from the community. They will be absolutely pivotal in delivering and making health plans, both through the health and well-being board and working with the CCGs. There is no way that DPHs could be a shrinking violet; as my noble friend Lady Cumberlege has just said, they really have to be able to mix it and get in there, but what they do has to be totally evidence-based. So it is a really interesting balance for someone who has their hands on all the facts but is not necessarily an introverted individual. One key thing that they really have to have is the support of the chief executive of the local authority. Furthermore, they have to report to them and have exactly the same status as, say, the director of adult social services so that they have that level of authority when going out and talking to various people in the health and social care community. That will be absolutely critical if the localism and local decision-making built into this Bill is going to work.

I have attached my name to Amendments 228 and 229. The person described in the amendments really should be seen as a person of standing, so they should have director status and be responsible to the chief executive of the authority. I was a bit alarmed when talking to my own MP this weekend. He was saying that he had learnt from his conversations with the chief executive of the local authority that the authority was not at all minded to do this with the appointment. That would completely undermine any sort of position that the director might have. They have the key role and need to be a person of standing. Without them having such a position within the council, many of the plans will be totally undermined.

[Lord Warner]

My Lords, I support the thrust of most of the amendments in this group and have added my name to Amendments 226, 259 and 339. As others have said, it is essential to have in the Bill a clear commitment from the Government, and indeed from Parliament, that three things are very clear when it comes to directors of public health. First, we have to make sure that they should be registered public health specialists, with appropriate qualifications and expertise. That seems to me a given if these people are to have standing in the local communities and, perhaps, even in a wider area. Secondly, the director should be accountable to the local authority’s head of paid service and be able to report directly to the local authority itself, particularly when there is an area of great concern in that local community. One does not want people intervening between the director and local authorities’ main committees when a serious incident is taking place locally.

Thirdly, for the reasons that everybody else has mentioned, we have to ensure that a director of public health cannot simply be fired on a whim because they are doing something which is uncomfortable or unpopular, or has brassed off a local interest of one kind or another. That is particularly critical when we see the difference of approach that the noble Baroness, Lady Cumberlege, put very well: between the evidence-based approach of a director of public health and the commitments that local authority members, quite reasonably, have to seek re-election from time to time. That is how the system works, but a different approach is likely to run through some local areas when something is uncomfortable for the local authority but is backed up by the evidence that the director of public health can put in the public arena.

Directors of public health need to be seen to be capable of doing the job and to be able to deliver bad news—as well they may have to. They should be able to expect to be supported and protected locally when they have to deliver uncomfortable news. Amendment 226 is part of that package of armour that we need to wrap around directors of public health. There may be better ways to do that in these amendments than in Amendment 226, but its purpose certainly ought to be in the Bill.

Amendment 259 is an important part of the protective armour that I have mentioned for directors of public health, in that it aims to ensure that they simply do not lose ground financially over time in their pay and conditions of service with NHS medical equivalents. I am not a supporter of creating situations where there are bidding wars between local authorities and the NHS. We have seen that with occupational therapists over the years, where one side decides that it can secure some advantage by upping the ante a bit for a specialist group when there is a degree of local competition for a sometimes scarce resource, so I am not in favour of doing that.



However, my experience—and I have worked six years in local government—is that where there are these bidding wars, usually the NHS specialist is further up the greasy pole in terms of pay and conditions of service, and the specialist at the local level is trying to catch up with what has happened. That is why Amendment 259 is important, in that it ensures that there is a catching-up process. Much more importantly, it tries to ensure that it is not necessary to have a catching-up process, because there is an agreed alignment between the pay of those specialists who are employed by the NHS and those who are employed by local authorities.

In speaking to Amendment 339, to which I have put my name, I should declare an interest, in that my daughter is a non-medical public health specialist, although I hasten to add that I have in no way discussed this with her, so she should not be held responsible for the views I am about to express. It is vital that public health specialists are brought within the purview of the Health Professions Council and that there is a separate register for non-medical public health specialists which comes under the purview of that council.

Increasingly, the behavioural aspects of successful public health policies and their implementation are absolutely critical. This is not an area where we should be relying only on personnel with medical or dental qualifications. If we are to have successful public health policies, it is vital that we have people with the kind of background where they can communicate, understand, and do research on the emerging areas of the behavioural sciences. I hope, therefore, that we can have a register which has public standing and is supervised by the Health Professions Council.

Before I sit down I would like to start this session with a mild chastisement of the Minister. I said at Second Reading that I had a benchmark for the Minister’s flexibility in accepting amendments to this Bill. However, he has been uncharacteristically inflexible in responding to many of the noble Lords’ concerns in their amendments. Of course, he has always been very polite; but we have not seen much evidence of the Government being willing to take away some of these issues and come back with amendments at a later stage. I would say to him that this set of amendments gives him a good chance to turn over a new leaf. They do not affect the Government’s policies in this Bill. However, they strengthen the ability of the Government to deliver those policies in the way that they have strengthened the arrangements around the appointment, the pay and the safeguarding of the independence of the directors of public health. I do hope, therefore, that we will see a different type of Earl Howe appearing in relation to these particular amendments.

[Lord Marks of Henley-on-Thames]

I, too, support this suite of amendments. I shall speak only briefly, not in favour of a reinvigorated Earl Howe but in support of Amendments 234 and 234A, which are to the same effect and concern the termination of the appointment of directors of public health.

The Bill provides for joint appointment of the directors of public health, by the local authority and the Secretary of State, and it is right that it does so. I entirely agree with the noble Lord, Lord Patel, that it is therefore essential that the Secretary of State should also have a crucial vetoing part to play in the termination of such an appointment. It is not only that it is logical and sensible that he should do so. It is also that it is more important upon termination that the Secretary of State has that power of intervention. It is important because the director of public health has to have a sense of independence and security. As my noble friend Lady Cumberlege and the noble Lord, Lord Warner, have pointed out, there is considerable potential for disagreement between the local authority and the director of public health. It is therefore crucial that, in the event of friction, the director of public health can act with confidence to disagree.

This is exactly the kind of decision in which it is the Secretary of State, having ultimate responsibility for the health service, who should have that role. The Secretary of State’s role is therefore the best guarantee of the independence and the freedom of action that directors of public health ought to have.

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[Baroness Northover]

I am absolutely delighted.

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

[Lord Warner]

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

[Baroness Northover]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[Lord Warner]

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

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I know that the Minister has undertaken to look in detail at all aspects of education and training, but I want to have on the record the postgraduate deans’ need to be independent. That is supported both by the deans themselves and the General Medical Council, because in considering the future, it is very important that we do not lose the educational expertise from the current set of deans.

[Lord Warner]

I suggest that this group of amendments has been provoked by the extremely unconvincing nature of the Government’s organisational structure for delivering the reforms they consider necessary to the NHS; they would in themselves, I suspect, attract a wide range of support. I want to address my remarks to Clauses 30 and 31 on the abolition of SHAs and PCTs. I think the concerns many of us have were well put by my noble friend Lord Hunt.

I want to divert a little from my remarks to congratulate the noble Lord, Lord Mawhinney, on his detective work. If he wants to continue in that vein, I suspect that he could find some examples in other parts of the country that go wider than that in Peterborough. He might want to entertain us with more of those examples at a later stage in the Bill because I suspect there are plenty of them. In a spirit of helpfulness, I say to him and to the Minister that among the department’s papers of around 2005 are quite a lot showing how you go about consulting local people about the removal of PCTs and how you use a proper legislative basis for abolishing them and replacing them with new, properly authorised and properly appointed PCTs. I would be very happy to give my approval to the opening up of those papers so that the Minister can help the noble Lord, Lord Mawhinney, see how you can go about this. It is often controversial, but there is a process for doing it, which is well documented, and you do not have to go along the path of clusters. It is perfectly possible to engage with people—sometimes they do not like it—and go through a proper process for replacing a number of them. It can be done, and it can be done in a proper way, but it takes a bit longer. I would be very happy for those papers to be made available to the noble Lord, Lord Mawhinney, and the Minister so that if they are struggling a bit in seeing how it can be done, they can draw on that example.

Some of us on these Benches have acknowledged that the 2002 NHS reorganisation rather overdosed on the number of SHAs and PCTs and, as I have just said, we tried to put that right in 2005 and 2006 with a reduction to 10 SHAs and 152 PCTs. Some of us would have liked to have gone a bit further and reduced PCTs further, but that’s life. You do not always get what you would want. In practice, that further reduction could have led, as I think the noble Baroness, Lady Finlay, said, to a much more straightforward way of making the changes that needed to be made and could have included a very large increase in the number of clinicians involved in the process of commissioning. I do not think anybody in this Chamber is opposed to the Government’s idea of increasing substantially the amount of clinical and, in particular, GP involvement in the commissioning of services. However, it could have been done without this process, and it could have built on the lessons of GP fundholding, on which I have always been a supporter of the Government’s approach. I thought it was a bold experiment, and I do not say that with any sarcasm at all. It was a bold experiment that was well worth trying and which we built on further with practice-based commissioning, so I do not think there is a lot of political dispute about more clinical involvement in commissioning.

The Government could have done that without clusters by simply reshaping PCTs, changing their membership, probably reducing their number and possibly increasing—dare I say this to some of my colleagues on these Benches?—the involvement of private sector skills in the commissioning function with the data analysis and information gathering. They could even have done it with a little more democracy in the membership of PCTs on which, as I recall, the Liberal Democrats were rather keen at one point. The coalition partners could have been brought onboard with a bit more democracy in PCTs as well. That might have been a good mix to go forward.

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I would say again to the noble Lord, Lord Hunt, that the local workings of the board will be accountable through their work sitting on the health and well-being board, as well as needing to have regard to the joint health and well-being strategy. However, I think that what he said begs a question. The noble Lord paints a somewhat halcyon picture of PCTs and SHAs being accountable to their populations. As I tried to indicate on Second Reading, I do not share that analysis. No one disputes the valuable role that PCTs have undertaken. They have some good people and some important skills. However, under the current system PCTs attempt to combine two roles: they must make clinical decisions about commissioning NHS services; and they must understand the needs of their population, involving and accounting to local people.

[Lord Warner]

I am sorry to interrupt, but I am really bemused by what the noble Earl has just said about the accountability of the local entity of the national Commissioning Board to health and well-being boards. Health and well-being boards have no budgetary responsibility whatever, as I understand what the Government are saying; whereas the national Commissioning Board has two lots of budgetary responsibility—for its own specialist commissioning and for its oversight of the money that it hands out to clinical commissioning groups. Perhaps the Minister can explain it to me. I can understand that it might want to consult the health and well-being boards but, in terms of accountability, I cannot understand how it can be accountable for its budgetary priorities and decisions to the health and well-being boards.

[Earl Howe]

It is accountable for its decisions at a regional or sub-national level in a real sense. If it was not interacting with the boards, the noble Lord, Lord Hunt, might have a point; but it will be. I think that that is accountability in a meaningful sense. The noble Lord, Lord Warner, talks about budgetary accountability, and I understand that that is a real issue. Of course there will be no budgetary accountability, but there will be accountability for the decisions and actions taken by the field forces.

I was saying that the structure means that all too often neither of the roles that PCTs perform is performed well. GPs, who actually make the clinical decisions, are not properly involved in PCT commissioning; and PCTs do not have the detailed understanding of their communities or the link to other local public services. The result is an unsatisfactory compromise, with commissioning that fails to deliver improvements in health outcomes and local services that are fragmented and not integrated.

It has been suggested by some noble Lords that one could have kept PCTs and parachuted in a whole lot of doctors, perhaps filtering out some of the administrators. Anyone who has visited any pathfinder CCG and put that question to the doctors and other clinicians involved will know the answers to why that would not have been a valid and sensible idea. The way in which services are commissioned has to depend on the judgment of clinicians and the wisdom of establishing geographic areas for commissioning groups that make sense in terms of patient flows and in terms of links with local authorities, social services and public health. It does not make sense to retain structures that, frankly, are administrative constructs that do not necessarily bear any relation to patient flows or relationships with local authorities. These clinical commissioning groups are being created from the bottom up by those who know what is in the best interests of patients, and it is to patients that we must always return in our thinking. We currently spend £3.6 billion a year on the commissioning costs of PCTs. PCT and SHA management costs have increased by £1 billion since 2002-03. That is a rise of over 120 per cent. We cannot make savings on the scale that we need to while retaining the administrative superstructure of the NHS.

The noble Lord, Lord Hunt, suggested that the pathfinder CCGs were being built on nothing at all. They are not being created from nowhere. They are building on, and are indeed a logical development of, practice-based commissioning groups, of which there were a very significant number. There are currently 266 pathfinder clinical commissioning groups covering 95 per cent of GP practices in England. As I have indicated before, I cannot say how many we will eventually end up with, but that will give noble Lords a rough indication of the order of magnitude.

The noble Lord, Lord Rea, quoted some words of mine from a debate of several years ago. I would simply say to him that I was speaking then of something completely different from the Government’s current proposals, and I am grateful to the noble Baroness, Lady Murphy, for pointing that out. These reforms place leadership of commissioning firmly with clinicians. I completely agree that giving leadership to a non-statutory, private-sector firm would be a bad idea. That is why there are very clear safeguards against this happening. With PCTs, I feel that there was a genuine question over where commissioning leadership really lay, and this is very firmly no longer the case.

On Amendment 236A, I must clarify one point. It is not the case that a clause stand part debate on Clause 30 would be consequential if a Division was to be called on Amendment 236A and won. It would simply amend this clause and not entail that it needs to be removed.

I hope that I have sufficiently covered the issues raised by noble Lords. I do not suppose that I have satisfied everyone, but I hope that I have at least indicated the direction of government policy in a coherent way.

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[Lord Warner]

Could the Minister give us an assurance that before Report he will give us some idea of the extent to which the current arrangements are going to meet the targets set by the Government for delivering the Nicholson challenge for this coming year, so that we can see the extent to which the Government are at risk if they abolish the SHAs from April 2013?

[Earl Howe]

My Lords, the SHAs have already published their plans for delivering the Nicholson challenge and those are on the SHA website. There is no secret about that. I can tell the noble Lord that we are on target to deliver the Nicholson challenge over the four-year period as a result of savings already made.

Health and Social Care Bill

Lord Warner Excerpts

Monday 5th December 2011 Lords Chamber

[Earl Howe]

I would be happy to write to the noble Baroness in the interests of time, but I was about to explain that as regards primary medical services the direction-making powers that I mentioned will also enable the board to arrange for clinical commissioning groups to carry out some contract monitoring functions and limited commissioning functions on its behalf should it so wish. So the board can enlist the help of the clinical commissioning groups themselves to do some of the monitoring function. That will not alter the board’s overarching responsibility for commissioning general practitioner services and holding their contracts. But I will write to the noble Baroness, as she asks.

[Lord Warner]

Can the Minister explain something to us, if necessary in writing in order not to detain the House? I am very confused about what happens in areas where historically there have been great problems with health inequalities in securing a volume of primary medical services to meet the needs of those communities. I am very unclear who we are expecting to ensure that there is a sufficient volume of primary medical services and what the relative roles of the Commissioning Board, the CCGs and the health and well-being boards are in that context. It is a longstanding problem for the NHS. I do not expect the Minister to answer now, but it would be helpful to have some thoughts in a letter on that issue.

[Earl Howe]

I undertake to write to noble Lords about that, and I agree that it is an important matter.

Health and Social Care Bill

Lord Warner Excerpts

Wednesday 16th November 2011 Lords Chamber

[Lord Warner]

My Lords, before the noble Earl responds, may I offer him a little piece of advice, as a former Health Minister who had to take controversial legislation through this House? I would say to him that if I had been confronted with this situation, I would have gone to my boss, the Secretary of State for Health, and asked him to facilitate the passage of this legislation through the House by making this information available to the House.

[Baroness Williams of Crosby]

My Lords, I, too, wish to ask the Minister one additional question. Can he give any idea of how quickly the proceedings that he mentioned in his recent letter to Members of the Committee will take? He showed in that letter that there needed to be discussions with other ministries and that there needed to be consideration of whether an appeal should be brought. I know that he appreciates, as much as the rest of the House does, that our debates in many areas would be very much affected by knowing what is in the risk register, and in particular, perhaps, those parts of it that the noble Baroness, Lady Thornton, suggests could be made available. Can he give the House any idea of the probable timetable, as we are all conscious of the fact that the debates might have to be repeated all over again if the information in the risk register is relevant to the things that we are talking about?

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My Amendment 82 focuses on how the board’s performance in commissioning services is to be performance managed. Will the noble Earl say—or write to me—about how, in commissioning plans, the board will seek to consult health and well-being boards? This is a rather general group of amendments. I am conscious that we have a usual channels agreement to finish 12 groups today before we rise. If there are some points that the noble Earl would seek to write to me about, that would be very good. I beg to move.

[Lord Warner]

My Lords, I speak to Amendment 79 in my name and those of the noble Lord, Lord Patel, who unfortunately cannot be here today, my noble friend Lady Pitkeathley and the noble Baroness, Lady Murphy. Our purpose is to focus clinical commissioning groups on the needs of the 18 million of our fellow citizens with long-term conditions.

We spend an awful lot of time and money in our healthcare system preoccupied with acute hospital care. Indeed, 50 per cent of NHS expenditure goes on acute hospitals. However, day in, day out, week in, week out, the bulk of NHS activity—some 75 per cent of it—goes on good, bad and indifferent treatments for people with long-term conditions. Of course, some of these people have acute episodes, often because their routine care has been neglected. For example, 10 per cent of NHS expenditure goes on people with diabetes. The number of people being treated with diabetes is rising. We know how best to look after people who suffer with diabetes but too often we neglect basic, routine care and maintenance of the condition, seemingly waiting for the inevitable crisis to occur.

The scale of long-term conditions is, in my view and that of the colleagues who signed this amendment, sufficient to draw particular attention to their needs in the Bill. That is what the first part of Amendment 79 does by adding the words,

“especially persons with long-term conditions”,

to Clause 11 at line 12 on page 7. However, we want to go further. A very high proportion of those with long-term conditions need help, both from the NHS and from adult social care services. That is why the second part of that amendment specifically requires clinical commissioning groups to pay attention to their need to secure improvement in the integration of health and social care in the delivery of services. Of course, we have already had one discussion on integrating health and social care services at the point of delivery, including specifying a definition and I suspect that we shall come back to integration on a number of occasions as the Bill progresses. I shall certainly return to this issue on Report.

In the mean time, I hope we will receive a more constructive response from the Minister to this amendment, placing a clear responsibility on clinical commissioning groups from the outset to focus on securing improvement in the integration of health and social care in the commissioning of services. We need to move from the rhetoric of integration to requiring it to happen in legislation. I beg to move.

[Lord Ramsbotham]

I wish to speak to Amendment 80. I wonder how many noble Lords are aware of the historic nature of the proposed insertion into the 2006 Act of new Section 3B(1)(c). It is the first time that mention has been made in a Bill of the requirement on the Secretary of State for Health to provide services or facilities for those detained in a prison or in other accommodation of a prescribed description.

When I was appointed Chief Inspector of Prisons in December 1995, I had to give up the chairmanship of Hillingdon Hospital National Health Service Trust because I could not guarantee the time required, but during my chairmanship I was particularly grateful that my extremely able director of mental health insisted that I trained as a lay assessor so that, in his words, I could be of some use to the hospital. What neither of us realised at the time was that he was enabling me to appreciate, at once, the full and avoidable horror of the situation that I found during my first prison inspection of Holloway, during my second week in post. He educated me about both the complex requirements of those suffering from mental health problems and what it was possible to provide for them.

That understanding fuelled my fury at finding that none of what I had been accustomed to at Hillingdon was present in the largest female prison in England in 1995, despite the appalling numbers of women with varying degrees of mental health problems. When I remonstrated about that, I was told that uniquely in the country, prison healthcare was not, and never had been, the responsibility of the NHS but had been retained by the Prison Service. I was then told that the director of prison health, a doctor, was not responsible for the provision of healthcare, merely for advising the prison’s board, which was actually responsible. When I asked how many of the prison’s board had medical experience or qualifications, I was told none.

So I set about trying to change this nonsense, writing a thematic review of the situation in 1996, entitled Patient or Prisoner?, in which I recommended that the NHS takes over responsibility as soon as possible. I quoted the vast well of psychiatric morbidity, exacerbated by the treatment of and conditions for prisoners being wholly unsuitable for those suffering from mental health problems, which invariably made them worse. I simply could not understand how this situation had been allowed to continue since 1947, not least the continued failure to include the needs of the 500 or so prisoners whose transfer to high or medium-secure hospital accommodation was recommended each year in National Health Service estimates. That meant that provision was always a matter of chance because of competition with funded community needs. Years of lack of NHS budgetary provision for any aspect of prison healthcare, including the additional expense that released prisoners add in the community, remain a millstone around the NHS neck.

It seemed abundantly clear to me that prison health was a public health issue, because every single prisoner except, for the very small number, sentenced to natural life was going to come out and the state of their mental and physical health when they did so was a matter of public interest. Not only was offender health not regarded as a matter of public health, but GPs had to fight to get information from prisons about any medical treatment a prisoner had received. That was of doubtful quality, because we found that only 10 per cent of prison medical officers were qualified to act as GPs in the NHS. In other words, not only did anyone going into prison disappear from the NHS radar screen, but the authorities seemed to disregard the fact that imprisonment—paid for by the taxpayer—presented a priceless opportunity to identify and initiate, or pick up and continue, essential mental and physical health treatment. This could then be continued on release to the benefit not just of the prisoner but also of the community into which he or she returned. It all seemed unbelievably short-sighted and, frankly, stupid.

In the event, the NHS was made responsible for prison healthcare in 2003—seven years later, or longer than World War Two; so much for the speed of governmental decision-making. Since then, there has been considerable improvement, particularly when good primary care trusts have taken very seriously their primary care contract responsibilities with individual prisons. The same has not been so true of mental health contracts, largely because provision has in no way been able to match demand. I shall never forget speaking to members of the first mental health in-reach team to go into Wandsworth. They had expected to have to deal with a few very serious cases; instead they found that they were swamped by the 70 per cent of the prison population who were suffering from one or more identifiable personality disorders. It did not make them sectionable, but suggested that there was something affecting their behaviour that, if identified, could be mitigated. However, as the resources to carry out the identification were, and are, lacking, mitigation was, and is, denied—a process that should be of public concern.

My reasons for spelling all this out are to explain why my proposed amendment is an appeal to the Minister to withdraw the words, “other accommodation of a prescribed description”, and substitute detailed descriptions of that accommodation. I say that because the Secretary of State is required to commission services for a number of entirely different places of detention with very different requirements. Public and privately run prisons require primary, secondary and mental health contracts appropriate for their population type, whether man, woman or child. Privately run secure training centres and local authority-run secure homes require child-centred services. Privately run immigration and removal centres, about whose healthcare provision there have been many complaints, require a range of services, including specialist knowledge of tropical diseases. In addition, if the Government adopt the diversion schemes recommended by the noble Lord, Lord Bradley, there must be appropriate psychiatric and nursing provision in both police and court cells, in which people may have to be held until moved to appropriate NHS accommodation.

The Department of Health is very fortunate to have an able director of offender health, Mr Richard Bradshaw, who can provide the necessary descriptions very quickly because he is well acquainted with the differing needs. I therefore ask the Minister to accept this amendment in the spirit in which it is meant, which includes trying to ensure that the dreadful situation that I have described is never allowed to reoccur in any prescribed place of detention.

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[Earl Howe]

They will be held in the first instance by the NHS Commissioning Board. I anticipate that if a CCG or a group of CCGs wishes to establish a new service that involves a new building, a dialogue will take place with the board to bid for the necessary funds.

The noble Baroness, Lady Armstrong, put a very important question to me about the needs of the homeless. As I have indicated, CCGs will have responsibility for meeting the reasonable secondary care needs of the homeless. CCGs are responsible for unregistered patients in their area as well as those who are usually resident. Primary care for the homeless will be, as now, accessed through GP practices, either as registered or temporary patients, or through open-access GP services, such as GP-led health centres or bespoke services for the homeless. It is important that the needs of the homeless are factored in to the plans not only of CCGs but of the joint health and well-being strategies formed at local authority level. Clinical commissioning groups will participate in formulating them.

Just to clarify the point I made to my noble friend Lord Greaves, I perhaps should have made it clear that the Commissioning Board could in practice allocate capital budgets to a CCG or a group of CCGs. I hope that was implicit in what I said. I re-emphasise that clinical commissioning will deliver better outcomes only if we allow clinicians the autonomy to identify the needs of their patients and communities and to make the key decisions about how best to meet those needs. With that in mind, I hope I have provided sufficient reassurance to the noble Lord for him to withdraw his amendment.

[Lord Warner]

Can the noble Earl help me, before we get to Report stage, on the issue of the integration of services? He used the same argument he used previously, which is essentially that integration is a process and what we should be concerned with in the future is the outcomes framework. The problem for those of us who want to see something more on integration in the Bill is that we cannot quite see how we can change the culture on integration without having something in the Bill. Outcomes frameworks deliver results later on in the process. We see in the future what has happened. The difficulty many of us have is that we do not believe that that future will arrive unless we are more vigorous in this legislation about specifying some requirements on integration. Will the Minister write to a number of us before Report stage to explain how the outcomes framework will deliver that change of culture without words in the Bill about integration, particularly integration between health and social care? I do not expect an answer today, but I would like a clearer answer than the noble Earl has been able to give to satisfy us that we do not need some words in the Bill.

[Earl Howe]

I understand the point the noble Lord is making and I will be happy to write to him and other members of the Committee. The Bill already provides a framework of powers and duties which will support more integrated approaches to meeting patients’ health and social care needs, ranging from requirements to ensure that use is made of research in the health service to the close relationship between commissioners and the local authority and the health and well-being board. We ought not to forget that the NHS Commissioning Board guidance under new Section 14Z(6) could well cover the exercise of this function of integration. I accept the noble Lord’s point that in large measure it is a matter of changing cultures and one cannot achieve that through the written word in a Bill that goes through Parliament. However, I would be happy to put some flesh on the bones for noble Lords in writing and I hope that that will be helpful.

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I hope that the Minister will respond sympathetically to these amendments, and indeed to others that other noble Lords will be making in the debate this afternoon. If he cannot reply in detail today, as time is pressing, I would quite understand if written communication were made later.

[Lord Warner]

I apologise to the House for my enthusiasm to get in to this debate on public health, which I regard as a key part of this Bill. I am extremely supportive of much of the thrust of the Government’s approach. I rise to speak to Amendments 62, 64, 65 and 68, which are in my name and in the name of the noble Lord, Lord Patel—and, in the case of Amendment 62, also in the name of the noble Lord, Lord Walton. Unfortunately, neither of those noble Lords can be with us today. However, I strongly support the remarks made by my noble friend Lord Beecham.

These amendments to Clause 8 are aimed at strengthening the Secretary of State’s duty on the protection of public health. Let me make clear that, as I said, I very much welcome the Government’s emphasis and commitment on public health and support the thrust of their changes. It is time for us to give much more prominence to public health if we are to relieve the pressures on the NHS in the coming years. However, I believe that we could go further than the Government have in terms of the Secretary of State’s duty, as currently expressed; hence these amendments.

Amendment 62 requires the Secretary of State, when taking steps to protect the public from disease or other dangers to health, to do so on the basis of,

“using the best scientific and other evidence available and without regard to special interests”.

The first prong of this amendment is to cement evidence-based policy into the discharging of the Secretary of State’s duty to protect public health, and to make clear the use of science in doing so. All Governments like to claim that their decisions are evidence based—nothing surprising or new in that—but all too often they are not. For example, it has been a very long haul getting all government departments to have chief scientific advisers. Even now, the Treasury has only recently appointed its first chief scientific adviser.

Your Lordships’ Science and Technology Committee, of which I am privileged to be a member, is currently looking at the experience of chief scientific advisers in different departments, and it is very clear that their status and influence vary considerably. In the area of public health, it is absolutely clear that using a strong scientific evidence base, including the social and behavioural sciences, is very important indeed. Nowhere was this more important than in the controversial issue of banning smoking in the workplace and in public places. The dangers of second-hand smoke were discounted until the scientific evidence made that position untenable. If I may say so, we are now seeing a rerun of that debate over the issue of smoking in cars and the danger to children of second-hand smoke. Without going into particular issues, I want to emphasise the importance of Health Secretaries—of all political persuasions—making public health policy and taking decisions on the best scientific evidence available, and of requiring them to do so in statute.

The second prong of Amendment 62 is something of a belt-and-braces approach, requiring the Secretary of State to not be overinfluenced by special interests. There have been long-running concerns about the influence of the tobacco, food and drink industries on successive Governments over public health policy. I am not making a party political point here. All Governments have been subjected to pressures by those particular special interests when they have tried to deal with protecting public health. I will not go over the ground in detail because it is well documented and in the public arena.

However, the issue has been given a new burst of life because of this Government’s attachment to nudging public behaviour in the right direction rather than legislating. Again, the Science and Technology Committee of your Lordships’ House, under the chairmanship in this case of the noble Baroness, Lady Neuberger, produced a report recently on this issue. While the nudge approach can be useful in changing public behaviour, that it is a sufficient remedy in many critical areas, such as obesity, is not supported by good evidence. The result is that powerful interests backed by skilful marketing can still defeat important public policy advances.

Lobbying by powerful special interests is a feature of all western democracies, and a potentially dangerous one in the sphere of public health. We should take the opportunity of this Bill to require future Health Secretaries in this position not only to pursue science-based policies but to resist the blandishments of special interests. Amendment 64 is a simple substitution of “must” for “may” in terms of the steps that the Secretary of State should take in carrying out his duties set out in new Section 2A(2).

Amendment 65 extends the final item of that list of steps, so that services made available assist the public to take,

“responsibility for improving their health and well-being, including access to their own medical records”.

Many of the pressures placed on the NHS result from lifestyle choices that we all make that can damage our health. We need to make it a central tenet of public health policy that we should assist people to take more responsibility for their own health and well-being, rather than simply expecting others to bear the cost of treating them when they become ill. Obesity is a good example. In most cases, the solution lies literally—if I may put it this way—in our own hands. Accessing and probably holding our own medical records would reinforce that personal responsibility. This Government, like the previous one, rightly emphasise personal responsibility alongside rights. In the sphere of public health, Amendment 65 gives a push to that approach. I hope that the Government will accept it in the spirit in which it is proposed.

Finally, Amendment 68 extends Clause 2A(4) to give the Secretary of State a bit more help in carrying out his duties to protect public health. This amendment requires the Secretary of State to appoint an independent standing advisory committee on public health of no more than 15 people to provide advice on a regular basis as well as when the Secretary of State seeks it on a particular issue. The reports of that committee will be available to Parliament and the committee can report to the Secretary of State on any matters of concern that it has about the state of public health. I would envisage this committee being a major focus for the provision of scientific evidence to underpin public policy in this area under Amendment 62. I think that Amendment 68 is self-explanatory and its benefits self-evident in an area as important as public health.

I hope that the Minister will see these amendments as constructive strengthening of the Government’s ambitions on public health and enabling a helpful legacy to be left to the next Health Secretary whenever this current Health Secretary chooses to leave his job. I believe that these amendments go with the grain of the powerful, recent report on public health by the Select Committee, which proposes further strengthening of the Government’s powers. I hope that the Government will be sympathetic to these amendments and to Amendment 95, in the name of the noble Lord, Lord Patel, to which I have added my name.

[Baroness Jay of Paddington]

My Lords, I wonder whether my noble friend could help me with something that seems to be implied in his very eloquent deliberations about the amendments. I agree with him entirely that, in the public health arena, political leadership—the role of Governments of whatever party—is enormously important, particularly, as he said, in resisting the blandishments of external lobbies and so on. Does he see a potential conflict between the additional powers which he is advocating for the Government and the Secretary of State in this area, which I would entirely support, and the decision of the Government to reduce the powers of the Secretary of State in general for health services, healthcare and the promotion of general health matters in the way in which the Committee has discussed at some length on earlier clauses?

[Lord Warner]

My Lords, my noble friend raises a very important point. I can see some differences of approach here. Today, I am speaking on the rather narrow issue of helping the Secretary of State to be a powerful influence in improving public health. Of course, it is for your Lordships' House to debate further, as we progress through the Bill, whether we want Clause 1 to go a little further than the Government seem to want in terms of the Secretary of State’s responsibilities. I have sympathy with my noble friend in seeing a slight confusion on the part of the Government in some of these areas.

[Baroness Williams of Crosby]

My Lords, I wish to express strong support from these Benches for the amendments spoken to by the noble Lord, Lord Warner. Perhaps I could mention one or two points. It is clear that the emphasis on public health, important as it is at the national level, must also be reflected at the local level. I say again, therefore, that the amendments about expecting clinical commissioning groups to have at least one board member with public health experience are important in reflecting the kind of things about which the noble Lord, Lord Warner, has spoken.

I also believe that the noble Lord has put forward in Amendment 68 a very interesting idea that ought to give a higher profile to public health advice on how to deal with diseases and illnesses in the population as a whole. Obviously I share the views expressed by the noble Baroness, Lady Jay, on the importance of putting the Secretary of State squarely behind these issues, and I shall give one example of that. The Bill provides for extensive redress on issues related to smoking and alcoholism, and perfectly properly so. People are perhaps more reluctant to point the finger in relation to some of the serious public health issues arising from the food industry, issues which have great implications for the food industry's relations with the overall economy. There has over many years been a very slow response to growing evidence that certain foods, particularly foods directed at children and young people, have a substantial impact on health. If one looks at the ways in which those foods have been advertised, with an emphasis on how attractive they are, not only so that people will taste them but so that there will be a certain addiction to them, one will see an issue on which there should be a major consultation between the Department of Health and that industry. So far that has largely been limited to issues such as labelling, which is sometimes so complex that the ordinary consumer would not easily pick it up.

There is a continuing emphasis on, for example, foods that attract young children but which contain high levels of salt, sugar and so on, which is all the more serious in a country such as ours which, sadly, has a growing problem of obesity. I strongly suggest that the Government should look closely at Amendment 68 and the idea of establishing a standing advisory committee on public health. I would also point out the importance of assigning responsibility all the way up to the Secretary of State to ensure that these negotiations with industries and special interests which are crucial to the nation's health are conducted at the highest level and that public health is recognised as a full companion to all the other aspects of health. In that respect, I am very pleased indeed that the Government have put emphasis on the independence of the public health area and allowed public health to be taken out of the Department of Health and given its own status. That is a very long step forward.

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[Baroness Northover]

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

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

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

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

[Lord Warner]

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

[Baroness Northover]

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

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

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

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[Baroness Northover]

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

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

[Lord Warner]

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

[Baroness Northover]

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

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

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

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

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

--- Later in debate ---

Tabled by

[Lord Warner]

62: Clause 8, page 4, line 26, at end insert “using the best scientific and other evidence available and without regard to special interests”

[Lord Warner]

My Lords, I do not wish to prolong this debate. I was very grateful for all the support that I got around the House for some of the ideas in these amendments. I wish to give notice to the Minister that I remain unconvinced by what has been said so far—that the Secretary of State’s duty will be exercised in a way that guarantees he takes account of independent scientific evidence. We will return to that later in this debate, but in the mean time I will not move my amendment.

Amendment 62 not moved.