Health and Social Care Bill

Baroness Gould of Potternewton Excerpts

Wednesday 16th November 2011 Lords Chamber

The first three amendments are aimed at making explicit the Secretary of State’s central responsibility for public health information and advice campaigns, and explicitly require him to consider the desirability of such campaigns when he draws up the mandate. The final amendment requires the board to include public health information and advice campaigns in its duty to promote education. These are all probing amendments, which are looking, essentially, for two things. First, they seek an assurance that large-scale public health information and advice campaigns will continue to exist and will be an important part of the public health armoury. Secondly, they seek an explanation of how in future public health information and advice campaigns will be originated, how they will be driven and how they will be controlled, funded and assessed. I beg to move.

[Baroness Gould of Potternewton]

My Lords, I support these amendments, which are so relevant to recent proposals in the Select Committee report on HIV/AIDS. The Bill calls for the Secretary of State to take steps to promote public health in England from disease or dangers to health. Without a doubt the most effective way of achieving that aim is through the provision of public information, advice and awareness-raising campaigns, first, in respect of prevention and, secondly, in respect of early treatment and care.

That proposal would mean the promotion of early testing as well as testing for the estimated 22,000 people who have HIV but do not know that they are infected and who, as a consequence, are likely to transmit the disease further. It would also ensure the availability of testing. At the moment the venues for testing are fairly restricted but the Government are considering proposals by the HPA and NICE to widen the range of settings where testing might take place, particularly in areas of high prevalence. We await the Government’s decision on those reports. The need to raise awareness of early testing is crucial to prevent onward transmission of the disease. There is no better example than the evidence obtained from antenatal clinics which have had campaigns and have given information to pregnant women about mother-to-child transmission and where the number of such cases is now extremely low. That advice should be taken by the Government.

I raise these points specifically because the Government’s response to the Select Committee on the need for awareness-raising campaigns did not give the assurances that we might have hoped for. While there are campaigns currently targeted at those most at risk of HIV—we hope that they will continue, but we are not certain that that will be the case—it was very short-sighted that there was no guarantee of the inclusion of HIV on any national sexual health campaigns, if in fact there are to be any. This amendment would be helpful in making that happen. There was a complete rejection of campaigns directed at the general public. Those were not considered to be necessary, yet we know that there is a growing diversification of HIV into other communities. For those people, early diagnosis is essential.

There was, however, a welcome for a web-based campaign run by the National AIDS Trust, which is specifically designed to get prevention and awareness messages to the general public. In a sense, therefore, we have a little contradiction in the need, and the process does go round in a circle. Lack of awareness by the public is one reason why the stigma of HIV persists and why there are so many mistaken beliefs about HIV. It is often the fear of that stigma that deters people who might be at risk from going for HIV testing or even STI testing. Effective awareness-raising campaigns would overcome some of those difficulties and are essential if we are to promote early testing and reduce the levels of HIV, which are growing each year, and thus reduce the levels of transmission.

It seems to me that not to have those campaigns is not only poor health practice but economically short-sighted. The HPA suggests that, if we had prevented the estimated 3,800 or so HIV infections acquired in the UK in 2010, we would have saved over £35 million annually, or £1.2 billion over a lifetime of cost. Treatment is very expensive. That seems to me an enormous amount of money when compared to the cost of running effective and regular public awareness-raising campaigns. Surely common sense tells us that the campaigns should continue.

[Baroness Masham of Ilton]

My Lords, these amendments relating to campaigns are very important. My question is: who will be carrying them out? I would like to highlight the problems of late diagnosis of HIV/AIDS, tuberculosis, hepatitis B and C, and meningitis.

Many people are living with HIV/AIDS who do not know that they are infected. There needs to be sensitive targeting of campaigns. If diagnosis is late, the condition is much more difficult and expensive to treat, as has been said. There are often co-infections of HIV/AIDS and tuberculosis. Late diagnosis in TB is very dangerous. Along with the growing problem of drug-resistant TB, there is extensively drug-resistant tuberculosis, which is very dangerous and much more expensive to treat and takes much longer.

I would like to mention the effective and important work of the group Find & Treat, which goes out to find homeless and other people who are difficult to find, who may have TB, and test them. The group now wants to test for co-infections, which would be much more effective and less expensive in the long run. This type of infection is on the increase. There is a fear that, unless local authorities and the National Health Service work together, there may be fragmentation, and these people, who should be treated early, may fall through the net. Find & Treat needs all the support that it can get to carry on this very important work.

Hepatitis B is very infectious, but there is now a vaccination, which is good. However, there is no vaccination for hepatitis C. Both types of hepatitis have been found to be a huge problem in prisons. There is a problem of liver disease with hepatitis C. Early diagnosis is important for all infections. In the case of meningitis, there have been far too many tragedies because of late diagnosis. The public—and doctors—need to be reminded continually how important this issue is by means of campaigns and guidelines. My GP always waits for guidelines from the Department of Health.

--- Later in debate ---

[Baroness Gould of Potternewton]

My Lords, it is interesting that there is not a universally accepted definition of public health. There are, however, broad domains of public health, be they health improvement, health protection or health services. The Faculty of Public Health defines public health as:

“the science and art of promoting and protecting health and wellbeing, preventing ill-health and prolonging life through the organised efforts of society”.

That is a very broad definition. It could almost include every range of local government services. It seems to me that there is a need for some guidance on what aspects should be included in the ring-fenced budget. We have previously been told that there will be no breakdown of the budget within that ring-fencing, which makes it even more important that some guidelines are laid down. The frequent reply from the Minister has been that we leave it to each local authority to determine what public health is. But while I appreciate that there will be a variation in needs between different authorities in different areas, some guidance and priorities might be useful to them.

I am delighted that my noble friend has highlighted sexual health as being important because there is a great deal of concern that sexual health will not be a favoured issue for many local authorities. Furthermore, as regards HIV for instance, there is no understanding that there is all too often a relationship between the required long-term care and other aspects of local government services. There is also concern that, unless it is highlighted, there will be a lack of understanding by local authorities of the divide within the commissioning arrangements for HIV and contraceptive services between the National Commissioning Board’s responsibilities and their own—for prevention and testing in the case of HIV and for the establishment of clinics for special cases in the case of contraception. Guidance would give local authorities greater clarity of their roles and responsibilities and the fact that they are a key player in this process of integration. I am sorry to refer again to the response to the Select Committee report on HIV and AIDS, but it is so topical. The Government identify that integration where possible—whatever that means—will be by the NHS Commissioning Board, clinical commissioning groups and health and well-being boards. That will apply to all health services so there is no need to have a special duty applying to the integration of specific services, such as sexual health and HIV. However, I think that is a misjudgment. Having some identification priorities would give guidance as to which areas require special duties.

At Second Reading, the Minister referred to the Advisory Committee on Resource Allocation, which is an independent expert committee that has been asked to advise on a public health formula to inform the distribution of the public health grant across local authorities, saying that it intends to publish further detail later this year. So I appreciate that we are not going to get the detail for which I would have asked on the distribution of that grant. If we could get some detail, that would be very helpful, but perhaps I may remind the Minister that there is only two months left this year and I hope that we will get that response before the end of it. The calculation of spend on public health, including sexual health services, must be based on robust and accurate data, so can the Minister identify how that can be achieved without a specific definition of what it should include? I appreciate that the Minister has so far always rejected the idea of coming up with a definition and he certainly might not agree with the list that is before him. Nevertheless, I would be grateful if he could rethink this. There needs to be some principle laid down to make sure that local authorities understand what public health actually means.

[Baroness Northover]

My Lords, Amendment 66 would add alcohol services to the list of examples that the Secretary of State may take under his new duty to protect health and Amendment 74B would add a number of steps, including one on alcohol, to the equivalent list of steps for local authorities to take up under their new duty. I appreciate the decision by the noble Baroness, Lady Finlay, to regroup and we will discuss her amendments a little later. However, the noble Baroness, Lady Thornton, followed by the noble Baroness, Lady Gould, decided that the group should stay in place.

Adding to the Bill's list of steps that may be taken may highlight an issue but would not materially alter the situation. The noble Baroness, Lady Thornton, with her governmental background, is clearly extremely familiar with the function served by these indicative lists. I appreciate her indication that she is probing on this. Obviously it is extremely important in these different areas.

I also note the definition of public health that the noble Baroness, Lady Gould, quoted. I scribbled down the part about the science and art of promoting health and well-being through the organised efforts of society. That illustrates that this is an evolving and moving area. We hope that it will evolve and move because public health has now been put with local authorities. By joining up all the different areas we wish to join up, we hope that the field of public health will move along. Therefore, it is not appropriate to put in the Bill such a definition, which is set at a particular time, because of the evolution that I hope will expand in a way that the noble Baroness—who clearly is not satisfied—will be happy with.

[Baroness Gould of Potternewton]

We are talking about a ring-fenced budget; we are not talking about a general local government budget. Therefore, there must be some guidance on what should go into that budget. I do not mind whether it is a definition in the Bill or guidance, but something must be done to make sure that we know what is in the ring-fenced budget.

[Baroness Northover]

The noble Baroness is absolutely right. This is not simply philosophy. Therefore, regulations will provide that guidance. In the mean time, I say that this is an issue on which we have spent considerable time working. She is probably aware of the July 2011 update to the public health White Paper. If she is not, I suggest that she looks at it. Paragraph A.10 on page 27 contains a list of the areas in which we expect local authorities to engage. I am sure that the noble Baroness, Lady Thornton, will be pleased that the list starts with tobacco control. The noble Baroness, Lady Finlay, may note that the second item is alcohol and drug-misuse services. Other issues that noble Lords have mentioned are also listed, such as obesity and community nutrition initiatives. The list is long.