Health and Social Care Bill

Baroness Hollins Excerpts

Wednesday 16th November 2011 Lords Chamber

[Lord Davies of Stamford]

My Lords, there is no provision on the Order Paper for debates on Clauses 8 or 9 to stand part. Rather than risk taking up the time of the House by necessarily opening such a debate, I wanted to make a few general remarks under the heading of this group of amendments because it touches on Clauses 8 and 9.

All of us in this Committee are very concerned about public health. It is a priority for anybody in public life and really must be. Some telling points have been made both this morning and this afternoon, and I particularly retain the remarks about the importance of addressing the threat of obesity, which we know causes an awful lot of medical conditions, and the very important issue of tobacco smoking. We have made tremendous progress in public health by bringing down smoking. The results are already clear in the reduction of the incidence of some of the cancers. It is also important to address the threat of sexually transmitted diseases, and some very good and sensible things have been said about AIDS and hepatitis B and C. To that list I would add chlamydia, which does not normally have fatal consequences but has very sad consequences for infertility. It is far too widespread at the present time.

There are a number of other areas about which we should all be concerned. One that concerns me is the introduction into this country of tropical diseases by airline passengers and the great importance of making sure that clinicians are properly trained to identify the symptoms as rapidly as possible and to deal with them. The facilities are there to quarantine where necessary people who have highly infectious tropical diseases.

Another public health risk that we ought to be aware of is the danger of strains of bacteria emerging that are immune to antibiotics, very largely as a result of the excessive and irresponsible prescribing of antibiotics—sometimes quite disgracefully as a placebo—and a lack of discipline on the part of patients in completing a course of antibiotics. That is a serious issue that has not been addressed by any public campaign, as far as I know.

All of us are concerned about the danger of a viral epidemic in the form of some new strain of flu or something of that kind. We are very much aware of it because the media talk about it a lot. That has not gone away; we must not get complacent about that. I am glad that in the area of the protection of public health, the Government have made it clear that, unlike in the area of the provision of clinical treatment, the Secretary of State has a clear responsibility stated explicitly and unambiguously in the Bill.

However, the Government have missed an opportunity to simplify and rationalise the bureaucratic structures and lines of accountability. That would have been very desirable. What is emerging here is an extremely complex structure of responsibility. The Secretary of State uniquely has responsibility for taking necessary measures for the protection of public health but shares that responsibility with local authorities in the area of improvements to public health. The Bill makes it clear that the Secretary of State “may” and local authorities “must” take measures in this area, so there is the prospect of a highly undesirable situation in which the Secretary of State takes such action but that duplicates what local authorities are doing. I do not think we have heard in the course of the debate exactly how the Minister envisages the relationship between Public Health England, the Secretary of State and local authorities with their new medical officers developing. I almost called them “medical officers for health” because I think this is a revival of that old concept, and they did a wonderful job in their time. However, I believe that they are going to be called “directors of public health” and are to be established under Clause 9 by all local authorities.

We need to understand what the relationship between these bodies is going to be. The noble Baroness, Lady Northover, said earlier that the Health Protection Agency is to be abolished. That is what it states in the Bill, but I understand that actually it is going to be subsumed more or less in toto into Public Health England. We need some transparency on that. I would like to know how many people are going to be involved in the agency because these bodies can be extremely expensive. We want to make sure that we are getting proper value for public money.

I am particularly concerned about the suggestion in Clause 19 that the Secretary of State may devolve on to clinical commissioning groups or the National Commissioning Board his responsibilities in the public health area. So there we have another bureaucracy that has the potential to become involved without being clearly defined. There is a frightening element in that clause which provides that any liabilities arising as a result of the involvement of the National Commissioning Board or clinical commissioning groups in the public health area will accrue to those bodies and to no one else; in other words, not to the Secretary of State. The Secretary of State is not delegating his authority; he is not using the National Commissioning Board or clinical commissioning groups as his agent under his direction, which would be an appropriate thing for him to do; but rather he is abandoning his responsibility to this completely different set of bodies whose main job is in the area of diagnosis and treatment. Again, that is a very confusing picture.

The proliferation of bodies and lack of clarity about bureaucratic responsibilities should be a matter of concern to us all for at least three reasons. The first is that it makes it very difficult for the general public. I find it difficult to understand exactly what the hierarchy of responsibility is. Human beings never give of their best unless their responsibilities are clearly defined and demarcated so that they can be held responsible for those areas for which they really are responsible. They are simply hopeless if other people might be equally responsible. We have not talked about the health and well-being boards. What have they got to do with public health? It is quite unclear to me, but presumably they have some role in this area. It is very confusing and I think that that is very undesirable.

The second reason is the matter of cost. Anybody who has dealt with the NHS as a Member of Parliament, as a business or in any other context knows that one of the great troubles with the NHS is that whenever a decision needs to be taken, there are around 26 people in the room from at least 12 different departments and agencies. That is extremely bad from the point of view of clear decision-making. It means that all decisions take a long time and the costs go up indefinitely. It seems that we have a formula in the area of public health for the replication or even the aggravation of that problem.

The third reason why we should have clarity of responsibility in this area is because people do not perform if they can simply get out of any kind of sense of responsibility by saying that it is someone else’s fault. We are providing endless opportunities for excuses to be made and for people to avoid their responsibilities. I would be very relieved if the Minister could reassure me that these fears are groundless and give clear reasons why that is so.

[Baroness Hollins]

My Lords, I shall speak briefly about the importance of information in an early diagnosis. I have two areas to focus on. First, people with learning disabilities often get a late diagnosis and suffer terribly because of it, with an earlier death as a consequence for many. Often that is because of a lack of accessible information. I speak as the executive chair of a social enterprise, called Beyond Words, which designs pictorial information to try to bring health and social care information to people who cannot read. Any public health information campaigns need to remember that not everybody can read information easily; it has to be designed to be inclusive.

Secondly, I have a question about how the accessibility of information about the bureaucratic structures of the NHS will help with early diagnosis. This is to do with the current “choose and book” system. Something that has happened to a close relative of mind in the past few weeks made me realise that I do not know how the Bill is addressing the whole issue of better choice for patients. I will briefly tell noble Lords the story. It is about somebody who needs an early diagnosis for what seems like a serious, rare, long-term condition and who has been referred through the choose and book system to four different hospitals to see four different specialists in different areas, where those specialists cannot easily communicate with each other because their hospital systems do not speak to each other. The person concerned chose the hospitals that offered the earliest appointments, which is what most people do and what choose and book offers you. You take the first appointment because you are worried, but the hospital consultant is unable to refer to a consultant in the same hospital with whom they would be able to consult. The patient has to go back to the GP and back through the choose and book system. It is not working.

There is something about information and early diagnosis here as well. I could not see where, apart from under information, I could raise this issue. I look forward to hearing a response from the Minister.

[Baroness Northover]

My Lords, Amendments 65A, 71ZA, 97A and 133A seek to raise the priority within the Bill of public health information advice designed to encourage the early diagnosis of serious conditions. Improving early diagnosis is an important objective across the whole health system, which includes the new public health system. I am very grateful to noble Lords for raising such a significant issue.

I completely agree with my noble friend Lord Sharkey as to the important role of information advice campaigns. I hope that I can reassure him that the changes to public health will not see the end of such campaigns. Where such campaigns work, we want to see more of them. We know how important early diagnosis is in treating cancer, for example. Thus, people coming forward for bowel cancer screening can be diagnosed at a stage where the disease is totally curable.

The noble Baronesses, Lady Masham and Lady Gould, emphasised other areas in which treatment is more effective earlier but also where there is a risk of infection, such as HIV, TB, hepatitis and meningitis. The noble Lord, Lord Davies, flagged up other STDs, among other issues. We are well aware of the importance of these areas. This is also where local authorities’ involvement in public health should assist rather than detract. The noble Baroness, Lady Gould, rightly flagged up this issue in relation to HIV/AIDS. No doubt we will return specifically to the points that she has raised when we debate HIV/AIDS on 1 December, World AIDS day, a debate to which I am responding. I look forward very much to our discussions then.

We will no doubt come back later to wider discussions of Public Heath England and the directors of public health, to which the noble Lord, Lord Davies, referred. Perhaps his notions can be revisited then when attached to the appropriate amendments.

As I outlined in the debate on the previous group of amendments, Clause 8 sets out the Secretary of State’s new duty to take steps to protect public health. It illustrates this duty with a list of steps that would be appropriate for the Secretary of State to take. That list includes the provision of information and advice. Amendment 65A would amplify that to specify that this could include information in campaigns around early diagnosis. I should explain that the list in Clause 8 is neither prescriptive nor exhaustive. The amendment would not therefore either require or give the Secretary of State a new power to do anything that the clause does not already accommodate.

Similarly, Amendment 71ZA would have the equivalent effect on a list of steps that local authorities may take under their new duty to improve public health. As we have already said, local authorities’ new responsibility will include behavioural and lifestyle campaigns to prevent serious illness and they will be funded accordingly. The Department of Health is also working with stakeholders from the NHS, local government and voluntary and community sectors to finalise the operational design of the new public health system. We expect to publish proposals shortly and they will set out how we expect to promote early diagnosis through the system.

Of course, the NHS will continue to play an important part in public health, a point emphasised by the noble Baroness, Lady Finlay, earlier. The Bill allows the Secretary of State to mandate or agree particular services that will be the responsibility of the NHS Commissioning Board. Amendment 97A seeks to ensure that he will consider early diagnosis campaigns when he does so. I hope that the noble Lord, Lord Sharkey, will be reassured that this is something which we are already considering. I can also reassure noble Lords that the objective of Amendment 133A is already met by the clause as drafted. Where the Commissioning Board is engaged in early diagnosis campaigns, then the duty to promote the integration of services would automatically apply to those campaigns just as they would to any other health, or health-related, services.

I emphasise that we especially expect advice and information to continue to play a major role in early diagnosis and local authorities will be able to contribute to that. Meanwhile, Public Health England, too, will be able to manage and support effective national campaigns. We will be publishing further detail shortly on how the different levels of the system will work.

In short, I believe that we are in total agreement with noble Lords about the principles underlying their amendments and with what noble Lords have said in the debate. We share their desire for improvement in this area. We all know what huge potential early diagnosis offers and the vital importance in this of public health campaigns. The Bill as drafted offers all the necessary support for that ambition. I therefore hope that the noble Lord will accept that and withdraw his amendment.

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[Baroness Hollins]

My Lords, I might add that Amendments 68A and 69A refer back to Clause 1 and the Secretary of State’s duty to promote a comprehensive health service,

“designed to secure improvement … in the physical and mental health of the people of England”.

Of course, I support the amendments and note that their purpose is different from the purpose of my own extensively debated and supported amendments, which sought to ensure improvement in the quality of services for people with illness. I specify both mental and physical illness. Rather than speaking about mental health, I actually speak about illness. Instead of detaining the House now, perhaps I could speak to the Minister at a later date.

[Earl Howe]

My Lords, I should be happy to speak to the noble Baroness on this topic. I have been reflecting on it since our debate some days ago. I do not suggest that the amendments tabled by the noble Lord, Lord Northbourne, are designed to do exactly the same as those of the noble Baroness, however they draw our attention to a similar definitional issue.

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[Baroness Hollins]

My Lords, as my noble friend Lady Finlay has eloquently explained, alcohol misuse is one of the major public health challenges that we face in the UK. It causes wide harm to individuals and places a significant burden on the National Health Service. Even more widely, it has a devastating effect on families, on communities and within wider society, and it is vital that the reforms to the NHS are effective in helping to address this challenge. This is an important debate in an uncertain time for alcohol services. I understand that local authorities are set to commission alcohol services out of their ring-fenced £4 billion budget, but there is no guarantee how much of that will go to alcohol services. Furthermore, public health is a wide-ranging area and there are concerns that alcohol services may have to compete with wider public health initiatives.

I hope that the Government will use this important opportunity to show how alcohol services will be prioritised in the reforms. I know that one particular opportunity lies in the Government’s alcohol strategy which is expected in the near future. I would welcome a commitment from the Government that this strategy will make clear how alcohol services will be made a priority in local authority delivery and in primary and secondary NHS care. At the same time primary care and the new clinical commissioning groups will need to continue to play a key role in screening and treating people with alcohol misuse problems, and it is vital that they are incentivised to do so.

The quality and outcomes framework is a vital primary care lever to ensure that GPs prioritise specific conditions. At present there is one very limited QOF indicator on alcohol to provide lifestyle advice to patients with hypertension. The Government have indicated that 15 per cent of the QOF funding will be assigned to public health and primary prevention indictors from 2013. However, at present all of the proposed public health indicators are focused on smoking, and the indicator on screening for alcohol misuse has, regrettably, been rejected.

What is clear is that integration of services will be the key to ensuring that people with alcohol misuse problems are not lost in the system and that the various agencies involved in care work together. The amendments in this group make the important case that people who understand alcohol misuse and alcohol services should be involved in health and well-being boards and in producing health and well-being strategies. Health and well-being boards seem to present significant opportunities ahead, but only if alcohol is made a clear local priority.

[Lord Wigley]

My Lords, I rise with some trepidation as this Bill applies to England only, although there are some consequential effects on Wales. As I was speaking in Grand Committee on the Welfare Reform Bill upstairs a moment ago on initiatives in Wales which should be copied in England, I hope that initiatives in this area will be copied by the National Assembly for Wales and I very much hope that the spirit of the amendments, some of which I have my name alongside, can be taken on board by the Government, even if the wording is not perfect.

I welcome the address made by the noble Baroness, Lady Finlay, in opening this debate and pay tribute to the work that she has undertaken in this context, which is recognised all round. I come from a generation in Wales where we used to have to smuggle ourselves out to the pubs because of the general ban on alcohol that used to exist. In previous generations, understandably and rightly, there had been a clamping down on alcohol use in Wales. My parents’ generation referred to whisky, for example, as medicine and very rarely used it. In fact, the pledge was a general feature of society there. My generation was responsible for a movement in another direction. The pendulum swung and is still swinging in that direction and it is time to start it swinging back.

I have no doubt at all that alcohol is one of the greatest problems that we have in our society today. I say that not as a teetotaller although I restrict myself two months of the year to not touching the stuff because it is so important that we have self-discipline as well as discipline that may come from the statute book. But in terms of violence, the break-up of families, poor performance at work—one remembers David Lloyd George’s initiatives in the First World War to try and clamp down on alcohol because of the effect on the war effort—criminality, injuries and the pressure on accident and emergency departments in hospitals, and the social disruption that arises from it, we can see the effect all around. The effect seems to be hitting people younger and younger. Children at the ages of 11, 12 and 13 are showing the effects of alcohol. That cannot be acceptable.

I realise that in an area of social responsibility such as this it is sometimes difficult to legislate. However, there must be pressure to turn the tide in another direction. Amendment 202 refers to establishing a duty to reduce alcohol harm. Amendment 328 covers the assessment of alcohol damage in local communities. Amendment 329 would provide appropriate places for representatives of alcohol services. These modest steps, taken together, would add up to a message that would come across. I implore the Minister, even if he cannot accept the amendments, to accept the thrust of the argument that lies behind them, because we have to do something about this great scourge of our society today.

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[Baroness Hollins]

My Lords, I shall speak to Amendments 203C and 215A. Although the Bill places a duty on each clinical commissioning group to,

“obtain advice appropriate for enabling it effectively to discharge its functions from persons who (taken together) have a broad range of professional expertise in … the protection or improvement of public health”,

it places no duty on clinical commissioning groups to act at all times with a view to the improvement of public health. Such an omission will render the delivery of public health outcomes significantly less likely, with clinical commissioning groups free to act without regard to the wider public health needs of the populations they serve.

The Government’s intention to leave public health—and therefore public mental health—entirely to local authorities could mean that the opportunity will be lost for clinical commissioning groups, local authorities and national agencies to work in consort to achieve better outcomes. There is a fundamental relationship between mental health and well-being and almost all other aspects of individual and public health. Handing responsibility for public mental health solely to local authorities could have deleterious consequences for achieving good outcomes in public health more generally unless precautions are taken.

The purpose of these two amendments is to try to mitigate the consequences of this decision. They would ensure that clinical commissioning groups are required to act in such a way that they contribute to the improvement of public health—and public mental health—and are required to demonstrate in what ways their actions fulfil such an obligation.

I should also like to add my support to the amendment of the noble Baroness, Lady Tyler. I was unable to participate in the discussion about the previous group— where perhaps the comments I am going to make might have been more relevant—because of a commitment to speak at the same time to an amendment in Grand Committee to the Welfare Reform Bill, due to the rather unfortunate timetabling of that Bill.

The point that is relevant here as well is that public health relies on the relationship between so many different agencies, and I am thinking here particularly about the contribution made by education. The example I want to give is about the health of the next generation, which relies so much on the way in which children are parented. Education and support for future parents seems such a worthwhile investment. I want to give just as an example the work of the charity Teens and Toddlers. It does not work by telling teenagers to change their behaviour, because that does not work; it offers them a holistic and transformative experience which has a much greater effect. It really is a health intervention as well as an educational one. The programme allows teenagers to spend two hours a week for 15 weeks looking after a toddler in a nursery. They also spend time talking through what that experience has taught them. What is so extraordinary is the effect of the programme, which is now available in 12 London boroughs and 13 other areas of the UK. Some 97 per cent of those who graduated from the programme have not become pregnant before the age of 20, and 92 per cent have continued in employment, further education or training. I am sure that the Minister will agree that public health is so much more than the responsibility of only the local authority and the NHS.

[Baroness Barker]

My Lords, I want to address briefly the question that Clause 15 should stand part of the Bill raised by the noble Baroness, Lady Thornton, and her colleague on the Front Bench. At this stage I do not intend to go over the points which have already been made so expertly. I simply want to ask a simple question. Clause 15 sets out the functions and the shared duties of local authorities and the Secretary of State to improve public health. What is not clear is which duty falls to the Secretary of State and which to local authorities at any one time. What would be the trigger for an intervention by the Secretary of State? It is quite important that noble Lords should understand this as we go ahead. Would I be right or wrong to assume that it would be exceptional, rather than the norm, for the Secretary of State to intervene? Is that what the department thinks? If it were exceptional, can the Minister set out under what circumstances it is envisaged that the Secretary of State would intervene?

For example, if a local authority unilaterally decided to cut its entire funding of sexual health services, would that be regarded as something which would cause the Secretary of State to intervene? If a local authority came up with a good argument for why it should not fund such services, or there was a major outbreak of an environmental nature, would the Secretary of State intervene under additional powers? I can understand the logic of this in that both the Secretary of State and local authorities need to have powers, and those powers should be shared, but I would welcome further clarification on how these powers will be exercised both jointly and separately.

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[Baroness Wilkins]

My Lords, Amendment 92A is tabled in my name and those of the noble Baroness, Lady Hollins, and the noble Lords, Lord Rix and Lord Wigley. It would make explicit the responsibility of the NHS Commissioning Board and clinical commissioning groups to be compliant with the public sector equality duty, as set out in Section 149 of the Equality Act 2010.

Section 149 states that a public authority should,

“take steps to meet the needs of persons who share a relevant protected characteristic that are different from the needs of persons who do not share it”,

as part of the duty on it to advance equality of opportunity. This essentially makes provision for such public authorities to be subject to making reasonable adjustments for individuals who may have specific or different needs as a result of factors such as age, disability and religion or belief. In the context of this amendment, the healthcare bodies concerned and the healthcare professionals who work in them would be required to take the necessary steps so as to offer appropriate care to people with these protected characteristics.

In particular, I am speaking about the provision of reasonable adjustments for disabled people, particularly those with a learning disability. People with a learning disability will often have particularly complex healthcare needs and therefore require specialist interventions in order to have them appropriately met. These interventions are about health professionals adopting a change of attitude towards disabled patients and not making assumptions as to their quality of care which would not be made towards non-disabled patients. For example, the use of hospital passports can help to provide key personal information about an individual’s medical details and, as importantly, details about how they communicate so that health professionals can better understand the patient’s individual needs and communication requirements. Additionally, learning disability liaison nurses can help to provide specialist support and guidance to medical professionals when treating someone with complex needs.

These measures are more often than not achievable, reasonable and proportionate, and help to ensure that health professionals are treating disabled patients with the dignity and respect they are entitled to. Whether this is for planned or non-planned admissions, it is necessary for the NHS to make adequate provision for patients with disabilities. This can be achieved through better disability and learning disability awareness training for all staff so that they can better understand the needs of such individuals who may be in their care.

A 2009 poll conducted by ICM on behalf of Mencap found that a third of healthcare professionals have not been trained in how to make reasonable adjustments for a patient with a learning disability.

At this point, Baroness Northover continued the speech for Baroness Wilkins.

This can lead to poor treatment and can exacerbate existing healthcare inequalities. The same ICM poll indicated that almost half of doctors and a third of nurses said that people with a learning disability receive a poorer standard of healthcare than the rest of the population. The Mencap report Death by Indifference in 2007 also revealed the premature and avoidable deaths, in the NHS, of six patients with a learning disability. Since then, a further 60 families have been in contact with Mencap with similar experiences to this. It is therefore particularly important for the NHS Commissioning Board and clinical commissioning groups to be fully aware as to their responsibilities and obligations under the public sector equality duty.

It is very important that disabled patients and their families can be expected to be treated in the NHS without being the victims of prejudice and discrimination. The amendment tabled in my name and others’ sets out specifically the requirements on these bodies to adhere to the public sector equality duty. They would safeguard disabled patients against malpractice, mistreatment and neglect in the NHS.

[Baroness Hollins]

My Lords, I am delighted to have this opportunity to support the amendment of the noble Baroness, Lady Wilkins. The noble Baroness has eloquently put forward the case for reasonable adjustments and has given good examples of reasonable adjustments that people need and why they are so important for people with a learning disability. I fully endorse her sentiments on this issue. I am also speaking for my noble friend Lord Rix, who was unfortunately unable to stay this evening.

It is vital, under the new arrangements, that health professionals and the various health bodies that will be created are fully aware of their legal responsibilities when treating disabled patients. As the noble Baroness said, this is particularly relevant for people with a learning disability who continue to experience large health inequalities and who are at a disproportionate risk of experiencing epilepsy, mental health problems and premature death. Not only do people with a learning disability experience poorer health outcomes, but they also receive fewer routine immunisations and blood pressure checks and have poorer access to cervical and breast cancer screening programmes.

In response to an earlier group of amendments to this Bill, tabled in the name of the noble Lord, Lord Rix, on day 3 in Committee, the Minister gave many assurances as to why it was not necessary to mention disability or learning disability specifically in the Bill. He cited NICE quality standards, Monitor, the NHS outcomes framework, Clause 12 of this Bill, clinical advisory groups, the duty of clinical commissioning groups to involve and consult people “appropriately”, the annual report by the Secretary of State and, above all, the public sector equality duty.

My noble friend Lord Rix and I are both extremely grateful to have heard all of these assurances, put forward by a Minister who is both sympathetic and determined to be as helpful as possible. But we cannot imagine patients with a disability, especially those with a learning disability, being conversant with all these facts, and perhaps even having to visit their GP or local hospital with a vast compendium of their entitlements tucked under their arms to place in front of the health professional—who, as we know, may have been inadequately educated in their responsibilities with respect to the requirement to make reasonable adjustments—before they receive adequate and correct treatment.

The amendment of the noble Baroness, in one simple and effective move, would bring together all of the Government’s good intentions in this area and remove any ambiguity or uncertainty, by making it 100 per cent clear as to the importance of public bodies in the NHS meeting their obligations under the public sector equality duty, not just for disabled people, but for all of the protected characteristics.

The Minister stated in reply to earlier amendments by my noble friend Lord Rix that the Government’s starting point,

“is that people with a learning disability are people first”.—[Official Report, 7/11/11; col. 18.]

He will not be surprised to hear that my noble friend and I fully concur with that view.