Health and Social Care Bill

Baroness Masham of Ilton Excerpts

Wednesday 29th February 2012 Lords Chamber

[Baroness Tyler of Enfield]

My Lords, I rise briefly to support Amendments 75 and 94, tabled and spoken to so clearly by my noble friend Lady Williams of Crosby, which are very important. The nub of the amendments is that they are designed to address the problem that we know still exists of a limited number of people who are not on GPs’ lists and who, as has been said, fall through the cracks and often—inappropriately—turn up in accident and emergency units. I can verify this because on a recent weekend I spent 12 hours in accident and emergency with two of my relatives. During that time, time after time people came in with needs that were real but which it was not for A&E to meet. Problems with access lead to some of the inequalities in health outcomes about which we on all sides of the House are very concerned.

When considering the Bill recently, the Minister agreed to new duties to ensure that CCGs and the national Commissioning Board include in their annual report details of how they have met their health inequalities duties. I very much welcome these changes to the Bill, but I am not convinced that this reporting after the event is going to be sufficient to tackle some of these very deep-seated inequalities, which often lead directly from difficulties in access to NHS provision.

Will my noble friend the Minister consider giving some very real teeth to the absolute imperative, as I see it, of universal provision—an absolute founding principle of the NHS, which I know is supported across the House—and see whether these duties could be extended in some way so that CCGs and the board also need to include health inequalities and issues of access in their commissioning plans and in the board’s performance assessment of CCGs? I would be very grateful if the Minister could reflect on this in his concluding remarks.

[Baroness Masham of Ilton]

My Lords, I have added my name to Amendment 96. These patients can have very complex and varied needs. Will the Minister give an assurance that they will not fall through the net between the Commissioning Board and the CCGs? There will be a great need to have excellent communication between the Commissioning Board and the CCGs. There is concern, as has been shown here today—and if there is concern here, my goodness, what will be the problem outside when funds have to be found for these patients? I implore the Minister to sort this out.

[Baroness Howarth of Breckland]

My Lords, I wish to add my voice to the need for clarification, as raised by the noble Baroness, Lady Finlay, between the services provided by the national and regional boards for rare diseases and conditions. I declare an interest as a patron and trustee of an organisation that deals with children with hypoplastic left heart syndrome and some similar conditions of right heart defects.

As the Minister will know, a recent Safe and Sustainable review has been looking at how those services should be delivered. Obviously the complex surgical procedures need to be carried out in specialist hospitals, but the aftercare very often takes place locally. The Safe and Sustainable review having stalled during the discussion about this Bill, parents are extraordinarily concerned about how that will be taken forward. I say this as an example but it is true of all families who have children or adult relatives with rare conditions that they want to be absolutely assured that the right service is commissioned at the right level, and need to know how that assessment is going to be made. At the moment it is extraordinarily unclear and I think that is why the noble Baroness, Lady Finlay, has tabled her amendment and the other issues have been raised.

All I am seeking is that clarification, partly because I have got to go and tell the parents this weekend at their AGM.

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The second part of my Amendment 107, which we discussed in Committee, deals with the voluntary sector itself. I will not repeat what has been said by many noble Lords. It requires the CCGs not only to take account of good practice but to co-operate with the sector, because it often knows better. The noble Lord, Lord Rooker, and others, including the Minister, have already made that point forcefully during debate. I endorse that and I beg to move.

[Baroness Masham of Ilton]

My Lords, I support my noble friend's amendment. Only yesterday, there were headlines in the press about the American study in the BMJ Open which found that sleeping pills were linked to increased death risks. It was found that death risk among users was about four times higher than among non-users. UK guidelines for NHS staff state that hypnotic drugs should be used for only short periods of time, because of tolerance to the drug and the risk of dependency, but they make no mention of an associated death risk, despite other studies having already reported that potential risk.

Many of your Lordships will know that doctors often do not review their patients’ drugs enough. Patients can have repeat prescriptions for years, putting them at great risk. Addiction to prescribed and over-the-counter drugs is an enormous problem. Groups which give support to the unfortunate people who become addicted themselves need support. Will CCGs be able to do that? Does the Minister think that that serious problem will get worse? My noble friend’s amendment is an effort to make that worrying situation better. I hope that the Minister will accept the amendment.

[Lord Williamson of Horton]

My Lords, the amendment deals with the distressing and serious problem of addiction to certain prescription drugs and, as is specified in the text, the problem of withdrawal from those drugs, because when such efforts are made, on many occasions they unfortunately fail and result in other difficulties for the patient in question.

Without going into detail about what may happen to the amendment, I hope that the Minister will be able to confirm that there should be an appropriate priority for the services available to treat that distressing problem. I do not press the point more than that, but it would be useful if we could have that sort of assurance from the Dispatch Box. In particular, whether the Minister agrees with this or not, some of us believe that in the past the issue has been allowed to fall into the shadows. That is what has happened in practice. It has been neglected and people have suffered in consequence. Perhaps we are improving but we could improve more, and I hope that the Minister will give an encouraging reply about the appropriate priority that ought to be given to the problem.

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[Lord Walton of Detchant]

My Lords, the case for supporting these amendments has been put very clearly by my noble friend Lord Patel and the noble Lord, Lord Turnberg. I do not wish to repeat those arguments but I should like to mention a point or two about history. My reasons for doing so I hope will become clear in a moment or two. When I was a young doctor, medical officers of health in major centres of population were very notable specialists in public health. Indeed, when I was a particularly young houseman, the medical officer of health in Newcastle upon Tyne was John Charles, who later became Sir John Charles and the Government’s Chief Medical Officer. He was succeeded in Newcastle by Professor WS Walton—I can assure noble Lords that he was no relation—who later became a very distinguished professor of public health in London.

As the years went by and the National Health Service matured, physicians in public health began to argue that they were actual physicians who, unlike physicians looking after groups of individual patients, were looking after communities. The situation developed until they were no longer directors of public health or medical officers of health. Instead they were transferred into the National Health Service as physicians in community medicine. They became individuals holding consultant appointments, and that was true of doctors and dentists working in community medicine. Eventually the faculty in the Royal College of Physicians grew into the Faculty of Community Medicine. Later it became clear that there were widespread public health functions which were not fully covered by that arrangement and therefore the title reverted to “public health”.

The questions I want particularly to ask relate to Amendment 125 about the:

“Appointment of directors of public health”.

This amendment seeks to ensure that public health specialists employed,

“by a local authority or in an executive agency of the Department of Health shall be employed on terms and conditions of service no less favourable than those of persons in equivalent employment in the National Health Service”.

First, could the Minister go a little further in confirming that medically and dentally qualified directors of public health who are transferred to work in local authorities will retain honorary consultant status in the National Health Service? It is crucial that they should have a formal arrangement whereby they have full access to all the NHS facilities necessary in relation to issues such as the control of epidemics and a whole range of other activities where access to those facilities will be needed.

My other question is one that I have raised before but to which I have not had a satisfactory answer. What is the position of young doctors and dentists who at present are training in the NHS as specialist registrars seeking to become qualified in public health? What is going to be their future? Where will they be employed and how will they continue to undertake a formal training programme if the directors of public health have been transferred into local authorities? This is an important issue that needs to be resolved. Finally, the regulation of non medically or dentally qualified specialists in public health is an issue that also has yet to be resolved.

[Baroness Masham of Ilton]

My Lords, in supporting these amendments, I want just to say that many demands are made on local authorities. If the Bill becomes law, they will have added responsibilities for public health. The control of infectious diseases is vital. We have increasing levels of drug resistance in conditions such as tuberculosis and sexually transmitted infections. We have the problems of alcohol and drug abuse. Food poisoning is always a risk. One never knows what new infection is around the corner—one has only to look at the recent very worrying virus in lambs. We need senior officers of public health because they are the important link between health and local authorities. They need to be in senior positions and to have a clear voice.

[Lord Warner]

My Lords, I have added my name to Amendment 125, and I had intended to add my name to Amendment 123, but somehow that did not work out. I speak in support of the excellent presentation by the noble Lord, Lord Patel. I am still concerned about whether we will end up in a situation where, in pay and in terms and conditions of service, public health staff at senior levels start to lag behind their counterparts in the NHS. It is a real risk and I am not completely convinced that the way the Government have gone about this is adequate to tackle it.

I also share the view expressed very well by the noble Lord, Lord Patel, that the Secretary of State should give his consent to the dismissal of any director of public health. These posts are exposed when the temperature rises in a particular area over a serious incident, so these directors deserve a bit more in the way of safeguards than are provided in the Government’s proposals.

I accept that the Government have moved on this, but I am a little concerned about how government Amendment 128 has been framed. I always get a bit wobbly when I see “may” used in guidance, and I wonder whether that could not be strengthened a little. I accept that Amendment 124 goes a long way towards giving an assurance that local authorities will be required to pay attention to the guidance but, as I read it, there is no guarantee that it will necessarily cover all the areas in the kind of detail that noble Lords have expressed their concerns about in this debate. A bit of strengthening of Amendment 128 would not go amiss unless the Minister can assure us that “may” really does mean that all these topics will be covered in the guidance.