Health and Social Care Bill

Lord Greaves Excerpts

Wednesday 16th November 2011 Lords Chamber

[Baroness Armstrong of Hill Top]

My Lords, I wanted to intervene on this group of amendments because I have been trying, without success, to find out how to table an amendment relating to how the new architecture will deal with the most chronically excluded. Some of them will require alcohol services, which we shall come to later, but many of them will require other medical services. In addition, many of them will not have a fixed abode or will not have a fixed abode for very long. Therefore, they will be moving around.

When I asked the chief executive of the Commissioning Board who would deal with these people, I was rather concerned to be told that it would be clinical commissioning groups. CCGs might do so, but I am not convinced that they necessarily will. First, CCGs may well not be very aware of the numbers involved, particularly if they are not inner-city commissioning groups, and they may well not be aware of the complexity of response that such people will require. These will be people who require some medical intervention as well as other forms of intervention and support.

At the moment, much of the medical attention that these people receive is fragmented and is often not the appropriate intervention, and they can be a real nuisance in places such as A&E. The Government need to listen to those in the voluntary sector who say, “We need a new approach to how we work with people with these multiple conditions and we need to make sure that we get it right”. However, the NHS has a responsibility—it does not stand outside this—and this matter will need to be looked at on a wider and more expansive level than simply that of the CCG.

In this country we assume that, because we have GPs, people will automatically be registered with them and will be looked after. However, my experience of working with these most frequently disturbed and disadvantaged people has been that they fall through the net again and again, and somehow we have to make sure that that does not happen. Due to work that I have done in the past and because I am currently involved with a voluntary organisation, I have previously discussed with the Minister ways in which that can be achieved effectively. I do not pretend that it will be easy or that we can simply lay something down in legislation and it will all happen. However, somewhere in the middle of that there is a way forward.

I hope that in considering the amendments—particularly those of my noble friend Lord Hunt—the Government will work on this issue and come back with clarification that this group of people will not fall through a net in the new architecture.

[Lord Greaves]

My Lords, I want to pick up on a point that I made on Monday. We are discussing the role, duties and powers of CCGs, and I want to talk about commissioning services. Where contracts are negotiated with existing providers—whether they are within the National Health Service, the voluntary sector or the private sector—it is fairly clear to see how the system will operate. However, I am not clear—and perhaps the Minister can enlighten me—about the role of CCGs in promoting and creating new services or facilities within the NHS.

The example that I particularly want to refer to concerns the provision of new health centres in my own area of east Lancashire. These are new significant capital schemes but they are not the direct responsibility of the hospital trust. Where the responsibility is that of the hospital trust, it will no doubt be responsible for the provision of new capital schemes. Here we have facilities that will be partly occupied by GPs; they may well be occupied in part by community-based services that are now the responsibility of the hospital trust. The hospital trust may wish to make use of the facilities as outreach facilities for day patients, and so on, but they do not fit neatly into the hospital trust. At the moment, they are the responsibility of the PCT. The existing primary care trust in east Lancashire has now approved in principle the provision of three health centres in three towns—Great Harwood, Clitheroe and my own town of Colne. Because of the changes and the fact that the PCT is not responsible in the future, it has now been passed to the cluster of PCTs, which is at a Lancashire level, and will have to be approved by the strategic health authority.

These are all bodies that in future will not exist. Who will be responsible for this kind of capital project within the NHS in future? It is not just a question of commissioning within an existing landscape of provision in different sectors, but a question of commissioning new services and new capital projects that do not fit into the hospital trusts. Will that be done at a national level? Will it be the responsibility of the CCG? Who will be responsible for the provision of finance for this kind of project?

[Baroness Masham of Ilton]

My Lords, this group of important amendments illustrates that good care for all is what is needed. I shall say a few words on Amendment 79 on long-term conditions. As has been said, there are many long-term conditions, and there is great anxiety all over the country because of the change. What the Minister says today will be very important and may allay some of the distress. There is a shortage of district nurses, which is an important issue for people who need dressings for leg ulcers, for example, which can last for a long time.

On a positive note, there is telecare and telehealth and other new technology for monitoring. People can be monitored in their own homes. If something goes wrong, people can call emergency services. Scotland is doing much better than England, and other countries in Europe, such as Poland and Holland, are using the system a lot. England could do a lot better for people with long-term conditions.

All the amendments in this group are exceedingly important and I am glad that my noble friend Lord Ramsbotham mentioned prisons and people in cells. When I went to see prisoners being processed, a GP was trying to fathom out what to do with a really serious alcoholic. I asked, “What are you going to do?”, and he replied, “If only I had some rehabilitation services for alcoholics, I wouldn’t have to send him to prison. What will happen is that he will be in and out all the time”. Many things can be made better, and I hope that the noble Earl will give us some hope when he responds.

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My noble friend Lord Greaves asked about the role of CCGs in setting up new services. I wish to be clear: CCGs will commission services, they will not provide services. A key commissioning function for CCGs will be securing the provision of services in their area to ensure effective provision of such services. If a new service is required, a CCG could choose to factor capital costs into the contract when commissioning the services.

[Lord Greaves]

In the example that I provided, it is not a service that I am talking about; it is a facility—a new building that hosts a series of services, some of which will be GP services, some of which may be commissioned by the CCG, and some of which may be hospital services. Who, in future, will be responsible for deciding to build a new building in, say, Clitheroe, and commissioning the contracts and so on in deciding to do it?

[Earl Howe]

I am grateful to my noble friend, and I apologise that I did not cover that point. There are, of course, capital budgets. These exist at the moment and will continue to exist. The Commissioning Board will hold them. Where a capital project such as a building needs to be pursued, that money—as opposed to revenue money, which of course funds the commissioning of care—will be used to finance projects that are shown to be cost-effective and necessary to meet the needs of patients in a local area.

[Lord Greaves]

I would like to get to the bottom of this while we are talking about it. At the moment, those capital funds are provided either through the PCT or by the PCT from the money it has in the bank. In future, who will hold the funds to fund those capital projects?

[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.

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[Baroness Finlay of Llandaff]

My Lords, I hope that the Government will be able to give some assurance that environmental health will be recognised in the new public health services that will be established. I became acutely aware of the importance and contribution of environmental health when I chaired the House of Lords Science and Technology Select Committee inquiry into allergy. Environmental health officers were most helpful on issues around climate change, air quality, diesel particles and the hyperallergenic effect of high levels of diesel in making pollen more allergenic.

When I chaired the inquiry into carbon monoxide poisoning, I had a great deal of help from the Chartered Institute of Environmental Health on gas safety and gas regulation. It brought its engineering and architectural expertise to inform that inquiry. It is important to be aware that although these professionals are called environmental health officers, they come from a broad range of backgrounds and bring in engineering, architecture and what you might broadly call environmental physics to inform the health debate. They are complementary to but not duplicated by the provisions in standard public health medicine.

[Lord Greaves]

I echo everything that the noble Baroness, Lady Finlay, has just said. The noble Lord, Lord Rooker, has raised some extremely important issues and hit some serious problems at the heart of the Bill. I am not sure that his solution is the right one, but it needs discussion. I am sorry that the noble Baroness, Lady Gould, in not in her place because she made the important point that the meaning of the phrase “public health” has evolved over the years. The core Public Health Act 1936 was about the role of local authorities in relation to public health and what we now call environmental health.

In the 1974 local government reorganisation, public health functions were split. Half went to the health service, the other half remained with local government, and the phrases “environmental health” and “environmental health officers” were largely invented at that time to distinguish the new environmental health service from what had previously been public health. Of course, in two-tier authorities environmental health is a function of the lower-tier authority.

The noble Lord, Lord Rooker, made a very important point. We have some amendments coming up, probably in a few hours’ time, when we will discuss this, so I will not say a great deal more about that now except to make the basic point that it is very important indeed that environmental health functions, which already rest with unitary authorities but in county and district areas will rest with district authorities, are properly integrated with the rest of the public health function.

As the noble Baroness, Lady Finlay, said, the things that environmental health officers and departments do are astonishingly varied. If a problem is clearly a public health or environmental health problem, they will find the expertise, go out and get expert advice if it does not exist within that authority, and tackle it. It is a very important function indeed. However, at the national level, environmental health, as defined in the Local Government Act 1974, rests with the Department for Communities and Local Government, not with the Department of Health. It probably ought to rest with the DCLG because it is very clearly a local government function, but again, at the national level, the Government need to take action to integrate it into the new, very important public health functions of the Secretary of State.

[Lord Whitty]

My Lords, as my noble friend Lord Rooker has said, I have an amendment in this group that is precisely the same as his, except that it was directed at a different point. My noble friend has made a strong case for this particular dimension of addressing environmental health issues, but there is also the wider issue of the lacuna in the Bill, as has been touched on. There is one major shift that the White Paper, the post-pause White Paper and now the Bill are driving for: the shift of public health, including environmental health, to local authorities. However, the Bill itself reflects very little of that. The noble Baroness, Lady Thornton, in response to the group of amendments before last, referred to the fact that work was being done on it and said that she hoped this would see the light of day fairly soon.

The establishment of Public Health England as part of the department-cum-executive agency is hardly reflected in this Bill at all. The issues that relate to the respective role of the local authorities, to which my noble friend Lord Greaves has referred, are not reflected in this Bill at all. We have a major shift, going back to pre-1974, that makes public health the responsibility of local authorities. We have a recent history in which all the expertise in environmental health departments has been seriously squeezed because the requirements are mostly non-statutory. EHOs have been diverted on to other issues. We are coming into a further famine of local authority funding. The local authorities will be receiving this new public health responsibility at a time when their total resources are being squeezed and restricted and other priorities are impinging.

Before this Bill completes its course, we need greater clarity on how public health and environmental health responsibilities are to be carried out; what the structure of them is going to be; what the co-ordination among local authorities, and from the centre to the local authorities, is going to be; what the exact role of Public Health England is going to be; and, frankly, at least some broad indication of how that is being resourced.

[Lord Greaves]

The noble Lord raised the question of funding. Does he agree that this will perhaps be exacerbated in two-tier areas because the ring-fenced public health funding will go to the top-tier authorities, whereas the environmental health functions will remain with the lower-tier authorities—which indeed are extremely squeezed on their funding because this is what we call “other services”, which are not regarded as a priority—and finding a way of getting some of that funding down to the lower-tier environmental health authorities is a question that needs to be looked at?

[Lord Northbourne]

My Lords, perhaps I may intervene now to ask the Minister to say, when he is winding up, what happens if the local authority does not do what it is supposed to do? It is not impossible. In fact, there is a great variety, as we sit here today, in the performance of local authorities. They are managed by elected members, who want to please their electorates, so there are all sorts of arguments for thinking that not every local authority is going to be very enthusiastic about these additional objectives.

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[Lord Greaves]

My Lords, I shall turn to Amendment 75ZA in my name in a minute. First, I congratulate the noble Lord, Lord Rooker, on putting his finger on the extremely important issue of the role of district councils where there is a two-tier local government system. I do not agree with everything that he said about local government but I agree with a great deal of what he said about the problems that we have. This legislation is designed for unitary authorities—metropolitan districts, London boroughs and the unitaries in the rest of England. The Government do not seem to have thought out exactly how it will work in two-tier areas. This is not an issue of principle or challenge to the Government. It is an attempt to make this system work better in practice when it comes in.

My amendment would remove the provision in the Bill that deletes shire districts from the definition of local authorities in new Section 2B to be inserted in the 2006 Act under Clause 9. I would argue the case for that but the noble Lord, Lord Rooker, suggests that co-operation and partnership is the way forward. My noble friend Lady Tyler has put forward an interesting amendment about the role of CCGs in local government functions and how that might work. There are other ways of looking at it. I sincerely ask the Government if we can have discussions between now and Report to thrash this issue out properly. In a sense, it is a technical matter but it may not work. In replying to a previous amendment, my noble friend Lady Northover said that we have to join up all the different areas that affect public health. The crucial word is “affect” because there is no doubt that a great deal of what district councils do affects health.

Like the noble Lord, Lord Beecham, I am sadly old enough to have been on a local authority committee, which was a municipal borough, in Colne before 1974. It was the housing and health committee, which received regular reports from the medical officer of health. The public health authorities at that time were the lower-tier authorities. While they have problems of resources and the ability to do things, again in the words of my noble friend Lady Northover, they have local insight and expertise, which has to be tapped into.

District councils carry out some duties. The Labour Front Bench amendment, which refers to retaining existing duties for districts, is important but it is an absolutely minimalist approach. A huge amount of what district councils now do are things that they do not have a duty to do but which they have taken on because there were problems and things that needed doing. They do it because they have powers but not necessarily duties.

Housing is crucial and there are still many council houses. If you are looking at listing the two or three main public health improvements which have taken place in this country in the past 100 years, the massive provision of council housing for 50 years of that time must be near the top of the list. They provided people with decent homes, decent environments and decent estates when previously they had lived in appalling slums. This has been a huge achievement, yet it was not a public health achievement; it was a housing achievement. Even now, they have their strategic role as housing authorities, which is very important even if they have pushed away their council housing to other organisations. Over the past 100 years the improvements in public health are down to improved housing conditions. Even poor housing conditions nowadays are usually immeasurably better than they were 100 years ago. This is all down to the work of local authorities. A huge amount of work still has to be done, particularly with the bottom end of the private rented sector—the sort of areas I know too well in my own ward.

All this kind of work is lower-tier local authority work. It encompasses the whole environmental health regime, which noble Lords have talked about, from food inspections to dealing with pollution and air quality. A huge improvement in public health was led by the introduction of the Clean Air Acts, which have made air breathable when, as many of us remember, it was hardly breathable. So local authorities tackled air pollution and air quality. Indeed, they are responsible for all sorts of things, such as contaminated land and pest control licensing. Of course, the lower-tier authorities are also responsible for enforcing the legislation on the prohibition of smoking in enclosed public spaces and for the whole operation of street cleansing and refuse collection—litter, dog fouling and tackling graffiti. You might think, “What has graffiti got to do with public health?” If you live in a neighbourhood that has been allowed to become run down, people are allowed to spray graffiti where they want and the whole place is rotten, the effect on people’s quality of life and their mental health is huge.

The whole of planning is about public health in many ways—the built environment, the nature of the built environment, the provision of facilities and the regeneration of areas. Leisure services and facilities, playgrounds, parks and the whole of the public realm have a huge effect. If people enjoy living in a town, a village, a suburb, a neighbourhood or wherever they live, if it is a pleasant place to live in and enhances their quality of life, their basic health will improve. The council may provide parks, playgrounds, sport and recreation activities, sports development activities, indeed the whole leisure field. However, a great deal of what local authorities do is discretionary.

In recent years, district councils particularly have taken on a lot of work on behalf of other authorities. They have been funded by PCTs and other parts of the health service, by central government and by other sources. I will briefly mention some of the projects that are going on in my own area of Lancashire at the moment: living and eating well schemes, run by the leisure trust; stop-smoking schemes; healthy workplace schemes; suicide prevention; intensive family support schemes; and schemes to reduce infant mortality by encouraging young women having children who otherwise would not go to prenatal classes to attend them and by putting them in touch with professionals. Things such as the provision of cycle racks may not appear to have anything to do with public health but, when you think of it, it is obvious that these are practical local schemes. Many such schemes are not very expensive but they are being funded at the moment through the PCTs, the health service and other bodies, and it is crucial that these kind of schemes continue.

I repeat the point I raised earlier about resource allocation. If this new system results in the district councils—the lower-tier authorities in two-tier areas—losing their funding, a lot of these schemes will not exist. What we need in all these areas is an audit of existing resources, an audit of what goes on at the moment and some kind of duty on the upper-tier authorities that will receive a lot of this money to pass the money to the district councils for appropriate schemes in appropriate places.

I do not know the best way of writing district councils’ roles and opportunities into the Bill, but I am absolutely clear that they have to be there. The present situation, in which all the Bill does is to strike them out and say they are not here in relation to public health, is not acceptable. So I ask the Minister whether we can have some discussions between now and Report stage to get this sorted out, as it is very important.

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[Baroness Northover]

My Lords, with Amendments 73 and 75, the noble Lord, Lord Rooker, has correctly identified the importance to public health of collaboration and co-operation between agencies. The noble Lords, Lord Rooker and Lord Greaves, come from somewhat different perspectives with regard to local government, perhaps based on their relevant or not relevant experience in this regard. I am, as ever, very grateful when my noble friend Lord Greaves offers me help, and we certainly can have discussions. Noble Lords, as these debates have shown, can offer experience across a wide area of knowledge and we would be remiss not to tap into that.

[Lord Greaves]

I thank my noble friend very much indeed for that. While the noble Lord, Lord Rooker, and I may come from different ends of the spectrum, we end up in the middle agreeing on a way forward.

[Lord Beecham]

And so do I.