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Lord Astor of Hever: My Lords, in my capacity as President of the Royal Society for the Prevention of Accidents, RoSPA, I was pleased to see, in the gracious Speech, the emphasis on partnership in the proposed reforms of the National Health Service.

That is particularly important in relation to prevention of accidents which remain the leading cause of death for people under 35 in this country. When I refer to accidents, I am sure that most people immediately think of the daily carnage on our roads, or the efforts we make to ensure safety at work. But today I should like to concentrate on the Cinderella area of accident prevention--home safety--which needs all the help it can get, and would benefit in particular from partnership working.

For many years, through its home safety liaison service, RoSPA has sought to bring local authorities, trusts, and other organisations together to promote accident prevention in the home. In some areas this has been highly successful and partnerships are thriving. Sadly, there are not enough of those success stories.

In some areas, health service personnel do not appreciate the scale of the accident problem, or that anything could contribute to its reduction. They seem content to leave the responsibility for prevention work to others. Some make an isolated attempt to tackle the safety problem issue without reference to local authorities and voluntary organisations already working in the same area, thus duplicating effort and wasting precious resources. There is sometimes a marked reluctance to take an active role in a positive partnership with a wholehearted sharing of resources, both human and financial.

RoSPA feels that that is short sighted and it welcomes the encouragement now being given to the health service to be more responsive to joint working and resource pooling in the future. Too often, this hidden epidemic of around 3,800 deaths and 3.5 million injuries at home has been overlooked when public health issues are under

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discussion. Those practitioners who undertake work in this field often have budgets as small as £200 per year. That is clearly insufficient for effectiveness.

Just over a year ago, RoSPA took the initiative and launched the first national strategy for home safety. Copies of the document called Home Safety - Making it Happen have been distributed to around 2,000 key people, including chief executives of all health authorities. Working groups, including representatives of the DTI, are now developing its 20 recommendations, among which are pleas for a more holistic approach to accidents from government departments, as well as local authorities and the health service and for better collection of useful data in a standardised format. That would allow comparability--which is essential to aid prioritisation--and assist in target setting and subsequent evaluation. Information also needs to be much more accessible to those who need to use it. Good national data are critical but thay are not enough to facilitate local action. Information must be available at local level as well.

It is laudable and natural for those from a health background to focus effort on the reduction of severity of injury. They often forget, however, that if the original accidental incident were to be prevented, neither death nor injury could ensue. RoSPA makes accident prevention, not injury reduction, its prime objective. RoSPA's mission states

    "RoSPA's purpose is to enhance the quality of life by exercising a powerful influence for accident prevention".

More willingness to tackle the root causes of accidents could ultimately pay higher dividends. Some of these may be addressed by the proposed health action zones. RoSPA will be watching the effectiveness of those with interest. The society also keenly awaits details on the role of the new regional development agencies which could be useful additional partners in the drive to prevent accidents. Perhaps the Minister could provide some information on that.

A substantial portion of the 12,000 deaths and 9 million accidental injuries a year in the UK could be avoided. If they were, think how much more the health service could do to help the sick. A modest investment in accident prevention now would reap handsome rewards for years to come. I look forward to that day.

5.35 p.m.

Lord Winston: My Lords, I should like to touch very briefly on a subject mentioned by the noble Lord, Lord Clement-Jones. I want to concentrate on one issue with regard to health and the health service. It is a matter which did not feature much in the Queen's Speech and which I think is worthy of attention because I fear there are problems looming ahead. I speak of my concern for the training of young doctors, post-graduate training and the Calman specialist training scheme.

I do not believe that it is unreasonably chauvinistic to say that medical education in this country is without parallel anywhere in the world. People talk of the NHS as being the envy of the world. That may or may not be true. That may be, to a certain degree, hyperbole. However, there can be no argument about our medical

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education. It is based on an extraordinary university system and the ability to project the best medical science. It has a solid clinical base of bedside teaching, which is so traditional in Britain. There is that wonderful mix of science and understanding of how the patient works.

I remember, when in training, the privilege of having great clinical teachers; for example, the great Donald Hunter, who used to jump into a ward full of students. They looked terrified at the bear of a man striding towards them with an extraordinary grimace on his face.

On one occasion he picked up one of my colleague's charts, looked at it and said, "This patient has pain in the abdomen, but where is the pain?". A student tried to describe where the pain was. Donald Hunter was not impressed. He said, "Old Chinese proverb, 'one picture worth a thousand words'. Where's the body stamp, Sister?". Sister was deputed to go out of the ward to collect the stamp, which was normally used to stamp a picture of the abdomen in the notes of the patient. Donald Hunter took the body stamp and placed it on the ink pad. He took the student's white coat and stamped it on one lapel. He stamped him on the other lapel and then on the forehead, the abdomen, the back and the sides. He stamped him 50 or 60 times. We never forgot that drawing a picture of the abdomen was the thing to do when trying to explain where the abdomen is.

I should like to refer to one of the problems with our medical education at present. I say this with care because, as an academic from Imperial College, I have an interest. It happens that Imperial College School of Medicine has one of the most adventurous training programmes for students. It is a daring, bold programme and one about which I believe there may be some concerns. However, it is innovative and it will be interesting to see how it works out.

Within two weeks of entering the medical school, the young students are put out into general practice. That may be a good thing and certainly may be a way for them to get an understanding of how people communicate. But it may also run the risk of damaging the formalisation of teaching that we had of the structures within the old anatomical system. Not all the universities have gone down that route. My son, who is at Cambridge, is studying traditional medicine, which I believe is quite outmoded. To my mind, the accent on two years' anatomy is largely a waste of time.

I have to say that I learnt my anatomy by cutting people open, but I do not believe that I did that much damage in the process. There are ways around that and I shall return to that aspect in a moment. However, there is a need for that systemisation. The old clinical clerk system is one which is important and one which follows the student right through his whole training and then through specialised medicine.

While I greatly endorse and totally support the Government's commitment to primary care, we have to be careful not to get the balance too far in one direction. It is absolutely right there should be a service which is more controlled by primary care groups and by GPs, but there are problems with that system. For one thing, it does not entirely control the fragmentation that we have

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seen in the health service. One of the problems with the recent reorganisation is that patients have not always been able to go to the best specialist centre; they have been forced to go where the contract is. I hope that that is something that the Government will consider in terms of the primary care groups. That is a real problem which may still arise in our health service.

In a major teaching hospital there is a unique research base, a unique clinical base and the ability to get those complex patients together to provide the best treatment. That combination is the example to everyone in the country and actually promulgates the best medicine. One of the problems that we have found in the old Royal Post-Graduate Medical School is that, with the fragmentation that has taken place, we have had far too few patients coming through in our speciality. Consequently, the young members of staff have not had the experience in looking at these varieties of complex patients.

There is nothing like a single complex disease to understand the simple basis for medicine. It used to be said, "Know syphilis and you know the whole of the human body". Nowadays we say, "Know diabetes and you know the whole of medicine". The reason for that is that those two diseases actually affect pretty well every organ in the body in a variety of ways. One of our concerns is that, with the more specialised areas, there may be a real loss as regards the way that we are going with the continued fragmentation and the failure to concentrate. While I totally approve of what the Government are saying about decentralisation, I must utter a word of caution: it must not be at the cost of those great institutions which actually lead our medical practice. I believe that that would be a grave error. Indeed, it is one that we are already at risk of seeing.

I turn now to the Calman training scheme. There is a major problem at present. I am not entirely sure whether this is the fault of the Government or the fault of the profession itself as regards how it is handling those recommendations. Perhaps we should, for example, consider my own general speciality of obstetrics and gynaecology. Although I do not practise the latter, I am still an obstetrician and gynaecologist. At present, there are 128 specialist trainees who have completed their training but who are without a consultant job. That is a terrible waste. Admittedly obstetrics and gynaecology is the worst case, but it is a major and important specialty. To some extent that is also true in some of the other surgical specialties. These people have to go back to basic jobs. It is understandable that there will be an elution of good people away from that important specialty. Oddly enough, it will not control the other problem; namely, that in order to staff posts we shall have to import people from overseas who are not necessarily always of the standard that we would like to see.

The other problem with the Calman system is that I do not believe that it is capable of promoting the best research activity. To have this year outside doing research is too limited. In my own career, there is no questioning the fact that, had I not had the ability to take three years and do decent research, I would not be a

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useful academic. The problem with the Calman system is that you have to get on to the gravy train. You have to start the system because of the competition. However, once you have started it, you cannot do a long period of research very easily.

I turn finally to the question of surgical training. We are at risk of promoting people who are deficient in surgical skills, both in obstetrics and gynaecology, and, indeed in general surgery. It is a major problem because they are not getting enough surgical practice. There are several reasons for that: first, there is the fragmentation of the health service which has meant that fewer cases have been coming through to the specialist centres; and, secondly, because there are often very long waiting lists many patients are electing to go for private treatment, which means that they are not available for younger doctors to operate on.

There are serious concerns that that situation combined with the statutory reduction of hours to which the noble Lord, Lord Clement-Jones, referred, will create a major problem. Whether we like it or not, you cannot have a well-trained service and actually reduce the number of hours of work below a certain level. It simply is not possible. If the training scheme is shortened to five years, I believe that that will result in major deficits; indeed, the edge that we have in our medical practice will be lost.

The key factor at present is the risk of litigation. If we continue to have too few consultants, there will be more litigation in the health service. It is becoming increasingly costly. Noble Lords may be aware that only two or three weeks ago someone received a settlement from my own trust in west London of half-a-million pounds for a trivial injury. What is happening with litigation in the health service is really quite extraordinary. There are real risks that it will escalate. The Government could solve the problem by recognising that there really is a need for a bigger consultant led service. That will be essential if we are to maintain the quality and the excellence to which we have become accustomed.

5.47 p.m.

Lord Rix: My Lords, this is probably my last contribution to a debate in your Lordships' House as Chairman of MENCAP. Next week I follow in the hallowed footsteps of my noble friend Lord Allen of Abbeydale and the noble Lord, Lord Renton, in becoming president instead of chairman. Those two noble Lords have made distinguished contributions both to wider public affairs and to MENCAP and that satisfies me that there is indeed a rich life after vacating the chair. I have studiously avoided any reference to moving up as in this country and in this life I am not sure that further elevation beyond your Lordships' House is constitutionally possible.

Before I turn to the gracious Speech, perhaps I may reflect for a moment on the reference by the noble Lord, Lord Winston, to the training of the medical profession. I believe that this also applies to other professions; for example, the nursing profession, dentistry and those working in hospitals, especially in regard to people with

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a learning disability. It is true to say that when the majority of doctors, GPs, specialists, nurses and dental surgeons go out into the world of work they have little knowledge of the 1.2 million people with a learning disability and of how their often complex needs have to be met. I believe that the noble Lord, Lord Winston, will agree that we have to make some advances in that direction.

To that end, we have been in touch with the Department of Health in the recent past, in collaboration with the Royal Society of Medicine, many of the Royal Colleges, including the Royal College of Nursing, the Royal College of Physicians and so on. We are attempting to set up a seminar and further operations which will impinge upon the training of the medical profession and ancillary professions in the years to come as to how to look after, treat and welcome people with learning disabilities.

It is not only to learning disability that this applies. It also applies to disability generally. There are some horrendous stories which are current about people being admitted to hospital and not receiving the immediate attention, care and nursing which they require. Indeed, the noble Lord, Lord McColl, who unfortunately is not in his place, could underline that with a story which he recently told to me after meeting the All-Party Disablement Group. I hope that attention will be paid to the wider field of training of the medical, nursing and dental professions in the near future.

In addressing the gracious Speech, I want to pursue the theme of rights, particularly rights within the justice system, but, briefly, other rights for people with learning disabilities affected positively or negatively by the Government's programme. The gracious Speech marked an historic turning point for people with learning disabilities. It promises a disability rights commission to assert the rights of those who, lacking a voice, have lacked the basic rights that others better placed take for granted. I am less enthusiastic about the changes in social security rights which the Government propose. I do not know at quite what point the curate's egg becomes so addled as to be inedible, even with the Bishop watching, but I do note, with regret, that the benefit savings envisaged substantially exceed the cost of those changes in incapacity and disability costs benefits, which otherwise we welcome.

I turn now to the rights enshrined in the youth justice and witness Bill. The Government have announced under that heading measures to give greater protection to vulnerable witnesses. This implements recommendations in a report, Speaking Up for Justice, which reviewed the treatment of vulnerable or intimidated witnesses in the criminal justice system. The report's 78 recommendations may be taken as indicating how far that system has been falling short of delivering justice for people with learning disabilities.

It is a basic test of a civilised society that justice should be accessible to those with the least natural advantages in assessing it. I see the new justice Bill as moving substantially closer to enabling our society to satisfy that test. While giving evidence in court about things that are personal and painful is likely to be a

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stressful experience for most of us, for people with learning disabilities it can be a particularly traumatic experience.

Their vulnerability in that situation stems from some, or all of, limitations of social and emotional maturity, communication difficulties, dependence on those whose conduct they are challenging, misunderstanding of what is at issue, anxiety to please, a misplaced sense of guilt and lack of experience of anyone willing to listen to their opinion. People with learning disabilities have often been denied even the opportunity to get as far as the witness box, the view being taken that they are not capable of giving evidence. However, if there is difficulty in this regard, the Government's own recommendations--the use of video interviews, video recorded cross-examination, evidence by live television link and the use of screens--are all special measures which can form part of the youth justice and witness Bill. These special measures can also apply to youthful witnesses, as already hinted at by the noble Lord, Lord Warner, in his most excellent maiden speech, and dwelt on by the noble Lord, Lord Mackenzie of Framwellgate.

MENCAP'S research report, Barriers to Justice, published in 1997, suggested that people with learning disabilities are twice as likely to be victims of crime as other people. The research also showed that many crimes against people with learning difficulties go unreported to the police, particularly when the victim is living in residential care. The victim himself or herself may not recognise that a crime has been committed and there is a tendency to disguise criminal acts by labelling them as "abuse" and tackling them as professional or staff disciplinary problems. Offences of violence are described as "abuse"; theft is described as "financial abuse"; and rape or sexual assault is described as "sexual abuse". We need to ensure that acts which have been dealt with as abuse but which were in fact criminal offences are properly recognised for what they are. Violence is violence, theft is theft, rape is rape. This involves better education--not in terminology but in ways of thinking--for people with learning disabilities, but also for their carers and other professionals.

Rights, of course, depend not only on what the law says and on knowledge of what the law says: they depend on those who manage the various parts of the justice system being trained to work with people with learning disabilities in securing their rights, rather as I have just suggested for the medical profession. This extends from the police recognising that someone has a learning disability and knowing how to work with that person, and what help they need in working with them, to members of the Crown Prosecution Service, solicitors and barristers, and judges themselves. There is currently little or no training in learning disability for members of the legal professions. I express the hope that the noble and learned Lord on the Woolsack will lend his considerable clout to securing full implementation of the training recommendations in Speaking Up for Justice. Without such training, the right to justice would be like the right to cycle in the fast lane of the M.25--on days when the M.25 has such things as a fast lane.

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Your Lordships will have read with growing horror, as I have done, the accounts of abuse in children's homes and in homes for adults, such as the Longcare homes in Buckinghamshire. Those of us who remember the Nuremberg trials remember the consolation, albeit slender, that the horrors described in graphic detail had not happened here in the United Kingdom. We cannot say that of the pain, humiliation and torment inflicted on our fellow citizens in the "house next door". One such house was tellingly described as "The Snow Queen's Castle". We are pleased therefore by the Government's commitment to increase care standards, as set out in the social services White Paper, stressing the need for action on the deployment and training of inspectors and others who can monitor and enforce the standards of decency we expect for our fellow citizens and who will actively seek the views of residents as to the quality of care offered.

We look to the youth justice and witness Bill for the training, structures and procedures which will pave the road to equal justice with something more substantial than good intentions. I would hope that we might also look for a switch from the namby-pamby penalties of the Mental Health Act applied in the Longcare case to the fivefold more punitive provisions which could be secured through a mainstream criminal offence of harming or exploiting a vulnerable adult.

It will be the highlight of my MENCAP chairmanship if I can have the assurance that my daughter, who is 47 tomorrow, and all those other sons and daughters with a learning disability, will have the same protection through the criminal justice system that I enjoy myself. I know that others of your Lordships entertain the same fervent wish.

5.58 p.m.

Lord Annaly: My Lords, I apologise for missing the speeches of some noble Lords but I had a meeting within this building which I had to attend. I shall be here for the rest of the debate. It is a great pleasure to follow the noble Lord, Lord Rix, whom I heard on the wireless this morning giving, with great aplomb, a preview of what will happen on Monday night. I was told at lunch today by a person from the BDA that the noble and learned Lord the Lord Chancellor has brought in a rule that there now has to be a properly qualified sign language interpreter for deaf people who have to go to court. I give full credit to the noble and learned Lord the Lord Chancellor for bringing in that rule.

On this the fifth and final day of debate on the gracious Speech I shall focus my remarks on a vulnerable group in society: deaf and profoundly deaf adults and children who have mental health problems. If this group of people have been born deaf--as opposed to becoming deaf in childhood, in adolescence, or as adults--in many cases they do not have a voice of their own. They communicate entirely by sign language.

In speaking on this subject and asking questions about what implications there are for this category of disabled people in our society, I must first declare an interest. I have a deaf half-sister in her thirties who relies on sign

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language to communicate. She lives in a semi-sheltered situation in Blackburn with a Royal National Institute for the Deaf outreach team who provide back up when required. I cannot speak highly enough of the vital support which they provide for my sister.

I also have a profoundly deaf stepsister who has already gained a degree at university and is now studying law at a university in London. She requires a note taker when attending lectures two days a week and has been unable to obtain a grant of any kind to help towards the cost of the note taker which amounts to a not inconsiderable sum. It costs about £14.75 an hour. The position at the moment is that, while undergraduates who are deaf are entitled to receive a disabled student's allowance to enable them to pay for communication support, postgraduate students are not able to apply for any allowance. This does not seem right. Deafness and the disability it brings do not stop when someone stops being an undergraduate.

I am also a trustee of a charity called SIGN which campaigns for the deaf with mental health problems. This has started up and supervises a growing number of residential homes for deaf people with mental health problems, some on a low support basis and others on a high support basis.

The Government propose in the recent White Paper that as far as possible there should be an all-inclusive education system for all children. I believe this could have a detrimental effect on deaf children who are sign language users. It will be difficult for this group of children to meet their linguistic and social needs in mainstream settings. They have a greater need for a specialist school setting. The number of such schools has fallen in the past 20 years. There are in the order of 20 in England now. The Government's proposals for total inclusion can only put these remaining specialist schools under threat, with local authorities under pressure to educate this group in all-inclusive settings. This will have the knock-on effect of putting these deaf children at greater risk of developing mental health problems.

All options in education should remain open so families can choose the best for their child, which may mean a specialist school or a mainstream school with specialist support, such as, for example, sign language communicators. There needs to be a national policy and standard which is set by the Government who should then ensure that the required standards are maintained all over the country. This would remove the lottery factor whereby the availability of specialist services varies hugely in different parts of the country and is dependent on the attitude of the local authority. I would be grateful if the Minister would bring my comments to the attention of his noble friend the Minister responsible for education.

I turn from the education of the deaf with mental health problems to the availability of, and their ease of access to, healthcare. In the Government's recent White Paper the mechanisms for funding highly specialised services seem to me to be unclear. Under the new commissioning arrangements it is likely that it will become increasingly difficult for deaf children and

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adults to access specialist services. For instance, the RSCAG (regional specialist commissioning advisory groups) are intended, under the Government's proposals, to commission specialist and highly specialist services. Some regions may recognise the need for that and give it priority and funding. Others may not, as indeed happens in the case of dyslexia which is still not recognised by all local education authorities.

A few months ago in Oxfordshire, where I live, I conversed with a teacher at a dinner. I have a dyslexic daughter who attends a special school in Warwickshire. The teacher asked me what I meant by dyslexia. She explained that Oxfordshire does not recognise dyslexia. I do not know whether the right reverend Prelate the Bishop of Oxford can put me right on that matter, but he is not present at the moment. It seems odd that some counties do not recognise dyslexia. I imagine it is all a matter of finance because if they recognised dyslexia, children with the condition would have to be statemented and that would involve more money.

Surely there is the need here for a standard which should be set and policed by central Government. The standards and objectives need to be specific and not vague. The user groups such as the deaf should be involved in shaping the standards and objectives.

How does a deaf person who relies on signing communicate with his or her general practitioner, for example? The availability of communication support varies from area to area. I heard only today at lunchtime that the notice required to book communication support--that may involve a sign language interpreter or someone who can lip read--varies between a few days, perhaps less than a week, to months. This obviously presents difficulties for a deaf person who has to see his or her GP at short notice. One cannot possibly plan an urgent appointment weeks or months ahead.

Under the proposed OATS (out of area treatments), specialist trusts such as Pathfinder NH Services will make two-year retrospective claims to the primary care groups. I understand that the PCG may or may not pay. How can a specialist service be developed on this basis and how will it receive its funding in the meantime?

I shall now discuss deafness in the community more generally. There is still great ignorance among the population as a whole about deafness. A 1995 survey commissioned by the Royal National Institute for the Deaf showed that, although five million people in the UK could benefit from a hearing test, a MORI survey showed that nearly four times as many people have had an eye test as have had a hearing test. Over 40 per cent. of people who report hearing problems have not even talked to their GP about that, let alone had a test. MORI found that only 22 per cent. of people aged over 55 have had a hearing test in the past 10 years, compared to 87 per cent. of people in this group who have had eye tests. That seems odd. This is in spite of the fact that, according to medical research, about 48 per cent. of over 55s have a hearing loss.

6.7 p.m.

Earl Baldwin of Bewdley: My Lords, there is much to be welcomed in this Government's approach to

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health, which is the subject I wish to address for the next few minutes. Their emphasis from the first on public health, and on the links with poverty, has been admirable, and has given the concept of preventative medicine a much-needed boost. Like others I lament the lack of legislative time for a Food Standards Agency, which when it comes will give a health-promoting role to good nutrition as well as removing the conflict of interest that lies at the heart of MAFF.

The gracious Speech talks of building a modern National Health Service to meet the needs of "the whole nation", and to replace the internal market with arrangements based on "partnership". If this is to be so, then I suggest that we need to take account of a factor which appears too little in Government pronouncements: the exponential rise of treatments such as osteopathy, acupuncture, medical herbalism, nutritional and environmental medicine, healing, homoeopathy, known collectively as complementary medicine.

At the meeting last month in Barbados of the Commonwealth Health Ministers a recommendation was made which stated in part:

    "National policies for health need to give greater consideration and recognition to the existence of traditional and complementary medicine and their value to health development and health sector reform".
The Ministers noted that such treatments should be seen as complementary, not alternative, in partnership--foreshadowing the words in the gracious Speech, re-emphasised by the noble Baroness in her introduction--with more conventional approaches. They also, and this is significant, proposed a working group to develop an action plan to promote and integrate complementary medicine within national health systems, and this working group will be based with the Global Initiative For Traditional Systems of health within Oxford University's Health Services Research Unit.

The latest reliable surveys show that one in three people in the United Kingdom has at some time used complementary medicine. That is an enormous number of patients, although if your Lordships' House is at all representative it does not in the least surprise me. This includes two-thirds of rheumatoid arthritis sufferers and two-fifths of those with HIV or AIDS. In the South Thames Region 93 per cent. of responding GPs and 70 per cent. of responding hospital doctors have referred patients for complementary treatments; overall nearly 40 per cent. of GP partnerships appear to be referring. With medical schools increasingly including complementary medicine in their curricula, and with practising doctors asking for training in complementary therapies, the days of so-called fringe medicine are long since gone.

The Journal of the American Medical Association gave us last month the picture from across the Atlantic. Forty per cent. of Americans used complementary medicine in 1997--100 million people! Visits to complementary medicine practitioners have increased by nearly 50 per cent. since 1990 and have now exceeded by far, with 629 million visits, the number of visits to all primary care doctors. As a regrettable aside,

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a relic doubtless of the days of mutual hostility, fewer than 40 per cent. told their doctors what they were doing.

There must be a reason for these remarkable statistics. They have very little, if surveys are to be believed, to do with a flight from science, which is how the old guard from the mainstream sometimes like to portray it. I believe the explanation is far simpler, and it is a very relevant one for governments everywhere. It is about plain, straightforward effectiveness, and most probably cost-effectiveness at that. The Chief Medical Officer appears to share this view; when he was asked in an interview published in the Lancet on 29th August whether there might be an increased role for complementary medicine, he replied:

    "Yes, . . . because it's what people want and people definitely benefit from it".

I have been a student of this field for many years now: as a patient, as a keen observer of existing practice and development, as Joint Chairman of the Parliamentary Group for Alternative and Complementary Medicine, and Chair of the British Acupuncture Accreditation Board, as a past Council member of the Research Council for Complementary Medicine. It is my firm conviction that complementary medicine, if given the chance, has a key role to play in the major health issues of our time.

All the evidence I have seen suggests that most long-term survivors of AIDS--those who were diagnosed five or more years ago--are alive and well because they have discarded their medication (if indeed they ever took it) and embraced a range of non-conventional treatments. The field of cancer is littered with survivors against the odds who have used unorthodox approaches, never systematically followed up by orthodox workers who alone have access to the funding and institutions that can provide the sort of research that is nowadays called for. The same is true of multiple sclerosis, heart disease, asthma and many of the conditions that come under the heading of mental illness. Some of your Lordships may have read of the successful trials of the herb St. John's Wort in the treatment of depression.

I could speak on this for a long time, but will only say now that I have become persuaded that it is a strength but also a weakness of modern medicine that it is wedded to a gold standard of evidence borrowed from the hard sciences which, when applied across the board, can actually retard genuine progress by distorting the true picture. I do seriously question whether the agenda of the academic and clinical research establishment chimes any longer with that of patients; and when these get out of kilter, I believe that society needs to take notice.

I cannot leave this subject without mentioning the question of safety. Modern medicine has brought many benefits, and no one in their right mind would want to jettison these. But it is unquestionably one of the most dangerous systems of medicine yet devised. Let me quote two findings from abroad and one from this

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country. In April this year the Journal of the American Medical Association reported that

    "The incidence of serious and fatal adverse drug reactions in US hospitals was found to be extremely high",
making them between the fourth and sixth leading cause of death. In May it reported that

    "51 per cent. of approved drugs have serious adverse effects not detected prior to approval",
and went on to say that

    "Each year prescription drugs injure 1.5 million people so severely they require hospitalization and 100,000 die".
And over here a study published a month ago found adverse reactions to be third in the list of causes of death, after heart attacks and strokes. These are not statistics of drugs misused: they are side-effects of normal treatment--institutionalised damage, one might say.

The worst enemies of complementary medicine could not say this of the therapies that come under that umbrella. I think there is no doubt that the relative absence of side-effects is one reason why the public has been beating a path to practitioners' doors, and I would invite the noble Baroness the Minister--who sadly is not in her place and we wish her a very speedy recovery--to consider the savings to be made in hard-pressed NHS budgets in not having to deal with the aftermath of treatments which are themselves for the most part expensive and high technology-based. At the same time I wonder how she would reconcile this with the current tendency among health authorities to cut back on their funding of complementary medicine, supposedly in the interests of saving money. I have worrying evidence of this happening on a wide front, almost as though it is a common policy, even in cases where clinical audit has shown great benefit to patients. The Parliamentary Group is compiling a dossier of such cases.

I have explained some of the reasons why many of us regret the Government's reluctance to back complementary medicine more strongly. I know that some help has been given, and we are grateful, even though it amounts to barely a fraction of a per cent. of the health budget. I know too, of course, that most complementary medicine is private medicine; but where it is so massively used, and where the Government are concerned, in the words of the gracious Speech, with the health of the "whole nation", this should surely not stand in the way of more positive support, especially for research. For otherwise it is the less well-off who will, as ever, miss out the most.

It remains to be seen how the new primary care groups will respond to the increasing demand for complementary medicine. If "partnership" means what it implies to the full, all may be well. If the larger groupings that will arise produce decisions against the use of chiropractic, Chinese herbs and massage, then we may well see a decline in their uptake. I wonder how the noble Baroness envisages the future development of the non-conventional health-care sector under the Government's new arrangements.

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I should like to end with a tale told in the 14th November issue of the British Medical Journal by the patient representative on the editorial board. She recounts how an excruciating knee injury threatened to put paid to her sponsored pilgrimage to Canterbury, and how the administration of the herb arnica saved the day.

    "I reported my miracle cure",
she writes,

    "to two colleagues at the BMJ editorial board meeting. One (a senior... editor) had never heard of arnica. The other (an American) knew it well. Before going home I went to pay tribute to...the BMA's herbal and medicinal garden...I noted that sage was useful for the disorders of the climacteric, admired the foxgloves and the periwinkle (we all know what they are for), and then on my way out, another label caught my eye: 'Arnica--used in the treatment of bruises and sprains'.

    "Does the BMA realise",
she concluded,

    "what seeds of subversion have been sown in the garden? If we all used these common herbs to cure common ailments what would happen to doctors and drug companies? And how much money would be saved by the NHS?"

6.18 p.m.

Lord Morris of Castle Morris: My Lords, Shakespeare's "Hamlet" opens with the changing of the guard. On the battlements of Elsinore, Francisco utters the immortal words:

    "For this relief much thanks",
words which everyone employed in the NHS might echo after reading the gracious Speech--"relief" that they will not be faced with massive reorganisations, multifarious new structures, bright new initiatives always described as "challenging" when what they are is "exhausting", and no looming increase in the avalanche of paperwork required by increasingly remote authorities.

What we are promised is one Bill, to end the internal market and GP fundholding, and replace them with something better. Good!

A period of peace will permit a number of successful initiatives to be developed without recourse to primary legislation. I am thinking particularly of the changing role of the nursing profession and the recognition of the need to train nurses differently. For too long, the relation of the nurse to the doctor has been at worst servile handmaiden and at best humble suitor at the feet of sapience. We all recognise the chestnut that a nurse is trained not to look after patients but to look after doctors. Not any more. I read recently an article in Practice Manager for June 1998 by Stephen A. Ryan, showing how his practice in Bolton has developed the nurse's role. After special training, four of his nurses began prescribing. Soon, they were allowed to prescribe all dressings for nursing homes. This alone saves thousands of pounds in his area. Nurse prescribing is spreading, and it is here to stay. Good. It gives patients a speedier service, GPs fewer interruptions, nurses increased job satisfaction, and the practice better cost control. Mr. Ryan has also pioneered a "nurse triage clinic". Triage is a process for sorting injured people into groups based on their need for, and likely benefit from, immediate medical treatment. It originates on the

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battlefield or at disaster sites, but in Bolton the triage nurse can be seen immediately, whereas the doctor may not have an available appointment for some time. The idea has spread like wildfire.

So there must be changes in the way nurses are trained. There must be far better career advice given in schools, for a start, and training in the old "practice rooms", now called "skills labs", in how to take blood, give injections and turn your patient must be reconsidered. Hospital doctors often complain that newly qualified nurses are marvellously adept at operating machinery the hospital has not got, but need six months on the ward to learn the basic skills. We must prepare nurses for the future; it is important that they learn new techniques--but not to the detriment of the fundamentals of nursing, like effective nutrition, maintaining the patient's skin quality, or learning lifting techniques.

This raises the question of whether or not nursing should become an all-graduate profession. There are good reasons why it should: graduates have higher status, they would guarantee deeper knowledge and higher skills, they would contribute to patient care on a much wider basis, starting pay would have to be improved. But it would debar entry to many people who are by nature fine and compassionate carers without being specially gifted intellectuals. Perhaps the best way forward is by greater investment in continuous professional development.

Probably the most conspicuous success in the new deployment of nurses is the nurse-led primary care pilots, set up under the primary care Act. The Government have wisely allocated £5 million to launch a second wave of them. Pat Cantrill, writing in Nursing Times, says,

    "primary health care will be successful only by ensuring the effective contribution from all members of the professional team".
It sounds obvious, a bland truism. It is not. Hitherto, it has been tacitly assumed that the leader, the manager, the boss in any primary health care system will naturally be the GP. It ain't necessarily so. The GP is the most highly qualified medical expert; it takes five years to train one, and a nurse can qualify in three years at most, starting from scratch. But not every GP is a good manager. Many are hopeless managers. There is a prima facie case for thinking that a nurse may be much better at allocating resources, liaising with other healthcare professionals, filling in forms, submitting returns and reports, and controlling the whole operation because so many of them are doing it anyway, by balancing their responsibilities for children, dependants and home against the shifting demands of their professional careers. So allowing the nurse to control and administer the service frees the GP to concentrate on clinical responsibilities and gives an opportunity to attract doctors into, or back into, primary care.

The first nurse-led scheme opened in Salford on 1st April last, led by Lance Gardner. It now has 2,500 patients. Catherine Baraniak runs another in Derby, and the present estimate is that eight of the 80 current pilot schemes are run by nurses. Of course, they have always encountered suspicion and hostility from

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some GPs. But that is vanishing like the morning mist on the mountain, and the example of university departments should help to dissipate it even faster.

In the olden days the professor was always the only head of the department. His was the kingdom, the power, and the glory. Then, as the administrative burden grew ever greater, and more boring, we allowed readers and senior lecturers to assume the headship, then even humble lecturers, and when the heavens did not fall, professors found they liked the new freedom to do what they were trained and paid for and did best more than they enjoyed wielding bureaucratic power. And so it will be with the primary care Act pilot schemes. All members will do what they are best at. As the Apostle St. Paul said (and he was not into partnerships, nor one of nature's "team-players"),

    "there are diversities of gifts ... and there are differences of administrations".
And if crusty old Apostles and bossy old professors can make power-partnerships work, so surely can the NHS. Many nurses, most nurses, are good organisers. They have to be. Nurses need to be trusted with greater responsibilities in healthcare. It looks as if this Government are willing to trust.

There is one other thing, however, that the Government should do, despite what I have previously said. The poet Dante, somewhere in La Divina Commedia (I cannot find the reference--answers on a postcard, please), has the phrase, apt to this occasion, "lunga promessa", meaning a promise long-delayed, or hope deferred, which maketh the heart sick. The delayed five-yearly review of the legislation governing regulation of nursing, midwifery and health visiting, commissioned from JM Consulting by the previous government in early 1997 and presented to Ministers in August 1998, is still firmly under wraps. If and when it does appear we may be sure of one thing: it will bear none of the stigmata of being a rushed job. A great deal of useful regulatory and developmental work is now being held up. For example, the UKCC's evidence to the review included recommendations for greater accountability in the regulatory system, broader powers for dealing with incompetent practitioners, and stronger sanctions in law for people purporting to be registered professionals when they are not. These are needed urgently, and major changes will require primary legislation.

I should end with a clarion call to the Government to give all nurses more pay immediately. And so I do, but I need not. For they have found a mightier champion than I could ever be in the Daily Mail, now running a high-profile campaign to secure justice for their case. I must confess I have previously viewed the Daily Mail as an organ slightly and regrettably to the right in its politics, but I must congratulate its editor and journalists on bringing this issue to the forefront of public consciousness.

So let me end where we all began, with the midwives. A few weeks ago they ran a demonstration outside the Palace of Westminster to publicise their problems. One

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placard boldly read "Midwives deliver. When will the Government?". My Lords, I think that in this coming Session of Parliament deliveries will commence.

6.28 p.m.

Lord Monson: My Lords, as I fear that most of what I have to say will be critical of one feature of the gracious Speech, may I start by giving credit where credit is due. Provided we are guaranteed that it will become law by not later than autumn of the year 2000, the Government are being entirely sensible in taking time over the freedom of information Bill, to ensure that we get it right.

When the matter of freedom of information is raised, most people's immediate instinct--mine certainly used to be--is that freedom of information ought to be all-embracing and that in peacetime official secrecy can hardly ever be justified. However, when one goes into the matter a little more thoroughly, it is evident that things are not quite so simple. For example, it must be right that Ministers should be able to speak with total frankness at Cabinet meetings, without having to worry about being pilloried later in print or on the airwaves.

The United States is always being held up to us as an example of a nation where freedom of information is universal and totally unrestricted. In theory, perhaps, but not in practice, as I know from personal experience. Government departments the world over are adept at stalling or leaving false trails when they think it expedient to do so.

Therefore, it is important to get the Bill right. I think the Government are wise not to try to rush it through in what will be a shorter than average Session. One hopes, incidentally, that both Houses of Parliament will be given an input to the draft Bill, and not only the House of Commons. We certainly want a freedom of information Bill, but it must be a properly worked out one.

I now switch to a topic where in my view--and I was pleased to hear that it is the view of the right reverend Prelate the Bishop of Winchester as well--the Government are mistaken: the proposal to give 16 and 17 year-old boys the green light to engage in homosexual activity.

When we last debated the matter, the noble Baroness, Lady Mallalieu, pointed out, in so many words, that a great many boys currently drive through those lights which are at present permanently set at red. Indeed they do. But the red lights at least deter a good many of them and, more important, they deter the older men who tempt them to drive recklessly across that particular intersection in their lives. I do not think and have never thought that the under-18s should be prosecuted for crashing the lights, and in fact very few are so prosecuted. But the older men who lead them into temptation certainly should be.

For as long as I can remember, I have taken the view that provided third parties are not harmed, consenting adults--I stress the word "adults"--should have the legal right to do as they wish in private with their own bodies, however dangerous or disgusting their actions may be. If grown men want to hold private homosexual

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orgies--which are currently still illegal, unlike heterosexual or female homosexual ones--or if they are warped enough to derive pleasure from hammering nails into one another's anatomy, then provided no permanent harm results, the criminal law should not interfere, however much most of us may disapprove on moral and aesthetic grounds.

However, where under-18s are concerned, libertarian principles must be subordinated to concern for the protection of minors. It is significant that when we were debating the proposal to outlaw under-age sex tourism to Asian countries, it was revealed that the United Nations consider young people under 18--not under 16--to be in special need of protection against sexual exploitation.

This Government are even more obsessed with health and safety than the previous administration, which is saying quite a lot. Yet although buggery is probably 2,000 to 3,000 times more dangerous than eating beef on the bone, the Government propose to facilitate the first, while continuing to ban the second. A young homosexual male in western countries is 430 times more likely to contract AIDS than his heterosexual contemporary. There are many other unpleasant and dangerous physical risks as well, some of which were outlined by the noble Lord, Lord Quirk, when we last debated the matter--he may well do so again this evening--to say nothing of possible psychological damage.

How many people in this country want such a fate for their sons, grandsons or nephews, if it can possibly be avoided and if they can possibly be steered away from it? That is, supposing they are balanced on the edge, as young men quite often are. How many people in this country, for that matter, want it for their daughters or granddaughters, given that the law is bound to apply to girls as well and given that girls of that age are vulnerable to being brow-beaten by dominant men to experiment with different sexual practices?

Dan Farson is a well known author and journalist. He is also an avowed homosexual. Yet he, as a homosexual, is totally opposed to any change in the law. In the Daily Mail of 15th July 1997, he wrote that the proposal to lower the age of consent is,

    "political correctness at its very worst, driven along by the aggressively show-off tactics of the so-called gay lobby. I fear the damage it will do is beyond calculation ...

    There can be confusion at that age about where your inclinations lie. Is it really sensible to make those difficulties even more acute by lowering the present 18 limit? Frankly, I doubt it ...

    when people are confronted with choices about their lives, they need the chance to work out the situation for themselves, in their own time and in their own way. Instead they are faced with the raucous proselytising of gay pride".

If, despite all that, the Government are still determined to press ahead, then at least let us protect young people from the most dangerous forms of homosexual activity. In the November 1998 issue of the Parliamentary Monitor, the right reverend Prelate the Bishop of Ripon wrote, in relation to anal intercourse:

    "This particular act is both a health hazard and for some a traumatic experience. There is a case for making this act illegal for under-18s even if other genital activity is permitted".

2 Dec 1998 : Column 552

I hope that the House and the Government will heed the wise counsel of the right reverend Prelate.

6.36 p.m.

Baroness Ludford: My Lords, I shall address my remarks to the proposed Bill on immigration and asylum, particularly concentrating on the asylum system.

The gracious Speech said that the Government's intention was to modernise the law in that area. It is becoming increasingly difficult to guess the direction that that "catch-all" term implies, but I shall go by the title of the White Paper: Fairer, Faster and Firmer. Like the right reverend Prelate the Bishop of Winchester, with whom I very much agreed, I wish the term "justice" to figure somewhere.

I look first at where we are now as a result of the legacy of the last government. I agree with recent assessments by Home Office Ministers that the present asylum system is a shambles. Many leading members of the present Government, like those on these Benches, were highly critical of many aspects of the Asylum and Immigration Act 1996. It created the worst of all worlds in which everyone loses, resources are wasted and unnecessary suffering created. Two-thirds or three-quarters of applicants are rejected, yet many of those are never removed. The White Paper gives a case history of an applicant who spent 13 years in the system, but at one point there was an extraordinary delay of two years and two months between the refusal of an application to remain and the serving of a deportation notice.

The test of a good and effective system should be that it is both efficient in use of resources and treats applicants with dignity and humanity. On that basis, the Government's new proposals are somewhat better than, but not sufficiently improved over, those brought in by the last government. Improvements are needed in both the procedures and the system of support.

There are currently almost 80,000 individuals stuck in the decision-making process. Around 58,000 applicants are awaiting a first decision and another 21,000 are awaiting an appeal. Shockingly, 10,000 people have been waiting over five years for an answer from the Home Office. Hundreds are detained arbitrarily without being given justification, without time limit and often in prison in conditions criticised by Her Majesty's Inspector of Prisons.

Meanwhile, tens of thousands of people are being inadequately but expensively supported by local councils, denied social security benefits but given subsistence shelter and food after court decisions under the National Assistance Act.

That has led to serious cost pressures on local authorities, especially in London. I declare an interest as a member of such an authority. It coincides with severe budget cuts devastating services like social services, at least in my own borough. But it also creates serious hardship and indignity for asylum seekers who may have to make 12-mile journeys across town to use

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vouchers at a designated supermarket. My own local paper in Islington reported a few weeks ago under a headline,

    "Refugees in food token bust-up",
that Albanian, Algerian and Romanian refugees had clashed in a fight over food tokens at a local housing office. The office had to be closed while police were called.

I do not know the rights and wrongs of the case and how much was caused by desperation and how much by deplorable behaviour, but the impact on local opinion, it may be feared, will not have helped to promote harmonious race relations. There is a rumour circulating that the council will have to close an old people's home and reopen it as a hostel for asylum seekers--which risks creating resentment towards foreigners. The need is urgent for a return to a proper national scheme of support, based on social security benefits, where the impact does not fall on local funding. I will return to that later.

Clearly, there is a need for an asylum system which offers real protection and prevents abuse. There needs to be a forum, a standard joint working party for practitioners, government officials and NGOs to discuss common concerns and attempts to agree procedural reforms. I hope the Government will consider that. It would be much better than the present adversarial battleground. It certainly seems true that there is a climate of appalling suspicion and mistrust between practitioners and the immigration service. Perhaps bodies like the Refugee Council, Amnesty International and the Medical Foundation--to all of whom, and others, I pay tribute--would identify the clash that exists as one between a positive desire to provide protection and a negative agenda simply of deterring arrivals and a culture of disbelief.

It seems to me that improving the system requires front loading of resources on initial decision making, because if the savings are made then with skimped decisions or inadequate information gathering the later costs of appeals will be all the higher. Often the poor quality of the initial refusal decision increases the likelihood of challenges through appeal and judicial review. Appeals can take years, delayed by poor organisation, lack of resources and adjournments. Most frequently these are requested, according to the Refugee Legal Centre, not by the applicant but by the Home Office or the court.

The system has been described as less a mechanism for making decisions than a series of processes for reviewing other people's decisions. I have not had the chance to visit Lunar House, but I have been told that it is aptly named because it might as well be on the moon, and its procedures are Dickensian. This is no doubt unfair on staff as well as on applicants.

The White Paper has some welcome elements. I will not tediously enumerate them all, but I would pick out the recognition of the contribution made to the life of this country by immigrants and asylum seekers, some of whom of course are present in this House. I would also welcome the adoption of an intelligence-led approach to

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the assessment of cases. That would be sensible, as is the use of new technology, especially the intention to have a computerised case management system, although there is considerable concern that it is behind schedule.

I am glad to see moves towards more openness and giving reasons for refusals, which is welcome. Also welcome is the emphasis on training and information. I wonder whether the Government will also consider training on gender guidelines, as advised by the Refugee Council--a special situation in which women may find themselves. I welcome new regulation immigration advisers to weed out the unscrupulous: that is indeed necessary. The six-month target for the combined decision and appeal is similarly welcome. The special treatment for older cases, which the Government are at pains not to call an amnesty, with special leave to remain is, I believe, essential to tackle the backlog. However, this still leaves some 20,000 awaiting an initial decision and 22,000 appeal cases. I would also mention the abolition of the white list and, finally, the firm intention to force the removal of those who have received a final refusal after appeal, as long as it is humane, respects human rights--and, as the White Paper points out, there is now the backdrop of the Human Rights Act. Of course, there have to be effective enforcement procedures.

The main concerns that I still have over the White Paper include the strengthening of pre-entry controls, like the Immigration (Carriers' Liability) Act and more airline liaison officers. The problem in this area is that it puts genuine refugees in a Catch 22 situation because those who are fleeing persecution are the least likely to have genuine papers or to apply for a passport or to be granted a visa. They are almost forced into the arms of traffickers or false documents. I wonder whether the Government will be considering a dispensation from fines for a carrier carrying genuine refugees who are unable to provide proper documentation, or to consider not applying controls to people from countries with serious human rights abuse when they arrive.

The five-day limit on appeals raises considerable problems, and not only for those who are stressed, bereaved and therefore disorientated, but to people like torture victims, who may have difficulty in getting the medical evidence in time. An option to extend that on compassionate grounds, and so on, I should like to see in the Bill.

The proposal for tighter controls on legal aid raises problems relating to the front loading of resources that I talked about. Proper legal advice and representation can shorten the whole process and save money in the long run. Therefore it seems to me that it could be a false economy to make cuts here. Could the Government consider more funding for the Refugee Legal Centre and the Immigration Advisory Service, which I know already get grants?

I know that other points will be raised by my noble friend Lord Dholakia and so I will leave those to him. The final issue that I will deal with is the system of support. It seems a reasonable proposal to identify the cost of supporting asylum seekers within the Home Office budget, but not to have a separate system of

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support with a national agency, giving support in kind and a system of dispersal throughout the country. The White Paper itself says that a cash support system is administratively more convenient and less expensive. It seems perverse really to go for a system which is expensive and complicated, when that remark has been made.

The proposal to disperse asylum seekers around the country and yet have support mechanisms only as a safety net after the support from friends and the local community has been exhausted does not seem to fit, because surely if applicants are expected to turn to their friends or relatives and the local community they are more likely to find that if they are living close to such people. The cheapest and best option in the context of a swifter and more efficient determination system, which will end the scandal which is said to exist of years on benefit, must mean a restoration of social security benefit. At the moment the Government reimburses local authorities to the tune of £165 a week for each adult, and £230 per family; so that does not seem to be a very efficient system.

There needs to be some cash allowance for necessities, including travel, phone calls and children's needs. Asylum seekers need to be housed in appropriate multicultural areas, with access to community agencies that can support them. The idea of having no choice of where to live may well be self-defeating if people are isolated from family and friends, as I have just said; and harsh means testing and lack of choice could leave asylum seekers destitute in London if they refuse to leave London. That could be far worse for the capital than for such people to live properly in London. There is nothing wrong as such with asylum seekers staying in London as long as the host communities are not being subjected to unfair competition with them for housing and funding, which is disastrous for race and community relations.

Before I say one last word about the European Union, may I ask the Government whether they are considering a relaxation to allow more asylum seekers to work? It seems to me that if we want, quite rightly, to save public money we ought to be allowing asylum seekers more chance to be self-sufficient and give something back in tax and skills. Perhaps, if a case is not decided after the target six months, that matter could be considered. Could the Government also look at speeding up the recognition of qualifications, for instance, for the 1,000 doctors at present unable to practise in the United Kingdom when there is, as was identified earlier by the noble Earl, Lord Howe, a nationwide shortage of doctors?

I deal finally with asylum policy within the European Union. It is disappointing that so far the Government have opted out of the chapter of the EU treaty on visa, immigration and asylum policy. We need to be part of a common EU policy not only because it is more rational and sensible but also so that we can influence the European Union in the direction of justice as well as efficiency. I hope that the Government will seek to opt into at least some measures under this chapter.

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In conclusion, I believe that the White Paper and thus the proposed Bill is likely to be (if the right reverend Prelates will forgive me for using the expression) a curate's egg: good only in parts.

6.50 p.m.

Baroness Seccombe: My Lords, I shall never forget this year's gracious Speech, for many poignant reasons, but my enduring memory will be the number of times that the words "modernisation", "modernising" and so on--whatever those words mean--were used. Even today those words were used in the first and last sentences of the speech of the Minister. I believe that it appeared 11 times in the Queen's Speech. The spin doctors use it in every soundbite and press release.

The right honourable Tony Blair, the Prime Minister, says that he wishes to create a modern country of which he can be proud. I am deeply saddened and perplexed that he does not share the feelings of millions of fellow citizens who are immensely proud of their country today, and always have been. Perhaps we should be thankful that past Administrations did not have the same obsession for modernisation; otherwise, we might not have inherited the wonders and richness of our history and ancestry.

I turn to the issue that I wish to deal with this evening. I hope and pray that this legislation is not brought before us as an example of modernisation. The reduction of the age of consent is far too important to be trivialised in this way. I understand that it will be subject to a free vote as a matter of conscience which I believe to be imperative in such a moral and ethical matter. An 18th birthday should be a very special and happy occasion. It is a time when young people are perceived to have reached an age of maturity and discretion. In the eyes of the law they become adult and take on added responsibilities. It is at this age that if criminal charges are pressed any subsequent case is heard in the adult court and not the youth court.

As it is such a significant milestone in a young person's life, I sought to discover what a person could do before reaching the age of 18. I refer to some of my findings. Until a person is 18 he cannot vote in general, local or European elections; he cannot serve on a jury; he cannot buy land, a house or flat; he cannot apply for a mortgage; he cannot act as an executor; he cannot open a bank account or apply for a passport without the signature of a parent; he cannot make a will unless he is a member of the Armed Forces; he cannot serve in Northern Ireland; he cannot make an application for civil legal aid; he cannot buy or sell alcohol in a shop; he cannot hold a licence to drive a medium size goods vehicle; he cannot enter a betting shop and place a bet or enter a bingo hall and play; he cannot be tattooed; he cannot join the Armed Forces without parental consent; he cannot take part in a performance of hypnotism; he cannot donate his body to medical science without parental permission; he cannot see an 18 category film; he cannot pawn an article in a pawn shop; and he cannot gain access to his school records. Lastly, I am informed that he cannot give blood until the age of 18. In addition, the Government have said that they would like to raise to 18 the age at which it is legal to purchase cigarettes.

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Some of these measures may appear to be more important than others, but I am sure that the government of the day thought that each was necessary to protect young people. Parliament in its wisdom voted that the age of consent should be reduced to 18 from 21. I did not support that amendment but accepted that as the age of majority was such a momentous milestone the majority view should hold. However, I cannot accept that the age should be lowered to 16.

Some young men of 18 are mature but others are still only boys who are coming to terms with their sexuality. These are the ones who are vulnerable and ripe for others to take advantage of them. Three weeks ago I read with horror how young people had been abused while in care. That care had been provided to children who had already suffered some traumatic incident in their short lives. As a result they had been taken in for protection only to find that for some there was further agony to come.

The Utting Report had a dramatic effect upon me. I felt deeply ashamed that we had let down these young people. I understand that most of the staff in children's homes are decent, dedicated people who try their best to create stability with as near a traditional home atmosphere as possible. As citizens we are all responsible for seeing that the welfare of young people in care is of the highest quality. I was pleased to hear that the Government proposed to introduce legislation to try to eliminate the horrors of the past.

To leave care to enter the wide world must be traumatic for any young person, but for a 16 year-old, who may never have had the guidance and love of parents, it is difficult to imagine if he is turned out from the only home he has known to fend for himself. At such a vulnerable time one can see how the advances of an older man can be seductive. It is our responsibility and duty to protect young people from those with evil intent. I believe that the age of consent is far and away the most important issue of any of those that I have quoted. Young men should wait until they are 18 before making a decision of such magnitude that could lead them into a different way of life.

As a mother of two boys and a grandmother of one I could not live with myself if I supported this Bill. As it proceeds through the House I shall do all in my power to see that the Bill as proposed does not reach the statute book. This Government is a master in the giving of messages. I plead with the Government not to give our young people such a disturbing message.

6.57 p.m.

Lord Hussey of North Bradley: My Lords, I must first declare an interest. Last month I ceased to be chairman of the Royal Marsden Hospital after 14 years. I am also a member of the management committee of the King's Fund. In that capacity I chaired two commissions on London's health services in which I was helped by four Members of your Lordships' House, not least by the noble Baroness the Leader of the House. Your Lordships may be interested to hear that in more than three years of deliberation on London's health not

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once was there any political division between the members of those commissions. In my opinion, on matters of health there is more that unites than divides your Lordships.

Perhaps my main interest--though hardly a financial one--is that I may be the only Member of your Lordships' House who was still in hospital on 5th July 1948 for treatment of injuries I had received in 1944. I clearly remember the impact that the announcement of the new National Health Service had on many of the patients. In those days sickness or illness was a total financial disaster. Some patients were in tears at the unbelievable concept of a service free at the point of delivery. I say that because, despite all the difficulties the NHS suffers, it remains a unique organisation. Like another unique organisation with which I have been recently connected, the NHS is the subject of constant criticism at home and undiminished admiration abroad.

The NHS, like the BBC, suffers from being known by three familiar initials which on their own are sufficient to catapult a story on to the front page regardless of merit. In 1948 the eyes of the world were on a great social experiment. It is appropriate that it should be the subject of your Lordships' attention as the 50th anniversary of the NHS draws to a close. Of course, there have always been problems. Nye Bevan, its founding father, disastrously miscalculated the cost of the new service when he predicted that as the health of the nation improved the cost of the NHS would decrease. Life expectancy and our expectations of treatment have risen. Advances in medical science have transformed care. Inevitably costs have soared.

In 1948 many doctors and nurses had worked in military hospitals both abroad and at home. Healthcare was another branch of our wartime service, fuelled by the same spirit that drove many young men and women to join up. That spirit flourishes undiminished 50 years later in the dedication of nurses, doctors and other staff in many centres, of which I believe the Royal Marsden Hospital to be one.

But as we look at what comes next, perhaps I may make one or two comments. First, I have long believed that there are two NHSs: one in the big cities where care is always fraught with difficulties, and another in the country where the standards are often superb.

In the second King's Fund report, we found mental health and care of the elderly in London in a dreadful state with the poorest and most disadvantaged in society finding the greatest difficulty in getting access to treatment. Last week, Sir Donald Acheson published the results of his independent inquiry into health inequalities. He too found the state of health of people in our deprived inner cities little short of a national disgrace. The King's Fund commented:

    "People in Britain in 1998 pay the price of poverty with their health and their lives".
Environment and public health are inextricably entwined. We shall not improve public health unless we tackle also the environment in which it languishes.

The gracious Speech forecasts the abolition of the NHS internal market and GP fundholding. It is too early to say what the effect of those changes will be. Our

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experience of GP fundholding was that it brought many benefits. Its replacement--primary care groups--is untested and will need considerable additional bureaucracy to work efficiently. I hope that this is not yet another change that will not help patients.

The internal market spawned a complex bureaucracy which reached down to the minutiae of hospital administration. This Government have pledged to remove much of the paper pushing of the past few years. I must say that after 18 months, from where I stand, the piles of paper have not diminished.

I hope very much that the Government will do more than just rejig the structure and will swiftly tackle the big issues of public concern. For that reason I applaud the Government's decision to put quality and clinical governance at the centre of their healthcare agenda. They are right to do so.

Your Lordships may know that the Royal Marsden is a specialist cancer service. Cancer has now overtaken heart disease as the biggest killer. We need specialist centres with the highest level of clinical skills to provide the best care. It is not acceptable that this country lags behind many others in Europe and America. Clinical practice ensuring that those who need specialist care are referred for prompt treatment to centres of excellence is what we require. Too often we get the referrals too late. The diagnostic and treatment skills of those specialist centres must be disseminated and practised across the whole country.

When I talk of clinical practice, I do not just mean the work of doctors. Development here will be increasingly the responsibility of nurses, as we heard from the noble Lord, Lord Morris of Castle Morris. To meet the challenges of present and future health needs, we must encourage the skills and dedication of our nurses. The crisis in nurse recruitment is critical. The new generation of young do not need persuading that public service is a worthwhile career any more than their grandparents did. But are we as a society prepared to reward their vocation fairly and not disadvantage it?

Over the next 50 years the success and quality of our health service will depend on the vocation, energy and skills of its staff. We must not work them so hard that they begin to believe that they no longer have the energy to deliver the service to which they are emotionally and practically committed. As the Government begin yet another reform of the NHS, I urge them to keep the wellbeing of the staff who will deliver that service as an unassailable priority.

7.5 p.m.

Lord Ahmed: My Lords, the gracious Speech referred to the proposed immigration and asylum Bill. I start by congratulating the Government on the abolition of the primary purpose rule. Such a swift response, so early in their term, showed commitment to fairer immigration policies and race relations generally.

The White Paper, Fairer Faster Firmer, is welcomed by me and many community groups as it outlines long awaited reform. I welcome the commitment to an informed and open approach. Many immigration practitioners and community advice agencies are

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looking forward to the systematic disclosure of the immigration directorate's instructions and the asylum directorate's instructions. For too long practitioners have had to rely on leaks, rumours and guesswork when advising their clients as to how IND staff will decide their case.

I welcome the Government's planned concession to the one-year rule in the case of victims of violence during their first year of marriage. But I have very real concerns about the burden on the applicant to "produce satisfactory evidence" before the concession can be applied. Such evidence is outlined in the White Paper as court orders, convictions and police cautions. It is important to take stock; and I ask noble Lords to visualise the "victims" whom this concession intends to assist. From experience I can say that such victims are usually scared, withdrawn and isolated individuals with little understanding of their rights or the legal process, and with a very basic knowledge, if any, of the English language. It is hard for me to envisage how such individuals could have reported the matter to the police, given a statement to the police or evidence in court, or instigated and funded civil proceedings such as an injunction and thus obtain the "satisfactory evidence" required. I ask the Government to think about the practicalities of the burden upon the applicant before the final drafting of the concession.

Chapter 5 of the White Paper relates to pre-entry controls. I confess that I read the chapter first hoping to see some form of commitment to the rights of disabled persons who wish to marry from abroad. As your Lordships will be aware, currently the requirement for entry clearance among other things is that the sponsor in the UK must be able to accommodate and maintain the applicant without recourse to public funds. Inevitably, the disabled sponsor will be reliant on public funds, and thus his or her spouse will not be able to satisfy the entry clearance requirements.

Sometimes the only opportunity that the disabled person has to marry is to choose a spouse from overseas who will agree to such an arranged marriage. If allowed to come to the United Kingdom, that person will enable the disabled UK citizen to live a more fulfilled and complete life. The law currently denies that. We cannot fly the flag for human rights and yet allow those requirements to apply to disabled sponsors.

I am aware that there is currently a Home Office policy to allow entry clearance where the sponsor is receiving benefits. But there would be no "additional recourse to public funds" by the applicant's presence in the UK. Despite that policy being quoted by practitioners to entry clearance officers, entry clearance is still being refused. If the Government are committed to that policy, let us urge them to implement it in the form of legislation in the forthcoming Bill.

Viewed purely from the financial point of view, it costs the Government more to provide care in the form of home helps, nursing and warm meals than to pay a married couple's allowance on top of the benefits already being received by the disabled sponsor. Further, it must be remembered that in any case the person from abroad would not be entitled to benefits for the first

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12 months. Can the Government calculate the human and financial cost and give serious thought to the implementation of a concession for disabled sponsors in the forthcoming Bill?

Finally, I welcome with some reservation the reintroduction of appeal rights for visitors; rights which were taken by the previous Conservative government. My reservations are threefold. First, appeal rights are granted only to those who wish to visit a "family member" in the UK. This discrimination against those with no family connections in the UK is not justified in the White Paper. Secondly, I have concerns as to the workability of a "fast" appeal in light of the delay and backlog in the appeals system. I hope that the appeal will not become a pure academic exercise long after the event for which the original visa was applied for.

Thirdly, I have real reservations on the true effect of the visitors bond scheme. The scheme is intended as a safety measure to stop "visitor visa" abuse. In my opinion, no financial penalty or bond scheme will deter a fraudulent applicant, but it will place undue financial hardship on genuine applicants and their families at a time when due to a family event resources may well be scarce. I hope that the scheme will not create a two-tier system where only the financially privileged will be allowed to enter the UK as visitors.

7.11 p.m.

Viscount Bridgeman: My Lords, I would like to speak briefly on the subject of the registration of domiciliary care workers. This is by any standards a large category. It is estimated that 2.6 million homecare hours are worked every week. Whereas regulations for carers for children, while not perfect, are reasonably well ordered, it is the care of the elderly which leaves much to be desired. The majority of assignments for the elderly are more or less unsupervised, caring for a growing section of the population which is very vulnerable to abuse.

We must recognise the desire on the part of all user groups in the care industry for a comprehensive register for all care workers, including home care, nannies, childminders and, of course, social workers. What the Government are currently proposing is a very limited register confined to senior and highly qualified social care staff; the general social care council. These highly qualified staff form a tiny proportion of the care workforce. Although influential in some types of work, they are rarely involved in day-to-day tasks and they are almost totally absent from the independent sector. Indeed, the need for action is greatest in respect of the unqualified people in that sector, who now deliver the overwhelming body of care. Regulation of all other workers is expected by the Government to rely on contracts of employment. I suggest that is inadequate.

One must appreciate the Government's concern that blanket registration requirements would inhibit the use of relatives, friends and neighbours, who form such a large and vital component for the care of the elderly. Nevertheless, a middle way must be found.

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Let us consider the reality. The workforce is in the main quite unstructured. It is highly transient and carers make frequent moves from agency to agency. It is possible for a rogue worker to walk out of a job in Aberdeen and take one in Plymouth. Ironically, it is with the most structured employers such as local authorities where the most rigorous checks apply. Agencies supplying the much less structured home care market in the independent sector have the greatest difficulty in checking applicants. Hospitals and local authorities simply do not have the time to give records of past employees and in frequent instances refuse to give references at all on grounds of legal liability. Genuine referees move on to new addresses; referees can be friends or relations of the applicant. The more enterprising applicant can give himself as the referee under a different name and address.

Furthermore, there is the growing number of individuals who arrange care for themselves under commendable initiatives by the Government, such as direct payments, which rightly encourage user choice. By their nature, these people are likely to be living on their own and to be especially vulnerable to abuse. The majority of them simply cannot be expected to find their way through the minefield of interviews and reference checks. They need a single and straightforward point of reference to give them the necessary reassurance.

There are some well organised user organisations within the care industry. These operate a code of conduct where interviews and checking are obligatory. They regard the setting up of a national care register as a matter of urgency. There is one area in particular where this would be of great value. At present, the ability to check on criminal records is hazardous. It is common for a carer to have multiple employers and to change these frequently. If these are in the same district the police may get, say, four checking requests in as many weeks and will have neither the time nor the inclination to co-operate. Nor in such circumstances will the proposed new central criminal records agency. But let us look at the position if there were to be just one central national carers register. The criminal records agency will then have only one inquiring source to deal with and communication between the two can be established in an efficient, productive and time effective way, including the vital annual update check of those already on the register.

As I have said, nothing must be done to discourage the vitally important care of the elderly by friends and relatives. But we must also have a broadly based register of carers, possibly based on a careful definition of the title "carer".

I understand that there is likely to be a delay of some one to two years before any register, however selective, is put in place and that the current thinking will apply to qualified personnel only. We simply cannot afford to wait that long, nor indeed to have such a restrictive--dare one say, elitist--base.

The care of the elderly can be a difficult and demanding task for which there is often scant reward or even appreciation. It is in the main not very attractive work, often, as I have said, unsupervised. Until a central

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comprehensive structure embracing substantially the whole of the industry is put in place many elderly patients will continue to be subject to abuse and in many cases physical danger. The register will not solve everything, but it will be an important first step in regularising the care sector and I do urge the Government to act and to act now.

7.17 p.m.

Lord Thomas of Gresford: My Lords, the noble Baroness, Lady Seccombe, rightly alluded to the rhetoric of modernisation which runs through the gracious Speech. Today we have had delivered to us a White Paper, Modernising Justice. So it is creaky, antiquated, on-its-knees justice which has stuffed 60,000 people into our gaols.

I find the proposals for youth justice rather tame. The noble Lord, Lord Warner, in his excellent maiden speech, said that the emphasis of the youth justice taskforce will be on earlier intervention and on trying to change the behaviour of young people. But he pointed out that even in the limited time in which his taskforce has been in operation, it is apparent that the Crime and Disorder Act 1998 left unfinished business. He said that the courts do not do enough. In so far as the details of the proposed Bill are known to us, they do not begin to address the weaknesses to which he referred.

If the Government want to be radical and reforming, the entire system of youth courts must be overhauled. The youth justice services, co-ordinated by youth offending teams in pursuance of a youth justice plan approved by the youth justice board--all those phrases come from the Crime and Disorder Act--are a means of ensuring best practice in dealing with young people after they have been convicted. They do not deal with the process of conviction itself. Juvenile offending is caused primarily by breakdown in the family. The child is not responsible for the inadequacy of his parents who fail to inculcate ideas of honesty and behaviour which are appropriate to his age. He has not chosen his parents.

Again, a secondary cause of youth offending is failure in schools. The child is not responsible for that. He may grow up in a depressing environment with a lack of opportunity for jobs or recreation which does not stimulate or encourage him to make the most of himself. That is just his bad luck. He has drawn the outside lane in the hereditary steeplechase. But the days of responsibility will come to him. There will come a point in a young man's life when he will be held responsible for his actions. The noble Lord, Lord Mackenzie of Framwellgate, for example, savoured the come-uppance of the Hartlepool hooligan. Of course, any society has ultimately to protect itself from crime by appropriate measures of detection and punishment.

However, I am concerned with the early years of a child's life when there is a hope that he may be deterred and guided away from a life of crime. Those are not new or original thoughts. Indeed, they were echoed in the speech of the noble Lord, Lord Warner. It was refreshing to hear his voice of progressive reform. That is a voice which has been drowned by the rhetoric, the baying of the dog fight, between Mr. Howard and

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Mr. Straw over the past five or six years. It is encouraging that he is back in the Home Office to calm things down.

As long ago as 1927, the Molony Report advanced the concept that the reformation and rehabilitation of the family was the keynote of the administration of justice. Juvenile courts were seen then as the instruments of reform. Then the Children and Young Persons Acts of 1932 and 1933 brought into being the juvenile court panel of magistrates for each petty sessional division and laid down the principle that their decisions in criminal and care proceedings must have regard to the welfare of the child. But those juvenile courts, valuable though their work has been, always operated with the traditional approach which involved the adversarial process, the proof of crime, a finding of guilt and, finally, punishment. The system had benefits and safeguards of due process but it has always criminalised youngsters at far too early an age.

It is interesting that in the 1960s, the noble Earl, Lord Longford, chaired a Labour Party policy committee which perceived, quite rightly, that society would benefit by the replacement of the juvenile courts with a more welfare-oriented council in which youth offending would be decriminalised, the goal being the care and protection of children rather than punishment and deterrence. He thought in those days that such a council could act as a forum where, as a first step, the child, the parents and social workers could come together to try to agree what had gone wrong and then institute measures to put things right. Only if the facts were disputed would the matter be referred to a family court for determination.

That report, a Labour Party policy document, was followed by a Home Office White Paper in 1965 which suggested that just such a family council should be brought into being to replace the juvenile courts. It happened in Scotland. That is why the children's panels in Scotland came into being. But the publication of those proposals in England and Wales coincided with the annual meetings of the Magistrates' Association and the Justices' Clerks' Society, both of which bodies in the climate of their prejudices in those days, heavily voted down such radical reforms.

Therefore, two separate systems have grown up in Britain. It is sometimes thought that children's panels derive from some ancient Scottish practice embodied in their separate system of law. But that is not the case. Children's panels were introduced there in 1968, following the 1965 White Paper. But in England and Wales, the Children and Young Persons Act 1969, following the lead that the Magistrates' Association had shown, retained the juvenile courts and the traditional findings of guilt and punishment.

In the 1970s, following the 1969 Act, there was a dramatic increase in custody for juveniles. In the 1980s there was a more enlightened approach. Sentences of custody for males between the ages of 14 and 16 dropped from 7,700 in 1971 to 1,400 in 1991. Therefore, prison for youngsters was being reduced until the beginning of this decade. We then entered into the period when "prison works" became the cry and the

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enlightened trend was reversed. Various events then took place. Well-established policies were turned over. Guidance in the Home Office circular which came out in 1994 limited the use of cautions to one for each offender. The 1994 criminal justice Act offered the court an increased range of sentences for 10 to 17 year-olds. Prosecutions became more regular for young people.

What we see in the Government's proposed Bill, referred to in the gracious Speech, is the idea that it will assist to lock up those young people more quickly; to process them through the juvenile court without any real thought being given to the process itself. Whereas I believe that the proposed sentence of referral to a youth offender panel is a step forward--and that, apparently, is to be proposed in the Bill--it is by no means the full answer.

In Scotland, the children's panels discuss solutions and disposals with parents and social workers in the presence of the children. In England and Wales, with the court system that we have, magistrates listen to submissions. They then retire and discuss the matter among themselves without any participation by parents and without the involvement and consent of those who are most concerned. The magistrates then give their decision and any explanation they may give--whether it is a sentence of probation, imprisonment or referral to the new panel--is confined to a few sentencing words.

Above all, the young person is still criminalised by the system which exists in England and Wales. As the noble Lord, Lord Warner, said, those young people who are socially excluded and disadvantaged need help and support as much as punishment for offending if the gaols of this country are not to become their permanent home.

It is essential that the practices and, indeed, the whole ethos of the youth court be drastically changed so that the young person is involved in what is to happen to him; that he is involved with recognising his problems and involved with working out the possible solutions. I hope that consideration will be given to that before the Bill comes forward.

The gracious Speech refers to provision for the protection of witnesses. That must be welcomed but the detail must be scrutinised with care. The noble Lord, Lord Mackenzie, seemed to be asking for the modernisation of justice for policemen as opposed to that for anyone else. He referred to lawyers and the sarcasm, forcefulness and venom they use against witnesses. On the other hand, he said, the police, with all their faults, provide a good service. The noble Lord should examine rather closely what he said: perhaps he will see that he is saying that the police are all good and lawyers are all bad. I do not believe that that is quite the case. There are two misconceptions in the noble Lord's remarks and there may be two misconceptions in the Government's proposals. One is that defendants are constantly personally cross-examining the victims in rape cases. That is not so. I know of only two such cases. The Lord Chief Justice, in the Court of Appeal, has given firm guidelines to judges on how they are to deal with such a situation if it arises.

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The other matter to which the noble Lord, Lord Mackenzie, referred was that irrelevant previous sexual history was brought into cross-examination for no other purpose than to embarrass the victim. That is not permitted in our courts. If it is irrelevant, it is inadmissible. Before anyone's previous sexual history is gone into in a rape case, the consent of the judge is required; it must be relevant. It may be that those provisions are addressing problems that have already been solved. I hope that witnesses will be protected when they give evidence in court, but I am concerned that the normal right of a defendant to defend himself fully and properly will be affected by the proposals that are put forward.

7.30 p.m.

Lord Colwyn: My Lords, before I begin, I apologise to the noble Lord, Lord Williams of Mostyn, for arriving in my seat so late. Sadly, I missed many of the earlier speeches and regret not hearing the speech of the noble Baroness, Lady Hayman, particularly as she kindly came and spoke to the annual dinner of the metropolitan branch of the British Dental Association on Monday night. I also regret missing the maiden speech of the noble Lord, Lord Warner, and the speech of the noble Earl, Lord Baldwin, whose views on complementary and alternative medicine I agree with 100 per cent.--perhaps, on reflection, 95 per cent. because I support the fluoridation of water supplies and know that he does not.

As a dental surgeon I must declare an interest and will start my remarks by saying a little about fluoridation. This Government came to power with promises to reduce inequalities in health and improve access to services. Dentists looked to them to address the problems of high decay rates in deprived areas and make NHS dentistry available to all patients who wanted it. For that the Government needed to remove all barriers to the fluoridation of water; provide financial incentives for practices to be established in deprived areas; and to improve funding for NHS dentistry so that those who had been forced by low fees to concentrate more on private, independent practice would be brought back into the NHS.

The Minister will not be surprised to hear that after 18 months of the new Administration the dental profession is disillusioned. The Government have been long on promises and short on performance. They have some good ideas but those are in danger of being strangled by red tape and smothered by indecision.

Water fluoridation has been shown throughout the world to reduce tooth decay. I know that I do not have to rehearse for the Minister the arguments on the safety and efficacy of fluoride at one part per million. There are far fewer bad teeth in the West Midlands, which has been fluoridated since the 1960s, than in the North West where water companies refuse to introduce this simple public health measure. The reduction in pain, suffering and removal of teeth--especially among children--is well documented. And we know that this beneficial effect lasts even into old age, where there is a reduction in decay in the roots of teeth which is difficult to treat.

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Sir Donald Acheson's report on reducing inequalities recommends water fluoridation as a means of achieving that.

Earlier this year in their Green Paper, Our Healthier Nation, the Government accepted the strength of the arguments for fluoridation, but a small vocal minority opposed it and the Government called for yet more discussion. No public health measure has ever been discussed or analysed so comprehensively. The dental profession look to the Government to take decisive action when they publish their forthcoming White Paper on public health.

The Minister of State has plans for a strategy for NHS dentistry. He made a speech in April promising this in the autumn. We are now at the end of the year with no sign of it. He wanted to work on it with the profession, but the formal request for this was not sent out until mid-October. Patients and dentists want to know what the Government have in store for NHS dentistry. So let us have no more delay, and perhaps a promise of action this evening, or certainly before the Christmas Recess.

The Government want to reduce oral health inequalities, meaning that dentists should be encouraged to go into unpopular places where at present it is difficult to make a practice viable. That will cost money. They will need to provide financial incentives and target resources to areas of the greatest need. Progress could be made through the Primary Care Act, brought in by the Conservative administration, by setting up personal dental services pilot studies. The first of those started in October, six months later than the equivalent medical counterpart. Progress is slow and negotiations made difficult by the Government's insistence that few extra resources would be provided.

With regard to access to NHS dentistry, the Government set up the Investing in Dentistry scheme and promised £19 million towards it. In July I asked the Minister how much of that had been allocated and was told that only £4 million had been spent. A later parliamentary Question in another place revealed that only £6 million had been spent in the first year up to 30th September, despite the fact that bids for over £20 million had been received. There was something about that on the "Today" programme this morning, and I may have missed an important government announcement. However, I should be grateful if the Minister could explain or write to me about the way that those bids are allocated. At present there appear to be no logical criteria applied to the applications, with relatively affluent areas having bids allowed and many deprived areas having no bids accepted.

Another of the Minister of State's challenges for dentists was for them to be better integrated with the NHS. Why is it that when any government paper is published, dentistry is always omitted? Dentists will not be on primary care groups, nor will they be on the NHS net--the IT network which will include all general practitioners and hospitals. There are many fine words from Ministers about the value of dentists, but few signs that they mean what they say.

The proposed legislation to "build a modern NHS" includes a provision to make changes to the Dentists' Act by order. Perhaps the Minister could give some

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indication as to when that might happen and assure me that there will be proper and full consultation with all interested parties before any amendments to the Act are initiated.

An example of what happens when there is no consultation was highlighted by a recent decision of the General Dental Council on the administration of general anaesthetics in dental practices. Without any warning the council decreed that only specialist anaesthetists could give such anaesthetics. Those of us who have offered that type of treatment in complete safety for many years--30 years in my case--overnight were prevented from doing so. Many dentists in specialised general anaesthetic practices have dedicated their professional careers to providing general anaesthesia and now find themselves overnight without a livelihood and little hope of compensation. Some practices have been the sole provider of a general anaesthesia service in an area, receiving referrals from both the community and hospital service. That service, which is needed by patients, will now no longer exist.

For instance, my partner has worked for 30 years with a colleague providing referral general anaesthetics for general NHS dental treatment for very young or difficult children. Perhaps the Minister has not considered how difficult it may be providing dental treatment--say, five or six fillings and a couple of extractions--for a three year-old. It cannot be done in the way that most of us regard as normal; it invariably requires a general anaesthetic. Overnight the facility has had to close down.

In a Written Question about this two weeks ago I tried to draw this problem to the attention of the noble Baroness, Lady Hayman. Her Answers were helpful but did not convince me that the Government had fully grasped the effect that that new regulation will have on hospital waiting lists and on finances. All those patients who were treated by dental practitioners will now be referred to the hospital service where the cost is approximately 10 times greater. I estimate an average of £1,200 per patient as opposed to £120. Many of us have had to equip our surgeries with expensive monitoring instruments and other apparatus, much of which has now become superfluous. I also asked whether the Government would be in a position to compensate those dental practitioners who had to buy their own equipment and did not receive any help from the regional health authorities. In her Written Answer to my Question the noble Baroness said:

    "The General Dental Council's amendment to its ethical guidance on general anaesthesia, sedation and resuscitation has not precluded the provision of general anaesthesia with dental treatment in primary care".--[Official Report; 19/11/98; col. WA220.]
I hope that the Government understand that the ruling has stopped all dentists from giving general anaesthetics and written off the £20.4 million allocated to regional health authorities between 1992 and 1994 specifically for further training and for contributing towards the cost of the mandatory equipment.

Finally, I heard yesterday that the Secretary of State for Trade and Industry and the Secretary of State for Health have issued a notice of appeal against a supplier of dental bleaching products--the technique whereby

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discoloured teeth can be saved from destructive crowning or veneering treatments by bleaching them at home. That treatment technique was the subject of a long and expensive High Court hearing last year which ruled in favour of the use of a CE marked bleaching product at home when prescribed by a dentist. Can the Minister say why this issue is being looked at again, who is likely to benefit and who will pay the massive costs which will inevitably arise during an appeal?

The dental profession looks to the Government to translate its ideas into action during this Session of Parliament. Dentists accept the need for change. We accept the need for modernisation, but such changes need a proper level of funding.

7.41 p.m.

Lord Quirk: My Lords, we have had several days of animated and very informative discussion on the Queen's Speech and I shall be brief in an attempt to spare the stamina of the noble Lord, Lord Williams of Mostyn, who has been here constantly for a long afternoon today.

I very much welcome the indications of the Government's determination to look further into the needs of young people, whether through the education system, through improving youth courts in our justice system, through better inspection of children's homes, or through strengthening,

    "the protection of young people from abuse of trust."
I look forward to studying the proposed legislation in all these respects, including the last, where the phrase I have quoted comes in the context of the forthcoming Bill on the age of consent, a matter already addressed by the right reverend Prelate the Bishop of Winchester, by the noble Baroness, Lady Seccombe, and by the noble Lord, Lord Monson, on these Cross-Benches.

Since almost irrespective of how old we are, there is always the risk of being unduly influenced by those in authority over us, recognising the need for special protection of the young implies the Government's belief that, so far as sexual consent is concerned, youngsters in their mid-teens are significantly more vulnerable to undue influence than those in their late teens or older. I trust that Ministers will reflect on the implications of this belief.

I am particularly concerned in this connection about the vulnerability of the school girls who--if the consent measure is like the one we had before us in July--will be affected merely as a matter of unintended consequence. That measure would have made consensual anal intercourse legal for girls of 16 as well as for the boys of 16 at whom of course the Commons amendment was solidly directed and on whom discussion was predictably focused. This is not the occasion to address an issue better left till we have the Bill before us, but we need to bear in mind the seductive pressures--both words in multiple senses--by which girls can be lured into anal sex, from allusions to avoiding unwanted pregnancy to hints about preserving some sort of technical virginity.

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As to what sort of "protection ... from abuse of trust" is to be afforded, I would submit that the best protected are the best informed, and I have to say that I am far from assured by what I have seen of the official information at present available for teenagers. If there is any area in which the admirable goal of "joined-up government" is

    "a consummation devoutly to be wished"
--and I quote "Hamlet" like the noble Lord, Lord Morris of Castle Morris--this surely is it, and I would urge on the departments responsible for education, health and home affairs the need for a speedy review of officially-sponsored material on sexual health for the young.

To give just one example, and that in relation to what I said earlier. We certainly need accessible information, in the plainest language, on the dangers of anal intercourse. At present, for very good and obvious reason, there is plentiful material in this connection on HIV and AIDS, and it is said to be both influential and effective. But such is the emphasis that there is grave risk of conveying the impression that "safe sex" is achieved once the insertive partner is equipped with a condom, ignoring the danger of lesions and other damage to the receptive partner.

Certainly, the numerous leaflets attractively produced and issued by the Health Education Authority give for the most part no hint of such dangers. For example, the current leaflet entitled Sexual Health Matters for Women repeatedly conjoins references to vaginal and anal intercourse as though they were equal options on a precisely equal health footing. Indeed, the only HEA document in which I have seen a specific warning about anal sex is the one entitled Gay Men and Safer Sex where, in relation to the practice known as "fisting", we are bluntly told that this can "cause tears inside the anus". I have seen no leaflet telling girls, just as bluntly, that so too can penile penetration.

I hope that when the Minister comes to wind up, we can be given the assurance that the Government will reflect on the points I have ventured to make, not least with respect to a vigorous, well-informed, wide-ranging, and relevant health-education campaign.

7.48 p.m.

Lord Lofthouse of Pontefract: My Lords, I shall confine my speech this evening to matters arising from the gracious Speech on health. I quote:

    "A Bill will be introduced to replace the NHS internal market which put hospitals, doctors and nurses in competition with each other. In its place will be decentralised arrangements based on partnership, quality and efficiency to put doctors and nurses in the lead in shaping local services".
Your Lordships will have heard my noble friend Lord Winston caution against too much decentralisation. I follow the noble Lord's argument. I shall express the situation as I find it to be in the area in which I live. I do that only because I know that in many parts of the country we will find similar experiences.

I have recently studied the British Medical Association and Royal Colleges consultative document Provision of Acute General Hospital Services. I understand that that

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report followed a report from a joint working party of the British Medical Association, the Royal College of Physicians in London and the Royal College of Surgeons of England which states that the effective size of a hospital to provide most acute services for medicine and surgery is one serving a population of 250,000 to 350,000. The report goes on to suggest that the ideal unit for fully comprehensive medicine and surgery is a hospital or integrated group of hospitals serving a population of 450,000 to 500,000.

While I recognise the expertise serving on the joint working party, I wonder whether we are getting too big and moving away from the loyalty and love that people have for their own hospitals. I also wonder whether these new units will become so distant that the average person will not be able to associate with them. Although I am sure that the public do understand that it may be necessary for there to be alternatives locally to hospital admission and that better outcomes may be achieved by travelling further to receive specialist services, I am sure they feel that distance should be minimised as much as possible.

When I think about the situation which is developing as to whether we have larger units, thus obliging people to travel further, I well recall the famous quote from Nye Bevan in 1947. He said:

    "I would rather be kept alive in the efficient but cold altruism of a large hospital, than expire in a gush of warm sympathy in a small one".
I can well understand that. However, when we consider that hospital services in this country have grown up around traditional populations in towns and cities, it is easy to recognise people's fears that, the longer the distance is from the area that they reside in to an acute unit, the more lives may be put at risk.

Since my younger days, and up to the present time, I have been accustomed to visiting the hospital in Pontefract where I live. I do not make that point to be parochial, because I have already said that many other areas in the country are probably in the same situation. I regret it now, but in fact the services of Pontefract, which have been provided for many years, may have to change and probably move to another part of the area. That will obviously cause people to engage in much more travelling.

I recognise that Pontefract is no different from any other town. I am aware that many other authorities in the country are undertaking work to close traditional general hospitals and develop services on a single site so as to serve a much larger population. However, there is current concern in the Wakefield district, as I am sure there is in other parts of the country, over the proposals to follow this pattern. People are worried about access to services that they have traditionally found available close to their homes.

I realise that technology has moved on and that the skills of doctors need to be used to the best effect. In many cases this involves sub-specialisation where a doctor is an expert on a particular part of the anatomy rather than on a specialised subject; for example, surgery. But people are worried over the

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balance between availability of services and the travelling time with which members of the public are increasingly having to cope.

I should like to quote a few statistics to the House, and do not apologise for doing so. I shall use them to emphasise the need for acute services in the areas such as Pontefract and Wakefield. This is quite understandable when you consider that Wakefield's aged standardised registration rates are the highest in Yorkshire for breast, lung, stomach and prostate cancer and that Wakefield's standard mortality ratio is 108 for all cancers--125 for lung cancer and 187 for cervical cancer. Moreover, Wakefield's aged standardised mortality rate is the highest in Yorkshire for lung and stomach cancers, second highest for breast cancer and third highest for prostate cancer. The five-year survival rate for breast cancer in Wakefield is joint worst in the country, at 54 per cent. For cervical cancer, Wakefield women have the second lowest five-year survival rate in the northern and Yorkshire region at 56 per cent.

I am sure that your Lordships will appreciate why the population of the Wakefield district is keen that an ideal unit for fully comprehensive medicine and surgery, equipped with the latest high quality medical and surgical services, should be provided. While people believe that the ideal would be a unit at each end of the district, as is the case at present with a general hospital at each end, it is recognised that the demand for funding of two such units is probably not realistic.

However, there is concern among a substantial number of the population because both the Wakefield Health Authority and the Pinderfield Pontefract hospital trust have made the strategic outline case for capital investment, including a preferred site. As I see it, this is the major problem and this is where the decentralisation comes in. Let us take, for example, a preferred site in an area which consists of about 315,000 people, as is the case in the Wakefield metropolitan district area--with probably 100,00 on the perimeters. If a hospital is to be built at one end of the area, like Pinderfield at Wakefield, it means that there will be no other acute services between Wakefield's Pinderfield site and York, which is something nearing 40 miles. This causes people a great deal of worry, which I am sure noble Lords will appreciate.

If the Wakefield Health Authority is successful with its bid to provide a new modern hospital--and everyone hopes that that will be so--there is a strong wish by, I think, the majority of people that it should be a site which is accessible to most of the people. I was very pleased to hear my noble friend Lady Hayman say in her opening remarks today that services should be provided around the people. If in fact areas like my own, and others in the country, are to be blessed with new facilities, which are very much needed, especially as regards acute services, I hope that they will be placed within the best possible spots, with the best possible travelling distances, for the convenience of all the people and not just a few. Those are the dangers that we face in Wakefield.

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I am sure that my noble friend the Minister will agree that the overriding feature must be the availability of care which will improve health. I submit that there must be a middle road which needs to be investigated and identified. Of course, if the recommendations of the consultation documents are given serious consideration, then such consideration must be given to the shortest possible travelling time and access to such facilities to ensure that the NHS is serving the population, with the needs of patients being paramount.

7.59 p.m.

Baroness McFarlane of Llandaff: My Lords, I must declare an interest as a retired professor of nursing. As such, I sat with great pleasure at the feet of the noble Lord, Lord Morris of Castle Morris, and heard his very authoritative and sensitive analysis of the situation in nursing. I was also greatly pleased to hear the intention of the Government, as stated in the gracious Speech, to improve care in our health service and the promise of a Bill to enable doctors and nurses to work in partnership, with much more emphasis on achieving quality and measurable improvement in performance throughout the health service.

I want to return to the contribution of the nursing service to the quality of care. All our aspirations for a better quality service--the National Institute for Clinical Excellence and its six-stage approach to establishing consistent clinical standards across the National Health Service--will be only a mechanistic tool unless flesh is put on the bare bones and breath is breathed into the framework by the quality of care given by individual health professionals to individual patients.

Nurses provide 80 per cent. of direct patient care and spend more time with patients than do any other health professionals. The patient's experience of nursing care is likely therefore to colour his or her experience of the health service to a great degree. There are signs that all is not well. Like many in your Lordships' House, I am distressed at the frequent reports I see in the media and hear personally about failures in care in the National Health Service. It seems to me that there are not nearly so many stories of the excellence of care that people receive in some places. Perhaps it is an occupational hazard that colleagues, friends, relatives and the people I meet tell me about their National Health Service experiences. Many are above praise but there is a disturbing increase both in informal complaints and those that reach a formal level.

Two recent examples in the press concern me. The first was a "personal view" contributed to the British Medical Journal of 21st November this year by a general practitioner. It is entitled:

    "Some NHS care is unacceptable".
She describes the distressing experiences of the husband of a friend of hers who in the last 12 days of his life witnessed the appalling lack of care given to the patients around him who were also dying.

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Evidently, the ward sister and the manager of consumer affairs--a new title since my time--agreed that the events described fell below acceptable standards of human decency but were likely to be repeated time and time again. She said:

    "I see things getting worse".
She ends her personal view by saying:

    "Witnessing poor care either brutalises you or outrages you. I am outraged, and I want to see acknowledgement of the problem and appropriate action".

A second recent contribution to the press was the publication of a monograph on "Trends in the Professions", edited by Digby Anderson, under the title "Come back Miss Nightingale". In his view most of the professions are now "professions without virtue". Nursing comes off not quite so badly as the Church, but the contribution on nursing written by an experienced nurse and a journalist GP recalls with nostalgia the traditional values of nursing taken from the monastic system, the uniforms based on Victorian housemaids, the Nightingale-style wards and the hospital school of nursing which, they said, generated a brand loyalty to the hospital. They looked back with nostalgia to the apprenticeship system of training, without all this high-falutin theory that is around these days. They believe that nursing has been sacrificed to feminism, careerism, to the managerial restructuring by the Salmon Committee and,

    "the Socialist leanings of the nurse leaders".

In the pain of the present, when we hear so many criticisms about lack of care, I think we must beware of looking back too nostalgically to the past and invoking Miss Nightingale. She worked indefatigably not only for change in nursing but for political change. She used a disciplined statistical approach to problems and wore down successive government Ministers to the point of exhaustion. Perhaps some of us should be emulating her example.

We must look at the facts. If there are examples of poor quality care--our perception is that these are increasing--we need to look at the causes. In the same issue of the BMJ in which the personal view of the GP was published, Hugh McKenna, Professor of Nursing at the University of Ulster, responded and rightly asked why nurses who have received a rigorous and systematic education would be party to such poor quality care. How could professionals, trained to give a high quality of care, allow standards to slide so far? He rightly says that there are explanations. Some of the explanations he gives are those that were given in a debate in this House based on an Unstarred Question asked by the noble Lord, Lord Morris of Castle Morris, on 16th June. Some of the points raised were these. We have the worst nursing shortage in 25 years, with more than 8,000 full-time posts across Britain vacant. We have the first ever shortfall in applications to nursing. There was a turnover rate of 21 per cent. in 1997. There are unfilled vacancies. And we have a retirement bulge, with 25 per cent. of registered nurses due for retirement by the year 2000. There is an acute shortage which inevitably affects the quality of care. If nurses are not there to give care, patients do not feel cared for.

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In addition, economies have been achieved in the health service by managers substituting care assistants, excellent in their own right, for registered nurses. The skill of the nursing workforce is thereby diluted. The resulting shortage of registered nurses often makes a proper standard of care impossible to maintain.

The worst blow to the morale of nurses in the past year was the phased introduction of the pay award recommended by the pay review body. That strategy has been adopted by successive governments, but it has eroded the role of the review body. The body was advised to take affordability into account. It did so, but then its independent conclusions and the justice of the case were laid aside.

I do not believe that the recruitment of nationals from other countries or the awards to clinical specialist nurses, desirable as those are, will cure the ills of the nursing profession. Morale is seriously affected and nurses vote with their feet. They find more attractive and less demanding work elsewhere. Nurse graduates are highly desirable in other sectors of society.

The changes effected in nursing education are often made the scapegoat for the state that nursing is in. The courses are said to be too theoretical. The graduate or diploma nurse is said to be less clinically competent than the products of the old hospital-based courses. The teachers of nursing are said to have a political agenda. I think we need to distinguish between fact and fiction. Project 2000 was designed to meet the needs of the nursing workforce from the year 2000 onwards with a broadly based introduction to the theory and the practice of nursing.

Since the inception of Project 2000 there have been tremendous strides in specialist and innovative roles in nursing, described so vividly by the noble Lord, Lord Morris of Castle Morris. I noted with pride that the first name he mentioned was that of a man who did a master's course and then a doctorate in the department of nursing at Manchester. That shows the contribution that graduates can make to the nursing profession in innovative roles and in saving the health service money.

In the future we shall need to consider carefully the role of nurses in the health service and the skills mix that we need. We talk about partnership but as nurses take over more and more functions that were once carried out by doctors we shall need to consider the skills mix and discuss between professions and across professions the kind of training that is needed. I have received from the council of deans and heads of the 64 UK university departments a paper entitled, Breaking the Boundaries, which sets out their approach to the future. They may see a graduate profession as a long-term goal in perhaps 10 years' time, but in the meantime, if standards of care are to be improved, much needs to be done as regards employment practices and the way in which nurses are helped to achieve future partnerships in the health service.

8.12 p.m.

Lord Naseby: My Lords, I am the final Back-Bencher to speak on the gracious Speech. Today we have had a varied debate stimulated by the maiden

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speech of the noble Lord, Lord Warner. As I prepared this evening's speech I wondered whether I was not to some degree responsible for the conditioning of the Prime Minister's modernising attitude to Britain. I say that because in May 1968 I was elected to the London Borough of Islington as a councillor, somewhat to my surprise I must admit. Not long afterwards I became leader of that council.

One of the first measures I had to consider was whether or not the new modernising concept of the previous Labour council with regard to estates, such as the Packington Estate, which comprise highly dense, small "boxes", was to be the way forward. I had to consider whether we should demolish the streets of late Georgian and early Victorian properties which were alleged to be slums. Indeed some of them certainly lacked the basic necessities for life. I took the view that those properties had the potential to be good homes for families. I saved great swathes of streets and squares that were due to be demolished in the forward plans. Our Prime Minister lived in one of those streets until recently. Certainly I have no regrets that he was able to live in and enjoy that lovely part of London.

That was the first experience of modernisation. The noble Lord, Lord Callaghan, was a member of the government when Lord Wilson introduced that first wave of the "white heat" of technology. The noble Lord, Lord Callaghan, may have warm memories of that period. I am glad that I opposed that plan and I am glad that I oppose three aspects of the Queen's Speech which I believe are wrong. Those three areas are the constitution, welfare and the beginnings of clear signs, in my judgment, of where the Government are going wrong with the health service. We understand that the noble Baroness, Lady Hayman, cannot be present for the end of the debate. However, I hope that the noble Lord, Lord Williams of Mostyn, will draw to her attention what I thought was a good contribution from my noble friend Lord Colwyn on the great problems faced by the dental profession. Tomorrow I shall visit a National Health Service dental practice for a routine check-up. That is an important part of the National Health Service and should not be left to wither on the vine.

The Prime Minister claims that his is a great reforming government which will modernise Britain. Noble Lords who read the House magazine will have noted the Prime Minister's first claim; namely, that 52 Bills were put on the statute book in the first Session. That is rather like an opening batsman claiming his half century. Sadly, that does not apply to an English opening batsman, but nevertheless elsewhere in the world that is seen as an achievement. The Prime Minister failed to mention the several thousand statutory instruments which flow from the 52 Bills. Who is cheering this new burden of several thousand new instruments that have flowed from this modernisation process?

Your Lordships have spent many days discussing devolution, but I do not believe any of us have discussed to any great extent how we will alter our procedures in this House, or the other place will alter its procedures to take account of the Scottish Parliament and the Welsh

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Assembly. Your Lordships will be as aware as I am that that situation is now just six months away. Is this the modern way to plan? If we are to be a reformed second Chamber, as I understand it, should we not have a lead role in relation to devolution and other constitutional issues? I understood that our role was a revising or a refining role. However, if the House will forgive my saying so, the Government gave us hell for accepting PR on the European elections Bill but rejecting the particular system which virtually ensured that candidates were controlled by parties rather than by the electorate as such.

Now I must move a little closer to today's main topic of the health service. I think it is generally accepted that public health is affected by welfare. I think the greatest tragedy that this Government have already "chalked up" is that despite all the rhetoric and all the good will that existed following the election, they have shirked the challenge of welfare reform. I do not know why Frank Field MP was not able to drive through his proposals, but your Lordships should be quite clear that compulsory funded stakeholder pensions are as inevitable as night follows day. These would complement the basic state pension and so return to families some of the responsibility for their own welfare and relieve the state of an ever growing burden of demeaning means tested benefits. They can be delivered by mutual organisations.

I declare an interest as the chairman of one of the friendly societies. We and all the mutual organisations have no shareholders. We follow entirely the wishes of our membership. We are non-profit-making. It can be done; it must be done. It is a tragedy that that particular issue has been shirked.

At last, I turn my focus on the National Health Service. Your Lordships should know that I was the only Conservative Member of Parliament who consistently voted against the health service reforms of the government of Mrs. Thatcher. At every stage, I went into the "No" Lobby, usually on a three-line Whip. Why? First, because I believe passionately that the NHS is a public service. At that time, there were clear signs of a move to some form of privatisation. Secondly, the then Secretary of State for Health was extremely anti the medical profession. Some of your Lordships may remember the references to the doctors and their wallets. Thirdly, I could not get from that administration a clear commitment to increase real spending on the NHS.

All that changed with the successor Prime Minister, John Major. His government gave a crystal-clear commitment to increase real expenditure on the NHS and, what is more, kept to it. He encouraged, rather than coerced, GP fundholding; he refined the PPRS; and significantly reduced the waiting lists. Despite the figures announced this morning, waiting lists today are not encouraging. It is not encouraging to know that the number of people waiting for more than 12 months has doubled since the election.

What do we have now? I speak as one who lives and works alongside a medical family. GP fundholding has been destroyed. All the ethos and spirit of successful group practices managing their own budgets, helping

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their patients, fighting for their patients, and saving money have been destroyed. Yes, that involved pitting one hospital against another to see which could do the better job and better respond to its patients' needs, but I repeat that all the good aspects of GP fundholding have gone. It is a tragedy.

Yes, there was bureaucracy. As one who, wearing my friendly society hat, works in the financial services industry, I have to say that if you want to see bureaucracy, cast an eye in that direction. Bureaucracy is even worse in that industry than in the NHS.

Sadly, nearly all that doctor-patient, practice-patient momentum has now gone. I understand that we are entering a brave new world in which co-operative primary care groups will look after 100,000 patients. As I hope that my background and life show, I believe that there is nothing wrong with co-operatives. However, leadership is needed in any group. In my judgment, as things stand, primary care groups are a recipe for confusion, inaction, and for resources being wasted on more bureaucracy. Clearly, local authorities will want to be involved. Alongside them are the commissioning health authorities and, of course, there must be the primary care trust boards. I ask Ministers: What will happen to all the little, but very important initiatives, which most practices were creating? Sadly, many of those have already been snuffed out as there is no money to fund them. That is already happening.

The second major area of health on which I want to comment is the PPRS. That is the mechanism for the interface between the NHS, as the purchaser of drugs, and the pharmaceutical industry. As your Lordships will know, we do not have price control in this country. We have a system that seeks to ensure that we have a profitable and responsible pharmaceutical industry. The system encourages research in the UK, encourages investment in new plant and encourages exports of pharmaceuticals. It has worked well under governments of all political persuasions. When I was a Member of another place, I served on the Public Accounts Committee. We investigated in depth the PPRS. Across all political parties, we came to the view that it was a good and sound system and that it worked well in the interests of the NHS, the pharmaceutical industry and patients in general. What on earth are the present Government doing? It is reported that they are considering dismantling that scheme. Perhaps the Minister can reassure us that that is not the position; if not, perhaps the noble Baroness, Lady Hayman, who I note is not in her place, will write to me and explain the situation.

The third area on which I should like to comment relates to the number of doctors. I listened with great interest to the noble Lord, Lord Winston. There is a national shortage of doctors. There may be a degree of prejudice on my part in what I am about to say--I hope not--but I believe that part of that shortage is because 50 per cent. of our medical students are female. I understand that we must have equality of opportunity, but all the analyses suggest that relatively few of them go on to be full-time practitioners, whether in general practice or in one of the other medical disciplines. That creates a shortage.

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Another cause of the shortage is that 25 per cent. of our doctors are trained outside the EEC. In addition, a huge number of doctors are coming up to retirement in the next five or six years. As one must add to that the fact that probably 10 to 15 per cent. of our doctors come from the EEC, surely it is time to recognise that one cannot have a health service without sufficient doctors, however important the nursing profession--and I listened with interest to the speech of the noble Baroness, Lady McFarlane of Llandaff. In my judgment, the vast majority of doctors should be UK-trained. That matter needs urgent attention.

If the Government are sincere in their modernising mode, that should be transparent. We still spend far too little of our gross national product on the NHS. At last, all political parties agree that there should be a public national health service. I suggest that it is time to reach agreement on how to move forward to increase the growth of the NHS budget.

Let us openly recognise that we ration treatment by way of the waiting lists. If we do not want to ration treatment--I suspect that no Member of your Lordships' House wants that--we must provide more resources. Let us all recognise that new drugs are vital. Let us leave the PPRS alone. Let us forget about limited formularies, black lists and white lists. Let the clinicians--not the bureaucrats--decide what is best for us, the patients. Let us try to find common ground, based on clinical excellence, and a consistent, stable framework, in which our doctors and all their support services can flourish. If we do not do that, I fear that all that we shall see ultimately are "illusions of progress" rather than real medical advances.

8.30 p.m.

Lord Dholakia: My Lords, may I too congratulate the noble Lord, Lord Warner, on his masterly contribution. He brings with him considerable experience, which will go a long way towards a balanced and reasoned approach to youth justice. I see that the noble Lord is not in his place, but perhaps the Minister will convey our good wishes to him.

I can do no better than follow up some of the points made by my noble friend Lord Rodgers of Quarry Bank in response to Her Majesty's gracious Speech. My noble friend was generous in awarding 9 out of 10 to the Government for trying, and 7 out of 10 for getting it right. I, too, am in a generous mood, having seen the noble Lord, Lord Williams of Mostyn, rubbing his eyes on at least 10 occasions. I have always awarded the noble Lord 10 out of 10 for humour and 9 out of 10 for the content of his contribution to this House. He lost a point by "tripping over" on at least three occasions in the previous Session. It is right and proper that I draw his attention to that.

Perhaps I may take up some of the matters that have caused us concern. On 25th August 1998 the Prime Minister announced that Parliament would be recalled on 2nd and 3rd September to consider new anti-terrorism legislation following the Omagh bombing on 15th August. Contained in the same legislation were the provisions to amend the Criminal Law Act 1977 to

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make it an offence to conspire to pursue a course of conduct that would amount to an offence where it was intended that the conduct would take place in a country or territory outside the UK.

Let me say straightaway that, while we on this side of the House had no hesitation in supporting the peace process in Northern Ireland, I believe that Parliament did not give sufficient time for the scrutiny of provisions relating to international terrorism. I therefore wish to stress that on future occasions we shall certainly press the Minister for the review and discussions in this House about this aspect of the Criminal Justice (Terrorism and Conspiracy) Act. I am sure that the concern expressed by many noble Lords at that time justifies that course of action.

During the passage of the Human Rights Act we on this side of the House pressed for a human rights commission to be established in this country. We argued that a commission is essential in Britain, as is now the case in Northern Ireland. We believe that such a commission would help public authorities comply with the new Human Rights Act and ensure access to justice. I urge the Minister to study the strong case made by the Institute of Policy and Public Research. In a foreword to the recently published book on a human rights commission, the noble and learned Lord, Lord Woolf, has this to say:

    "For me, the most important benefit of a commission is that it will assist in creating a culture in which human rights are routinely observed without the need for continuous intervention by the courts. Human rights will only be a reality when this is the situation".
We need a commission that is independent of Parliament and of other interests.

We welcome the proposal for a disability rights commission, and we welcome the review of the race and sex equality laws announced this morning. Equally, as the gracious Speech pointed out, as we commemorate the 50th anniversary of the Universal Declaration of Human Rights, we appreciate that the Government remain committed to the effective promotion of human rights worldwide. Towards that aim, we shall certainly press the Government to establish a human rights commission here, as they have done in Northern Ireland.

The third matter that I wish to raise relates to an important amendment moved by the noble and learned Lord, Lord Ackner, during the passage of the Crime and Disorder Act. He advocated, and we on this side supported, the establishment of a standing advisory council on criminal justice and the penal system. The matter was carried by this House, only to be rejected in the other place. I do not wish to rehearse all the arguments again; suffice it to say that sentencing tariffs have increased in our courts. The establishment of a relatively independent and dispassionate mechanism will certainly be helpful, particularly to ensure that crime and penal policies are not hijacked for political opportunism and other considerations.

Of course we welcome the work of the Criminal Justice Consultative Council and its area committees. We should study its revised terms of reference carefully. But we remain concerned that the Government did not accede to the weight of support from Members of all parties in this House.

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The Queen's Speech contains some welcome proposals in the area of youth justice and improved protection for vulnerable witnesses. However, I hope that we shall take into account the concerns already expressed by my noble friend Lord Thomas of Gresford. The proposed youth justice reforms include a new system for referring young offenders facing their first court appearance to a "youth panel", which would agree a contract with them regarding reparation and work to tackle the causes of offending. Once a young offender has completed the contract, his or her conviction would be regarded as "spent". That provision has worked successfully in the United States, and I believe that the same would happen in this country. We shall need to examine the details of the legislation carefully. However, in principle this is an imaginary first step towards a system that places more emphasis on preventing re-offending than on over-formalised court proceedings, which often mean very little to young offenders and their parents. The procedure of a youth court panel should make it easier to involve offenders and their parents in taking responsibility for a youngster's actions and agreeing on actions to make amends.

I wish to draw attention to four areas of policy that were not mentioned in the Queen's Speech and on which further action is urgently needed. The first is the need to relieve the pressure on the prison system. The prison population has risen by over 60 per cent. since the end of 1992, from just over 40,000 to around 66,000. That has reduced the ability of prisons to provide constructive regimes; it has led to many prisoners being placed in distant prisons, which makes it difficult to maintain family links; and it has halted much of the progress that the Prison Service made in the early 1990s following the Woolf Report.

The Government have now set in train some welcome steps to reduce the prison population--in particular a new scheme for the early release of selected non-violent prisoners under a "home detention curfew" monitored by electronic tagging, which comes into operation on 28th January. However, if prisoners are subject to a home detention curfew, they must first have a home. There are presently problems within the Probation Service across the country. Probation services in some areas are advising that hostels in their area are suitable for home tagging, but other probation areas are ruling out the possibility. Will the Government take steps to bring about consistency between areas and to ensure that suitable prisoners who can be safely tagged in voluntary hostel accommodation can benefit from the new scheme? Will Ministers also take every opportunity to advance in public the powerful arguments for reducing our over-use of imprisonment?

The second area is the resettlement of short-term prisoners. Those prisoners who are sentenced to less than 12 months' imprisonment do not receive statutory supervision on release. They are the ones in need of help. However, this area of probation work is given lower priority. There is also the role of voluntary organisations, including NACRO, of which I am chair. It is particularly important in ensuring that this group of

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prisoners receives the help they need to avoid returning to crime and prison. Will the Government undertake a national monitoring of partnership arrangements between the Probation Service and voluntary organisations, together with a review of present financial arrangements, with the aim of reducing the current patchiness of resettlement provision for this large group of prisoners and ensuring that the role of the voluntary sector is fully recognised and adequately resourced?

The third area is that of sex offenders. The Government have introduced a series of measures that will help reduce the risk posed by such offenders, of which the most important is the new power introduced in September to order extended supervision on release from prison. However, if supervision is to be fully effective, it must be reinforced with an adequate number of sex offender treatment programmes, both inside and outside prison. Research has found that treatment programmes can significantly reduce the likelihood of re-offending. In recent years, both the Prison Service and the Probation Service have greatly increased the number of treatment programmes for sex offenders. However, two-thirds of those discharged from prison have not been through such a programme. Will the Government ensure that adequate resources are provided to increase further the number of such programmes, together with the staff training that is needed to ensure their quality and effectiveness?

The fourth area is the crucial one of race and criminal justice. My noble friend Lord Meston drew attention to that. The proceedings of the Stephen Lawrence inquiry have not only brought into the open the inadequate police response to racially motivated crime; they have also highlighted the wider lack of confidence of many black and Asian people in the criminal justice process. For example, the way that institutional racism in the operation of such police powers as stop and search has alienated many black people, especially young black people, from the agencies responsible for law enforcement.

We hope that the Government will take speedy action to implement any proposals of the Lawrence inquiry designed to combat discrimination by criminal justice agencies in their treatment of people from minority ethnic groups.

I turn now to the subject of immigration and asylum. I do not know whether it was intentional, but the "F" word appears prominently in the White Paper: Fairer, Faster and Firmer--A Modern Approach to Immigration and Asylum. We shall scrutinise the legislation to see that fairness has not been sacrificed in preference to a faster and firmer policy. I have argued on previous occasions that the heavy emphasis on excluding the ineligible, rather than giving prompt and sympathetic attention to the rights of the eligible has led to administrative practices which bear with particularly adverse effects on genuine asylum seekers.

The proposed asylum and immigration Bill will be the third piece of legislation in this area to pass through this House since 1993. The Government have quite rightly described the current situation as a shambles and it is in everyone's interest that we get the legislation

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right once and for all. The challenge that is presented to us is trying to find the right balance between the fairer, faster and firmer components of the Bill and not sacrificing one component in the pursuit of others.

There are several aspects of the Bill which give us cause for concern. For example, the use of certain pre-entry controls, such as airline liaison officers, which may prevent refugees from getting out of the countries in which they are being persecuted; the extension of police powers for search, entry and seizure to immigration officers who are not as accountable as the police officers; the failure to recognise that good quality legal advice at all stages of the asylum application has a central role to play in making the system both fairer and faster; the Government's decision not to repeal Section 8 of the 1996 Act which forces employers to check the immigration status of employees, despite having opposed it while they were in opposition.

However, in the short time that is available to me, I wish to concentrate my remarks on two issues in the Bill which are of particular concern to us. I begin with the proposal to set up a cashless support system for all asylum seekers. While we welcome the fact that the Government will ensure that support for asylum seekers will once again be a national responsibility and not a burden placed on a small number of local authorities, we are worried that the new system may be worse than the current one.

In their own White Paper, the Government recognised that their proposed cashless system will be more cumbersome to administer and more expensive per person to run. Many asylum seekers who have been dependent on the National Assistance Act for their survival have suffered severe hardship, as illustrated by the Refugee Council's report Just Existence. We very much hope that good quality advice and the appropriate approach to that group of people will result in a remedy in terms of their needs.

I wish to take the second policy area which we are concerned about relating to the detention of asylum seekers. The current system operates in an arbitrary way and allows asylum seekers to be detained in prisons or detention centres for unlimited periods of time, without giving them an automatic judicial review of the decision to detain. The Government propose to reform the system to give all detained asylum seekers an automatic bail hearing after seven days, which is a positive but inadequate initiative.

We believe that there is ample opportunity and I wish to congratulate the Home Office on trying to effect an integrated approach to the management of casework, both at the immigration and nationality department and abroad in entry clearance posts and to draw a line under recent legislation.

We welcome the right of appeal for refused visitors. Equally we welcome a pilot project for a financial bond, but as was pointed out by the noble Lord, Lord Ahmed, let us hope that it does not discriminate against those who cannot make sums easily available.

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We welcome the commitment to set up a statutory scheme for immigration advisers, but this must also include members of the legal professions who are governed by the code of conduct of their professional body.

There are exciting times ahead. I shall not only look at the ministerial Bench for a positive response to our concerns but also at the Opposition to see whether they have had a change of heart after the disastrous penal policies of the previous government.

Britain is often held as an example to the world. The way we regulate our policies on home affairs will have a bearing on what will happen in other parts of the world. Our policies must be legal, decent, honest and true. They must be accompanied by dignity, fairness and justice. Take away any of those ideals and we lose our claims to being a civilised society.

8.44 p.m.

Lord Henley: My Lords, seeing the sufferings of the noble Baroness, Lady Hayman, the Minister responsible for health, one might be tempted to indulge in a bit of schadenfreude. However, suffering from a similar bug, I extend to her my deepest sympathy and commiserations. I offer to the House an apology for my voice and throat. I hope that they will last for the few remarks I wish to make in winding up the debate.

As was said earlier, I was originally under the impression that in winding up I would have to wind up five days of debate. I decided at an early stage that I had no intention of so doing. My noble friends on these Benches have adequately wound up the earlier debates. I shall therefore concentrate my remarks largely on this afternoon's debate, particularly--as my noble friend Lord Howe said--on my Front Bench interest in home affairs. I shall leave it to the Minister whether he wishes to take up the challenge of trying to sum up all five days of debate; it is a matter for him. I am not sure that it is necessary on this occasion. I shall devote my efforts this evening, as I imagine he will, to the remarks we have heard from this evening's speakers, particularly those who are still with us.

I also offer my congratulations to the noble Lord, Lord Warner, on his maiden speech. He brings an enormous wealth of experience from both the Civil Service and local authority social services and as special adviser to the Home Secretary and chairman of the newly-created Youth Justice Board for England and Wales. We look forward to his active participation in the House. He kindly referred to one of my former noble friends, the late Lady Faithfull. He explained how formidable had been her work for children over the years. For a number of years I sat in front of her and I can bear witness to the formidable nature of some of her work. I probably still bear the scars to prove it, as I suspect the noble Lord, Lord Carter, knows.

This debate has, as always, been one where we have gone beyond matters confined to the gracious Speech and departmental subjects suggested as topics for today's debate. I make no objection; it is one of the strengths of these debates. We have ranged high and low. My noble friend Lord Astor of Hever, with his

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experience of RoSPA, spoke of the dangers of accidents at home. We heard a great deal about medical training from the noble Lord, Lord Winston. Many of us were amused by his remark that, "I learnt my anatomy by cutting people open". Alarmed looks appeared on faces around the House.

We heard about the problems of people with learning difficulties and their access to justice from the noble Lord, Lord Rix. My noble friend Lord Annaly, spoke about similar problems for deaf people. We heard not only of mainstream health matters, but of complementary medicine from the noble Earl, Lord Baldwin of Bewdley. We even had references to "Hamlet" and "The Divine Comedy" as we have come to expect from the noble Lord, Lord Morris of Castle Morris.

I shall not go into the vast range of subjects covered, but there has been a large number and some of them went wide of the subjects we have been debating. At this stage I wish to pick up a small point made by the noble Lord, Lord Meston, who called for more discrimination legislation. I do not argue that particular case at this moment, but I should like to make one small point, on which I hope I might get some support from the noble Lord, Lord Morris of Castle Morris, purely in terms of the use of English. I would be most grateful if in the future one could talk about "unfair discrimination" at work or wherever. I think it is very important that we are seeing what might be termed the bastardisation of the use of that word "discrimination". I see a nod from the noble Lord, Lord Morris of Castle Morris. I find it very sad that one can no longer talk with praise about a person being "a man of some discrimination". We all have to discriminate when we interview people for jobs and when people apply for a post. What we are talking about is unfair discrimination, and I think it is very important that we maintain the distinction.

As I said, we are here to debate Her Majesty's gracious Speech and the various commitments made in the Speech in the fields of health and home affairs. As I said, I intend to concentrate on home affairs. We heard in the gracious Speech of three particular Bills that were to be introduced and legislated upon this Session. One Bill will be introduced to modernise the youth courts and to give greater protection to vulnerable witnesses against intimidation in criminal cases. Parliament will also be given the opportunity to vote on the age of consent; and a Bill will be introduced to modernise the law on immigration and asylum, including the appeals system and support arrangements for asylum seekers.

We also heard of the draft Bill relating to freedom of information. Perhaps I might start by saying a word or two about that draft Bill. As the noble Lord the Minister will be aware, we discussed this very briefly at Question Time on Monday. The noble Lord made it quite clear in his first Answer that this draft Bill would be subjected to pre-legislative scrutiny by another place and by another place's Select Committee for Public Administration. When pressed, the noble Lord accepted that if this House wished it, it would be possible to have the pre-legislative scrutiny but that would be a matter for

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the usual channels. That is slightly at odds with the precise words of the gracious Speech, which made it clear that the Bill would be given pre-legislative scrutiny in both Houses.

This is important, and I would be very grateful for some assurance from the noble Lord as to what exactly the Government have in mind in terms of pre-legislative scrutiny for this House. It could possibly be some Moses Committee type of procedure, with the noble Lord and the appropriate members of the Opposition Front Benches being involved. I imagine it could be something much closer to our European Communities Committee work. However, I do have to ask him whether he could spell out to the House this evening exactly what is being proposed and how it will operate. This is an important matter because to publish Bills in draft is a relatively new idea and one that might in time grow if that would ease the work of Parliament. I make no particular comment on whether that is necessarily a good or bad thing, but if we are going down this route I think it is very important that we should get our procedures right, and right from the start.

I should like to turn to the other three Bills very briefly--three Bills that we have obviously not yet seen and which we will be able to debate in detail when they come to this House, though we have had the benefit of a number of White Papers which set out what I imagine will largely be in the Bills.

Perhaps I could start by talking about the asylum Bill, the subject of a White Paper published last July, Fairer, Faster and Firmer: a Modern Approach to Immigration and Asylum. As the noble Lord will be well aware--he takes the trouble to read the White Papers with great care--this makes a number of recommendations about what will be needed in legislation. I perhaps might refer in particular to paragraph 13.12 where different legislative possibilities are set out chapter by chapter. Can the noble Lord say whether other matters will be included in this Bill? For example, he will remember there was the issue of unscrupulous immigration advisers and that problem was set out in the January 1998 consultation paper. Can the noble Lord give an assurance that these matters will be included in the Bill and be addressed on this occasion?

Regarding youth justice, I refer to a report, rather than a White Paper, which was produced by an interdepartmental group, entitled Speaking Up for Justice. That made some 78 recommendations, some of which, I imagine, will require primary legislation, although others will not. I presume that the Bill relating to youth justice will be based on that. Again I should be grateful for confirmation from the noble Lord that that is the case.

I turn now to the Bill relating to the age of consent and to the fact that the gracious Speech referred to the Bill giving strength to the protection of young people. A number of your Lordships, including my noble friend Lady Seccombe, the noble Lord, Lord Quirk, the right reverend Prelate the Lord Bishop of Winchester and the noble Lord, Lord Monson, referred to this particular Bill. As the noble Lord will be only too well aware, there is enormous concern about the Bill: the noble Lord

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was on the receiving end of considerable discussion some time last July when, regrettably, I was not able to be in my post and left the matter to others.

We are grateful for the fact that the Government will seek, as they put it, to strengthen the protection of young people. That says something about the work of this House and what this House achieved on that occasion. If we had not made that stand then, we would have a lower age of consent without any attempt by the Government to offer some protection to young people. However, I have to say that we shall wait with interest to see whether the Bill will achieve exactly what it says. I hope that the noble Lord will be able to show, either now or later, that that will be the case. I can assure him that he will again have a very interesting time, if I can put it in those terms, on that Bill in this House. He knows that it is something on which the party Whips will not be operating and he also knows that it is a matter on which many people on both sides of the argument feel extremely strongly. I will not attempt to explore those arguments this evening.

Another Bill which I imagine comes within the ambit of this evening's debate was given its First Reading by the noble and learned Lord the Lord Chancellor this afternoon: the Access to Justice Bill. Obviously in the time available I have not been able to see that Bill and I shall not set out any strong views on it. All I can say from these Benches is that we are very grateful that the noble and learned Lord is giving this House the opportunity to debate the Bill first. That will certainly ease the pressures on the business managers in due course in what is going to be a relatively busy but perhaps shorter Session, in that we have begun it somewhat later.

I would ask the noble Lord the Minister when he comes to reply to say whether the question has been addressed as to whether the Bills to which I have referred--or for that matter other Bills which have been dealt with during the four or five days--could start in this House. I know we are having a social security Bill, I think, some time next week and others will follow. I should be particularly grateful if the noble Lord could respond--I say this personally--in relation to Home Office Bills. I could then make my own arrangements with greater ease.

There is a last point that I wanted to deal with in my brief remarks, again moving beyond the contents of the gracious Speech. In opening, the noble Baroness, Lady Hayman, almost as an aside, slipped in a reference to the fifth report of the noble Lord, Lord Neill, on the funding of political parties in the United Kingdom. I believe that the noble Baroness told the House that the Government would publish a draft Bill in the summer but made no mention of precisely what would be in it other than that it would deal with the funding of political parties. Noble Lords will be well aware that in his fifth report the noble Lord, Lord Neill--I have checked it very carefully following the remarks of the noble Baroness--made about 100 different recommendations. Not all of them were related directly to the funding of political parties. Some dealt with honours, the media and advertising and the establishment of an election commission.

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Speaking from memory, recommendations 83 to 93 referred to the conduct of referendums. Over the past 20 to 25 years increasing use has been made of referendums. I believe that if they are to be seen by the people (if I may use a word that is often on the lips of the new Government) as both fair and valid, it is important that a proper set of rules is established. Therefore, I ask the Minister to give a commitment that the Government will sign up to all of Neill and not simply cherry-pick those parts of the report that they want and reject the rest.

We are all aware of the use made of referendums by various unsavoury demagogues in the past and that the desired result can be achieved by careful phrasing of the question. I revert to the light-hearted story told by the noble Lord, Lord Mackenzie of Framwellgate, about the injured man who is asked how he is feeling and responds that he is very well. The idea behind it, as the noble Lord put it, is that one usually gets the desired answer if the question is phrased in the right way. There are concerns about referendums. If they are to be used more frequently, it is vitally important that they should be seen to be valid. Therefore, it is very important that the recommendations made by Neill are adopted. I ask the noble Lord to give very serious consideration to the reproduction of all 100 recommendations in the draft Bill that will appear in the summer.

9.2 p.m.

Lord Williams of Mostyn: My Lords, I am sorry that the noble Lord, Lord Henley, is not feeling well this evening. I advise him to bear it with resignation! He said that these days it was not right to speak of a man of some discrimination. I respectfully disagree. In my experience, the noble Viscount, Lord Cranborne, was indeed a man of some discrimination and a man of his word. Since he has done something that the control freaks in Conservative Party Central Office do not like he is subject to instant dismissal. On a personal basis, I am very sorry that he has gone. Agree or disagree, he was a very good servant of this House.

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