Previous Section Back to Table of Contents Lords Hansard Home Page

I will begin by declaring my interest as the honorary president of the Dispensing Doctors' Association. Its members live and work in rural areas of our country and are a vital part of the NHS. For a great part of my life, I have had the services of dispensing doctors. I still have very fond memories of my first doctor, Dr Shegog, in his surgery in Market Rasen with its spluttering gas fire in the waiting room, handing out what, in those days, always seemed to be foul-tasting medicines, which seemed to do the trick. We are talking about a comprehensive health service, and it must include the health service in rural areas. The legislation before us has to be rural-proofed, and we must consider how it will affect rural doctors and their patients.

The Dispensing Doctors' Association values the principles of clinical leadership and choice, on which the reforms are based. The DDA absolutely agrees with the principle of "No decision about me without me" and the need for true patient choice. Rural patients depend on the services provided by dispensing doctors, and the DDA believes that several of the Bill's principles tie in directly with the needs of these patients. It considers it essential that the final legislation supports and promotes joined-up services and therefore better patient outcomes for rural patients. However, the DDA was not consulted directly during discussions on the Bill, and therefore much of it appears to be pharmacy-based rather than dispensing doctor-based.

In the rural health system, the DDA knows that dispensing patients want a choice in where they collect their medicines. For many, travelling to a pharmacy is not always the most convenient option and requires a

11 Oct 2011 : Column 1565

separate trip in addition to the original GP appointment. Patients in rural areas overwhelmingly support collecting medicines from their dispensing doctor. In 2008, more than 60,000 patients wrote to the Department of Health in support of dispensing practices. Regulations need to be addressed to ensure that all rural patients have access to choice. If "No decision about me without me" is to become a reality, all rural patients should be able to choose where and from whom they obtain their medicines-a dispensing doctor or a pharmacy.

There is a clear need for integrated service provisions for rural patients and for clear guidance from the Government on how these can be promoted. A joined-up approach for dispensing doctors and pharmacies is crucial to ensure that patients receive care in the most convenient location for them, and this should be assessed locally as part of the local authority remit. Failure to address this will lead to an increase in health inequalities. I hope that the Minister can reassure me on these points in relation to rural health service practices.

Turning to industrial relations-a key element in the success or otherwise of the proposals in the Bill-UNISON, a major union in the NHS that represent thousands of its vital workers, believes that the Bill is,

because of the dangers it introduces of fragmentation, instability and inequity. These fears stem from UNISON's membership, and those members should and must be listened to and considered as we debate the Bill. If those who work in the NHS do not believe in its aims and aspirations, it will not work.

What are their major fears about the Bill? Under the planned reorganisation, NHS staff face nearly 13,000 redundancies, according to the Government's own statistics, and of course the numbers will treble when the workers' families are taken into account. The Government do not acknowledge the need for the retention of national workforce structures for terms and conditions, pay and bargaining. This is foolhardy in the extreme. Workforce turmoil helps no one, while a contented workforce brings benefits to all. "Dedicated" is a word that is often used in relation to the NHS and its workers, and indeed they are dedicated. However, we cannot expect this dedication to continue if they feel undervalued and undermined.

A further and real fear surrounds the removal of the cap on private patient involvement. When the cap was established, its aim was to stop hospitals pushing NHS patients to the back of the queues, which are already lengthening. If we are not careful, "Can pay, will pay" may well become a future catchphrase about the NHS, to the detriment of NHS patients-a danger that is acknowledged in the recently revised impact assessment.

There are fears, too, about the NHS being based on competition, not co-operation, because of the market system established in Part 3 of the Bill. I know that other noble Lords have spoken about this area. Surely the Government should be promoting co-operation and collaboration rather than competition. Is there to be a rationing of care because of this competition, and what does the term "any qualified provider" really mean? Additionally, the larger role envisaged for the

11 Oct 2011 : Column 1566

private sector brings a chill to many a heart. Have we learnt nothing from the awful events at Winterbourne View and Southern Cross?

Of all the other briefings that I have received, I believe that the one from the Coalition of UK Medical Specialty Societies is of prime importance. The coalition is a group of professional bodies representing clinicians and other health professionals working within the NHS who would like to see,

Key points made in this briefing are that: for the overwhelming majority of the coalition's patients, having access to high-quality and suitable care is paramount; patients' choice must be real and informed-patients should know the details of the experience and qualifications of those who treat them; choice must be for the patients rather than the provider; competition could result in the fragmentation of patient care, and many different providers could make it harder to deliver integrated care and prevent health professionals working together in multi-disciplinary teams; and continuity of care must remain a high priority among all providers.

I end by agreeing with the Minister, the noble Earl, Lord Howe, on one thing: the NHS must remain patient centred above all else.

5.36 pm

Lord Black of Brentwood: My Lords, it has been a genuine privilege today for me to listen to so many speeches from noble Lords with distinguished records of service in the health sector, either as clinicians, former Health Ministers or specialists, and to hear their views. Like my noble friend Lord Rodgers, I am afraid that I am just a layman. I can offer no such professional input to match this canon of wisdom but speak simply as a consumer of the NHS's services, as indeed were my late parents.

As I prepared my remarks, I thought in particular of the care that the NHS provided for my mother during a range of illnesses as she grew older: osteoporosis, heart failure, osteoarthritis, a transient ischaemic attack or mini stroke, and chronic obstructive pulmonary disease. It was that personal experience of the weight of these conditions that brought home to me in the most vivid fashion the extraordinary financial demands that are placed today on our health services as patients live longer and contract age-related illnesses in a way that would not have been the case only a few years ago, let alone in 1946 when the NHS was formed, and how in turn that places huge human burdens not just on GPs but on emergency departments, geriatric wards, carers and others involved in the vital chain of support for older, frail people and how they all work together.

It is of course a cause first and foremost for celebration that some 65 years or so since the founding of the NHS the advances in care and treatment, and above all in public health, have produced longer and more fulfilling lives for so many people. However, one central truth flows from that-the NHS has to change in order to survive. It is, after all, reaching pensionable age itself, and a new way of life is needed.

I come from the world of the media. In recent years we have seen at first hand how the dramatic changes in technology, lifestyle and demographics have shattered

11 Oct 2011 : Column 1567

the business model that supported media companies. We have had to enter a period of permanent evolution-changing the way we do business and changing the services we offer our readers and customers-just to survive.

The same is true in the NHS. Demand is growing rapidly. Long-term conditions of the sort I mentioned earlier and that consume about three-quarters of the entire health budget are becoming more common. The renewal and regeneration of our great National Health Service is not just an option; it is essential. My noble friend Lord Mawhinney talked earlier about scaremongering. If there is something that we should be scared about, it is that we fail to change.

Osteoporosis-a subject about which I care deeply-is an excellent example of what I am talking about. As the population becomes older, this terrible illness becomes more prevalent. Between 1999 and 2009 the number of bed days attributed to hip fractures increased by 32 per cent. As our population rises by 17 per cent, it is projected that in England they will increase by a further 100 per cent between now and 2036, by which time treating and caring for hip fractures in the UK could top over £6 billion a year, which is a huge figure when considering the current burdens on the NHS. Broken bones already affect a greater number of older people than both heart attacks or strokes and TIAs. Osteoporosis is a costly disease, not just in straightforward economic terms but in the impact on individual lives, and that pressure will grow.

There could not be a more pertinent example that makes it obvious, even to non-experts such as me, that the NHS will have to change if it is to survive another 15 years, let alone another 65. That is precisely what this Bill is all about. Change means that it has to become more efficient, more focused on the challenges of public health and more accountable, and above all that there has to be a greater voice for patients who, in my view, are acutely aware not just of how much they owe the NHS but how it can be made even better.

I believe that this Bill delivers those ends, and that it does so in a way that should command widespread support. After all, as my noble friend Lady Bottomley reminded us earlier, the extension of choice and the extension of competition are not new principles; those of all parties and of none have long supported them. Involving GPs in clinical care is not new. GPs have been providing increased ranges of services for many years, and this Bill provides a logical and coherent extension of their powers rather than the piecemeal approach we have seen in recent years.

I spoke just now about the issue of osteoporosis, a subject that I raised in my maiden speech in this House and have talked about on a number of occasions since. To give a personal example, that one subject provides a prism through which we can see in a practical way how this Bill can help with one of the most chronic and debilitating conditions that are at the root of the need for reform of the NHS. Let me explain why. Giving responsibility to GPs for commissioning health services is giving responsibility to precisely the people who can spot this condition early and initiate treatment for it. They can play a pivotal role in the prevention, diagnosis, treatment and care of patients

11 Oct 2011 : Column 1568

who are at risk of broken bones, for osteoporosis can be reduced only by involving professionals from a range of settings in the commissioning process.

Of course, GPs are not alone, and many fractures originate in care homes. Adult social care professionals need to be involved too, and the health and well-being boards, which this Bill will introduce, are a perfect way to bring stakeholders together to oversee local fracture services; and clinical senates will be able to act as vehicles for cross speciality collaboration, strategic advice and innovation to support commissioners in local areas. These are developments of real value to the patients of the future, and they spring directly from this Bill.

I also welcome the proposals to increase the amount of choice and information available to patients. Patients with, or at risk of, broken bones should be able to access information about the quality and outcomes achieved by their local services, and this Bill will deliver that. That is a very welcome step for the hundreds of thousands of people who suffer from osteoporosis.

Of course, issues will need to be raised in the Committee stage of the Bill, which quite rightly should take place on the Floor of the House, where, as the noble Baroness, Lady Murphy, said earlier, we have experts to deal with these issues. I highlight in particular the provision of information about whether local hospitals or GP surgeries have fracture prevention services in place. I believe that steps must be taken within the scope of the Bill to ensure that the ability to choose the location in which care is provided is extended to disadvantaged groups, including the frail and immobile. I also hope that the Government will include indicators that measure admissions for fractures in older people in their initial NHS adult social care and public health outcomes frameworks, but these are issues that can be sorted out.

The key point is that with a long-term condition such as osteoporosis-I have deliberately used this as a personal and practical example-the Bill will, for the first time, put in place a framework that will allow us to improve lives through early diagnosis, greater accountability and the cohesion of care services. That is a precious prize.

Of course, as we have heard, this Bill is controversial. Change always is, but if we really care about something-everyone in this House cares about the NHS-we must have the courage to face up to that. If we fail, we will be letting down not just ourselves but those who will come after us.

5.44 pm

Lord Hutton of Furness: My Lords, I declare an interest in that my wife is director of Nuffield Health, the independent healthcare charity.

I very much agreed with the speech of the Minister when he said that the biggest challenge that the NHS currently faces is how to improve patient care against a background of significant improvements in efficiency. If we agree with that, the question for us all is: how will this Bill, in its current form, help the NHS to meet that challenge? Today I have not heard a sufficiently convincing answer. I say that with very considerable regret.

11 Oct 2011 : Column 1569

I agree with the noble Lord, Lord Black, that the NHS will need significant change in the future if it is to meet this enormous challenge, which is both economic and demographic. It will need effective competition if it is to stimulate new thinking and new ideas. It will certainly need greater local freedoms from the centre to support the necessary innovation, and it will certainly need less bureaucracy. Sadly, I am not sure that any of these useful objectives are likely to happen under the Bill in its current form.

My noble friend Lady Warwick of Undercliffe drew our attention to the speech of the Secretary of State for Health when he introduced this Bill in the House of Commons. He rightly and properly said that the Bill was designed,

Those are good intentions. The Secretary of State gave voice to a noble purpose. However, what happened next was utterly predictable. The groundwork for these very important reforms was not properly laid by Ministers, and it probably was not helped when the Secretary of State told the House of Commons that he could do these reforms without this legislation at all. The legislation certainly contradicted the coalition agreement, so the arguments for reform barely got off the ground before they were shot down by internal arguments inside the coalition. I am afraid that politics rather than policy prevailed. Today we have again had a demonstration of an iron law of government: good intentions do not always result in good legislation.

In my experience, the Second Reading debate on any Bill is about the general principles. I am afraid that the longer this Bill has progressed, the harder it has become to discern what those principles are. Does the Bill favour or hinder localism? I think that it probably hinders it. The national Commissioning Board is a dramatic centralisation of power. Does the Bill represent an attack on bureaucracy? I think not. There seem to be even more layers of management. Some of the bodies coming into existence are the clinical commissioning groups, the clusters, the clinical senates and the well-being health boards, and sitting on top of all these is this new quango, the national Commissioning Board. I am sure the Minister knows that there is enormous upheaval going on in the NHS at the moment, and enormous uncertainty. Given the scale of the current challenge, I do not think that any of this is helpful.

What about promoting competition? I am in favour of that as long as it is properly managed. There is demonstrable research evidence showing that the introduction of new providers and new ideas in recent times in the NHS has improved the health of the poorest at a faster rate. I saw that in my own constituency and that was my experience over seven years as a Minister in the Department of Health. Competition can make the NHS more equitable. So, on this, I am afraid that I part company with some of my noble friends. I do not believe that competition is necessarily bad for the NHS, and I do not share the prophecy of doom that I have heard today. It is all about setting the proper ground rules. Are they being set properly? As I understand it, the amendments made to Monitor's duties in the House of Commons were designed largely

11 Oct 2011 : Column 1570

to camouflage the political wheeler-dealing that went on behind the scenes. Are the changes to Monitor's duties significant? We have not the faintest idea, and we need to know. It is an extremely unsatisfactory situation.

So, any sense of direction and principle has largely been sacrificed. What the Bill stands for now depends very much on which Minister you talk to. It started out as a revolution, but the R was deleted in Committee in the House of Commons. We have ended up with some very obscure concessions whose significance is far from clear. The NHS needs clarity.

I strongly support, as I always did when I was a Minister, a greater role for clinicians in commissioning healthcare. There can be real advantages for NHS patients if we can get that right. However, I doubt that the proposals in the Bill represent the best and most effective way of doing it.

The White Paper rapidly became a white elephant, and now all we hear is white noise. That is a great shame. It has set back the case for the real reforms that the NHS needs today. It needs more enterprise and the stimulus that new providers can bring, but I am not sure that it will get that. It needs less centralisation; instead, it is getting the biggest quango that we have ever created in parliamentary terms. It needs less bureaucracy; I think that it will get the opposite of that. I do not think that the Bill moves any of the important principles of NHS reform sufficiently forward. Ministers have only themselves to blame for the situation they find themselves in.

However, I shall not be voting for the amendment of my noble friend Lord Rea. I do not believe that it is the duty of this House to form a view about whether a Bill has democratic legitimacy; that is very much the view of the House of Commons. It is they who eventually have that rendezvous with the electorate. They have to account for themselves and how they have run the country, we do not. So the Bill should have a Second Reading. The challenge for us is how we can best improve it. That is why I shall support the amendment of the noble Lords, Lord Owen and Lord Hennessy. It has been a distraction from that argument for some noble Lords to have said today that that amendment would represent some delay to or obfuscation of the Bill, which is not a fair interpretation of it. We can look to improve the Bill. My objective is to improve it, not to delay it. The Government have a mandate and are entitled to their legislation.

The stakes are very high. The case for principled reform remains important. That is not being helped by the way in which this Bill has been presented, amended and brought before us today.

5.52 pm

Lord Marks of Henley-on-Thames: My Lords, I agree with other noble Lords who have expressed the view that the Bill has been transformed during the pause. We should now welcome it in principle as offering a secure future for the National Health Service in the face of ever increasing demand, as defining a clear but decentralised structure, as making great progress in integrating health and social care, and as concentrating decision-making about patient care in the hands of clinicians and patients, where it should be.

11 Oct 2011 : Column 1571

However, the Bill needs further improvement. In particular, perhaps I, too, may say a few words about the duties of the Secretary of State, especially in view of the very wide currency given to the published legal opinions obtained by 38 Degrees and in view of the report of your Lordships' Constitution Committee and the Government's recent response to it. I welcome the indication from my noble friend the Minister this morning regarding flexibility in this area, which seemed strangely at odds with his letter to the noble Baroness, Lady Jay, last night.

Although much of the strictly legal analysis of 38 Degrees' counsel stands up, his implied conclusions on the political effect of his advice are overstated. The Bill does not threaten the notion of a National Health Service, nor does it deprive the Secretary of State of the ultimate responsibility for the NHS-particularly with regard to three features of the Bill's proposals: first, the annual mandate to the Commissioning Board; secondly, the power to make regulations, the "standing rules"; and, thirdly, the power to intervene in the event of "significant failure" by the board or Monitor.

It is true that the duties of the Secretary of State are altered and that a duty to promote a comprehensive health service does not amount to a duty to provide services directly, but it is also true that direct provision has not been the practice for many years. Moreover, the Bill is a strongly decentralising measure-indeed, that is one of its best features-and you would expect such a change. However, a duty,

remains in the Bill and, in my judgment, is no less potent than the duty in the 2006 Act to "secure the provision" of services. The problem with the proposed duty is that it is to be performed,

and that includes, "in accordance with the duty to promote autonomy".

It is the "duty to promote autonomy" provisions which are my principal concern. Promoting autonomy is of course good. As the noble Baronesses, Lady Bottomley and Lady Williams-in their different ways-and others pointed out, the Secretary of State should avoid micromanagement and generally allow the board, commissioning bodies and Monitor to get on with their jobs. However, the autonomy provisions weaken the force of the duty to secure that services are provided, because they would make a failure by the Secretary of State or the board to intervene very difficult to challenge by judicial review except in an extreme case. Generally, the Secretary of State could simply defend himself against any challenge by pointing to his duty to promote autonomy. That is why 38 Degrees' counsel calls this a "hands off" clause.

In this I regret that I cannot agree with the passage in my noble friend's letter to the noble Baroness, Lady Jay, which states:

"The duty of autonomy will never prevent the Secretary of State intervening in the interests of the health service".

I fear that it could. Deleting the two duties to promote autonomy would not materially weaken the Bill or do violence to its intention, because the Bill's very structure builds in decentralisation and autonomy. I hope that

11 Oct 2011 : Column 1572

the Government will in due course accept the force of these concerns and rebalance the structure proposed in the Bill accordingly.

Perhaps I may mention two further possible improvements to the Bill. The first concerns the regulations, or standing rules. As drafted, the Bill is unclear as to whether it is mandatory to make such regulations. One subsection of Clause 17 suggests that they must be made, while others do not. The standing rules will be of great importance. I therefore suggest that provision be made that regulations should be made at specified intervals and, further, that Parliament should have the extra opportunity of scrutinising the draft regulations by their being referred to the Health Committee for advance consideration before they are laid before Parliament as a whole.

The second point is that the Bill removes the powers in Sections 7 and 8 of the 2006 Act for the Secretary of State to give specific directions to individual bodies within the NHS. What remains is a power to intervene in the case of significant failure by the Commissioning Board or by Monitor, each of which has wide powers of intervention. I am concerned that the bar may be set too high against the Secretary of State's intervention, because in each case the significant failure concerned has to amount to a failure by the board or by Monitor to perform its functions at all or, at any rate, to perform them properly. Failure to perform them in a way that the Secretary of State considers to be in the interests of the NHS would not be enough. I regard that as an important lacuna. Some amendment of those provisions, too, would be a welcome improvement.

In the Third Reading debate in the other place, the Minister, my honourable friend Mr Paul Burstow, undertook,

It is now for your Lordships' House to ensure that that aim will be achieved.

6 pm

Lord Williamson of Horton: My Lords, we all have a profound interest in our national universal health service, which in my view is one of our national treasures. This interest is demonstrated today by the very large number of letters that we have received and by the number of speeches in the debate. I shall try to restrict my comments to a limited number of points because evidently this package of 720 pages-that is to say, a Bill of 445 pages and an explanatory note of 275 pages, which are often difficult to comprehend-is likely to have a long life in Committee, where it requires, and will no doubt receive, detailed examination.

The first main question to the Minister is not about what is being proposed-although that is evidently important-but why is it being proposed? In short, why are the Government considering so substantially revising the current system, in particular the strategic health authorities, the primary care trust-which are now to be abolished under Clauses 30 and 31 of the Bill-the whole current provision of health services generally and the administration of hospitals? Obviously

11 Oct 2011 : Column 1573

improvements in the National Health Service are highly desirable. We have them all the time, in terms of medical knowledge and patient care.

I know that the Minister dealt with the reasoning. However, he was somewhat overwhelmed by the myriad changes to which he had to refer that, perhaps in winding up he will have another try at telling us why such a massive change is to be made, bearing in mind that changes on this scale are bound to cause some disruption and possibly an adverse effect on the morale of the people who really matter-that is to say, doctors, nurses, healthcare assistants, social workers and all the people who comprise the system of care for the whole nation. However, because the Bill's proposals are so large, I put it back to the Minister in the words of Tom Jones: "Why, why, why, Delilah?"-which I am unfortunately not allowed to sing here. This is my first question.

In addition to the basic question-why are we having all these changes?-I would like the Minister to respond to three points that I have selected either from recent parliamentary discussion or from the 445 pages of the Bill. From recent discussions, I ask what has happened to the practical steps for improving the services to patients that were presented to the House by the noble Lord, Lord Darzi, towards the end of the period of office of the previous Government. If I recall rightly, these included the possibility of strengthening patients' services through the establishment, particularly in some inner cities, of GP clinics that would provide a wider range of services at one site-for example, radiology, nursing and physiotherapy-which could have the effect of reducing the overload on hospital A&E services. This system works well in some countries.

Evidently, there are many people in Britain, particularly in the inner cities, who look to the A&E services as the first point of call if they have a health problem. The result is an inevitable overload. In the medium term, do the Government support the proposals of the noble Lord, Lord Darzi? Secondly, have the Government a view on the possibility of establishing more separate specialist units to deal, for example, with the limited number of major health conditions associated with the ageing population, thus also reducing the potential blocking of beds in general hospitals? It might be effective and good for patient confidence for such persons to look to dedicated units or clinics of which we do not have very many at the present time.

From the text of the Bill, I make one major point. The clinical commissioning groups, which are not necessarily large groups-we are told there may be 300 or 450, we simply do not know-are none the less the bedrock of the new system. There really is concern about how in practice they will be able to assess and provide for, to quote the Bill,

I am quite sure that there will be good will, but can this task be easily done at the level of, for example, a single large GP practice?

We do not know the size of these clinical commissioning groups, how much advice they will get or how they will operate on the ground. After all, the

11 Oct 2011 : Column 1574

members of these clinical commissioning groups-at least, the clinicians-have to care for their own patients as well as having an enormous number of duties that are cited in the Bill in Clause 23-"effectiveness", "efficiency", "improvement in quality of services", "reducing inequalities", involving each patient, giving "patient choice", obtaining "appropriate advice", promoting "innovation", "research", "integration" and the NHS constitution. These all relate to the clinical commissioning groups. They may relate to others as well, but in the Bill they also relate to them. Is it fully workable? Will the Minister comment on the workability of these desirable objectives all at once at this basic level?

On the why and workability, I have some concerns. As an independent and always open-minded Cross-Bencher-as the Minister knows-I come to two points that I welcome. First, it is indispensable as the population ages and medicine becomes more complex to ensure the most efficient integration of medical and social care. There is room for improvements. For many patients, it is the most important element of their health, mobility and daily living problems. Therefore, I note with satisfaction that Clauses 191 and 192 of the Bill establish the health and well-being boards, which must encourage persons who arrange for the provision of any health or social care services to work in an integrated manner and to provide advice, assistance or other support. This is good.

In view of my long-standing interest in mental health, my final point is to welcome Clause 40, which makes local social service authorities responsible in relation to independent mental health advocates and inserts a provision into the Mental Health Act 1983,

This is also an improvement.

6.07 pm

Viscount Simon: My Lords, there continues to be too much reliance on market forces, pitching primary care against secondary care, damaging both as a consequence, while not recognising the existing strengths of primary care in providing a generalist service and secondary care in providing a specialist service. The Government seem to think that a specialist service can be provided by both. I suggest that this is wrong.

From all of the e-mails and correspondence that we have received, it appears that the continuing merry-go-round of bureaucracy, new legislation and reorganisation is damaging morale within the NHS. Not even senior doctors and managers are able to keep up with the changes. I wonder whether that is the intention of the Government. The Minister said that one of the intentions of the Bill was to depoliticise the NHS. If the Government are concerned about depoliticising the NHS, how come they have appointed police commissioners, which introduces a political element into the police? The two items of course are completely different, but they do not add up.

The words "any qualified provider" have appeared; these include private companies that will be able to provide services in the future, thereby draining resources from both primary and secondary care, cherry-picking

11 Oct 2011 : Column 1575

the low-risk cases without having to fund the technology or expertise of the more complex cases, or indeed the training and educating of doctors and nurses of the future. A few years ago, I was a member of the Select Committee looking into the provision of allergy services. We visited a number of places. One of them was Addenbrooke's Hospital in Cambridge. This unit is regarded as the country's leading allergy unit. I understand that it has been informed by the local commissioners that under the new Bill they are under no obligation to fund allergy services in Cambridge. That will threaten the very survival of this leading unit which treats patients from near and far and trains doctors to become specialised in allergic conditions, which are exceedingly complex. Is this in anticipation of what the commissioners consider the Bill will require? The noble Lord, Lord Kakkar, said that he is concerned with the future training of doctors and nurses and, with the potential closing of this very specialised unit, I agree with him.

Further, a neurosurgeon at Addenbrooke's recently told me that, due to the financial cuts, eight of his beds had been closed. How will patients with serious problems view this restriction? Could these be regarded as examples of the direction in which the NHS will go under the Bill?

The noble Lord, Lord Clement-Jones, said that the cuts already in place are not understood. In view of what is and might be happening at Addenbrooke's Hospital-and, I suspect, other hospitals-I am not surprised that patients, let alone health professionals, do not understand what is happening.

Finally, in order to have an example of one of the e-mails that we have all received on the official record, I would like to quote one from Mr Russell, which is short and to the point. He writes:

"Please do all in your power to prevent this awful bill from going through. We didn't vote for this level of change-it really should have been in a manifesto if the NHS is to be less accountable more bureaucratic and effectively partially privatised".

6.11 pm

The Countess of Mar: My Lords, like most noble Lords who have spoken or will be speaking, I am concerned about some of the contents of this Bill. I acknowledge the Government's good intentions but believe that they should, perhaps, consider a little more carefully where their good intentions might lead them.

I intend to concentrate on Clause 8, which deals with the Secretary of State's duties as regards the protection of public health, and to voice my concerns about the proposals for HealthWatch. Other noble Lords far more qualified than I am have dealt and will deal with the more complex matters. I remind the House that I am chairman of Forward-ME, a loose alliance of CFS/ME charities, and patron of several charities which care for people with ME or are funding research into the illness. I also suffer from the chronic effects resulting from sheep dip poisoning.

As has already been said, I believe that the Secretary of State must take the steps listed in Clause 8, which inserts new Section 2A into the National Health Service Act 2006. It is highly unlikely but possible for him or

11 Oct 2011 : Column 1576

his successors to ease themselves out of what are recognised to be very important functions because they are not obliged by law to undertake them. I am sure that the noble Earl cannot have failed to notice my frustration when I have been trying to get what I consider to be very reasonable recognition and treatment for people with myalgic encephalomyelitis or CFS/ME-sheep farmers and farm workers who are ill as a result of being exposed to organophosphates, and Gulf War veterans-only to find that no one is ultimately responsible for ensuring that they receive adequate medical treatment. It is the "Not me guv" syndrome. I find it hard to believe that in 20 years of campaigning so little progress has been made.

That is particularly so with members of the CFS/ME community. They were delighted when, in 2002, the Chief Medical Officer arranged for £8.5 million to be ring-fenced in order for specialist centres to be set up regionally for the purposes of diagnosis and treatment of this illness. Some centres were established, but several have gradually disintegrated because the hospital trusts have withdrawn continued funding for appropriate staff. This has left many very sick people without recourse to inpatient treatment in a specialist centre since the ward at Queen's Hospital in Romford was recently closed, without daycare or, in some cases, without the continuing services of a GP. Perhaps most distressing is the dearth of provision for children who frequently become very ill because they have been pushed too hard in the early stages of their illness by people who do not understand ME.

If Her Majesty's Government are seeking to improve the lot of NHS patients, it is those who suffer chronic illnesses of currently unknown aetiology, who do not respond to standard drug or other treatments, who most deserve to be protected. I can think of no other group that is systematically discriminated against by the medical profession and social services. No other illness than ME has such a big impact on the lives of so many people and yet is given such limited funding for specialist care services and scientific research.

In desperation, frustration, or perhaps, egged on by periodic dramatic pronouncements from a small group of psychiatrists and eagerly taken up by the media supporting allegations of the spurious nature of this illness, medical practitioners and social workers too frequently resort to incarcerating adults in psychiatric hospitals under Section 3 of the Mental Health Act or, in the case of children, imposing child protection proceedings under the Children Act after accusing their parents of fabricated illness ideation. They are then subjected to treatment which I believe to be excessively harsh. When that fails, the patient is accused of failing to co-operate and is abandoned by the professions.

As the Minister knows, this is not fundamentally a psychiatric condition-there is an enormous amount of international, peer-reviewed research that points towards viral or environmental toxin causation, though it is not surprising that some patients show occasional signs of anxiety or depression as do sufferers from other chronic illnesses such as arthritis or cancer. Are they made to have cognitive behavioural therapy or graded exercises without any medical treatment? Why are the international consensus criteria published in

11 Oct 2011 : Column 1577

the Journal of Internal Medicine in July 2011, which laid out clearly the criteria for diagnosis of ME, and its predecessor, the Canadian criteria, rejected by NICE and the NHS?

ME is assumed to affect about a quarter of a million people in the UK. Some are mildly affected, some moderately affected and about 25 per cent are believed to be so seriously affected that they are housebound or even bedbound. There is no central register of cases so there is no accurate assessment of its prevalence. I suggest that this disease should be the responsibility of the NHS Commissioning Board to ensure that services are provided. ME would otherwise simply get lost in the sea of other much higher profile conditions such as cancer, diabetes and heart problems, which will dominate the allocation of resources by local commissioning groups.

There is a strong economic argument for ensuring that GPs can recognise and refer ME to clinics that can intervene early and mitigate the severity of the illness. This potentially reduces the levels of social care and welfare support required and, in time, should make huge net savings. A recent study by Simon M Collin et al, The Impact of CFS/ME on Employment and Productivity in the UK, showed that,

The researchers conclude:

"The main implication of our findings is that effects on employment and productivity must be accounted for in estimates of the cost-effectiveness of CFS/ME interventions and service provisions".

They make the point that many adults are not referred to specialist centres and that this financial estimate is very conservative. Indeed, earlier research by Sheffield Hallam University concluded that the total costs to the nation of CFS/ME exceed £3 billion when account is taken of the costs of healthcare, welfare support and social care in addition to lost earnings.

Simply looking at the economic aspects of the illness, it makes good sense to ensure early diagnosis. Research shows that early intervention by specialist teams will frequently prevent the illness becoming severe. There is clearly a need for joined-up thinking. Clause 12 inserts new Section 3B(3), which requires the Secretary of State to have regard to four key points. I think that I have made the case for ME to be an appropriate case for the board to prescribe services and facilities. It is time that the discrimination against these patients ended, and this Bill could provide just the vehicle.

I will not say much about my concerns about the proposals for HealthWatch at this stage, except to say that there should be a smooth transition from LINks and that it should be totally independent of local authorities and the Care Quality Commission. I know that noble Lords, including the noble Lord, Lord Patel, will be tabling amendments to that effect. Is the Minister aware that there is a long-standing charity of the same name? I fear that NHS patients may be confused and possibly disadvantaged. Can that conundrum be solved?

11 Oct 2011 : Column 1578

I do not believe that the House should reject the Bill outright at this stage. I am minded to support my noble friends in their Motion that part of the Bill should go to a Select Committee, but will wait until I hear what the noble Earl has to say before I make up my mind.

6.20 pm

Lord Haskel: My Lords, I cannot remember the last time I troubled your Lordships on health. There are so many others far better qualified than me to speak, but there are so many aspects to this Bill-nonclinical aspects-that I felt that I had to speak up.

My first concern is the Government's absolute failure to convince a reasonable proportion of the public of the need for the Bill. Yes, we have had a listening exercise; we have had the Future Forum; there has been debate and argument; yet the public remain confused and unconvinced of why the reforms are necessary. A decent analysis of why they are needed and what has gone wrong could win over the public, but it has not happened. I think that most of us in your Lordships' House would agree that, except in an emergency, forcing through legislation without convincing the public is usually both bad government and bad legislation-especially when, as my noble friends Lord Rea and Lady Thornton explained, the Government have no mandate.

Worse, the Bill ignores some of the lessons that we have recently learnt. I give a couple of examples. The Bill sets out to create a rather complicated structure of deals with the private sector to deliver some of our clinical services. We now know that the public service as presently organised is not set up effectively to manage such an arrangement. How do we know? We know because the Public Administration Select Committee has told us. So has the Institute for Government. So has the King's Fund and many others. They have all drawn our attention to the problems of additional complexity. The skills to oversee that sophisticated commissioning and contracting are just not there. According to the Select Committee, the Government are not responding to that. Indeed, cuts are leading to the loss of the very key skills required for the managerial complexity about which the noble Lord, Lord Darzi, spoke. Is the Minister listening and taking the necessary steps, or is he just hoping for the best?

We are told that all this will be regulated by Monitor-holding the ring, as the Minister put it. We now know that this kind of regulation does not always work, especially as the Bill does not lay down any licensing rules. In these days of dysfunctional markets, even regulated companies fail. Tighter regulation strangles competition. Loose regulation means that the public can be exploited. Get it wrong, and we know that the public will be the losers-in every way. We also know that we do not fully understand how to regulate this kind of market without it becoming permeated by the logic and interests of the participating businesses-all at the expense of the consumer and the benefit of the big players. For proof, I ask the Minister to look no further than the current situation in banking and at his next gas and electricity bills. That is why the public are becoming disillusioned with market solutions. I suspect that that is why the Government have been

11 Oct 2011 : Column 1579

unable to have a meaningful dialogue with the public about the Bill. That is why I support the Motion of the noble Lord, Lord Owen, to send part of the Bill to a committee for further scrutiny. Let us take evidence and learn from recent experience.

You would have thought that with those problems of administration and regulation-problems central to the success of the Bill-a responsible Government would not implement change unless they were sure that they had all the tools, levers and skills in place. It is surely a mark of irresponsibility to do otherwise. Is there a crisis requiring urgent action? No. Does all this haste suggest that things are bad in the NHS? No. So why, as the noble Lord, Lord Williamson, asked? In 2001, 39 per cent of the public was satisfied or quite satisfied with the NHS. In 2009, that figure was 64 per cent. Those figures suggest that the task is not reform but to build on what is good. Surely, that is how to satisfy the rising demand, expectation and cost about which the Minister told us.

It is not as if now is an opportunity to be taken for reform. On the contrary: this is exactly the wrong time. The current Budget settlement requires the NHS to make year-on-year efficiency gains of 4 per cent for the next four years, yet the Government insist that spending on the NHS will increase by 3 per cent per year. No wonder NHS managers-to say nothing of the rest of us-are confused and worried about the lack of clarity and transparency in NHS finances.

In my other life, I spent 30 years building up a business, but it did not take me that long to learn that the discouragement and disarray presented by mixed objectives, confused budgeting or not carrying the staff with you meant that no objective was properly and fully achieved. As others have pointed out, it is also unclear who is in charge and who is accountable.

All of that is a sign of poor leadership and poor management by the Government: the kind of management that burns through money before you even know it has gone. We all know that, irrespective of whether we have had a life inside or outside of politics. I am sure that the Minister knows it as well.

Having demonstrated that this is a bad Bill, what should a competent and responsible Government do? With no mandate for radical change, it seems to me that the Government should be concentrating on incremental change to streamline and improve the performance of the NHS. The Secretary of State himself said that 90 per cent of what he wanted was possible in the existing structure.

I hesitate to trespass on clinicians' ground, but we have all received authoritative briefing about obliging clinicians and nurses to follow best treatment guidelines; the huge concern about mental illness; the need to be a lot more active in improving public health by insisting on standards for healthier food; avoiding the need for medical treatment caused by passive smoking or the violence and injury that alcohol causes, by more responsible marketing that does not target children or glamorise consumption. The Government have an important role in giving leadership in all those areas. Indeed, the Minister himself was very positive about that when he responded to the debate on this very

11 Oct 2011 : Column 1580

topic last Thursday, especially when a noble Lord suggested that it was that that could overwhelm the NHS.

I remind the House that one of the legacy promises attached to London's bid for the Olympic Games was that, through the National Health Service, 1 million extra people would be taking more exercise every week. That was a promise made on the grounds that that would radically improve the nation's health. Press reports say that that has been quietly dropped. Is that true?

This is an important Bill. Our task in your Lordships' House is not political point-scoring; it is to bring our experience to bear. I have tried to show that mine tells me that this is a bad Bill: badly thought through and badly timed. In an ideal world, Second Reading would be quietly dropped, perhaps like the Olympic health legacy. By convention in this House we do not vote down Bills at Second Reading, but on this occasion I shall be supporting my noble friend Lord Rea so that we can devote our time to far more pressing and difficult matters.

6.30 pm

Lord Tugendhat: My Lords, I declare an interest as chairman of the Imperial College Healthcare NHS Trust. I begin by paying tribute to the staff of the NHS. They have had to respond to a bewildering set of changes, of direction, of organisational structures and of objectives during the past 15 months. All have played their part in keeping the show on the road but a particular word of praise should go to the managerial staff who are so often and so unfairly traduced in this House and indeed in the other place. It is they who are at the greatest risk of having their jobs merged or cut and it is they who are having to bear the particular burden of implementing some of the changes, many of which are caught somewhere between their departure point and their destination. Those staff deserve a considerable vote of confidence.

I speak as someone who is in favour of change in the NHS. Indeed, I have done my bit to promote it. I chaired the steering committee that brought about the merger of the former Hammersmith Hospitals Trust and the St Mary's Hospital Trust to create the Imperial College Healthcare Trust, which is one of the largest in the country. I have also been deeply involved in the creation of the Academic Health Science Centre, which comprises my trust and Imperial College. It is one of only five academic health science centres in the country and one of the most exciting innovations to have occurred in the National Health Service for a very long time.

I give that background because I want it to be clear that when I say that the Government were unwise to introduce the Bill, I am not against change-far from it. I support much of what the Government are trying to achieve: enhancing patient choice, foundation trust hospitals, the reduction in administrative structures, more efficient decision-making, the reconfiguration of services, more use, where appropriate, of private providers and more involvement of general practitioners in commissioning. I could go on. I do not agree with everything in the Bill by any means but I agree with a great deal of it.

11 Oct 2011 : Column 1581

The Government's mistake was to introduce a Bill that sought to impose a massive programme of management and structural change on top of an ambitious cost-cutting programme. I refer, of course, to what is now known as the Nicholson challenge-to make efficiency savings of £20 billion between 2011 and 2014. As many noble Lords will know, that is quite unprecedented and in itself is a huge and effective agent of change. The achievement of the Nicholson challenge is also of considerable importance to the Government's economic policy. In my view, the Government should have used the Nicholson challenge as their great engine of change. They should also have recognised that much of what they wish to achieve in relation to patient choice, FT hospitals, service reconfiguration, private providers and involving GPs in commissioning, could, as other noble Lords have pointed out, have been achieved by building on what the previous Government had done with little or no recourse to primary legislation. If the Government had proceeded in that way and been more selective in their objectives, they could have achieved more, to the practical benefit of the NHS, of patients and of their own economic policy. They could also have avoided what can only be described as a haemorrhage of political capital.

So what is to be done? In my opinion, at this stage there can be no going back. There has been too much change already, too many administrative structures have been dissolved and are in the process of being reformed, and too many objectives and policies are uncertain and in a state of flux. The eggs have been broken but the omelette has not been made. Although the Bill is in need of a good deal of improvement and will no doubt, rightly, be subjected to a good deal of amendment, the National Health Service needs closure. It needs the stability that only the statute book can provide. I therefore urge noble Lords to reject the amendment in the names of the noble Lords, Lord Owen and Lord Hennessy. I understand what lies behind it and the advantages that they seek, but the NHS now requires closure and stability. I am struck by the fact that other noble Lords who are themselves directly involved in the NHS all appear to share this view.

In the time allotted to me, I cannot deal with many of the big issues already raised in this debate. Rather than touch on several in an inadequate fashion, I shall concentrate on one that I consider of critical importance. I refer to service reconfiguration, those slightly fancy words used to cover the rationalisation of services, their concentration on fewer sites and the scaling back of some hospitals. At present, there is too much duplication of services on too many sites. Too much is being done in hospitals that ought to be done in surgeries and at home. This is both needlessly costly and clinically unsound. There is a mass of evidence that shows that clinical standards improve if some specialist services are concentrated in bigger centres so that surgeons can perform complex operations more often and more regularly. The same applies not just to operations but to other treatments. This also facilitates investment in expensive state-of-the-art equipment. Likewise, modern medicine can often offer better care by getting patients out of hospitals and moving services into the community.

11 Oct 2011 : Column 1582

As we all know, it is hard to convince the general public of both those propositions. Shifting services from one site to another and scaling back hospitals, let alone closing them, causes acute local anguish and corresponding political protest. Of course it requires, and should require, extensive local consultation. My fear is that some of the new structures and procedures introduced in the Bill will make that consultation and those procedures even more complicated than they are at present-or, rather, than they were before the Bill was introduced. As a result, there is a big danger that the changes will not be undertaken on a planned and rational basis that takes due account of patient needs and clinical requirements; rather, they will be salami sliced in an ad hoc fashion in order to get around consultative procedures and to meet arbitrary deadlines.

The NHS is already under intense financial pressure that is bound to lead to some diminution of services. Ministers would do well to warn the country more loudly than they have of what is in store. It is vital, though, that as far as possible-and it will not always be possible-financial requirements should go with rather than against the grain of patient needs and clinical priorities. With that in mind, I hope that the Government will give serious consideration to a proposal from the King's Fund, designed to depoliticise this process as far as possible. The proposal is that instead of the Secretary of State, the Independent Reconfiguration Panel should act as the final arbiter on reconfiguration proposals. I think that the King's Fund is right when it argues that this would make the process more transparent and send a strong message to the local level that political considerations would not be the deciding factor, as they have so often been in the past. I believe, too, that this would speed up the process, which would be in the interest of clinical priorities and of meeting the Nicholson challenge. It would also be in line with the argument, in Liberating the NHS, that the Secretary of State should concern himself less with operational detail and more with strategic direction.

6.40 pm

Baroness Wilkins: My Lords, I am delighted to follow the noble Lord, Lord Tugendhat, since I received the help of the excellent district nurses in his trust, for which I am grateful. I stress yet again the volume of concern that has been expressed about this Bill and that has just been so ably expressed by the noble Lord, Lord Haskel. I trust noble Lords will not ignore the fact that the public are deeply fearful about the Government's plans for their health service, and that they are relying on this House to protect it.

Knowing the number of speakers today, I decided to be brief and concentrate on just one issue-the co-ordination of services for children. I am grateful to the Every Disabled Child Matters campaign and the Communication Trust for their help. There are around 770,000 disabled children living in the UK, a number that will increase in the future as medical advances ensure that more children survive birth and childhood illness. To succeed in life a disabled child and their parents and carers need help and support, not only to identify their support needs but to overcome any problems that arise. This requires partnership working across health, social care and education boundaries.

11 Oct 2011 : Column 1583

The current system is already a difficult maze to negotiate for parents seeking support. If the changes go ahead, I fear that it will become even harder.

While health and well-being boards will be charged with co-ordinating the planning and delivery of health, social care and public health services at a local level, there will be no place at their table for education providers. However, experience tells us that the most effective interventions are often those delivered in non-health settings such as a school or children's centre. We are already seeing some PCTs altering their structures in anticipation of a reformed health system to pilot new programmes. However, there has been no guidance on how children's health services will be commissioned and delivered. It is sadly typical; children and young people are forgotten again in a health and social care system designed for adults. Worse still, the Education Bill, currently before your Lordships' House, will remove the duty on schools, academies and colleges to co-operate. As has happened so often in the past, where agencies are not required to work together there will be a loosening of ties. A government policy of simply hoping that co-operation will happen is no guarantee that it will, whatever the Government's warm words, and it is disabled children who will miss out.

What, then, about the welcome proposals in the Department for Education's recent Green Paper? It suggests new approaches to special educational needs and disability and calls for more co-ordination: a single assessment process, a joint education, health and care plan and a local offer, all of which will set out the services available to a disabled child in a local area. I fear that it will remain an unmet aspiration as energy and money are devoted to tearing up current systems and installing new structures, new acronyms and new titles-all of which are expected to work within a reduced budget.

Take, for example, the commissioning of speech and language services for children with speech, language and communication needs. One child in 10 has a speech and language difficulty. It is the most common disability in childhood and the most common type of primary need for pupils with special educational need statements. Unaddressed, issues with a child's speech, language and communication needs risk problems with literacy, numeracy and learning as they move through the education system. Just 20 per cent of children with these problems achieve the expected level in maths and English at the end of primary school, compared with 72 per cent of all children. Needless to say, the gap widens even more by the end of secondary school. However, as Sarah Teather, the Minister for Children, admitted earlier this year, the chance of a child with speech, language and communication needs now receiving speech and language therapy is between low and nil. How will tearing up the current system enhance the chance of a child with speech and language problems receiving adequate help-help that is best delivered by co-ordination between health and education services?

I remain deeply concerned that while we spend time debating more changes, and more time, energy and money are spent on designing new systems rather than simply making the current structure work better, once again it is the needs of disabled children that will be forgotten.

11 Oct 2011 : Column 1584

6.45 pm

Lord Greaves: My Lords, I declare an interest as a member of a local authority and, like everybody else, a patient-or perhaps a consumer of NHS services. I worked out that I would certainly have been dead at least three times if it had not been for the NHS at various times in my life. No doubt other noble Lords are in the same state-that is, we are alive and well and thriving, despite that. We have heard a wealth of detailed knowledge and experience, although we are not yet half way through this astonishing debate. I have had at least one e-mail this afternoon from somebody who has been watching and listening to the debate and commenting on it. Perhaps all noble Lords will get that when they get back to their computers. I associate myself particularly with many of the remarks made, particularly those of my noble friends Lady Jolly, Lady Williams of Crosby and Lord Marks of Henley-on-Thames.

I shall make several general remarks that put the Bill into a wider political context. If it gets a Second Reading, as I expect it will, I shall hope to take part in the Committee stage on areas where I perhaps have something to contribute and that relate to local structures, the role of local government, the complexity of the proposed structures and systems and how we can sort them out a little, and the representation of the interests of patients and citizens.

As we know, the debate in the country on the Bill is extremely polarised. People often ask me about my work as a Member of your Lordships' House and we end up having a fairly complicated discussion about what we do and how we do it; I do not know whether they are impressed. This Bill is different. People simply say, "Will you vote for it or against it?". There is a lack of understanding of many of the changes that have already been made to the Bill. It would help the process of improving the Bill if many of the campaigners and the Opposition would recognise the genuine progress that was made before it came here. A great deal of that progress resulted from action taken by the Liberal Democrat party conference in Sheffield in the spring, the pause that was a direct result of it and the changes that came from that. Unless we understand what the Bill was like when it started and how it changed in the House of Commons-there were allegedly 1,000 amendments-we will not understand how it comes to be what it is now and what we can do to improve it further.

Some of the changes that have been made include the fact that competition can now be on the basis only of quality and not of price. That is a great improvement on the legacy of the Labour Government. Commissioning groups will be more accountable, involving the health and well-being boards in their decisions. These commissioning consortia will meet in public and publish all their plans in draft form for public consultation. That is a significant improvement in local accountability. We are told that there will be no more cherry picking of easy, profitable services by new private providers. Along with all these things, that is something that we shall want to probe. There is no doubt that, despite the House of Commons having spent a very long time debating the Bill, the changes at the end were all put through in two days. Many of them were not properly

11 Oct 2011 : Column 1585

debated at that stage. If the Bill gets a Second Reading here, one of the jobs that this House must do is to look at those changes, understand them and see whether they will work or need fettling a little more.

NHS commissioning is to remain a public function in full compliance with the Human Rights Act and Freedom of Information laws. That is very important. Commissioning decisions are not to be outsourced to private companies; they have to be made by the commissioning consortium. That is also very important, and something that a lot of people have been concerned about. Monitor will have a primary duty to promote patients' interests. There is a big debate still to be had about its role in relation to competition, but it is no longer to promote competition; it is to prevent anti-competitive behaviour. I am sure your Lordships will want to scrutinise what that means. There have been huge improvements. Unless we understand them and the role of the Liberal Democrats in achieving them, we will not get as far as we should.

Is the job done? No, it is not. It is part-done and if the Bill is to remain, there is a great deal more to do. Should we give it a Second Reading and scrutinise it in detail, improve it by debate, negotiation and if necessary Division, in the normal way in which the House of Lords works? If we are going to do that it is vital that it is given enough time. The intention is for it to have 10 days in Committee. There are days and there are days, as we have seen with the Localism Bill. Some days can be half an hour, and others can be a full day. Ten days are not enough, and the Government would not be right to push this through as quickly as possible. If the House is going to do its job properly, it has to be given the time and the resources to do it.

The letter sent by the Minister, the noble Earl, Lord Howe, said that the House must have proper time to examine the Bill. He also said that it should be done expeditiously. The relationships between the two Front Benches in this House have not always been the best during this Session of Parliament, but like other noble Lords I was impressed by the Minister's presentation and that of the noble Baroness, Lady Thornton, who, if I understood her correctly, promised that the Labour Party would not delay for delay's sake but would seek to scrutinise the Bill properly. If that happens and there are good relationships around the House, the job can be done well.

What is the case for supporting the amendment from the noble Lord, Lord Rea? It is that if this Bill is passed it will be forced through in the face of massive opposition and concern within the health service. This is the fault of the Government, perhaps of a gung-ho Secretary of State and certainly of the language used. As I think the noble Lord, Lord Warner, said, you listen to different Ministers and still get a different message. Some of the concern is certainly justified, some may be a result of misunderstanding, and some is possibly deliberate misrepresentation. We attack the views of so many professionals at our peril. They cannot all be wrong.

The Bill will be forced through in the face of massive concerns from the public, and those of us on these Benches ought to be aware of the massive concerns among Liberal Democrat voters in particular. Opinion polls are not too reliable on this kind of thing, but it is

11 Oct 2011 : Column 1586

clear that there is no settled consensus in the country behind these reforms. The Government have lost the argument in the country and in the NHS. The noble Lord, Lord Tugendhat, said that it is a haemorrhage of political capital. I would say that they have lost the plot. It will be very difficult indeed to get the argument in the country back on to a reasonable level and away from, "Are you against wrecking the NHS?", which is the argument at the moment.

What is the best way of doing this? We can vote for the Bill to have its Second Reading, as I suspect we will, and we can scrutinise it properly, and I will certainly take my full part in that; or we can refuse to give it a Second Reading, tell the Government to go back and sort out the reorganisation of the NHS that is taking place in a semi-botched way as the Bill casts its shadow before it-this can be done without further legislation-and concentrate on sorting out the 4 per cent efficiency cuts. I am minded to support the amendment in the name of the noble Lord, Lord Rea, if it is put to the vote, but I shall continue to listen to the debate before that vote takes place.

6.54 pm

Baroness Hollins: My Lords, I worked in the NHS for 40 years, initially as a GP but for 30 years as a consultant clinical and academic psychiatrist, and of course I know that change and development are constantly needed to improve everyone's health and well-being. I must admit, though, as a survivor of many top-down NHS reforms, that I favour incremental reform.

As a past president of the Royal College of Psychiatrists, I have been talking to the college and mental health charities regarding the Bill. I and they recognise many positive elements in it, in particular the proposed strengthening of clinical leadership and the focus on clinical outcomes and the interests of patients.

I want to make five points today. My first point is a question. Is there is a need for legislation at all? Is the Bill needed to enable the Government to press forward with their key reforms? I put this question to the chief executive of the NHS last night. If the Bill were dropped, what would the legislative gaps be? He replied that there would be a lack of certainty in the direction of travel. This Bill seems to have generated its own uncertainty among health professionals in the NHS.

Let me share the results of an electronic survey conducted over the weekend of members of the Royal College of Psychiatrists working in England. I am afraid that it is not good news. A staggering 84 per cent of nearly 2,000 respondents-20 per cent of eligible members-are asking for the Bill to be withdrawn. Eighty-five per cent think that the Bill would result in a more fragmented system of healthcare, and 86 per cent said that the Bill would not decrease bureaucracy. Successful reform requires the confidence and buy-in of those who work in the NHS.

My second point is about how this Bill can best address mental and physical health needs together in the NHS. We know that it is often the neediest who are denied access to psychiatric and medical services. It is true that sometimes mental health service users and people with learning disabilities may be more difficult to engage with due to their illness or their ability, and

11 Oct 2011 : Column 1587

that can require extra time and skill. Our patients and the health professionals who work with them often face the problem of stigma, which other health professionals do not usually have to deal with.

What can the Government do about this? I suggest that one way would be for them to strengthen the presence of mental health in the Bill. I am preparing some amendments to help this to happen and I do hope that the Minister will see the wisdom of my suggestions. Specifying physical and mental illness in the Bill instead of just illness would enable the Government to stand firmly by their stated intention in the mental health strategy to ensure parity of esteem for mental and physical illness, and to recognise that there is no health without mental health.

Mind you, there is a long way to go to ensure parity of provision. Twenty per cent of the disease burden in the United Kingdom is attributed to mental health problems, compared with only 16 per cent for cardiovascular disease and 16 per cent for cancer. Unfortunately, only 12 per cent of the available resources are currently allocated to mental health, and sadly this inequity includes a lack of adequate investment in specialist services and research. No other health condition matches mental ill health in the combined extent of its prevalence, persistence and breadth of impact.

However, mental and physical illnesses are not quite as different as is sometimes supposed. It is unsurprising, given that the brain and the heart are in the same body, that depression and heart disease are so closely related. But people who are already patients of mental health or learning disability services suffer terribly from diagnostic overshadowing. In other words, if they have a diagnosis of depression, all their symptoms may be attributed to the depression. Their physical illnesses just do not get the same attention. Likewise, those with a primary diagnosis of heart disease, diabetes or stroke often fail to get adequate psychiatric attention. The mind/body split, which has been made far too concrete in the separation of service providers and in simplistic attempts to define tariffs, has not served patients well.

There are some statistics that highlight how, with more enlightened clinically-led services, we will perhaps be able to save lives and money. For example, more than 40 per cent of smokers have a mental health problem; and let me stress that smoking did not cause their problem. Paying greater attention to treating mental health problems might be a cost-effective way to improve many more people's health and well-being.

My third point is about choice. Enhancing patient choice is not quite the right answer in mental health, unless by choice we mean involving service users in designing and managing their own care pathways. Indeed, choice is often rather a hollow concept in mental health services, with so many patients being treated against their will. Mental health services work closely with local GPs and other agencies in the community. Increasing choice for our patients could actually hamper access to an integrated and safe service, and to continuity of care-especially as these services are already about both health and social care, and the coterminosity of providers is important. Increasing the presence of the

11 Oct 2011 : Column 1588

service user's voice is much more important than choice, and the role of an independent HealthWatch could be key.

This brings me on to my fourth point, which is about introducing the new commissioning challenges at a time of austerity. I heard today from a senior psychiatrist about how the cuts are affecting direct patient care in his mental health trust, where 15 per cent of consultants are expected to leave in the next three years, and 10 per cent of community workers are to be lost in the next year.

For the first time, a health Bill has a very welcome clause about reducing health inequalities but there is doubt about whether the structures proposed will achieve this. The most significant concern emerging from mental health charities and the Academy of Medical Royal Colleges is that the Bill might actually increase health inequalities. I am sure that everyone in this House shares my wish to keep the NHS as a publicly funded service providing comprehensive care for the good of all the people. However, it is difficult to be optimistic about more positive outcomes being achieved through the new commissioning arrangements proposed for people with mental illness or people with learning disabilities.

Monitor's role will include setting the price for services once commissioning boards have defined what will be bought. However, in mental health there are real difficulties in defining population and individual need. There is already good evidence to show that joint strategic needs assessments are failing to understand the needs of people with mental illness or those with learning disabilities. Given the wish of the Government to give more responsibility to clinicians, we need to make sure that new commissioning bureaucracy does not get in the way of letting individual clinicians create collaborative, innovative pathways with inbuilt continuity in partnership with patients. I am not talking here about Monitor's duty to maintain organisational continuity but instead about the continuity of individual care pathways, which is exactly what is required for so many patients with serious mental illness or for people with learning disabilities who also have associated physical or mental health problems. I can see neither how the new commissioners will be able to acquire such expertise in the near future nor how Monitor will be able to develop appropriate pricing expertise in complex mental health and social care in order to avoid horrendous planning blight for the foreseeable future. My experience is that planning blight has impeded progress after every top-down reform and that mental health and learning disability services have never been at the top of the priority list to sort out.

My fifth and final point is about public health and the link with wealth inequality. When I was a child and first talked about wanting to be a doctor, my father told me that the greatest improvements in health in the 20th century were due to the efforts of the Victorian engineers who reduced the incidence of cholera by better drains. However, an analogy with a utility company such as water would be simplistic in the 21st century. The 21st century equivalent of better drains is better public services above ground. Some of these will be health services, but health services are not fully responsible

11 Oct 2011 : Column 1589

for preventing disease. A Government committed to rebalancing the current levels of wealth inequality that are bad for the whole population, not just disadvantaged groups, would achieve the greatest reduction in most chronic illnesses.

Most commentators talk of the NHS in terms of waiting lists but it is the management of chronic conditions that require continuity and flexibility that is more challenging. These are conditions that require people to stay in touch with specialist services for long periods of their lives. Such patients want a trusted local service, with in-patient beds for the times they get too ill to stay at home. This is not about shopping; it is about integrated personalised care.

7.05 pm

Baroness Howells of St Davids: My Lords, I decided today to bring to the attention of the House excerpts from the correspondence that I received from people who in the early days were invited by the British Government to come to Britain and serve in the National Health Service. They have taken the trouble-although most of them have retired-to write to me and ask if I would bring to the attention of the House the fact that the United Kingdom has been admired for its National Health Service that looks after the health of the nation. Those people remember that every Government thus far has seen it as a privilege to be the custodians of the NHS-and they are very proud of the part they played in that.

Despite what the Minister said in his opening speech, the letters suggest that if this Bill goes through in its present state it will reduce accountability to the Secretary of State and thereby to the taxpayers. The clause in the Bill relating to this has created many problems forthe citizens of the UK, as has been said today. One of the anxieties is: to whom is the NHS accountable, if not through the Secretary of State to the electorate? I hope that the Minister will reply to this because it is a burning question for not just those who wrote to me, but nearly everyone in this Chamber who mentioned accountability.

As the Bill stands, there will be increased bureaucracy and costs, and-dare I say-potential legal challenge through the application of procurement law. Will the new and inexperienced commissioning consortia be the appropriate responsible bodies for dealing with these legal challenges? How will this improve the National Health Service, especially at this time when we have a downturn in the economy, squeezes in all areas of government, reductions in staff numbers and immense pressure on the confidence, well-being and mutual trust of staff and patients? The National Health Service is not about things. It is about people. People are different. There is still uncertainty as to the impact of competition law. It is very likely that competition law will apply to the NHS. Have the implications been properly considered? If not, the NHS will be subject to uncertainty and delay, and it will prompt access to legal action that will take away finances from the treatment of patients.

The NHS has often been described as world class because those who work in it have been considered by others as being the most dedicated public servants in

11 Oct 2011 : Column 1590

the country. Other countries seek to learn from our comprehensive system of practice and its role as the medical home for patients needing continuity of care and co-ordination. The NHS's reputation has always had a focus on evidence-based medicine, supported by internationally respected clinical researchers; with the funding from the public purse it continues to impress worldwide. There is a great fear among these people that with later developments in other countries the citizens of the United Kingdom will not be able to depend on the National Health Service, which we always boast is free at the point of need.

There have been criticisms of the NHS by users and managers alike in the past. This Bill is meant to improve and enhance the NHS and to evaluate whether it is fit for purpose in the changing world. The Government have had two goes at this Bill and still the criticism comes aplenty in letters from clinicians, patient groups, individuals and trade unions. One of the letters I read was from a doctor who was trained in this country and worked for the National Health Service until he retired. He said he pleaded for my support to protect the founding principles of our National Health Service. He further suggested that the Bill has the potential to destroy the NHS as a universal service. It is very difficult to disagree with him after the other speakers I have heard today.

The Minister in his presentation said that responsibility was not taken away from the Secretary of State. I am afraid market competition and profit, not patient need, will drive the service if we accept the Bill as it is. Taking dentistry as an example, while we accept that competition can drive innovative services, how can it benefit ill people who are poor, illiterate and without internet access? This service as is proposed will cause more harm to patients than good. Those who live outside the radar of the healthy, the employed andthe respectable will be sorely disadvantaged if this Bill is rushed through. Sick people need their local hospital or clinic to remain open and to provide comprehensive care. By introducing competition law this Bill has the potential to erode collaboration between primary and secondary care providers. It will not enhance it.

The Bill also has the potential to destabilise the training of doctors, nurses and ancillary healthcare workers. The number of illnesses far outweigh the service they can give because of the pressures on them. As has been said, this Bill has no electoral mandate. It further appears to flout open promises made by the Prime Minister not to engage in top-down reform. That is exactly what it is proposing. There is a sea of worry out there with good cause. Long-term illnesses will be driven into a US-style of healthcare which Professor Pollock describes as,

A well known political figure recently said the NHS as it stands is one of the most efficient, cheapest and fairest health systems in the world. Most practitioners and service users in the field of health and social care share a singular desire-the best possible future for the NHS-and this is not yet shown in this Bill. I ask on behalf of those who wrote to me that we re-examine the way this Bill will become law.

11 Oct 2011 : Column 1591

7.14 pm

Baroness Morgan of Drefelin: My Lords, this has been a powerful debate already and, as number 51 on the speakers list, I represent perhaps the move into the beginnings of the home straight for the Minister and all the winders. I have been particularly impressed by the contributions today and am very much convinced by the arguments for the amendment of the noble Lord, Lord Owen, not least because of my concerns about the issues around Monitor and the failure regime. Given the lateness of the amendments, there is a need to scrutinise that part of the Bill and perhaps hear evidence from those outside this Chamber.

I want to focus on three important areas that have not been touched on in much detail so far: research; commissioning, particularly for cancer patients; and patient involvement. For the record, I declare an interest as chief executive of the research charity Breast Cancer Campaign.

On research, we have already heard from the noble Lord, Lord Willis, that the role of medical and scientific research in the promotion of high-quality healthcare is extremely important and highly significant. I am delighted that I am not the only one who has highlighted research today. The noble Lord, Lord Darzi, also made a very important point. We should not forget that long-term improvements in treatments are largely derived from and are dependent upon medical research, which requires long-term investment. The NHS offers a unique setting in the world for research and has enormous potential to enable and support advances in research. My concern is that we are still far from maximising the potential for patient benefit.

I am pleased that the Government have responded positively to concerns about the future for research in the NHS by introducing duties to promote research, which will be placed on the Secretary of State and commissioning consortia alongside the existing duty on the Commissioning Board. The AMRC and other medical research charities, including my own, have campaigned for that. However, I will be pressing the Minister to provide further detail as to what these duties will mean in practice. As the noble Lord, Lord Willis, said earlier, we need to be very careful that these duties are not just window dressing. In particular, I want it to be clear that there should be measurable benchmarks developed as a result of these duties.

I, too, must raise the issue of the regulation and governance of medical research. The key report by the Academy of Medical Sciences on this subject has been widely welcomed and I look forward to hearing more from the Minister about a timetable for the further development of the Health Research Authority-I do not understand at all why this cannot be in this Bill. Surely there is a great opportunity here to get that right and establish the authority.

The same Academy of Medical Sciences report raised the need to simplify the use of NHS patient data. This is a really important opportunity for progress. Another example of the positive use of patient data is the million women study-a collaborative project among Cancer Research UK, the NHS and others that involves more than 1 million women aged 50 and over-which identified the cancer risks of hormone replacement

11 Oct 2011 : Column 1592

therapy, which is a key issue for women in this country. Will the Minister explain what consideration he and his colleagues have given to taking action on patient data to ensure greater simplicity within the system in order to promote such vital research?

My second point is on commissioning. We have heard a lot about commissioning, but I want to focus particularly on the commissioning of cancer services. We know that improving outcomes in cancer can be promoted only by collaboration and by commissioning across primary, secondary and tertiary services and public health, taking into account the need for high-quality research, because we know that patients do better when they are part of clinical trials.

For example, radiotherapy is a service that needs to be co-ordinated at regional and national levels, as it requires large planning populations and has a significant capital cost to be considered. In a recent report by the Cancer Campaigning Group, 81 per cent of GPs surveyed said that they believed that radiotherapy should be commissioned at a regional or national level, but is this what is going to be proposed? I still do not fully understand that.

Another example is the commissioning of pathology, which I am also concerned about. This issue is close to my heart because Breast Cancer Campaign has established the UK's first tissue bank, which has been a huge endeavour. NHS pathologists have contributed to that, often in their own time, and have really gone the extra mile because they believed in making the project happen. How that will work going forward is of great concern. We rely on a lot of good will from NHS employees to make research possible in this country.

The Cancer Campaigning Group-whose membership includes over 50 charities, including Macmillan Cancer Support, the Prostate Cancer Charity and Cancer Research UK, which I have already mentioned-has argued very strongly for the vital role that cancer networks must play, which must be maintained. The Government have listened to these arguments and made funding available to fund and support cancer networks, which are a vital source of expertise and drive in promoting improved quality in cancer services, but that is only until 2013. I hope that the Minister will be able to set out how the Government intend to guarantee the best future for cancer networks going forward.

I know that there are implications for other disease areas, too. I would be particularly interested to hear the Minister's thoughts on how to ensure that networks receive sufficient funding, have the capacity to commission high-quality cancer care for patients at all stages of their cancer journey and have a suitable accountability structure. I would also like to hear about how their role can work in supporting patient involvement. I am happy for the Minister to write to me in response, because I have a feeling that he may have a lot of points to come on to later. We have all seen real improvements in cancer care in recent years in this country, which has been driven largely through collaboration and integration, and we need to understand how that can go forward.

In my last point, I want to say something quickly about patient involvement, which I believe is fundamental to improving the quality of care. "No decision about

11 Oct 2011 : Column 1593

me without me" sounds great, but I understand that the assessment of the Richmond Group of patient-led health charities is that this principle has not yet been fully adopted in the context of NHS service design and planning processes. To do that would mean that the duties on commissioning bodies and Monitor to obtain advice in discharging their functions should be further extended to more fully encompass patient involvement.

7.24 pm

Baroness Wheeler: My Lords, in this marathon of debates, I want to focus my attention on two of the key issues that I will be leading for on behalf of the Front Bench. These arise from Part 5 of the Bill, and it is clear from the debate so far that they are matters which will absorb much of your Lordships' attention in the coming weeks. First, I refer to the issue of how patients' voice and involvement can be truly embedded into the Bill, and, secondly, how we might ensure that the Bill promotes integration across the NHS, public health and community and social care and gives impetus and encouragement to the progress that has been made over the past few years, despite the difficulties and obstacles that can be faced joining services up to the benefit of patients and carers.

In the 15 September debate in your Lordships' House on the implementation of the Future Forum recommendations, which noble Lords variously described as an overture or limbering up for today, my noble friend Lady Pitkeathley described reflecting patients' voice in health and social care as,

This sums up in a nutshell what must arguably be the major priority if the laudable aim of "no decision about me, without me" is to become a reality for the majority of patients and clients. The Future Forum underlined the importance for the voice of patients and the public to be embedded in our health services, including the voices of children, vulnerable adults, carers and those who are often excluded. In evidence to the House of Commons Select Committee on the reconvened Bill, the chief executive of the mental health charity Rethink, Paul Jenkins, supported the need to,

We support that aim, which, along with harnessing the collective patient view of such organisations as Rethink or the Stroke Association, will be essential if services that are high quality and sustainable in the future are to be designed. We will seek changes in the public involvement provision in the Bill to place greater emphasis on the proactive involvement of public and patients before decisions are made. I would also ask how lessons in future are to be learnt from the mid-Staffs experience, where we know that this collective patient voice was ignored.

It is clear from the contributions in the debate today that there needs to be much discussion and development to define what patient involvement and shared decision-making actually means at each level,

11 Oct 2011 : Column 1594

and that the Bill as currently constructed does not deal with or address these issues and is in effect woefully inadequate in embedding the patients' voice into the new structures. From these Benches we will table and support amendments to the Bill which strengthen the emphasis on patient and public involvement in the structures of all local bodies, including foundation trusts, clinical commissioning groups and health and well-being boards. We will aim to get the current loopholes and get-out provisions, for example in the requirement for these bodies to hold public meetings, well and truly plugged. Health commissioners and providers must operate under the same standards of good governance to which local authorities and other public bodies comply.

We will also support the proposals from key patient groups to define what the duty under Clauses 20 and 23 to promote the involvement of each patient means, and the specific aspects of involvement that commissioners should promote. We will seek specific proposals in the Bill to recognise expert patients, carers and patient organisations as people from whom commissioners should obtain advice. As the Patient Voice has said:

"It is about commissioning care and treatment services in such a way that those services engage patients as fully as possible in managing and controlling their health and care".

How will the NHS Commissioning Board and CCGs be held to account for promoting patient involvement?

We also support the need for the establishment in the Bill of a duty of candour for any organisation providing NHS and social care, so patients and clients can be informed when things go wrong with their care and treatment, as soon as it is known, not after months of denial, legal obfuscation and cover-up. This is a new area of development, and I ask the Minister if the Government would support the provision of such a duty.

Finally HealthWatch England must have the teeth, strength and independence to be an effective patient champion. We strongly support the principle of a national body representing patients, with local outposts, but running alongside other measures which ensure patients and public are directly involved in decision-making. We do not support HealthWatch England being a sub-committee of the Care Quality Commission, and will seek amendments to the Bill that delete this provision. We agree with members of the current Local Improvement Networks, LINks, that HealthWatch's role, work, independence and authority will be severely compromised if the proposed CQC relationship remains. Instead, HealthWatch's powers should be extended to enable it to make recommendations direct to the Secretary of State and to the various arm's-length bodies to which it relates. We will also be seeking to ensure that these bodies are required to respond publicly to HealthWatch. We will also seek to ensure that local HealthWatch organisations are properly resourced to undertake the important and key work that they will have.

Let me turn to the issue of integration of NHS public health and social care. In his written response to questions raised by me during the 15 September debate on the Future Forum's continuing role, and how its findings would be fed into the Bill, the Minister responded:

11 Oct 2011 : Column 1595

"The future work of the forum is focused on implementation of the Government's modernisation plans, and is therefore unlikely to require further amendments to the Bill".

So, no second pause, then. The forum has been asked to look at how to ensure that,

Good question. The forum will be asking where services should be better integrated around patients, service users and carers-both within the NHS and between the NHS and local government. I am pleased to note that they are particularly interested in social care examples, for example better management of long-term conditions, better care of older people, more effective handover of a person's care from one part of the system to another.

From these Benches we will be tabling and supporting amendments to provide for a definition of integration in the Bill so that it encompasses NHS, public health and social and community care. Given the Future Forum's continuation into what is becoming to look like a pretty permanent role, what better way than to provide a clear legislative framework, context and direction for the forum to work to?

There is much confusion about what is meant by integration, which needs to be addressed. Even the Prime Minister himself is confused, since one of his famous five pledges is on integration but relates primarily to NHS integration, not integration across health, public health and community and social care.

In practice, integration models in the NHS and social care are varied and diverse. You have provider integration in the NHS; commissioning integration across health and social care; structural integration across health and social care organisations, such as healthcare trusts; integrated pathways, which are mostly NHS focused but with some excellent examples across both systems, such as stroke and reablement; and finally, integration around individual patient users, such as personal budgets and direct payments.

We strongly support defining integration in the Bill to ensure that national policy promotes the supporting context for integration. Currently, health and local government are only required to "act in an integrated way". Both the excellent work undertaken, for example, by the Nuffield Trust in its Integration in action case studies, and by the Local Government Association report by Professor Gerald Wistow, Integration this time?, point to how such a strategic overview definition could be developed and framed. It would help rebalance the Bill into more of a health and social care Bill. Does the Minister intend to clarify and define integration in the Bill?

Finally, in closing, I want to stress our recognition of the importance of the future role that health and well-being boards need to have in ensuring integrated services and promoting patient and public involvement in the commissioning of services. We support health and well-being boards and the health and well-being strategy-in the context that the local authority has real powers over its implementation.

Moreover, if health and well-being boards own the well-being strategy then they must also own the plans to deliver it. CCG commissioning plans should be

11 Oct 2011 : Column 1596

agreed by the health and well-being board, and we will be putting down amendments which seek to give the boards this important power of sign-off. Only in this way will we achieve genuine joint ownership between boards and CCGs of commissioning plans which match local needs and are firmly based on the health and well-being priorities of the local community.

7.34 pm

Lord Colwyn: My Lords, before saying a few words about the National Health Service dental service, which I would remind my noble friend is not entirely free at the point of delivery, I should remind the House that I have actually worked as a dental surgeon in the health service for more than 25 years.

This is a time of great change for dentistry. Alongside the changes to commissioning introduced by this Bill, the next few years will also see the introduction of a new NHS dental contract, with a greater emphasis on prevention. Pilots for this contract started last month in 67 dental practices across the country, and are due to run for at least the next 12 months. On the whole these changes have been warmly welcomed by dental professionals, because they start addressing the lingering problems that the previous set of reforms created in 2006. Nevertheless, there are a number of points where there is still a need for more detail and greater clarification, and I hope that the Government will be able to address these issues as the Bill progresses.

Dentists strongly support the decision that the commissioning of general dental services and secondary dental care should be carried out by the national NHS Commissioning Board. This arrangement has the potential to be a considerable improvement on the current system of PCT commissioning, which has resulted in inconsistencies across the country. However, if these arrangements are to deliver improved dental provision, there is a clear need for expert dental advice to be available to the Commissioning Board to inform its commissioning decisions. At present there is nothing in the Bill that explains who will offer this advice, or the mechanism by which it will be provided.

At a national level, local expertise will also be vital in the new commissioning arrangements. When the Commissioning Board makes decisions about service provision for specific areas, it will not only need to call upon expert dental advice, it will also need an input from professionals with local dental expertise. This local input is a key element that the Bill has yet to cover and the Government need to clarify how they will utilise the existing sources of local dental expertise, such as local dental committees, in the new commissioning arrangements.

The role of consultants in dental public health will also be of great importance, particularly given the Government's reform of the public health system and the changes that the Bill makes to the public health responsibilities of local authorities. The Healthy Lives, Healthy People: Update and Way Forward Command Paper, which the Government issued in July, explained that under the new arrangements they envisage that specialist dental public health expertise will become part of Public Health England, a move which would be welcomed by many consultants in dental public health.

11 Oct 2011 : Column 1597

However, their expertise will also need to be available to local authorities, in particular to the new health and well-being boards. Much more detail is needed as to how these new arrangements will work in practice. At present it also appears that there will be no obligation on health and well-being boards to take advice from, or consult with, any source of local dental expertise when drawing up a health and well-being strategy and a joint strategic needs assessment. The Government should consider whether there is a case for giving them a statutory duty to do so.

It is very unclear what role, if any, Monitor will play in the regulation and licensing of dental practitioners. The profession is already subject to a significant burden of regulation, with dentists regulated by the General Dental Council, by the Care Quality Commission, through Performers Lists Regulations and through their regulatory and contractual obligations to the NHS. It would not be appropriate for Monitor licensing duties to cover dentistry. It could be argued that it would impose an unnecessary burden which would be contrary to Monitor's duty to review regulatory burdens, as set out in Clause 64 of the Bill. I ask the Minister to clarify this issue and to confirm that dental services will be exempt from licensing by Monitor.

As I said in my opening comments, this Bill is just one aspect of the Government's reforms of dentistry. If the benefits of central commissioning and the new public health arrangements are to be fully realised, it is vital that the Government also stay focused on the pilots for the new contract. The pilots may not be part of the Bill, but they are central to the reforms of NHS dentistry that the Government are pursuing. I hope that the Minister will maintain the Department of Health's commitment to a co-ordinated approach and that they will drive forward progress on the pilots alongside the reforms contained in the Bill.

I shall conclude with a couple of issues associated with indemnity. Outside the indemnity provided by the NHS, doctors and dentists have to make their own indemnity arrangements for clinical negligence claims. My noble friend will be aware of the massive costs to the NHS that arise from negligence and other errors. The Bill is silent on indemnity, but must be amended to address the arrangements for clinical negligence indemnity in respect of services commissioned by clinical commissioning groups and the National Commissioning Board. There should be clear guidance specifying the type and amount of indemnity that is required in order to protect patients.

Clauses 251 to 259 relate to the powers of the Health and Social Care Information Centre to require, publish and otherwise disseminate information, including patient identifiable information. There are two specific areas of concern around patient confidentiality and conflicts of interest. I was intending to read out the relevant clauses, but owing to the restriction on time, I shall just draw my noble friend's attention to Clauses 255(1) and 255(7). As currently drafted, the Bill appears to provide wholly inadequate protection against inappropriate disclosure of patient identifiable information. It removes important rights to confidentiality and would place doctors and dentists in an unacceptable

11 Oct 2011 : Column 1598

position. There is concern that any protections afforded by the Data Protection Act would not apply in these circumstances.

The Bill, if enacted as currently drafted, would require doctors and dentists to ignore their regulatory professional obligations and it abolishes their common law duty of confidence. The indemnity organisations seek clarity as to whether the Secretary of State has, or intends to issue, guidelines about dealing with conflict of interests and what the legal status of any guidelines would be. They should also be able to understand what other steps are to be taken to ensure that there are adequate and appropriate arrangements in place to manage real, perceived and potential conflicts of interest for clinicians who may be providers, commissioners and performance managers as well as having financial interests in other providers.

I hope that the Bill will progress to a Committee stage unhindered by both amendments.

7.41 pm

Baroness Andrews: My Lords, under normal circumstances one might have thought twice about taking part in the debate on a Bill with so many speakers of such expertise. However, this is in no sense a normal Bill, as so many noble Lords have made clear. It was presented as a fait accompli, without prior mandate or consultation; and such is the Government's anxiety to put these changes beyond reach that they began with implementation, proceeded to legislation and concluded with consultation. The noble Earl spoke in his opening remarks of the intense scrutiny that the Bill had received in another place. Many of the changes enforced on the original Bill have yet to be debated at all. The failure regime is yet to be put before us, and critical parts of the process have been undebated.

We are therefore looking at a Bill that breaks some of the basic rules of democratic engagement. Given the fears that have been raised by what is proposed, and the fact that these most radical changes are being introduced against the greatest financial slowdown in the NHS since the 1950s, it is a duty and a privilege that we can make our voices heard, as so many people outside this House have asked us to do. I argue that the bigger the reforms, the bigger the mandate needed. This Bill may have moved away in some sense from the more extreme political ambitions for a future NHS powered by market forces, but it has left behind a morass of confusion and dismay.

Medicine, par excellence, is evidence-based; and there is evidence of how the NHS has improved. In fact, for the first time for decades, the NHS is off the front pages of the tabloids. The evidence we have, for example, of real progress in areas such as cardiovascular disease and stroke can be attributed, according to the man who led the changes, Sir Roger Boyle, to collaboration-not a word that we see in this Bill, yet. Many noble Lords, quite rightly, have spoken very powerfully of the evident need for change in the NHS and the consensus that can be built around change-driven by new possibilities, new knowledge and new expectations, but also by the inescapable challenges of an ageing society and new threats to public health.

11 Oct 2011 : Column 1599

Despite the recent-and very welcome-letter from the Minister, which set out the necessity for modernisation, one of the critical failures of the process around the Bill is that there has been no compelling public narrative or debate around that necessity. That would have enabled us all to test out the proposition that the provisions in this Bill were the only solution to the challenges of rising demand, rising costs and rising aspirations. I wonder what other organisation the size of the NHS-£128 billion-would plan change without such a narrative on which to build consensus, or an evidence base that could have been publicly contested. As the noble Lord, Lord Darzi, said-and he should know-change can happen when everyone comes together: leaders, managers, clinicians and patients. The tragedy of the situation we face is that there is, indeed, an irresistible and entirely responsible case for change, which could have consolidated a proper role for clinical commissioning, competition to raise quality, greater integration of services and greater choice, without raising the spectre of a market in health and without undermining the ethical basis of the NHS.

Above all, that case for change could have been won without exposing the service to "irreparable harm" and patients to greater risks. Those, of course, are the words of the 450 public health doctors last week. Yes, the Government have introduced important changes to the original Bill, but surely they should never have been needed in the first place-broader clinical leadership in terms of commissioning groups should have been a given. In particular, Monitor should never have been charged with a mandate to promote competition. Some things in the Bill are overdue and some are certainly worth supporting-for example, the health and well-being boards-but the Bill has now lost whatever coherence it might have had. Instead, it has turned into a sort of Frankenstein of a Bill; a lumbering improvisation of stitches, patches and mechanics. I do not want to push the metaphor too far, but the noble Earl will know that the original monster died pathetically from a lack of understanding and love. We will not, I can assure this House, let that happen. Instead, we have to work with a Bill that raises profound and distracting questions about constitutional responsibility, accountability and workability, and which is shot through with risks. It is those risks that I want to talk about.

The greatest risk is the uncertainty, following the changes to Monitor's role, as many noble Lords have alluded to, about where the limits to competition will now lie and to what extent this is within control. Monitor may now have become a body intended to prevent anti-competitive behaviour when it is not in the interests of the patient. What on earth does that mean in practice? How will it relate to competition law? How will integration, in practice, relate to choice and competition?

I was told this morning of an instance where local GP practices wanted to offer teledermoscopy for the quicker and faster identification of malignant moles by way of photography. A local private company wanting to bid for the service has mounted a legal challenge, which has now stopped this possibility in its tracks while all this is sorted out. Imagine this sort

11 Oct 2011 : Column 1600

of instance multiplied across the health service in various disciplines while patients wait and conditions worsened.

The Minister also spoke of a new level playing field for providers. The Government may want to believe that these new services will be run within the benign culture of social enterprise. In fact, we already have compelling evidence, from the failure of Central Surrey Health, that even the Government's flagships cannot compete with the large private providers. Why else would Central Surry Health have lost out to Assura, which is 75 per cent owned by Virgin? If it cannot compete, frankly, who can?

The second and related risk is the congested landscape of commissioning, which has been very well described by other noble Lords. The organigram is enough to raise anyone's blood pressure. The Minister referred to the NHS being consumed by layers of bureaucracy. However, he will have heard time and again-and he will go on hearing, I am afraid, from the next 50 speakers-that there are deep concerns about the new layers of bureaucracy, the landscape of decision-making, the higher costs and greater fragmentation; and, therefore, about the command and control role of the NHS Commissioning Board.

I have a few specific questions about the future of local services and commissioning. Can the Minister tell me, for example, how many patients are still not allocated to commissioning groups? Can he tell me who will now own the local hospital-previously the clear responsibility of the PCT-where there are possibly two competing providers that cross local authority boundaries? Can he tell me what will happen if the money runs out half way through the financial year when commissioning groups are still not in place? Some practices are still in the dark-although they know they have to take on extra staff, not least an accountant, because they do not know their budget for next year.

These are questions put to me by GPs, who say they are keeping them awake at night. As one described his new responsibilities: "If I had wanted to be a town clerk, I would have been one". He actually put it rather more strongly than that. This confusion around the delivery and configuration of services in the future, which are major questions of capacity and responsibility, is precisely why we need absolute confidence in the role and the responsibility of the Secretary of State. I know the Minister is particularly good at listening. He helped the last Government improve their legislation and we have a genuine coalition across this House in the making of policy, which was to the huge benefit of the health service. He has made it clear he wants to work with noble Lords and I hope some way will be found out of the impasse over reference to the Select Committee. It will be a way of building confidence-and that is central to our task in this House.

We have been put in a very difficult position. We are seen as the point of last resort and reason. We will not play politics with the NHS, but neither will we cut short our scrutiny just because the Government have gone ahead and started dismantling the service on the ground before Parliament has decided what is right. This is a problem of the Government's own making and our absolute and clear duty is to scrutinise and

11 Oct 2011 : Column 1601

challenge the Bill as fully as we can. I fully support the reference into a Select Committee, particularly of Part 3 of the Bill, which I think desperately needs to be challenged and unpicked. Yesterday, one of the many messages I received simply said:

"I have never known people generally to be so looking forward to the Lords doing their duty".

We shall do our duty.

7.50 pm

Baroness Tonge: My Lords, whatever the noble Earl, Lord Howe, said earlier, we were promised by both parties before the general election that there would be no top-down reorganisation of the NHS. It did not appear in the coalition agreement either and therefore this Bill should not have appeared at all. The noble Lord, Lord Rea, made the arguments for his amendment superbly in his speech and I do not propose to repeat them, but the Bill has no mandate; it is undemocratic and I hope it will be thrown out.

I did not come in to this House because of great works in the NHS, as many colleagues here did. In fact, I am never quite sure why I did come here. But in the NHS, I was a doctor; my children called me a barefoot doctor, working mainly in women's health screening and family planning. I managed community health services, district nurses, health visitors, the physios, the speech therapists, the porters, the admin staff-all the professions allied to medicine: the poor bloody infantry of the NHS. They come into very personal contact with the patients and they need to be spoken for.

My job changed with each reorganisation and there were very many of them in the time I served. I was a middle manager, trying to keep the staff happy and patient-focused while we underwent each upheaval. Each one wastes a great deal of time and money and, above all, it takes staff away from patient care. A 4 per cent efficiency saving-very lightly called the Nicholson challenge this time-is enough to cope with and may precipitate a lot of change on the way staff do things anyway. But they cannot cope with the uncertainty of this Bill at the same time. In any case, what is the point? The PCTs could have been ordered to include clinicians on their boards and management teams. Some do anyway. An inspection of the way PCTs conduct their business would be useful: there are some PCTs that are not very efficient and are overstaffed. But there are experienced teams that are coterminous with the local authorities, and that will be lost with this Bill.

The GP commissioning groups will need a bureaucracy; they are not going to do it at night after work. Nothing is stopping them employing private medical companies to advise or even do the commissioning-private medical companies spending NHS money and which may be commissioning from their own providers. I find this a nightmare. How long will the NHS survive this scenario?

Many of my old colleagues-and I was with a lot of them last week, which is why I was not here-think that this is the main purpose of the Bill: to gradually privatise the NHS. This view is shared by the thousands of people inside and outside the NHS who have sent

11 Oct 2011 : Column 1602

individual letters, anecdotes and briefings to us all. Are they to be totally disregarded? We must also consider the effect of letting GP groups decide on the availability of treatments in their area. This will totally disrupt the doctor-patient relationship.

The Secretary of State for Health says that the NHS is broken. The Minister earlier quoted OECD statistics, but other international bodies do not agree with him. According to the World Health Organisation, we have similar health outcomes to Germany, which on the most recent figures spends 2 per cent more than we do. France has slightly better outcomes, but it spends over 3 per cent more than we do. Everyone knows that the USA has poor health outcomes on a much higher expenditure. The King's Fund and the RSM, to which I refer noble Lords, have also said very good things about the efficiency of our health service. If it ain't broke, then don't fix it.

The noble Lord, Lord Darzi, argued earlier that changes were already occurring-that the PCTs were being broken up. I ask the Minister whether it is legal for that to be happening already. The noble Lord told us about the patient under anaesthetic who would die if the operation was not allowed to proceed. I have a lot of respect for the noble Lord, but just consider: if the patient had not given proper consent and the wrong operation took place on that patient, causing the patient to die slowly and in agony, it would be just like the NHS following this very wrong operation. It is better to stop now and think.

The point which is most frequently made in defence of reorganisation is that health needs are changing. I have a very good joke about this which some of you may have already heard. If so, noble Lords should put their fingers in their ears. For those who have not heard it, it is worth it. When the health service was founded, it cared for us from the cradle to the grave. It then had to cater from the womb to the tomb. Then, as medical science progressed, the health service had to provide from the sperm to the worm. The problem with the health service now is that it has to provide for us from erection to resurrection. That is the problem; noble Lords should think about it.

We need more care in the community than ever before because of our ageing population and we need provision for more and more complicated and wonderful treatments available. The general public understands this, and also understands that resources are finite. Choices are going to have to be made about what we provide on the NHS. As the noble Lord, Lord Owen, has said, rationing already occurs-it has to. We need a national consultation and debate about what the health service should provide and where. The general public should be consulted as well as health professionals. We have not done this.

I urge noble Lords to think out of the box: be brave-show the British people that the House of Lords is really worth a place in our national life. Throw out this Bill entirely by voting for the Motion in the name of the noble Lord, Lord Rea. I say this with great sadness: my party is taking part in what I and my old NHS colleagues feel is the ultimate destruction of the NHS, which has been, and still is, the envy of the world. We should be ashamed of this. I am.

11 Oct 2011 : Column 1603

7.59 pm

Baroness Armstrong of Hill Top: My Lords, I would first like to declare my interests. My husband works as an independent consultant, largely in health, and I am a non-executive director of County Durham and Darlington foundation trust. I always enjoy listening to the noble Baroness, Lady Tonge. When we were together in the other place, I always enjoyed what she had to say, but when I was Chief Whip I was very pleased that she was not one of my charges.

We come to debate this Bill today with many members of the public expressing confusion and anxiety, almost at best, about it. The tragedy is that we did not need to be here. The public got used to NHS reform over the past decade and, indeed, one of the reasons we were elected in 1997 was their concern about the state of the National Health Service. They liked the outcomes of our reforms; they liked shorter waiting times, new hospitals, new GP surgeries and more choice. They felt, and they told pollsters, that it was better than they had known it, and it was more popular with the public than ever. When they were elected, this Government could have decided to get cross-party agreement and build on those reforms. One would have thought that that would be in the spirit of coalition politics, but no. Instead, despite what was in the manifestos and the coalition agreement, we were promised a revolution in the NHS. Then, after the pause, we were told by the Prime Minister, and were presumably meant to be reassured, that actually nothing much would change in the NHS. I think he said that the NHS would remain largely the same.

Today, I am still not sure what the Government believe and what they want. I have sympathy for the Minister who has always been incredibly generous with the House as a whole and with individual Members. He is certainly doing his best, but I am afraid that his Secretary of State has not been giving us clear, consistent messages. The Government had a very clear message on tackling the deficit. Even if I did not agree with all their prescriptions on that, I knew what they were, I know what they are today, and I understand where they are trying to get to. However, the NHS has not been dealt with or talked about in the same clear way. We were told that the NHS was outside the tackling of the deficit and its budget was to be protected. It is being protected, but all of us know that that is not sufficient. If we keep going the way we are, the increase in the budget would have to be phenomenal, and the economy could not bear it. But we have had this confusing message, and that is what the public have heard. They have heard, "Money is being protected, so we do not need all this reform".

What has actually happened is that the Government have simply failed to explain what they want to do and why, and we have had a major failure in the politics of handling reform. I believe that has taken us back years. When he came in, the Secretary of State immediately halted reconfigurations that were going through the pipeline, particularly in London. Now, I understand that all those decisions have been reversed, and the reconfigurations that were in progress and in programme have continued. Eighteen or 20 months later, what has that cost in money and probably also in lives? This

11 Oct 2011 : Column 1604

confusion, this inability to be consistent and clear, has led all of us to lack confidence in what the Government are seeking to do. The measures in the Bill will make reconfiguration much more difficult, and we will need to look at, for example, what the King's Fund is advising on this. I will certainly want to come back to that in Committee because I believe that whatever changes are needed in the health service will have to be approached in a very agile way. I am terrified that the Bill will reduce what agility there is-and there ain't very much there now.

The reality is that no matter how long the Government manage to protect the budget of the NHS, great changes will still be needed in years to come. Given the trends in the economy, reductions of 3 or 4 per cent a year will not be enough. If there is not enough ability to make major changes, what we will see is simply cut after cut that will end up with a reduction of service year on year. These arguments are difficult, but the public have the right for us to make them, and the tragedy is that the Government have ducked them. As many noble Lords have said, the challenges come not just from the economic crisis, they also come from changes in the population, particularly with regard to the increase in the number of people with long-term conditions, the increasing number of people living longer-which is a good thing, but it will put increasing demands on the health service-and changes within healthcare itself. These push us into changing the way we offer care and support patients. This Bill was an opportunity that, to date, the Government have squandered. I find it difficult to believe that such a strong, clear case could be so messed up by a Government in their first couple of years.

My noble friend Lord Hutton said many of the things that I intended to say, so I have cut most of them out, but I, too, remain unconvinced that the key objectives will be met by the Bill as it stands. One of the objectives is to reduce bureaucracy, but I have said a number of times to the Minister that the number of organisations is increasing and the coterminosity with local authorities is being lost, which will increase bureaucracy, not reduce it. The localisation of decisions is simply not happening in the way that we all know it needs to. The power of the national Commissioning Board is increasing, and the more that is given to it, the more it will control what will go on rather than decisions being made locally. We will have to come back to all these things during the passage of the Bill. We will need to come back to choice and competition. I want to mention one other issue: people who have multiple needs. They may be homeless, mentally ill or addicted. I am unconvinced by any of the arguments that I have heard that the Government are properly addressing them, and I will want to come back to this.

The Financial Times today says of this Bill:

"What has emerged can best be described as a dangerous hotchpotch of measures certain to bring tears to patients and politicians".

In my angrier moments, I say to myself, "Let them get on with it. They are making a real mess of this. Let them get on with it and let the Government pay the price". The problem is that it will not be the Government who pay the price. It will be the people of this country,

11 Oct 2011 : Column 1605

and therefore we in this House have a responsibility to look after them and the NHS, and that is what we will seek to do.

8.08 pm

Baroness O'Neill of Bengarve: My Lords, like other noble Lords, I return to the theme of accountability and the approach taken in the Bill. However, I am going to say only a very little about accountability to the Secretary of State. I fully agree with the Government that that accountability should not be managerial or executive. There is something absurd about the locution that has it that the Secretary of State delivers services. We have many organisations in which accountability to the top does not rest on the top having executive power. Charities and schools, corporations and universities do not hold to account by using managerial or executive powers. They hold managerial and executive powers, and those who exercise them, to account. In these types of institutions, accountability, as we know, is variously to trustees, governors, boards, councils and so on. Accountability in the NHS will be distinctive, and it needs to be clear that the Secretary of State is not on the hook for every failure of delivery. However, he or she needs well-defined powers for dealing with a range of contingencies, of which the noble Baroness, Lady Williams, and the noble Lord, Lord Marks of Henley-on-Thames, reminded us.

Getting this right will not be easy, but I hope that we can achieve acceptable clarification within the timetable of the Bill. I hope that this might be done by allocating additional time on the Floor of the House in Committee, even at the expense of other legislation, and that the usual channels will look on the necessary adjustments sympathetically. I am privy to nothing and I may be mistaken in that hope.

The forms of accountability to which I mainly want to draw your Lordships' attention and about which I want to talk at greater length are much less exalted. Many noble Lords have emphasised the importance of cultural change if the new structures are to achieve what the Government hope they will. However, we all also know that demands for detailed accountability come trooping in the wake of legislation. They accumulate in regulations, codes of practice, guidelines and guidance, and all of these can militate against cultural change by requiring NHS staff to follow time-consuming procedures that are often perceived as tedious and bureaucratic, and that may even damage the very services to patients for which staff are being held to account. Over the years as we have gone through one piece of legislation or another, noble Lords have often heard Ministers reassure the House that some lacuna or difficulty in a Bill will be dealt with later by adding regulation, guidance or codes of practice. I fear that the record of mopping up the difficulties of an Act by such add-ons is not very encouraging-and can be extremely discouraging to those so held to account.

Excessive and ill-designed forms of accountability for front-line staff may not only demoralise but have detrimental effects on the very services for which they are held to account. Where health professionals are distracted or harassed by ill-designed forms of accountability that they perceive as destructive, wasteful or unproductive, or simply as excessively bureaucratic,

11 Oct 2011 : Column 1606

cultural change will be undermined, and productive and co-operative working relations will be made harder and may indeed be prevented. Unfortunately, examples of destructive, wasteful and unproductive accountability requirements are not uncommon.

As an example of destructive forms of accountability we need only consider those cases where accountability creates perverse incentives to act in ways that undermine or damage the very activities for which people are held to account. To take an example that is, I hope, out of date, some interpretations of accountability for achieving targets for waiting times incentivised the diversion of effort into, let us say, imaginative ways of logging the "beginnings" of waiting times. As I said, I hope that this example is out of date, but it would be naive to imagine that perverse incentives will never be introduced -always with the best of intentions-and the Bill needs to incorporate measures to provide for realistic challenges to proposals for additional forms of micro-accountability.

As regards wasteful forms of accountability, I offer an example that I met a few years ago when chairing an inquiry into the safety of maternity services in England for the King's Fund. A midwife told us in evidence, "It takes longer to do the paperwork than to deliver the baby". I have no doubt that that was a bit pithy and exaggerated but her words have stayed with me. While I have no reason to think that a consequence was that the women in labour received inadequate care-although it is possible that this happened-or that the requirement to complete this paperwork actually destroyed good clinical care, this was surely a waste of the midwife's skills and of NHS resources.

With regard to unproductive forms of accountability, I offer the example of requirements for NHS staff to log data that do not provide useful feedback for them. While accurate statistics matter for many purposes, the provision of formative feedback to those who compile the information can matter most, and it can change a mindlessly boring clerical task into one that has a point and can even be motivating. An NHS that prioritised formative uses of information would enable healthcare staff to find out more about their own unit's performance and its strengths and weaknesses.

I recognise that Ministers would never intend to introduce destructive, wasteful or unproductive forms of accountability, but I fear that, because accountability creeps in the wake of legislation, it often turns out to be unintelligent or defective in more than one way. The demands for better regulation that have been extolled, and indeed encouraged, for so many years have often proved ineffective. Therefore, if we want intelligent accountability we shall, I think, all need to take a very active view of how this can be achieved, and accept that with accountability more is not always better; indeed, it can paralyse.

That control of the proliferation of damaging requirements for accountability also affects medical research. For example-the noble Lord, Lord Willis of Knaresborough, and the noble Baroness, Lady Morgan of Drefelin, referred to this-current interpretations of the Data Protection Act 1998 impose an extraordinary and, in my view, unnecessary burden of complexity on clinical research in this country.

11 Oct 2011 : Column 1607

Therefore, I should like to ask the Minister what steps he proposes to take to prevent and deter the creation of reams of additional, time-consuming, excessive and even destructive forms of micro-accountability in the NHS as it emerges from these changes. Could he perhaps consider a Churchillian move by assigning to the new institutions a duty to penalise the promulgation of excessive forms of micro-accountability, perhaps by insisting that such documentation be written in plain English and be no longer than a single side of A4? Oh that he could, but I doubt that that is possible. Or are we to believe that the intentions of the Bill will magically stem existing predilections for excessive and sometimes stupid forms of accountability?

8.17 pm

Lord Brooke of Alverthorpe: My Lords, I want to address my remarks to Clauses 8 and 9 on protecting and improving public health. As we all know, if we could move public health policies higher up the agenda and seriously start to address some of the fundamental health problems facing us, the savings that would accrue would not only lead to a better lifestyle for many of our population but go a long way towards easing the financial problems facing the NHS.

The major health problems confronting us have not just descended on us. It is worth recalling that it is now nearly a decade since Sir Derek Wanless was asked to look into the NHS. In 2002, he produced his first report in which he forecasted that, unless people can be persuaded to lead healthier lives, NHS costs would spiral out of control. He suggested a number of options for the way forward, ranging from, on one side, full engagement with the public health agenda to, at the other extreme, a minimal programme and uptake at fairly minimal expenditure compared with the rest of the NHS budgets. If the latter option were chosen, he warned that the NHS would have to meet additional costs of £30 billion a year by 2020.

Wanless was then asked to do a further piece of research and, in 2004, he delivered a report focusing on transforming the NHS from what he described as basically a national sickness service into one that was about preventing sickness, which is now proving so prohibitively costly to us. He offered a range of ideas, including a ban on smoking in public places, taxing fatty foods and boosting physical activity, with the main onus on motivating individuals to take better care of their health. He identified the main threats which could reach epidemic proportions as being obesity and its related illnesses, alcohol abuse, smoking and sexual health issues. That was back in the early part of this new century and those issues are still before us. His report anticipated that, unless positive actions were taken to improve public health, by 2050 we could expect 60 per cent of our men and 50 per cent of our women to be obese, with 25 per cent of our children falling into that category, with a consequentially steep rise in heart disease, strokes, cancer and diabetes.

Regrettably, as we all know, Wanless's warnings have not been heeded and acted on. Since then, there has been only one significant major lifestyle change for the better: the ban on smoking in public places. Notwithstanding the brickbats which he has received

11 Oct 2011 : Column 1608

recently, I congratulate our former Prime Minister Tony Blair on having the boldness and the guts to stick with that and to force it through against some very severe opposition at the time. Regrettably, we did not maintain the same fervour for driving through the other changes needed.

The issues that clearly stick out are fatty foods, sugar and alcohol. The drink and food industries were successful in persuading us that self-regulation was the way forward rather than resorting to legislation. There have been some self-regulated changes since, such as the traffic-light labelling on excessive fat, sugar, salt and calories. Not surprisingly, the industry even disagrees among itself about how that should be put forward and we have ended up with two sets of traffic lights, which leads to confusion among the public. Self-regulation has moved in the right direction, but not particularly well and at a very slow pace.

In the mean time, we now have even more worrying forecasts about the spread of obesity and related illnesses, and the facts on alcohol are equally depressing. Average consumption of pure alcohol has nearly doubled from fewer than six litres per person in 2000 up to 11.5 litres in 2008. Alcohol, which is now 62 per cent cheaper than it was in 1980, makes a major contribution to obesity, weight gain and problems such as diabetes which are often associated with obesity.

I know that the noble Earl has been very busy recently but he may recall that I recently asked him a Written Question on this topic. I asked him when the Government,

His response stated:

"The Government have not met the food manufacturing industry about adding information on calorie contents to the labels of alcoholic drinks.

The department last discussed the inclusion of calorie information on alcohol labels with the Portman Group early in March 2011. The Portman Group's guidelines on alcohol labelling refer (in paragraph 3.11) to the possibility that individual companies may wish to trial presentations of such information on labels".-[Official Report, 3/10/11; col. WA 95.].

We shall wait and see what happens on that with the Portman Group. That kind of response raises little optimism for me about self-regulation and about the value and effectiveness of the long-awaited strategies that are coming on obesity. The same applies to the long-delayed publication of the coalition's strategy on alcohol.

On a pleasanter and more supportive note, I am very pleased that the Government have decided to devolve some of the public health issues down to localities. However, those of us who tried recently to amend the alcohol licensing provisions in the recent Police Reform and Social Responsibility Bill, to extend the criteria for granting licences to sell alcohol to take into account public health consequences, ran straight into a brick wall with the Government. I would have thought that giving localities the power to deal with wide-scale issue of licences in many areas, which many local medical people oppose, was the kind of issue that,

11 Oct 2011 : Column 1609

under the devolved arrangements set out before us, would be embraced with alacrity by the Government, but they rejected it.

Like others who have spoken today, I have considerable confidence in what the Minister does within this Chamber. I should like him to try to convince me that the new health and well-being bodies that are going to be established will have some real teeth and will not end up merely as talking shops for canvassing views and establishing strategies and needs, which in reality will deliver little more than did many of the strategies that my own Government produced in recent years.

I should also like to ask the Minister, based on a briefing which he gave recently, whether it is intended that local bodies will be required to operate within the strategies which have been drawn up at national level. That was my understanding of what he said. If so, I shall be concerned that we may end up with weak central strategies leading to weakness down the line. What facilities will there be for people to amend the national strategies at a faster pace than has normally been the case in the past?

Finally, I come back to where Wanless took us in the early part of this century. We have two options. The first is minimal spend on public health policies and continuing difficulties with alcoholism, obesity, sexual health and so on; the other is spending even more money on public health in the future than we have in the past. Are the Government prepared truly to pin their colours to effecting a major change there, so that we can see a shift in the allocation of the money being spent on public health within the NHS budget?

8.27 pm

Baroness Eccles of Moulton: My Lords, I am delighted to support this Bill. It is a good Bill, which has moved on a lot since it was first presented to the other House in January. The listening exercise in the spring has been described as a sign of weakness by some, but a Government who listen to people's opinions and are not too fixed in their position to accept improvements is refreshing. Equally, the Future Forum's invaluable work and the changes proposed in its report have put this Bill on a much surer footing. I would particularly like to acknowledge the contribution of the Secretary of State and, of course, my noble friend the Minister for so readily accepting its core recommendations. All will agree that, as long as we end up with a Bill that works for patients, which we must not forget is crucial, the rather choppy ride that it has received through Parliament will be all but forgotten.

This evening I shall focus also on public health. It is such an important subject that I am pleased that, by extraordinary coincidence, the noble Lord, Lord Brooke, has already spoken to us on it and focused your Lordships' minds on it. Public health is one of the key areas in the Bill and is a topic that we so often forget to talk about.

What do we mean by public health? So often when we hear the term, it evokes memories of the great Victorian public health Acts of 1848 and 1872. They sought to reduce the levels of cholera and dysentery by providing more hygienic waste disposal networks and sanitising water supplies. Those were pressing

11 Oct 2011 : Column 1610

issues in those days. Today, public health is still faced with many problems. Some of them have been around for a long time, although they change in shape and form as time goes on. Examples, which have already been mentioned by the noble Lord, include poor mental health, alcoholism and substance misuse, although there are many more. One that stands out as a new threat to health is obesity. It is important that these problems are tackled head on through this Bill. I do not know how many of your Lordships listened to the debate introduced in the Chamber last week by the noble Lord, Lord Crisp. Many of your Lordships might know that obesity is a subject on which my noble friend Lord McColl focuses a lot. My noble friend's speech last Thursday was very much focused on the principle of eating less. He reckons that if people eat less they will not weigh so much.

England's NHS budget increased from £35 billion in 1997 to £106 billion last year. However, for reasons that it is difficult to understand, there seems to have been little attempt to focus on preventive measures and public health in general. I am repeating a bit what has already been said. The scale of the problem is alarming. Every year 18 per cent of all deaths can be attributed to smoking; there are around 15,000 premature deaths per year in England associated with alcohol misuse; and more than half of all adults are overweight or obese. Poor public health inevitably affects the most vulnerable communities in our society.

We need to have a greater awareness of the importance of prevention. Talk to any public health expert and they will extol the virtues of preventive approaches and early interventions. Preventive public health strategies can include innovative health guidance, talking therapies, effective targeting and community care. All have proven benefits. They are, however, sadly all too often missing from commissioning strategies. Therefore, any effective public health strategy must have persuasion and prevention at its heart. The Bill will have many positive influences in these areas. For example, for too long money that was given to local health trusts and earmarked for public health was seen as a general pool to dip into when times were tight. This is why it is very helpful to see a commitment from the Secretary of State to ring-fence public health funds. At last local areas will have budgets that are safe, secure and will be spent on public health.

At a national level there is a rationale for health protection to rest with central government, as the nature of various threats to health, ranging from infectious disease to terrorist attacks, are not generally amenable to individual or local action and clearly need to be centrally organised. As a result, the disappearance of the Health Protection Agency and the transfer of its responsibilities to the Secretary of State and Public Health England are to be welcomed. More locally, directors of public health will be the linchpin behind the intended public health reforms in the Bill. Giving these directors budgets and providing a democratically accountable leader for improving health in a local area is entirely welcome. Co-ordinating those engaged in public health will also be important.

The NHS Commissioning Board will be commissioning extra health visitors. The clinical commissioning groups will be commissioning certain public health services

11 Oct 2011 : Column 1611

and will also be working closely with the new health and well-being boards. These organisations will need to work together in an effective way. This will require strong leadership from the directors of public health. To do this, these positions will need to be given the flexibility and independence that will attract strong candidates. It is not yet quite clear that, as they currently stand, they are seen in this light. Are they the interesting, important roles that give the opportunity for outstanding candidates to make a real difference, or will they give directors the responsibility for changes that they will not have the authority to achieve? My noble friend the Minister will want to look at this area very closely in Committee.

There is much to support in the Bill. It is said that we do not need the many changes-that in times of austerity too much is at risk. However, the problems we face are too serious for inaction. I hope that this Bill will initiate a sea change in the way that we approach the nation's health and be a worthy successor to the public health Acts of long ago.

I will not be supporting the amendments of the noble Lords, Lord Rea and Lord Owen. It would not be right for the health service to be kept waiting any longer for the Bill by delaying the Bill's passage through the House.

8.34 pm

Lord Touhig: My Lords, people with autism routinely struggle to access the health services that they need. Consequently, outcomes for children and adults with autism are poor. I wish to focus my remarks on how I see the Bill affecting them.

It is a fact that 70 per cent of children with autism also have one or more mental health problems, yet research by the National Autistic Society shows that child and adolescent mental health services are failing to improve the mental health of two-thirds of children who access their services. A third of adults with autism say that they have experienced severe mental health problems because of the lack of support. People with autism are often disadvantaged in accessing health services as their needs are not properly recognised and understood by professionals.

In a debate in this House on 1 March, I pointed out that 80 per cent of GPs who were audited by the National Audit Office said that they needed additional guidance and training effectively to support patients with autism. Research conducted by the National Audit Office into public spending on autism found alarming gaps in training, planning and provision across a range of services.

The National Autistic Society tells me that it has some concerns about elements of this Bill, but it also sees an opportunity to address long-standing inequalities. Based on its briefing, I would like to share some ideas so as to be constructive about the Bill and to leave the Minister with some questions to answer.

One of the best ways to resolve structural and data problems is to establish specialist autism teams within the local authority area or GP consortium. The adult autism strategy for England, published in April 2010, recognised that where things were working well in a local area this was often as a result of the development

11 Oct 2011 : Column 1612

of such a team. It recommended that the new bodies look at the models of teams that have been established and consider developing one locally.

I share the warm welcome that the National Autistic Society has given to the drive towards joined-up working, but I also share its concerns about how such teams will be commissioned and funded in the future. How will the NHS Commissioning Board oversee the commissioning of specialist autism services? How will the Government and the NHS Commissioning Board incentivise GP consortia to work with the local health and well-being boards to ensure the setting up of specialist autism teams, such as the Liverpool Asperger Team, which has been shown to be very cost-effective?

Currently, several specialist autism teams are jointly funded by PCTs and local authorities. But if 80 per cent of the commissioning budget sits with consortia while the health and well-being boards are responsible for the commissioning of joint services, there is a worry about major budgets held by GPs who may not decide to commission services whose primary benefit in the short and medium term will be to local authorities. That commissioning problem could become more complicated when a health and well-being board has a number of consortia in an area.

The NHS Future Forum recommended that wherever possible there should be coterminosity between local authorities and GP consortia. However, there will still be a number of GP consortia within a local authority area, so mechanisms will be needed to ensure that the consortia and the health and well-being boards can work together effectively.

Currently, the proposal is that a health and well-being board can send back a commissioning plan to GP consortia if it believes that it needs revision. However, there is no mechanism for resolving disagreements between these boards and the consortia. Do the Government agree that an arbitration service may be necessary to help resolve conflict between the consortia and the health and well-being board?

More, the National Autistic Society has significant concerns that unless GPs and others on the GP commissioning consortia are given the necessary support, they may struggle to commission the right services for people with autism. Do the Government agree that quality standards need to be at the heart of commissioning decisions made by GP consortia? What progress has the health department made to ensure that autism is part of the core training for doctors-an issue which we have debated for a long time? How do the Government intend to ensure that autism training is available to GP consortia?

Next Section Back to Table of Contents Lords Hansard Home Page