The Parliamentary Under-Secretary of State, Department for Work and Pensions (Lord Freud): The most recent forecast from the independent Office for Budget Responsibility is for unemployment to level out and then fall from the second half of 2012. There is no separate forecast for youth unemployment, but this would be expected to follow a broadly similar trend.
Lord Peston: Am I to understand, when thanking the Minister for that Answer, that the Treasury does not look specifically at youth unemployment when considering its policies? Is it the case that no Minister in the Treasury, no official and none of its excellent economists or statisticians has a view on when the rate of increase in unemployment, especially for young people, will become a rate of decrease?
Lord Freud: Well, my Lords, the forecasts have now gone to the Office for Budget Responsibility and are the basis for planning. Clearly, the forecast that I have just given noble Lords is somewhat out of date and we are looking to have another later this month. Clearly, the implication of what the Governor of the Bank of England has just said is that growth will, on his forecast, run at 1 per cent this year and next, and this will be built into those kinds of forecasts.
Lord Roberts of Llandudno: My Lords, faced with the tremendously high rate of youth unemployment, is it not time that both parties accept that under both of them youth unemployment has increased? Is it not time that we put by party differences and had a united effort to tackle the problem of youth unemployment?
Lord Freud: Yes, my Lords. It is very easy to get tied up with the tyranny of round numbers. The reality is that we have a genuine structural problem that has grown over the last decade and needs handling in a comprehensive way.
Lord Howarth of Newport: Is it not the case, particularly in old industrial areas, which have found it very hard to attract new private sector investment, that by withdrawing public sector expenditure too fast and
16 Nov 2011 : Column 680
Lord Freud: My Lords, of course we are not withdrawing regional support. We have put in a £1.4 billion growth fund and have a series of programmes designed to help young people. We have help in terms of work experience, the sector-based work academies and the work programme, which will together provide support for 350,000 youngsters over the next two years.
The Lord Bishop of Blackburn: My Lords, I am grateful to the Minister that he refused to adopt a false optimism in his reply. We all know from previous recessions that the impact on young people, particularly their morale and self-respect, lingers long after the recession is ended and creates ongoing social problems. Would the Minister agree that, instead of decimating youth services at this time, the Government should be seriously investing more in such work so that we have some chance of avoiding the loss of a whole generation to cynicism and hopelessness?
Lord Freud: My Lords, I was very impressed, as I am sure many noble Lords were, with the report by Professor Wolf on what has been going wrong for young people. Her conclusion was that there are four things that young people need: a job, proper educational qualifications, apprenticeships or work experience. This Government are trying to concentrate on really effective solutions for young people.
Lord Knight of Weymouth: My Lords, the Government inherited falling youth unemployment, yet this is the eighth consecutive monthly rise in unemployment and precedes the eurozone crisis. This crisis is down to this Government's decisions to scrap the EMA, to cut post-16 education funding and to scrap the future jobs fund, and an austerity plan that has choked off growth. How bad will it get before the Government realise that you reduce the deficit by growing jobs, thereby cutting the cost of benefits and increasing tax receipts? When will we get a credible jobs plan, or will it take another million youngsters on the scrapheap before the Government finally get it?
Lord Freud: No-let me tell you the real figures. The total number of unemployed and inactive youngsters went up from 1.4 million in 1997 to 1.45 million now and 1.39 million last year. That was an increase during the longest boom that this country has ever seen. Why did that happen? That was not cyclical, it was structural.
Lord Roberts of Conwy: My Lords, my noble friend will be well aware of the even higher youth unemployment rates in Europe, particularly in Spain. He will also be
16 Nov 2011 : Column 681
Lord Freud: Indeed, my Lords. The Germans have had a long tradition of apprenticeships and that is something that we need to copy and build on. We have put in money to fund an additional 250,000 apprenticeships over this spending review; we had 442,000 apprenticeships starting last year, an increase of 50,000; and we are putting in measures today to encourage smaller firms to take on apprentices.
Lord Martin of Springburn: My Lords, apprenticeships and the initiatives that the Government are embarking on are good news for young apprentices. However, will these apprenticeship schemes be spread evenly throughout the country?
Lord Freud: My Lords, clearly our intention is to put support where it is most required. Therefore, the schemes will be widespread but naturally there will be an emphasis on the areas that need most support.
To ask Her Majesty's Government whether they have plans to amend the Constitutional Reform Act 2005 so that the president of the Supreme Court is not required to chair the selection commission for the appointment of his successor.
The Minister of State, Ministry of Justice (Lord McNally): My Lords, the noble Lord will be aware that this is one of the matters being considered by the Constitution Committee of this House under the chairmanship of the noble Baroness, Lady Jay. However, the Government are committed to implementing the recommendations of the Advisory Panel on Judicial Diversity, which was chaired by my noble friend Lady Neuberger, including the recommendation that no judge should be directly involved in the selection of their successor. We are considering this issue along with the evidence presented to the House of Lords
16 Nov 2011 : Column 682
Lord Pannick: I am grateful for that very helpful answer. Does the Minister appreciate that there is some urgency about this because the president of the Supreme Court, the noble and learned Lord, Lord Phillips of Worth Matravers, is retiring next summer? I think that the Minister is saying that he agrees that it is highly undesirable that a retiring judge, however distinguished, should play so significant a role in the appointment of his successor. Can he please indicate that there will be some urgency in the way in which the Government deal with this?
Lord Bach: My Lords, perhaps I may say how much we on the opposition side welcome the Minister's response to the noble Lord, Lord Pannick. If the Government will act urgently on the point that the noble and learned Lord, Lord Phillips, has spoken about, we will do everything that we can on our side to make sure that such a matter goes through Parliament as quickly as possible. Perhaps I may ask briefly about judicial diversity, in which I know the Minister has a particular role. Are the Government satisfied that they are doing enough to make sure that our judiciary is diverse enough? Many judges at all levels have spoken about this in recent weeks and it is a matter of considerable concern.
Lord McNally: I thank the noble Lord for his initial remarks about co-operation, which will again help with the sense of urgency. On the question of judicial diversity, one of the most encouraging things in recent days is the way in which members of the senior judiciary have been going public on the need for urgency on the matter. It is a fact that four members of our 161 judges in the High Court are of black, Asian and minority background. In England and Wales, four out of 42 members of the Court of Appeal are women and we have one woman on our Supreme Court.
Lord Tebbit: Will my noble friend consider that what we need on the judges' Bench are the best judges? They should be selected solely and absolutely on merit and there should be no more talk of integration and diversity among judges than among Olympic athletes.
Lord Faulks: My Lords, do the Government have any view on the so-called tie-break principle, whereby if there are two candidates of entirely equal merit there will be a favouring of either female applicants or members of the ethnic minorities?
Lord McNally: Yes, my Lords. This is often called the "tipping point" criterion: whether, if there are two candidates of absolutely equal merit, the one from the black and ethnic community or the woman should be given the post. I go back to the point made by the noble Lord, Lord Tebbit, that the aim should be to get the best person for the job. That is something that I believe in but, if there are two candidates of absolutely equal merit and one is a woman or from the black and ethnic minorities, you might take into account that they have had a greater struggle to reach that point of merit. That may come into your final conclusion.
Lord Borrie: May I question the Minister's view that diversity has been sufficiently practised by the Government and is being pushed in the way in which it is being pushed in discussion in this House? The most recent appointments to the UK Supreme Court were of two men: one came up the usual route from the Court of Appeal and was promoted; the other has not had any full-time judicial experience but is a distinguished Queen's Counsel. Those are the most recent appointments, yet, as the Minister himself said, there are several women members of the Court of Appeal. Are they being sidelined?
Lord McNally: I do not think one should take a snapshot of the last two appointments and say that means that there is no diversity. There will be four appointments to the Supreme Court in the next 24 months. Let us wait and see.
Lord Elystan-Morgan: Where there are two candidates of absolutely equal merit, is it not the case that the appointing body only has one of two choices: either to toss a coin or to apply the relevant provision of the Equality Act?
Baroness Deech: My Lords, do the Government acknowledge that the combination of high tuition fees and the cuts in legal aid will have a very bad impact on diversity at the young end of the legal profession, especially the Bar, and that there will be less diversity in years to come unless it is made possible for young people of all backgrounds to get a start at the Bar?
Lord McNally: We will be debating in the near future the cuts in legal aid. Where I do share concerns is that to get into the legal profession, whether as a
16 Nov 2011 : Column 684
To ask Her Majesty's Government what representations they have made to Bahrain regarding a fair retrial in the civilian courts for the 20 doctors and nurses detained in relation to the protests there.
The Minister of State, Foreign and Commonwealth Office (Lord Howell of Guildford): My Lords, on hearing of the sentences imposed on the medical and nursing professionals by a Bahraini special tribunal on 29 September 2010, my right honourable friend the Foreign Secretary led the international criticism by issuing a statement of the UK's deep concern at the disproportionate sentences. He called on the Bahraini judicial authorities to follow due process carefully and transparently. The Parliamentary Under-Secretary of State, Alistair Burt, also called the Bahraini ambassador in London the next day to reiterate our concern, and the UK's national security adviser also raised the case of the medical staff during his recent visit to Bahrain.
Lord Hoyle: I thank the Minister for that reply. I hope he will agree that when we condemn the violation of human rights, we should do so with all countries that do that. Will he do his best to use this country's influence with Bahrain to ensure that when the trial of these people comes about it is fair and transparent and is witnessed by observers from different countries?
Lord Howell of Guildford: Yes, we will certainly do that. One can draw some cautious optimism from the fact that the retrials are by civilian courts. The military courts have been closed and certain detainees have been released-not in this case, of course. A substantial commission report on human rights is about to be published next week that will cover all aspects of the kinds of concerns that we have and the noble Lord rightly has about what has been going on in Bahrain.
Baroness Falkner of Margravine: My Lords, on the subject of the international commission of inquiry, which is due to come out on 23 November, will my noble friend tell the House whether he has complete confidence in the impartiality of this commission? He will know that the opposition parties in Bahrain were very concerned at the delay in the publication of the commission's report and fear that there had been external pressure for the commission to revisit its findings?
Lord Howell of Guildford: I believe my noble friend's concerns to be unfounded. There were delays. It is a massive report and there were sheer technical problems
16 Nov 2011 : Column 685
The Minister of State, Foreign and Commonwealth Office (Lord Howell of Guildford): My Lords, the United Kingdom has urged the United States to pay its assessed contributions to UNESCO until at least the date of Palestinian accession to UNESCO was decided. It is not yet clear which programmes might be affected by the US decision to withhold its assessed contributions to UNESCO.
Lord Rennard: My Lords, does the Minister agree that it is simply morally wrong potentially to withdraw funding from UNESCO projects that may save thousands of lives in future tsunamis, educate people about the Holocaust and foster free media in some of the newly emerging democracies of the Middle East in retaliation for others simply disagreeing with the United States about Palestinian membership of UNESCO? Does the Minister think that we should tell our friends in the United States that this is the way to lose friends and fail to influence people?
Lord Howell of Guildford: We do think it wrong-and we have raised this with our United States colleagues-that the United States should not merely consider withdrawing its contribution for the future, which, it is argued, is necessarily triggered by existing law in the United States, but should stop the contribution that was already due this year and on which UNESCO has already made spending plans. Obviously, the sudden withdrawal of commitments that have already been made will cause grave difficulties. A lot of people will lose their jobs and UNESCO has had to freeze all new plans. That is wrong; I agree with my noble friend. We raised this matter with the State Department and the point is being debated. Of course, the matter will be put to Congress, which is the driving force in this issue, but the general point that my noble friend makes is quite right.
Baroness Deech: Does the Minister recall Britain's withdrawal from UNESCO for a long period in the 1980s, which unfortunately was part of the continuing use of UNESCO as a political and ideological tool? Can pressure be brought to bear on UNESCO to do something about Syrian behaviour, given Syria's recent speech to UNESCO about the importance of youth and women's education and so on, which seems a bit odd in the current circumstances?
Lord Howell of Guildford: The kind of pressure that can be brought to bear on UNESCO, and may have to be brought to bear as it faces the huge cut of 22 per cent in its budget, is to suggest that it should streamline and improve its administration. There have been improvements; it has made progress, and it is focusing on some very valuable programmes, as my noble friend pointed out. On the specific issue of Syria and Syrian projects, I cannot comment as I have no details. I will look into the matter. Broadly, there is now a British member on the UNESCO board, and we believe that UNESCO, which had some difficulties in the past, is improving and can focus on valuable things, of which the tsunami warning programme is a very good example.
Baroness Falkner of Margravine: Does my noble friend accept that as UNESCO's new Secretary-General is attempting to put it on to a much more streamlined and efficient path, the shortfall in funding will only undermine her position? Have the UK Government been in touch with other Security Council members to see whether they, as well as the G20, might be able to assist in making up the shortfall, at least on a temporary basis until UNESCO can revise its budget?
Lord Howell of Guildford: It is early days for that. We will have to see whether the United States follows through on what appears to be its intention not merely to withdraw future funds but current funds as well. A very large number of countries-107-voted for Palestine's membership of UNESCO. There were 52 abstentions and 14 countries voted against. Therefore it was a fairly solid commitment to Palestinian membership. On the question of funding, we will have to wait and see how the matter turns out. Certainly there are major difficulties to be faced and resolved.
Lord Liddle: My Lords, noble Lords on this side of the House all share the concerns about the future of UNESCO and agree with the Minister's comments. The fundamental issue behind this question is how strongly we are prepared to make clear to the United States our difference of view on the recognition of Palestinian statehood. While the Government's position was sympathetic, it was ultimately a decision to have no position-to vote neither for nor against. How does this advance the peace process and the cause of a two-state solution, given the present stalemate and Israel's very recent decision to announce further settlements that will be deeply counterproductive? Should we not be more robust on these issues?
Lord Howell of Guildford: That is, of course, a broader question. The noble Lord is absolutely right that the question of Palestinian statehood lies behind the question of whether partial arrangements, as it were, for statehood should be made by Palestine applying
16 Nov 2011 : Column 687
Lord Howell of Guildford: I have absolutely no idea. The world is not like that. It is not a question of representations. Obviously there are discussions in the corridors at multinational meetings on who is going to subscribe to what. That is perfectly natural, but we make our own decisions in the end.
Lord Dubs: My Lords, is not the real issue that, given that no sensible negotiations are taking place, the Palestinians have very few options left and that their bid to become members of the United Nations, and initially of UNESCO, is the only way forward for them? If we keep talking about negotiations when they are not happening, are we not simply saying, "Let us leave it as it is"?
Lord Howell of Guildford: I am not sure that the noble Lord has got that right at all. It is perfectly true that Mr Netanyahu is not, or does not appear to be, a great proponent of negotiations at the present time, but the quartet is proposing some views. We think that there are pressures that can carry negotiation forward and we are not at all convinced that the Palestine statehood idea, if it went to the Security Council and produced the veto and the freezing up of negotiations all round, would be much of an improvement on the situation. I agree with him that it is not good, but it would certainly be very much worse in our view if we followed this course.
Lord Grocott: My Lords, in terms of acts that could be considered to be threatening to any future peace talks, surely there can be no equality between on the one hand the Palestinians wanting full membership of UNESCO, which is a fairly benign movement in its
16 Nov 2011 : Column 688
Lord Howell of Guildford: No, none whatever. We regard the continued expansion of settlements as illegal, most unwise and highly provocative. That is part of the broad scene, and that must halt as part of the move forward to the negotiation that will bring Palestine to its full and rightful statehood. I agree. I am not quite sure what point the noble Lord is making. There is no comparison at all.
Baroness Royall of Blaisdon: My Lords, given the pressure of business in this House and the lack of business in the other place, all noble Lords are anxious to know when this longest-ever Session of Parliament will end. I would therefore be grateful if the noble Lord the Leader of the House could confirm the information given by his right honourable friend the Leader of the House of Commons on Thursday 10 November, at col. 454 of Hansard, that the Queen's Speech will be held in May.
The Chancellor of the Duchy of Lancaster (Lord Strathclyde): My Lords, the noble Baroness the Leader of the Opposition quite correctly gave notice of her question to my office just before Question Time, and I am very grateful to her.
I have not had time to consult my right honourable friend the Lord Privy Seal, Sir George Young, and neither he nor I wish to mislead either House in any way. However, I have now had his words drawn to my attention, and I have read them, so perhaps I can give some context and perspective to the words he used. He was answering a question from his opposite number
16 Nov 2011 : Column 689
That is very much what he intended to say. The context of this is the new Fixed-term Parliaments Act under which Sessions will run after general elections in May, and from May to May. That was what he was trying to say.
My right honourable friend may also be taking a very pessimistic view of the progress of business in this House. I think that the usual channels have a plan to deliver this Session in a timely manner, and I hope that we can do better than that.
Lord Peston: Can the noble Lord clarify one bit of his answer? This has not only been a very long Session; it has now also become about the most boring Session of my 25 years in this House. Is he saying that the facts of the matter are that the Government have not made up their mind at all about when the Queen's Speech will be?
Lord Grocott: My Lords, I wonder whether it would be helpful to the House if, rather than explaining the context in which Sir George Young made his Statement in the other House, we actually repeated the words that he used. He said:
"I made a statement, I think, last year on the fact that the Queen's Speech will be held in May to coincide with the fixed election dates of every five years".-[Official Report, Commons, 10/11/11; col. 454.]
That promise-and I think that I can put it in those terms-was repeated endlessly during the passage of the Fixed-term Parliaments Bill by, I think, the noble and learned Lord, Lord Wallace of Tankerness. I even put down an amendment to try to ensure that there would be a fixed date for the Queen. Given the Government's obsession with fixed-term Parliaments-which I oppose, but the Bill has been passed-there should be fixed Sessions. Surely there is a logic to that. Frankly, if the Queen's Speech is not in May of next year, it will be very close to breaking faith with the clear undertakings given during the passage of the Fixed-term Parliaments Bill. I therefore ask the Leader to do more than just consult his colleague down at the other end-perhaps they should try to get their acts together.
Lord Strathclyde: My Lords, we will make an announcement in the first part of next year about when the actual date will be, and we are very happy to stick with spring. It is true that this Session has been very long, for reasons which I think will be readily understood. However, we believe that from the start of the next Session, we will go towards annual Sessions that will aim to finish around April or May.
Lord Higgins: My Lords, is it not becoming rather ridiculous that we still have not had a debate on the crisis in the eurozone? Perhaps the expression "fiddling while Rome burns" would be appropriate in this context. The usual debate on the Chancellor's normal Statement is not really a substitute for a debate on the crisis in the eurozone. We need to debate both.
Lord Foulkes of Cumnock: My Lords, returning to the Queen's Speech, in all seriousness, is this uncertainty not causing tremendous problems for people planning ahead-not just Members of the House of Commons but Members of the House of Lords, all those involved in the State Opening and, not least, Her Majesty the Queen? Is it not incumbent upon the Government to say now when the State Opening is going to be held so we know exactly how to plan ahead for next year?
Lord Strathclyde: My Lords, the noble Lord, Lord Foulkes, does a good job of righteous indignation on this subject. I assure him that in past years it has been entirely normal to announce the date of the Queen's Speech about four or five weeks in advance, and we aim to do precisely the same this year.
Lord Soley: I admire the Leader's ability to put this in perspective. I have to say, it is easier to get things in perspective if you do not have to stand on your head. Is not the reality behind this that actually, as Members on all sides of the House have said, the problem for the House is the quantity and quality of the legislation being brought before it?
Lord Strathclyde: My Lords, I have already answered many questions on this. The quantity is no greater than similar Sessions after a general election, and of course Parliament is trying to improve the quality by putting amendments and occasionally defeating the Government.
Baroness Thornton: My Lords, I rise to intervene on this Motion today with a very heavy heart-and empty-handed, because the Government have refused to release the risk register on the implementation of the Health and Social Care Bill, as instructed in the judgment of
16 Nov 2011 : Column 691
Noble Lords may recall that I drew this important matter to the attention of the House on Monday and specifically asked the Minister to assist the House in its deliberations by making the risk register available. I am most grateful that the noble Baroness, Lady Williams, supported my appeal. Since Monday, it has become clear that the well respected Conservative MP, Dr Sarah Wollaston, made the same plea to her own Secretary of State in a letter to the Evening Standard.
I beg the leave of the House to say I have nowhere else to raise this important matter. I do not wish to delay the House but I want to make two points and ask two questions of the Minister. There is a precedent that I urge the Minister to consider. In 2008 the noble Earl's then honourable friend, Miss Justine Greening MP, recently promoted to the Cabinet, used an appeal to the Information Commissioner to get the release of the risk documentation on the Heathrow third runway. I am sad to report that my own Government did not cover itself in glory in this matter, refusing to part with the information for more than a year. However, the key difference between then and now is that of course the third runway was not the subject of a very large piece of primary legislation that aims to bring radical change to our NHS and that the information we are being denied could be very relevant to our deliberations.
I have already written to the noble Earl about this matter and intend to follow the same route as my right honourable friend John Healey MP by putting an FOI request in for the most recent risk register about this matter. I urge other noble Lords who share my concern to do the same. The reason I am doing this is because the Secretary of State suggested yesterday that the version of the risk register that my right honourable friend John Healey asked for would now be a year out of date. I regard that as both a glib and disrespectful remark.
The Minister told the House on Monday that most of the information from the risk register is included in the impact statement that was published when the Bill arrived in the House. Can the Minister say exactly how much of the risk register is contained in the impact assessment and how much is not? Perhaps the Minister might assist the House by publishing the information that is not contained in the impact assessment but is in the risk register. The Government say that this is a very secret document, but also that it is available. I am sure that the House would like to know which it is.
Finally, there is a course of action open to the House, which is to refuse to resolve itself into a Committee on the Bill as an expression of its concern about this matter. I have discussed this course of action with several noble Lords, and we have a genuine dilemma here. Many feel that it is a very serious error
16 Nov 2011 : Column 692
Lord Warner: My Lords, before the noble Earl responds, may I offer him a little piece of advice, as a former Health Minister who had to take controversial legislation through this House? I would say to him that if I had been confronted with this situation, I would have gone to my boss, the Secretary of State for Health, and asked him to facilitate the passage of this legislation through the House by making this information available to the House.
Baroness Williams of Crosby: My Lords, I, too, wish to ask the Minister one additional question. Can he give any idea of how quickly the proceedings that he mentioned in his recent letter to Members of the Committee will take? He showed in that letter that there needed to be discussions with other ministries and that there needed to be consideration of whether an appeal should be brought. I know that he appreciates, as much as the rest of the House does, that our debates in many areas would be very much affected by knowing what is in the risk register, and in particular, perhaps, those parts of it that the noble Baroness, Lady Thornton, suggests could be made available. Can he give the House any idea of the probable timetable, as we are all conscious of the fact that the debates might have to be repeated all over again if the information in the risk register is relevant to the things that we are talking about?
Lord Campbell-Savours: My Lords, I read the report the other day and it seems to me that the Government are refusing to publish because they have got something to hide. We want to read this document. The Information Commissioner's report is a fascinating document which repeatedly, under a number of paragraph headings, states that the Government should publish this document and act in a transparent way in the public interest. That phrase is repeatedly referred to in the course of the document. It is quite incomprehensible that the Government should have taken this very silly decision-a sort of ostrich in the sand approach to these matters.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): My Lords, I fully appreciate the strength of feeling that noble Lords have on this matter and I hope that the House will accept my assurance that I have no wish to be, or to
16 Nov 2011 : Column 693
However, I should bring the House up to date. The ruling of the Information Commissioner carries with it very significant implications, not only for my department but for every department across government. The risk register is a basic tool for the management of policy implementation. It is a working document which informs advice to Ministers. Publication of departmental risk registers, were this to become routine under the Freedom of Information Act, would fundamentally affect the day-to-day working of government. In this context we are of course looking carefully at the issue of precedent, and I am grateful to the noble Baroness for having raised this.
The Government, as a whole, must therefore consider whether or not to appeal the Information Commissioner's ruling. Officially, we are allowed 28 days from the date of the ruling in which to do this. Consequently, I regret that I cannot make any specific commitment on these matters today. I emphasise that the Government's wish to take some further time to consider the way forward is in no way an attempt to string this matter out in a needless or obstructive manner. We intend to act with maximum speed. If a decision is taken not to appeal the Information Commissioner's ruling, we will proceed to comply with it immediately.
I hope, however, that noble Lords will understand the Government's view that it is reasonable to allow time in which to take a decision on a matter that is both complex and important. Meanwhile, I am very willing to consider the noble Baroness's constructive suggestion that I should examine whether there are any risks covered in the Department of Health risk register which have not already been placed in the public domain and which could be provided without further ado. I shall give a progress report to the House on these issues at the earliest opportunity.
Lord Hunt of Kings Heath: My Lords, this group of amendments brings us to the general function of clinical commissioning groups. New Section 1F to be inserted in the National Health Service Act 2006 under Clause 7 states:
I suppose that, in many senses, clinical commissioning groups are the flagship of the Government's reforms, but that those functions are not particularly inspiring.
16 Nov 2011 : Column 694
It is very important that words to that effect are in the Bill in order that clinical commissioning groups are under no misapprehension that they have an obligation to ensure that patients receive comprehensive services. Recently, the Secretary of State has felt it necessary to intervene with primary care trusts because there has been evidence that in order to balance their books, they have been putting restrictions on treatments both in terms of the actual treatments but also in artificially delaying access to non-urgent treatment for a number of weeks. The Secretary of State has ruled that this is unacceptable.
The question that arises is: if that situation arose with clinical commissioning groups, what is there to be done to ensure that CCGs are reminded that their job is to ensure that their patients receive comprehensive health services? Essentially, that is what my first amendment is about. It is of course linked to Clauses 10 and 11. As we have already generally agreed, Clause 10 is one of the essential parts of the Bill's intention to change the foundation of the NHS. The clause would remove the Secretary of State's duty under Section 3 of the NHS Act 2006 to provide key listed health services to meet all reasonable requirements throughout England and, crucially, would remove the area-based responsibilities of primary care trusts.
In Clause 10, we see in their place the clinical commissioning groups-the bodies responsible for persons on lists and other persons usually resident in unclear and potentially non-contiguous areas. As far as I can see, those specified services would clearly have to be provided for everybody except, arguably, emergency care. In addition, Clauses 8 and 9 would in effect remove from Section 3 public health functions such as immunisation, screening and health promotion, so these PCT services would not have to be covered by clinical commissioning groups. I have to say that the provisions of Clauses 8 and 9 are particularly opaque, and the interface with Clause 10 in unclear. I would also point out to the noble Earl that new charging powers are proposed in Clause 47 for those services that are free at present, although I think that the noble Earl has suggested that they would be commissioned by local authorities and would not be part of the National Health Service. My Amendments 76 and 77 would delete Clause 10 entirely, retain Section 3 of the 2006 Act in its entirety and add a new clause that would give clinical commissioning groups the duty to arrange provision for all persons usually resident in their area and, as regards emergency care, for everybody present in their area.
I was going to put a number of questions to the noble Earl, but he has written a letter that relates both to the pilot schemes to make it easier for people to move between GP practices and, if they move, to stay on with their old practice if they are likely to return to their former residence. That would apply, I suspect, to people such as students. He has also given some
16 Nov 2011 : Column 695
A second issue arises from the noble Earl's letter, particularly about the allocation of patients on GP lists. As the NHS Commissioning Board will hold the contracts of GPs-it would be deemed a conflict of interest if clinical commissioning groups held them-the Commissioning Board itself will be responsible for allocating patients to lists if they cannot get on a particular list. How on earth is this practically going to happen? Does this not make it inevitable that not only will the NHS Commissioning Board have to establish regional offices, but, given the size, it will need local offices so that the public can get in touch with it? Presumably that means, too, that the NHS Commissioning Board will oversee the system for complaints made against GPs in terms of their primary care delivery function. So there are quite a lot of difficult issues here about how practically the NHS Commissioning Board will carry out its duties. As for the allocation of patients, what will happen about patients with severe learning difficulties or complex mental or physical health problems, or asylum seekers and the homeless, those of no fixed abode who traditionally have often found it difficult to get on a list? How will the NHS Commissioning Board know what to do about this unless it has some kind of local presence? I do not believe it can be done from the headquarters of the Commissioning Board in Leeds-or at least it would be very difficult to do so.
I know that we have discussed the issue of the clinical commissioning groups not being area-based, and I will come back to that. The noble Earl's maps are very instructive. I would point out that the Heart of Birmingham PCT hardly covers the catchment area of the Heart of England NHS Foundation Trust. That is a matter of great regret to me because it currently has a thumping great surplus, unlike the PCTs that serve my own foundation trust. I can no doubt look to the noble Earl for a helpful intervention in that-or perhaps not.
There are lots of questions here that stem from, first, the guarantees that clinical commissioning groups will provide a comprehensive service for their patients; and, secondly, the allocation of GPs to lists, moving away from area-based commissioning and some of the practical difficulties that will come from that.
Again, why is it only "may"? Surely those services would be part of any comprehensive provision. Would the noble Earl agree to a gentle amendment to make it "shall"? That would be a visible sign that CCGs are there to provide comprehensive services-or to make sure that their patients receive them.
Some of the considerations are relevant to the duties of the national Commissioning Board itself. My Amendment 81B is designed to ensure that the Secretary of State will require the board to commission services for rare conditions. If devolved to clinical commissioning groups, I think it unlikely that they would commission rare services. This has been a problem in the past, even with primary care trusts, because they are not used to such rare services. If a patient goes to a GP needing them, there is no precedent or protocol for obtaining them. I would be interested in any thoughts that the noble Earl has on rare services. In a sense, it is parallel to the orphan drug issue that the NHS also faces.
My Amendment 82 focuses on how the board's performance in commissioning services is to be performance managed. Will the noble Earl say-or write to me-about how, in commissioning plans, the board will seek to consult health and well-being boards? This is a rather general group of amendments. I am conscious that we have a usual channels agreement to finish 12 groups today before we rise. If there are some points that the noble Earl would seek to write to me about, that would be very good. I beg to move.
Lord Warner: My Lords, I speak to Amendment 79 in my name and those of the noble Lord, Lord Patel, who unfortunately cannot be here today, my noble friend Lady Pitkeathley and the noble Baroness, Lady Murphy. Our purpose is to focus clinical commissioning groups on the needs of the 18 million of our fellow citizens with long-term conditions.
We spend an awful lot of time and money in our healthcare system preoccupied with acute hospital care. Indeed, 50 per cent of NHS expenditure goes on acute hospitals. However, day in, day out, week in, week out, the bulk of NHS activity-some 75 per cent of it-goes on good, bad and indifferent treatments for people with long-term conditions. Of course, some of these people have acute episodes, often because their routine care has been neglected. For example, 10 per cent of NHS expenditure goes on people with diabetes. The number of people being treated with diabetes is rising. We know how best to look after people who suffer with diabetes but too often we neglect basic, routine care and maintenance of the condition, seemingly waiting for the inevitable crisis to occur.
The scale of long-term conditions is, in my view and that of the colleagues who signed this amendment, sufficient to draw particular attention to their needs in the Bill. That is what the first part of Amendment 79 does by adding the words,
to Clause 11 at line 12 on page 7. However, we want to go further. A very high proportion of those with long-term conditions need help, both from the NHS and from adult social care services. That is why the
16 Nov 2011 : Column 697
In the mean time, I hope we will receive a more constructive response from the Minister to this amendment, placing a clear responsibility on clinical commissioning groups from the outset to focus on securing improvement in the integration of health and social care in the commissioning of services. We need to move from the rhetoric of integration to requiring it to happen in legislation. I beg to move.
Lord Ramsbotham: I wish to speak to Amendment 80. I wonder how many noble Lords are aware of the historic nature of the proposed insertion into the 2006 Act of new Section 3B(1)(c). It is the first time that mention has been made in a Bill of the requirement on the Secretary of State for Health to provide services or facilities for those detained in a prison or in other accommodation of a prescribed description.
When I was appointed Chief Inspector of Prisons in December 1995, I had to give up the chairmanship of Hillingdon Hospital National Health Service Trust because I could not guarantee the time required, but during my chairmanship I was particularly grateful that my extremely able director of mental health insisted that I trained as a lay assessor so that, in his words, I could be of some use to the hospital. What neither of us realised at the time was that he was enabling me to appreciate, at once, the full and avoidable horror of the situation that I found during my first prison inspection of Holloway, during my second week in post. He educated me about both the complex requirements of those suffering from mental health problems and what it was possible to provide for them.
That understanding fuelled my fury at finding that none of what I had been accustomed to at Hillingdon was present in the largest female prison in England in 1995, despite the appalling numbers of women with varying degrees of mental health problems. When I remonstrated about that, I was told that uniquely in the country, prison healthcare was not, and never had been, the responsibility of the NHS but had been retained by the Prison Service. I was then told that the director of prison health, a doctor, was not responsible for the provision of healthcare, merely for advising the prison's board, which was actually responsible. When I asked how many of the prison's board had medical experience or qualifications, I was told none.
So I set about trying to change this nonsense, writing a thematic review of the situation in 1996, entitled Patient or Prisoner?, in which I recommended that the NHS takes over responsibility as soon as possible. I quoted the vast well of psychiatric morbidity, exacerbated by the treatment of and conditions for prisoners being wholly unsuitable for those suffering
16 Nov 2011 : Column 698
It seemed abundantly clear to me that prison health was a public health issue, because every single prisoner except, for the very small number, sentenced to natural life was going to come out and the state of their mental and physical health when they did so was a matter of public interest. Not only was offender health not regarded as a matter of public health, but GPs had to fight to get information from prisons about any medical treatment a prisoner had received. That was of doubtful quality, because we found that only 10 per cent of prison medical officers were qualified to act as GPs in the NHS. In other words, not only did anyone going into prison disappear from the NHS radar screen, but the authorities seemed to disregard the fact that imprisonment-paid for by the taxpayer-presented a priceless opportunity to identify and initiate, or pick up and continue, essential mental and physical health treatment. This could then be continued on release to the benefit not just of the prisoner but also of the community into which he or she returned. It all seemed unbelievably short-sighted and, frankly, stupid.
In the event, the NHS was made responsible for prison healthcare in 2003-seven years later, or longer than World War Two; so much for the speed of governmental decision-making. Since then, there has been considerable improvement, particularly when good primary care trusts have taken very seriously their primary care contract responsibilities with individual prisons. The same has not been so true of mental health contracts, largely because provision has in no way been able to match demand. I shall never forget speaking to members of the first mental health in-reach team to go into Wandsworth. They had expected to have to deal with a few very serious cases; instead they found that they were swamped by the 70 per cent of the prison population who were suffering from one or more identifiable personality disorders. It did not make them sectionable, but suggested that there was something affecting their behaviour that, if identified, could be mitigated. However, as the resources to carry out the identification were, and are, lacking, mitigation was, and is, denied-a process that should be of public concern.
My reasons for spelling all this out are to explain why my proposed amendment is an appeal to the Minister to withdraw the words, "other accommodation of a prescribed description", and substitute detailed descriptions of that accommodation. I say that because the Secretary of State is required to commission services for a number of entirely different places of detention with very different requirements. Public and privately run prisons require primary, secondary and mental
16 Nov 2011 : Column 699
The Department of Health is very fortunate to have an able director of offender health, Mr Richard Bradshaw, who can provide the necessary descriptions very quickly because he is well acquainted with the differing needs. I therefore ask the Minister to accept this amendment in the spirit in which it is meant, which includes trying to ensure that the dreadful situation that I have described is never allowed to reoccur in any prescribed place of detention.
The purpose of the amendment is to ensure that those who have served our nation and who have quite rightly received the highest standards of care-both in theatre in the battlefield at the time when they sustained horrific injuries, then during their immediate aftercare back here in the United Kingdom and thereafter while remaining members of the Armed Forces receiving ongoing rehabilitation-can be certain that, once they are discharged from the services and return to civilian life, they are able to avail themselves of the necessary specialist services for years and decades hence. There is no doubt that what is achieved in battlefield salvage is quite remarkable, and those who sustain horrific injuries that some time ago would not have been survivable are now saved and can continue, from a young age, with the prospect of a good quality of life. However, the injuries, particularly the limb losses and multiple limb losses that they have suffered, will require ongoing specialist care.
Her Majesty's Government have recognised the importance of this area and the noble Earl's honourable friend the Member for South West Wiltshire, Dr Andrew Murrison, has recently published a report, A Better Deal for Military Amputees, in which he reviews both what is achieved acutely for these brave servicemen and what their ongoing clinical and other needs may be. He makes a number of important recommendations in the report. He suggests that a nationally commissioned service for veterans is the best fit for service-attributable amputees and, of the options he puts, looks at the option most likely to deliver the most for the wider amputee community. He goes on to make a specific recommendation that:
"Ministers should take appropriate powers to provide for national commissioning of specialist prosthetic and rehabilitation
16 Nov 2011 : Column 700
So there is a broad recognition by those who have been commissioned by Her Majesty's Government to look at this issue. The commissioning of specialist services for amputee veterans to ensure their long-term good clinical outcomes-that they may avail themselves of advances in the future, which are going to be dramatic and important in the decades hence and which could have an important impact on their ability to function-and that they have a high quality of life will only be achieved through national specialist commissioning of amputee services.
"I am passionately committed to our Armed Forces. As a country and as a Government we have a particular duty to servicemen and women injured on operational duty. This report maps out a clear strategy for ensuring that those brave people can be confident they will receive the same levels of access to prosthetic limbs and specialist care from the NHS as they do at Headley Court. They deserve nothing less. Based on the recommendations in this report, this Government will make the resources necessary to meet that need".
This amendment provides an opportunity to ensure that those needs are met. I strongly believe that only through the specialist commissioning of these particular services will the long-term interests of our brave service personnel, who have lost multiple limbs and who have to contend with that in their veteran lives, be properly secured. I hope very much that Her Majesty's Government and the noble Earl will consider this amendment seriously.
Baroness Pitkeathley: My Lords, having put my name to Amendment 79, I support the powerful case made by my noble friend Lord Warner for the inclusion of long-term conditions and integrated services in the Bill. I particularly draw your Lordships' attention to those long-term conditions that can be fluctuating as well as progressive. While it may be progressive in an overall sense, an illness such as multiple sclerosis has periods of varying intensity, when needs are different, and even periods-sometimes quite long periods-of remission. It is very important, therefore, that services are not only commissioned across health and social care-it is very important that there is a whole package of support; that is of such significance to users and their families-but also that those packages of care are flexible enough to cope with the varying progress of these illnesses.
The last thing that an MS sufferer, for example, wants when a period of remission suddenly ends with a fresh attack, as it frequently does, is to go back to square one on clinical commissioning, especially as far as the integration of clinical and social care commissioning is concerned. They do not want to go back to starting
16 Nov 2011 : Column 701
Lord Cotter: I shall speak to Amendment 81B, to follow on from what the noble Lord, Lord Hunt, said. Brevity will be my watchword, of course, because we do not wish to drag out proceedings. This is a particularly important amendment, referring as it does to commissioning for rare conditions. There are many such rare conditions that people suffer from, but I refer particularly to one called arthrogryposis, which my wife has suffered from from birth to today. As with many people who have struggled with a rare condition from childhood to the age she is now, it has been difficult to get not just treatment but diagnosis. She was originally not diagnosed with this condition, which is associated with the nervous system and the muscles and mobility. Throughout her life she had the difficulty of being misdiagnosed, and then when she was diagnosed she had difficulty getting treatment. I welcome the amendment for that reason.
Many people have that struggle to get the treatment that they need appropriately in their area. For example, we recently went to Birmingham, where they have done some research work. It is so important to get research work done for rare conditions, to establish where they came from and whether people were born with them. I so much welcome-as my wife and others with her condition will welcome, as well as those with other conditions of various sorts-the fact that we are drawing attention to the need for commissioning for rare conditions. You could say that only a small proportion of the public has each rare condition but, when you add all the rare conditions together, there is quite a proportion of people with those problems.
I draw to a close on that basis and hope that the Minister will consider this very carefully, as we and many other people have had experience of rare conditions, with the difficulty of diagnosis and treatment and of getting it recognised throughout their lives.
Baroness Murphy: My Lords, this is an interesting group of amendments about how prescriptive the powers and duties should be for CCGs and about dividing up who should do what between the groups and the board. We have to be careful about how prescriptive we want to be, because it may vary in different areas according to the board's confidence in the ability of groups to commission. However, I take the point that there are some fundamental principles which we would like to see in each of these groups. That was why I added my name to the amendment tabled by the noble Lord, Lord Warner, and others, about the need to strengthen the co-ordination of
16 Nov 2011 : Column 702
I am sympathetic to the amendments on special conditions and rare conditions, but-coming back to what the noble Lord, Lord Warner, said-the areas where we need most improvement include everyday, ordinary, complex multiple conditions of older people and simple but common surgical emergencies. It is the ordinary, everyday things that we need-ensuring that we have the right commissioning groups at the right level and that they concentrate on these broad responsibilities relating to the population.
I support the question that underlines Amendment 82, in the names of the noble Baroness, Lady Thornton, and the noble Lord, Lord Hunt of Kings Heath. This is about how agreement will be made between health and well-being boards and the commissioning intentions. We need some understanding of the ground rules which will underpin those negotiations. My experience of negotiating contracts in the NHS is that they can be an awful long time in coming and being finalised unless you have some clear ground rules. I wonder how far the Government have got in thinking about that.
I wish to speak to Amendment 178 on behalf of the noble Earl, Lord Sandwich, and the noble Lord, Lord Mancroft, neither of whom are in their place today. This again is about clinical commissioning groups' awareness. Amendment 178 is a plea that commissioning groups should take into account-particularly into financial account-what is already being provided for voluntary organisations. Often these provide a more cost-effective and responsive service to client groups. In the noble Lords' minds particularly were services for those who misuse drugs or alcohol, but there are also services in mental health or in specially targeted support and rehabilitation for specific ethnic groups. For example, a support worker from the same ethnic community can be so vital in establishing mutual trust and compliance with a care plan.
I very much hope that commissioning groups will take into account what is already being provided when they commission. Of course, I understand that alcohol and drug misuse services will be commissioned largely by local authorities. This is entirely positive because they often have a greater understanding of the involvement of voluntary organisations in being able to contribute to a wider service than the NHS often does. Nevertheless, this is an important amendment.
Baroness Armstrong of Hill Top: My Lords, I wanted to intervene on this group of amendments because I have been trying, without success, to find out how to table an amendment relating to how the new architecture will deal with the most chronically excluded. Some of them will require alcohol services, which we shall come to later, but many of them will require other medical services. In addition, many of them will not have a fixed abode or will not have a fixed abode for very long. Therefore, they will be moving around.
When I asked the chief executive of the Commissioning Board who would deal with these people, I was rather concerned to be told that it would be clinical commissioning groups. CCGs might do so, but I am not convinced that they necessarily will. First, CCGs may well not be very aware of the numbers involved, particularly if they are not inner-city commissioning groups, and they may well not be aware of the complexity of response that such people will require. These will be people who require some medical intervention as well as other forms of intervention and support.
At the moment, much of the medical attention that these people receive is fragmented and is often not the appropriate intervention, and they can be a real nuisance in places such as A&E. The Government need to listen to those in the voluntary sector who say, "We need a new approach to how we work with people with these multiple conditions and we need to make sure that we get it right". However, the NHS has a responsibility-it does not stand outside this-and this matter will need to be looked at on a wider and more expansive level than simply that of the CCG.
In this country we assume that, because we have GPs, people will automatically be registered with them and will be looked after. However, my experience of working with these most frequently disturbed and disadvantaged people has been that they fall through the net again and again, and somehow we have to make sure that that does not happen. Due to work that I have done in the past and because I am currently involved with a voluntary organisation, I have previously discussed with the Minister ways in which that can be achieved effectively. I do not pretend that it will be easy or that we can simply lay something down in legislation and it will all happen. However, somewhere in the middle of that there is a way forward.
I hope that in considering the amendments-particularly those of my noble friend Lord Hunt-the Government will work on this issue and come back with clarification that this group of people will not fall through a net in the new architecture.
Lord Greaves: My Lords, I want to pick up on a point that I made on Monday. We are discussing the role, duties and powers of CCGs, and I want to talk about commissioning services. Where contracts are negotiated with existing providers-whether they are within the National Health Service, the voluntary sector or the private sector-it is fairly clear to see how the system will operate. However, I am not clear-and perhaps the Minister can enlighten me-about the role of CCGs in promoting and creating new services or facilities within the NHS.
The example that I particularly want to refer to concerns the provision of new health centres in my own area of east Lancashire. These are new significant capital schemes but they are not the direct responsibility of the hospital trust. Where the responsibility is that of the hospital trust, it will no doubt be responsible for the provision of new capital schemes. Here we have facilities that will be partly occupied by GPs; they may well be occupied in part by community-based services that are now the responsibility of the hospital trust. The hospital trust may wish to make use of the facilities
16 Nov 2011 : Column 704
These are all bodies that in future will not exist. Who will be responsible for this kind of capital project within the NHS in future? It is not just a question of commissioning within an existing landscape of provision in different sectors, but a question of commissioning new services and new capital projects that do not fit into the hospital trusts. Will that be done at a national level? Will it be the responsibility of the CCG? Who will be responsible for the provision of finance for this kind of project?
Baroness Masham of Ilton: My Lords, this group of important amendments illustrates that good care for all is what is needed. I shall say a few words on Amendment 79 on long-term conditions. As has been said, there are many long-term conditions, and there is great anxiety all over the country because of the change. What the Minister says today will be very important and may allay some of the distress. There is a shortage of district nurses, which is an important issue for people who need dressings for leg ulcers, for example, which can last for a long time.
On a positive note, there is telecare and telehealth and other new technology for monitoring. People can be monitored in their own homes. If something goes wrong, people can call emergency services. Scotland is doing much better than England, and other countries in Europe, such as Poland and Holland, are using the system a lot. England could do a lot better for people with long-term conditions.
All the amendments in this group are exceedingly important and I am glad that my noble friend Lord Ramsbotham mentioned prisons and people in cells. When I went to see prisoners being processed, a GP was trying to fathom out what to do with a really serious alcoholic. I asked, "What are you going to do?", and he replied, "If only I had some rehabilitation services for alcoholics, I wouldn't have to send him to prison. What will happen is that he will be in and out all the time". Many things can be made better, and I hope that the noble Earl will give us some hope when he responds.
The Countess of Mar: My Lords, I rise briefly to support Amendment 79 moved by the noble Lord, Lord Warner, although he should not have moved it at this stage perhaps; he should have just spoken to it.
As the Minister knows, I am concerned about people with CFS/ME. They are the most neglected, denigrated and discriminated-against group in the country and there are some 60,000 of them who are severely ill, which means that they are homebound and bed-bound. They have multi-system symptoms, which are far too
16 Nov 2011 : Column 705
Earl Howe: My Lords, CCGs will be under a duty to arrange for services to meet the reasonable requirements of patients for whom they are responsible. This is the language of the current duty on the Secretary of State in Section 3 of the 2006 Act and will remain one of the fundamental principles in the future. Additionally, under their discretionary power in new Section 3A inserted by Clause 11, CCGs will have the power to arrange the provision of services and facilities for the people for whom they are responsible where that will improve physical and mental health or improve the prevention, diagnosis and treatment of illness in those people. However, CCGs do not have commissioning responsibility for all services-for instance, those that the NHS Commissioning Board will commission. For that reason, Amendment 60A would be inappropriate. However, the Bill is already expressly designed to ensure that the comprehensive health service is maintained and that patients' needs are meet.
Amendments 76 to 78 seek to revise the commissioning responsibilities of CCGs, as set out in Clauses 10 and 11. In effect, Amendment 76 would give each CCG responsibility for commissioning for everyone normally resident in its area, removing the link between the provider of primary medical services with whom a person is registered and the CCG responsible for commissioning services for them. We think it is important to maintain this link. PCT responsibilities currently include people who may be registered with a GP in that area but who live outside the geographic boundaries of the PCT, so this is not something new. Clause 10 also includes some necessary provisions for the Secretary of State to clarify the responsibilities of CCGs in regulations-for example, when a CCG has ongoing responsibility for a patient's care even if they are no longer a registered patient of a member of that CCG, which is an important element of the policy of continuing healthcare, and when somebody might be excluded from their responsibility, which might apply to patients registered with a GP in England but living in another part of the United Kingdom.
Amendment 78 would change the discretionary power that CCGs would have under new Section 3A into an obligation. That would go much further than the current discretionary powers of the Secretary of State. It would place CCGs in the situation of being legally obliged to arrange any services that it felt were appropriate to meet a patient's needs. This would conflict with their duty under Section 14P to exercise their functions effectively, efficiently and economically, and could leave them open to challenge. These are
16 Nov 2011 : Column 706
The same arguments apply to Amendments 177 and 178. On the latter, the noble Baroness, Lady Murphy, made an excellent point about the key role that the voluntary sector can play in providing high-quality and cost-effective services. The noble Earl, Lord Sandwich, is a great advocate of services for those addicted to prescription drugs. I pay tribute to his work, about which I have spoken to him, and I hope he will be reassured that this area of care is not forgotten and that the voluntary sector has a major role to play.
If I had to single out one area where I expect to see a step change in the quality of care delivered to NHS patients as a result of the creation of CCGs, it would be long-term conditions. However, it is unnecessary, as Amendment 79 proposes, to emphasise that the power in new Section 3A applies to securing improvement in the health of persons with long-term conditions, because the new section covers all those for whom a CCG has responsibility, regardless of their health needs. Neither is it necessary to make additional provision for integration, important though that is.
New Section 14Y in Clause 23 would require CCGs to exercise their functions with a view to securing integration. We covered integration in earlier debates. Rather than focusing on integration as an end in itself, the duty under new Section 14Y rightly focuses on the outcomes that we want to deliver through the provision of integrated services. When that duty is considered in conjunction with the power of CCGs to do anything calculated to facilitate the discharge of any function conferred on them, it is clear that the Bill already achieves the intention behind the amendment.
I fully agree with the noble Lords, Lord Ramsbotham, Lord Kakkar and Lord Hunt of Kings Heath, that the services covered by Amendments 80, 81B, 82 and 83 should be commissioned by the NHS Commissioning Board. It would be very difficult for me to take issue with the powerful points that they advanced for the care of those in the criminal justice system, Armed Forces veterans and those with rare and specialised conditions. However, it is our firm view that it is better to provide this detail through regulations, which will give the Secretary of State flexibility, as the services that the board commissions and the settings in which they are provided will no doubt change over time. This will also provide greater flexibility over when the board takes on these responsibilities, to allow co-ordination with the other agencies involved.
The noble Lord, Lord Kakkar, made an extremely compelling speech about amputee veterans. The Government accepted the recommendation in Dr Andrew Murrison's report, A Better Deal for Military Amputees, that Ministers should take appropriate steps to provide for the national commissioning of specialist prosthetic and rehabilitation services for amputee veterans. Clause 12 already includes provision for the Secretary of State to require in regulations made under new Section 3B of the 2006 Act that the NHS Commissioning Board
16 Nov 2011 : Column 707
In the context of Amendment 82, the noble Lord, Lord Hunt, asked how the board would involve health and well-being awards in its commissioning plans. The NHS Commissioning Board will be required to appoint a representative to attend local health and well-being boards in certain circumstances. It will thus have an active role in the preparation and development of joint strategic needs assessments and joint health and well-being strategies. It will have a duty to have regard to those strategies in exercising its commissioning responsibilities. However, it would not be appropriate to require commissioning plans to agree with health and well-being boards, or for the boards to have a right of veto. The Local Government Association agrees with us on this.
Clearly it is also important that the board develops its responsibilities in a way that complements and supports other local health and social care commissioning. As I have said, the board will have regard to joint health and well-being strategies. It would confuse lines of accountability, and would actually be unworkable, if we forced a duty on the board to agree its commissioning plans with health and well-being boards. Clause 20 also enables the Secretary of State to specify in the mandate to the board matters by reference to which he will assess the board's performance, including in the services it will commission.
The noble Lord, Lord Hunt, asked how the board will be able to manage its primary care responsibilities effectively. Sir David Nicholson has set out his expectation that the NHS Commissioning Board will have a local field force, which is likely to be based-at least to begin with-on the areas covered by the PCT clusters. The field force would manage those aspects of primary care commissioning that require local expertise. There is a very informative section in the document, Developing the NHS Commissioning Board, published a while ago, which talks about this. It refers to Sir David's aim to have,
The noble Lord also asked me what would happen if a CCG refused to commission a service. I reassure your Lordships that, first of all, CCGs will be under a statutory obligation to arrange for the provision of care to meet the reasonable requirements of the people for whom they have responsibility. I have covered that point. The board will have a duty to perform an annual assessment of how well each CCG has fulfilled its duties in the previous financial year, and that will include in particular an assessment of how well it has taken account of assessments and strategies under new Section 116B(1) of the Local Government and Public Involvement in Health Act 2007, inserted by Clause 190. It is intended that the NHS Commissioning Board, supported by NICE, will develop a commissioning outcomes framework so that there is clear, publically
16 Nov 2011 : Column 708
My noble friend Lord Greaves asked about the role of CCGs in setting up new services. I wish to be clear: CCGs will commission services, they will not provide services. A key commissioning function for CCGs will be securing the provision of services in their area to ensure effective provision of such services. If a new service is required, a CCG could choose to factor capital costs into the contract when commissioning the services.
Lord Greaves: In the example that I provided, it is not a service that I am talking about; it is a facility-a new building that hosts a series of services, some of which will be GP services, some of which may be commissioned by the CCG, and some of which may be hospital services. Who, in future, will be responsible for deciding to build a new building in, say, Clitheroe, and commissioning the contracts and so on in deciding to do it?
Earl Howe: I am grateful to my noble friend, and I apologise that I did not cover that point. There are, of course, capital budgets. These exist at the moment and will continue to exist. The Commissioning Board will hold them. Where a capital project such as a building needs to be pursued, that money-as opposed to revenue money, which of course funds the commissioning of care-will be used to finance projects that are shown to be cost-effective and necessary to meet the needs of patients in a local area.
Lord Greaves:I would like to get to the bottom of this while we are talking about it. At the moment, those capital funds are provided either through the PCT or by the PCT from the money it has in the bank. In future, who will hold the funds to fund those capital projects?
Earl Howe: They will be held in the first instance by the NHS Commissioning Board. I anticipate that if a CCG or a group of CCGs wishes to establish a new service that involves a new building, a dialogue will take place with the board to bid for the necessary funds.
The noble Baroness, Lady Armstrong, put a very important question to me about the needs of the homeless. As I have indicated, CCGs will have responsibility for meeting the reasonable secondary care needs of the homeless. CCGs are responsible for unregistered patients in their area as well as those who are usually resident. Primary care for the homeless will be, as now, accessed through GP practices, either as registered or temporary patients, or through open-access GP services, such as GP-led health centres or bespoke services for the homeless. It is important that the needs of the homeless are factored in to the plans not only of
16 Nov 2011 : Column 709
Just to clarify the point I made to my noble friend Lord Greaves, I perhaps should have made it clear that the Commissioning Board could in practice allocate capital budgets to a CCG or a group of CCGs. I hope that was implicit in what I said. I re-emphasise that clinical commissioning will deliver better outcomes only if we allow clinicians the autonomy to identify the needs of their patients and communities and to make the key decisions about how best to meet those needs. With that in mind, I hope I have provided sufficient reassurance to the noble Lord for him to withdraw his amendment.
Lord Warner: Can the noble Earl help me, before we get to Report stage, on the issue of the integration of services? He used the same argument he used previously, which is essentially that integration is a process and what we should be concerned with in the future is the outcomes framework. The problem for those of us who want to see something more on integration in the Bill is that we cannot quite see how we can change the culture on integration without having something in the Bill. Outcomes frameworks deliver results later on in the process. We see in the future what has happened. The difficulty many of us have is that we do not believe that that future will arrive unless we are more vigorous in this legislation about specifying some requirements on integration. Will the Minister write to a number of us before Report stage to explain how the outcomes framework will deliver that change of culture without words in the Bill about integration, particularly integration between health and social care? I do not expect an answer today, but I would like a clearer answer than the noble Earl has been able to give to satisfy us that we do not need some words in the Bill.
Earl Howe: I understand the point the noble Lord is making and I will be happy to write to him and other members of the Committee. The Bill already provides a framework of powers and duties which will support more integrated approaches to meeting patients' health and social care needs, ranging from requirements to ensure that use is made of research in the health service to the close relationship between commissioners and the local authority and the health and well-being board. We ought not to forget that the NHS Commissioning Board guidance under new Section 14Z(6) could well cover the exercise of this function of integration. I accept the noble Lord's point that in large measure it is a matter of changing cultures and one cannot achieve that through the written word in a Bill that goes through Parliament. However, I would be happy to put some flesh on the bones for noble Lords in writing and I hope that that will be helpful.
Lord Cotter: My noble friend has given a careful response, as always, to the points made. However, will he accept that there is a very special need for focus on
16 Nov 2011 : Column 710
Earl Howe: I am grateful to my noble friend and I did mean to make specific reference to his speech, which I found very impressive. He is of course absolutely right. There is no doubt that the commissioning of specialised services in recent years has improved in many areas but it is still variable. I do not believe I am misrepresenting those who champion the cause of patients with rare conditions by saying that they welcome the fact that the commissioning of specialised care will now fall to the NHS Commissioning Board. In other words, the commissioning will be done once and not, as at the moment, very frequently 10 times at strategic health authority level. It is absolutely clear that for all sorts of reasons greater consistency and better quality need to be injected into the commissioning of specialised care. The points my noble friend made were ones that we certainly subscribe to.
Baroness Williams of Crosby: When the noble Earl was talking about the relationship between health and well-being boards and the local commissioning groups, he said that consultation would be expected but that in the last analysis if there was no agreement there would be no question of the health and well-being board having to approve of the CCG's plans. In the event of a serious difference of opinion, for example, about provision for the homeless or provision for special needs in a community, would there be any possibility of referring the matter up to the board or would it just be left to them to try to reach the best agreement they could?
Earl Howe: Part of the function of the board is to support decision-making at a local level if that is ever required. If there were a serious disagreement of the kind my noble friend describes, I envisage that the resources of the board could be made available to the decision-makers at local level to try to find a way through whatever disagreement had occurred.
Lord Hunt of Kings Heath: My Lords, I am grateful to the noble Earl, Lord Howe, for his response. Essentially what he is saying is that the reasonable requirement duty based on current legislation, together with the discretionary power in Clause 11, is sufficient to ensure that clinical commissioning groups will commission in a comprehensive way and deal with the many specific issues raised by noble Lords in this very interesting debate. He went on to assure us that if they are not doing that, the annual assessment based on outcomes alongside clinical commissioning guidance will make sure that CCGs are kept up to scratch.
My concern as to whether that is going to be sufficient partly comes because of the attitude of some GP practices to what one might call "difficult to reach" patients; for example, homeless people or people with mental health problems. We have heard about the rare disease issue. I am sceptical that the views of GPs
16 Nov 2011 : Column 711
My noble friend Lord Warner referred to the question of interventions, which is relevant to this. I am still not clear. The Secretary of State has been right to intervene with PCTs on the question of artificial waits for treatment but CCGs will do the same because they will have the same problems with resources. We were told last week that we have got this cancer fund, about which there will be no option. Ministers will make other promises in the future and yet money is being taken out of the health service. There is bound to be tension around the CCG board table. What if it decides that the 18-week wait is no longer important to it or it has a rule that if it is not urgent, a patient has to wait for a certain amount of time-because it is a way of controlling its costs? Where, then, is the intervention going to be?
My final point is about this whole question of the mechanism of health and intervention. I have not picked up the local field force yet-this is an innovation. However, it is quite clear that the NHS Commissioning Board, at a local level, will have to be a local player. It has the right of attending health and well-being boards, and presumably, if we do not get integrated health and social care, it will have to take advantage of that presence. It will hold the contracts of all GPs, so I assume that it will deal with complaints. The local field force will have to deal with the allocation of patients to practices where GPs are refusing to accept them. I am left with a sense that, in fact, there will be quite a large bureaucracy at the local level; the difference being that now it is under a proper public board. In the future it will be an outpost of a massive organisation based at the centre. I question whether that really is an improvement on what we have.
This has been a good debate. I sure we will want to come back at Report stage on the reassurance we need about comprehensive commissioning by CCGs, but, at this stage, I beg leave to withdraw the amendment.
Lord Beecham: My Lords, we now come to the important area of public health. This is the time for your Lordships' House to dip its collective spoon in the good part of this curate's egg of a Bill. I have to say that, of course, in the context of this Bill, "good"
16 Nov 2011 : Column 712
In this context, of course, it is critically important to recognise the need for a high degree of professionalism, and in particular to ensure that public health specialists are thoroughly engaged at a senior level within local government and that they have a considerable measure of independence, both at national and at local level. There are amendments that we will be discussing-not necessarily in this group but as we go through the Bill-that address those particular issues.
One amendment in this group that I will not be moving or speaking to today is Amendment 94A, which relates to the making of Public Health England into a special health authority. By the vagaries of grouping, Amendment 267, in the name of the noble Lord, Lord Patel, relates to a later part of the Bill, although it could have been grouped with my amendment. It would be discourteous of me to anticipate that debate, given that the noble Lord's amendment is down for future discussion. In general, we need to examine the role of government and their capacity either directly or through any of the other bodies created by the Bill to deal with the broader issues of public health at the local and national level.
Amendment 60B is the first amendment in my name. It simply incorporates the concept of promotion of public health as well as protection and improvement of public health in the rubric to Clause 8. It strikes me as a more positive and perhaps wider responsibility, which is echoed in some of the amendments we will discuss in this group about promotion through information, publicity and the like. It also perhaps has slightly less of a strictly medical connotation than the original rubric contains.
More significantly, Amendments 67A and 75ZZA relate to the proposed requirements on the Secretary of State to produce annual reports in dealing with the public health impact of budget changes and, as regards Amendment 75ZZA, in respect of finance generally. As ever, there is a significant issue around finance, which cannot be dealt with in terms of the context of the Bill. But it is critical that the reform is carried through with a workable system of financing the new arrangements. Considerable concerns about that have been voiced in response to the consultation documentation about funding the public health service from a number of quarters, including local authorities, the Faculty of Public Health and other organisations.
The difficulties of course are that at the moment public health is funded through the PCTs. It is by no means clear what the total quantum will be defined as in terms of the money to be redistributed direct to local authorities-ring-fenced, as we know it will be-let alone how that quantum will be distributed by way of formula. In addition, there is the new concept of the
16 Nov 2011 : Column 713
These are difficult matters. The Select Committee suggested that the public health impact of financial changes should be the subject of report. Both amendments simply follow the recommendations of the Health Select Committee of the House of Commons. I hope that the Minister will be able to agree them or at least agree to consider them and come back on Report.
"We are no nearer an announcement on the distribution formula or quantum after the third trawl for data. We remain concerned that it may be dealt with in isolation from wider issues about the design of the wider systems and the role and cost of Public Health England".
Clearly, the finance will not be dealt with in the Bill but we need to know as we go through the Bill and approve-I hope improve-the proposed structures, how the financial system would work. Perhaps in reply the Minister could give an indication of when it would be expected that the financial framework will be explained and judgments might then be made about the adequacy or otherwise of those arrangements because they will impinge heavily on the eventual outcomes that we are all seeking.
Amendment 69ZA will extend to local authorities the duty to have regard to and promote the health equalities agenda, which we have discussed previously in relation to the national Commissioning Board and the national players, as it were. It seems to me sensible that there should be a matching requirement for local authorities to have particular regard to that issue.
Amendment 89A is a suggestion, really, that the provision in the Bill conferring on CCGs the responsibility of arranging vehicles for residents who need them could also be a concurrent function of local authorities, some of which, I think, currently operate such schemes. Given the arrangements that local adult services and, indeed, children's services of departments already have for supporting people with conditions requiring such mobility, it would seem sensible to permit those to be included in the arrangements.
I hope that the Minister will respond sympathetically to these amendments, and indeed to others that other noble Lords will be making in the debate this afternoon. If he cannot reply in detail today, as time is pressing, I would quite understand if written communication were made later.
Lord Warner: I apologise to the House for my enthusiasm to get in to this debate on public health, which I regard as a key part of this Bill. I am extremely supportive of much of the thrust of the Government's approach. I rise to speak to Amendments 62, 64, 65 and 68, which are in my name and in the name of the noble Lord, Lord Patel-and, in the case of Amendment 62, also in the name of the noble Lord, Lord Walton. Unfortunately, neither of those noble Lords can be with us today. However, I strongly support the remarks made by my noble friend Lord Beecham.
These amendments to Clause 8 are aimed at strengthening the Secretary of State's duty on the protection of public health. Let me make clear that, as I said, I very much welcome the Government's emphasis and commitment on public health and support the thrust of their changes. It is time for us to give much more prominence to public health if we are to relieve the pressures on the NHS in the coming years. However, I believe that we could go further than the Government have in terms of the Secretary of State's duty, as currently expressed; hence these amendments.
The first prong of this amendment is to cement evidence-based policy into the discharging of the Secretary of State's duty to protect public health, and to make clear the use of science in doing so. All Governments like to claim that their decisions are evidence based-nothing surprising or new in that-but all too often they are not. For example, it has been a very long haul getting all government departments to have chief scientific advisers. Even now, the Treasury has only recently appointed its first chief scientific adviser.
Your Lordships' Science and Technology Committee, of which I am privileged to be a member, is currently looking at the experience of chief scientific advisers in different departments, and it is very clear that their status and influence vary considerably. In the area of public health, it is absolutely clear that using a strong scientific evidence base, including the social and behavioural sciences, is very important indeed. Nowhere was this more important than in the controversial issue of banning smoking in the workplace and in public places. The dangers of second-hand smoke were discounted until the scientific evidence made that position untenable. If I may say so, we are now seeing a rerun of that debate over the issue of smoking in cars and the danger to children of second-hand smoke. Without going into particular issues, I want to emphasise the importance of Health Secretaries-of all political persuasions-making public health policy and taking decisions on the best scientific evidence available, and of requiring them to do so in statute.
The second prong of Amendment 62 is something of a belt-and-braces approach, requiring the Secretary of State to not be overinfluenced by special interests. There have been long-running concerns about the influence of the tobacco, food and drink industries on successive Governments over public health policy. I am not making a party political point here. All Governments have been subjected to pressures by those particular special interests when they have tried to deal with protecting public health. I will not go over the ground in detail because it is well documented and in the public arena.
However, the issue has been given a new burst of life because of this Government's attachment to nudging public behaviour in the right direction rather than legislating. Again, the Science and Technology Committee of your Lordships' House, under the chairmanship in this case of the noble Baroness, Lady Neuberger,
16 Nov 2011 : Column 715
Lobbying by powerful special interests is a feature of all western democracies, and a potentially dangerous one in the sphere of public health. We should take the opportunity of this Bill to require future Health Secretaries in this position not only to pursue science-based policies but to resist the blandishments of special interests. Amendment 64 is a simple substitution of "must" for "may" in terms of the steps that the Secretary of State should take in carrying out his duties set out in new Section 2A(2).
Many of the pressures placed on the NHS result from lifestyle choices that we all make that can damage our health. We need to make it a central tenet of public health policy that we should assist people to take more responsibility for their own health and well-being, rather than simply expecting others to bear the cost of treating them when they become ill. Obesity is a good example. In most cases, the solution lies literally-if I may put it this way-in our own hands. Accessing and probably holding our own medical records would reinforce that personal responsibility. This Government, like the previous one, rightly emphasise personal responsibility alongside rights. In the sphere of public health, Amendment 65 gives a push to that approach. I hope that the Government will accept it in the spirit in which it is proposed.
Finally, Amendment 68 extends Clause 2A(4) to give the Secretary of State a bit more help in carrying out his duties to protect public health. This amendment requires the Secretary of State to appoint an independent standing advisory committee on public health of no more than 15 people to provide advice on a regular basis as well as when the Secretary of State seeks it on a particular issue. The reports of that committee will be available to Parliament and the committee can report to the Secretary of State on any matters of concern that it has about the state of public health. I would envisage this committee being a major focus for the provision of scientific evidence to underpin public policy in this area under Amendment 62. I think that Amendment 68 is self-explanatory and its benefits self-evident in an area as important as public health.
I hope that the Minister will see these amendments as constructive strengthening of the Government's ambitions on public health and enabling a helpful legacy to be left to the next Health Secretary whenever this current Health Secretary chooses to leave his job. I believe that these amendments go with the grain of the powerful, recent report on public health by the Select Committee, which proposes further strengthening of the Government's powers. I hope that the Government
16 Nov 2011 : Column 716
Baroness Jay of Paddington: My Lords, I wonder whether my noble friend could help me with something that seems to be implied in his very eloquent deliberations about the amendments. I agree with him entirely that, in the public health arena, political leadership-the role of Governments of whatever party-is enormously important, particularly, as he said, in resisting the blandishments of external lobbies and so on. Does he see a potential conflict between the additional powers which he is advocating for the Government and the Secretary of State in this area, which I would entirely support, and the decision of the Government to reduce the powers of the Secretary of State in general for health services, healthcare and the promotion of general health matters in the way in which the Committee has discussed at some length on earlier clauses?
Lord Warner: My Lords, my noble friend raises a very important point. I can see some differences of approach here. Today, I am speaking on the rather narrow issue of helping the Secretary of State to be a powerful influence in improving public health. Of course, it is for your Lordships' House to debate further, as we progress through the Bill, whether we want Clause 1 to go a little further than the Government seem to want in terms of the Secretary of State's responsibilities. I have sympathy with my noble friend in seeing a slight confusion on the part of the Government in some of these areas.
Baroness Williams of Crosby: My Lords, I wish to express strong support from these Benches for the amendments spoken to by the noble Lord, Lord Warner. Perhaps I could mention one or two points. It is clear that the emphasis on public health, important as it is at the national level, must also be reflected at the local level. I say again, therefore, that the amendments about expecting clinical commissioning groups to have at least one board member with public health experience are important in reflecting the kind of things about which the noble Lord, Lord Warner, has spoken.
I also believe that the noble Lord has put forward in Amendment 68 a very interesting idea that ought to give a higher profile to public health advice on how to deal with diseases and illnesses in the population as a whole. Obviously I share the views expressed by the noble Baroness, Lady Jay, on the importance of putting the Secretary of State squarely behind these issues, and I shall give one example of that. The Bill provides for extensive redress on issues related to smoking and alcoholism, and perfectly properly so. People are perhaps more reluctant to point the finger in relation to some of the serious public health issues arising from the food industry, issues which have great implications for the food industry's relations with the overall economy. There has over many years been a very slow response to growing evidence that certain foods, particularly foods directed at children and young people, have a substantial impact on health. If one looks at the ways in which those foods have been advertised, with an
16 Nov 2011 : Column 717
There is a continuing emphasis on, for example, foods that attract young children but which contain high levels of salt, sugar and so on, which is all the more serious in a country such as ours which, sadly, has a growing problem of obesity. I strongly suggest that the Government should look closely at Amendment 68 and the idea of establishing a standing advisory committee on public health. I would also point out the importance of assigning responsibility all the way up to the Secretary of State to ensure that these negotiations with industries and special interests which are crucial to the nation's health are conducted at the highest level and that public health is recognised as a full companion to all the other aspects of health. In that respect, I am very pleased indeed that the Government have put emphasis on the independence of the public health area and allowed public health to be taken out of the Department of Health and given its own status. That is a very long step forward.
Baroness Finlay of Llandaff: My Lords, I have some amendments in this group to which I would like to speak. The first is Amendment 62A, a probing amendment which seeks a government response. This amendment would require the Secretary of State to report annually on the steps taken in relation to the duties listed in the Bill. Currently we have the Chief Medical Officer's annual report, which is excellent and provides an enormous amount of information particularly on matters relating to public health. However, given this Bill and the dramatic changes we will see in the delivery of healthcare across England, it seems important that we should have regular annual reporting that can be tracked from year to year against a specific set of headings. Over the years this would create comparators that could be used to see whether the quality and health improvements on which the Bill is focused are being achieved.
Similarly, I have amendments about undertaking an audit of healthcare providers' processes and outcomes in terms of how they improve public health and implement the public health advice they receive. Amendment 71A, another probing amendment, suggests changing the wording of the provision so that there is an obligation to consider diagnosis and treatment rather than diagnosis or treatment, as the Bill currently provides. I tabled this amendment because I was somewhat horrified to see that the Bill provides a requirement to consider treatment but not to ensure that the diagnosis guiding the treatment is correct. Treatment for the wrong condition will result in morbidity and mortality related to the treatment plus progression of the underlying condition. I wonder whether that might not be a drafting issue which the Government might be inclined to look at again.
However, perhaps I may give a little evidence in support of this pressure to require reporting and audit at every level. There is high-powered and strong evidence from public health itself. Public health is a competency set, not a separate discipline. All public health practice needs epidemiology, biostatistics and a commitment to organisations and community understanding, with a focus on prevention and the implementation of evidence into practice. Evidence is not just a matter of, "Yes, there is evidence", or, "No, there is not". There is a hierarchy of scientific evidence in relation to public health.
It is important to understand that there are five criteria in relation to the reporting requirements that I am asking for. First, there may be evidence of no benefit. Secondly, there may be no evidence of benefit. Thirdly, there may be uncertain evidence of benefit. Fourthly, there may be evidence of efficacy. Fifthly, there may be evidence of both efficacy and effectiveness, which means that these interventions would incontrovertibly improve efficacy and seem feasible for large-scale implementation based on effectiveness trials. So that is very high-level evidence, and the others are hierarchies right down to the first I listed, which was a reason for decommissioning and stopping the use of an intervention.
Perhaps I may give some examples of where that hierarchy has influenced clinical practice and the reason why public health cannot be divorced from clinical practice. Even though this has been put on local authorities and will have a strong influence, I hope it will not become divorced from clinical practice. It needs to be linked to commissioning by GPs for the following reasons. First, it has been demonstrated that general practitioners and clinicians can save money if they provide advice on health in the consultation as well as dealing with the presenting complaint. Secondly, involving clinicians in detecting alcohol problems as part of a routine consultation has been shown to save money and lives. Thirdly, in nurse-led clinics there is evidence of cost-effective secondary prevention when they are used for targeted areas such as coronary heart disease. They can be extremely effective. Fourthly, drug treatment is a public health issue and there needs to be close working in the clinical setting to make sure that the use of drugs in conjunction with the appropriate use of pharmacy advice can maximise health benefit. Fifthly, primary care itself is more effective where public health is involved in the way that primary care is delivered. A very powerful trial conducted in the USA has shown that to be the case. Last but not least, high-tech interventions that at first sight might seem expensive, when properly evaluated in public health terms, have been shown to save lives and money, so they become an investment for savings.
Those are just some of the examples of why we need public health right at the heart of the changes, but we also need the monitoring that public health can bring to ensure that things that should happen are happening.
Lord Clement-Jones: My Lords, from the outset the noble Lord, Lord Warner, and my noble friend Lady Williams have hit the button on this debate. Like the noble Lord, Lord Warner, I am a sceptic about nudge theories and think that they need to be investigated. I thought that the House of Lords committee under my noble friend-my former noble friend-the noble Baroness, Lady Neuberger, interrogated the issue extremely well. We are in an obesity crisis. We are expecting 50 per cent of adults to be obese by 2020 and I believe that we are going to have to do something rather more drastic than simply nudge people. Personally, I am quite attracted to the idea of a fat tax. Let us see the evidence of whether a nudge is going to prevent us from facing a major obesity crisis by 2020 that is even greater than the one that we already have, or whether a fat tax is the only way that we are going to get there. The spirit of the amendment moved by the noble Lord, Lord Warner, is absolutely correct in that respect.
Very ingeniously, the noble Lord has introduced the idea of patient control over their own records. I do not know whether this is the right place in the Bill to be debating this issue, but I do know that it is an extremely important suggestion. Patients should have control over their own records, which should not be simply under the control of the local GP. It is increasingly important for pharmacists to have sight of a patient's records-with the consent of the patient; that is the essential control-and that other healthcare professionals should do so. There should not be a monopoly on the sight of patients' records for general practitioners. With the consent of patients, other health professionals should be able to see them. We will then have proper integration of healthcare without expecting GPs to be the gatekeepers for all an individual's healthcare needs.
Baroness Cumberlege: My Lords, I should like to make a short intervention to ask my noble friend one or two questions. When I was a Minister I was responsible for the Health of the Nation policy, which I much enjoyed. At the time we introduced the five-a-day programme. That was 21 years ago, so we can see how long it has taken to get that message deep into the psyche of the British people. There is something about promoting good health and habits of living to the population-it takes a very long time.
I want to speak to Amendments 62, 65 and 68. I was very much hoping that we would have a debate on Amendment 94A, which is about Public Health England. But courtesy is the hallmark of this House and, as the noble Lord, Lord Patel, is not here, it is absolutely right that we should not debate it today.
On Amendment 62, on scientific and other evidence, from the noble Lord, Lord Warner, it is the "other evidence" that I want to ask my noble friend about. As my noble friend Lady Williams said, other evidence is something that you build up, and I am quite concerned about how we are going to get this evidence into health and well-being boards and how we will ensure that the Government have enough evidence that builds
16 Nov 2011 : Column 720
I agree with my noble friend Lord Clement-Jones that this may be not quite the right moment to discuss medical records, but I really cannot resist it, although I will be brief. Some 21 years ago, in this House, from the place where my noble friend now sits, I made my maiden speech on medical records, so it is something that I have quite an interest in. When I produced a policy document on changing childbirth, one recommendation was that women who were pregnant should hold their own medical record, sometimes known as hand-held maternity notes. That has had an enormous impact; it has made those women feel that they are very important-they are pregnant and they are going to have a child and a whole readjustment to family life. That is a very important time in a woman and her partner's life, and it acted as a sort of passport to them. Bearing in mind that 30 per cent of women who are pregnant are obese, which has a huge impact on the next generation, it seems to me that having hand-held records or access to or ownership of your own records is terribly important. Of course, we have the red book that women get about their children so that they can share that information with health professionals.
My last point is on Amendment 68 and the standing advisory committee. I absolutely understand why the faculty of public health and other people like that idea. I am not sure whether that advisory committee, as has already been suggested by the noble Baroness, Lady Finlay, will make an annual report. That is possible. We will have the Chief Medical Officer's report annually, as she said, which is a very brave and independent document; the Chief Medical Officer says how it really is, and I know that it is very often extremely uncomfortable for the Government.
When we have Public Health England, will it make an annual report? I am concerned that we do not get too confused. Some of these standing advisory committees have been extremely effective, such as the Joint Committee on Vaccination and Immunisation. When I left the Government, in our last year we did not have a single
16 Nov 2011 : Column 721
In addition, advisory committees breed. It is absolutely extraordinary. Yes, you want to keep the good ones. There are others that I have set up and given a time limit to complete a task within two or three years. Then you try to get rid of them. It is so difficult, because they get dug in, they love the work they are doing and many get paid for it. In the end, they become not so much a help but more of a nuisance. So I have some reservations, but when we get to the debate on Public Health England we will see how some of this knits together.
Lord Turnberg: My Lords, I am also pleased that public health receives such a high profile in this Bill. I speak to Amendment 60B and one or two others in this group. There seem to be several aspects to the public health parts of this Bill being probed by these amendments. However there is one area of public health that might fall between too many bodies and where we might usefully explore how we can arrange for them to be better co-ordinated. The area is child and maternity services.
As I understand it, local authorities will be responsible for child public health services; the Commissioning Board for health visitors and immunisation services; and clinical commissioning groups for child health and maternity services. That will require all sorts of collaborations to be set up, and that is always a recipe for some problems. I hope that the noble Lord can give us an idea of how these sets of services can be rationalised in some way.
I shall now speak to Amendment 62 and some others. Clause 8 describes the Secretary of State's duty to protect the public's health. It details a number of specific responsibilities which, it so happens, are currently undertaken by the Health Protection Agency. I would like to comment on them. I have extolled the virtues of the HPA on a number of occasions, having observed it closely as the chairman of its predecessor, the PHLS, some years ago. Incidentally, the hero of the noble Baroness, Lady Cumberlege, is an employee of the Health Protection Agency. It is a remarkable organisation and the envy of the world. It jumps on outbreaks of infection very rapidly and has prevented many an epidemic. There are many examples of that.
I reiterate this because the HPA is to be swept up into a new arrangement, as we have heard, much more directly under the influence of the Secretary of State. Thank goodness it will not be within the Department of Health, but it will be very close to it. My fear is that we will weaken something of great value to the country. I have some specific questions for the noble Earl.
First, is it expected that all the current functions of the HPA will be taken on board, or are we to lose some? The list is pretty comprehensive but it may leave things out. If so, what would be lost and what would
16 Nov 2011 : Column 722
Lord Ribeiro: My Lords, I should like to speak very strongly in support of Amendment 65 in the name of the noble Lord, Lord Warner. Were the noble Lord, Lord Patel, here today, I am sure that he would also speak strongly in support of it because he raised the issue of patient records yesterday when we had a meeting with Professor Steve Field of the Future Forum. We were discussing information provision for patients and the use of computer records. He said that for many years when working in maternity he had given patients their own notes, and in all that time he could remember only two occasions on which the notes had gone missing. On one occasion, the patient reported that a dog had eaten the notes and, on the other, the notes were left on a bus and shredded, someone having recognised that they were important. Therefore, only two sets of notes were lost over a period of some 20 years. Patients are perfectly capable of looking after their own notes. When I was a surgeon in Ghana in 1974 it was certainly quite common for patients to come to the clinic with their notes, which often would otherwise have been lost.
The final message that came through was that we have spent billions of pounds on creating paperless records and computer records and are about to spend even more. The information that we were given yesterday at the Future Forum was that we should be looking at what can be done locally, bearing in mind that GPs have a computerised system of records. We heard another anecdote about an old lady who went to the out-patients' clinic for her appointment and the consultant said, "I'm terribly sorry but we've lost your notes today". She put her hand into her handbag and came out with a memory stick, saying, "Doctor, it's all on here".
I hope that the Minister will take note of Amendment 65 because I feel that it may well stimulate us to look again at patient records and the use of technology. We are, after all, in the 21st century and, although paper records are wonderful for us to have as a tactile instrument, they do not always contain the information that we need.
Baroness Northover: My Lords, given that my hard-working noble friend Lord Howe deserves at least a short break, I shall be addressing these amendments. If I do not cover them sufficiently comprehensively, given the time, I shall be very happy to write to noble Lords.
This is a very large group of amendments covering Clauses 8, 9, 14 and 19, which together set out the fundamental legislative basis for the new public health system. I thank noble Lords for their general welcome of these provisions, which of course put public health very much front and centre in the new system.
The Public Health White Paper sets out the Government's commitment to protecting the population from serious health threats, helping people to live longer and to enjoy healthier and more fulfilling lives, and to improving the health of the poorest the fastest. At a national level, there is a clear rationale for accountability for health protection to rest with the Secretary of State. The nature of various threats to health are not, of course, always amenable to individual or local action. They require a clear line of sight from the Secretary of State down to local services.
Clause 8 inserts new Section 2A and gives the Secretary of State a new duty to take steps to protect the health of the public in England. In practice, Public Health England, the national component of the new public health system, will play a key role in health protection, bringing together a fragmented system and strengthening the national response on emergency preparedness. It is our intention that it will be an executive agency of the Department of Health. Public Health England as an executive agency will have an operational distinctiveness that will allow it to build and maintain its own identity. Agency status will support the ability of scientists in Public Health England to give expert, objective and impartial scientific advice, which noble Lords have called for, to both the Secretary of State and more widely. I entirely share the view of the noble Lord, Lord Warner, that we must make use of the best scientific and other evidence available. We intend to set out clear proposals shortly on how the Secretary of State and Public Health England will receive professional advice. I am confident that those proposals will at least match the intention of the noble Lord's amendment.
Lord Warner: I hesitate to interrupt the noble Baroness on her debut at this point, but does she understand that by its very nature an executive agency is within a government department and does not have the same level of independence as a non-departmental public body? We are seeing played out in the public arena at present some of the consequences when there is disagreement between people in an executive agency and a Minister. That concerning the Home Office is currently being played out on the front pages of our newspapers. Does she agree with me and, I think, my noble friend Lord Turnberg, that having scientists in an executive agency fetters their freedom compared with in a non-departmental public body?
Baroness Northover: The noble Lord flags up a concern that has been expressed about the independence of the new organisation. I would point out the example
16 Nov 2011 : Column 724
It is extremely important that it should have that expert advisory position. That is why it was moved out of the Department of Health, which was the original proposal. The noble Lord will know that it was going to be within the Department of Health, but the Future Forum flagged up that concern and the decision was taken that it be arranged in this way, to address the points that the noble Lord has raised.
Coming back to what I was saying about the Health Protection Agency, I remind noble Lords that Clause 53 abolishes that agency and repeals the Health Protection Agency Act 2004. That is central to the Government's plans for unifying national health protection activity and creating a more transparent and accountable service under the Secretary of State. In so many ways the Health Protection Agency has done an outstanding job, and we certainly pay tribute to those who have worked within it. It has established an outstanding international reputation, as the noble Lord, Lord Turnberg, pointed out. Public Health England will be able to build on that recognised expertise not only from the Health Protection Agency but from other organisations that we can draw into our public health system. There was talk about whether this should be a special health authority. The noble Lord, Lord Beecham, said that he wished to address this later on, so no doubt we will come back to this and to the points the noble Lord, Lord Warner, made about independence and why we are not proposing to do things in quite that way.
Clause 50 requires the Secretary of State to publish an annual report. Noble Lords wanted to know about the reporting mechanisms. This annual report covers the performance of the comprehensive health service in England. I wish to highlight that the content of the report will include public health. The noble Lord, Lord Warner, was right to emphasise the importance of good evidence. This will be key to the analysis and taking forward of effective policy. I understand exactly what he means by "special interest". However, the drafting of his amendment might have the unintended consequences of people not being able to consult groups that they might wish to consult-such as the royal colleges, which might be regarded as being special interest. The key thing here is not only the commitment to rely on scientific evidence but also transparency. That is essential. If you have transparency over where information is coming from and who is meeting whom, that should help to allay some of the concerns that the noble Lord has expressed.
We have heard a certain amount about medical records. The Department of Health's information strategy, which will be published this winter, will include consideration of the benefits of greater transparency of provider performance and outcome information as well as setting out how increased transparency and greater access to information can support improvements in care, giving people greater access to and control of
16 Nov 2011 : Column 725
Clause 9 inserts new Section 2B into the National Health Service Act 2006, giving local authorities a new duty to take steps to improve the health of people in their areas and the Secretary of State the power to take steps to improve the health of England. There has been a bit of a debate as to the balance here. As noble Lords will recognise, there is undoubtedly a shift in the devolution of the responsibility to local authorities. We welcome the enthusiasm that has been shown by local authorities and the Local Government Association in taking on this responsibility, which belonged to local authorities in earlier years and made such a dramatic improvement, particularly in the 19th century in terms of sanitary reform when it was at local authority level that enormous change took place. It is easier to see the joining-up of all the areas that need to be joined up, as shown in the Marmot report, if public health is seen as a local authority responsibility. Giving this role to local government opens up new opportunities for community engagement and for developing holistic solutions to health and well-being by embracing the full range of local services. Crucially, unlike primary care trusts local authorities are also directly accountable to the local electorate for their performance. Directors of public health will lead this work as the principal advisers on health to the local authority.
I hear what the noble Lord, Lord Beecham, says in regard to inequalities. However, I hope to reassure him that our reforms will give all levels of the public health system key roles in tackling health inequalities. The shift to local authorities should help in this regard. As these changes take effect, we would expect them to have the largest and earliest impact on those communities with the worst public health by joining up services in that way and because the public health budget will be ring-fenced for local authorities and therefore will be less likely to be raided by the rest of the health system.
The Secretary of State for Health will publish a public health outcomes framework that will set the strategic context for the system from local to national level. The framework will set out the broad range of opportunities to protect and improve health across the life course and to reduce inequalities in health. As I mentioned, from 2013-14 the department intends to allocate to local authorities a ring-fenced public health grant, targeted for health inequalities. We are also developing a health premium to reward communities for the improvements in health outcomes that they achieve.
The noble Lord asked when funding for local authorities would be made. We expect to announce a baseline figure for 2012-13 very shortly, which will allow local authorities to plan ahead for 2013. Our estimate of the global figure, as he will know, is in excess of £4 billion.
Amendments 69A and 60B would effectively give the Secretary of State a duty in relation to health improvement. In drafting Clauses 8 and 9, we took care not to duplicate duties, as this could inadvertently
16 Nov 2011 : Column 726
In addition, there have been a number of amendments in relation to the steps that may be taken under parts of new Sections 2A and 2B. We have avoided defining health protection or health improvement in a restrictive way. Instead, these steps illustrate the nature and extent of the functions by listing a number of steps that the Secretary of State or local authority may take. In some cases, we have also selected the steps to remove any doubt as to whether they could be taken in the exercise of the new functions.
|Next Section||Back to Table of Contents||Lords Hansard Home Page|