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in relation to treating NHS patients. This is intended to ensure that risk selection does not take place on the part of providers, whereby they accept for treatment only less complex cases or patients, with a view to maximising profit. The Bill also instructs Monitor and the board to take account of the different types of patients treated by providers, and the range of services offered. The amendments suggest that this must also be considered in the national tariff, when that is used, because in looking at tariff adjustments, the Bill does not adequately safeguard against the potentially destabilising effect on existing providers, where other providers choose to deliver only simple or profitable services.

This could increase the relative burden on those providers who deliver a wide range of services, including ones that are more complex and less profitable; also when they provide support at a tertiary rather than a secondary care level, they are providing support into other secondary care services. The amendments would ensure that when the board and clinical commissioning groups discharge their duties in relation to patient choice, they have regard to the effect on the stability of the local health economy and the providers within it; and that they provide this wide range for their patients.

I have made inquiries about what is already happening around the country and I am grateful to the British Association of Dermatologists for giving me some information. It has reported to me that private providers already appear to have been awarded contracts without the appropriate range of specialist staff in situ when starting a service; and private providers appear to be contracted to deliver services that are not necessarily integrated with the existing local secondary care services. They are also decommissioning in isolation without looking at the impact on other local specialist services. For a subject such as dermatology, that becomes really important, because it has a small but important role when extremely complex conditions are looked after by other secondary care providers, and where sometimes the skin holds a light to the true diagnosis.

The association has also drawn to my attention the problem in which some providers set up outpatient clinics which have no educational component. By doing that, they are setting up clinics which are unsuitable for secondary care training, both to doctors in training and nurses who want to train to become specialist nurses. This is a field in which a rising number of specialist nurses have an increasingly important role. The amendments are also designed to make sure that choice is appropriate and that the Commissioning Board does not have to prioritise patient choice over efficiency and effectiveness; quality of services; or over its duties to reduce inequalities and promote integration. These are important duties in the Bill, which many of us have welcomed. I hope that the priority for those is paramount, because they will affect the population at large and reduce inequalities.

Regarding Amendments 175A and 175B, I want to outline briefly why it would be important to be able to appoint a secondary care clinician from within a clinical commissioning group area, rather than being restricted either to somebody from outside the area or somebody who is retired. As we have already debated, there is a

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great need to promote integration. The report Teams Without Walls, to which I have already referred, stressed the importance of this integration with clinical leadership across primary and secondary care. The Government's commitment, in response to the Future Forum's report, that clinical commissioning boards would include at least one specialist doctor and a nurse was welcomed. I hope there will be some reciprocity by having a general practitioner representation on the board at foundation NHS trust board level, at a governance level, to facilitate such integration.

I was concerned that the Secretary of State for Health stated that a hospital doctor on the Commissioning Board should either be from outside the area or be retired. I was particularly concerned about the latter, because there did not seem to be any statement about how recently that person should have retired. People rapidly become out of date with what is going on in an area. For those doctors who work in a fairly large geographical area, it would mean that the secondary care doctor may have to travel a great distance, and perhaps be represented on the clinical commissioning group of an area where the secondary care services are pretty well unknown to him. In saying that, I draw on my own experience of being previously on a health board simply adjacent to the one in which I worked. There were many times when I felt I could contribute much more at a local level, across different services, because of having an in-depth knowledge, than having to explore the various ramifications of secondary care services in the area of the health board on which I sat before I was able to contribute fully to the debate within the board itself.

I also believe that it would help to drive up standards if somebody came from within the board. In saying that, it is important that we learn lessons from problems that have arisen. No one wants to prejudge what the Francis inquiry will recommend but the transcript of the oral evidence that doctors gave to the inquiry appears to indicate that the doctors and the hospital were isolated; that they did not have good networks with other local doctors who worked in different environments; and that when they complained about standards of care they did not report their concerns outside the trust's structures. That suggests a degree of geographical isolation. There would be merit in reconsidering the stipulation and the restriction that the doctor must be drawn from outside the area.

I do not believe that appointing a clinician from within the clinical commissioning group area results in an unmanageable conflict of interest. First, the role of the secondary care doctor is to offer expertise to inform commissioning decision-making, not to represent one hospital or one specialty. Secondly, GPs will have the same degree of conflict of interest. Therefore, I suggest that the safeguards against this affecting their decision-making need to apply to other healthcare professionals-whoever they are-who sit on the clinical commissioning boards. That also applies to the nurse who sits on the board.

Since the secondary care doctor would not represent any one provider or specialty, there would be no conflict. The model of having a single representative across specialties is not new and exists within the

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current system-for example, with medical directors in trusts. Other clinical advice will come from clinical networks and senates, and there will be a degree of co-terminosity in the advice received by the clinical commissioning group. That might allow a degree of consistency, which would support some of the difficult decisions that the group will have to make, particularly about issues such as decommissioning services. Therefore, the secondary care doctor will not be able to overrule or push a personal agenda. They will be bound to governing board decisions in the usual way and should have no right of veto. I hope that the Government will reconsider the position of the person on the clinical commissioning group.

For the involvement of patients, it is important to differentiate between public involvement and the involvement of each individual patient in the management of their care and treatment. Amendments 194 and 195 seem important if the mantra and important principle of "no decision about me without me" is to be made real. That phrase is one of the most important things that this Government have put in place. It is certainly a phrase that I have often used in making presentations about various aspects of healthcare delivery.

The importance of involving patients is made clear when you look at the 17 million patients with long-term conditions, many of whom provide more than 80 per cent of their care themselves or with the help of their relatives. If patients understand what is going on with their illness and how to manage their condition, their demands on the health service will decrease. The Health Foundation is developing ways of embedding techniques for supporting people to manage their care and treatment through its Co-creating Health programme. This has already been shown to have excellent outcomes by empowering individual patients to take a degree of control over their own illness and condition. Therefore, I hope that the amendments in my name will be considered by the Government in revising some of the apparently restrictive aspects of the Bill.

5.45 pm

Lord Warner: My Lords, I rise to speak in support of Amendments 124, 125, 126 and 196, which are in my name in this group. These amendments are on slightly different aspects of patient involvement and patient choice in new Sections 13H and 13I in Clause 20.

Amendment 124 adds words to the duty under new Section 13H to promote the involvement of each patient. Nothing seems more likely to promote that involvement than ensuring that patients have easy access to their own medical records and, even better, hold their own medical records. The amendment puts those matters in the Bill as part of the duty of promoting patient involvement in decisions about their treatment and care. If patients are to be involved in decision-making, it is important that they can be confident about the information about them that is being held by clinicians and used by those clinicians in making decisions about them. We have moved a long way from a position in which doctors could say, "Trust me, I'm a doctor". That is not to say that patients do not place a lot of trust in doctors, but the more examples of systems failure that patients hear about, the more I suspect they will want to be sure about what the system has on

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record about them. This is particularly true when we are dealing with end-of-life issues. Some of us are very keen to ensure that doctors and nurses observe our advance decisions in living wills that are placed in medical records rather than just make decisions on our behalf.

Amendment 125 literally follows on from Amendment 124 and reflects a number of conversations that several of us have had with National Voices, which speaks on behalf of many charities, especially those representing people with long-term conditions. National Voices, with assistance from the Health Foundation, has drawn on a lot of work to distil what it believes service-users expect from those commissioning care. The noble Baroness, Lady Finlay, referred to the work being done by the Health Foundation. This work with National Voices was born from the huge frustration of patients, service-users and carers about the way that they are often treated by those providing services. National Voices has also set out the results of this work in an excellent document called Principles of Integrated Care. Many Members of this Committee may well have a copy of it. If the Minister has not seen it, I commend it to him. I am certain that it has been sent to Sir David Nicholson. Around 50 chief executives or chairs of voluntary organisations involved with National Voices signed a letter to him, commending this piece of work.

Amendment 125 tries to ensure that there is a clear obligation on clinical commissioning groups to pay heed to patients' and service-users' voices in their commissioning of services and that the board issues guidance in this area to clinical commissioning groups. I hope that today the Minister will at least take away this amendment, discuss it in detail with National Voices and those of us who are involved in this area, and agree a version that can be included in the Bill and with which everyone is content. Of course, if he wishes to say "Snap!" to these words, we will be delighted. I emphasise that Amendment 125 does not come from the fertile minds of people in this Committee. It comes from the experience and views of many thousands of people with long-term conditions whose representatives have discussed and researched this very thoroughly within the ambit of the Health Foundation and National Voices.

Amendment 126 is on a different topic altogether. It tries to sharpen the duty of patient choice in new Section 13I in Clause 20, which in my view is pitifully vague. When they are exercising choice, people need to know what the speed of access to diagnosis and treatment is; where the location options and alternative providers of service are; and some information on the different levels of performance by those providers. Choice cannot be exercised in a vacuum. If people are to exercise meaningful choice, they need information that they can draw on to make their decisions about what is best for them. They should not simply be guided to local incumbents, which is too often the case in the system as it works now. Very often, those local incumbents may not be the best option for the patient seeking services for their particular condition at a particular time in their life.



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I speak with some confidence on this, having spent two years as a Health Minister trying to advance the cause of patient choice. I have had a fair exposure to clinical views about patients not wanting it and just wanting a good local hospital. I have seen at close quarters commissioners in excessively close relationships with local providers. I have heard the voices of patients frustrated at being denied the information they need to exercise choice. I have experienced, at first hand, consultants declining to place their consultation slots on the Choose and Book system. I know that we need much more than the vague wording of new Section 131 in Clause 20 of the Bill. I hope that the Minister, who I know to be a strong advocate of patient choice, will throw away his brief and say yes, we do need more specific wording of the kind in Amendment 126.

I hope the Minister will do likewise in respect of Amendment 196, which applies the same increased precision to the duty as to patient choice and places it on clinical commissioning groups as well as the board. I will not go over the arguments again, as they are exactly the same as those I have deployed on Amendment 126. It is even more important to disturb the cosiness of provider incumbency when we come to clinical commissioning groups. I have added a little piquancy to the clinical commissioning groups amendment by a specific reference to end-of-life care, where we badly need more options for people to choose from if their preferences are to be delivered.

I have spoken for too long already, but I also wish to add my support to the amendments in the name of the noble Lord, Lord Patel, to which I have added my name.

Lord Clement-Jones: My Lords, I shall speak to Amendments 127B and 197B. As they relate to pharmacy, I declare an interest as the chairman of the Council of the School of Pharmacy, University of London. The intention of these amendments is to ensure that all relevant healthcare providers, including community pharmacists, are consulted when the NHS Commissioning Board and commissioning groups are discharging their functions and developing their business and communications plans. The essence of these amendments is to retain the long-standing arrangement whereby, under the 2006 Act, commissioning bodies have to consult widely and in good time with all relevant stakeholders, including local service providers or their representatives.

Under the current system, primary care trusts are required to consult widely in relation to their commissioning duties. There is concern in the pharmacy profession that the current provisions under Clause 20, new Section 13J, for the board, and Clause 23, new Section 14V, for clinical commissioning groups, to obtain appropriate advice are too vague. It is important that consultation with all local healthcare providers should be done via local representative bodies as well as directly with providers. Clinical commissioning groups should consult pharmacy professionals when making decisions in relation to the commissioning of relevant services in order that the professional skills, knowledge and expertise of pharmacists are used in planning,

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commissioning, delivering and evaluating NHS services. They should also demonstrate arrangements systematically to seek the views of all appropriate local clinical groups throughout the commissioning process, in general and for particular services. This would include ensuring that all local representative committees are fully engaged in the commissioning process and signed up to the outcomes agreed.

As part of their local leadership role, clinical commissioning groups also need open and transparent processes for reconciling different professional perspectives and contingency arrangements for seeking the agreement of non-GP professional groups in the case of urgent service change. These processes should be clearly set out as part of the CCG's governance procedures for commissioning decision-making. The above will be of particular importance in the immediate term, given the influx of new commissioners into the market, to ensure commissioners commission services effectively. Without relevant healthcare providers being consulted, the different contributions that such providers, including pharmacy, can make to local healthcare could be lost.

If used effectively, pharmacy has the potential to deliver a great deal more both to patients and commissioners. For example, it is estimated that some 57 million GP consultations each year involve minor ailments which could be dealt with at a pharmacy. If these patients could be moved to a pharmacy, more than £812 million could be saved annually, and GP capacity could be freed up to deal with more complex cases.

In summary, it is critical that there is a duty on commissioning groups, when developing their commissioning plans, to consult primary care providers such as pharmacists as there is a danger under the proposed legislation that some groups may not do so, leading to ineffective commissioning of services. At the Royal Pharmaceutical Society Conference in September, the Minister said that pharmacists are pivotal to every aspect of the Government's plans to modernise the NHS. I find those words very encouraging and hope that he can give further encouragement in the course of this debate.

Lord Patel: My Lords, I support the amendment of the noble Lord, Lord Warner, on patients holding their own records. Speaking from personal experience, I know that it was not uncommon in maternity services years and years ago for patients to be given their old, shared maternity card. The difference was that that card was extra to the actual notes, so what doctors and midwives wrote in those cards was probably an abbreviation.

For 25 years of my life, I allowed patients to carry their complete set of records, thus avoiding having to write another card. That meant that what you wrote and what you told the patient had to be precise, and clear thought had to be given to the purpose of writing it down. It also taught people not to use abbreviations that do not mean anything, or that might be misconstrued. It is not uncommon for doctors to use abbreviations such as SOB or NAD. They do not mean what you think they might mean. SOB stands for "Shortness of breath", and NAD stands for "No abnormality discovered". This also meant that when you were putting the results of diagnostic tests

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into the notes you were forced to explain to the patient what those results meant. If the results were ambiguous, then you had to explain to the patient what that ambiguity was. That improved the quality of record keeping, communication with the patient and the quality of care given to the patient. In 25 years of allowing thousands of my patients to carry their own notes-and some of the noble Lords sitting today are well aware of my habits-I lost only two notes. One was eaten by a dog in the patient's house and the other was torn up after being left by the mother-to-be on a bus. Apart from that, there was no loss of notes, while in hospitals usually you can hardly find any notes.

There is a double issue here. How do we make notes that are compatible-easy to write and yet which communicate with the patient. An electronic version is better, but even a hand-written version works. I am convinced that allowing patients to carry notes is not a problem.

6 pm

Lord Harris of Haringey: My Lords, this is an extremely important group of amendments, but I hope it is, by and large, an uncontroversial one. The Government say they are committed to patient involvement and patient choice. They say they want to see all decisions being taken with the patient rather than simply by professionals. These amendments all contribute to achieving those objectives. It is worth distinguishing between a number of different elements in terms of patient involvement. There is the involvement of the individual; there is the involvement of the specialist group of patients; and there is the collective involvement of patients. I hope that these amendments provide a means of addressing all three groups.

The involvement of the individual patient-specifically included in Amendment 121 and in Amendment 124, to which the noble Lord, Lord Patel, has just spoken, on access to medical records-is an example of where it is vital to write this into the Bill if you are serious about the Government's mantra of, "No decision about me without me". The experience is that, where patients are involved in all decisions about their medical care, better decisions are made and compliance with them by patients is far fuller than would otherwise be the case. Therefore, requiring patients to be involved in every decision affecting them is part of delivering a good and effective health system. My experience mirrors that of the noble Lord, Lord Patel, because the experience of patients' organisations is that, where patients are given charge of their medical records, they look after them extremely carefully-often much more carefully than under the old system of trolley-loads of not dog-eaten but dog-eared files in hospitals-and are much more likely to be protected by the individuals concerned.

I have put my name to Amendments 123, 192 and 205, which talk about the involvement of healthwatch organisations. Amendment 123 places a duty on the board to promote the involvement of local healthwatch, and it is important that the board sets the tone for the NHS in the way in which healthwatch organisations are expected to be involved at every level. It needs to come from that level. Amendments 192 and 205 relate to the duties of clinical commissioning groups. There

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is a gap in the Bill, because it seems to be implied that commissioning groups will involve patients and healthwatch organisations, but I am not sure that that is stated explicitly, which is why those amendments are so important.

However, the reason why it is helpful to engage healthwatch at every level within the NHS is the support function that local healthwatch organisations and HealthWatch England will provide to the three levels of patient involvement that, as I have stated, are so important. That is because, as local healthwatch organisations and HealthWatch England, they will have an understanding of the way in which the health service is functioning. They will have an understanding of the pressures on the health service, commissioning groups and local providers and they can therefore support specialist groups of patients with a particular knowledge of their condition in how to exercise their influence most effectively within the organisation. It is those specialist groups of patients who will be tremendously valuable in improving the quality of service. They will often have far more knowledge about the way in which their condition operates than even the clinicians who support them-maybe not the specialists but general practitioners and so on-because they have that detailed knowledge and experience, day in and day out, particularly when they have a chronic condition that may continue over many years. That involvement is crucial in terms of the quality of decision-making, but it is important that they are supported by organisations such as healthwatch, which will then be able to put a context to the way that the local NHS is functioning.

Finally, there is the critical issue of the collective involvement of patients in decisions about the disposition and organisation of health services at a local level. That will be best articulated through local healthwatch organisations. This will be about what best serves the local community and what meets the differing needs within a community. The only simple mechanism by which that can be achieved is through something such as local healthwatch organisations. That is why such involvement must be built into the commissioning process, and the board must lay down how crucial this issue is crucial to the determination of services.

Lord Kakkar: I shall speak to Amendment 198 in my name and that of my noble friend Lord Patel. It would impose a duty on clinical commissioning groups to consult relevant academic bodies in their area, including potential future academic health partnerships. I remind noble Lords of the entry in the Register of Lords' Interests on my involvement in University College London Partners-one of the five academic health science systems currently designated by the Department of Health.

Academic health science partnerships can take a variety of forms but are all based upon a simple principle: the delivery of healthcare should be combined with high-quality teaching, training and research to drive the highest possible clinical standards achievable. Indeed, throughout healthcare systems in the world it is well recognised that alliances between the academic and service-delivery elements of healthcare help us to achieve the best possible clinical outcomes. That view

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has been recognised by the Department of Health in the designation of the five current academic health science centres in our country.

A number of other initiatives are moving forward at the same time as this Bill and are considering a broader role for academic health service partnerships. These include the ongoing review, conducted under the auspices of the chief executive of the National Health Service, which is looking at innovation in the NHS and how that might best be promoted as we move forward. It is possible that that innovation review could propose a broadening of the current five academic health science centres to a larger number of academic health partnerships that would have responsibility for the promotion of innovation, and would ensure that the results of research and other innovative ways of delivering care are more broadly and rapidly disseminated across the NHS. That dissemination of best practice and innovation could also be used to create an environment in which to stimulate economic growth. That is an important additional opportunity that the NHS and academic medicine have for our country.

There is also the detailed discussion that has taken place in Committee, outside the Chamber, and in the work of the NHS Future Forum with regard to future arrangements for education and training. In those discussions, there is a recognition that academic health partnerships should play an important role, not only in the configuration of Health Education England but in local arrangements, potentially with academic health science partnerships playing an important role in defining the structure and core of local education and training boards.

Therefore, at least two initiatives, in addition to the mechanisms and structures proposed in the Bill, will turn to partnerships between the NHS, academic institutions and other academic elements in the delivery of healthcare in our country. The purpose of my amendment is probing in order to try to understand what view Her Majesty's Government take of the potential future role of academic health partnerships and what relationship the Government foresee with regard to clinical commissioning groups working at a more local level with potential academic bodies and partnerships in their vicinity. This is particularly important because we heard today in Committee about the vital importance of clinical commissioning groups being appropriately informed. One of the important roles that academic health partnerships may play in the future is providing that kind of information to better inform the decisions that local clinical commissioning groups take. With the vast amount of evidence that academic health partnerships will have in their structures, bearing in mind that these partnerships are broad and include not only academic institutions but a variety of different service providers brought together with a common purpose, it would be peculiar if clinical commissioning groups did not at least make themselves informed of their information and expertise. It would also be peculiar if, in creating a framework and structure for education and training based around a partnership between academic elements and service and provider elements at local level in local education and training boards, clinical commissioning groups did not avail themselves of the opportunities from that.



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Previously in Committee, I proposed to the Minister that clinical senates may be constituted around these broad partnerships of academic health service alliances. There was some concern that this might represent a conflict of interest. However, the very broad nature of these partnerships, with multiples of potential providers as seen in the current five academic health science systems, potentially overcomes the risk of conflict of interest. They provide a natural structure and environment to serve the function of clinical senates, to serve the function of the core of local education and training boards, to provide a useful source of information to clinical commissioning groups with regard to understanding the best pathways of care available in their regions and to promote clinical outcomes, patient safety and patient experience. They also provide a very important basis to serve the objectives of the current innovation review to promote not only best practice but the benefits of economic growth associated with innovation and implementation with regard to healthcare.

I would like to ask the Minister about Her Majesty's Government's view of the future role of academic health partnerships, with specific reference to clinical commissioning groups, to understand whether there is an intention that the current five academic health science centres are more broadly expanded into health academic health partnerships. If they are, how will arrangements be made in future to ensure that clinical commissioning groups avail themselves of the great expertise and knowledge that will be available in such partnerships?

6.15 pm

Baroness Pitkeathley: My Lords, I agree with my noble friend Lord Harris that this is an extremely important group of amendments. I rise very briefly to support those emphasising the significance of patient involvement and, in particular, Amendment 191 in the names of the noble Lords, Lord Patel and Lord Warner, which changes "promote" to "pay regard to".

There is no doubt that we have made progress in recent years in addressing patient interest and hearing the voice of patients and carers, and we should acknowledge that. We still have a long way to go, however. When you work with groups of patients and carers, or with individuals, you always get the same reaction. They say something like, "I feel consulted out. I have been to every meeting, I've talked to every clinician, I've given my opinion endlessly, I sometimes think they add the words 'patient' and 'carer' to every paragraph of every document that comes out of any commissioner, but what I do not know is what happens as a result of my involvement". This is what we must bear in mind. Changing the wording in that amendment would strengthen the ability of the patient, the user and the carer to ensure that something happens as a result of their involvement. That is what we must concentrate on. We should never forget that the involvement of patients is not a tick-box exercise; it is there to ensure we shape services around the needs of patients, not the convenience of commissioners.

Baroness Murphy: My Lords, I rise to add a number of comments to one or two of these amendments. I have my name on Amendment 196, also in the name

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of the noble Lord, Lord Patel, which is about making choices real for patients. My experience is exactly the same as his-that patients have actually benefited very little from the wide range of choices they could have if they understood the information about accessibility, about the sort of provider, about the range of other services that that provider might have and about the performance of that provider. If you are skilled you can use information available on the internet now to find details on the various providers you have been offered under the "Choose and Book" system used by general practitioners. However, the vast majority of patients simply do not have the skill to negotiate the choices. Making that choice a reality is therefore vital.

I also support the amendments proposing that patients, wherever possible, should carry their own records. To cheer up my noble friend Lord Patel, I say that he will be reassured to know that most maternity units now do have the patient carrying their own records, and that has proved to be of great benefit because they hang on to them when the NHS loses them. It has worked very well in maternity services and I certainly support it. There should be more of that in mental health services, where there has been too much holding on to information-not always accurate information-in patients' records. It would be much better if the patient held on to those data and was able to carry a great deal of the data with them. Of course, it would be much better if people had access to information on simple records but they do not because we do not have electronic patient records in every place. The more information the patient can carry with them, the better it is for those who are going to encounter them in the future; it is also better for the patient to have accurate data about their condition.

I come now to the question of whom the clinical commissioning groups should consult in the way of secondary providers when commissioning care. I do not support the amendment of the noble Baroness, Lady Finlay, which suggests that the specialist on the clinical commissioning group should be local rather than a person from another area. No doubt when you have too much conflict of interest, specialists on a clinical commissioning board, and a PCT which engages with the local providers and takes account of their desires, local institutions become favoured. We have seen that many times. It is simply the institution the provider belongs to. That is when you are making a decision, so it is very important that the decisions should be made by somebody who can input and hold in their heads all the necessary secondary specialist information. The decision should nevertheless not be made by a local person with an interest in secondary care.

However, when it comes to gathering local information, local institutions and specialists in those institutions should be consulted about what is possible in the area, what has been done before and what could be thought about in the future. That is where primary care trusts in some parts of the country so often, unfortunately, have not appreciated what they could benefit from locally in terms of academic health partnerships and how they could use their academic health science groups to assist them with the commissioning function. They need to take account of what is available locally,

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and need to understand and get help and consult with local academic institutions and providers, but when the decision is made it should be made by individuals who do not have a conflict of interest locally.

Lord Marks of Henley-on-Thames: My Lords, I shall speak briefly to Amendments 193 and 197, amendments to proposed new Sections 14T, on promotion of involvement of each patient, and 14U on the duty as to patient choice.

The Bill and our debates on it have been characterised by a recognition of the importance of patient involvement and patient choice, and a great deal has been said about those two things in this debate. It is important that we recognise and welcome the new Sections 14T and 14U to the NHS Act, which will enshrine those in statute, but it is also important to note that this is not an entirely new idea. In many areas of medical care, patient choice has been with us for some time. Patients currently have a choice of GP practice; they have a choice of hospital; they have a choice of the GP whom they wish to see within a practice; and they have a right to be informed.

However, there is in practice all too often a gap between the theory and reality. The reality is that although people may theoretically have the choice, they do not know that they have the choice. They do not know despite the excellent section on choice on the NHS website and the literature that is put out about choice at the national level. The amendments are designed to impose on clinical commissioning groups at the local level the duty to take steps to inform patients about their right to be involved and their right to make choices. They state, in certain terms, that each group,

and, in the other cases,

They are simple amendments, and it may be a matter of regret that they are necessary, but simply having the right in the statute book will not do unless we can also ensure that patients are informed of those rights.

Lord Walton of Detchant: My Lords, I rise briefly to support the principle underlying Amendment 198, so ably proposed by my noble friend Lord Kakkar, relating to the crucial importance of making clear that there must be a relationship between the NHS Commissioning Board, local commissioning groups and academic health partnerships. In using that term, I want to be quite clear in what I mean. I am not referring simply to the five academic health science partnerships which have been created within the past few years specifically in certain areas of the country by the NHS; I am talking about the crucial importance of being involved with everyone who is concerned with the teaching of medical students and the training of young doctors and other healthcare professionals.

There is no doubt that years ago, when the health service began, there was an article of faith to the effect that professors, lecturers and readers in the medical schools and universities employed by the universities, those that had clinical contracts, had a duty to spend

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half of their time on service to patients. In other words, they had honorary clinical contracts, they saw patients and they carried on in that capacity giving services to the NHS, in return for which there was also an article of faith that consultants employed by the National Health Service in teaching hospitals had a duty to involve themselves in the training of medical students and the supervision and training of young doctors who were being prepared for work in a variety of different professions.

There has been a total transformation of the scene over the course of the past 20 or 30 years, because academic appointments are no longer restricted to a small group of hospitals, which used to be called the teaching hospitals. They also take place and are based, in many instances, in other hospitals, sometimes in old regional hospitals at a distance. In those hospitals, not only do we have academic people employed by the university involved with teaching, but many of those hospitals are now called university hospitals. It is a recognition of the fact that medical students now are trained across a huge number of hospitals in what were the regions. Many of them spend considerable periods away from the centre around the medical school. Therefore, a crucial relationship must arise between the academic doctors working in those other hospitals outside the main centre and the commissioning groups.

We must also not forget the crucial importance to the NHS, as we heard a few days ago in discussion of the amendments of the noble Lord, Lord Willis, relating to research, of not only the academic departments but also the consultants working in general hospitals and others who have significant responsibility for being involved in clinical research. As I said when we discussed those amendments, today's discovery in basic medical science brings tomorrow's practical development in patient care. In particular, these academic relationships are crucial when one begins to consider the importance of clinical trials of new procedures, new drugs, and so on, which may be carried out across not only a wide range of hospitals but in the community. A great deal of teaching is now going on in general practices, which makes the relationship between academic doctors in academic centres and commissioning groups even more important. I therefore support the principle and the purpose underlying Amendment 198.

Lord Neill of Bladen: I make one comment on the amendments, which also goes to the Government's fundamental philosophy, with which we all agree, that patients should be told about their condition and kept fully informed. My experience in recent years has been visiting hospitals and wards with elderly people in them. You cannot but become aware of the inability of a lot of the patients to understand what it is they are being told or to look after their own notes. There is a danger, if we are not careful, of theory and reality moving apart from each other. There has to be a true awareness of the need to get the relevant knowledge to the right person. Sometimes, it will not be the patient; it will be the patient's spouse, daughter, son or whatever. We should keep that in mind.

Baroness Masham of Ilton: My Lords, I add my support to the patient involvement amendments and the HealthWatch amendments. Whose life is it anyway

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if it is not the patients?' Patients can now be very much at risk, if they are not involved with doctors, through drugs available through the internet which are counterfeit medicine. I was at a meeting this afternoon and heard from a Minister that the Government had asked China for help, because it is a problem place, and the Chinese are now going to introduce the death penalty for people selling counterfeit medicine on the internet. That is a serious problem. Patients need to be involved; they need to have a voice; and they need to work together with everybody else concerned. Otherwise, they will feel left out and shunned, and that would not be a good thing.

6.30 pm

Baroness Wheeler: My Lords, I am pleased to support the spirit, intention and thrust of all the amendments in this very large and, I hope, uncontroversial group, which are intended to ensure that provisions in the Bill to involve the public, patients, carers and specialist professionals and patient groups in the development and decisions about services, care and treatment are reinforced and strengthened. We recognise that the duties proposed by the Government for the NHS Commissioning Board and clinical commissioning groups-to promote the involvement of each patient and to enable patients to make choices on the services provided to them and obtain advice from specialist professionals-are a significant step forward from the original provisions in the Bill. They build on the foundation work on this issue undertaken by my own Government. However, it is clear from this excellent debate that these general duties do not go far enough to mark the significant step change that we need in getting genuine shared decision-making and participation of patients, carers, and patient groups in decisions about care and treatment, and on how services are planned and developed.

We also now have the added complexity of the reorganisation itself. Senates, networks and health and well-being boards are acting as the system integrators, all alongside our newly enlarged CCGs with their giant private sector support organisations behind them, as we now know from the Government's recently issued draft guidance on commissioning which was referred to in the previous debate by the noble Baroness, Lady Williams. This will be a highly complex raft of interactions and interconnections with no notable route to accountability. I would be grateful if the Minister could give me some insight into how he envisages the voice of patients being heard among all the clamour and shouting that will go on between these different spheres of interest.

We must try to achieve real involvement. For individuals, that means involvement in care planning and support for patients with their carers, relatives and support groups to manage their conditions and share in the choice of treatment. On collective involvement, this means that knowledgeable patients' groups should be able to advise commissioners on how to design services, rather than to have token consultation after decisions have already been made, which is the case now in so many situations. We must make sure that we harness fully the collective experience and knowledge of patients and specialist care organisations.



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We recognise that this will involve a major cultural change in the behaviours, approaches and attitudes of key professionals from across the specialisms, moving away from seeing patients as units of disease, not as people with rights to information and to participation in discussions and decisions about their care and treatment, as the Health Foundation puts it. We need to change the way that patients and clinicians, in particular, relate to each other, and change the way that the NHS relates to patients in terms of, for example, information provision and the organisation of clinics, and in the style of consultations that professionals have with patients.

In respect of the NHS Commissioning Board, we support Amendment 121, which calls for the board to have the duty to secure rather than promote the involvement of patients, carers and their representatives in decisions about the provision of health services. This is important, and Amendment 150C-which seeks to ensure that the board's annual report includes accounting for how it has carried out its duties in involvement, choice and advice-complements and underlines the importance of this duty.

Amendments 125 and 126, tabled by my noble friends Lord Warner, Lady Thornton, and Lord Patel, turn the focus on clinical commissioning groups and call for a published guidance to CCGs to ensure that they are clear about what is required of them to meet the duty to promote the involvement of each patient. I also pay tribute to the work of National Voices on the principles of integrated care and on other patient and involvement issues relating to these matters.

We know that many commissioners, both nationally and in CCGs, are unaware of the increasing evidence that involving individual patients in their care and treatment is proven to be more clinically effective, provides better patient experience and makes much better use of healthcare resources. In other words, it is the vital underpinning for the Nicholson challenge and for commissioners' other duties to improve quality. A far stronger signal is needed in the Bill and in statutory guidance to draw commissioners' attention to the proven interventions that they require from their providers. I would be grateful to hear from the Minister how he intends to do this.

Clearly, many CCGs will not make the changes that we need without help and support. Amendment 125 is therefore crucial, as it calls on the NHS Commissioning Board to draw up guidance to CCGs which will enable patients, carers and their representatives to make informed decisions. This includes patients having the means to express their views on the quality of services provided, opportunities to consult with service providers, access to appropriate information about their care and treatment, opportunities to consider available treatment options and their risks and benefits, and to participate in decisions about their care and treatment and its managers. The information they receive about these areas must be simple and well presented-not league tables or comparison charts, but clear information about treatment options, how effective they are and what the consequences might be for the patient. As other amendments underline, these rights of patients must be accessible to all patients.



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Amendment 126 stresses how important it is to have information on access and location and about the providers of health services and performance if informed decision-making is to become a reality for the majority of patients. We fully support Amendments 127A and 197A, which would give expert patients' organisations equal status to professionals in providing advice to commissioners. This would help ensure a patient voice in the clinical senates and networks. It is an approach that was supported by the clinical work stream of the Future Forum but overlooked in the Government's response. We also strongly support Amendments 175A and 175B from the noble Baroness, Lady Finlay, which calls for regulations providing for the governing bodies of CCGs to include individuals who are fully aware of the different aspects of specialist provision in the areas covered by CCGs.

Amendments 140 and 142, tabled by my noble friends Lady Thornton and Lord Hunt, require the Commissioning Board to ensure that patients are involved and consulted in the development and planning of commissioning and in the consideration of how proposals for change in health services are organised and delivered. Most importantly, Amendment 205 secures the involvement of the local healthwatch in these decisions, vital if HealthWatch is to be able to fulfil its key watchdog and patients role. The importance of this role was ably underlined by my noble friend Lord Harris, so I will not expand further on it.

On patient choice, we support Amendment 127, which proposes a definition of patient choice. Research shows that patients care most about being able to exercise choice about the care and treatment they receive, but currently the NHS performs poorly in involving patients in this way. A full definition of patient choice should be included in the Bill to ensure that commissioners provide opportunities for patients to exercise choices that go beyond the choice of provider. Does the Minister accept the need for this definition in the Bill, and if not, how will he seek to achieve the cultural change in systems and attitudes that we all want to see?

All these amendments seek to ensure that the NHS Commissioning Board and CCGs understand fully their responsibility, and that they commission for involvement. These changes would give a clear signal to the system that the Government mean business in wanting meaningful patient participation and involvement, and that real change can be achieved.

Earl Howe: My Lords, this large group of amendments all relate to the different ways in which patients, the public and others will be involved in decision-making, and although I shall be suggesting that noble Lords should not press them, I am very much in listening mode on the themes that they raise. The only thing that I cannot promise to take forward is the suggestion of the noble Baroness, Lady Masham, that I should introduce an amendment on the death penalty, but, no doubt, she can persuade me.

The issues that noble Lords have covered are central to our vision of informed and empowered patients, and responsive commissioning that is clinically led.

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These are also issues that were considered in great depth as part of the listening exercise, in response to which significant improvements were made. Those improvements created much stronger duties than currently apply to primary care trusts, so it is important to begin by recognising how this Bill takes us forward from the current position. Nevertheless, I recognise that some confusion remains about what we mean when we talk about involvement, and what the different duties in the Bill are intended to achieve. The noble Lord, Lord Warner, has tried to frame an all-embracing definition of involvement through Amendment 125, and I find little to criticise as regards the purpose and intent of that amendment. However, I would argue that much of what the noble Lord intends through this amendment is already provided for in the Bill. Indeed, it is because there can be different elements to involvement that would be appropriate in different situations that I would be cautious about trying to wrap them up in a single definition.

It will be helpful to begin by considering the duties on the board and clinical commissioning groups to involve patients in decisions about their own healthcare. The noble Lord, Lord Harris, made some useful distinctions on this point. These new duties reflect our vision of shared decision-making, referred to by the noble Baroness, Lady Finlay-"no decision about me without me", and an NHS where patients are involved fully in decisions about their care in partnership with clinicians. This is primarily about the relationship between the individual patient and their clinician; it does not extend to commissioning decisions. Therefore, I do not think that it would be appropriate for HealthWatch or indeed any other body to have a role in what are meant to be sometimes very personal decisions.

There is clearly a role for CCGs as commissioners, as distinct from the role of general practitioners, in supporting and encouraging this personal involvement. However, it is not completely within their control, so I do not think that it can be for them to secure, as the amendment proposes. Nor do I think that there should be any sort of hierarchy, where the board is in the lead with a weaker duty on CCGs. That would run counter to what we are trying to achieve, which is after all a more personalised service. Therefore, I am afraid that I cannot agree with Amendments 121, 123, 124A, 191 and 192. However, such a service might include giving patients greater control over their medical records, as Amendment 124 suggests. The noble Lord, Lord Patel, may know that this was a key theme of our consultation on an information revolution. Responses to that consultation showed a clear desire to enable people to be more in control of their care, supported by greater access to the information held about them in their care records. We are committed to this and our forthcoming information strategy will set out how we propose to achieve it.

These duties are of course closely linked to those relating to enabling choice. As noble Lords will be aware, patient entitlements to choice are set out in the NHS constitution. These are underpinned by directions by the Secretary of State, which will in future be the standing rules and regulations under Clause 17 which we have already discussed.



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I reassure noble Lords that, as now, the role for commissioning bodies in respect of enabling choice in the future will include acting with a view to making people aware of their rights and entitlements, giving them the information that they need to make informed decisions and working with providers to ensure that these are delivered. I did, however, listen with considerable care and sympathy to the noble Lord, Lord Neill, regarding patients who need advocates to speak on their behalf. This will be further reinforced by the new duty that the board and clinical commissioning groups will be under in relation to promoting the NHS constitution among both patients and staff. The board will set the choice offer, establishing the parameters for choice and competition, based on the choice mandate that the Secretary of State will set as part of the annual mandate to the board. I remind the Committee that we recently sought views on these issues through the consultation, Liberating the NHS: Greater Choice and Control. This is an important approach because it allows the Secretary of State and the board to manage the rollout of choice in a controlled way-something that I know many noble Lords are anxious to ensure. That is why we have deliberately used broad terms in describing the types of choice that patients can exercise. Indeed, I think that defining them in more detail, as some of the amendments attempt to do, could paradoxically limit their scope. They could also be unsuitable or indeed unfeasible in particular circumstances, and that is why, although I am in sympathy with the spirit behind them, I am unable to agree with Amendments 126, 127, 193, 196, 197 or 197ZA.

Greater choice means, among other things, patients being able to choose between a greater range of providers. Amendments 125A, 125B, 195A and 195B are particularly concerned with the impact that greater choice and provider plurality might have on the viability of existing services-a matter that we discussed at our last session in relation to amendments tabled by noble Lords opposite about the interdependency of services. That is an issue that I completely understand. In securing healthcare services to meet the needs of their patients and populations, commissioners must have regard to the stability and financial viability of those services, including taking account of the interlinkages between services, where relevant, on an ongoing basis. Commissioners will need to commission high-quality integrated care that will deliver value for money for local communities and promote opportunities for patients to exercise choices in relation to their care. In taking commissioning decisions, they will have to consider what the noble Baroness, Lady Pitkeathley, reminded us of-that is, what will be in the best interests of their patients. This would always be their primary concern, and we would expect the board to ensure sufficient competency over these issues in authorising CCGs to take on their new responsibilities and in holding them to account for doing the job.

6.45 pm

Monitor would need to support commissioners in carrying out their duties by promoting economy, efficiency and effectiveness in the provision of services while maintaining or improving quality. That would include setting prices that deliver sufficient reimbursement for

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the efficient costs of providing the services specified by the board. It would also mean supporting commissioners in securing sustainable, continued access to services where communities were dependent on one or very few providers. However, above all, our focus and that of commissioners should be on securing the best possible outcomes for patients, and I do not think that protecting the interests of individual providers should come above that priority. I hope that the noble Baroness, Lady Finlay, will therefore understand why I cannot accept Amendments 125A, 125B, 195A and 195B.

The board and clinical commissioning groups will also be under duties to make arrangements to secure the involvement of people in decisions about service provision in their area, just as primary care trusts and strategic health authorities are now. The very purpose of these duties is to ensure that commissioning decisions are informed by, and responsive to, the views of local people, as indeed Amendment 207 seeks to ensure. They will apply to anyone who is already using services or who may do so in the future, and in that sense they are all-encompassing. Therefore, there is no need to specify that this includes carers or representatives, as Amendments 141B and 206B propose. Nor is there any need, as Amendment 205 suggests, for an additional role for local healthwatch, whose role on health and well-being boards and in providing recommendations to commissioners we have already considered. In my view, it is right that the duty should apply specifically to changes to services that affect patients, rather than applying to every aspect of the board's work, as Amendment 142 would require.

I also believe that it is important to allow these bodies some leeway to exercise their judgment in how they fulfil these duties. Consultation will not be appropriate in every case. However one defines it, there will always be a need to determine what is or is not appropriate in a specific instance. Where information is provided, it should certainly be made available in accessible forms, where necessary, and the board would be required to consider this under Section 149 of the Equality Act 2010. Therefore, I am afraid that I cannot agree with Amendments 140, 141, 141A and 141AA or 206, 206A and 206AA.

I appreciate that the intention behind many of these amendments is to prevent the board and CCGs undertaking, so to speak, cosmetic exercises in public involvement without really engaging with people or taking account of their views. However, the Bill as it stands includes a number of safeguards to prevent this-in particular, the fact that CCGs must set out the principles that they will adopt in exercising this duty as part of their constitution, and the requirement that the board's and clinical commissioning groups' commissioning plans and annual reports, as well as annual assessments of CCGs, must all include particular consideration of this duty. I also appreciate the concern to ensure that the board and CCGs-

Lord Warner: I am sorry to interrupt the noble Earl's flow but I have been extremely restrained today. Can he clarify for me the point that he has just made concerning clinical commissioning groups' constitutions? As I understand it-he can correct me if I am wrong-

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they have a considerable amount of freedom on how they frame the obligations in those constitutions. Is the Minister saying that there would be some requirements on them centrally from the board to cover areas such as patient involvement and patient choice?

Earl Howe: I am. The intention is that no clinical commissioning group will be authorised in the first instance unless it can demonstrate to the board that it can fulfil the legal duties that the Bill places on it. That is key to our thinking. Indeed, as time goes on, it will be under a continuous duty to show it is abiding by those duties. In the first instance, it is very important that clinical commissioning groups demonstrate they are fit for purpose in that sense.

I also appreciate the concern to ensure that the board and CCGs benefit from as wide a range of advice as possible. The Government have been clear that everyone with a role to play in securing the best possible services for local people should be able to do so. The definition used in the duties to obtain advice is that used to define the comprehensive health service. It would encompass the areas covered by Amendment 127C. Indeed, I do not think it would be possible to cast it in broader terms. These duties will apply to every function the board or a clinical commissioning group will exercise. Again, within those broad parameters it is important to retain some discretion for the board and CCGs to determine how best to exercise this duty.

The board and CCGs will certainly have to work closely and effectively with all the providers with which they contract as Amendments 127B and 197B suggest. I would say to my noble friend Lord Clement-Jones that that most certainly would include pharmacists. I also agree as to the expertise and the unique perspective that patients and their representative bodies can bring not just to the commissioning process but also to the way the board and clinical commissioning groups approach many of their functions. The same would apply to many other groups, including academic institutions, as the noble Lords, Lord Kakkar and Lord Walton, have highlighted.

The noble Lord, Lord Kakkar, spoke powerfully in favour of academic health partnerships. Academic health science centres have been successful at developing these partnerships within their local areas but understandably have been less successful in spreading innovation across the NHS. As the noble Lord set out, the NHS chief executive's innovation review is due to be published next month. That will set out how we can accelerate the adoption and diffusion of innovations across the NHS. It will include a mix of bottom-up, horizontal and top-down incentives and pressures that will drive adoption and diffusion of innovation and behaviour change. The role of academic health partnerships may or may not feature in this review. I hope the noble Lord will forgive me if I do not at this stage anticipate or pre-empt what the report will say by elaborating any further. However, I counsel noble Lords to play close attention to what the noble Lord said in his speech.

While these duties refer to obtaining advice from people with expertise in relation to the health service,

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that is not confined to clinical expertise. Indeed, in fulfilling these duties we envisage a role for clinical senates, as we have already discussed, in providing not just clinical advice but multidisciplinary advice from professionals in health, public health and social care backgrounds alongside patient and public representation and other groups as appropriate.

I am sure we all share a desire that these duties are effective. However, I am not convinced that imposing specific duties as to where the advice should come from, including through the membership of governing bodies, or how the advice should be acted on is the right way to proceed. If we become too prescriptive we risk overburdening CCGs with so many duties and obligations that they could never be sure whether they were doing enough and in reality we must trust them to build these relationships themselves and judge them on the outcomes they achieve.

The noble Baroness, Lady Finlay, asked me about the secondary-care doctor role on CCGs and whether it had to be somebody from outside the area or retired or whether it could be a local person. We are looking carefully at that question. The secondary-care doctors on CCG governing bodies will not be able to have a conflict of interest in the decision-making process of the CCGs. That is where the noble Baroness, Lady Murphy, was absolutely correct. We will use regulations to set out more detail about this and we will work with stakeholders, including pathfinders, to develop these proposals. The noble Baroness referred to the secondary-care doctor coming from either outside the CCG area or being retired. Those are two ways in which a conflict of interest could be avoided but they are only examples and do not represent an exhaustive list.

I want to finish by returning to a point raised earlier by the noble Lord, Lord Warner. We too are aware of the very good work of National Voices, as well as a range of other organisations, on how patient and public involvement could be strengthened in the Bill. While I have explained why I think these specific amendments are not necessary, I am happy to go on listening. I feel that the Bill is already strong in this area but we are always open to new ideas and I look forward to further discussions on this general topic. It is for those reasons that, while sympathetic to the intention behind the amendments, I am unable to accept them and I hope noble Lords will agree not to press them.

Lord Patel: My Lords, on behalf of all noble Lords who took part in the debate I thank the Minister for his comments. He excited us all by first saying that the only thing he would not be able to accept would be the death penalty. He finished by saying he could not accept most of what we were saying, partly because it was already in the Bill, which most of us did not think was the case. He demonstrates a commitment that patients' voices and public involvement will be paramount and that all the commissioning boards and commissioners will be expected to demonstrate that they listen to the voices of patients and the public. We will watch and see how they are made accountable.

The Minister referred to innovation. Of course, the next group of amendments focuses on innovation, so we may come back to it and also the involvement of the academic health centres. We have had a good

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debate and maybe after reading Hansard some of us can decide whether we will come back to some of these issues. In the mean time, reluctantly, I beg leave to withdraw the amendment.

Amendment 121 withdrawn.

Amendments 122 and 123 not moved.

Amendment 124

Tabled by Lord Warner

124: Clause 20, page 18, line 11, at end insert "including access to or holding of their own medical records"

Lord Warner: My Lords, I listened very carefully to the Minister's response to my amendment on patients' access to or holding of their medical records. As I understood what he was saying, it was that we could eagerly look forward to the Government's long-awaited information strategy which might well be moving this agenda forward. If that is indeed the case I hope we can consider further with the noble Earl and his officials whether we should enshrine that moving forward in the Bill so patients have a clear statutory right to have access to and to hold their medical records. I will not move the amendment.

Amendment 124 not moved.

Amendment 124A not moved.

Amendment 125

Tabled by Lord Warner

125: Clause 20, page 18, line 11, at end insert-

"( ) In discharging this duty, the Board must publish guidance for clinical commission groups that ensures that patients and their carers and representatives have-

(a) the means to express their views on the quality of services provided,

(b) opportunities to consult with service providers through a variety of means,

(c) access to appropriate information about their care and treatment,

(d) opportunities to consider available treatment options and their risks and benefits,

(e) the opportunity to participate in decisions about their care and treatment and its management, and

(f) the means to ensure informed consent is given to care and treatment."

Lord Warner: My Lords, I am glad to note that the noble Earl is willing to reflect on this and perhaps discuss it further with us. I would very much like to talk to him with National Voices to see whether we can craft some wording which meets people's concerns in this area. I will not move the amendment.

Amendment 125 not moved.

Amendments 125A and 125B not moved.

Amendment 126

Tabled by Lord Warner

126: Clause 20, page 18, line 14, leave out from second "to" to end of line 15 and insert "the access, location and provider of the health services available to them at all stages of their life, including information about the performance of different service providers"



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Lord Warner: My Lords, this is an important issue about choice. We need more beef in the Bill about what it means. We have not gone as far as we need to go. In the mean time, I will not move the amendment.

Amendment 126 not moved.

Amendments 127 to 128 not moved.

7 pm

Amendment 128A

Moved by Baroness Thornton

128A: Clause 20, page 18, line 24, after "provision" insert "and commissioning"

Baroness Thornton: My Lords, we move on now to discuss innovation and research. The amendments in this group are very important and were prefigured to an extent by the discussion we have just had. The amendment tabled by the noble Lord, Lord Hunt, and me, is modest in some ways. However, it strengthens the promotion of innovation in the provision and commissioning of health services. Taken together with the amendments tabled by my noble friend Lord Warner and the noble Lord, Lord Patel, it strengthens the Bill significantly and in a very important way.

We have come to what seems an intractable problem: how to encourage innovation in the NHS. This is part of the Minister's area of responsibility and was also part of the area of responsibility of my noble friend Lord Warner when he was a Minister. I look forward to both of their contributions on this matter.

We know that often, the taking up of great innovation is a painfully slow, complex and bureaucratic process. Our amendment strengthens the promotion of innovation through commissioning as well as through the provision of health services. I would like the Minister to explain why that should not be possible-because it would strengthen and help innovation-and also how it could be done, because we are looking for incentives to promote and spread innovation throughout the NHS.

Last week, the noble Lords, Lord Willis and Lord Ribeiro, and I, with others, enjoyed a dinner and an evening with organisations and businesses to discuss how to ensure that innovation is disseminated, promoted, supported and invested in throughout the NHS so that both the NHS and UK plc benefit. The point was made during the evening that often we do not talk about sophisticated issues but about simple changes to nursing practice, such as the way dressings are done, or to information management, that nevertheless can have an important impact on patient care and progress.

I will not speak further on the amendments because I will be very interested to hear what other noble Lords speaking to their amendments in the group will say. I hope that the Minister, with his passion in this area, will give us some comfort on the matter. I beg to move.

Lord Warner: My Lords, I will speak in support of Amendments 129 and 129A in the group. First, I will take up the point made by my noble friend Lady Thornton about the long-standing problem of the slowness of the NHS to take up innovative ideas, and the frustration often felt by people in this country who have invented new approaches and created new

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innovations, only to find that they have had to go abroad to get them projected, promoted and sold, with the NHS being one of the last to take up the innovation, which was often funded in one form or another with public money by the British taxpayer. It is a long-standing problem and not a party-political issue; it has been a challenge for successive Governments. One of the most embarrassing moments one has as a Minister is when one meets foreign delegations or travels abroad to back Britain and is asked, "Has this innovation been taken up in the NHS?", whereupon one has to shuffle one's feet and think of a suitably weaselly form of words to avoid answering the question directly. It is a very long-standing and difficult issue.

Amendment 129 draws attention to the importance of the procurement of goods and services in the promotion of innovation, and to the duty that that places on the national Commissioning Board. There are many reports about the importance of public procurement in advancing innovation and in ensuring the take-up of UK inventions and innovative practices. The latest one was by the Science and Technology Committee of your Lordships' House, of which I was a member. The report brought out some of the dilemmas around using procurement to take forward innovation. Yet again it cast doubt on central government's use of their purchasing power and muscle to drive the take-up of UK innovations in public services.

The NHS is not alone in having this problem, but it is part of the problem and it is a big part of the public sector. A major and long-standing problem is that too many purchasing decisions are taken too far down the organisational food chain, with too little intervention at senior level and too little willingness to use large-scale purchasing to spread the use of innovative approaches. Whatever else the national Commissioning Board has, it has a lot of financial muscle. It must use that, through the NHS's purchasing capacity, to drive innovation, which often comes from publicly funded research. I hope that the Minister, who is well aware of the issue, will see the sense in putting something like Amendment 129 in the Bill. We cannot say too often that public procurement is a way of helping to establish and drive innovation in the NHS.

Amendment 129A seeks to add the idea of an innovation fund to the board's armoury on innovation in new Section 13K. There is nothing novel in this. The amendment continues and builds on the proposals of my noble friend Lord Darzi, which led to regional innovation funds that strategic health authorities currently manage. Again, we need to strengthen the mechanisms in the Bill for driving innovation in an NHS that historically has been slow to take up innovations and apply them to scale for the benefit of patients. We are not talking about huge sums of money in the innovation fund, but relatively modest amounts in relation to the scale of NHS expenditure. However, an amendment of this kind would ensure the continuance of the useful work that has been started by the strategic health authorities following the promptings of my noble friend Lord Darzi.

It is typical of what we sometimes do in this country. We start an initiative with a fund at strategic health authority level and then shuffle the cards so that

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somehow, along the way, some of the initiatives and their benefits get lost. I hope that we can get some reassurance from the Minister that some kind of innovation fund will be available so that we can continue the work that my noble friend Lord Darzi so ably started to ensure that patients can secure the benefits of UK innovations.

Lord Patel: My Lords, I support the amendments tabled by the noble Lord, Lord Warner, to which I have added my name.

First, I will speak very briefly about innovation and procurement. I also contributed to the report by the Science and Technology Committee on procurement. The public sector could learn a lot from the private sector about using procurement to drive innovation. Perhaps the Minister can comment on this. The NHS is a huge organisation that uses about £20 billion-worth of procurement a year and if that was done in a co-ordinated way, it could drive an immense amount of innovation within the NHS.

My second point is about how to drive innovation into clinical care. There are lots of examples I could give, but I will give one from my own specialty. It took us 20 years to take the learning from research into the kind of treatment to be given to the mother in premature labour that would considerably reduce the incidence of respiratory distress syndrome, which causes a lot of harm and death in neonates, and embed that into practice. There are lots of examples of such innovations not being embedded into the NHS and we need to look at ways of doing that faster.

My third point is how to use tariffs to drive innovation. If I as a provider will not be given a higher tariff if I drive innovation or innovate a different way of providing the service, and all that will happen is that the tariff for procuring my services as a provider will be less the following year, there is less incentive for me to use innovation in clinical care to improve patient care and also to make it cheaper.

The fourth issue is about an innovation fund, which I support. Together with the Wellcome Trust, the Government have an innovation challenge fund that asks for tenders in particular areas of innovation. The one I know about is in reducing infection rates. Innovation funds of this kind will drive further innovation; for example, in the United States Medicaid and Medicare have a joint innovation fund to drive improvements in healthcare. So I support that amendment.

Baroness Finlay of Llandaff: My Lords, I rise to speak briefly to Amendment 129ZA, which is really a probing amendment. I hope that the Minister will be able to explain what these "prizes" are that are referred to in the Bill. The Explanatory Notes do not really help. They talk about the Bill providing for,

and that:

"Innovation will originate primarily from the actions of commissioners and providers but it is intended that the NHS Commissioning Board will take a lead role in promoting it".

The changes should bring about continuous improvement and innovation often happens outside the main NHS.

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Indeed, in my own discipline, end-of-life care, the innovations have happened by and large in the third sector, particularly in care in the last 48 hours of life. In some ways, this is where these organisations, the different hospices and those working with them, have felt freed up to pilot different ways of doing things which have subsequently been adopted within the NHS.

There is a huge need for more health services research and for good, qualitative methodology. My only anxiety about the word "prizes" being in the Bill is not that I do not want innovation to happen-I desperately want innovation to improve services for patients-but that I want to make sure that innovations are also properly evaluated; that they are piloted, evaluated and audited in the long term. It is terribly easy for people to have great flashes of inspiration and great ideas but they might not necessarily roll out appropriately across all aspects of the health service. Many of us have seen innovations that seem to be excellent in one setting but when they are rolled out without adequate support and training, mistakes are made and problems arise.

I had the privilege of chairing the commission into medical generalism, and our report noted the shortfall in both funding in primary care and in researching ways of delivering primary care to common conditions. We welcomed the National School of Primary Care Research and the recognition that more funding was needed, but we urged the MRC and other funders to create a dedicated funding stream for clinical research in primary care as it is difficult to secure funding. I hope the Minister will explain what these "prizes" are and say that they will in no way detract from the much needed research funding to really evaluate innovations and innovative ideas, particularly in primary care.

7.15 pm

Baroness Morgan of Drefelin: My Lords, I rise to speak to Amendments 130, 131, 147, 150, which are in my name. I have also added my name to Amendments 215 and 218. These are very big groups and the Minister has my sympathy. I am sure he is listening very carefully to all the advice that he is receiving. I would particularly like to add my support to the remarks made about the power of procurement to promote innovation.

I want to speak about research and the research duty. My amendments are designed to add weight to the research duties in the Bill and follow on from the excellent debate on Clause 5 in relation to the Secretary of State's research duty. I thank the Minister for his letter, which he has circulated to those who took part in that debate, although I fear that it may have raised rather more questions than it has answered. I apologise to the noble Earl for that, and I would like to go through a few of them now. I declare an interest as chief executive of a medical research charity, Breast Cancer Campaign.

In the debate on the research duty in Clause 5, many excellent examples of research were highlighted. It might be useful very briefly to reflect again on the impact that research has on the lives of people in this country, and to mention a report on cancer survival rates by Macmillan Cancer Support that had a great impact in the media last week. It highlighted that people now live nearly six times longer after their

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cancer diagnosis than was the case 40 years ago. Many noble Lords will be aware that for nine of the 20 cancers studied by Macmillan, median survival time is three years or less, with little improvement since the 1970s. The report highlighted the achievements that research has made but also that there is an awful lot more work to do.

It is also important to remember that there is a lot of research about quality of life. For instance, median survival time for breast cancer has doubled since the 1970s. Investment in research has played a fundamental role in this and yet more than 12,000 women still die from breast cancer every year. As I said, research is not only about improving survival rates. Many women with advanced breast cancer live with complex support requirements that are frequently not met, as evidenced by the research published recently by Breast Cancer Care and funded by my charity, which raises serious questions about pain control, for example. Ensuring that the NHS is committed to supporting research is absolutely key to addressing long-term improvements in survival but also improvements in quality of life for patients today.

Amendments 130 and 131 are intended to strengthen the research duty that has been placed on the Commissioning Board. Amendment 39, which we talked about a few days ago, removed the phrase "have regard to the need to" from the research duty on the Secretary of State, thereby strengthening it, and Amendment 130 seeks to do the same for the research duty on the Commissioning Board. During the debate on Clause 5, the noble Lord, Lord Willis, explained eloquently why the words "have regard to the need to" in the clause would be better removed ,and how by doing that we would have greater clarity and a better statement of intent would be established. So it would be helpful if the Minister could explain why we need to see those qualifying words in this clause. It would be particularly useful to be given practical examples of the effect that removing the words would have, because I suspect that they are not necessary and that the Bill might be better off without them.

I was also extremely heartened to hear the Minister say that he sympathised with me and with many other noble Lords when we argued that the research duty should be strengthened and that he would undertake a "closer consideration" of the research duty. I would welcome hearing a little more about his thoughts on that today, particularly whether any amendments to Clause 5 could be in the making, and whether they could be read across into Clause 20.

Moving on to Amendment 131, this seeks further clarity on the meaning of,

I do not want to rehearse the arguments made previously in relation to Clause 5 and the wording of this phrase except to request a further explanation of its definition, including practical examples to aid our understanding which I hope the Minister will be able to provide either today or later in writing. In correspondence, the Minister helpfully clarified that public health was covered by the current definition, which was an important point for the noble Lord, Lord Warner, as I recall. However, the intention of Amendment 131 is to seek further

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clarification and a definition of the phrase so that we can understand whether it is sufficiently comprehensive. Public health is one issue that we are very clear about. It is covered, but we need to be confident that the duty is comprehensive in that regard. I believe that a more substantial definition is required and I am pleased to have the opportunity to request this today. For example, with this definition in place, what are the implications for NHS staff who are involved in supporting research? Will there, for example, be sufficient research nurses to support research activity, will clinical training incorporate time for research and how will research successes be recognised and encouraged as part of NHS career progression and structures?

In terms of what we know about the Commissioning Board, what will it be doing with respect to research? The Government have attempted to reassure noble Lords that the Commissioning Board is aware of the need to promote research and indeed that one of the board's most important functions will be to support a culture that promotes research and innovation. I welcome this but I feel that in practice there is still very little detail about how this will happen. It appears that research will not form one of the six key portfolios of the board, but will fall under the commissioning development portfolio. Will this include, as I believe the Minister's letter suggested, the development of commissioning tools and commissioning guidance ensuring that patient care is commissioned so as to support the conduct of research in the NHS? I note with interest that the Government are committed to ensuring that the systems and processes for commissioning used by the NHS Commissioning Board and clinical commissioning groups will ensure that research is promoted, supported and funded by the NHS, including the tariff, commissioning guidance and processes for authorising and supporting the development of clinical commissioning groups. That is important, but I would be grateful if the Minister were able to provide further detail on the activities of the Commissioning Board in relation to research.

Will the development of commissioning tools and guidance as defined be sufficient to embed a culture of research in the NHS? While we have heard that the tariff for patient care will incorporate the costs of patients who are taking part in research projects, how will infrastructure costs be captured? Obviously I am thinking about the cost, for example, of storing tissue for research purposes. I fear that what we have been provided with so far is a number of ad hoc references to research that do not attempt to embed comprehensively a research culture into the NHS or set out a vision of what the research duties would mean in practice.

That brings me to Amendments 147 and 150. Two clear opportunities to ensure that the board is accountable for its actions with respect to the research duty now present themselves in relation to the business plan and the annual plan. I note with interest-and I believe that many others have noticed this-that the board must publish a business plan setting out how it proposes to exercise its functions in that year and in each of the next two following years, and at the end of the year it must also publish an annual report on how it intends to exercise its functions. There is therefore a great

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opportunity here. However, I am puzzled as to why Clause 20 establishes that the business plan and the annual plan must report how the board proposes to discharge its duties only under new Sections 13E and 13P, and likewise explain in the annual report its performance under those sections, which cover the duties on the improvement of quality of services and public involvement in consultation by the board. Again that is very important, but there is no comparative requirement with respect to new Section 13L and the duty on research. Again, there is an opportunity here to improve the feedback loop. I would be grateful if the Minister could explain what plans there might be to bring forward government amendments or to accept the amendments now before the Committee.

Lord Willis of Knaresborough: My Lords, I am delighted to follow the noble Baroness, Lady Morgan, and particularly to support her comments about the duties in respect of research. But perhaps I may also say that the noble Baroness, Lady Thornton, raised a very important issue in her opening remarks, which is the definition of the difference between a duty to provide and a duty to commission. There is a subtle but important difference between the two. Commissioning, as the noble Lord, Lord Warner, clearly stated, is something for which there is a huge budget, so it is very important indeed that it is used effectively. I was particularly interested in Amendment 129A tabled by the noble Lord, Lord Warner. We are all puzzled about the Government's intentions in terms of prizes and incentives to encourage innovation and to bring research out of the labs, if you like, to the bedside.

There are some extremely good examples of this. The noble Lord, Lord Warner, mentioned the work of his noble friend Lord Darzi, particularly the Health Innovation Challenge Fund. I have just finished chairing the fund's three-year review, and it is interesting to note that three years into the five-year programme, new devices, technologies and procedures are being brought forward from research to clinical outcome. Some 13 of these are now up and running, and some are quite remarkable. We have seen the groundbreaking research to deal with the onset of blindness being undertaken at Oxford. Within five years we will have gene therapies that will make a huge difference to patients suffering from a whole range of conditions, including macular degeneration. That will have a massive effect not only on patients' lives, but also on the health service budget itself. It is important work and there are other good examples on which we need to move forward.

I want to speak specifically to Amendments 215 and 218 tabled in my name and those of the noble Baroness, Lady Morgan, and the noble Lords, Lord Patel and Lord Turnberg. I should also declare an interest as chair of the Association of Medical Research Charities. Amendment 215 concerns the role and responsibilities of clinical commissioning groups towards research and includes, within their commissioning plans, how they intend to execute their duty as defined in new Section 14X. That commissioning groups should have a duty to promote research was recommended by Professor Steve Field, the chair of the NHS Future Forum, when he said in his report:



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"Support for research and innovation is also important for evidence-based commissioning and practice, so the report recommends that commissioning consortia should have a duty to promote research and innovation and the use of research evidence in the NHS"-

a recommendation which was immediately taken by the Government, to their credit, and, indeed, was welcomed by the medical research community.

7.30 pm

It is important that that is in new Section 14X as inserted by Clause 22 of the Bill. However, as the Bill stands, there is a duty on commissioning groups to promote research but absolutely no mechanism to make sure that it is actually done. There is a duty without the wherewithal. Amendment 215-it is a simple but effective amendment-does exactly that by making it clear that the CCG commissioning plan should include clear evidence about how commissioning groups propose to carry out their duty to promote research. I cannot believe that the Government cannot accept that very simple amendment to put that into practice. I think it is very helpful.

However, this amendment goes further than that because it seeks clarification from the Minister about "evidence based commissioning" and how a "research aware culture" is to be embedded in the NHS through clinical commissioning groups-the very things that Professor Field recommended and the Government supported from the Future Forum. Clinical commissioning groups will have to report in their commissioning plans how they have sought improvements in quality of services, patient care and, indeed, how they have worked alongside their counterparts in health and well-being boards when developing their plans. Why not include in those plans how research is being used too? It makes good sense to have that as a separate issue. If the clinical commissioning groups' approach to commissioning services is to be informed by evidence, then research is a fundamental part of securing that evidence. Research and patient benefits are two sides of the same coin. By making research part of the commissioning plan for CCGs, Amendment 215 would automatically trigger a requirement for outcomes to be included in the commissioning report. Also in the commissioning report-a matter alluded to the noble Baroness, Lady Morgan-was how the costs for non-commercial clinical research in the NHS were to be met and, specifically, the role that excess treatment costs play in supporting this.

Clearly, the Government decision to confirm the continuation of this funding stream to support, in particular, charitable funders undertaking clinical studies in the NHS is very much welcome. However, there is considerable uncertainty around just what is being proposed by the Government, particularly following the Minister's comments on 5 November. I cannot stress sufficiently just how crucial the medical research charities are to medical research in the NHS. In 2009-10 more than 3,000 clinical studies were conducted using NHS patients. Thirty-seven per cent of them were funded by AMRC charities and, in the case of clinical trials for cancer, 75 per cent of all cancer patients involved in clinical trials were on Cancer Research UK funded trials. Clarifying how costs will be apportioned is hugely important. The Minister has assured us that

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systems and processes will be in place for meeting these costs but implied that both the NHS Commissioning Board and clinical commissioning groups will have a role in ensuring that they are funded by the NHS. However, as clinical commissioning groups will commission secondary care, will excess treatment costs occurring on a research study taking place in secondary care come from a clinical commissioning group's budget?

Similarly, if the NHS Commissioning Board is responsible for commissioning primary care, will the NHS Commissioning Board be liable to cover the excess treatment costs associated with research studies conducted in primary care? At present, these costs are covered via the PCT commissioning budgets. In its review, the Academy of Medical Sciences identified that mechanisms in place for trusts to claim these costs were not clear, they were not consistent and, in turn, led to many trusts becoming disincentivised to undertake clinical research. In fact, there are examples of PCTs refusing to meet excess treatment costs in certain studies, leading to delays in getting the studies set up and therefore affecting patient outcomes and care. The Bill is an opportunity to send out a clear message and I hope that in responding the Minister will be able to put the record straight and, if not, to write to us as he often does.

Amendment 218 examines the role of the NHS Commissioning Board and how it will assess and encourage research to be undertaken by the NHS. Within the new structure there are a large number of bodies with research functions or an interest in research. There is the National Institute for Health Research; the NHS Commissioning Board; Public Health England; the Health Research Authority to be set up; NICE; and, of course, local commissioning care groups. NIHR will stay in the Department of Health, outside the NHS Commissioning Board, and retain its research budget to provide funds to support the infrastructure for research with clinical research networks and biomedical research centres and units. It is essential that this infrastructure is appropriately aligned with NHS activities. The NHS Commissioning Board will include a medical director who, I understand, will have responsibility for research. Presumably this will include executing the NHS Commissioning Board's duties towards research. Can the Minister confirm that is the case?

What is not clear is where the buck stops with regard to the leadership of research culture throughout the NHS. The Government have accepted a commitment to embed a research culture in the NHS. Amendment 218 is an attempt to clarify the role of the NHS Commissioning Board's duty to promote research and its duty to lead CCGs in their duty as well. This amendment recognises that co-ordination between all the bodies will be critical to identify and implement national strategic priorities for research. The link between the NHS Commissioning Board and the CCGs will be crucial. If we do not get that right, and we do not get the leadership, then heaven knows where we will get to.

CCGs will need clear leadership from the NHS Commissioning Board as to how they are expected to carry out their duty towards research, which is why the Commissioning Board's research leadership role must

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be made clear. We have evidence from programmes of work such as the North West Exemplar Programme that we need a culture shift in the UK better to embed research as a core part of the NHS. The intention behind Amendment 218 is simply to make it a requirement for NHS Commissioning Board to assess the performance of each CCG when carrying out its duty to promote research. This would complete a virtuous circle whereby both the NHS Commissioning Board and the local commissioning groups would have to define how they would carry out their duty on research and then report on it in a way that could be openly challenged. It seems a sensible way to progress and gives a clear definition as to what should happen. I hope the Minister will accept both Amendments 215 and 218.

Lord Turnberg: I wish to speak to some of the amendments that are in my name. I would also like to comment briefly on Amendments 128A and 129, dealing with innovation. We know that we are quite slow in taking up innovations in the UK. It is not simply that there is a bit of sluggishness in the system-there are hurdles in the system. I want to mention two examples of very simple innovations that would not cost any money to the health service, but which have been blocked by the systems under which we operate.

One example is a consultant colleague of mine, a gastroenterologist-my own field-who set up a clinic in which he took phone calls from GPs and patients and was able to answer many questions without actually having to see the patients. It had a rapid turnover. It was considered to be innovative but was blocked because it did not earn any money for the hospital trust which found that it was not getting the patients referred. The second example concerns a similar situation in which the same consultant saw new patients from 8 am until 9.30 am. He sent them away for tests, scans, endoscopies and so on, and saw them again at about 11 am with the results of the tests and gave them the treatment that was necessary. This, too, was considered not to be earning money for the PCT, because it was paid for items of service, and it would have got twice the money with the normal system. This is a hurdle to innovation which we should surely be able to overcome. We have discussed that with the Minister. He expressed sympathy for the idea so I hope that it can be acted upon. It is not simply that we are slow; we have hurdles.

I come to Amendments 130, 131 and a number of others in my name. I have no doubt that the Government have firm intentions to promote research and innovation. It is mentioned in several places in the Bill and I know that the noble Earl's heart is in the right place on all this. The amendments in my name are simply there to help the Government in their own aspirations by emphasising and reiterating the need to keep research and innovation at the forefront. I simply emphasise the points made so eloquently by the noble Baroness, Lady Morgan, and the noble Lord, Lord Willis. The amendments make it clear that innovation and research are of such central importance that they should be explicit in the board's business plans, in reporting its activities and in clarifying how it is going about achieving these aspirations. The amendments make sure that the board actively promotes research as against simply

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having regard to it. I hope that the Minister will find the amendments helpful in the light of the Government's intentions.

Amendment 131 returns to the issue of research that protects the public's health. Here I make two particular points that the Minister might consider answering in one way or another. First, how will it be possible to ensure that the local authorities taking over the directors of public health also promote research? What levers will there be with the local authorities? Secondly, I ask a question that has been posed before. How will we ensure that the Health Protection Agency, which engages in much important research, will have access to external funds? We have discussed this before, but it would be nice to know whether it is clear that the HPA will have access to grants from external funding bodies.

Earl Howe: My Lords, the NHS has a long and proud track record of innovating and delivering better care for patients. That must continue-we all agree about that. That is why new Section 13K of the 2006 Act places a duty on the board to promote innovation when exercising its functions, including innovation in the provision of services and the,

That last phrase means the commissioning of services. As a result, although we completely sympathise with the principle behind Amendment 128A, it is not necessary. The duty is intended to support the delivery of quality and productivity improvements across the NHS to help transform healthcare for patients and the public. In response to the noble Lord, Lord Warner, I say that I expect that innovation in procurement of goods and services will be an essential part of this. The duty certainly allows for it as it stands. It is an important part of the QIPP programme at the moment, and I am sure that it will continue to be. If we were to specify one area of activity in which the duty should be exercised, as Amendment 129 suggests, we would face the perennial problem of listing those areas where the duty should be exercised to the detriment-

Baroness Thornton: I am sorry to interrupt, but it strikes me that if none of us understood that that was what those words meant-that was what led us to table the first two amendments in this group-maybe the Minister should look at those amendments, because they offer more clarity.

Earl Howe: I am always keen to accept the wise suggestions of the noble Baroness, and I will of course go away and consider the words that she has proposed.

I was just referring to the amendment proposed by the noble Lord, Lord Warner, on procurement, and saying that we would face the perennial problem of listing those areas where the duty should be exercised to the detriment of those not listed.

Lord Warner: I have an uneasy feeling that we are going to hear a lot about lists today. On lists, some things are more important than others, and I think that the argument about lists does not hold a lot of water unless the Minister can show us some other items that will be missed out that are as powerful as procurement of goods and services in further research

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and innovation. If there are others, I would be happy to consider the matter, but the reason why the amendment has been tabled is because it is a very powerful way in which to promote something that the Government want. Many of the other things may not be as powerful in delivering that.

7.45 pm

Earl Howe: I recognise that and, after what I said a moment ago, we know that procurement can be an important lever in the innovation agenda. Indeed, that will be recognised in the innovation review, which is due to be published next month. Furthermore, we are planning to launch a procurement strategy by April 2012. I will not go into huge detail about it, although I have it here, but it will consist of three elements-system levers, standards for procurement and system level support. We can look to take forward some of the ideas that the noble Lord, Lord Warner, put forward in his speech.

All this goes to show that there is a substantial amount of work already under way to create the right conditions for innovation to flourish. These include dedicated regional innovation funds to support front-line innovation and innovation challenge prizes to recognise and reward ideas that tackle some of the biggest health and social care challenges facing the NHS and in future. I have named only two from a long list of current initiatives.

I will just say to the noble Baroness, Lady Finlay, that the Secretary of State already has a power to awards prizes. New Section 13K of the 2006 Act, inserted by Clause 20, simply gives the board the same power. Should it choose to use the power to make payments as prizes-and it is a power rather than a duty-this is one way in which it might decide to promote innovation in the provision of health services. Recently I presented the very first group of innovation challenge prizes, and it was a very heart-warming and exciting occasion.

The noble Lord, Lord Warner, rightly made the point that the NHS was slow to take up innovation and that people were forced to go elsewhere to take their new ideas forward. Again, this is an issue that we are tackling with considerable energy in the NHS chief executive's review of adoption and diffusion of innovation, which will be published next month. I look forward to talking more to the noble Lord about what is in that review in due course.

I say to the noble Baroness, Lady Morgan, in particular that the main way in which the board will collaborate with research funding bodies is to fund the treatment costs of patients who are taking part in research funded by government and research charity partner organisations.

The existing innovation funds were not put in primary legislation; there is no need to put a specific power in the Bill, as Amendment 129A seeks to do, to enable the board to establish an innovation fund. As with prizes, establishing innovation funds is only one way in which the board might seek to exercise its duty to promote innovation; innovation funding is being considered as part of the chief executive's innovation review.



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Amendments 130 and 131 reflect the similar and previously debated Amendments 39 and 41 on the equivalent duty on the Secretary of State in Clause 5. I agreed to undertake a closer consideration of that duty and I shall do that. I reassure noble Lords that our discussions will include the board's duty. Work is under way to look at these duties ahead of future stages of the Bill. Indeed, I undertake to reflect carefully on the points raised by the noble Baroness, Lady Morgan of Drefelin, and to write to her with answers to her questions. I have also written to all noble Lords who spoke in that earlier debate, picking up points that I was not able to cover at the time. I explain in that letter how public health falls within the definition of the health service, which was one of the points touched on by the noble Baroness. It will therefore be covered by the existing duty on the board to promote research in proposed new Section 13L of the 2006 Act.

The noble Lord, Lord Patel, spoke about the role of the tariff in promoting innovation. He is absolutely right to do so; the new tariff could indeed play a key role in encouraging innovation. The Bill introduces a new, independent, transparent and fair pricing system where the board and Monitor would collaborate to set prices for NHS services. That would create a more stable and predictable environment, allowing providers and commissioners to invest in technology and innovative service models to improve patient care. We are actively looking at the way in which the tariff could drive that.

My noble friend Lord Willis and, indeed, the noble Baroness, Lady Morgan, asked how exactly the board will go about promoting research. As previously set out, we will make sure that the systems and processes for commissioning used by the board and clinical commissioning groups ensure that research is promoted, supported and funded by the NHS. That will include the tariff, the commissioning guidance and the processes for authorising and supporting development of clinical commissioning groups. However, noble Lords will be aware that a great deal of the practical detail of the board's role is still under development. Further detail will be published in due course and we must respect the autonomy of the board in devising for itself how exactly it will undertake this function.

I turn to Amendments 147, 149A, 150, 215 and 218. Given the wide range of statutory duties placed on the board and CCGs, the approach we have taken in the Bill is to emphasise a few key duties that the board must look at-in particular, in its business plan, annual report and its performance assessments-and that CCGs must, in particular, look at in their commissioning plan and annual report. We feel we have chosen the right duties to emphasise, not because they are the most important but because they are duties about which any annual report, business plan, commissioning plan or assessment should provide explicit evidence, specifically linked to the exercise of the board's or CCGs' functions.

That said, with respect to clinical commissioning groups I say to my noble friend Lord Willis that the department has published Developing Clinical Commissioning Groups: Towards Authorisationand that, to be authorised, a CCG will need to demonstrate that it has in place the systems and processes both to

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promote patients' recruitment to and participation in research, and for funding the treatment costs of patients taking part in research, so this will not be overlooked. However, we are clear that an annual report, business plan, commissioning plan or annual assessment should provide an assessment of all the body's functions, including the exercise of its innovation and research duties. There is also nothing to prevent the documents going into significant detail about the exercise of a specific duty. I add that the board has the power to issue guidance to CCGs on the contents of commissioning plans and directions as to the form and content of the annual report. I hope that those remarks are helpful in answer to the questions and points from noble Lords, and that they will be sufficiently reassured by what I have said not to press their amendments.

Baroness Thornton: I thank the Minister for those remarks and all other noble Lords for theirs. This has been a very high-quality, expert debate. I do not want to delay noble Lords from their supper and, indeed, on this side, from an opportunity to defrost-we have hypothermia on this side. The Committee has again shown its great expertise, commitment and enthusiasm to innovation and research and there is great consensus across the Committee about this. This suite of amendments would have given practical action and voice, and would have strengthened this part of the Bill on innovation and research. We need to look at what the Minister has said. I am grateful for those areas where he said that he would reflect upon these issues and let us know. However, it is safe to say that because of the consensus in the Committee on these issues, we would all be keen to make sure that the issues of innovation and research are, indeed, put beyond doubt in this Bill. I beg leave to withdraw the amendment.

Amendment 128A withdrawn.

Amendments 129 to 131A not moved.

Amendment 132 had been withdrawn from the Marshalled List.

Amendment 133 not moved.

House resumed. Committee to begin again not before 8.56 pm.

Subsidiarity Assessment: Food Distribution (EUC Report)

Motion to Take Note

7.57 pm

Tabled By Lord Roper

Lord Carter of Coles My Lords, in the absence of the noble Lord, Lord Roper, I beg leave to move the first Motion standing in his name on the Order Paper. It fell to the EU Sub-Committee on Agriculture, Fisheries and Environment, which I chair, to carry out detailed scrutiny of the latest proposal in relation to food for the deprived. In doing so, we were conscious of the consideration which we gave a year or so ago to the previous version of the proposal. Both the sub-committee and the EU Committee itself, which the noble Lord, Lord Roper, chairs, took the view that the changes made to the latest proposal did nothing to remedy the failure to comply with the principle of subsidiarity.

It is tempting to use this occasion to talk about the common agricultural policy as the evolving backdrop to the scheme to distribute food to deprived persons but, since time is limited, I will make only two remarks in this respect. First, when the scheme was initiated in 1987, a largely unreformed CAP generated excesses of butter, milk powder, beef, sugar, rice and cereals-the so-called food mountains-which allowed food to be released to charitable organisations in participating member states. Those days are long gone. Surplus stocks are now very low and in recent years the scheme has in fact relied on open-market purchases of food, so the link between the scheme and the CAP, clear enough in the past, has become more and more tenuous in the present.

I hope that your Lordships will take the view, as the committee has done, that the task of tackling deprivation faced by our fellow citizens rightly falls on the member states, not on the EU itself. No one should downplay the scale of the challenge on social protection across Europe. Data on expenditure in that regard in October this year-I am relying on data from Eurostat, the European Commission's own source-showed that, in 2009, the 27 member states spent over €3 million million on this support. That is, greater than the figure 3 followed by 12 zeroes of euros: a colossal amount of money. Compare the scheme for deprived persons that is being proposed here of €500 million or so. Doubtless that can buy a great deal of food, but in respect of the total spend by member states it is not of great significance.

8 pm

Your Lordships will know that, in their Explanatory Memorandum, the Government have made clear that the UK has not participated in the scheme since the mid-1990s because of dwindling UK intervention stocks, and because of the bureaucratic overhead associated with ensuring compliance with the scheme's rules to prevent fraud. The Government go on to say that,

As our report explains, we share the Government's view on this matter. We are clear that the proposal does not comply with the principle of subsidiarity, and we hope that the House will accept our recommendations and agree to issue a reasoned opinion on the latest proposal. I beg to move.



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Lord Roper: My Lords, I support the arguments that have been put forward by the noble Lord, Lord Carter, who chairs the European Sub-Committee of the European Union Committee dealing with agriculture, fisheries and the environment and who prepared the report that we are considering today. This is an important issue and one of the occasions on which this House has the opportunity to argue why subsidiarity matters and why some things ought to be done at a national level, not at a European level.

As the noble Lord said, the food distribution programme made sense when there were significant European surpluses. However, in the 24 years since the programme was introduced, probably at the time when the noble Lord, Lord Williamson, was responsible for these matters, things have changed. There are no longer surpluses that it is perfectly legitimate for the European Union to distribute to member states where there are needy people. The argument has therefore changed. That is why, despite the fact that the European Commission, in preparing its proposals for this document, modified them from the document on which this House gave an opinion about a year ago and suggested that there was a reasoned opinion against subsidiarity over the old proposal, in our view there is no longer a satisfactory situation.

We do not believe that any European value-added is produced by producing €500 million on buying things from the open market to give to needy people. Member states should do that-there are lots of reasons why they should-but that is a decision for the 27 member states of the European Union. That is why this report has been produced and why, although the earlier proposal has been withdrawn as a result of a judgment by the Court of Justice of the European Union, we still believe that this is a serious error.

As we say in our report, neither the proposal nor the Commission's Explanatory Memorandum produces an explicit subsidiarity justification as required by Article 5 of the protocol on the application of the principles of subsidiarity and proportionality. However, it seems clear from the summary of the impact assessment that accompanied the original proposal of three years ago that the Commission sees three reasons for this. These include the view that the programme addresses problems of hunger, deprivation, poverty and social exclusion in the spirit of the treaty and that it supports the objective of strengthening the Union's social cohesion.

Our report sets out our consideration of those justifications. I will not repeat them at length. The nub of our assessment, this year as last, is that the spirit of the treaties can be respected without the European Union acting in this respect. Moreover, we consider that member states are capable of acting individually to fulfil those objectives if they so wish, and in any case the failure of European member states to act is not in itself a reason why the EU should act. In conclusion, we again take the view that there is no compelling argument to suggest that the Union is better placed than its member states to ensure a food supply to its most deprived citizens.

We know that the Government share our view on this proposal-indeed, I believe that it is also the

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view of the opposition Front Bench-and in their Explanatory Memorandum they have stated their belief that,

The Scottish Parliament has taken a similar view and the Swedish Parliament, the Riksdag, has also issued a reasoned opinion sharing our view. Other member states such as Denmark and the Netherlands share our concerns, though we are not yet sure whether they have issued reasoned opinions.

The Government have told us that, unfortunately, agreement in principle on this measure has been reached following a decision by Germany to accept a time-limited extension of the scheme to the end of 2013. There appears to have been movement at the political level but certainly not, in our eyes, at the level of the underlying policy.

While the European Commission has made changes to the proposal that we considered a year ago, we think that those changes make no difference to our assessment of whether the proposal is in compliance with the principle of subsidiarity. We consider that it is not compliant with that principle and therefore recommend that the House should issue a reasoned opinion on the latest proposal.

Lord Williamson of Horton: My Lords, it was of course only in November last year that the House took the view that a proposal from the European Commission on the distribution of food products to the most deprived persons in the Union did not comply with the principle of subsidiarity, and we sent a reasoned opinion to that effect to the Presidents of the European Parliament, the Council and the Commission in accordance with the treaty. As the noble Lord, Lord Roper, stated, on 13 April 2011 the European Court of Justice annulled the provisions of the food distribution plan providing for purchases from the market. In consequence, the Commission has now submitted a new proposal, which we have before us, from 2011, document number 634 final, adding a new treaty base, Article 175(3) of the Treaty on the Functioning of the European Union, which relates to social cohesion. As has been stated, the reason for this is that the Commission wants to make market purchases a permanent source of supply for the scheme when there are no longer the intervention stocks that used to exist in the Union. They have gone and the Commission wants to turn to the market.

The European Union Committee of the House has recommended that the objection on the grounds of subsidiarity that applied to the earlier proposal applies equally to the new one, and that we should issue the revised opinion in paragraphs 5 to 11 of the committee's report. I agree that we should be consistent and follow the advice of our European Committee. Of course there may be good reasons for supplying food to the most deprived citizens, but today we are concerned only to judge whether this might be done at EU level and on the EU budget. The principle of subsidiarity that is in the treaty on the European Union in Article 5(3) states inter alia that,

We do not agree that this proposal corresponds to that part of the treaty.

Although the principle of subsidiarity may not have much impact, it is none the less an important provision. It is in line with much of British opinion and we should play our role in seeking to ensure that it is respected. As we seldom see the text of a Commission proposal for legislation in this Chamber, I would add three short comments. First, the Commission proposal, which as usual is clearly drafted and easy to understand, is not a law. Bureaucrats in Brussels cannot and do not make laws on a subject such as this. Substantive laws are made jointly by the Ministers of the member states in the Council and the European Parliament. This may seem self-evident, but in view of the widespread public misunderstanding, I emphasise it in this case.

Secondly, it is interesting to note that the European Court of Justice annulled provisions of the earlier proposal because the legal base was not sufficient, showing the value of the oversight by the court. Thirdly, and lastly, as has already been stated, this case shows clearly the transformation of the agricultural policy of the Union-the old CAP-as market intervention has been removed or drastically reduced and intervention stocks are no longer generally available for this scheme. I support the proposal of the European Union Committee of this House.

The Earl of Caithness: My Lords, I am delighted to follow and to support everything that has been said by the noble Lord, Lord Carter of Coles; our committee chairman the noble Lord, Lord Roper; and the noble Lord, Lord Williamson, particularly with his experience of dealing with the situation when it was entirely different. I propose to add nothing to what they say, but to ask a few questions of my noble friend. Does he agree with me that this is a serious matter? As far as I understand it, this is only the third reasoned opinion that this House has given, but it is identical to the one we passed on 3 November. Why are reasoned opinions passed by this House taken so lightly by the Commission? What negotiations has the Minister had with the Commission? What was its reaction to our previous reasoned opinion?

It is all very well for the Commission to make a slight tweak to what it presents to us because the European Court of Justice ruled it out of order, but that does not satisfy me. I want to know what the Commission has done to take on board our concerns. I hope my noble friend will update me on that. If the Commission does not take on board member states' concerns about reasoned opinion, there is no point in us producing reasoned opinion. If it is as dismissive as it has been to date, it will only intensify the disregard and dislike of the Commission that many in this country have.

May I also ask the Minister about the current state of negotiations? I was appalled to read the letter from his fellow Minister, Mr Paice, of 15 November, in which the Germans seem to have decided with the French in, if no longer smoke-filled rooms, the

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corridors of power to do some dirty deal and produce a draft joint minute telling the rest of the European Union's members what they can accept from the Germans and the French. That is pretty unacceptable, too. I hope that he has made strong representation to the Germans about this. Surely it is wrong in principle, as has been well said, for some sort of shady deal in which this matter is done at European level rather than at member-state level to the end of 2013. Let us hope that in negotiations about what will happen after that, when the French will be keen to continue this into the next round, the Germans will be in a weaker position than they would be if they remained firm and principled.

Baroness Sharp of Guildford: I should declare an interest as a member of the EU Sub-Committee D, which has brought forward this opinion. It has now considered this and similar proposals from the Commission on three occasions. On all three, it has taken the view that the proposal has little justification now that intervention stocks have more or less disappeared. Redistribution to deprived groups within society to relieve their poverty is essentially, we maintain, a matter for member states, not for the Union, and it is really ridiculous that CAP funds-€500 million-should be used to buy foodstuffs on the markets for such redistribution. If anything, such purchases would tend to drive prices up and exacerbate food poverty rather than the reverse.

8.15 pm

As we have seen, however, the Commission is very persistent. In its explanatory memorandum it justifies its actions on the grounds that in March 2009, the European Parliament strongly advocated the maintenance of the full Union's funding scheme, which amounts to €500 million, and that this opinion was reinforced in January this year by the European Economic and Social Committee. In addition, it points to the current economic crises and suggests that certain member states that have benefited in the past might not be able to meet the co-financing proposals that were put forward last year and that this justifies dropping them.

As for the European Court of Justice's opinion that the justification for the scheme under Articles 42 and 43-the agricultural articles-could support the scheme only when it was redistributing surpluses acquired through intervention powers, the Commission now comes back to justify it under Article 157(3) as helping to promote economic, social and territorial cohesion. I join others in thinking that the opinion that this House came to last year still stands: purchasing food from the market and distributing it to deprived people is a matter for local decision. At present, 20 member states, including it would seem both France and Germany and some of the richest countries within the Union, benefit from the scheme. Perhaps that is one reason why the Commission can claim that it is backed by so many member states. Breaches of the subsidiarity rules are justified only where action by the Union would, by reason of its scale or effects, produce clear benefits which would not be available if similar action were taken by member states. In this debate last year, the noble Baroness, Lady Howarth, who is also a

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member of our committee and was at one time chair of the Food Standards Agency, spoke about various local schemes that had been set up in the UK to relieve food poverty. She said:

"Food networks are local, direct and know their communities. They are not overbureaucratic and, consequently, are flexible in responding to need. Above all, they are transparent. We should leave them uncluttered by intervention by the Commission, however well intended".

She concluded that there appears,

I concur entirely with what she said this time last year. Nothing has changed since then to alter the conclusion. I fully endorse it and, in so doing, support the Motion to issue another reasoned opinion of the same ilk.

Baroness Byford: My Lords, I should like to reinforce what my noble friend Lady Sharp has just said. I declare that I am also a member of Sub-Committee D. Unfortunately, through illness, I could not be here last year to participate in the discussions. I have one or two basic questions for my noble friend when he comes to reply. Like others, I certainly think it is the responsibility of individual member states to look after those who are in need; that is the best way to supply it.

However, the proposal was to raise the sum of money to €500 million. My question to my noble friend is: which countries have benefited from it and how much have they had? Although the UK takes the very clear stance that it should be done locally, which I hope my noble friend will reflect in his comments, clearly the money will come from Europe, to which we contribute. If the Minister has figures that he can share with us tonight, I would be interested to hear them. If he does not, perhaps he will write to us to let us know. It seems a very unusual situation-to be opposed to something that is being proposed and will be imposed, over which we have no control except to have the debate that we are having here tonight. I should just like to reinforce my concerns about the way in which it is being proposed.

Some 17 member states and some 18 million people benefited back in 2010, but, as other noble Lords have said, when there was a surplus it made sense to use it and distribute it. However, that is not the situation that we face today. I assure noble Lords that buying in from the market is not the cheapest way to do things. Therefore, we look to my noble friend for some steer on the Government's thinking about how they will deal with what is proposed, and how we can say, "No, we don't think this is a good idea". As one of the member states, we are presumably committed to providing that money up front.

I apologise to other noble Lords for not being able to take part in discussions last year through illness, but I am very glad that we have had the debate tonight. I reinforce my support for the Motion moved by the noble Lord, Lord Carter, and for the comments of other noble Lords. Clearly the situation should not continue.

Lord Hylton: My Lords, it is very good to hear the principle of subsidiarity being upheld and defended. I

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am also inclined to think that this House should be consistent in maintaining the reasoned opinions that it has previously given.

The Commission, and perhaps some member states, might like to examine how food stamps in the United States have worked out in practice. The United States probably has less comprehensive and less long-term social welfare arrangements, compared to many European countries. On the other hand, I expect those who devised the food stamp scheme took full account of the interests of commercial food producers and of the market generally.

I conclude by asking the Government how many civil servants within the Commission have been employed, or are still employed, in dealing with these matters. If things go ahead in the way that we wish, will some of them no longer be needed? What will happen to them? Having said that, I support the Motion.

Lord Grantchester: Like others, I begin by thanking the noble Lord, Lord Roper, and my noble friend Lord Carter of Coles for the work of European Union Committees that they chair and for their exposition tonight. The House has heard that this is essentially a repeat of the Motion debated on 3 November last year, since the amended Commission proposal does not materially alter the thrust of the original document. All sides of the House concur that the revised food distribution programme is still defective, as the substance and objective of the measure remain basically the same.

We have heard how the proposal has fared since the debate last year. In April this year, the European Court of Justice annulled the provisions of the 2009 distribution plan providing for purchases on the market. As a consequence, the budget for 2012, based entirely on intervention stocks, accounts for only €113 million against a proposed €500 million. This is a success indeed against the mission creep of the original scheme. However, in July, the European Parliament called on the Commission and the Council to develop a solution to avoid a sharp cutback in food aid as a result of the reduction in funding. The memorandum states:

"Numerous representations of the European civil society, ranging from local authorities to NGOs and charities, have expressed their worries for the future of the scheme".

This suggests that it will not be a simple matter to resolve the situation in the manner this House would wish. The Minister at last year's debate, the noble Lord, Lord Henley, assured the House that no charitable organisations in this country had asked the Government to participate in the scheme. He also stated that,

Where does the support for this programme seem to come from? There does not appear to be a member state that looks on this as part of its budget. Is there any similarity or region characteristic to the 18 million people said to have benefited as recently as 2010?

On cofinancing, the memorandum states, in very similar fashion, and again on page 4:

"National authorities of participating member states and very numerous representatives from the civil society have recently expressed their wish for the scheme to remain fully funded out of the EU budget".



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What discussions have taken place between those member states and the Government? While the Minister last November, the noble Lord, Lord Henley, commented that there was some way to go before this proposal would succeed, the intervening period seems to underline that the proposal's supporters will not easily be deterred. The Economic and Social Committee and the Committee of the Regions of the European Union also came out in favour in January this year.

I support the Motion in the name of the noble Lord, Lord Roper, and commend the committee for its deliberations. I understand that although the question of subsidiarity did not feature in the treaty of Rome, the position is covered under the Lisbon treaty that, in matters of shared competence, the EU can act only and in so far as the objectives of the proposal cannot be sufficiently achieved by member states. Could the Minister clarify the Government's position? Are the Government content that the reversal to the original intention to distribute only out of intervention stocks could still continue, albeit now on a much reduced budget? Do the Government consider that the Treaty on the Functioning of the European Union can be used as a legal base to the amended proposal? I look forward to the Minister's update and his proposals to carry forward the determination shown tonight by all sides of the House against the amended proposal.

The Parliamentary Under-Secretary of State, Department for Environment, Food and Rural Affairs (Lord Taylor of Holbeach): My Lords, I am grateful to the noble Lord, Lord Roper, and the EU Committee for giving us the opportunity to debate this matter this evening, and indeed to the noble Lord, Lord Carter of Coles, for introducing our debate and for chairing the committee. Its report is welcome. This debate has been opportune and I am able to update noble Lords on meetings as recent as today. Let me make it quite clear at the outset that the Government continue to share the committee's view that the Commission's latest proposal is not consistent with the subsidiarity principle. In that position it is supported not only by the committee but by all speakers in our debate this evening, so many of whom, I am pleased to see, are members of the committee.

I know that your Lordships are well aware of the background to this scheme, and the noble Lord, Lord Williamson, pointed out that we had debated this topic as recently as last November. When the scheme was first introduced in 1987, it was used as a mechanism to derive benefit from the growing intervention stocks and to save European embarrassment in running down these stockpiles. I point out to my noble friend Lady Byford that the 18 million people who benefited from these stockpiles came mainly from the following list of countries. In the 2012 allocation, the countries were: Spain, €18 million; France, €15 million; Italy, €22 million; Poland, €17 million; and Romania, €12 million. In fact, all member states participate, other than Denmark, Germany, Cyprus, the Netherlands, Austria, Sweden and the UK.

8.30 pm

In the current context, this scheme no longer has a basis in the intervention stocks because they are

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significantly reduced to the point at which they are more or less insignificant. As a result of an increasing focus on purchasing products on the open market, the Commission has had to provide new proposals to adapt the scheme. I am unable to say how many civil servants have been engaged in this exercise, but I shall do my best to ascertain the number, although it may be difficult to satisfy noble Lords on that point.

Several recent proposals have failed to achieve a qualified majority in favour within the Council. Yet we have before us another proposal. Perhaps I may say to my noble friend Lord Caithness that the noble Lord, Lord Grantchester, is absolutely right to say that under the Lisbon treaty certain criteria must be met. The proposal depends on the number of reasoned opinions received. One-third of votes are required from Parliaments that consider that the proposal is not compliant with the principle of subsidiarity-a so-called yellow card-or more than half the votes in the Council must consider that the proposal is not compliant. Based on the response to the 2010 proposal, neither of those conditions was met. Therefore, our reasoned amendment is not without force or consequence, but the Commission has been unnecessarily determined to push its proposal despite our criticism and reason for it.

What is specific about this latest proposal? One key development earlier this year was a judgment in the Court of Justice of the EU on the provisions of the 2009 distribution scheme that provided for purchases on the open market. In the court's view, the existing regulation did not provide an adequate legal base for the purchase of food on the market other than on an exceptional basis when intervention stocks are temporarily unavailable. This ruling has had an immediate impact on the operation of the scheme by limiting the budget for 2012 to approximately €113 million. On current projections, there will be no intervention stocks to supply the programme in 2013.

Against this background, the Commission has made a further amended proposal that reflects the Commission's attempts to justify the provisions for the sourcing of food from the market as a matter of course, rather than on an exceptional basis-as was the case in the past. The Commission has indicated that it intends this proposal to be a transitional measure to ensure the continuation of the existing programme until the end of the current multiannual financial framework in 2013. The Commission is expected to come forward with further proposals for a food distribution scheme for deprived people to be funded solely by the European Social Fund from 2014, under heading 1 of the EU budget.

Nevertheless, the Government's view has not changed. We remain unconvinced as to the merits or appropriateness of this proposal. The Commission's attempt to make use of social cohesion as a legal base confirms our view that the scheme is no longer an agricultural measure but one which has a fundamental social principle behind it. My noble friend Lord Caithness will know that the Government share his view of the behaviour of the Commission in this matter. As several noble Lords including the noble Lord, Lord Hylton, pointed out, in accordance with the principle of subsidiarity

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there is a long-standing general principle of union law, currently enshrined in Article 5 of the Treaty on European Union, that the Government consider the EU should act collectively only where there are clear additional benefits or EU added value compared with action by member states either individually or in co-operation.

We consider that such measures to assist the neediest members of society can be better and more effectively delivered by individual member states through their own social programmes and not at EU level. As noble Lords will know, we have a Healthy Start programme here in this country. It is the member states and their regional and local authorities that are best placed to identify and meet the needs of deprived people in their countries and communities, and to do this in ways that are administratively simple and efficient. The proposal has long been discussed in Council and the UK, along with a number of other member states. We maintained our opposition to the scheme on the grounds that social measures are a matter for individual member states, and therefore the proposal is not in line with the principle of subsidiarity.

However, in the margins of the Agriculture Council's meeting on 14 November, following French and German bilateral discussions to which my noble friend Lord Caithness has drawn our attention, the German Minister indicated that she could accept a time-limited extension of the scheme until the end of 2013 provided there was a guarantee that funding would not continue into the next financial perspective. During discussions in the special committee on agriculture earlier today, it was clear that Germany had not received the assurances it was looking for from the Commission in not coming forward for new proposals for a similar programme in the future, and as such I can say that the qualified majority in favour does not yet exist.

The Government will consider their position, as they should in light of any proposed compromise, but they will continue to oppose the principle of expenditure on social measures of this kind being funded from the EU budget. Clearly, as my noble friend Lady Sharp pointed out, it is important that all our citizens have enough food to eat and supporting them through these difficult times is no doubt a matter of some priority for each member state.

In the UK, the Healthy Start scheme, for example, provides a nutritional safety net in the form of vouchers for basic healthy foods and free vitamin supplements for pregnant women and children under four in disadvantaged and low-income families. Also, as many noble Lords will know, FareShare and FoodCycle provide good examples of the essential work that charities are doing to support communities to relieve food poverty. In 2010-11, the food distributed by FareShare contributed towards 8.6 million meals, with the number of people being fed daily averaging 35,500. The point remains, that ensuring the availability of adequate food for the most deprived citizens is an activity not best undertaken at EU level, nor in our view an appropriate use of the EU budget, as the noble Lord, Lord Williamson, said.

I hope this helps your Lordships in completing your scrutiny of this proposal. I suspect noble Lords will want to remain on continuous alert where this

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proposal is concerned but I thank the committee for its report, and the Government support the Motion on the reasoned opinion.

Motion agreed.

Subsidiarity Assessment: Food Distribution (Reasoned Opinion)

Motion to Resolve

8.39 pm

Moved by Lord Roper

Motion agreed.

8.40 pm

Sitting suspended.

Health and Social Care Bill

Committee (8th Day)(Continued)

8.56 pm

Amendment 133ZA

Moved by Lord Patel

133ZA: Clause 20, page 18, line 37, at end insert-

"13L1 Duty in respect of education and training

(1) The Board must promote education and training of the health care workforce, having taken note of the responsibilities of the regulatory authorities, academic and professional organisations, and consulted Health Education England.

(2) In exercising its functions, Health Education England must take steps to ensure that providers of health services in England have due regard to any minimum numbers of training placements that it may specify."

Lord Patel: My Lords, we return yet again to education and training. There is so much anxiety about the issue of education and training and workforce planning that I have had several representations, in particular one from the Royal College of General Practitioners.

Government Amendment 43 places a duty on the Secretary of State to ensure that there is an effective system for the planning and delivery of education and training of the healthcare workforce. In order for this to be an effective system, a duty must be placed on the NHS Commissioning Board to promote education and training. This amendment seeks to do exactly

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that. As the board is nationally accountable for the outcomes achieved in the NHS and is also tasked with providing,

it is only right that this duty to promote education and training is included as part of the core responsibilities of the NHS Commissioning Board alongside the existing duties in respect of research, variation in the provision of health services, and so on.

We must try to get education and training structures right so that the long-term sustainability of the health service is maintained with patient care continually improving. This must be reflected in the approach taken to commissioning, with the NHS Commissioning Board taking note of the needs identified by regulatory authorities and academic and professional organisations so that plans are in line with national strategies. In carrying out this important role the board should consult Health Education England as it has a vital role in providing sector-wide leadership and oversight of workforce planning, education and training in the NHS.

The second part of my amendment deals explicitly with the role of Health Education England, as it will oversee the current system for providing education and training via a levy set on providers, and aims to make sure that there is adequate capacity in training to meet the needs of the health service. Under the current proposals, healthcare providers are to work together in provider-led networks to manage the planning and commissioning of education and training. However, if there is no specification of the minimum number of placements-the minimum number of trainees that should be provided in each sector-providers, especially those such as alternative or private providers that might work to make profit, with shareholders to answer to and an increasing range of competitors, will have little impetus to provide adequate numbers in the long term. The future of the NHS depends on having sufficient numbers of trainees in all specialties, including general practice, and the training of the next generation of doctors and other healthcare professionals will be put at risk if these plans are not strengthened. Furthermore, with the likely greater specialisation of some providers, and the non-requirement for all providers to provide educational opportunities, there is a risk that the overall quality of postgraduate generalist medical education will be affected due to reduced opportunities to widen the range of disease types and treatments that the students will see.

The policy of any qualified provider, alongside the pressures of the Nicholson challenge, should not be allowed to affect the provision of education and training by providers, whether they are new or old. Health Education England should therefore be tasked with taking steps to set a minimum number of trainee placements for each sector within the health service and to hold providers to account where necessary.

The amendment demonstrates the anxiety felt by a whole range of people in different parts of training and education. I know that the chairman of the Academy of Medical Royal Colleges, the medical school deans and the postgraduate deans have recently sent a letter

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to the Secretary of State expressing their concerns. I hope that it will be possible to get this right with a solution that is acceptable to all sides, including the Government, so that we have in the Bill something which does not affect government policy but demonstrates that the Government are serious about making sure that the education and training of the healthcare workforce will be a priority.

The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): My Lords, it may assist the Committee if I indicate at this early point in the debate that the Government are extremely sympathetic to this group of amendments. As noble Lords will know, I have already committed to publishing, prior to Report, a much more detailed set of proposals for health education and training in the light of the forthcoming recommendations of the NHS Future Forum, and I hope that this will prove helpful. However, I can now go further.

These amendments focus on how commissioners in the new system will foster high-quality education and training in the health sector and on the potential role of regulators and Health Education England in supporting the education and training system. The Government have listened carefully and we are persuaded by the intent behind these proposals. I therefore now commit to taking away the amendments, considering them in a constructive spirit and bringing forward our own proposals on Report aimed at addressing the issues raised by the amendments. I hope that the Committee will welcome this undertaking. I am of course willing to meet noble Lords between now and Report to discuss the underlying issues further.

Lord Patel: I am grateful to the Minister for those comments and am greatly encouraged.

Baroness Finlay of Llandaff: I add my thanks for the Minister's remarks. I look forward to seeing amendments which thread education and training through all parts of the Bill with duties on everybody at every level.

Lord Walton of Detchant: The Minister has completely taken the wind out of my sails. I had every intention of going at this hammer and tongs because all the medical organisations and all those involved in education and training are deeply concerned about the absence of detail in the Bill. The Minister has now reassured us greatly. We look forward earnestly and with keen anticipation to seeing what he proposes for the Report stage and hope that it will be adequate.

Baroness Emerton: I rise without notes, which is very unusual for me, to thank the Minister very much indeed. There is anxiety about education among nurses, midwives and particularly community nurses-they are getting very agitated. Therefore, I am absolutely delighted that we shall see something soon.


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