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I know that the Minister has undertaken to look in detail at all aspects of education and training, but I want to have on the record the postgraduate deans' need to be independent. That is supported both by the deans themselves and the General Medical Council, because in considering the future, it is very important that we do not lose the educational expertise from the current set of deans.
Lord Warner: I suggest that this group of amendments has been provoked by the extremely unconvincing nature of the Government's organisational structure for delivering the reforms they consider necessary to the NHS; they would in themselves, I suspect, attract a wide range of support. I want to address my remarks to Clauses 30 and 31 on the abolition of SHAs and PCTs. I think the concerns many of us have were well put by my noble friend Lord Hunt.
I want to divert a little from my remarks to congratulate the noble Lord, Lord Mawhinney, on his detective work. If he wants to continue in that vein, I suspect that he could find some examples in other parts of the country that go wider than that in Peterborough. He might want to entertain us with more of those examples at a later stage in the Bill because I suspect there are
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Some of us on these Benches have acknowledged that the 2002 NHS reorganisation rather overdosed on the number of SHAs and PCTs and, as I have just said, we tried to put that right in 2005 and 2006 with a reduction to 10 SHAs and 152 PCTs. Some of us would have liked to have gone a bit further and reduced PCTs further, but that's life. You do not always get what you would want. In practice, that further reduction could have led, as I think the noble Baroness, Lady Finlay, said, to a much more straightforward way of making the changes that needed to be made and could have included a very large increase in the number of clinicians involved in the process of commissioning. I do not think anybody in this Chamber is opposed to the Government's idea of increasing substantially the amount of clinical and, in particular, GP involvement in the commissioning of services. However, it could have been done without this process, and it could have built on the lessons of GP fundholding, on which I have always been a supporter of the Government's approach. I thought it was a bold experiment, and I do not say that with any sarcasm at all. It was a bold experiment that was well worth trying and which we built on further with practice-based commissioning, so I do not think there is a lot of political dispute about more clinical involvement in commissioning.
The Government could have done that without clusters by simply reshaping PCTs, changing their membership, probably reducing their number and possibly increasing-dare I say this to some of my colleagues on these Benches?-the involvement of private sector skills in the commissioning function with the data analysis and information gathering. They could even have done it with a little more democracy in the membership of PCTs on which, as I recall, the Liberal Democrats were rather keen at one point. The coalition partners could have been brought onboard with a bit more democracy in PCTs as well. That might have been a good mix to go forward.
As I said, the Government have managed to go along a totally different path and on many occasions they have stuck to their guns when there has been the
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The beauty of the previous arrangements, whether they were strategic health authorities, regional health authorities or regional hospital boards, was that, first, it was transparent that they were there; secondly, they were properly appointed; and, thirdly, they often had people who had some knowledge about the areas for which they were responsible. That function will not go away. What we are doing now is burying that function somewhere in the national Commissioning Board and, as my noble friend Lord Hunt made very clear, we are not at all clear how it is going to be discharged. To make life even more complicated, the Government have thrown in senates for good measure. It is not terribly clear how they are going to function or whether, in practice, they will be a block on the process of changing the configuration of services. It is not just me saying that; groups such as the NHS Confederation are very concerned that what we will have created is a kind of paralysis in decision-making at local level and in between the local level and the centre. I will put it no clearer than that because I do not think it is any clearer than that. Something is floating around in the ether: presences between the local level and the national Commissioning Board. That is where we have ended up. Clusters were invented, I think, to try to recognise that we need to reduce the number of PCTs, but there was no appetite for going through the process to do that in a proper and considered way.
Just to make things really interesting, the Government have also introduced an interesting new geographical concept for commissioning services based on GP practice areas. They have not just stuck with GP practice areas. They have invented-actually, we are seeing the invention as we sit here-new arrangements for new kinds of areas in which someone is forced to take some responsibility
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It is not surprising, in that set of circumstances, that people are anxious about what is going to happen in a period when the NHS is trying to deliver the Nicholson challenge of £20 billion of productivity improvements or savings-call it what you will-over four years. People are worried because the NHS has never introduced the kind of productivity improvements that are needed to deliver the Nicholson challenge. Put cautiously, this is 5 per cent a year in real terms. The NHS has never delivered that annual saving in one year, let alone four years on the trot. Here we are throwing all the organisational cards up in the air-if I may put it like that, as that is what it feels like to many people in the NHS-and saying we are going to get rid of strategic health authorities in April 2013. That is the Government's plan. The very organisations which might have kept some kind of grip on the finances and the way the NHS is being managed have been put on notice that they are going to disappear. Some of them will reappear in some guise, although not as a public body, somewhere in the middle of the national Commissioning Board. Others will appear as local offices. They may not be called that, as we are not yet quite sure what they are going to be called, but they will reappear as a local presence of the national Commissioning Board.
We are relying on a huge amount of faith in the Government knowing what they are doing. We are relying on that in regard to about £120 billion, give or take, of public money every year. Not surprisingly, coming to the amendments in this group we see that people think there should be some checks. We need to have some safeguards in here, so that if it does go a bit wrong there is some way of salvaging the situation, instead of people assuming that we will keep all the expertise that we currently have in PCTs and SHAs. I know that PCTs and some SHAs have had their problems, but there is also a lot of expertise there. The bits of that expertise which disappear and the bits which remain will, I suggest, be slightly random; it will revolve around a lot of personal choices as much as anything. So we need some checks in this. It is not too late for the Government to be mature and recognise that we need better safeguards. That is why I am very sympathetic to changes which preserve the SHAs, in particular, for a longer period until we have actually got through the financial challenges that the NHS faces.
Lord Walton of Detchant: My Lords, I shall speak briefly to Amendments 236AA and 236AAA. As I listened to the noble Lord, Lord Warner, I reflected
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On reading them and understanding the intention underlying them, these amendments look absolutely praiseworthy. I do not believe that they would have been necessary if the Government had been clear in what they intend to do about the subnational outreach of the national Commissioning Board. This has been promised to us by the Government and by Sir David Nicholson. It is intended to deal in every respect with the specialised commissioning of highly specialised services with regard to long-term conditions and with the issue, raised in many debates in the course of the last week or two, of the rising problem of rare diseases and their management and the new means of treatment that are being introduced.
Having said that, we hear that the Government are going to have clinical senates at a subnational level. It is intended that at these clinical senates there will be subnational outreaches of the national Commissioning Board that will fulfil the functions set out in Amendment 236AA. If that is right, my concern about supporting Amendment 236AA is that it looks as though it carries the potential danger of introducing yet another tier of management within the NHS. I look back with horror as I remember Keith Joseph's reorganisation of the NHS in 1974. I was heavily involved at the time as the dean of a medical school. It created regional health authorities, area health authorities and district health authorities. The tiers of management were impossible and the decision-making machinery congealed.
I am very anxious that we do not go down that route. If we could have clarity from the Government about the subnational senates and the outreach organisations of the national Commissioning Board, Amendment 236AA would not be needed and would have the potential danger to which I have referred.
I agree with every word my noble friend Lady Finlay said about the role of the postgraduate medical and dental deans. As I said at Second Reading, and later, it is the financial responsibility of the NHS to provide education and training for all healthcare professionals and to provide training for young doctors and dentists who are being trained for specialities in various branches of the profession. It is absolutely right that that authority and responsibility continue to be imposed upon the postgraduate deans, but surely the right place for them is not only in Health Education England but in these clinical senates-the outreach organisations of the national Commissioning Board to which I have referred. I hope that the Minister can give us assurances about this.
I would hate to say that this amendment, so ably proposed by my noble friend Lady Finlay, is in any sense weak. It is not-it is a strong amendment-but it might not be necessary in the light of the developments to which I have referred at the subnational senate level. I am concerned, too, that if it were accepted it might prejudice the Government's acceptance and agreement, which the noble Earl gave us quite recently, to the
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Lord Newton of Braintree: My Lords, I will speak briefly. First, I remind the Committee that when I spoke on a related matter last week, as my noble friend Lord Mawhinney has reminded us, I indicated that I have an interest as my wife is a PCT non-executive. I wish to put that on the record again.
I rise in the same spirit of helpfulness as the noble Lord, Lord Warner, with whose every word I agreed-the Minister needs to know that. I am also conscious, as my noble friend Lord Mawhinney reminded me, of my hurt last week when I was accused of using extravagant language. I will try to do better-well, worse, perhaps-this time. I indicated at that time that when we got to these amendments I thought my noble friend Lord Mawhinney would leave no one in doubt about his views. He has not, and I have not got up in order to disagree with him.
I want to concentrate on two things: the constitutional issue and the conflict of interest issue. The constitutional issue is perhaps arguable, but if you take the view, as my noble friend did, that the Government have in effect-certainly this is how they present it-abolished PCTs before this Bill has even been passed, there is a real question mark. Perhaps it is no more than a question mark because they will say that they have not abolished PCTs and will not do so until an order in two or three years' time, but that is how it feels, looks and is perceived on the ground, and your Lordships might like to bear that in mind.
The second point troubles me even more and it is very clear; it is what I call the conflict of interests point. It might arise with SHAs and the clustering of SHAs that has gone on. I think I am right in saying that the SHA for eastern England, which now covers the east of England and the Midlands, stretches all the way from Yarmouth, the easternmost point of the United Kingdom, in Norfolk, to the Welsh border. How seriously can one body deal with the relevant issues over such a hugely disparate area, covering as it does on the way the massive conurbations of the West Midlands? I do not understand that. The appointments look like an east of England takeover, which perhaps is fine for those of us in the east of England. The chairman is from the east of England, the chief executive is from the east of England and large numbers of the executives are from the east of England. All that has happened-well, not quite all because not everyone is from the east of England-is that they have moved from Cambridge to Nottingham. How far is Nottingham from Yarmouth or Norwich? All sorts of questions are raised by this.
However, I want to concentrate on PCTs. As everyone, including the Minister, acknowledges, cluster boards had no legal existence. PCT boards continue to have a legal existence and to have all the responsibilities and duties that they had until whenever this started to
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Let us look at Cambridge and Peterborough where, if I am right, there are particular tensions. My noble friend indicated that there would be three people from one area and three from the other-I do not know what exactly happened-with a chairman drawn from one area, which would mean four people and three people from the areas concerned. If there is any debate or confusion, how will anyone believe that that body is taking decisions in the interests of the minority area? A fortiori, if more than two bodies were clustered, no one would have a majority and the question could be asked in every area how far this body could represent the interests that it was supposed to serve in its capacity as the board of that area. This body has the same duty to everybody in two, three or possibly more areas. I do not understand how it will work. In some cases, there will be clashes, or at least different perspectives, between the hospitals that they represent.
Let us take a simple situation in which three PCTs each have a big district general hospital that may well have rival interests. If a service has to be allocated or a decision taken by the commissioning body or this cluster board on the basis that I have described, how will anyone be satisfied that the situation is fair between those three DGHs? I do not see how that will be achieved. One PCT responsibility is dealing with the allocation that it will still get as an individual PCT. How will the people of one area be persuaded that the proper decisions are being taken by a board that is no longer the representative or the chosen representative of the people in that area? I just want some answers to these questions.
I do not know what my noble friends think and I am not a natural troublemaker, but there are questions that have to be answered before this House or the other place can be satisfied. I very much hope that we will get some tonight. This issue clearly has not been properly thought through. I should be grateful to know whether my noble friend-he may want to shy away from this-can honestly say that he is clear that this process would be invulnerable to judicial review, which I very much doubt. I want him also to make it clear that the door is not shut on thinking again about some of the important issues that have been raised in this debate.
Like my noble friend I hope that this will not be pressed to a vote because the Government need to do some thinking and should be able to do it between now and Report. Ultimately, that depends on the reaction to what he says and whether we can have some hope that these issues will now be thought through and modifications made if necessary before we come back to this.
Baroness Murphy: My Lords, apart from the postgraduate dean amendments, the rest of the amendments in this group in effect fall into the category that one might call "Stop the Bill, I want to get off".
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The noble Lord, Lord Hunt of Kings Heath, says, "No, we can't do it now because it's too expensive and we have to save £20 billion". I suggest that it is not the £20 billion that we need to worry about; it is the increased costs that will continue to accrue through the changing demographics and changing technology over the next 20 to 30 years. If we continue to use the same direct management system, with its intermediate and many tiered system that we have used for the past 50 to 60 years, we will never address the challenges. All we will do is have a meagre, minor, reduced NHS of the same sort that we have now. We will have less and will not adapt and create something better. I am very much in favour of moving away from the direct management system with its so-called intermediate tiers, which I have served on as best I could over many years, to an independent regulator system where the providers at least are freed up and the commissioners, with the clinicians in charge, have the freedom to think about what they need to shape this service.
I agree with the noble Lord, Lord Newton, that the transition pathway in certain areas still needs to be clearly set out. We have had a clear indication of how that will work. Nevertheless, it is not all finalised. At this stage in the passage of a Bill, my experience is that things are put into place. That was certainly so in 1990 with the working on the patients' transition and the other transitions that were put into place by the Labour Party. There were arguments in this Chamber and the other place about the fact that everything was being set up. Proleptic appointments and the transition of structures were being made-heavens, it would have been improper if they were not. The fact that some of these changes are happening is very helpful.
The centred primary care trusts and strategic health authorities have been mentioned before. Is it not strange that two to three years ago nobody could wait to get rid of them because they were not performing very well? I agree that they have improved. Nevertheless they have not proved to be that helpful structurally, as they have become extremely bureaucratic and have not performed as well as we had hoped. To the noble Lord, Lord Rea, I would say that the speech made by the noble Earl some time ago could be repeated word for word today because there will be no private commissioning. There will be public sector commissioning that is supported in some instances only by the expertise of the private sector, which the noble Lord, Lord Warner, said is often very useful in these circumstances. I hope that the noble Earl will be able to reassure him about that.
It seems to me that if we want to create a new system-which I think we must, because the NHS cannot continue as it is at the moment-we will need some very serious structural changes. We need to progress and move on as quickly as we are doing now to get the SHAs and PCTs out of the way in an orderly fashion and to get the new structures for a new sort of regulated system in place.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): My Lords, Clauses 30 and 31 abolish strategic health authorities and primary care trusts and remove the relevant parts of the NHS Act 2006. Let me start by addressing the noble Lord, Lord Warner by setting out where I feel we have consensus, because I think there is some consensus.
There is agreement that decisions in the NHS need to take place at different levels and we need to ensure that decisions take place at the appropriate level. I agree with the noble Lord that these levels do include an intermediate tier and there are decisions which should happen. However, where we differ is on how best to facilitate these decisions. We do not feel that the best solution is to have separate statutory bodies to play this role. Instead, we propose flexible arrangements that will best meet the changing demands of what needs to happen at this level-hence the board's field force, which noble Lords have spoken about, which will be adaptable in the future to grow and evolve in partnership with CCGs. That is the background to our approach.
As we have already discussed, many of the necessary functions and duties SHAs currently undertake will, in future, be undertaken by the NHS Commissioning Board or by clinical commissioning groups. Where existing functions or duties are unnecessary, we are removing them, making the system more streamlined and reducing administrative burdens. The amendments in this group would prevent the abolition of strategic health authorities until such time as the Secretary of State is satisfied that all of their functions and duties have been transferred to other bodies.
I understand the importance that noble Lords place on getting the timing of the transition right. As the NHS Future Forum pointed out following its consultation exercise, some people felt that the changes were proceeding too quickly, while others were concerned that the pace of change was not fast enough. The forum recommended further changes to phase the transition, and the Government responded by postponing the abolition of SHAs by a year. I believe this allows enough time for a safely managed transition.
The NHS Commissioning Board is due to take on its commissioning responsibilities in April 2013, and we believe that it is vital that SHAs and PCTs do not continue beyond that date. There are two main reasons for that. A key aim of the Bill is to ensure that the functions and duties of all bodies within the system are clearly defined. To have a confusion of responsibilities would be a retrograde step. The second reason is that allowing SHAs to run beyond the current proposed deadline for their abolition would also incur extra costs and hinder the Government from meeting the efficiency targets set by the quality, innovation, productivity and prevention programme. I will say more about that factor in a moment.
Turning to primary care trusts, we expect PCTs to retain commissioning responsibility while clinical commissioning groups develop and establish themselves. Once clinical commissioning groups are able to take on their commissioning responsibilities, we intend that PCTs should be abolished, and this will occur in
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Where a clinical commissioning group is not able to take on some or all aspects of commissioning by April 2013, the NHS Commissioning Board will commission on its behalf, and in this role will be subject to the same duties of transparency and engagement. All clinical commissioning groups will have the right to take on full responsibility once they have demonstrated that they are ready.
I also hope that my statements regarding strategic health authorities and primary care trusts address the concerns of the noble Lord, Lord Beecham, and the noble Baroness, Lady Thornton, in relation to Amendment 245AA. There are a host of consequential amendments contained in Schedule 4 to the Bill which aim to ensure an effective transfer of responsibilities from PCTs and SHAs to the proposed new organisations. To remove these would result in legislative confusion and would also risk important functions not being picked up by the new organisations.
This leads on to Amendment 236AA, which would establish the sub-national functions of the board as separate, statutory, local NHS commissioning boards, each with its own full board of directors-in other words, a reinvention of the regional tiers in the NHS. I believe that this approach, recreating a statutory layer of management, would be not only unnecessary but also inefficient. It would almost certainly make it impossible to cut the overall costs of administration by a third, as our existing proposals will, creating savings to reinvest in frontline services. I cannot see how the new bodies that the noble Lord, Lord Hunt, proposes would add to accountability in the way that he suggested. The board will carry out a range of functions that will need to be carried out at both a national and a local level. We think it is best that these are carried out by a single body, with the autonomy and flexibility to design its own infrastructure, in a way that meets the needs of the local health service yet provides consistency nationally.
Turning to Amendment 256A tabled by my noble friend Lord Mawhinney, let me first say that I agree that it is vital to ensure a smooth transition of commissioning responsibilities to the newly established CCGs and to ensure that there continues to be proper governance of PCTs and PCT clusters in this initial period. I appreciate my noble friend's anxieties on this score. However, we continue to believe that PCTs and PCT clusters are best placed to do this by retaining their current structure and ensuring they continue to have governance arrangements in place. I will elaborate on that in a second. Where CCGs commission services for patients during the initial period, they will be doing so on behalf of PCTs through arrangements made under paragraph 11 of Schedule 6, rather than through exercising the CCG's own statutory functions. Until CCGs are able to carry out their commissioning responsibilities independently, the PCT will remain statutorily responsible for those functions.
My noble friends Lord Mawhinney and Lord Newton, to whom I apologise for my own extravagance of language last week, raised serious questions over PCT clusters. PCTs have been brought together into clusters precisely to ensure that accountability is maintained. Without clustering, the NHS would have seen PCTs being overseen by incomplete and patchwork teams of interim appointments as people in posts anticipated the abolition of PCTs and moved on to different organisations and roles. That would have led very definitely to unclear lines of accountability. Our view was that it represented a risk to ensuring that PCTs were able to continue effectively to carry out all their possibilities. Through clustering we have ensured that every PCT, through the cluster, will have a complete and able management team until, subject to Parliament, they are abolished. I would say to my noble friend Lord Newton that my clear legal advice is that clustering has a firm basis in terms of the use of legal powers and, furthermore, it is a reasonable use of those powers.
My noble friend spoke about conflicts of interest and the lack of proper representation on clusters. There is always the potential for any board member to come across a conflict of interest, and that is particularly true for non-executive positions, which are generally part-time and where people often have other roles outside of their non-executive responsibilities. It has therefore always been necessary for PCT boards to manage potential or actual conflicts of interest as they arise. We expect them to continue to do that in their new clustered states. We expect all board members effectively to work in the interests of the people served by all of the PCTs in the cluster and for non-executives and chairs to act in a manner that is in keeping with the Nolan principles.
We do not believe that, in effect, increasing the geographic scope of PCT board members by asking them to discharge their responsibilities on more than one board raises greater risks than may have existed with PCTs that were already very large. Some, as my noble friend knows, were already very large-all of Norfolk and all of Suffolk, for example. I hope that that explains at least the rationale for clusters and gives my noble friends some reassurance about the legal basis on which the clusters have been formed.
Lord Mawhinney: My noble friend knows that three months ago in the Peterborough PCT there was a non-executive chairman and six non-executive directors. To the best of my knowledge, they have all gone. What now constitutes the Peterborough PCT and how does it make decisions when a cluster refers something to it for legal validation?
Earl Howe: The clustering is a clustering of the boards. In other words, there is one board serving two or three PCTs, depending on the area of the country. The staff of the PCTs remain in place. There is capacity there to carry out the functions of PCTs. That is why PCTs remain statutorily accountable and they are in a position to perform the functions that the law places on them. We have streamlined the direction from board level. That is a practical and efficient thing to do and I do not think that it poses the kinds of risk that my noble friends were suggesting that it would.
I am very happy to meet both my noble friends again. I would say to my noble friend Lord Mawhinney that I was smiling when he spoke only because I know that Sir David Nicholson would be amused to be referred to as the chief technocrat. I would simply say that the NHS chief executive, while no substitute for me, I quite agree, may nevertheless prove helpful. That is certainly the object of his offer to meet my noble friend.
Lord Newton of Braintree: My Lords, I think that we are talking about conflicts of interest in two different senses. My problem about conflicts of interest goes back to the accountability point that the Minister touched on. These two or three PCT boards remain accountable at least in part to the people of the area they were appointed to represent. Then there is conflict of interest in the narrower sense. I am chair of the board of the Suffolk Mental Health Partnership. If I had an interest in a private sector mental health outfit, I would obviously declare that and that is normal business. I am talking about a fundamental conflict of interest between the people on these boards and the interests of the people to whom they are supposed to be accountable, wearing three different hats.
Earl Howe: My Lords, my point was that such conflicts have been managed in the past and can be easily managed in future. While there may be a specific example my noble friend wishes to draw to my attention, which of course I shall take seriously, I am not aware of any such examples. The clustering arrangement in practical terms is working efficiently around the country. Of course, I regret if hard-working non-executive directors who have served PCTs in the past have stepped down, because they have done sterling service, but it has been necessary to rationalise that structure.
Lord Beecham: Would the Minister care to reply to the rather disturbing question of the noble Lord, Lord Mawhinney, about the threat to members of the PCT who decline to resign and the consequent apparent disqualification from subsequent appointment?
Earl Howe: My noble friend refers to the current legal position-that a non-executive director can leave his or her office in only one of two ways: by resigning or by being forced to resign. There is no desire on anybody's part to force non-executives to resign. These are not non-executive directors who in some way have misbehaved-not at all. However, it is necessary in the interests of the NHS that we rationalise the system.
The proposal put before non-executive directors was that, in the interests of the health service, they should consider their positions. That is not because they have done anything wrong but because of the transition that we find ourselves in. I would ask any non-executive directors who are listening or who read Hansard not to take offence at this. It is no reflection of their service to the public or the health service; it is simply a reflection of the transition that we are going through.
With my noble friend's permission, I should cover some of the other questions that have been raised. Of the many functions transferring from SHAs,
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As the noble Baroness indicated, I have undertaken to come forward with more detailed proposals on education and training between now and Report. I repeat that assurance. Further work is under way on the detail of those arrangements with the right accountabilities for the quality of education and training to Health Education England and the professional regulators. That detail will be published as soon as possible. I hope I can reassure her that we have listened to the concerns in this area and that we are taking steps to address them
I would also like to address the matter of Clause 45 standing part of the Bill, which is part of this group. This clause will ensure that the Secretary of State will be able to establish new special health authorities only temporarily, for a maximum of three years. If there is a compelling reason for a special health authority to continue to exercise its functions beyond the three-year deadline, it is possible to extend its existence. However, any decision to do so would be subject to full parliamentary scrutiny via the affirmative procedure. This is to reflect our intention that any body in the health system exercising functions on a longer-term basis should have those powers transparently conferred on it in legislation.
The noble Lord, Lord Hunt, spoke about accountability. I think that, in fact, the board will be more accountable in many ways than existing NHS organisations. It will account to the Secretary of State and Parliament through the mandate and accompanying outcomes framework and the requirement to publish its annual business plan and annual report, and it will account for its decisions through the requirement to involve and consult the public over changes to commissioning arrangements.
I would say to the noble Lord, Lord Walton, that the precise structure of the board will start to take shape now that the NHS Commissioning Board Authority has been established to take preparatory steps towards the establishment of the board. The discussion document Developing the NHS Commissioning Board, published by Sir David Nicholson in July, set out the likely approach to how the board will be organised. It is clear that clinical advice will be central to the way in which the board operates, and clinical senates should be seen in that context, not as representing an additional layer of bureaucracy.
I would say again to the noble Lord, Lord Hunt, that the local workings of the board will be accountable through their work sitting on the health and well-being board, as well as needing to have regard to the joint
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Lord Warner: I am sorry to interrupt, but I am really bemused by what the noble Earl has just said about the accountability of the local entity of the national Commissioning Board to health and well-being boards. Health and well-being boards have no budgetary responsibility whatever, as I understand what the Government are saying; whereas the national Commissioning Board has two lots of budgetary responsibility-for its own specialist commissioning and for its oversight of the money that it hands out to clinical commissioning groups. Perhaps the Minister can explain it to me. I can understand that it might want to consult the health and well-being boards but, in terms of accountability, I cannot understand how it can be accountable for its budgetary priorities and decisions to the health and well-being boards.
Earl Howe: It is accountable for its decisions at a regional or sub-national level in a real sense. If it was not interacting with the boards, the noble Lord, Lord Hunt, might have a point; but it will be. I think that that is accountability in a meaningful sense. The noble Lord, Lord Warner, talks about budgetary accountability, and I understand that that is a real issue. Of course there will be no budgetary accountability, but there will be accountability for the decisions and actions taken by the field forces.
I was saying that the structure means that all too often neither of the roles that PCTs perform is performed well. GPs, who actually make the clinical decisions, are not properly involved in PCT commissioning; and PCTs do not have the detailed understanding of their communities or the link to other local public services. The result is an unsatisfactory compromise, with commissioning that fails to deliver improvements in health outcomes and local services that are fragmented and not integrated.
It has been suggested by some noble Lords that one could have kept PCTs and parachuted in a whole lot of doctors, perhaps filtering out some of the administrators. Anyone who has visited any pathfinder CCG and put that question to the doctors and other clinicians involved will know the answers to why that would not have been a valid and sensible idea. The way in which services are commissioned has to depend on the judgment of clinicians and the wisdom of establishing geographic areas for commissioning groups that make sense in terms of patient flows and in terms of links with local authorities, social services and public health. It does not make sense to retain structures that, frankly, are administrative constructs that do not necessarily bear any relation to patient flows or relationships with local authorities. These clinical commissioning groups are
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The noble Lord, Lord Hunt, suggested that the pathfinder CCGs were being built on nothing at all. They are not being created from nowhere. They are building on, and are indeed a logical development of, practice-based commissioning groups, of which there were a very significant number. There are currently 266 pathfinder clinical commissioning groups covering 95 per cent of GP practices in England. As I have indicated before, I cannot say how many we will eventually end up with, but that will give noble Lords a rough indication of the order of magnitude.
The noble Lord, Lord Rea, quoted some words of mine from a debate of several years ago. I would simply say to him that I was speaking then of something completely different from the Government's current proposals, and I am grateful to the noble Baroness, Lady Murphy, for pointing that out. These reforms place leadership of commissioning firmly with clinicians. I completely agree that giving leadership to a non-statutory, private-sector firm would be a bad idea. That is why there are very clear safeguards against this happening. With PCTs, I feel that there was a genuine question over where commissioning leadership really lay, and this is very firmly no longer the case.
On Amendment 236A, I must clarify one point. It is not the case that a clause stand part debate on Clause 30 would be consequential if a Division was to be called on Amendment 236A and won. It would simply amend this clause and not entail that it needs to be removed.
I hope that I have sufficiently covered the issues raised by noble Lords. I do not suppose that I have satisfied everyone, but I hope that I have at least indicated the direction of government policy in a coherent way.
Lord Rea: The staff of PCTs below management level are going to be rather disappointed that the Minister did not answer my question regarding their employment and the possibility of their being moved over to the CCGs, where many of their functions are going to be precisely similar. Are they going to be made redundant? Is it going to be possible to move staff over smoothly without a break in their employment status?
Earl Howe: My Lords, the rules apply on transfer of employment, and we anticipate that around 60 per cent of PCT staff will transfer to clinical commissioning groups, local authorities or the NHS Commissioning Board. It has been necessary to institute a programme of managed accelerated retirement for those for whom there will be no posts. However, this is being done in as friendly and generous a way as possible and the process is working well. But on the noble Lord's main concern, yes, the terms and conditions of employment should not alter for those who stay.
Lord Warner: Could the Minister give us an assurance that before Report he will give us some idea of the extent to which the current arrangements are going to meet the targets set by the Government for delivering the Nicholson challenge for this coming year, so that we can see the extent to which the Government are at risk if they abolish the SHAs from April 2013?
Earl Howe: My Lords, the SHAs have already published their plans for delivering the Nicholson challenge and those are on the SHA website. There is no secret about that. I can tell the noble Lord that we are on target to deliver the Nicholson challenge over the four-year period as a result of savings already made.
Lord Hunt of Kings Heath: My Lords, this has been a very interesting and instructive debate. I should tell the noble Earl, Lord Howe, that I do not have a rose-tinted view of primary care trusts. They were improving, I believe. But the question that I put to the Government is why on earth, instead of going through this convoluted and complex restructuring, they did not say immediately to primary care trusts that they should divest themselves of the services that they ran and get a move on with giving more responsibility to GPs? They could have done it on their first day, instead of which, instead of SHAs and PCTs, we have a much more complex structure, with clinical commissioning groups, health and well-being boards, senates, the NHS Commissioning Board and-blow me down-their field offices as well. I can tell the noble Baroness, Lady Murphy, that as the NHS Confederation says, we now have a very complex structure-not a streamlined approach that will deal with all the problems of the NHS. My goodness me, this structure will cause as many problems as it is potentially there to deal with.
There are some very serious questions about how the Government have done this. I am glad to know from the noble Lords, Lord Mawhinney and Lord Newton, that I am now part of the same region as they are. I look forward to further discussions and perhaps meetings in Nottingham from time to time, if we are summoned together.
The fact is that, in effect, primary care trusts have been abolished in advance of legislation. I understand what the Minister says-that by creating a cluster with non-execs from the PCTs, in effect those non-execs become the non-execs of each primary care trust. That is how the Government are essentially doing it, but that is a very disingenuous way in which to deal with the issue. They are skating on very thin ice, and the potential for judicial review is, I suspect, quite considerable.
Let us take this issue of the interest of the non-execs in Peterborough and Cambridge. I do not know the area particularly well, but let us say that, because of the financial issues facing Peterborough, a decision was made by the cluster to reduce services in Peterborough and ensure that those patients then went into Addenbrooke's. I suspect that might well be a proposal. The question arises as to the legitimacy of that decision if people in Peterborough think that they are being marginalised from that decision. That some bold decisions need to be taken I do not doubt, but I suspect that there will be some issues about legitimacy.
As for the issue of tiers, my noble friend Lord Warner is surely right. Since 1948, the health service has not done without a regional tier. The fact that the Commissioning Board is going to have to set up local field forces is a recognition of that, but they will have a heavy responsibility. The financial challenge, the reconfiguration challenge and the specialty challenge call for strong leadership at that level. My argument for the Minister is that they surely need to be accountable and seen to be accountable in their communities. I do not believe that in the end the mandate set by the Secretary of State or the outcomes framework really satisfies that kind of accountability, given that they are clearly going to have to intervene at local level and deal with issues to do with finance and reconfiguration.
I have listened to the noble Lord, Lord Mawhinney, when he advised me not to oppose that Clause 30 or 31 stand part of the Bill. I fully accept what he says. However, as the Minister has made clear, my Amendment 236A stands apart from that. It is a question of timing, and I do not believe that these changes should take place until we are sure that they are right. I beg leave to test the opinion of the House.
Lord Hunt of Kings Heath: My Lords, we come to a no less interesting subject than the issue of fluoridation of the water supply, which I know will be of interest to many noble Lords. I ought to start by declaring an interest as president of the British Fluoridation Society and, as someone convinced by the benefits of fluoridation, I want to ensure that those benefits continue in the future.
In 1964, Birmingham became the first UK city to introduce a water fluoridation scheme. By 1970, six years after its introduction, the number of teeth affected by decay in five year-olds had dropped by 46 per cent in a part of Birmingham, Northfield, as compared to those in Dudley, which fell by only 2 per cent. A report by the regional director of public health in 2006 found that children in fluoridated areas of the West Midlands with relatively high levels of social deprivation often had better dental health than children in relatively affluent areas where water supplies were not fluoridated. I am keen that progress continues to be made and that more areas are fluoridated in the future. The question before us is whether the arrangements in the Bill actually help or hinder that.
Under the new arrangements, it will be for a local authority, or local authorities, to make a proposal on fluoridation to the Secretary of State. If the Secretary of State agrees that such a proposal should be supported, the proposer must notify all other local authorities affected by the proposal and make arrangements as to how they should proceed. Regulations are apparently to be made on how local authorities might come to a consensus view.
An important question arises as to payment. The current 1999 Act provides a mechanism under which authorities can be made to bear the full cost of fluoridation. The Secretary of State can require the local authorities affected by arrangements made by the Secretary of State for the fluoridation of water with the water undertaker to meet the Secretary of State's cost incurred under the terms of the arrangement. In the new situation that we have, I am concerned that the whole process of approval and funding of such schemes seems to be rather convoluted. I hope that the noble Baroness may be able to reassure me on this point.
The first key question is: will there be sufficient resources to meet the cost of existing or future fluoridation schemes? Local authorities do not, of course, provide dental services and they do not have dental service budgets to call upon; yet clearly the impact of fluoridation is to reduce tooth decay. If less money is spent on
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At this stage, this is essentially a probing amendment to ensure that the Government are as committed to fluoridation schemes as I believe they ought to be. I see that the noble Earl, Lord Baldwin, is in his place. From my point of view, the evidence is convincing. It is important that if local authorities come to a view that they wish to fluoridate or to continue to fluoridate, the money will still flow as smoothly as the fluoride in the water in places that are lucky enough to benefit from water fluoridation schemes. I hope that the Minister can assure me.
Earl Baldwin of Bewdley: My Lords, I support what the Government are doing here, though with some reluctance, for reasons that will not surprise the noble Lord, Lord Hunt. I am reluctant for two reasons that lie at the heart of a fluoridation policy: the scientific evidence for it and the medical ethics. It will pay to revisit those briefly this evening.
It is now 15 years since I started putting down Questions to the Government, chiefly on the evidence surrounding fluoridation. In the late 1990s the previous Government conceded that the studies they relied on were old and not of very good quality. Sir Iain Chalmers, a leading healthcare scientist who was then director of the UK Cochrane Centre, joined me in pressing for a high-quality systematic review. The Government agreed. That review, which came to be known as the York review, was conducted by the NHS Centre for Reviews and Dissemination at the University of York. I served on its advisory board as it examined 50 years of the world literature. The results, published in 2000, surprised many people.
Not one good-quality study could be found. This meant that nothing could be stated with clear confidence: not efficacy in preventing caries-though that did appear likely-not safety, and significantly not the hoped-for evidence that fluoridation might even out the inequalities in dental health between social groups. So poor was the evidence for that question that the four senior research scientists who were involved in the review described it in a letter to Health Ministers at the time as "weak, contradictory and unreliable".
I know from the previous amendment that it is dangerous to quote the noble Earl, but I was interested to reread the speech of the noble Earl, Lord Howe, on the regulations of the Water Act in 2005, and to read that he, too, was impressed by the lack of good evidence as shown by York. I emphasise that the York review was not just any old review-there have been plenty of those. This was a Rolls-Royce systematic review, conducted to the highest international standards, the only one of its kind in the field. A more recent Australian systematic review has been unable to find anything that would change York's conclusions.
I wish I could say that this better understanding of the evidence had influenced policy. Having accepted
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The question of ethics, which is my second objection, can be put in a nutshell. In our society, a person faced with a healthcare intervention is free to accept or reject it. This is the principle of individual informed consent. We find it in case law and in pronouncements from all kinds of medical bodies. Fluoridation is invasive and unavoidable. Therefore fluoride designed to protect teeth should not be delivered by this method. I could say much more, as indeed I have many times in your Lordships' House, but now is not the time or the place. These twin objections, evidence and ethics, are what motivate most of the large number of people who oppose community water fluoridation.
Given, however, that such schemes exist, and that the Government are determined to provide for new schemes, how best should they be structured? I believe that what the Government are proposing here is a significant improvement on what went before. The old system where water companies had a veto over new schemes was clearly not ideal. Since the Water Act 2003, strategic health authorities have been in the driving seat. Curiously enough, the All-Party Group against Fluoridation that I subsequently chaired was given an assurance by Health Ministers in the previous Government that they would put elected local authorities in charge, as is now proposed. However, when it came to their Water Act, it did not happen.
The problem with the unelected SHAs was-is-that they almost inevitably reflected the dominant medical view. Fluoridation was a classic case of premature consensus, on weak evidence from the 1950s and 1960s, and it became a kind of sacred cow, resistant to new evidence, as I have indicated with the York review. The regional director of public health who advised the SHA that recently decided to fluoridate Southampton, against the expressed wishes of its population, described fluoridation correctly as the "professional orthodoxy". Sir Iain Chalmers, who knows more about medical evidence than most people, has described it publicly as a "religion".
A most unfortunate feature in all this is that so many prominent bodies should have signed up with the National Alliance for Equity in Dental Health as campaigners for fluoridation-not just supporters, campaigners. The website of the British Fluoridation Society shows the British Dental Association, the British Medical Association, the Faculty of Public Health Medicine, the NHS Confederation, the UK Public Health Association, among dozens of other such bodies, including some royal colleges and about 60 primary care trusts. If you have signed up to a campaign, not only are you compromised in terms of impartial advice but it is very hard to draw back. It is much easier to keep going forward with your professional peer group. And, if you are the people whose advice is being sought and heeded, there is likely to be only one outcome.
While fluoridation continues, these clauses may offer the least worst way forward. In parenthesis, referendums would show more clearly what local people want. There have been quite a number in America, but as they have tended to reject fluoridation the Government may be wary of them. Even here, to have your healthcare treatment decided by a majority vote of your neighbours is not a principle known to medical ethics. At least local authorities are accountable to the populations they serve and, while quite properly taking advice from all quarters, should be better able to gauge than the SHAs have been what is right for their communities. People should not have to accept what Big Brother, or rather Big Doctor, thinks is good for them. I broadly support these clauses, but the devil will be in the regulations.
I conclude by putting three questions to the Minister. First, will she consider providing for a neutral body to set out the current state of the evidence in any future public consultation? This was suggested by Iain Chalmers back in 2003. Some of the misstatements during the Southampton consultation were pretty terrible. Secondly, will she include in that a revision of the Chief Dental Officer's guidance letter of February 2008 to decision-makers over fluoridation? I think that the noble Earl, Lord Howe, suggested to me that this would happen. Thirdly, will she give the undertaking, given by the previous Government during the passage of the 2003 Act and the regulations in 2005, that no new scheme will go ahead unless the local population is in favour? If so, will she ensure that any undertaking given-the noble Lord, Lord Warner, who is not in his place, was one who gave it at the time-will not be watered down in the regulations so as to lose its effect, as happened last time?
Baroness Eaton: My Lords, like the noble Earl, Lord Baldwin, I feel that there is an improvement in the fact that fluoridation of the water supply should be determined locally. Local authorities are democratically accountable bodies, and surely they are the best placed to make decisions on behalf of the local population.
My concern, not just about this section of the Bill but about the amendment of the noble Lord, Lord Hunt, is around consultation and the ethical issue, which we have already heard mentioned, about the fluoridation of water and what that creates. I would appreciate hearing whether the processes by which the public are consulted about the fluoridation of water could enable communities to reject proposals to do so.
Members of the public are very cynical about consultation. They believe that, whenever their opinions are requested by any public body, no one takes action based on those opinions. It is important that communities are consulted and that the results of those consultations are taken notice of. The effect of fluoride on teeth may be a matter for dentists, just as the effect of fluorides on the rest of the anatomy may be a matter for scientists or doctors, but the question of whether it is right to use public water supplies to convey to the entire population a medication that is intended to influence the bodily development of 0.4 per cent of the population-that is, children whose teeth are
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I would be grateful if the Minister could reassure the House that consultation as referred to will actually have meaning and that local authorities, consulting on the matter of water fluoride with the residents, should be bound by the results of such consultations. It appears that the Bill allows the Secretary of State to ignore the results of consultation. Would the Minister explain this and give examples of where she envisages the Secretary of State taking decisions that disregard the results of the consultation?
Baroness Gardner of Parkes: My Lords, when I saw that the noble Lord, Lord Hunt, was moving that this clause not stand part, I could not believe it-I thought that someone from Birmingham could not possibly be anti-fluoride. Having listened to him, I now understand what he is on about and that is a slightly different angle.
I am strongly in favour of water fluoridation. The noble Earl, Lord Baldwin, tells us that he has been tabling questions for 15 years, but the issue has been before this House for much longer than that. We had probably the bitterest debate I have ever seen in my life in the House in about 1983, following the Strathclyde judgment. Strathclyde is a place in Scotland-given the current Leader of the House, I suppose I hardly need say that-where the council introduced water fluoridation. Suddenly, decay in children's teeth decreased by 40 per cent. Then local people got very upset and said, "We don't want this; it's poison and it's terrible". The fluoride was taken out of the water, and immediately dental decay went right back up again. A court case was brought-I have not read the decision because it is 400 pages long-and the court ruled that fluoride was not a poison in the water, and after that other authorities put it in. As I say, though, the debate here was very bitter, and I am pleased that those who have spoken against fluoridation today have not shown the same bitterness that we had at that time, when people almost got up off their death-beds to come in and oppose it.
There are a number of other points that I feel I must take up. The noble Earl, Lord Baldwin, was talking about the Australian comparison. I had an interesting visitor from Australia, the shadow Minister for federal health, or the federal Minister for shadow health-I think I have got that muddled up, but anyhow he is the opposition man on health. He was telling me that in Australia it has become very fashionable to drink bottled water, and they have found that people who are drinking that water are all getting dental decay back again, which again proves how effective fluoride is. I have a nephew who is a dentist in Sydney, and he tells me that he can tell if a boy has come from the country where all you would have to drink would be rainwater or water from a river-they come in with terrible teeth and you can spot them immediately.
The noble Baroness, Lady Eaton, asked whether this is medication, and what about pure water? At one stage I was very involved with the water supply for London. Thames Water explained to me that every drop of water that we consume has been used eight or
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I also have been asking questions for a very long time. One question that is highly relevant is: what is the difference between the decayed/missing/filled rate-that is the dental classification-between Birmingham, which has the best teeth, and Manchester, which has probably the worst? The difference is vast. When I have asked the further important question, "What's the difference in their health? Is there a difference in the pattern of what people die from or what illnesses they contract in Birmingham?", the answer is that there is no difference. There is exactly the same health pattern in both these areas, but the difference is that one has better teeth than the other.
I still have a few questions to ask the noble Baroness. For example, we keep using the words "operable" and "efficient" everywhere, and asking whether something is or is not operable and efficient. Who will decide whether it is operable and efficient and what sort of criteria will be used?
I also notice that, in Clause 32(9), new Section (3A) refers to the Secretary of State wanting to make the fluoride proportion lower than the general target concentration. The target concentration is one part per million, and when water is being reused it is often required to reduce it to one part per million. However, that is not what this clause says. The clause says that the Secretary of State might want to reduce it to below the optimal point, which puzzles me. I should like to know in what sort of circumstances the Minister envisages wanting fluoride in the water but also wanting to reduce it. I could understand it if the time came when it was proved that there was some problem. That could then be the case but, if it were, surely new and urgent legislation would be needed immediately. People complain that there is too long or too short a time in which to test something, but you could not really say that the period since 1964 is too short. It really has been tested for a very long time without ill effects on people's health.
It is very important that these clauses are kept in. I hope that the money will be found, and I am not really worried about where it is found from. There are small children in Manchester, often from ethnic communities, whose first presentation to the dentist means that they have to go to hospital to have all their baby teeth taken out under general anaesthetic. That is just not good enough and could be prevented if fluoride was in the water there.
Lord Colwyn: My Lords, my noble friend Lady Gardner reminds me of how I used to practise. It is not a lot of fun to pull a load of teeth out for a child under general anaesthetic. We are in great danger of getting into a pro and anti-fluoride debate, which I do not want to do. However, I want to support the noble Lord, Lord Hunt, who is a patron, or vice-president, of the British Fluoridation Society, as am I.
As it stands, Clause 32 will mean that after 1 April 2013 the money currently spent on the existing NHS schemes will pass to local authorities, which do not have a dental budget. They would have to pass it on to the Secretary of State via Public Health England to pay the continuing bills. Would it not be more efficient and quicker if the current NHS spend on fluoridation went directly to the Secretary of State-that is, Public Health England? It would mean that the organisation that pays the bills has the money in its account and is not reliant on transfers from local authorities.
As the Bill stands, when any new schemes are agreed by local authorities after they take charge of consultations on fluoridation, the Secretary of State will look to them to pay for those schemes. However, local authorities are not responsible for dentistry and have no dental health budget. The amendment of the noble Lord, Lord Hunt, means that although local authorities will be the decision-making bodies in future, the money for any fluoridation schemes that they support will come from the dental health services budget of the NHS Commissioning Board-the body that stands to benefit from the reduced treatment costs that would inevitably follow. The NHS Commissioning Board would transfer funds to the Secretary of State, who would pay the bills submitted by the water companies. Does the amendment of the noble Lord, Lord Hunt, not simplify the process?
Baroness Northover: My Lords, let me first set out the Government's position on fluoridation. The Government's policy is that decisions on fluoridation should be taken locally. That is why we have transferred the responsibility for conducting consultations and determining their outcome to local authorities. More than 5 million people, mainly in the West Midlands and the north-east of England, receive a water supply in which the fluoride content has been topped up to a level of one part per million. Worldwide, some 200 million people now receive fluoridated water in the United States and 11 million more in Australia. There are also fluoridation schemes in Ireland, Canada and Hong Kong.
I hear what the noble Earl, Lord Baldwin, said about evidence. A report, A Systematic Review of Public Water Fluoridation, commissioned by the department of health at the University of York, was published in September 2000. It concluded that water fluoridation increased the proportion of children without tooth decay by 15 per cent and that children in fluoridated areas had, on average, 2.25 fewer teeth affected by decay than children in non-fluoridated areas. However, as the debate has shown, there is a great range of views on this matter. That is why we feel that decisions must be taken at a local level following extensive consultation.
Our view is that the responsibility for proposing fluoridation schemes and for conducting consultations on such schemes should transfer to local authorities, while the responsibility for contracting for fluoridation schemes should transfer to the Secretary of State. In practice, the Secretary of State's functions would be carried out by Public Health England. Making local authorities responsible for consultations on fluoridation schemes fits well with their responsibilities for public health. We anticipate that proposals for fluoridation schemes will derive from the joint strategic needs assessments that local authorities and health bodies will make of their populations.
The noble Lord, Lord Hunt, raised the question of whether local authorities would neglect dental health. Dental ill-health would seem to have wider repercussions. The great difficulty, particularly among older people whose teeth have decayed, certainly bears out the necessity of preserving teeth in younger life. It is not simply a matter of looking at children's teeth and the impact on them but of seeing dental health as lifelong. Health and well-being boards would therefore have a responsibility to consider dental health because of that significance.
More than one authority might be involved in any scheme that is put forward because water distribution systems are generally larger than the area of an individual local authority. The Bill sets out a number of initial steps that the lead or proposing local authority must take, including consulting relevant water undertakers and the Secretary of State to ensure that a proposed scheme is operable and efficient. Unless only a single authority is affected, or the other affected authorities do not wish to participate in the process, the Bill requires local authorities to arrange for a joint committee to carry out the consultation process and make subsequent decisions in relation to the proposal. From 2013-14, the department intends to allocate a ring-fenced public health grant to local authorities. The ongoing costs of fluoridation schemes will be reflected within the grant to those local authorities.
The noble Earl, Lord Baldwin, asked about neutral information. This is an area where we should proceed on the basis of evidence. Public Health England might well be the right body to assess such evidence. The noble Earl also asked about schemes going ahead only with the support of the local population. The provisions in the Bill transfer responsibility for consultations to local authorities and include powers for the Secretary of State to specify the steps that local authorities must take in relation to consultation. We expect that the evidence base will still determine a decision to consult. However, putting local authorities in charge of consultations would make decisions on fluoridation more democratically accountable. We intend to consult on the detail of the regulations, including the process that local authorities must follow when ascertaining public opinion.
My noble friend Lady Eaton asked whether people would be able to reject local fluoridation. Of course, consultation needs to be meaningful. The decision to consult and whether to fluoridate will be for local authorities, not the Secretary of State, to take. We expect them to take account of the scientific evidence as well as public opinion.
I acknowledge that these provisions and the whole area are complex. Much of the technical detail will be included in regulations. No doubt we will have further profound discussions of this. We intend to consult on the policy proposals for the regulations that we will make under the powers in this clause in a consultation document that we will publish in due course. In the light of this, I hope that noble Lords will be content not to move their amendments, and that the noble Lord, Lord Hunt, will be happy for the clause to stand part of the Bill.
Lord Hunt of Kings Heath: My Lords, I am very grateful to the noble Baroness, the noble Lord, Lord Colwyn, and the noble Baroness, Lady Gardner of Parkes, for their support for fluoridation. The noble Earl, Lord Baldwin of Bewdley, with whom I have very much enjoyed taking part in previous debates on fluoridation, put his points powerfully. I do not agree with him, but that is not the point at issue tonight. I certainly agree with the noble Baroness, Lady Eaton, that the transfer of responsibility from SHAs to local authorities is a key advance. Birmingham City Council took a decision in this regard in 1962, which had a very positive impact on oral health in Birmingham and led to a more general introduction of fluoridation through much of the West Midlands.
I note what has been said about the role of health and well-being boards in relation to oral health. That is important. I also note that the Government believe that this is a local matter. That is fair enough, but I hope that the Government will also take a somewhat more strategic role. It is for the Government to make the general point that improving oral health is a good thing to do and that fluoridation can play its part. I hope that in saying that this is a local decision, the Government will remain in support of the general principle of fluoridation.
On funding, I took the noble Baroness to mean that a part of the ring-fenced grant to be given to local authorities in relation to their new public health responsibilities will reflect the cost of fluoridation schemes in areas that currently have fluoridation. I hope that she will confirm that in writing. For instance, Birmingham City Council will get an additional grant because the water is being fluoridated. Taking that principle further, I assume that if Manchester finally decides to fluoridate its water schemes, the city council will then receive an additional grant. That is very important.
As regards the convoluted and complex basis of the legislation, it is hard to see how the money circulates. I will not press my opposition to this clause stand part debate but I hope that the Government will give a little more thought to whether they can come up with a rather more straightforward approach to how the money circulates. The present arrangement is rather complex. I am very grateful to noble Lords who have taken part in this debate.
We humans occupy more ecological niches than any other species on the planet. This is because our brains are superlatively evolved to adapt to our own particular environment: a process known as neuroplasticity. Thanks to their plasticity, the connections between our brain cells will be shaped, strengthened and constantly refined by our individual experiences. It is this personalisation of the physical brain, driven by unique interactions with the external world, that arguably constitutes the biological basis of each individual mind, so what will happen to that mind if the external world changes in unprecedented ways, for example with an all-pervasive digital technology?
A recent survey in the US showed that over half of teenagers aged 13 to 17 spend more than 30 hours a week, outside school, using computers and other web-connected devices. It follows that if the environment is being transformed for so much of the time into a fast paced and highly interactive two-dimensional space that is unprecedented, the brain will adapt accordingly, be it for good or ill, in unprecedented ways. Professor Michael Merzenich, from the University of California, San Francisco, gives a typical neuroscientific perspective. He states:
"There is a massive and unprecedented difference in how their (the digital natives') brains are plastically engaged in life compared with those of average individuals from earlier generations, and there is little question that the operational characteristics of the average modern brain substantially differ".
The implications of such a sweeping change in mindset-let us call it mind change-must surely extend deep and wide into future education policy. Most obviously, time spent in front of a screen is time not spent doing other things. Indeed, several studies have already documented a link between the recreational use of computers and a decline in school performance. More basic still, though, is to understand in the first place why a screen environment using only sight and sound out-competes three-dimensional activities with all five senses stimulated.
Perhaps most important of all, we need to understand the full impact of the current cyberculture on the emotional and cognitive profile of the 21st century mind. Inevitably, there is no single catch-all soundbite but rather a variety of diverse issues. In the brief time permitted, let us look at just three. First, what is the impact of social networking sites on interpersonal skills and personal identity? Eye contact is a pivotal and sophisticated component of human interaction, as is subconscious monitoring of body language and, most powerful of all, physical contact, yet none of these experiences is available on social networking sites.
It follows that if a young brain with the evolutionary mandate to adapt to the environment is establishing relationships through the more sanitised medium of a screen, the skills that are so essential for empathy may not be acquired as naturally, as well or as quickly as in the past. In line with this prediction, a recent study from Michigan University of 14,000 college students has reported a decline in empathy over the past 30 years, which was particularly marked over the past decade.
Such data in themselves do not, of course, prove a causal link, but just as with smoking and cancer some 50 years ago, epidemiologists could investigate any possible connection. Similarly, the factors should be explored that account for the appeal of the cyberworld for those with already recognised impairments in empathy, typifying autistic spectrum disorders. What about exploring other coincidental trends for a causal link, such as the obsession with the solipsistic read-out of unremarkable moment-by-moment daily routines, for example through Twitter? The psychologist Sherry Turkle, from MIT, has argued persuasively in her recent book Alone Together that the more continuously connected people are in cyberspace, paradoxically the more isolated they actually feel. More worrying still is the tendency to define oneself by the amount of attention garnered online, particularly when excessive bullying, spitefulness and plain cruelty are used to enhance such attention, as with the pernicious trend of "trolling". Might these phenomena, based as they are on the reassurance of incessant feedback, indicate a less robust sense of identity?
Secondly, on video games, I declare an interest as a patron of the charity Safermedia, and mention that I recently met representatives from the industry who are very keen to discuss the best way forward in the light of growing concerns. For example, neuropsychological studies suggest that frequent and continued playing might lead to enhanced recklessness. Perhaps this is not surprising as it is surely a dangerous lesson to learn that actions do not have consequences and that victims of a shooting can become "undead" the next time around. In addition, data indicate reduced attention spans and even possible addiction. In line with this, significant chemical and even structural changes are being reported in the brains of obsessional gamers that require at the very least wider discussion beyond the scientific community.
No single paper is ever likely to be accepted unanimously as conclusive, but a survey of 136 reports using 381 independent tests and conducted on more than 130,000 participants concluded that video games led to significant increases in desensitisation, physiological arousal, aggression and a decrease in prosocial behaviour. Needless to say this "meta-analysis" has itself been criticised, but then such is the iterative nature of evaluating research. This is neither the time nor place for an exhaustive review of the literature, but there should be a means for all these burgeoning scientific findings to be translated on a rolling basis into simple, jargon-free summaries which the non-specialist can readily access, evaluate, and, most importantly, question.
Thirdly, on search engines, can the internet actually improve cognitive skills and learning, as has been argued? The problem here is that efficient information
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"I worry that the level of interrupt, the sort of overwhelming rapidity of information-and especially of stressful information-is in fact affecting cognition. It is in fact affecting deeper thinking. I still believe that sitting down and reading a book is the best way to really learn something. And I worry that we're losing that".
We need to understand much more about the impact of search engines on comprehension skills. I suggest that the difference between processing and isolated fact, and understanding it, is the ability to place that fact into a wider conceptual framework that indeed gives it a meaning. Hence, the famous line from "Macbeth"-"Out, out, brief candle"-is powerful, not because of the literal image of a flickering flame but because the extinction of that flame can be linked to the extinction of life.
Conceptual frameworks can also have a time dimension: hence the meaning of an object or a person can be derived from how that object or person has connected to events and relationships in the past. This is why perhaps the characters in novels are compellingly meaningful in a way that an icon in a computer game is not. When you play a game to rescue the princess, you probably do not care much about her as a person.
Given the plasticity of the human brain, it is not surprising that adaption to a cyberenvironment will also lead to various positives-for example, enhanced performance in a variety of skills that are continuously rehearsed, such as a mental agility similar to that needed in IQ tests or in visuo-motor co-ordination. However, we need urgently to gain a much fuller picture.
I agree that the UK Council for Child Internet Safety-UKCCIS-already brings together more than 170 organisations and individuals from diverse sectors to keep children and young people safe online. However, much more is surely needed than minimising the threats. The time has come to start to maximise the opportunities. Whether it be through UKICCIS or some other co-ordinating organisation, or even a new mind-change initiative, I urge the commissioning of epidemiological studies exploring the significance of various societal and medical trends in relation to a screen-based lifestyle, as well as ring-fencing funds for basic brain research into, for example, the neural mechanisms of addiction and attention, the long-term effects of various screen-based activities on brain structure and function, and the neural processes perhaps underlying deep understanding and creative insight.
The design of truly innovative software that attempted to offset some of the perceived or agreed deficiencies arising from the current digital culture would also be enormously valuable. Most immediately we need more detailed profiles and breakdowns of computer use in the UK, along with surveys of the views and insights of various relevant sectors such as parents, teachers and employers, who until now have had no voice. Then finally, in the light of all this input, this hypothetical body would make recommendations for proactively planning the most effective environment. It might well include a root and branch, paradigm-shifting
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Currently, we are in an economic crisis, but this would be massively helped by innovative wealth creation, new types of jobs, new and more varied types of training for the growing numbers of unemployed school-leavers and possibilities other than a conventional university education whereby only one in 80 graduates can obtain an appropriate job.
Science and technology are transforming society. We have an extended life span and extended leisure time. Could not baby boomers who currently feel undervalued but have precious entrepreneurial and interpersonal skills be teamed up with the younger generations who are so adept at cutting-edge digital technologies, so that they could develop and commercialise unprecedented goods and services that neither group could conceive or produce unilaterally? Such a scheme could be brokered by the Government and funded by the companies currently dealing only with student loans-along with investment from the private sector. These ventures would be based on a comprehensive appreciation of not just how the future consumer will think and feel but on innovative ways for bringing real added value to them.
Like climate change, this transformational scenario of mind change is complex, unprecedented and controversial. However, unlike climate change, the end point is not one of just damage limitation but rather of ensuring that we deliver to the next generation an environment that can for the first time enable the realisation en masse of each individual's full potential.
Lord Black of Brentwood: My Lords, I am sure that we are all indebted to the noble Baroness, Lady Greenfield, for securing this debate, which is of huge long-term importance to our society. I had the pleasure of sitting next to the noble Baroness a year or so ago at a dinner for Autistica, which does such remarkable work in the field of autism, and I know from our conversation how passionately she feels on this subject. We are incredibly lucky that she has introduced this debate.
I should begin by declaring an interest as executive director of the Telegraph Media Group, as it is a company with digital technology at its heart. Perhaps more so than for any other sector of the economy, embracing digital is vital for the future of the media because the ways in which people consume and indeed participate in news in an online world have altered fundamentally in the past decade. News is now an active commodity to which people can contribute rather than just absorb. That is just one aspect of the way that the internet has changed people's lives-especially now that it is so easy to access.
Thanks to the decline in the cost of PCs and vibrant competition in the UK's broadband market, digital technology is part of the life of at least three-quarters of the population. Of course, it is not just at home that people access digital technology. Smart
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The noble Baroness has talked rightly about some of the problems of this sea change in the way we live, but it is worth while reflecting on some of the positive contributions that can take place in a young person's development-and in particular on the impact of social networking sites, such as Facebook, MySpace and Bebo. These sites-and it is a characteristic of the internet in general-can be valuable in three ways. They are participatory, they force users to learn new interfaces, and they create new channels for social interaction.
A study published this year in Australia, The Benefits of Social Networking, found that these sites can in fact help deliver beneficial educational outcomes as well as facilitating supportive relationships and promoting a sense of belonging and self esteem. Of course it is vital that these sites are used responsibly, and there is a plethora of controls in place to underpin this. However, if that is done, social networking can help the flexibility of the mind and encourage the formation of political, ethical and cultural identities. Young people can also use such sites to access news in a way that they perhaps would not from a printed paper-and that is extremely useful in fostering an interest in current affairs and civics. All that is good for the mind.
The noble Baroness will be aware of a body of work undertaken by Steven Johnson in the United States that tracks the link between the increasing complexity of popular culture, including video games-mentioned by the noble Baroness-powered by new technologies, and the rise of IQ scores in the US over the past several decades, which he attributes to the development of critical thinking skills.
Perhaps even more important for us is the impact of digital technology on literacy. A report from the National Literacy Trust conducted among 3,000 pupils in 2009 found that 56 per cent of young people have a profile on a social networking site, and 25 per cent have their own blog. This compelling research shows that technology is important in offering a range of writing opportunities for young people. In turn, the trust reports a link between blogging and social media activity, writing ability and the enjoyment of writing. Young people who write on a blog are much more likely to enjoy writing in general than young people who do not-by a margin of 57 per cent and 40 per cent. About the same proportion also display greater confidence in their literary ability, believing themselves to be good writers. That was true across all socioeconomic classes.
The same goes for the enjoyment and understanding of music. The launch of the iPod in 2001 changed the way we listen to music and now delivers it digitally to 300 million users worldwide. That brings benefits beyond
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This is a vital subject because it impacts directly not only on the health and well-being of young people but on the future direction of our society. I readily admit the problems and the unanswered questions, and I very much echo what the noble Baroness said about the importance of more research. However, it is important that this evening we take note of the positive advantages of digital technology and the role that it can perform in training young minds to think creatively and flexibly, in encouraging literacy skills and in fostering a sense of participation in society.
Lord Alderdice: My Lords, we are in debt to the noble Baroness, Lady Greenfield, for taking the opportunity to introduce this debate in your Lordships' House. As the noble Lord, Lord Black, has indicated, there are very many positive things about cyberspace and the internet.
I, too, want to address some of the concerns to which the noble Baroness, Lady Greenfield, referred, coming from my background as a psychiatrist, and particularly perhaps as president of ARTIS (Europe) Ltd, a research and risk analysis company which takes an interest in terrorism and politically motivated violence. That is where I came from and how I got interested in this area. It became clear to me that a number of organisations, domestic and international, were using cyberspace as a new modality through which they could conduct their nefarious activities. Of course, we have had land, sea, air and, more recently, space as media or spaces in which to conduct conflict, whether it be terrorism or interstate conflict. However, it is quite extraordinary that for the very first time humanity has created a new space in which activities can take place. This is quite unprecedented.
Of course, we created space in our minds to do things but cyberspace is quite different. This is a space in which it is possible not just to conduct traditional kinds of crime and terrorism-for example, it is well known that a number of organisations use cyberspace to communicate with each other, to pass encrypted messages, to bring groups of people together, and to recruit and train young people in various kinds of terrorist activity-but where the possibility clearly now exists for state and non-state actors to engage in attacks on the very infrastructure of each other's nations. This is happening at an extraordinary rate. Indeed, in a recent Written Answer, HL12997, the noble Lord, Lord Henley, informed us that the Office of Cyber Security and Information Assurance reckons that it is costing the United Kingdom alone in the region of £27 billion per annum.
Today, however, we are looking not at the economic but at the mental aspects of this issue. We all know that when we get behind the wheel of a car many of us behave in a different kind of way. Certainly, when we write e-mails we may react rather more emotionally than when we write a thoughtful letter. I see that the noble Lord is particularly careful, knowing that these things can appear in all sorts of places. However, if
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It seems to me that in the short time we have at our disposal this evening all we can do is to flag up that this is a wonderful facility, as the noble Lord has done, but also a clear and present danger, as the noble Baroness has described. I trust that your Lordships, whether in the Chamber, in all-party groups or in other ways, will be able to explore this matter more fully. In the mean time, I ask the Minister whether he can indicate how much Her Majesty's Government are spending on research into the psychology of this area, as distinct from the hardware and software. Psychology is, in the end, the most crucial aspect.
Lord St John of Bletso: My Lords, I join in thanking my noble friend Lady Greenfield for introducing this topical short debate. She is certainly best qualified to address the challenges for the mind, as well as the opportunities, from digital technologies. There is no doubt that the internet has totally revolutionised the way that we do business, conduct research, find entertainment and even socialise. However, in the face of the non-stop barrage of technology-induced stimulation, a key question on the minds of many parents, education authorities and scientists is how, and whether, this is affecting young brains.
My interest in this subject stems from having managed and run data centres, catering predominantly for the online gaming industry, and also, perhaps just as importantly, from being the father of four children aged between 12 and 16 who constantly, in their spare time, play games on their mobile telephones or on the PlayStation. What amazes me about their plugged-in life is that they end up multitasking, often doing their homework while instant messaging classmates, downloading music, texting their friends, surfing the internet and often conversing on Facebook. While there is a common perception that multitasking saves time, I was surprised to read that there is solid scientific research showing that dividing the brain's attention between two or more tasks simultaneously has its toll on both performance and time.
The recent Nominet report The Impact of Digital Technologies on Human Well-being made it clear that it is important to understand the implications of our online life for our offline working. There is no doubt
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There is no doubt that the information explosion brought about by the internet and other modern technologies has had a hugely positive influence on society. The noble Lord, Lord Black, mentioned the impact on literacy. However, I believe that it is important for there to be more guidelines on the efficient and effective use of digital technologies. I have become increasingly focused as a parent on setting firm boundaries for my children, particularly on the time that they spend on the PlayStation. One of my concerns is that many parents are totally unaware of the nature of social media sites and are therefore ill equipped to monitor for potential problems, including cyberbullying, inappropriate content and addictive games. I am not an advocate of focusing on the negative impacts of digital technologies on the brain. Yes, video games tend to be addictive, and, yes, I believe-though there is no empirical scientific evidence-that technologies could physically change our brain and mindset.
I am rapidly running out of time. I believe that the noble Baroness, Lady Greenfield, has an important point about promoting youth employment. There is potential for job creation in this exciting era. I also believe that more resources should be directed towards promoting online education. In conclusion, it is important that we embrace the positive impacts; I hope the Minister will elaborate on what Government initiatives are planned to promote more research-possibly through Ofcom-in this important subject.
Lord Lucas: My Lords, I find myself on the optimistic side of this debate. Listening to the noble Lord, Lord Alderdice, reminded me of reading Socrates's strictures on writing and the dangers of the spread of that new technology. Much of the activities that the noble Lord attributed to modern terrorists must have been in Socrates's mind as he was thinking of what they could do now that they had this additional skill.
When I was young, the scare was television. It probably has not done us much good one way or the other: we are probably less healthy than we were; we are probably less good at concentrating and socialising. In that context, the internet, social networks and
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The noble Baroness, Lady Greenfield, referred to the plasticity of our brains. That is indeed one of our great characteristics. We must therefore be conscious that any great change, such as what we are experiencing, may have effects of which we ought to be careful. As she said, we ought to be doing research into this, particularly meta-studies to give us a clear picture, because individual studies will always have a scatter of results. We ought to be doing proper meta-studies to really look at the questions raised by the noble Baroness. I hope she will be sufficiently piqued by Ben Goldacre to contribute to that process herself.
Lord Addington: My Lords, much of what I thought I would be saying that was original tonight has already been covered in the brief way we have charged around this debate. The noble Lord on the Front Bench seems to be indicating he has a similar problem. The one thing we can be sure about in the new digital world is that it has changed everything, and it has changed it faster than any of us has ever imagined possible, even 15 years ago. The whole level of interaction in a personal way has changed: people no longer natter obsessively on phones; they now exchange e-mails obsessively. As my noble friend Lord Lucas has said, the great demon that was television-indeed, independent television with adverts, which was the great bugbear of my youth-has now been accepted and gone beyond.
However, the noble Baroness and I did a little bit of digging online to discover a speech she made about a year ago which covered similar ground. In it, she pointed out that certain types of activity that offered immediate satisfaction from certain types of video game-particularly done for very long periods of time-affect the way our brains develop. That is not a big surprise to anybody who thinks about it for a second, because the way you use your head changes the way your body operates and learned responses go into muscle and brain. It is just there; it is not a big surprise. Anybody who has ever played a sport knows that you can change the way your reflex patterns go from the way you interact with people.
The problem here is that this may be something which cuts out other types of human interaction. I believe that was roughly what the noble Baroness was
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What are we going to do about it? I am afraid that the Government have either got to do the research themselves or encourage others to discover what is happening here. We are effectively putting out feet into a new pool. The change in activity and the volume of time spent is the great problem; it is not the fact that you actually play a game and destroy the aliens or the advancing hoards from some Narnia coming out from your screen. It is a problem if you spend hours and hours at a very young age doing that. That is the difference. Obsessive behaviour has consequences.
I do not knock the digital: I would not be able to write at all without digital help because I am severely dyslexic, so it has been a huge bonus to me in certain ways, and to many other people. Unless we can actually get at what is happening and take a realistic view of it, we are going to have some problems here. One thing we can be sure of is that new technology will encourage the fear-mongers and the panic buttons to be pressed and the wrong information will come out. We have to encourage people to look at this in a realistic and sensible way. Without that, interesting as the noble Baroness's thesis is, as much attention will be focused on people who are saying, "I spend 43 hours a week online playing one game and it doesn't do me any harm and, by the way, what month is it?" We have to have some interaction and study between those who use this and those who do not. Without this, we will merely carry on swapping opinions and not knowledge.
Lord Stevenson of Balmacara: My Lords, I thank the noble Baroness, Lady Greenfield, for securing this debate and other noble Lords for their contributions. I am not out of sympathy with the approach that was taken by the noble Baroness, Lady Greenfield. The internet has spawned a positive tsunami of innovation and that can be very unsettling as we try to make sense of it all. We now have access to devices, as other noble Lords have said, with immense speed, power and versatility. However, I shall make two observations. The first is rather banal and is that everything we do in one way or another, to some degree or another, reconfigures our synapses and the connections in and the shape of our brains. I am not sure what shape my brain will be in after I sit down following this short speech, but I know it will not be exactly the same as when I stood up.
The second point is a little more serious and follows other noble Lords who have mentioned that as well as the points on the one side, led off by the noble Baroness, Lady Greenfield, there is now increasingly some good research on the effect on children of playing some of these new and highly immersive video games. It finds
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As a parent of teenage children, I agree that there are some issues around potential addiction and overuse, but there is still far from a settled view on the causes or the effects, so we should proceed with care before leaping to any conclusions. In particular, as has been mentioned by a number of speakers, we have to be careful about fanning the flames of moral panic. I hope that the noble Baroness, Lady Greenfield, will forgive me if I mention some of the headlines that appeared after she raised some of these points on earlier occasions:
I think the word "more" is the interesting one there. As has been said, we have had these moral panics before. They have been about writing-the noble Lord, Lord Lucas, reminded us about Socrates-and about Shakespeare. Why was the Globe built outside the City walls? It was because there was concern that audiences would be inflamed by the passions in his plays. There were moral panics about penny dreadfuls, early cinema films-which have been rather neatly recreated in Martin Scorsese's latest film which shows some of the effects of early cinema on audiences-TV and video nasties, and now there is the internet.
To be serious, if the case being made by the noble Baroness is accepted and therefore we should be doing some research, who will do it and how are we going to evaluate it to make sure that we get the best out of it? I take from her introductory speech that at the very least we should be looking at the way in which it is alleged that empathy is declining, which would need some fairly large-scale epidemiological studies, and that video gaming has aspects that lead to aggression, attention deficit and addictive behaviours, so there would need to be some serious research on chemical and structural changes in the brain. If we also follow her line about the impact of search engines in changing the way we seek and store knowledge, we would obviously have to research how we acquire and store knowledge.
This is a very wide and quite intensive research programme so I have some questions for the Minister which I hope he will be able to answer when he responds. First, do departments currently have the capacity to carry out research on this scale? A quick look at the current research projects in DfE does not reveal anything in this area as far as I could see. Given that the budget is about £25 million and that it is likely to be the same next year, I think the Minister should share with us whether resources would be available if such a research programme was to be started. Secondly, by its very nature, this research would have to be collaborative and we would need to seek around Whitehall for partners and others to work on it. It would be
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Finally, as I am sure your Lordship's House is aware, the House of Lords Science and Technology Committee is currently carrying out a review of the role of departmental chief scientific advisers. There was an evidence session a couple of weeks ago. The committee has already established that there are 13 departments, including DfE, which have chief scientific advisers, which is a good thing, but in only two or three of them does the chief scientific adviser operate at board level. Mr Nick Gibb MP, a colleague of the Minister, said in his evidence on 23 November 2011 that Carole Willis, the chief scientific officer of DfE, is not on the board of that department and is not even a director-general. Given that Mr Gibb also said that his Secretary of State is particularly keen on ensuring that they have evidence for their policy, will the Minister explain how any research evidence that might be commissioned in this area would impact on policy given the low status accorded to the department's CSA?
The Parliamentary Under-Secretary of State for Schools (Lord Hill of Oareford):My Lords, like other noble Lords, I start by thanking the noble Baroness, Lady Greenfield, for giving us this chance to reflect on the potential impact of digital technologies on the mind, and to take part in the wider debate for which she calls. As many noble Lords have said, the themes that we have discussed are in some ways not new. My noble friend Lord Lucas mentioned Socrates, who was worried about the invention of writing because he was afraid that people would,
At a later stage, people were worried about the development of the printing press, the translation of the Bible into English and the development of the television, as my noble friend Lord Lucas also mentioned. But because these concerns turned out largely to be misplaced, that does not mean that we should today be complacent about the important questions raised by the noble Baroness, Lady Greenfield-I think that there is agreement about that.
Before addressing some of the concerns that have been raised, it is worth reminding ourselves, as other noble Lords already have, of some of the benefits of technology. As we have heard, these benefits are educational, economic and social. So far as education is concerned, we know that technology can support good teaching and help raise standards. It can bring subjects to life, add whole new dimensions to learning and give pupils the chance to have access to the best content, lessons and lectures in the world. We know that the Khan Academy provides 2,700 high-quality
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We know that, so far as more disadvantaged groups are concerned, having a computer to help with learning at home is associated with improvements of two grades in overall GCSE test scores. We heard earlier that the use of multimedia books in early reading can improve literacy in children. We know that technology can be particularly powerful for pupils with special educational needs, whether that is for those with a visual impairment or dyslexia, as my noble friend Lord Addington reminded us, or some other learning difficulty. The Echoes project is helping primary schoolchildren with autism experiment with difficult social scenarios. That is a positive. I know that concerns have been raised about autism in the context of digital technologies, but that is a good example of how digital technologies can come up with helpful ways forward for children with autism. Speech and language communication disorders would be another obvious area where technology can make a big difference.
We also know that technology is changing education through its potential to create better ways for seeing how children are doing. Teachers can now monitor how each student in a class is doing at the same time, then provide them with the amount of support that they need. Problems can be picked up earlier, and able pupils can be stretched. Technology can help with teacher-training so that teachers can more easily observe other teachers and learn more from them.
We have also heard some of the social benefits-for example, of social networking-from my noble friend Lord Black of Brentwood. I think of my 84 year-old mother, fairly recently widowed and living on her own in the countryside, being able to Skype her grandchildren wherever they are.
So far as the economic benefits are concerned, we have heard how technology has transformed the business world and led to the emergence of whole new sectors-the games industry, for example, and the developments in the media industry mentioned by my noble friend Lord Black of Brentwood, who reminded us of the extraordinary changes that we have witnessed in recent years. These are industries and new sectors where Britain is now a world leader.
What is also astonishing-and this is part of the case made by the noble Baroness, Lady Greenfield-is the speed with which technology has galloped ahead in such short order. When I left 10 Downing Street in 1994, I had a secretary who did shorthand. During the 1992 general election I had a mobile phone the size of a brick. By the end of 1994, with one exception-and he went on to become the Government's e-Envoy-none of us working at No. 10 was connected to the internet. That was only the end of 1994, yet today, as we have heard, over a quarter of adults and almost half of teenagers now own a smart phone. Around three-quarters of homes are connected to broadband. Most of us-although not me-shop online. Two-thirds of five to seven year-olds use the internet at home, and 90 per
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Then, as we have heard, there are the viewing figures for the telly. Five to seven year-olds are watching an average of nearly 15 hours a week. That rises to over 17 hours a week for 12 to 14 year-olds. The amount of exposure which children and young people are having, whether to the internet or the telly, does raise questions.
If we accept-as I think has broadly been the case-some of the benefits of digital technologies, we also recognise that there are concerns. The noble Baroness, Lady Greenfield, raised a number of them: the risk of shorter attention spans; the loss of the ability to see an argument or take on information in a broader context; and substituting virtual relationships for real ones, increasing the risk of atomisation.
My noble friend Lord Alderdice also raised the important issue of cyberspace being used for terror activity and state sabotage and the effect that it could have on moral decisions distancing people from the consequences of their actions. We could also add: the lack of downtime and relaxation, as the noble Lord, Lord St John of Bletso, reminded us; the risk of sexual exploitation of children; and-a point which has not been raised today-the risks of obesity caused by a sedentary life.
If those are some of the potential downsides, what evidence do we have? A number of points have fairly been raised about the research base of the evidence that exists. As I fear is often the case, the evidence that I have had drawn to my attention seems largely mixed and does not enable me to draw clear and decisive conclusions of the sort that noble Lords would find helpful. We know that in 2007 the previous Government asked Professor Tanya Byron to look at the risks that children face from the internet and video games. Her review also touched on some of the issues raised by the noble Baroness, Lady Greenfield, today. Professor Byron found that the impact of technology on children depends on a number of biological, psychological and social factors, which meant that it was difficult to generalise about the impact of technology on particular individuals because each person's background and context varies considerably. It seems that a sensible perspective on children and technology would need to take account of differences in age, experience and stage of development.
Earlier this year, Dr Paul Howard-Jones of Bristol University, who was involved in the Nominet research to which reference has been made, carried out a review of what the field of neuroscience has found regarding the implications of using interactive technologies for young people-for their brains, behaviours and attitudes. He highlighted the need to understand the specific uses of technologies in a specific context rather than to label particular technologies, or technology, as good or bad. He found, for example, that existing forms of online communication for supporting existing friendships are generally beneficial for their users. He also found that some technology-based training can improve working memory and that others can provide mental stimulation
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The Government agree it is important that children should access only content that is appropriate to their age and that they should not be exposed to violent video games, which is why we support the statutory use of pan-European games information age ratings that should help parents to supervise their children's use of technology and video games. About four in five parents already put in place rules on internet use, and I have learnt that the noble Lord, Lord St John of Bletso, does so in relation to his children's use of gaming.
It seems that excessive video game-playing can be an issue for some people and that it could have an adverse impact on attention levels and well-being or even interfere with people's daily lives. We know that there is some evidence that playing violent video games is associated with aggression, although the link to actual violence is less clear, which reinforces the importance of age restriction. I think it is true that parents and teachers will also want to be careful that certain technologies are not providing a distraction to children focusing on the task in hand, but I have not been shown robust evidence that technology use does cause issues like ADHD.
We have not seen research that shows there is evidence that the prevalent use of digital communications by teenagers is directly damaging brains. Findings suggest that using the internet to maintain relationships can improve social connectedness and well-being, but we need to be aware of the risks from cyberbullying and inappropriate content. We are working with the UK Council for Child Internet Safety, the Child Exploitation and Online Protection Centre and the 170 other organisations mentioned by the noble Baroness, Lady Greenfield, to provide advice and guidance to parents, schools and young people about how to stay safe online and work with industry to improve their products and services.
We are grateful for the opportunity to debate this issue. I am grateful for all the contributions that have been made during this debate. It is clear that extensive use of technology is having an impact on us all, and I think there is broad recognition that while technology brings us many opportunities and benefits that we could not have imagined only a few years ago, we should be aware of potential risks and issues, especially around e-safety or excessive use unbalancing people's lives.
On the important question of research raised by the noble Lord, Lord Stevenson of Balmacara, and my noble friend Lord Addington and others, we are not aware of an extensive evidence base on negative impact from the sensible and proportionate use of technology. This may be an area that the UK research councils will wish to explore, and I am told that they have these issues firmly on their agenda. We will look at any new research that is published and approach it with an
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It is easy to see the benefits of new technology, but the noble Baroness is right to remind us that we must not be blind slaves to the power of novelty. As in so many things, there is a balance to be struck; and just as any technological revolution can lead to great progress, so it always also leads to unexpected problems, to which we must indeed always be alert.
(a) after "duty of the" insert "clinical commissioning group or",
(b) omit "Primary Care Trust or" in each place it appears,
(c) for "such time as the" substitute "such time as (in relation to England) the clinical commissioning group or".
(2E) The Secretary of State may by regulations provide that the duty imposed on the clinical commissioning group by subsection (2) above is, in the circumstances or to the extent prescribed by the regulations, to be imposed instead on another clinical commissioning group or the National Health Service Commissioning Board.
(2F) Where regulations under subsection (2E) above provide that the duty imposed by subsection (2) above is to be imposed on the National Health Service Commissioning Board, subsections (2D) and (2E) above have effect as if references to the clinical commissioning group were references to the National Health Service Commissioning Board.
(a) after "section "the" insert "clinical commissioning group or",
(b) omit "Primary Care Trust or" in each place it appears, and
(c) after "means the", in the first place it appears, insert "clinical commissioning group or".
Lord Patel of Bradford: My Lords, I believe that I speak with some authority in proposing this amendment as a former chair of the Mental Health Act Commission and one who has worked for many years as a practitioner, manager and researcher in the field of mental health. Many noble Lords are also familiar with the particular needs of those with mental health problems and we have already debated some of the key issues and omissions in the Bill with respect to mental health. Although the noble Earl has been understanding and generally supportive, we have not yet seen any movement by the Government on issues such as ensuring parity between physical and mental illness. I sincerely hope that we will see some movement with respect to this clause because I am in no doubt that it will have the effect of reducing the quality of service and safety to some of the most vulnerable people in our society, those who have been detained under the Mental Health Act.
On the surface, Clause 37 appears quite reasonable. It seeks to amend Section 117(2) of the Mental Health Act 1983 in order to transfer duties that currently sit with the PCT to the newly created clinical commissioning groups. Section 117 concerns the provision of aftercare services. Aftercare services for this extremely vulnerable group of patients are absolutely vital. They consist of a range of services in a single care package. Some examples are visits from a community psychiatric nurse, going to a day centre on a regular basis, befriending and support services and having medication, counselling and supportive accommodation.
Everyone with mental health needs is entitled to a community care assessment to establish what services they might need. However, Section 117 of the Mental Health Act at present goes much further and imposes a duty on both health and local authorities to assess and provide aftercare services to patients who have been detained under a variety of sections from the 1983 Act. That means that these agencies are under a joint duty to provide aftercare services free of charge until both NHS and local authority commissioners agree that the service user is no longer in need of such services.
However, the real problem here-and it is a serious one-is that Clause 37 does more than transfer these duties to the clinical commissioning groups. In effect, it significantly alters these duties so that the protections currently afforded by the Mental Health Act are greatly weakened. Separating the statutory responsibilities between CCGs and local authorities in the manner proposed by Clause 37 will allow one agency to decide to end the provision of services without notice or consultation with the other agency or even the patient. The duty established by Section 117 of the Mental Health Act was applicable to the ongoing care of roughly 18,000 people discharged from detention in hospital last year alone. I should point out that this
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There are three things about Clause 37 that concern me most. First, it removes the duty of co-operation on delivering aftercare services between the health service, the local authority and the voluntary sector. Secondly, it turns what is currently a free-standing duty into a gateway provision, which will restrict the scope and effect of aftercare services. Thirdly, as a consequence of this, it provides a back-door route by which aftercare services for detained patients will become chargeable.
I will start with the duty of co-operation. Clause 37 has the following effects. First, with respect to Clause 37(2)(c), (e) and (f), the joint duty to provide aftercare services is split between health and social services authorities. Each can separately decide when to withdraw its own services without requiring the agreement of the other. Secondly, at line 8, page 73 in Clause 37, CCGs will no longer be under a duty to arrange aftercare,
I am sure that my noble friend Lord Adebowale will say more on that subject. This is not about general health responsibilities or duties. It is about fundamental recognition of the impact of being detained under the Mental Health Act. For example, on leaving hospital after a prolonged period of detention, a person is likely to have lost their accommodation and will be in need of somewhere safe and appropriate to live. They are also most likely to be feeling very vulnerable and low. During their period of acute illness they may have offended or alienated family, friends and neighbours. They may be particularly vulnerable to abuse as a consequence of the stigma of having been detained and, while they may certainly be recovering, they will not be better. They remain in need of treatment whether through medication, counselling or both.
None of the after-care services that they will need will be effective on their own. These services work and thus prevent readmission to hospital or worse because they are joint and co-ordinated, which means that neither authority can unilaterally decide to remove an element of their after-care package without the agreement of the other. Most importantly, they are also required to work collaboratively with the voluntary sector on these arrangements. This means that a local authority cannot decide that it can no longer afford to provide the funding for supported accommodation in the voluntary sector and unilaterally decide to withdraw from the arrangements. In the current economic climate, it seems to me that that scenario would become likely if the clause is passed as part of the Bill in its current form. It is absolutely certain that there will be greater scope for dispute between the various authorities and the voluntary sector, which will be left ultimately responsible at the end of the day. We need think only of the burden of the expenditure cuts in health and social services to realise that that will be the case, as both CCGs and local authorities seek to restrict their
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My amendment would retain the joint duty on CCGs and social services authorities. It would also ensure that CCGs continue to arrange for provision of services under Section 117 of the Mental Health Act, in co-operation with relevant voluntary agencies. But it is not just the potential loss of co-operation and shared responsibility for care that is at stake here. My other two concerns are with respect to the fact that the current protection afforded by the duty to provide after-care services is a freestanding duty. Clause 37 fundamentally changes this. First, it states that CCGs' duty to commission health care services will be limited to services of a kind that must be provided under Section 3 of the NHS Act 2006 or may be provided under Section 3A of the NHS Act. This removes the clear and unambiguous responsibility on PCTs and local authorities to provide appropriate after-care services.
The current wording of the clause has the effect that the duty to provide after-care falls only on CCGs and, as such, will be only for health services, not social care services. By definition, after-care services must go beyond those provided by health alone, as they involve all the things I have already mentioned with respect to picking up your life after being detained-housing, counselling, befriending and advice, alongside the traditional health treatments and support. The wording is insufficient to ensure that these protections continue, and it clearly alters the nature of what was a freestanding duty to make it a gateway provision.
Secondly, Clause 37 states that Section 117 will be treated as a duty under Section 3 of the NHS Act 2006 and will be provided under the same duties as other healthcare. By removing the freestanding duty and making duties to provide after-care for detained patients the "same duties as other healthcare", Clause 37 opens the way for charging for after-care services. For example, a potential effect of the clause is that it would allow for means-tested charging for such services as care home fees. They are currently exempted on the grounds that having detained a patient the state owes something of a reciprocal duty to provide after-care and that charging for such services would therefore not be acceptable. I spoke of this at Second Reading, when I reminded the House of the judgment made in this very issue in the Stennett case before the Appellate Committee of this House. Let me remind noble Lords of this landmark judgment more fully.
The exact case concerned Manchester City Council and two other councils, which appealed High Court rulings that they could not charge for the residential care of patients who had been discharged into such care from detention in hospital. Mr Stennett was one of those three patients. The judgment was made on 25 July 2002. In essence, the case established that Section 117 established a freestanding duty to provide after-care and that, as it contained no charging provisions, no charge should be made for after-care under that section, including for the provision of residential accommodation.
The argument that this was in fact a gateway provision, whereby other statutory protections would be triggered was completely rejected by the appellate court. I hope
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If I am not mistaken, I believe that the noble and learned Lord, Lord Mackay of Clashfern, was part of the panel of judges that agreed with that judgment. The importance of this being a free-standing duty is that the relevant authorities are required to sort out the funding for the package of aftercare between them.
Furthermore, one of the greatest issues in ensuring that aftercare services are effective is securing the agreement and co-operation of the patient. This is known to work best when aftercare services are free and seamless. The current protections afforded by Section 117 represent best practice for vulnerable patients with mental health problems as it ensures that there is a joint support with a package of integrated services. The requirement that, once in place, this joint package of care cannot be broken without everyone's agreement means that patients are more likely to get access to the services that they need for as long as they need them. My amendment seeks to ensure that the arrangement of services by CCGs under Section 117 is not limited to services arranged under Section 3 or Section 3A of the NHS Act, by deleting the proposed new subsection (2E). In addition, the amendment will ensure that the duty on CCGs will not be regarded as a duty under Section 3 of the NHS Act. This means that it remains a freestanding duty under Section 117 of the Mental Health Act.
I am grateful to the Law Society and to Mind, which have helped in preparing briefings on this amendment and the key issues at stake. In addition, the Law Society has obtained independent legal advice on the specific implications of the current wording of Clause 37, which leaves me in no doubt that my concerns about this aspect of the Bill are justified. It is clear to me that the impact of Clause 37 would be to make a very vulnerable group of patients more likely to fall between the gaps created by the confusion and scope for dispute that it will create. Moreover, it strikes me that removing this protection goes against the ethos and promise of this Bill, which is for more, not fewer, integrated services. The joint duty on health authorities and local authorities to provide health and social care, coupled with the fact that Section 117 is a freestanding duty to provide aftercare, effectively prevents either health authorities or local authorities charging for such services. I believe this to be necessary and a vital protection for this vulnerable group of patients.
I sincerely hope that the Minister will see the necessity of this amendment and agree that it seeks to ensure that vital protections for some of these patients remain
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Lord Adebowale: My Lords, I support the amendment in the name of the noble Lord, Lord Patel of Bradford. I should first declare my interest as the CEO of the social enterprise, Turning Point, which provides mental health, substance misuse and LD services.
When I looked at this clause, I wondered whether there was malice aforethought but I was reassured by the civil servants that that is not the intention. I know full well that the Minister's intention is always to be helpful. I understand that it was not the intention of this clause to wreck a partnership between health and social care that has been around since 1983 and has ensured that detained patients obtained an appropriate care plan, provided by a joint duty requiring PCTs and local authorities to work together to provide aftercare. I think that this clause was an attempt to tidy things up in some way and to provide clarity.
However, I should warn the House of the consequences of such a tidying-up exercise on the lives of detained patients. The current arrangements effectively hide the wiring about who pays and any debates on their provision of aftercare. There was a statutory curse on both the local authority and the NHS, should they fail to sort it out, which in effect has ensured that people who are detained get the care and support that they need on departure.
More to the point, experience tells me that the removal of this duty creates the very real possibility of one or other of the parties refusing to pay, thus leaving the client in an expensive limbo. The really worrying changes suggested in the clause refer to the fact that CCGs will no longer be under any duty to arrange aftercare in co-operation with relevant voluntary organisations. Furthermore, the clause goes on to state that CCGs, due to commission healthcare services, will be limited to services under Section 3A, effectively meaning-as set out by the noble Lord, Lord Patel-that health services only may be provided, thus opening up patients to funding disputes about whether they get care, and if so who pays.
There are other worrying suggestions in this clause that give cause for concern and that open up the possibility, as the noble Lord, Lord Patel, has pointed out, of charging for the services of aftercare. The question I would put to the House is: who is charging whom? Who pays under these circumstances?
In the excellent briefing provided by the Royal College of Psychiatrists, Mind, Rethink, the Centre for Mental Health and the Mental Health Foundation, a scenario was set out which I want to put to the
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Mr B had a diagnosis of schizo-affective disorder and was unable to read or write due to also having a learning disability. He had a history of being detained under the Mental Health Act and of being discharged with Section 117 aftercare packages and then withdrawing from services in due course as his situation improved. However, as is often the case, he would then relapse and be returned to hospital. His aftercare package comprised a care worker from his community mental health team, who spent about two hours per week helping Mr B with paperwork-such as housing, rental and other benefits and community appointments-and the community psychiatric nurse, who administered medication. On health grounds, the health authority decided that the community mental health team support was to be withdrawn, but made no provision for further support with paperwork or appointments. Without that support, Mr B could not manage his tenancy, bills or get to his GP for his medication; he would certainly have relapsed quickly and stayed in a relapsed position, costing the state, the health authority and social care far more. There had been no recent reassessments of Mr B's needs by social services and they had not agreed to the withdrawal of any services.
With the help of an advocate, Mr B was able to argue that Section 117 aftercare was his right and should not have been withdrawn without the agreement of social services. As a result, the support was left in place, he won his argument and social services agreed to review his needs before any further decision was made. That is the result of what we currently have in place. Remove that, and Mr B does not have those rights and is left in limbo.
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