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House of Lords

Wednesday, 8 February 2012.

3 pm

Prayers-read by the Lord Bishop of Chichester.

Dogs: Microchipping


3.05 pm

Asked by Lord Hoyle

The Parliamentary Under-Secretary of State, Department for Environment, Food and Rural Affairs (Lord Taylor of Holbeach): My Lords, we are close to finalising a package of measures to tackle irresponsible dog owners, and intend to make an announcement soon. In putting the package together, we have considered and set out the pros and cons of various approaches towards compulsorily microchipping dogs. The final package will cover future government handling of the issue, as well as plans to improve standards of dog ownership.

Lord Hoyle: I thank the Minister for that reply. It is very helpful in itself. Taking the old adage that there are no bad dogs, just bad owners, microchipping would certainly make for more responsible dog ownership. It would also make it easier for dogs that have strayed to be found by their owners. It would cut down on the number of stolen dogs. As a Government who are seeking popularity, it would be highly popular, as 83 per cent of the public who have been surveyed support this.

Lord Taylor of Holbeach: I am very grateful to the noble Lord for his support for what may indeed be included in the package. It might help the House to know that the cost of rehoming each stray is £1,100. The economic cost to this country of irresponsible dog ownership is enormous, let alone the human damage that can be caused by out-of-control dogs.

Lord Low of Dalston: My Lords, is the Minister aware that attacks on guide dogs are now running at over seven a month? The person who first drew this to my attention said, "What on earth are they doing putting a tax on guide dogs? Whatever next?". But actually it is a very serious problem. It can mean a vulnerable person being left alone, in need of assistance, and without a dog for a considerable period of time. The dog may need to be treated, retrained or even withdrawn from service altogether. As each guide dog costs £50,000 over its lifetime, this has huge financial implications. Will the Government consider making attacks by dogs on assistance dogs a punishable offence in the same way as attacks on human beings?

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Lord Taylor of Holbeach: I assure the noble Lord that we take this very seriously. It is an increasing problem. As the noble Lord said, there seven attacks a month on guide dogs. Sometimes, of course, the dogs carrying out these attacks are out of control; they are not even on a lead. The whole purpose of the policy will be to try to encourage responsible dog ownership. I am very pleased with the contribution the noble Lord has made to the issue by asking his question today.

Baroness Parminter: My Lords, the number of stray dogs in this country has risen to 126,000 and has been steadily increasing for the past four years. Does my noble friend agree that compulsory microchipping would help local authorities with the spiralling costs of kennelling, and help them reduce the number of healthy dogs they have to put down each year, which was 6,000 in 2011?

Lord Taylor of Holbeach: Yes, my Lords, I drew the House's attention to the enormous economic cost of stray dogs; £57.5 million is spent by charities and local authorities in caring for and finding new homes for stray dogs. That is part of the thrust behind our proposals, which, as I say, we will be announcing shortly.

The Countess of Mar: My Lords-

Lord Renton of Mount Harry: My Lords-

Baroness Anelay of St Johns: My Lords, I think that the mood of the House is that the noble Countess, Lady Mar, has been waiting. Perhaps my noble friend Lord Renton might speak after her.

The Countess of Mar:My Lords, does the noble Lord agree that if all puppies were microchipped before they were eight weeks old, it would ensure that they could be traced to their breeders, which would prevent much of the iniquitous practice of puppy farming?

Lord Taylor of Holbeach: This is certainly a proposal that we are looking at, and I thank the noble Countess for her contribution.

Lord Renton of Mount Harry: My Lords, perhaps I may suggest to my noble friend that the Government consider very carefully before insisting on the compulsory microchipping of dogs. Many dogs take badly to having a chip in them; they get very sore and so forth. Surely anyone who cannot control a dog should not have one; that should be the course.

Lord Taylor of Holbeach: I am not sure that the respondees to the consultation share my noble friend's view on the matter, and I am not sure that the Government share it, either. We see microchipping as one measure we can take to address an increasing problem. The cost of stray dogs is something that we have discussed. The human cost of dog attacks is another matter that the House should bear in mind in considering these measures.

Lord Grantchester: My Lords, the House has heard many times before from the noble Lord that these matters will be dealt with soon. May I press him again

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on when "soon" may be? I was told that microchipping had already started and that six databases were up and running. The information on the databases will be useful only if it is up to date and accurate. What plans do the Government have to ensure that this will happen?

Lord Taylor of Holbeach: Some 58 per cent of dogs are already microchipped on a voluntary basis. The noble Lord asks about timing. When I say "very shortly", I do mean "very shortly", but the timing is not within my gift. I have clearly flagged up the possibility of an expansion of microchipping in the responses that I have given today, and we are working with everybody to make sure that this will happen.

Baroness Byford: My Lords, will the new compulsory system apply to dogs coming to this country? If not, what will the Government do about that?

Lord Taylor of Holbeach: Yes, my Lords, the pet travel scheme requires that all dogs coming to this country are microchipped.

Baroness Fookes: My Lords, as a former chairman of the RSPCA, perhaps I may point out that it has been the wish of that society and many others that there should be compulsory registration for dogs, as this is the only way to deal with manifold problems. May I remind the noble Lord-although he will probably not know-that in the House of Commons I tried twice to get this introduced, well over 20 years ago?

Lord Taylor of Holbeach: This House always provides noble Lords with the opportunity to fulfil their ambitions, and it may be that my noble friend will achieve just that.



3.13 pm

Asked By Lord Warner

Baroness Northover: My Lords, the UK Government are very concerned about the impact of movement and access restrictions on the health of children in Gaza. We regularly press the Israeli authorities on the need to ease restrictions and to address the humanitarian situation. My right honourable friend the Secretary of State for International Development raised these issues during his recent visit.

Lord Warner: My Lords, I am grateful to the Minister for her reply. Is she aware that only 5 per cent of the water coming out of Gazan children's taps is drinkable and the rest is not? Gastroenteritis is endemic among children in Gaza, about 70 per cent of whom are anaemic. Is she also aware that doctors working in the main hospital claim that about 500 people have died as a result of the shortage of basic medication, many of whom are children? Can we not approach the Israeli Government with a greater sense of urgency to secure a change in the situation of these children who are being collectively punished?

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Baroness Northover: I have been replying to the noble Lord on the issue of water so I am extremely well aware of the situation. We are very concerned about the situation in Gaza and it is a tragedy that people are living in such circumstances. Thirty-eight per cent of Gazans live in poverty, 66 per cent depend on food aid, and, indeed, 90 per cent of mains water is unfit to drink. We are pressing the Israeli authorities all the time to try to address these problems.

Lord Avebury: My Lords, last week representations about this were made even by the UN Secretary-General, which demonstrates once again the futility of all efforts by the international community to alleviate, let alone to resolve, the humanitarian crisis in Gaza. Can my noble friend tell the House what replies we have received to our repeated representations to the Israeli Government? In particular, will the Israelis facilitate the onward delivery of $1.5 million-worth of medical supplies which were landed in the port of Ashdod by a Turkish aid agency last Saturday?

Baroness Northover: My Lords, the important thing is to seek a political resolution. It is only following that that some of these problems will properly be addressed. My noble friend is right to highlight some of the problems that are occurring at the moment. We have to emphasise yet again that it is in Israel's future interest to make sure that these problems are properly addressed and that it will never be secure while this situation continues.

Lord Turnberg: My Lords, is the Minister aware that medical supplies for Gaza are shipped by Israel to the Ministry of Health in the West Bank, which then has to deliver them to Gaza? There is considerable mistrust and poor communication between the two ministries of health, and that is one of the main causes of the delay in the transfer of medical supplies. Is she aware of that?

Baroness Northover: I am aware of that. The noble Lord is right that the division between Gaza and the West Bank, both geographically and politically, is indeed playing a part here. We urge all sides to co-operate together to ensure that medicines get across and do get into Gaza.

Baroness Deech: Is the Minister aware that around 300 Questions have been tabled during this Session on Israel, Gaza and the associated areas, with, sadly, little effect? We have had only around 20 Questions on Iran, 30 on Syria and only one relating to the Arab spring. Is the Minister confident that this House is seeing the widespread crises throughout the Middle East in perspective and that British representations on Gaza are set in the context of the whole area? I find it very odd-maybe other Members do as well-that we have not had a debate on the Arab spring.

Baroness Northover: The noble Baroness is right to flag up problems in other areas across the region. All these issues need to be addressed, and of course what happens between the Israelis and the Palestinians also plays out in those other areas. It is extremely important that we seize these issues right across the region.

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Lord Eden of Winton: My Lords, in her reply my noble friend referred to representations that the British Government have been making to the Government of Israel on this issue. That frequently is the form of reply which is given on many other issues relating to Gaza and Israel. Does Israel give assurances in response to those representations, and do Her Majesty's Government ever follow up any undertaking given by the Government of Israel? When are we going to have any positive action to redress this wrongdoing?

Baroness Northover: The noble Lord is right: there is a lot of communication all the time. There have been some shifts-some of the restrictions on crossings have been lifted to some extent-but it is nowhere near what is required. Therefore, constant pressure is needed. However, I come back to one of my original points. It is necessary for both sides to see that it is in their long-term interest to find a political solution. It is only when we get people on to that path that we will start to crack some of the other problems.

Lord Davies of Stamford: My Lords, is there not a ready solution available to hand? All that needs to happen in order for the remaining restrictions to be lifted is for the Hamas regime in Gaza to accept and adopt the quartet conditions; to accept existing agreements, including the Oslo accords; to recognise the state of Israel, and to abjure violence. Do the Government think that any of those suggestions are unreasonable; and if not, even though we do not have any relations with the Hamas regime directly, will they find a way of communicating that thought to it?

Baroness Northover: The noble Lord's premise of a simple route rather defies the current situation. We welcome the reconciliation between the Palestinians, Hamas and Fatah, which we are monitoring very closely, and we welcome the moves towards elections. However, as the noble Lord and others will know, you have to take a balanced approach and recognise that one side will feel that you are not being fair if you demand X of them, and the other side likewise. That is why it is extremely important to try to bring the parties together and to seek a political solution which is in everybody's best interests.

EU: Structural and Cohesion Funds


3.22 pm

Asked by Lord Vinson

The Parliamentary Under-Secretary of State, Department for Business, Innovation and Skills (Baroness Wilcox): My Lords, the Government will seek significant cuts to the EU structural fund's budget from 2014, aiming at reducing it to zero in richer countries after

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2020. The United Kingdom will achieve substantial savings from the EU budget only by not contributing to the structural fund budgets of all wealthier member states, but that would require unanimous agreement by all 27. No other countries want to go down this road and we cannot unilaterally opt out of our treaty obligation to contribute to the EU budget.

Lord Vinson: I thank the Minister for her reply and hope that we might eventually see some of her words turned into deeds. Meanwhile, does it really make sense to continue with this farcical monetary subsidy merry-go-round? Surely we as a great country are perfectly capable of running our own regional policy without the help of others. Would it not make sense to repatriate these powers, albeit unilaterally, and thereby save billions of pounds which could be directed in a much more positive and worthwhile fashion into exercises that would create the many millions of jobs that this country so badly needs today?

Baroness Wilcox: In the current EU budget period, the United Kingdom has already spent almost half its allocation. If we stopped drawing down the remainder, we would forfeit approximately £1.6 billion and have to break live contracts with costly consequences. We would then not receive back 100 per cent of the unclaimed funds-only two-thirds-due to the rebate process, which, of course, is a preferential deal for the United Kingdom that was politically hard-fought-for and must be protected by us. Any rebated funds to the United Kingdom would not necessarily be available for economic development, so this important area of activity would suffer as a sharp drop in funding occurred.

Lord Wigley: My Lords, would the Minister give an assurance that if this money was repatriated, those areas within the United Kingdom now benefiting from European structural funds-such as a large part of Wales because of the low level of income per head-would continue to receive the benefit needed to stimulate their economies?

Baroness Wilcox: In saying "if this money was repatriated", I presume that the noble Lord follows on from the previous question asking us to repatriate it now. The answer is: no, we won't. Is that not what the noble Lord asked? I am sorry.

Lord Wigley: With the leave of the House, that was not what I asked. If it is repatriated, can assurances be given? If they are not given, it is in the interest of these areas to continue to get those funds from Europe.

Baroness Wilcox: I apologise for not understanding the question at first. The answer is yes.

Baroness Royall of Blaisdon: My Lords, at the special summit last month, a large sum of money-I do not recall how much-was made available for tackling youth unemployment in the European Union. Will the UK apply for some of that money, or will it be spent only in the 25 states that have signed up to the new treaty?

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Baroness Wilcox: Interestingly, I do not have the answer to that question with me. I do so wish I did. I would be delighted to respond to the noble Baroness by letter.

Lord Pearson of Rannoch: My Lords, more worryingly, did we not send £10.2 billion in net cash to the European Union for it to waste last year? That should be compared to the mere £6.2 billion of our own public expenditure cuts. Why do we need any of the 75,000 fat Eurocrats in Brussels, who have little to do but strangle our economy with their endless regulations and waste our money which could be better spent at home? Surely the answer from the Minister to the noble Lord, Lord Vinson, should be that if we want to do what he so sensibly suggests, the only way is to leave the European Union.

Baroness Wilcox: The noble Lord has his own agenda which he is free to pursue. Fortunately, Her Majesty's Government do not at the moment agree with him.

Lord Swinfen: My Lords, how much is lost in administrative charges as our funds pass through Europe on their way back to this country?

Baroness Wilcox: I do not happen to have the figures to hand on how much it costs us. I will happily write to the noble Lord.

Lord Harrison: Is it not in the British interest that we support the help to poorer countries of the European Union so that they can participate in the single market actively and bring their standards of living up so that eventually British firms and services can be provided within the European Union for our benefit?

Baroness Wilcox: I completely agree with the noble Lord. The aim of the structural and cohesion funds as set out in the EU treaty was to reduce disparities between regions to create a more cohesive single European market. Structural funds have helped to underpin enlargement of the European Union, opening up new markets in central and eastern Europe to British companies. We have done very well by that.

Cyclists: Accidents


3.28 pm

Asked By Baroness Gardner of Parkes

Earl Attlee: My Lords, I am sure that all noble Lords will agree with me that every road accident is a tragedy. With regard to the roads in London, under devolution it is for the mayor and Transport for London to decide their cycling priorities and allocate their budget accordingly. We will of course continue to work closely with them to improve safety.

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Baroness Gardner of Parkes: Is the Minister aware that more women cyclists are killed or suffer very serious injuries on these junctions than men? The reason, it is believed, is because the women wait at the red lights and the men go through them. Large vehicles turning left have a degree of difficulty in seeing people. For that reason, I would like his comments on the so-called "Trixie" mirror-not named after me, and nothing to do with me, I might add-which is proposed for large lorries. Will he also suggest that the Government look into the possibility of the system just being introduced in Paris whereby at dangerous junctions they will have specific lights for cyclists?

Earl Attlee: My Lords, the noble Baroness asked me about the male/female ratio. We are aware of the hypothesis. The figures for accidents are mercifully low but, unfortunately, increasing. It is difficult to extract measurable data to formulate policy or make effective regulations. The noble Baroness also talked about "Trixie" mirrors; these mirrors are placed on traffic signal posts and help HGV drivers to see cyclists on their near side in the blind spot at signalised junctions. The department provided approval to TfL to extend the use of these mirrors across the cycle superhighway network, and it will consider further requests for "Trixie" mirrors by other authorities. Unfortunately, I was not aware of the situation in Paris.

Lord Berkeley: My Lords, is the noble Earl aware that in the present mayor's time in office accidents have actually increased? It is thought that he has increased the free-flowing of cars and lorries through the junctions, and reduced the time for pedestrians and cyclists to go across. He has also reduced the amount of space on the road for cycle lanes, and things like that-in spite of bringing in the new "Boris bikes", which of course we all welcome. Could that be looked at? Do the Government think that the idea of a £200 million fund from the Campaign for Better Transport in London to help cycling facilities would help to reduce deaths?

Earl Attlee: My Lords, it is true that, in 2011, 12 out of the 16 cyclist fatalities in London involved a goods vehicle, with seven involving construction vehicles, but it is too early to see whether there are any undesirable trends. Both Transport for London and my department will study these matters very carefully indeed.

Lord Mackenzie of Framwellgate: Will the Minister indicate what proportion of these accidents are caused by people jumping the red lights, as the noble Baroness, Lady Gardner, suggested, and what the Government are doing to encourage the police to enforce the provision?

Earl Attlee: My Lords, the last point is the important one. It is an operational matter for the police how they enforce the law. Clearly, the mayor and other authorities will look closely at the police's performance in driving down road traffic casualties generally, but in particular those of cyclists, because they are vulnerable road users.

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Lord Bradshaw: My Lords, the "Trixie" mirrors to which the noble Baroness, Lady Gardner of Parkes, referred, have to be fitted on traffic signals and have to receive the assent of the Department of Transport under present regulations. Most authorities that wanted to use them would have to submit a form to the department for the Secretary of State or his representative to sign. Would the Minister look at that bureaucracy? He mentioned that the Government were re-examining the regulations with a view to improving them by 2014, but I do not think that comes under the definition of "soon" that we heard on an earlier Question.

Earl Attlee: My Lords, the noble Lord makes an important point about the need for the department to approve traffic signs. It is important that the traffic signs are consistent right across the United Kingdom to avoid a plethora of different designs of traffic signal, which would be very confusing to motorists.

Lord Young of Norwood Green: My Lords, does the Minister agree that, without trying to lay blame on cyclists or lorry drivers, we want to promote safer cycling and a greater awareness among lorry drivers? I venture to suggest that the problem is not just in London, although I cycle practically every day so I am aware of it. For the Minister's benefit, I can say that the Paris experiment is about allowing cyclists to go through red lights where the situation is safe, so that will be interesting. Finally, could he give us any information on the number of accidents where wearing a cycle helmet would have improved the chances of a fatality not occurring?

Earl Attlee: My Lords, the Government encourage the use of cycle helmets but we think it undesirable, as did the previous Administration, to make them compulsory because this could have the unintended effect of reducing cycling despite its undoubted health benefits. On the question of turning left, my noble friend Lord Spicer has an Oral Question about left turns coming up shortly. As part of my research on that, I have just had a working lunch with the chief examiner of the Institute of Advanced Motorists.

Lord Cormack: My Lords, would the roads of London not be less congested and safer for cyclists, and indeed for us all, if there were restrictions on the hours in which delivery vehicles could operate?

Earl Attlee: My Lords, the noble Lord has asked a slightly wider question. There is a freight operator recognition scheme-FORS, a membership scheme-that aims to improve freight delivery in London. It is free, voluntary and open to any company operating vans or lorries in the capital. It has been developed by TfL and is a reward and recognition scheme with the aim of improving safety and operational efficiency.

Lord Roberts of Llandudno: My Lords-

Lord Brooke of Alverthorpe: My Lords-

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Health and Social Care Bill

Bill Main Page

Report (1st Day)

3.36 pm


Moved by Earl Howe

Lord Owen: My Lords, before the House agrees that the Report should be received, I would like to raise some important constitutional questions. On 4 April, the day the Prime Minister and the Deputy Prime Minister embarked on their "listen and explain" experience and the legislation was paused, I wrote to the then Cabinet Secretary, Sir Gus O'Donnell-now of course the noble Lord, Lord O'Donnell-and raised with him the fear that, because of the long drawn-out legislative process, discussion of the Bill in this House could be pre-empted. I also told him that I had consulted the clerks in Parliament and it appeared that there was no written convention that guides the Government on what is or is not acceptable to take in advance of Royal Assent. Obviously they cannot implement the legislation in full.

Many of my concerns since then have been more than justified. I received a letter on 7 April from the then Cabinet Secretary that said:

"The Treasury guidance on 'Managing Public Money' sets out how, in some circumstances and if ... conditions are fulfilled, departments can incur expenditure on the measures contained in a bill prior to Royal Assent. In addition, a department may take steps to prepare for implementation using existing statutory powers. I have therefore discussed your concerns with Una O'Brien, as Accounting Officer, in the light of this guidance. She has confirmed"-

this is important-

As a result of that, there has been broad acceptance in this House that on these controversial questions, some of which are already agreed, the Government are proceeding under existing legislation.

On 16 September I was informed by the chairman of the Constitution Committee that that committee had briefly discussed the pre-legislative disappearance of PCTs, and had in front of it my correspondence with the Cabinet Secretary, which I had made available to Professor Tomkins, one of its advisers. I was asked whether I would provide more information about changes that had been introduced following Second Reading of the Health and Social Care Bill but prior to it coming to the House of Lords. I enclosed an up-to-date document in great detail that had been sent out for consultation by the Midlands and East Strategic Health Authority, which I thought gave a pretty clear indication

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of the anticipated massive changes to the whole architecture of the NHS, many of which seem as if they will be introduced despite the fact that the full legislative process was continuing.

I also drew attention to a speech that had been made in the other place by a Member of Parliament that had again raised the question of whether it was proper to stop the legislation when so much was already being done and so much pre-emption had occurred. Today I have written to the Constitution Committee on this question because an MP drew my attention to a letter that says that people,

On today's "World at One", the chief executive of the Foundation Trust Network warned of a no-man's land if the Bill did not go through.

This raises pretty big questions for legislation that is still to go through all its stages in this House, and it is a matter of great concern to this House when it considers reform. These conventions will become very much more important if we have an elected House of Commons-which of course we have-and an elected House of Lords, which I personally would like to see. There is no question that these conventions are important.

There are two important points here. First, the House should be aware of the fact that the Constitution Committee is seized of the problem and may well wish to make judgments on it. Secondly, we should not feed the idea that legislation can reach us but we cannot do anything about it because it has already been pre-empted. Whatever our views on the Bill, and it is controversial, it is important on democratic grounds that we maintain the position that legislation does not have full authority until it has gone through all its processes. That point needs to be reaffirmed. We should give no comfort to the opposite view in what we say in this House in the remaining stages of the legislative process.

The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): My Lords, of course, the noble Lord, Lord Owen, had no obligation to give the Government advance notice of the issue that he has just raised. Nevertheless, I am sorry that he did not. I just say to him that everything that has happened to date in my department's implementation of the transition programme has been done under the Secretary of State's powers under the 2006 Act. This is all proper and lawful. However, this can go only so far. It is not a permanent solution, hence the need for the primary legislation that we are now debating.

It has been the practice of successive Governments, once a Bill has passed through the other place, to do as we have done and make preparations for that Bill's implementation. The previous Government did it on a number of occasions and we are doing so as well. Furthermore, we are doing so in a measured and structured way. It is not an overnight process-it never could be. It is being done over a period of years. It in no way pre-empts the will of this House, which has made its views, to which the Government have listened very carefully, known on a number of issues.

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While thanking the noble Lord for raising this concern, which I shall of course consider very carefully, as I always do, I hope the House will feel that it is unconstrained in how it presents amendments to the Government and how it argues for them. We, in our turn, will respond in a constructive manner, as I hope always to do.

3.45 pm

Baroness Thornton: My Lords, I think the noble Earl has answered the question as far as it goes, but he raises several points. First, this Bill did not need to be in front of us at all because many of the changes that are taking place do not need primary legislation. Secondly, his colleagues in another place have constantly said that the Bill cannot be dropped because it has gone too far. We are not in the same place now as we were at the end of Committee; millions of people in the health service have now expressed their view that this Bill should not happen at all. Given that, do the Government have a plan B in case they need to withdraw the Bill? Do they have people working on that in case the Bill has to be dropped?

Lord Warner: My Lords, before the Minister responds to that question, will he consider later-if he cannot answer now-the budgets for clinical commissioning groups? I understand from a meeting of the national Commissioning Board, which was held in open session on 2 February, that Sir David Nicholson is reported as having said that clinical commissioning governance is, in effect, moving on apace, and that more than 95 per cent of clinical commissioning groups have now agreed their constituent practices and geographies and are already seeing benefits in their services from the work that they have been doing. At the high level, around 50 per cent of the commissioning spend is already delegated to clinical commissioning groups from PCTs under various delegation schemes. That seems fair enough, but there is a final point on which I would welcome the noble Earl's clarification. It says that the ambition is for all this to be so delegated to clinical commissioning groups by 1 April 2012. Will that delegation still be part of the present powers, or is it in anticipation of the legislation being passed in time?

Lord Howarth of Newport: My Lords, has the noble Lord, Lord Owen, not drawn our attention to a particularly egregious example of a problem that is, however, long-standing? Have successive Governments not taken the will of Parliament for granted following Second Reading of measures and begun to spend money and implement transitional arrangements on that basis? Has it not always been improper, and should Governments not be particularly careful when they are well aware that the policies embodied in their legislation are highly contentious? I hope that we may hear some considered reflections by the Government on the generality of this practice, as well as on this particular incidence. It may be that the relevant Select Committees of both Houses of Parliament will want to consider this problem.

Earl Howe: My Lords, in answer to the noble Baroness, Lady Thornton, there is no suggestion that the Bill could be withdrawn. We are clear that it is the

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right thing to do. Reform of the NHS is necessary and in the national interest, and the measures in the Bill represent the best way forward.

The noble Lord, Lord Warner, asked me about the powers of delegation. All I can say to him is that the delegated budgets to which he referred are delegated under existing powers, so there is no issue in law if that is what he was implying. However, I will endeavour to write to him if I have any further details for him on the subjects that he talked about.

The noble Lord, Lord Howarth, suggested that the Government were beginning to spend money. In one sense he is right because there have been redundancies in the NHS, but in another he misses the point. We have started to save a great deal of money. These measures will save £1.5 billion every year from the end of this Parliament and around £3.2 billion during this Parliament. We have begun to implement efficiencies and improve patient care at the same time. I hope he will look at these issues in the round.

Report received.

Clause 1 : Secretary of State's duty to promote comprehensive health service

Amendment 1

Moved by Lord Patel

1: Clause 1, page 2, line 6, after "of" insert "physical and mental"

Lord Patel: My Lords, it is a dubious privilege to speak to this amendment. I say "dubious" because the noble and learned Lord, Lord Mackay of Clashfern, is on a well-deserved rest and recreation leave and the noble Baroness, Lady Hollins, who is better qualified than me in this area, is unfortunately also detained on a lecturing commitment in Rome. However, I am pleased to say that the noble Lord, Lord Alderdice, whose name is also to the amendment, and who is much more knowledgeable on these matters than me, will no doubt speak later.

The House will remember that when we discussed this issue in Committee there was widespread sympathy for and acknowledgement of the need to recognise mental illness and accord it a similar importance as that accorded to physical illness. The noble and learned Lord, Lord Mackay of Clashfern, who tabled this amendment, wrote a note to me to say he was sorry that he would be away when it came up for consideration. He said that some time ago he was travelling with a lawyer colleague who had been a chairman of mental health tribunals for many years. He asked his colleague what was his impression of progress in this field. The reply was that it was not great compared with that in other health fields. The noble and learned Lord's view is that it is desirable to emphasise the importance of mental illness and its treatment for the well-being of our people, and that it is wise to do so through this amendment to this comprehensive Bill. He feels right at the start of the Bill is the vital place to do so. Thereafter, the definition clause will carry this meaning where appropriate. The noble and learned Lord does

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not agree with the objection that if the provision is inserted at this point in the Bill, it must be inserted everywhere the issue arises. In his view, the definition will carry that burden and make later repetition unnecessary.

The amendment would place an explicit duty on the Secretary of State to promote parity of esteem between mental and physical health services. The duty would sit within his or her existing duty to improve the quality of health services. It also clarifies that the Secretary of State has a duty to promote a health service designed to secure improvements in the prevention, diagnosis and treatment of both physical and mental illness. The amendment would put the Government's own commitment to parity of esteem between mental and physical healthcare on a statutory footing and make it clear that the Secretary of State is fully committed to improving the nation's mental health services and the prevention and treatment of mental and physical illness and expects the NHS board and the CCGs to do the same.

When the Government launched their mental health strategy, No Health WithoutMental Health, in February 2011, the Minister for Care Services stated that he wanted to see parity of esteem between mental health and physical health services. This was a recognition of the fact that, despite the prevalence of mental illness-one in four people experience a mental health problem during their lifetime-mental health has never received the funding or attention it needs. Progress in improving the quality of commissioning and services has been much slower for mental health. Parity of esteem is not defined in the document itself. However, it would be reasonable to expect that this would mean a recognition of the equal importance of mental and physical health and the need to consider both aspects of people's health when they present with either physical or mental illness. I would expect this recognition to be evident in terms of access to mental health services and funding for services proportionate to the disease burden. However, this has not been the case.

Over the past 10 years things have begun to improve. For example, we have seen significant and very welcome investment in talking therapies under both the present and previous Governments-£173 million in 2007-10 and £400 million from 2010-14. However, given that mental health services started from a very low baseline, we simply cannot afford to go backwards-and talking therapies are only one aspect of mental healthcare. During previous spending squeezes-for example during the financial year 2005-06-mental health services have been unfairly and disproportionately targeted for cuts, perhaps because they do not enjoy the same level of public support and understanding as other services. I admit that I often push for cancer services and maternity services, so I pay regard to that.

However, mental illness is a leading cause of suffering, economic loss and social problems, and it is time to recognise and act on the plentiful evidence that good mental health underlines all health. Poor mental health is associated with diseases such as cancer, cardiovascular disease and diabetes; and poor physical health increases the risk of mental illness. In the current climate of scarce resources, expenditure reduction, welfare reform

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and cuts to legal aid-I might as well get all that in-mental illness and mental health problems are likely to increase. However, while mental illness represents 23 per cent of the disease burden, it accounts for only 11 per cent of the health budget. It is therefore vital that mental health spending should be proportionate to the need, and mental health must not be the poor relation of physical health.

More than one-fifth of the population in England experiences a mental disorder at any one time. An even larger proportion experiences sub-threshold mental disorder. Almost half of adults experience at least one episode of depression during their lifetime. Only a quarter of affected individuals receive any intervention, except those with psychosis. Compared with people with no mental health problems, men with severe mental illness can expect to live 20 years less, and women, 15 years less. A combination of lifestyle risk factors such as smoking and diet are higher, as are unnatural deaths such as those caused by suicide and accidents. Poor physical healthcare contributes to this premature mortality. If such a disparity of mortality rates were to affect a large segment of the population with less stigmatised characteristics, we would witness an outcry against the socially unacceptable neglect of that group.

While the amendments cannot solve all this, creating an explicit duty on the Secretary of State would set a clear expectation that commissioners need to give full consideration to the mental health of those with physical health problems, and to the physical health of those with mental health problems-and to give full consideration to mental as well as physical health. It is simply not acceptable for the mental health needs of children and adults to continue to be neglected.

There is an imbalance between mental and physical health in both healthcare and health promotion in many places. A better balance could bring a number of benefits to people living with, or facing the risk of, mental ill health. Health and social care policy should be developed with mental as well as physical health needs in mind. A duty to promote equality should encourage policymakers at all levels of the system to consider mental health alongside physical health, rather than making policy for the latter, and later adjusting to fit the former.

I know that the Minister is very involved with people in the area of mental health because I know that he has been a patron of several charities related to it, and he therefore has great sympathy towards recognition of mental illness and its treatment. I hope that his answers to the amendment will be such that there will be no need to seek the opinion of the House, and I look forward to his reply. I beg to move.

4 pm

Lord Alderdice: My Lords, the noble Lord, Lord Patel, has characteristically underplayed his own grasp of this important area, but, as noble Lords have heard, he has on his own behalf and on behalf of the noble and learned Lord, Lord Mackay of Clashfern, and the noble Baroness, Lady Hollins, presented an elegant, informed and very persuasive case for the

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amendment, to which I have put my name. In many ways, there is not much to say other than to support him. However, when noble Lords say that in your Lordships' House, it is often because they actually have quite a lot to say, and I shall say a few words.

On 2 November last year in Committee, your Lordships debated three amendments which would have placed the responsibility on the Secretary of State, the national Commissioning Board and all clinical commissioning groups to regard mental health on the same basis as physical health. That is to say that they should give full consideration to all those suffering from mental illness in the same way as they would those suffering from physical illness.

One reason for trying to insert such a commitment into the Bill was that, despite the efforts of the previous Government-to whom the noble Lord, Lord Patel, is quite right to pay tribute-to address the needs of people with mental illness by allocating more money for talking treatments, on which the coalition Government have substantially built, as the noble Lord said with reference to the legal friend of the noble and learned Lord, Lord Mackay, out there in the real world, mental illness and problems of mental health do not get the same attention and concern. As we said in the debate in November, many people think of mental illness as a subset of illness, like cancer, diabetes, or whatever, but it is not. It is a quite different aspect. When you fall ill with something physical, something happens to you but your personality and your self are not affected; but when you fall mentally ill, the very essence of your self is affected. That is a very different business. It frightens people. They often turn away from paying attention to it because they are so troubled by it. The provision required is different. Often, much more than is the case with other illnesses, a whole range of services has to come together to provide treatment and support.

Our concern in that debate-which was supported by noble Lords on all sides of the House; no one spoke against-was that all the efforts until now have been less than fully successful in building up the regard and esteem in which mental health and mental illness is held. So the proposition for the amendments was not a belief that there was a particular technical flaw in the Bill which meant that mental illness would not be addressed; we are very much aware that it is addressed in the Bill. That is not the problem. The problem is: how do we find a way continually to bring mental illness to the attention of commissioners? The noble Lord, Lord Patel said, as was said in the November debate, that in times of financial pressure and austerity, the tendency is to pull back financial commitment from those areas where there is least pressure. When people are physically ill, they can often nevertheless continue to exert pressure; but when people are mentally ill, they often do not give due regard to themselves, never mind press for the needs of others who are suffering from similar disorders.

Our concern is not about those three specific amendments but the principle. The noble and learned Lord, Lord Mackay of Clashfern, went away and produced a single amendment. The noble Earl was kind enough to give a considerable amount of time to

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me and the noble Baroness, Lady Hollins, to discuss the question. A concern was expressed by him and some people in the department that if one included this in one place, one would have to put it in every place because otherwise the implication would be that it applied only to the issue to which it refers directly. I have to say that the noble and learned Lord, Lord Mackay of Clashfern, was wholly unimpressed with that argument. As he is a former Lord Chancellor, I think one takes that pretty seriously.

The point is that we must find some way in which to make it absolutely clear beyond peradventure that concern for those who have mental health problems is every bit as great and the responsibility on commissioners is every bit as great to ensure the proper provision of services. One reason why this comes up as the very first amendment Report is that we want to ensure that in all aspects of health care, mental health care is attended to: no health without mental health and indeed, as the Royal College of Psychiatrists' report said, no public health without public mental health.

It is regrettable that the Royal College of Psychiatrists, of which I am a member, has over the past few days been saying that the whole Bill should be set aside. That is not really a helpful way of engaging in these kinds of questions. The college knows perfectly well that the Bill is not going to be set aside-in fact, it would not be at all helpful if it were. I have seen these kinds of situations in other places, with people polarising in an unhelpful way. I appeal to the Minister, to the Royal College of Psychiatrists and to others who are interested and concerned in this field to find a way to get together again before the completion of the Bill to ensure that the concerns that we are expressing are reflected in a cast-iron fashion. It is a question not of these particular words or of this particular amendment but of receiving solid assurances so that we and those who care for people with mental illnesses, as well as those who suffer from such illnesses, can be confident about the new NHS.

Lord Walton of Detchant: My Lords, in rising briefly to support the amendment so ably proposed by my noble friend Lord Patel and supported by the noble Lord, Lord Alderdice, I ask the Minister one very simple question. In Clause 1(1)(a) the Bill talks about the,

and says that the health service must be "designed to secure improvement" in that health. What on earth could the objection possibly be to inserting in paragraph (b) at line 6 the unexceptional words listed in the amendment? They simply stress the crucial importance of mental as well as physical illness. How on earth could this be construed as doing any damage whatever to the Bill? It is something that I hope very much the Government can be persuaded to accept.

Lord Carlile of Berriew: My Lords, I should like to say a word on behalf of those who have had to care for family members-often a young member of the family-who have suffered from severe mental illness. Those who have suffered that experience-and I am one-know how marooned they feel when they find that someone in their family has a serious mental illness. If somebody

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has a broken leg, you can locate the leg and take the medicine. If somebody has even cancer, it may not be curable but at least you have the knowledge of the location or locations of the cancer and the topical treatment that is to be applied to it.

The problem for families who experience in their midst mental illness is that no medicine can be applied topically to the place where the hurt or illness is taking place. The prognosis is uncertain, the mortality rate is depressingly high and usually at the hands of the sick person, and accessing good health service facilities is quite chancy, I am afraid. There is a real postcode lottery with mental health treatment. If, for example, you live in a remote rural area, only some therapies will be available and they may be the wrong therapies, particularly if the patient is a child or adolescent suffering from serious mental illness. Therefore, I simply say to the Minister who, as has already been said, cares deeply about these issues, that the adoption of this very simple amendment, as the noble Lord, Lord Walton, rightly described it, would send out such a telling message of support to families who have to care for people who suffer, perhaps temporarily, from mental illness that it would be seen as a declaration of purpose by this Government.

Baroness Whitaker: My Lords, briefly, from a lay perspective, I urge the Minister to take this amendment very seriously. I will not rehearse what I said at Second Reading from my experience on the board of the Tavistock and Portman clinic or from other walks of life about how widely damaging and destructive it is not to have parity, and how it needs to be explicit parity to change culture and to erode the stigma and the neglect associated with mental ill health. If the Government are rash enough not to accept the amendment-and I am quite sure that the noble Earl is not like that-I hope that there will be a Division. If the debate lasts until five o'clock, when I am committed to chairing a meeting, I hope that the House will accept my apology but I will return to vote.

Lord Newton of Braintree: I have two excuses for speaking. First, I have chaired two mental health trusts and, although I no longer do so, I have a continuing interest of a non-financial kind. Secondly, before my noble and learned friend Lord Mackay left for what was described as his well earned rest and recuperation, I was the nearest thing to anybody he anointed to take care of his interests while he was away, which includes this amendment.

I do not need to speak for long because I think that this is a no-brainer. Everybody agrees on the importance of mental health and endorsed the Government's No Health Without Mental Health strategy. We are all keen on that-even the Government. Yet the little birds tell me that the amendment will be resisted on the grounds that it is not necessary and does nothing to add to the 2006 Act. I spent a lot of years as Leader of the House of Commons and I got fed up with Ministers who came to me on Private Member's Bills and other things and said, "It's not necessary-we are going to do this anyway". They then proceeded to immolate themselves on a bonfire for an amendment that would have cost nothing and done no harm-it certainly would not have added anything-but would

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have pleased a lot of people. That is idiotic. It would not cost the Government anything to do this and, as my noble friend said, it would please a lot of people, so we should simply get on with it. If my noble friend has been told to resist it I will sympathise with him, but frankly if the noble Lord, Lord Patel, feels that he should push it, I will push it with him.

Baroness Meacher: My Lords, I support this amendment very strongly and shall speak extremely briefly. Others have spoken most eloquently and very much made the case. My fear, too, is that the Minister will regard it as unnecessary. I have absolutely no doubt at all about the Minister's commitment to mental health, but I believe that this is necessary because of the context in which the amendment is being posed-in other words, the Bill itself. What I mean is that the Bill is designed more than anything else to introduce privatisation of the NHS-slowly, slowly. It will not be done overnight, but in 10 years' time we can be sure that a substantial proportion of our NHS will in fact be in private hands. If we look across the world to the US, Germany and other countries, we find that privatised health services do not support mental health to the degree that we in the NHS have supported it in the past. That is the most fundamental argument in my view. We have to protect our mental health services, albeit that they have been a Cinderella relative to the acute sector, but not to the degree that mental health services are Cinderellas in other countries where private health dominates.

That is my most important point. The only other part of the context is that the Bill will do nothing to make the changes that we need in the NHS, such as closures of redundant acute hospitals and redundant acute departments. I hope that this Government, unlike many previous Governments of whatever hue, will take the leadership role and show that they support mental health. I appeal to the Minister not to say that this is unnecessary. I appeal to him to agree that it is necessary and to give and show the Government's commitment to equality of parity of mental health and physical health in this country.

Baroness Williams of Crosby: My Lords, my noble friend Lord Alderdice made the strong point that in the real world mental health is not regarded as being on all fours with physical health. For the reasons presented by my noble friend Lord Carlile and others, clearly in the real world mental health is often hidden. It is often an issue that people do not freely address and it is vital that we send a clear signal from this House that mental health is absolutely equivalent in significance and importance to physical health, and that we believe that.

I shall briefly say what has already been said. Will the Minister at the very least consider taking this debate back and looking at whether there could be an agreed amendment that would meet his difficulties? There may be drafting difficulties, but it would not in any way resile from the statement that this House believes that mental health is vital and we want it on the face of the Bill. I plead with him to consider doing that.

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4.15 pm

Lord Ribeiro: My Lords, I follow the noble Baroness in saying that I am speaking not because I see this as an amendment that should be pushed to a vote, but rather because I see it as a probing amendment that would allow the Government and the Minister to listen to the arguments being put today.

The whole thrust of the reforms is to provide care right across the community-secondary care, primary care and, let us not forget, social care. The mental health institutions started to be closed some 30-odd years ago, and care moved into the community. The ability to identify, diagnose and treat patients admitted into accident and emergency departments, often with psychotic diseases, is a major challenge. It certainly is for surgeons-for me in particular. As more psychiatrists are diverted to care in the community, the diagnosis and treatment of patients who appear in A&E departments is a challenge. It is quite difficult for those of us who have not had psychiatric experience. I was very fortunate that my house officer rotated through a psychiatric firm, so I had the benefit of somebody who was able to identify patients with psychotic illnesses and could advise me how best to deal with them.

It is important to identify the difference between physical and mental illnesses. I feel that this amendment would make a difference by clearly stating that there is physical illness and mental illness in this section. I very much hope that the Minister will listen to the strength of the debate and come back with some answers.

Baroness Finlay of Llandaff: My Lords, I hope that the Minister will be able to break away from his brief and accept this amendment, because it is critical. As my noble friend Lord Walton has pointed out, the first part of the amendment talks about physical and mental health, but the second part implies that prevention, diagnosis and treatment are of illness, and there is a real danger of reading that as physical illness. The most tragic situation is where physical illness is misdiagnosed as mental illness or mental illness is misdiagnosed as physical illness. The consequences of that for patients can be disastrous.

In primary care, patients present with a completely undifferentiated picture. The general practitioner has to start from scratch, sort out the different parts and then refer to or consult other parts of the service, as appropriate, if he needs to. My noble friend Lady Meacher suggested that those services are in imbalance, and I agree with her that there is a danger when funding is short that you will lose the mental health component of services and that the culture change that this Bill is meant to bring about will not happen. A culture change is needed. Stigmatising labels have been attached to people with mental illness for many years. People with learning difficulties do particularly poorly in services overall. If we are going to take the opportunities of this Bill, we have one with this amendment: to flag up that there are mental and physical components to illness that need and deserve accurate diagnosis, the one as much as the other, that they are interrelated, that one affects the other and that we cannot provide a comprehensive health service without due regard to the totality-to the holistic person who is the patient in front of us.

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The Countess of Mar: My Lords, I too support this amendment very strongly, and I think the Minister knows why.

In my dealings with people with ME/CFS, I have found that many of them have been sectioned and put into wards that I can only describe as barbaric. There was one recent case where the man had a very clear physical illness and he spent nearly nine months in a hospital in Torbay-Torbay, the hospital that has been praised left, right and centre; but its mental ward is not worthy of praise. If the funding is equal for mental and physical treatment, this will somehow redress the balance.

My mother was mentally ill for 17 years and she was treated barbarically by psychiatrists. She was hooked on barbiturates and she was given a leucotomy. I thought those days had gone but we are not far from them with the things that I have seen with ME patients.

Lord Eden of Winton: My Lords, we have listened to many powerful and persuasive speeches. I am tempted to go all the way with those who have advocated the inclusion of this amendment in the Bill, but I take up the words of the noble Baroness, Lady Finlay, who referred to the need for a cultural change. I think all noble Lords would agree that there is the need for a cultural change. I only question whether it is right to try to achieve that change through legislation. Surely what we are seeking to do is to change attitudes and get people to understand that there is no difference between physical and mental illness. For that reason, I think we need to hesitate before including words in legislation. What we need to do is to make people throughout the health service and everyone associated with the administration aware of the fact that there is no difference between physical and mental illness, and that those with mental illness need to be treated on an absolutely level footing with those with physical illness.

Baroness Thornton: My Lords, we on these Benches liked this amendment the first time round and we have not changed our minds. It may be symbolic in its effect-in fact, we think it all the better for that. Legislation should be the expression of policy and this amendment flows from important policy commitments by successive Governments about the parity of policy-making at all levels of the system to consider mental health alongside physical health. We give our very full support to the mover of this amendment and we urge the Minister to accept it.

I have two other remarks to make. First, I always listen extremely carefully to the noble and learned Lord, Lord Mackay of Clashfern. Frankly, if he says it is good enough for this Bill, that is good enough for me. Secondly, I agree with the noble Lord, Lord Newton, that it is a no-brainer. To the noble Lords, Lord Ribeiro and Lord Alderdice, and the noble Baroness, Lady Williams, I say that we are on Report. This is not the time for probing amendments. This is the time for taking decisions about what we want in the Bill. The Minister had the opportunity to take this away and consider it after Committee, when the House was as united in its view about this matter as it is today. Today I urge the Minister to accept this amendment but, if he will not, the House needs to express its view about this matter if at all possible.

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Earl Howe: My Lords, we have had an excellent debate to mark the start of Report and I am very pleased-and, I must say, unsurprised-that the spirit of our debates in Committee has continued. I am particularly pleased that we have started with a topic as important as the parity of esteem between mental and physical health.

Amendment 1, moved by the noble Lord, Lord Patel, would ensure that the reference to "illness" in the description of the comprehensive health service refers to mental as well as physical illness. I am grateful to all noble Lords for the powerful case they have made for this amendment. I very much understand why this issue is of such importance to noble Lords, and why they believe that there is a declaratory value in inserting these additional words at this point in the Bill. As the noble Lord, Lord Patel, will be aware from our recent mental health strategy, achieving parity of esteem for mental illness is a priority for the Government. Therefore, I do not dissent in the slightest from the central principle being argued for here.

The question I have asked myself since Committee is whether the addition of these words would achieve what noble Lords intend, and whether they would add real value. In a strictly legal sense, they will not add value because legislation already makes it clear, through the definition in Section 275 of the National Health Service Act, that any reference to illness in the Act shall include both mental and physical illness. Therefore, wherever in the Bill the word "illness" appears, it already refers to both mental and physical illness. However, as my noble friends Lord Eden and Lord Alderdice said, what is required here-what really matters-are not words but concrete actions that will result in changes in attitudes and behaviours.

Before I tell the House which way I am leaning on the amendment, I will set out the steps that the Government have taken to that end. First, we are using the Bill to enhance the role of the NHS constitution. This plays an important role in emphasising the prominence and importance of mental health. It already contains a strong opening statement about mental and physical health. It declares that the NHS is there,

Current legislation requires all NHS bodies and providers to the NHS to have regard to the constitution. The Bill creates new duties on the NHS Commissioning Board and clinical commissioning groups not just to have regard to it but to promote it. This is why we feel that NHS bodies, staff, patients and the public will in future be much more aware of, and hence responsive to, the NHS constitution and the parity of esteem that it champions. Therefore, I am afraid that I cannot agree with noble Lords who implied that the Bill is silent on parity of esteem. We are giving greater prominence to the NHS constitution precisely because we want to see greater awareness of the values, including parity of esteem, that it contains.

Secondly, we have used a range of operational levers to drive forward the importance of improving mental health. Mental health is featured prominently in the NHS operating framework. We have updated

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the NHS outcomes framework to include indicators for mental health outcomes in a holistic context. The public health outcomes framework has a set of key mental health and well-being outcomes identified for national and local action.

Thirdly, our mental health outcomes strategy makes it crystal clear that mental health services should have parity of esteem. We said in the document that it is our ambitious aim to mainstream mental health in England. Furthermore, as noble Lords know, we titled the strategy, No Health Without Mental Health. I can tell the noble Lord, Lord Patel, that we are going further still by looking to publish a full implementation framework for the strategy in April this year. This will be co-produced and jointly owned by national mental health organisations in partnership with government. Work is under way to develop the content of the framework, including consultation with a wide range of partners. My conclusion is that much work is afoot, as well as levers already in the Bill, to deliver the parity of esteem between mental and physical health that we all want to see in clinical practice.

I turn to the amendment. Should the noble Lord, Lord Patel, invite the House to add these words to the Bill? I am afraid that I have concluded that the noble Lord should resist the temptation. Having reflected very hard on these words, I believe that they could be positively unhelpful to his case, as well as to the business in which we are jointly engaged, which is the drafting of clear, economical and unambiguous legislation. "Illness" is already defined in the Act and, for me, these words are not only legally superfluous, they also suggest that there is a divide between mental and physical illness rather than a convergence.

4.30 pm

The noble Lord may believe that little harm would be done by his amendment, but I respectfully suggest to him that that may not be so. However, while I would urge him to withdraw it, I can tell the House that I am going to break away from my brief because my feeling has changed over the course of this debate. I agree that, given the nature of the Bill and the amount of time and discussion the House has dedicated to it, we could do more about the terms it uses, especially at the very start. In the light of that, and in response to the arguments made today, I would like to commit to undertake to do some further work to make clear the Government's commitment to parity of esteem. The first thought I have had-and I do not dare look behind me to my left-is that there is potentially an important role for the Explanatory Notes to the Bill. I can confirm, because I shall see to it myself, that we will be revisiting the Explanatory Notes to make it clearer that, with respect to Clause 1, "illness" refers to both mental and physical health. That is a very easy thing to do.

Secondly, I would like to invite the noble Lord, Lord Patel, and possibly other noble Lords, including my noble and learned friend Lord Mackay of Clashfern, if he is available, to have further conversations with me and with my ministerial colleague Paul Burstow to consider if there is anything further we could do, whether in the Bill or outside it, to promote parity of

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esteem between mental and physical health. I realise that I have not been able to meet the noble Lord on precisely the same territory as he has proposed, but I hope nevertheless that with the reassurances I have given, he will on balance be able to withdraw his amendment.

Lord Newton of Braintree: My Lords, perhaps I may say that if it was me who my noble friend was referring to as being on his left, I am thrilled to bits by his rather more constructive response. I congratulate him.

Lord Patel: My Lords, I wish that I did not need to speak at this point because I am really quite torn. I know how sincerely all those who have spoken feel about this amendment, and about emphasising the need to promote mental illness as having the same parity as physical illness. At the same time, I know how sincere the noble Earl is, and therefore it is difficult not to accept what he has said and the promises he has made. None the less, the comment made by my noble friend Lord Walton is the one that has affected me most: what is the key objection to putting these two words at the front of the Bill to signify that mental illness is as important in its management as physical illness?

In my professional life I have dealt with physical illness, but I was always deeply affected whenever I had a patient suffering from postpartum depression or antenatal anxieties and sometimes psychosis; they were the most difficult to deal with. I would then have to seek the assistance of my psychiatrist colleagues.

Lord Elton: The noble Lord said that his noble friend was awaiting an answer to his question as to what was the objection? I have understood my noble friend to say that the objection was that it could actually make things more difficult because it would imply that there is a distinction between the two forms of medical treatment, which is exactly what we wish to negate.

Lord Patel: I did hear what the noble Earl said and I cannot say that I can accept that it would create difficulties if we included mental illness with physical illness. I do this with a very heavy heart, but I know that if I do not push the amendment, others will do so. On that basis, I think we should resolve the issue by seeking to test the opinion of the House.

4.34 pm

Division on Amendment 1

Contents 244; Not-Contents 240.

Amendment 1 agreed.

Division No. 1


Aberdare, L.
Adams of Craigielea, B.
Afshar, B.
Ahmed, L.
Alliance, L.
Anderson of Swansea, L.
Andrews, B.
Armstrong of Ilminster, L.
Bach, L.
Bassam of Brighton, L.
Beecham, L.
Berkeley, L.
Bew, L.
Bichard, L.

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Bilimoria, L.
Billingham, B.
Bilston, L.
Blackstone, B.
Blair of Boughton, L.
Boateng, L.
Boothroyd, B.
Borrie, L.
Boyce, L.
Boyd of Duncansby, L.
Bragg, L.
Brooke of Alverthorpe, L.
Brookman, L.
Brooks of Tremorfa, L.
Browne of Belmont, L.
Browne of Ladyton, L.
Butler of Brockwell, L.
Butler-Sloss, B.
Campbell of Surbiton, B.
Campbell-Savours, L.
Carlile of Berriew, L.
Chorley, L.
Clancarty, E.
Clarke of Hampstead, L.
Clinton-Davis, L.
Collins of Highbury, L.
Colville of Culross, V.
Corston, B.
Coussins, B.
Craig of Radley, L.
Cunningham of Felling, L.
Darzi of Denham, L.
Davies of Coity, L.
Davies of Oldham, L.
Davies of Stamford, L.
Desai, L.
Dixon, L.
Donaghy, B.
Donoughue, L.
Drake, B.
Dubs, L.
Eames, L.
Eatwell, L.
Elder, L.
Elystan-Morgan, L.
Emerton, B.
Evans of Parkside, L.
Evans of Temple Guiting, L.
Farrington of Ribbleton, B.
Faulkner of Worcester, L.
Filkin, L.
Finlay of Llandaff, B. [Teller]
Foulkes of Cumnock, L.
Gale, B.
Gavron, L.
Gibson of Market Rasen, B.
Giddens, L.
Glasman, L.
Golding, B.
Gordon of Strathblane, L.
Gould of Potternewton, B.
Grantchester, L.
Greengross, B.
Grenfell, L.
Grey-Thompson, B.
Grocott, L.
Hall of Birkenhead, L.
Hameed, L.
Hanworth, V.
Harries of Pentregarth, L.
Harris of Haringey, L.
Harrison, L.
Hart of Chilton, L.
Hattersley, L.
Haworth, L.
Hayman, B.
Hayter of Kentish Town, B.
Healy of Primrose Hill, B.
Henig, B.
Hennessy of Nympsfield, L.
Hilton of Eggardon, B.
Hollick, L.
Hollis of Heigham, B.
Howarth of Breckland, B.
Howarth of Newport, L.
Howe of Idlicote, B.
Howie of Troon, L.
Hughes of Stretford, B.
Hughes of Woodside, L.
Hunt of Chesterton, L.
Hunt of Kings Heath, L.
Hylton, L.
Irvine of Lairg, L.
Janner of Braunstone, L.
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4.50 pm

Amendment 2

Moved by Baroness Finlay of Llandaff

2: Clause 1, page 2, line 6, at end insert ", and

"(c) in the education and training of health care professionals"

Baroness Finlay of Llandaff: My Lords, this group of amendments addresses education and training as part of a comprehensive health service. The Government have given the Secretary of State,

that is now Clause 6. This is a welcome amendment to the Bill that we originally saw, and I warmly welcome the Government's amendments, particularly Amendments 61 and 104, which will embed a duty to promote education and training in the core duties of the board and the clinical commissioning groups.

My Amendments 63 and 105 are very similar. They specify that all providers, whether NHS or private, must train clinical staff adequately. They seek to ensure that private providers of services for NHS patients cannot undercut NHS providers by failing to provide adequate training for their staff. All providers should ensure that clinical and other skills are kept up to current standards and that future generations of clinicians are also trained. I therefore hope that the Minister will be able to provide assurances that that will be spelt out in regulation, if it is not already clear. I expect that he may say that the Government's amendments cover the points of my amendments as they refer specifically to Clause 6 and its comprehensive scope. If I am right, it would seem that my amendments are not needed, as the point is covered-but, as I said, I would appreciate clarification. I hope, too, that the Minister can confirm that training must involve staff at every level, whether professionally qualified or not.

Let me turn to the lead amendment in this group, designed to place a duty on the Secretary of State to secure improvement,

There are currently almost 1.2 million staff in the NHS, of whom 52 per cent are professionally qualified. We have been told, in debating this Bill, that the intention is for professional leadership in the NHS. These 600,000-plus staff must be able to take on that responsibility. Let me explain why this strategic overview and responsibility is needed at Secretary of State level. The rationale behind the Bill, we have been told, is to drive up quality and put patients at the heart of the NHS. There is a need for all healthcare services to be learning organisations, constantly reflecting through audit on whether they are reaching the required standards,

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ensuring that their staff are up to date with technical and scientific aspects of care delivery, and having a constant drive to having good attitudes and a culture of responsibility and care for those who are vulnerable-the patients and their families. These are fundamental to the ability to deliver a comprehensive health service.

Clause 1 has the Secretary of State's duty to,

and now,

physical and mental illness. It is impossible to achieve these without securing ongoing improvements through the education and training of all professionals. In his letter of 12 January, the Minister wrote outlining four key elements of the new system proposed for education and training, covering the plans for Health Education England, local education and training boards, the transparent funding of the system and transitional arrangements. We will debate these later in detail, and this amendment in no way detracts from the amendment tabled by my noble friend Lord Patel, which is coming up later on in proceedings. All those amendments are compatible with putting the education and training of health professionals at the very top of the Bill, in Clause 1, as they are part of the comprehensive package that the NHS uses to deliver the best care to patients.

There are almost 98,000 medical and dental staff in the NHS. Medicine and medical care is underpinned by science. Medicine bridges the gap between science and society. This science is constantly evolving; its appropriate application to human health is a crucial aspect of clinical practice and care to achieve better outcomes for patients. Medicine is distinguished by the need for judgment in the face of uncertainty. Much of medicine's unpredictability calls for wisdom as well as technical ability. Everything flows from accurate diagnosis. A commitment to quality improvement allows crucial skills to be passed on to the next generation.

We have heard much about the merits of competition. Doctors and those in many other disciplines in healthcare are almost inherently competitive, and they generally want to be providing high quality service with better outcomes and to be rated highly by their colleagues. That is the competitive spirit that the Government should be able to exploit to drive up standards. Good attitudes are bred from good role models.

There are core values, behaviours and relationships that underpin professionalism in relationships with each patient, and these were exposed in the report by the noble Baroness, Lady Cumberlege, Doctors in Society, on behalf of the Royal College of Physicians. The attitudes and values that healthcare professionals must be committed to in their day-to-day practice involve integrity; compassion; altruism; continuous improvement, which means always learning; a desire for excellence; and an ability to work in partnership with others in the wider healthcare and social care team.

Patients certainly understand the meaning of poor professionalism and associate it with poor care. The public are well aware that an absence of professionalism is harmful to their interests. There have been too many reports into inadequate care in recent years. They

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repeatedly catalogue a lack of standards and poor quality processes and repeatedly recommend education and training of staff at all levels. The NCEPOD report, Emergency Admissions: A Journey in the Right Direction?, said that trainee doctors,

The Healthcare Commission report into the substandard care in Mid Staffs states on page 45:

"From April 2008, there was only one permanent consultant, virtually no education and only limited supervision".

On page 46 it says:

"Senior members of the department said that there was a 'non-existent culture' with regards to education and training. Additionally, several interviewees specifically mentioned that three-quarters of dedicated teaching sessions for junior doctors were cancelled, usually by managers on operational grounds".

There is a virtuous spiral of education, integration and quality improvement. Learning across professional boundaries has been shown to foster integration as healthcare professionals understand better what others can offer in care, thereby driving up quality. They also learn the limits of their own experience and different ways of doing things, to the benefit of all.

If we are to have a constantly improving NHS, education and training must be at its heart. If we are to expect GPs to commission properly, they will need training to recognise poor commissioning advice. If we expect better care from the staff, we must ensure that they are in a system that is driven constantly to improve. I beg to move.

5 pm

Lord Turnberg: My Lords, I put my name to Amendment 12 but I have shifted my allegiance to Amendment 13, along with other noble Lords. However, I want to speak to the other amendments in my name in this group. In doing so, can I say how much I, too, very much appreciate the government amendments in this group?

At the end of the day, education and training have to be provided within hospital trusts, in general practice and-a slightly separate issue-in local authorities for public health consultants. At this level, local education and training boards are to be given responsibility for overseeing the provision of all this education. Here, local employers are to play a key role in the trusts. These local employers clearly have an interest in being able to plan for their manpower needs and in having an influence on what sort of training their employees should have to do the job that they want doing. However, they are not in the best position to decide the educational content of the programmes that the trainees go through. They are not best able to design the training or education of an orthopaedic surgeon or cardiologist, for example.

Furthermore, they may have a conflict of interest when they are asked to make sure that the facilities for training are adequate to their trusts' needs. Is there a full range of patients coming through the hospital to give trainees the necessary experience so that a specialist

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trained in one area can practise somewhere else? Are there enough staff to enable trainees to have the time they need for education? Will they have the time to attend courses? Will it be in the trusts' best interests to allow the rotation of their trainees to other trusts? In all these areas employers may have different priorities. For this reason, it is vital that we have the input of those with particular expertise in and knowledge of education and training, and enough independence to ensure that the training needs of the trainee are met.

Hitherto, specialist postgraduate training has involved the medical royal colleges in designing the curricula and educational programmes for trainees, and in setting and running the postgraduate exams and assessments, while the postgraduate deans are responsible for ensuring that local conditions are right for trainees-that training posts are available and for funding those posts. With the dissolution of the strategic health authorities, the postgraduate deans and deaneries are left in the air and the local education and training boards are to be taken over by the employing authorities. The amendments in my name try to redress that balance by ensuring that the training boards have in their membership the independent voices of those-namely the universities-whose prime role is to help them with the activities. To this I would add the postgraduate deans and colleges. Furthermore, it is important that the local education and training boards, while quite reasonably including local employers, should not be led by them. Boards should have sufficient independence to keep employing authorities focused on meeting the needs of trainees. That is why I have tabled these amendments.

I know that the Minister has given some reassurance from the Government along those lines in the letter that he has written to some us. He said in his letter, which I hope he will not mind my quoting back to him:

"This framework will be maintained in the new system, with the LETBs assuming responsibility for the quality management role at local level".

That bothers me a little. Quality management should be independent of the employers themselves. We now need to see something in the Bill that will give us the confidence that it will happen.

My name is also attached to Amendment 105. Here we are concerned specifically that private providers should not be able to shirk their responsibility for training. There is no doubt that training requires more time and money. If private sector providers are able to avoid training, they will have an unfair advantage over NHS providers. Of course, there is much valuable experience and training to be gained from private practice. For those reasons, I am happy to support this amendment, too.

Lord Willis of Knaresborough: My Lords, I support government Amendments 61 and 104. As regards Amendment 2, which the noble Baroness has introduced, Clause 6 adequately describes the duties of the Secretary of State in relation to education and training. My noble friend the Minister has done an incredibly important job in recognising the real anxiety that existed at Second Reading about education and training. Indeed,

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we are grateful to the noble Lord, Lord Walton, for withdrawing his amendment at that time as that has enabled major discussions to take place on the issue.

Government Amendments 61 and 104 bring us to the heart of who will be driving much of the education and training-that is, the national Commissioning Board and the local commissioning groups. In fact, neither of these groups seems to have any responsibility for education and training, even though, as the noble Lord, Lord Turnberg, rightly says, they will be right at the heart of commissioning the healthcare required, whether it is in an NHS setting or a private, approved setting. That appears to be an omission in the Bill.

Although I have much sympathy with Amendment 109 of the noble Lord, Lord Turnberg, and he is right to point out that there is a requirement on private sector providers or, indeed, third sector providers, to engage in training, I hope that when the Minister winds up on this group of amendments he will point out the advantages to those providers of engaging in education and training. Indeed, he has privately assured many of us that they are more than willing to do so because they cannot become qualified providers unless they are engaged in cutting-edge training and education.

In Amendment 109, the noble Lord, Lord Turnberg, raised the important issue of the involvement of universities. It worries many of us that the universities which have been very much at the heart of education and training, particularly postgraduate education and training, appear to be sidelined in the new architecture of the Bill. Frankly, that is unacceptable. It should not be for local employers to decide whether or not they want a university to be involved; it should be a requirement for universities to be involved. We must not have a situation where universities are regarded as predators in relation to education and training, as they are fundamental to it. If research is a fundamental part of the architecture of the Bill and of improving patient care, frankly, it is absurd to have universities outside that remit. Therefore, I hope that when the Minister responds he will assure us that universities are part of the solution-as the noble Lord, Lord Turnberg, rightly said-and are not seen as part of the problem.

Lord Walton of Detchant: My Lords, I have just counted that in the course of the past few weeks and months I have attended 28 seminars, group discussions and personal meetings with Ministers, the Bill team and others. That was extremely useful. We have spent a lot of time discussing education and training. I pay warm tribute to the Minister-the noble Earl, Lord Howe-and his team and colleagues for the way in which they have responded and listened to many of the concerns which we have expressed about these problems. The Government have tabled a number of very helpful and constructive amendments. However, I seek to ascertain whether they meet all our concerns.

I know that the noble Lord, Lord Willis, will say that our earlier concerns about research and its role in the NHS have been completely met. I agree with him entirely. We are satisfied on that point. However, in relation to education and training, I said at Second Reading that since the health service began, undergraduate training of doctors, medical students and dental students

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had always been the financial responsibility of the universities, but that it had always been the responsibility of the NHS to provide the clinical facilities in hospitals and general practices of the United Kingdom for the training of those undergraduate students. Of course, in more recent years, the newer universities-the former polytechnics-have played a major role in the training of other healthcare professionals such as nurses, physiotherapists, occupational therapists, speech and language therapists and others. That commitment has been totally accepted.

However, postgraduate training of doctors, as the noble Lords, Lord Turnberg and Lord Willis, have said-those who are training to become physicians, surgeons, psychiatrists, and specialists in any branch of medicine-is the financial responsibility of the National Health Service and has been from the very beginning of the NHS. At the same time, the NHS has employed postgraduate deans who have been very helpful and responsible in helping to provide that training. It has also been monitored throughout by the royal colleges and faculties that have provided the content and curricula for the training of these groups of specialists. It is crucial that that interrelationship of all these bodies be enshrined in the Bill, even when Health Education England comes into being. I am mildly surprised that all the amendments grouped with Amendment 2 deal with education and training, but so too do Amendments 13, 16, 62 and 106 that are equally important and crucial to this whole programme.

I therefore ask the Minister whether he is satisfied that in the amendments that the Government have tabled, or in regulations that he can assure us will follow, the responsibilities of the universities and other institutions of higher education will be enshrined and clarified. Is he satisfied that through the postgraduate deans and the clinical senates-wherever they are housed, or whether they are housed with the National Commissioning Board and its outreach into parts of the country-the responsibilities of the royal colleges and faculties will also be enshrined, and the postgraduate deans will thereby continue to supervise the programmes? Is he satisfied-and this is crucial-that independent foundation trusts and any qualified providers that are providing NHS services will be required to accept responsibilities for the training and education of healthcare professionals, just as NHS hospitals, general practices and other NHS institutions are?

It is crucial that these issues are confirmed, and I trust that the noble Earl will be able to tell us that in the government amendments, and in regulations that may follow, all our anxieties about these major issues will be accepted and covered to the benefit of the healthcare workforce and the National Health Service overall.

The Earl of Listowel: My Lords, I rise briefly to pay tribute to the noble Earl, Lord Howe, and his colleagues for giving this most important issue such great attention since the Bill arrived in this House.

I wish to look at the experience in social work, where there has been great deterioration in the attention given to the professional development of social workers. I remember reading a letter from the noble Lord, Lord Hunt, when he sat on the Front Bench a few years ago,

8 Feb 2012 : Column 284

acknowledging the fact that newly qualified social workers were being placed in situations where they had too large a case load and were not being properly supervised. Fortunately, some steps have been taken to address this, but there is clearly still a long way to go on supervision of social workers, and the culture and state of morale of social workers has for many years been eroded by the lack of attention to their professional development. There was a time when there was good professional development; so it can happen, and it could happen in the medical professions.

Perhaps I may draw attention to the experience of teachers in Finland. This is particularly relevant to the Minister's and the Government's desire to increase autonomy within the health service and devolve responsibility down to the professionals closest to the front line. About 20 years ago, Finland reviewed its education system and decided to emphasise the professional development of its teachers. It decided to select its teachers very carefully, and now all practising teachers have a masters qualification before practising with children. Only one out of 10 applicants for teacher training places is accepted: there is huge competition to get on those courses. A few years ago, when PISA started publishing league tables of education system performance across the world, the Finns came out top of the numeracy, literacy and science tables, not just in one year but in successive years. Teachers are given a huge amount of respect within their society, very good professional training and development, and are well recruited. There is no inspection of the education system-teachers are so well trusted to do the best for children.

I pay tribute to the noble Earl and colleagues for giving this the best possible attention in the course of proceedings in your Lordships' House.

5.15 pm

Lord Patel: My Lords, I pay tribute to the noble Earl for how he has met our concerns in the Committee debate on education and training. The noble Lord, Lord Walton, mentioned Amendments 13 and 16. To me, Amendment 13 is crucial. The reason I degrouped them is because Clause 6 addresses the Secretary of State's responsibility for education and training. I hope that we will have the debate about the issues that he raises when we debate Amendment 13. I agree with the amendment of the noble Lord, Lord Turnberg-Amendment 16-which provides that universities need to take a greater part in education and training than they have hitherto.

Lord Hunt of Kings Heath: My Lords, as this is a new stage of the Bill, I should declare a number of interests which are also listed in the register; I am chairman of the Heart of England NHS Foundation Trust, a consultant and trainer with Cumberlege Connections, president of the British Fluoridation Society and of the Royal Society for Public Health.

I put my name to Amendment 2, tabled by the noble Baroness, Lady Finlay, which has perhaps not received as much enthusiasm as I would have wished from noble Lords, who have pointed to Clause 6. Behind her amendment is real concern to ensure that

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we will train enough health professionals in the years ahead and that they will be of sufficiently high quality. There is some history here. I very much support devolving as much as possible decisions about the commissioning of training places to local NHS organisations. I warmly welcome the work of Dame Julie Moore and her team, who have produced the report. She is chief executive of the UHB Foundation Trust in Birmingham and brings a lot of expertise to that position. Some noble Lords will have been to a seminar where the report was debated. I have no argument with its general thrust, but we know from experience that when money is tight, the NHS reduces the number of people that it trains and its training budget. That always happens and, a number of years later, the NHS then pays the consequences. If we are to have a highly effective National Health Service in future, we need to recognise that the quality of our professional staff goes to the core of what we seek to do. Therefore, it is right that the Secretary of State should be seen to have major responsibilities enshrined in legislation. That is the essential point of Amendment 2, whatever the technical deficiencies to which noble Lords have kindly drawn our attention.

In that regard, let me say that I welcome the government amendments in this area and the work of the noble Earl, Lord Howe. Of course, he is also responsible for research in the department, and I think that he well understands how the education and training of our professionals very much ties in to the research agenda. I know that we will come to research later tonight.

In relation to the other amendments in this group, I have already welcomed the government amendments, but perhaps I may pick on Amendment 63. It is right that the national Commissioning Board should have regard to the promotion of training of clinical staff in any provider from which it commissions services. There is essentially a parallel amendment-Amendment 104-which applies to clinical commissioning groups. The whole point here is to ensure that there is a level playing field. If, regrettably, the Government persist with this lunatic idea of a competitive approach within the health service, it is essential that when it comes to commissioning decisions all qualified providers contribute to education and training. It would be an absolute disgrace if clinical commissioning groups and the national Commissioning Board started to commission services from organisations that did not play their full part in education and indeed research. I hope that the noble Earl, Lord Howe, will make it clear that that is what his Amendment 104 means when it says, in parliamentary counsel terminology, that clinical commissioning groups must,

I take that to mean that the amendment does not permit CCGs to place contracts with qualified providers who do not make a contribution to education and training.

Overall, I echo the words of the noble Lord, Lord Walton, regarding the work of postgraduate deans and his question about their future. Where are postgraduate deans going to lie in the future? Are they going to lie in the local branch offices of the national

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Commissioning Board; are they going to be aligned with the clinical senates; or are they going to float free? I think we should be told.

I also echo the words of the noble Lord, Lord Willis, regarding the role of universities. It should not be an option; they need to be round the table. It needs to be what I would describe as a "hard partnership". I think we are all well aware of the issues and concerns surrounding the quality and outcome of nurse training. The noble Earl, Lord Howe, himself has often commented on issues such as dignity, nutrition and so on, where matters have been raised by patients and there is concern about whether today's nurses are getting the kind of training that is required. It is very important that those who commission from universities do so in as vigorous a way as possible and hold those universities to account. However, equally there has to be a partnership. The noble Earl, Lord Howe, will know about the intention to expand academic clinical science networks. That is a very good example of universities and the health service coming together, and we need to encourage that in the future.

Finally, the noble Lord, Lord Walton, raised a point about the duty on any willing provider regarding training or research. I think that I have covered that, but he also mentioned NHS foundation trusts. I am not aware of any situation in which NHS foundation trusts are ignoring their responsibilities but I certainly agree with him that, as they are more independent of the Secretary of State than other parts of the NHS, some assurances from the noble Earl in that regard would be welcome.

Lord Northbourne: I wonder whether the noble Lord could clarify a point for me. In his Amendment 62 he speaks of the "healthcare workforce", whereas the noble Baroness, Lady Finlay, in her amendment talks of "healthcare professionals". Are these identical groups of people? I am particularly interested in whether nursing staff are included in one or both of those terms.

Lord Hunt of Kings Heath: My Lords, that is a very good point. As I say, it is always helpful when noble Lords point out errors and omissions in the drafting of amendments. Amendment 2 refers to "health care professionals", and I am clear that nurses must be embraced within that definition.

On Amendment 62, I would not detract from the use of,

Earl Howe: We are not debating that amendment yet.

Lord Hunt of Kings Heath: My Lords, the noble Earl, Lord Howe, has kindly reminded me that we are not debating Amendment 62. It will be debated in a later group, which allows me a little time to reflect on the point raised.

Earl Howe: My Lords, this has been a very useful debate. Perhaps I can begin with a clear statement that the Government are committed to the education, training and continuing development of the healthcare workforce. This is fundamental in supporting the delivery of excellent healthcare services across the NHS. I am pleased that so many noble Lords share that view.

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We are, however, in the rather odd position of having before us two groups of amendments on education and training. Given that we still await a further debate on the subject today, I should like to reserve some of the detail of my remarks, if I may, for that debate, when I address one of the amendments in the name of the noble Lord, Lord Patel. However, to begin with, and for now, I think that it will be helpful if I set the scene.

First, I confirm to the noble Baroness, Lady Finlay, that we made it clear in Liberating the NHS: Developing the Healthcare Workforce-From Design to Delivery,which was published recently, that we are committed to a national framework for education and training, with Health Education England providing national leadership and being directly accountable to the Secretary of State.

Health Education England will ensure that the healthcare workforce has the right skills, behaviours and training, and is available in the right numbers to support the delivery of excellent healthcare and health improvement. It will work with a range of key partners, including the medical royal colleges, professional regulators and the academic and research sectors. The national input and oversight will be there in all the areas which, rightly, the noble Baroness is concerned about. Health Education England and the wider education and training system will, as I said, remain accountable to the Secretary of State, who will have a duty to secure an effective system for the planning and delivery of education and training in the NHS. Employers and healthcare professionals will play a leading role in workforce planning and development through the establishment of local education and training boards, working with the education and research sectors. I shall have more to say about that in a moment.

I can reassure noble Lords straight away that postgraduate deans will continue to be a critically important part of the medical training arrangements. The Government listened to the concerns expressed in Committee by a number of Peers that the Bill did not go far enough in safeguarding the future education and training system. In this group of amendments, which I shall speak to shortly, we have tabled a number of proposals designed to address the gaps that noble Lords identified.

On Amendment 2, tabled by the noble Baroness, Lady Finlay, the Government have already introduced a duty for the Secretary of State to maintain an effective system for education and training. Our duty is more comprehensive than this amendment in that it applies to the whole healthcare workforce and not just doctors. The noble Baroness asked about the scope of Clause 6. Our duty applies to people who are employed, or who are considering becoming employed, in an activity which involves or is connected with the provision of services as part of the health service in England. This covers healthcare professionals at the centre of delivering healthcare, including doctors, dentists, nurses, midwives, pharmacists, healthcare scientists and the allied health professions. It includes registered and unregistered professions. It also covers non-clinical staff who are involved in, for example, the commissioning or administration of services. In the

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light of that, I hope that the noble Baroness will feel reassured to some extent and feel able to withdraw her amendment.

5.30 pm

The noble Lord, Lord Walton, put particular emphasis on the universities being involved in local education and training boards. We wholeheartedly agree that it is crucial that universities and other education providers are integral partners in the planning, commissioning and delivery of education. Health Education England will set robust criteria for the establishment of the local boards, and strong and meaningful partnerships with universities will be a key element of that assessment. The core purpose of the local boards is to lead planning and education commissioning to ensure security of supply of the local health and care workforce and to support national workforce priorities set by Health Education England. They will have a number of functions which I have detailed in a recent letter to noble Lords. One of them will be to hold and allocate funding for education and training. Others will be to commission education and training, to secure quality and value from education and training providers and to secure the partnerships that we want to see with clinicians, CCGs, local authorities, health and well-being boards, universities and other providers of education, research and innovation. At the same time, however, Health Education England will be overseeing that, securing national coherence and greater transparency in the education and training investments that employers make in their workforce.

The noble Lord, Lord Turnberg, asked me about the role of the royal colleges and postgraduate deans. We have no intention of tampering with national standards. Professional regulators will continue to set professional standards. The royal colleges will continue to shape curricula and will work in partnership with Health Education England to ensure that education and training reflect best practice and are of high quality. Professional regulators have a statutory responsibility for setting standards and ensuring those standards are met and maintained. The new system goes further because we have developed quality indicators that will bring quality to the heart of the commissioning process. The education outcomes framework, which I will say a bit more about when I come to address the later amendments tabled by the noble Lord, Lord Patel, will set out the outcomes expected to achieve quality healthcare, education and training. Indeed, one of Health Education England's key functions is to promote high-quality education and training that is responsive to the changing needs of patients and local communities.

Let me say a little more in answer to the noble Lord, Lord Walton, about postgraduate deans. Postgraduate deans will remain critical to these training arrangements. We expect local education and training boards to be able to demonstrate that their postgraduate deans will be able to act independently of any perceived conflict of interest that may arise between training and service priorities. There will be clear checks and balances in place and quality metrics to hold local education providers to account for the quality of the education that they deliver. Postgraduate deans will

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have all the powers that they have now to respond to concerns about the quality of training, to take action where required to improve standards and to assure the professional regulators and Health Education England that poor performance, if it occurs, is identified and tackled. In the new system, they will have what I hope will be the welcome support of the local education and training board, and, if necessary, Health Education England, to challenge poor quality and behaviours. We believe that the checks and balances will be there in the system.

The noble Lords, Lord Walton of Detchant and Lord Hunt of Kings Heath, asked about the involvement of qualified providers other than NHS providers. All providers of NHS-funded services will be expected to participate in the planning and delivery of education and training. Health Education England will allocate funding for investment in the future workforce only to those that participate. We will be considering in future weeks what additional duties we might place on all providers when we look at proposals for a future Bill on education and training.

The noble Lord, Lord Hunt of Kings Heath, referred to funding. Many respondents to the consultation called for education and training funding to be protected. We agree, so we will ensure that Health Education England establishes transparent systems to make sure that organisations that receive MPET funding are held to account for using it for the education and training of the NHS workforce.

As I said, the Government have listened to the concerns expressed in Committee by a number of Peers. We have already introduced the duty on the Secretary of State to exercise his functions so as to secure an effective system for education and training. Amendment 15 puts more flesh on that duty by specifying the Acts that contain functions that must be exercised by the Secretary of State so as to discharge his education and training duty.

Building on that, we have tabled amendments to strengthen links with the wider system. Amendments 61 and 104 place duties on the board and on CCGs to have regard to the need to promote education and training. These duties are designed to ensure that commissioners of NHS services consider the planning, commissioning and delivery of education and training when carrying out their functions.

Nationally, Health Education England will work with the NHS Commissioning Board to ensure that its strategic framework for education, training and workforce planning reflects service commissioning priorities and that workforce development implications of innovation and changes in the pattern and nature of services are addressed and identified. As I indicated earlier, CCGs will work with the local education and training boards to consider the workforce implications of their local service commissioning decisions.

The other amendments tabled in this group by noble Lords are, I believe, designed to have much the same effect. I hope that noble Lords will be reassured by the vision I have set out for education and training and by the amendments that we are proposing, and

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that they will feel able to support those amendments in due course when they are moved and, for now, that the noble Baroness will withdraw hers.

Baroness Finlay of Llandaff: I am most grateful to the Minister for the amendments that he has tabled on behalf of the Government, and for all the listening. This short debate has demonstrated just how far we have moved, how much he personally has taken on board and committed to improving education and training, and that the amendments that are there for us to approve later provide a scaffolding throughout the Bill for education and training that was not there before. I fully accept that the amendment in my name is probably in the wrong place in the Bill and that to restrict it to professionals is too narrow-it is the whole workforce. Therefore, I beg leave to withdraw the amendment.

Amendment 2 withdrawn.

Amendment 3

Moved by Baroness Thornton

3: Clause 1, page 2, leave out lines 7 to 9 and insert-

"(2) The Secretary of State must for that purpose provide or secure the provision of services according to this Act."

Baroness Thornton: My Lords, we originally put down Amendments 3 and 4 in Committee back in the autumn. It has to be said from the outset that this is actually still a very bad Bill. Since Committee, the context in which we are discussing this Bill has without doubt changed. It seems that it has no support from anywhere except in the Department of Health-and possibly not even from everybody there. It still has no mandate.

Going back on previous commitments to,

the Prime Minister and his Health Ministers, including the noble Earl, have adopted what we on these Benches would like to term the "Attlee defence", in deference to the noble Earl, Lord Attlee-and I mean the Government's Earl Attlee, not ours, as it were. Last March, during a debate on the Building Regulations (Review) Bill, in trying to explain the Government's position, the noble Earl came up with:

"I gently remind the Committee that I answer for Her Majesty's Government, not for the previous Opposition".-[Official Report, 4/3/11; col. 1352.]

That is a remarkable statement. Perhaps the Minister could gently remind the Prime Minister and the Health Secretary of their coalition agreement.

It is significant that the Prime Minister has had to come to the Bill's rescue today, not least because a Downing Street source yesterday was reported to threaten the very life of the Secretary of State-I think that the words used were "taken out and shot"-for his failure to communicate the Bill and the Bill's policy. We in the Opposition have never advocated such a thing. Perhaps the Minister would like to comment on this particular version of the Secretary of State's ultimate responsibility in his job.

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The Prime Minister's words were also revealing in that the Government intend to push this Bill through. I do not believe that that is a respectful way of referring to the remaining stages in your Lordships' House. It begs a question that I should like to ask the Minister early in Report stage, which arises from what happened recently as regards the Welfare Reform Bill. Will he give the House notice now as to whether the Government intend to use the financial privilege mechanism to strike down any amendments that this House might agree during the remaining stages of this Bill?

I have searched in vain for a precedent of legislation that is so unwelcomed by those who have to deliver it, so incomprehensible to those on whom its consequences will be wreaked and so difficult to explain in simple terms. But even the Minister, who is acknowledged by the whole House to be an outstanding performer and someone who can normally enlighten us about most matters in clear, plain English, has had to resort on many occasions to seeking to justify points of this Bill in the managerial jargon of his boss, Mr Lansley, which is as dense as the Bill itself. If any noble Lords doubt that, I suggest that they need only to peruse the record of the Committee stage.

We do not work in a sealed bubble in this Chamber and I appreciate that the Government might prefer it if that were the case. But the public's view of this Bill has shifted and hardened since we completed the Committee stage before Christmas. The views of those who have engaged with this Bill for more than a year have changed and we need to hear their voices throughout Report stage.

As we all know, the discussions around the role of the Secretary of State have been of great significance. What has emerged is that the reasons for changing the role have never been made clear. As has been pointed out, there is a continuity around the role of the Secretary of State which goes way back to the founding of the NHS. I will not rehearse all the arguments that we heard in Committee and at Second Reading, and which some of us have been rehearsing during the months between those stages and up to last week. The reality is and always has been that the legal duty on the Secretary of State is to provide services. Even securing the provision of services has been delegated to organisations which deliver that duty on behalf of the public. Public accountability is and always has been vital to maintaining public confidence in the NHS. Ultimate political accountability exists in the person of the Secretary of State.

In no way can the Secretary of State argue that any failure to provide necessary NHS services is not his or her responsibility. The argument that if there is an issue the Secretary of State must work through failure regimes, regulations and directions to others is not good enough. As the Health Select Committee and many noble Lords, including the noble Lord, Lord Mawhinney, said in Committee, it would not be believed anyway.

We will be moving to the alternative wording in the next debate. We on these Benches have supported the process that has led to that wording. However, I should like the Minister to explain-I would be very happy to hear that explanation when he responds to the next

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debate-the difference between these words and those that are before the House. I am giving the Minister notice that this remains a bit of a mystery.

As with so much else in this unloved Bill, we are left with the question: why? Why on earth did the original Bill propose a radical change to the role of the Secretary of State? The Minister in the Commons, Simon Burns, was ready to die in a ditch for the wording. It was a liberation ideology for him. Why, throughout the scrutiny in the Commons, was the line rigidly held by coalition Ministers and MPs, and why is the Secretary of State-I really do think the House needs to know the answer to this question, but again I am quite happy to wait-now briefing royal colleges saying, "Actually, the changes that noble Lords have agreed in their Chamber will make no difference to the Bill"?

Our amendment and the others that deal with the role of the Secretary of State are important and we have undoubtedly prised improvement out of, if not a reluctant noble Earl in this Chamber, certainly out of a reluctant Government. Many of these issues are proxy arguments about what kind of NHS we want. During the rest of the Report stage we will focus our energies on the many other things that need to be changed, particularly in Part 3. These are part of the argument about why we do not want a full market, why we do not want regulation along the lines of that for the utilities or for the banks, and why we need to protect and preserve the tradition, well established and well understood, of the role of the Secretary of State.

I will be withdrawing the amendment, as I promised the Minister I would, but I would like some answers to the questions that I have posed in these remarks. I beg to move.

5.45 pm

Baroness Williams of Crosby: My Lords, perhaps I may respond very briefly. The real argument that we should be having is almost certainly on the next group of amendments, and I have no intention of taking away from that debate in which, as we know, the noble Baronesses, Lady Jay and Lady Thornton, and other noble Lords-although unfortunately not my noble and learned friend Lord Mackay today-will take part. It is an important debate that symbolises for me something of crucial significance, and that is that in this House we have moved towards all-party agreement on the constitutional underpinning of the National Health Service; that is a great achievement.

I shall not take further from what the noble Baroness, Lady Jay, will want to say-except that perhaps I shall follow her on this issue-beyond saying that I am deeply saddened that over the past day or two we have seen what I believe to have been a far-reaching and radical attempt in this House to try to present an all-party consensual underpinning for the National Health Service being turned into what one can only describe as the most petty of political rows whose seeming intention is to try to acquire political balance for one side or the other. That is a great shame.

I think that many of us believe that the wording which has been accomplished-although I note the commitment of the noble Baroness, Lady Thornton,

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to the word "provide"-means that we can be satisfied with the constitutional group. We do not need to change the wording and what is now set out in the Bill after this long exercise is in fact legally watertight. I say that because some of the most distinguished lawyers in this House were part of the drafting process, including on the Labour side the noble and learned Baroness, Lady Scotland. On the Conservative side we had the outstanding figure of the former Lord Chancellor, my noble and learned friend Lord Mackay of Clashfern, and on my side, among others, my noble friends Lord Clement-Jones and Lord Marks of Henley-on-Thames. All these lawyers put their heads together in order to establish a basis on which we could agree, and I would suggest to the noble Baroness, Lady Thornton, for whom I have a great deal of respect, that if the word "provide" did not surface during that exercise, it is because it is to a great extent at odds with the facts at the present time as to who actually provides services for the NHS, and of course that has changed radically in recent years. It has changed radically because of steps taken not only by the present Government but also by the previous Government, when a great deal of provision came from newly established elements in the private sector, including intermediate treatment centres. Efforts were made to bring about an extensive network of hospitals to look at how far private treatment could be accepted and it was done on the basis of trying to bring new providers on the scene, which the noble Lord, Lord Darzi, among others, has talked about. I am probably one of those who are more "old-fashioned" in their view of the privatisation of the NHS, which I certainly would not support. That is not the same as talking about the competitive providers who under the previous Government and the present one have made some contribution to the services of the NHS.

I say with great respect to the noble Baroness that this pair of amendments is unnecessary. I think that, legally, the existing wording now stands up and has the precious boon of having been supported by all parties in this House and those who sit on the independent Cross Benches. We should therefore move on to the next group of amendments and be able, among other things, to celebrate our achievement, which I hope will enable the National Health Service to flourish and survive into the rest of this century.

Earl Howe: My Lords, as my noble friend has correctly reminded us, the next debate will give us the opportunity to discuss the package of amendments designed to clarify the Secretary of State's accountability for the health service. I recently completed a series of meetings with Peers from across the House to understand their concerns about this and related issues. Thanks to the efforts of so many here today, including the noble Baroness, Lady Thornton, I am pleased to say that we have sufficient consensus to table a series of amendments on this matter. I very much look forward to discussing them when we reach subsequent groups.

Amendments 3 and 4, tabled by the noble Baroness, Lady Thornton, seek to reinstate the duty to provide. I do not wish to dwell too long on what I have said on previous occasions, but the noble Baroness will be

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aware that we are retaining the wording of the NHS Act 1946, where appropriate. For example, the Secretary of State retains his duty to,

and his duty to,

The reason for our removing the 1946 duty on the Secretary of State to provide services himself is that it fails to reflect the reality of the way that NHS services are delivered. In general and for many years, the Secretary of State has not himself exercised functions of providing or commissioning services. The functions are delegated to SHAs and PCTs. Under the Bill, however, this function will be conferred directly on a dedicated NHS Commissioning Board and CCGs.

Indeed, as my noble and learned friend Lord Mackay of Clashfern has pointed out previously, there has never been a straightforward duty to provide services. The requirement was framed as a duty to,

services. In practice, Ministers or the NHS bodies responsible for exercising the Secretary of State's functions have usually exercised the second option, securing the provision, rather than the first, actually providing. The Secretary of State-that is, the Department of Health-has not provided NHS services directly for many years. Our policy is that the Secretary of State should neither provide nor commission NHS services.

It is clear from these amendments that the Opposition are harking back to a centralist, top-down approach. They sometimes say that they want clinical commissioners, but these amendments contradict that. They would not create a system of clear responsibility but instead one where Richmond House was always right. That model has been tried to the point of exhaustion and has been found wanting. In contrast, the Bill establishes a framework in which the Secretary of State no longer has the powers to provide or commission NHS services. Instead, those functions are conferred on other bodies in the system. An amendment to Clause 1 to impose a duty on the Secretary of State to provide services-or a duty to exercise his functions so as to provide them-is simply not consistent with that framework.

When this issue has been debated previously, one of the main arguments against losing the duty to provide was that it would result in reduced accountability to Parliament for provision. Although that has never been our intention, we have, as I said, tabled amendments to put beyond doubt the matter of ministerial accountability. Given that the Secretary of State does not provide services directly, and that the amendments we will debate shortly clarify beyond doubt the Secretary of State's continued accountability to Parliament, it is not clear what an amendment to reinstate the duty to provide would achieve in practice.

If these amendments are about ensuring that the Secretary of State takes the steps required to secure the proper provision of NHS services, I simply reassure the noble Baroness that the Bill already does this. It requires the Secretary of State to,

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That is a strong and onerous duty, sufficient to ensure that the Secretary of State discharges his responsibility for the NHS.

In explaining these amendments, the noble Baroness repeated her call for the Bill to be withdrawn on the grounds that nobody supports it. I acknowledge that there are opponents of the Bill but she must also acknowledge that many in the medical community and in the wider public support our reform programme. We know that clearly from the listening exercise last year when many thousands of people contributed their views. Those views about the principles of what we are trying to achieve came through loud and clear. In the main, the concerns revolved around implementation. We believe that we have addressed those concerns in amendments to the Bill and in other announcements that we have made that are non-legislative in nature. We continue to believe that our plans for modernisation are essential if we are to put the NHS on a sustainable long-term footing. I will explain a few ways in which that is true, and will try to do so in clear, layman's language without resorting to departmental technical speak.

Without the Bill, Ministers would remain free to continue to micromanage the NHS. There would be no legally enforceable duties to tackle health inequalities as the Bill introduces such duties for the first time in this country. There would be no legally enforceable duties on quality improvement because it embeds quality improvement throughout the system. There would be no duties on NHS organisations to involve patients in decisions about their care. Failing organisations would continue to be propped up using taxpayers' money-the Bill tackles that problem in a creative way. Governments would be able to prioritise the private sector over the NHS-the Bill ensures that such behaviour is prohibited. Patients would continue to lack the means to hold the NHS to account because the Bill gives patients real power by establishing HealthWatch so that the interests of patients and the public can be championed throughout the NHS. Withdrawing the Bill would cause disruption and chaos at a time that the NHS most needs certainty about the future. As has been said today, the NHS is already in a state of change. That cannot be sustained indefinitely because it puts additional strain on management capacity and creates additional cost.

Lord Lester of Herne Hill: Does my noble friend agree that one of the vices in the amendment is that it would encourage judicial review proceedings and legal uncertainty? I say that as somebody who has taken advantage of the old wording to bring successful judicial review proceedings in Northern Ireland. The advantage of what we now have in the Bill is that it will not place judges in the position of seeking to run the health service, instead of Parliament, Ministers and the health authorities themselves.

Earl Howe: I defer completely to my noble friend, who is right to point out that one thing that we wish to avoid is a charter for a legal action and judicial review. I believe that we have avoided that because of the way in which accountability is now described in the Bill-or will shortly be described, when the amendments are passed. It is accountability primarily through the Secretary of State to Parliament. I thank the noble Lord for his observations.

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6 pm

Baroness Jay of Paddington: The Minister has clarified the difficulty that I was in, partly because of the intervention from the noble Lord, Lord Lester, but also because of what the noble Baroness, Lady Williams, said. As I understand it, all their remarks are posited on the basis that the subsequent amendment, Amendment 5, will be accepted by the House. When they refer to the terms of the Bill, they are referring to the Bill as it now stands and not as it will, I hope, be amended in the conclusion of our next debate.

Earl Howe: I am grateful to the noble Baroness, who is of course quite right.

I have been handed a note which says that when I said that there would be no legally enforceable duties on quality improvement, I should have clarified that that would have a follow-on. I should have said, "across the NHS system".

The noble Baroness, Lady Thornton, referred to potential privilege responses from the Commons. My noble friend the Leader of the House made a Written Statement last Thursday about the financial privilege of the House of Commons in which he drew attention to a paper by the Clerk of the Parliaments, available in the Library. I think that questions about procedure may be best directed to my noble friend, but I shall do my best to assist. The Clerk of the Parliaments makes it clear in his paper that,

That is what we should do. I would much regret it if the House thought that I was trying to restrict its role of revision. The Marshalled List sets out more than 100 amendments in my name, tabled in response to debate in Committee, and if the House agrees to those amendments I can assure noble Lords that the Government will encourage the other place to accept them.

The essence of the noble Baroness's question is about privilege reasons for the Commons rejecting amendments proposed by this House, and on that I can say two things. First, any amendment with implications for public expenditure might involve privilege, but that is a matter for the Commons alone. Decisions on financial privilege are for the Speaker of the Commons on advice from the Clerks of that House. If the Commons reject a Lords amendment in which the Speaker has determined that privilege is engaged, the only reason that it can send this House is a privilege reason. There is no discretion.

Secondly, this debate is by its nature premature. I hope that our debate and dialogue will lead to this Bill being sent to the Commons in a form that that House will accept. Until we see how Report unfolds, it is too early to speculate on the reaction from the Commons. One cannot have a reply to a question until the question has been asked.

Baroness Thornton: My question was actually about the Government's intentions. That was a very enlightening and helpful remark about privilege. The Speaker of the Commons will not presumably, by and large, take a view on privilege unless the Government ask him to. So my question was about the Government's intention on this matter.

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Earl Howe: I have taken advice on this, and I believe that what I am about to say will not mislead the House as I have been given this advice on authority. It is not for the Government to do anything; it is not within our power to do anything. The noble Lord, Lord Martin, who spoke last week on this matter, is par excellence an authority on this. A view is taken by the Clerks in another place on the amendments passed in this House as to whether privilege is engaged. The Speaker is then advised. The Government have no role in that process at all; it is a Commons privilege, not the Government's privilege.

I hope that what I have said will persuade your Lordships that the course down which the Opposition would wish to take us is the wrong one. The Bill, once amended-if that is your Lordships' wish-through the amendments that have been jointly agreed on a cross-party basis, will therefore be fit for purpose in clarifying beyond peradventure the Secretary of State's accountability for the health service and the exercise of his powers. With that, I hope that the noble Baroness, Lady Thornton, will feel able to withdraw her amendment.

Baroness Thornton: I thank the Minister for that response. I made it clear in my opening remarks that I would not seek to push the amendments to a Division, although the remarks of the noble Baroness, Lady Williams, and the Minister made me wonder whether I ought to do so, because certain things that were said were not justified.

First, the noble Earl took us through a list of things that without the Bill would not be happening. On almost every single one, I thought that without the Bill you could do all those things. You do not actually need this Bill to do most of the things that the noble Earl listed as being desirable objectives. I am sure that we would agree about most of them being desirable objectives.

The noble Earl mentioned the listening exercise as being proof that this is not the unloved Bill that I would suggest it is. Only yesterday, a former special adviser to Downing Street said that the listening exercise was a tactic as part of managing the Bill. Frankly, I was horrified by that. If I had been Professor Steve Field or one of the 40-odd people who, with every good intention of doing a public service unpaid, gave their time to take part in that listening exercise, I would think that it was really shocking. So I think that the noble Earl should be careful about praying the listening exercise in aid in explaining how loved or unloved this Bill is.

It is time that we moved on. I intend to reserve my praise for the next debate and leave my criticisms in this debate. I intend to withdraw my amendment, even if the noble Earl will not withdraw the Bill.

Amendment 3 withdrawn.

Amendment 4 not moved.

Amendment 5

Moved by Earl Howe

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