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The noble Earl needs to be commended for his determination and hard work in this area. We think that it is an important issue. This is a growing problem and the noble Earl makes very reasonable requests, for which he has widespread support. I agree with the noble Baroness, Lady Masham, in that I fear this problem may get worse before it gets better, but I hope that the Minister will have good news for us about it.

Earl Howe: My Lords, we return to an issue of enormous significance for the individuals and families affected. I refer of course to those suffering from addiction, or withdrawal from addiction, to certain prescribed drugs. I am grateful to the noble Earl, Lord Sandwich, for his amendment, which would put in primary legislation a requirement for clinical commissioning groups to provide a specific service and, in so doing, to co-operate with and take account of the good practice of specialised agencies.

I think that the desire for good practice and for improving practice is common ground between us. The noble Earl will know that local areas are currently responsible for the design and provision of treatment and support services. We think that that is right. Having said that, it is clear that we need to do all we can to prevent dependence occurring in the first place. I am fully with him on that. For those who do develop dependence, it is important that they have access to the services they need to help them to recover, rebuild their lives and contribute productively to society. By placing the funding and responsibility for commissioning services to support people to recover from dependence with the local authorities, the Bill will provide local areas with opportunities to improve integration of commissioning and provide more effective joined-up services to meet local needs.

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I heard what the noble Earl said about generic drug and alcohol services and his view that they are not appropriate for people who are addicted to benzodiazepines. I beg to disagree with him on that. Drug and alcohol action teams are the people best placed to help people addicted to drugs of whatever kind. They commission to provide help for a wide range of drug users, including people dependent on medicines like tranquilisers, sleeping pills and painkillers. It is not a one-size-fits-all approach. In many cases, services for people dependent on such drugs are provided at different sites or times than those for people dependent on illicit drugs.

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The noble Earl has put forward an extremely powerful case and I do not wish to detract from that in the slightest. He is right to highlight the particular needs of this patient group. Nevertheless, we remain of the opinion that it is not appropriate to require in the Bill that CCGs commission particular services for all persons. CCGs are already under a duty to commission services to meet the reasonable needs of all the people for whom they are responsible. As noble Lords will be aware, they have a duty to ensure that they obtain appropriate advice in support of that. That was the theme of the last group of amendments. There are also duties to engage with their health and well-being boards to find out what local needs actually amount to, to prioritise the strategies that are required to address them and to develop those strategies and plans accordingly.

The Government believe that local bodies have greater knowledge and understanding of local health needs and that they are best placed to assess the need for services, including rehabilitation and support services within their areas. Moreover-and this is the most fundamental point-under the arrangements set out in Healthy Lives, Healthy People:Consultation on the Funding and Commissioning Routes for Public Health, local authorities will be responsible in the future for commissioning services to support people to recover from dependence in line with local need.

In terms of the work of my department, I can again confirm to the noble Earl that a great deal of thought and effort is being given to this important issue. As he knows, we are working with a range of experts in doing so. If I may, I would like to write to him to set out fully our future plans in this area. I hope he will understand the stance that we have taken on this. Having received my letter, he is very welcome to meet me, if he would like to, to enable me to update him on the work that we are doing on this important issue.

The Earl of Sandwich: My Lords, as the noble Baroness, Lady Thornton, implied, we are moving to the fast-track of this Bill, and I do not want to hang around for too long. I thank my noble friend Lady Masham for bringing to our attention the issue of early death, and my noble friend Lord Williamson, who has a lot of experience, for his support. My noble friend Lady Finlay made the important point that the responsibility falls within primary care, and I am encouraged by what she said about guidance. However, the Minister did not even pick that up. One might have thought that he could have just said, "Yes, we are going to do something in the guidance", but I do not know whether he actually heard the point.

Earl Howe: I am happy to pick that up, because it was a point that arose in connection with an intervention from the noble Baroness, Lady Finlay, in the previous group of amendments. Of course, we will be relying on the NHS Commissioning Board to issue guidance in a number of clinical areas. Again, when the noble Earl and I meet, I will update him to the extent that I am able to on the thinking in that regard. The point of such guidance-which will relate to numerous areas of

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care and services-is that it should inform joined-up commissioning in local services, so that we really do get a step change in the quality of commissioning in local areas.

The Earl of Sandwich: It is quite true that the CCGs are going to be overwhelmed with guidance from all directions, but I maintain that this is an important aspect.

I thank my noble friend Lady Hollins for the very important point that she made. I did not even talk about prescribing today but I hope to come back and talk about it later-the whole question of training and what young doctors are being told. "Rational prescribing" is a phrase that I will now be able to repeat.

I know that the Minister accepts the arguments, and of course there are many things that we have in common-good practice and the use of the voluntary sector. I take the point about the duty that falls on local authorities, but I still maintain that we have to separate this out from the mainstream of drug addiction and alcohol treatment. It is the kind of treatment that only the very careful, experienced volunteers can describe. I do not think that I can begin to describe the actual treatment. However, the NHS will soon get to grips with what is happening. I welcome the chance of having a meeting. I will of course come to talk, and I hear that there is to be a range of experts. I feel that the Minister has given a little bit of a Civil Service answer, because there are only but one or two people who follow this subject in the department. I do not mind talking only to two people-it will be a very good opportunity to take this further. Meanwhile, I beg leave perhaps to consider this again at a later stage of the Bill, and to withdraw the amendment.

Amendment 107 withdrawn.

Amendments 108 to 111 not moved.

Amendment 112

Moved by Earl Howe

112: Clause 25, page 44, line 17, after "14Q" insert ", 14S"

Amendment 112 agreed.

Amendment 112A not moved.

Amendment 113

Moved by Lord Marks of Henley-on-Thames

113: Clause 25, page 45, leave out lines 24 and 25 and insert-

"( ) For the purposes of this section-

(a) a failure to discharge a function includes a failure to discharge it properly, and

(b) a failure to discharge a function properly includes a failure to discharge it consistently with what the Board considers to be the interests of the health service."

Amendment 113 agreed.

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Amendment 114

Moved by Lord Marks of Henley-on-Thames

114: Clause 25, page 47, leave out lines 35 and 36 and insert-

"( ) For the purposes of this section-

(a) a failure to discharge a function includes a failure to discharge it properly, and

(b) a failure to discharge a function properly includes a failure to discharge it consistently with what the Board considers to be the interests of the health service."

Amendment 114 agreed.

Amendment 115

Moved by Earl Howe

115: Clause 25, page 48, line 39, leave out "This section has" and insert "Paragraphs (a) to (c) and (h) of subsection (1) have"

Amendment 115 agreed.

Amendment 116 had been withdrawn from the Marshalled List.

Amendment 117

Moved by Earl Howe

117: Clause 25, page 49, line 24, at end insert-

"section 14XA,"

Amendment 117 agreed.

Clause 26 : Financial arrangements for clinical commissioning groups

Amendments 118 and 119 not moved.

Clause 29 : Appointment of directors of public health

Amendment 120

Moved by Baroness Northover

120: Clause 29, page 56, line 8, after "6C" insert "(1) or (3)"

Baroness Northover: My Lords, in Committee we had a number of excellent debates about the role of local authorities in public health. A number of noble Lords raised concerns, and I hope that this debate will show that the Government listened very carefully. As a result, we propose to make a number of important changes.

I will begin with Amendments 120, 127 and 129, which are minor and technical amendments to Clauses 29, 30 and 31. These contain lists of local authority functions, including references to,

The amendments change the reference to functions by virtue of Section 6C(1) and 6C(3). The reference to Section 6C(2) is unnecessary as it provides a power to impose requirements for how local authorities should exercise their functions, rather than a power to confer

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those functions. I look forward to an interesting debate on the other, more fundamental amendments in the group. I beg to move.

Lord Patel: My Lords, I will speak to Amendments 121, 122, 123, 125 and 126 in my name. I will also comment on the Government's Amendment 124.

Amendment 121 covers the appointment of a public health specialist. It states:

"The individual so appointed must be a registered public health specialist who has a broad range of professional expertise in public health".

When we debated this in Committee I made it clear that doctors-public health specialists who are trained in medicine-not only do medical training at undergraduate level but do several more years of training in public health before they are given a certificate of completion of training that allows them to be registered on a GMC register of public health specialists. The situation is similar for public health dentists; they go through similar training.

The problem is that non-medical public health specialists-of whom there are many-do not go through any specific training. Registration is voluntary. We will come to registration issues at a later date. The amendment states that those appointed must be registered public health specialists with a broad range of professional expertise in public health, which they must demonstrate at the time of appointment. I hope that the noble Baroness, Lady Northover, will comment on that.

The noble Baroness was absolutely right to say in her opening speech that the Government had listened. I am grateful to both the noble Earl and the noble Baroness for the time they took to meet me, and to meet representatives of the Faculty of Public Health. I declare an interest as an honorary fellow of that faculty. As a result, the Government have brought forward amendments and produced a document, which I will refer to at a later stage, that is very helpful in identifying the role of public health doctors in a local authority.

Amendment 125 is linked to this issue. It concerns the appointment of directors of public health. It states:

"Any registered public health specialist or other person who is employed in the exercise of public health functions by a local authority or is an executive agency of the Department of Health shall be employed on terms and conditions of service no less favourable than those of persons in equivalent employment in the National Health Service".

If we are to appoint directors and consultants of public health in local authorities and attract high-calibre individuals, we will have to make sure that they are not disadvantaged by taking a job in a local authority. The amendment merely alludes to that. Currently all specialists in the NHS, be they physicians, surgeons, obstetricians, paediatricians or other specialists, are appointed by an advisory appointments committee. The constitution of that committee is statutorily determined. The committee includes a representative from the appropriate college faculty. In this case it would be the Faculty of Public Health.

6.15 pm

Why is that necessary? The Bill states that appointments will be made with the presence of representatives from Public Health England. I have no objection to

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a representative of Public Health England, who works closely with the director of public health, being on the appointments committee. However, it is important that an external person should be nominated by the faculty to the appointments committee-as happens with other specialists-because external adjudicators will make sure that the person appointed has the appropriate training and experience.

The Government's Amendment 124 concerns appointments of public health specialists. It states:

"A local authority must have regard to any guidance given by the Secretary of State in relation to its director of public health, including guidance as to appointment and termination of appointment, terms and conditions and management".

The important question is: will the guidance be followed? How will the department make sure that the guidance is followed? What does "have regard to" mean in this situation? Why can we not have the same arrangements as for other specialists in the NHS?

I recognise that foundation trusts can offer different terms and conditions to the people they employ-but they do not do so, because before they became foundation trusts they were NHS hospitals, and they were used to appointing consultants through the process that I described. Local authorities do not have this experience. Therefore, it is more important that they should start off by using the same system as for the appointment of consultants in the NHS.

Amendment 123 would require the consent of the Secretary of State to the dismissal of a director of public health. The Bill states that the Secretary of State would be advised. Why is this not adequate? It is likely that a director of public health, who will have responsibility, when it comes to the health of the population that a local authority serves, for making appropriate plans for both preventing disease and responding to emergencies, may come into conflict in particular with councillors who may not like the idea of certain statutory or other requirements and who may dismiss them, despite the fact that they may be doing the right thing. Therefore, it is important that the Secretary of State should have all the information and should agree to the dismissal, rather than just be advised of it.

Amendment 122 states:

"The director of public health shall be a person for whom the head of the paid service is directly responsible and shall be required to report directly to the authority as to the exercise of the post".

This may now be redundant. Perhaps the noble Baroness will reassure me that that is so because the Government have declared that the director of public health will be appointed at senior officer level, and therefore will be directly accountable to the chief executive, as head of service in the local authority.

Amendment 126 is the key amendment in this group. The Bill is quite unclear on how the response to an emergency will be handled, and who will be responsible for making sure that the response is appropriately carried out. The confirmation given in the document that I referred to, Public Health in Local Government, produced by the Department of Health between Committee and Report, was very helpful.

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The document says that the director of public health will,

and I welcome that very strongly. However, although the document provides a great deal of detail about the way in which health protection and emergency preparedness and response are to be addressed under the new system, and clarifies the responsibility of the director of public health within the local authority, the picture at the local level is fragmented, with responsibility resting not with the local authority but across the NHS and Public Health England. I believe this fragmentation places public safety at great risk.

In Committee, the Minister affirmed the need to deal,

and asserted that,

I agree, but we must ensure that when incidents occur all the respondents are prepared and fully understand the parts they play. As it stands, the Bill is unclear about the roles and responsibilities of directors of public health and local authority functions in planning for and dealing with an emergency.

It is essential that there be clarity over who within the various local agencies involved has the lead responsibility for ensuring that the response to an emergency or outbreak is effective and appropriate. It is important to establish in this legislation that this responsibility lies at the local level with the local authority-and on its behalf the director of public health-for ensuring that plans are in place. What the Bill currently provides is not sufficient. The local authority has to be in charge.

The inclusion of this amendment in the Bill would remove any doubt or ambiguity and make clear that local authorities will be responsible for protecting and improving the health of their populations at all times, including during outbreak and emergency situations. Of course, the local authority will not normally deliver the response itself-that will normally be provided by Public Health England and supported by the NHS and others in the local community-but the local authority will be responsible for ensuring that an effective, appropriate and integrated response is delivered. It will be able to hold Public Health England and its outposts to account for the local service it provides.

There are two examples that might help demonstrate how this may happen. Let us assume it is next winter and a school has two pupils who develop meningitis. Both have group B infection and one dies. Public Health England recommends the vaccination of all 1,800 pupils in the school. The director of public health agrees this recommendation, as does the local authority. However, there are no school nurses to deliver the immunisation as the commissioner has decided not to commission a clinical service for school nursing.

Another example: three pupils in one secondary school have all developed infectious tuberculosis. Public Health England recommends that all pupils in the school are screened. The director of public health and

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the local authority agree this decision. However, commissioners have reduced the TB nursing and clinical support services. They now no longer have sufficient staff to enable the students to be tested. How will the disconnect between the advice of the director of public health and commissioning be breached?

These two scenarios illustrate the difficulties posed by the proposed new system. While the director of public health may be given accountability for emergencies, in these clinical emergencies the response has been delivered through the NHS-it is a different scenario. To date, the director of public health has director-level responsibility for NHS resources and so can ensure that these resources are used where necessary to deliver a public health response. However, in the new world neither the director of public health nor the local authority will have any control over either NHS resources or the commissioning decisions.

These examples illustrate the tensions that are as yet unresolved in the design of the new public health system. While I am absolutely delighted with the document the Government have produced, there is some way to go in making sure that we do not fall through this lacuna again about the preparedness for the health of the local population. If the noble Baroness is not minded to accept these amendments-and I will not be surprised if she is not-perhaps she might accept that there is an issue here to be addressed. One way might be to push for a vote, but I am not going to do that. I would much rather she accepts that there is an issue to be addressed here, and is willing to work with the Faculty of Public Health to make sure that the appropriate mechanism is put in place.

Lord Brooke of Sutton Mandeville: My Lords, I shall speak to my Amendment 122A. The aim of this amendment is to probe the intended scope of local authorities' public health obligations, with particular reference to areas that are primarily business in character. It does so by seeking to make clear that the directors of public health to be appointed by local authorities and the Secretary of State under this clause will have health responsibilities for those working in their authorities' areas as well as for residents. It may come as no surprise to your Lordships that I have in mind the constituency which I represented in the other place for 24 years, and particularly the eastern portion of it comprising the City of London.

The Bill, through an amendment to the National Health Service Act 2006, envisages that county councils, unitary authorities in the rest of England and London local authorities will be given an additional function: improvement of the health of their communities. In the words of subsection (1) of new Section 2B of the 2006 Act, inserted by the Bill:

"Each local authority-

the authorities I have just referred to-

As to the discharge of that function, Clause 29 inserts a new Section 73A into the 2006 Act. That will require the local authorities in question, acting with the Secretary of State, to appoint a director of public health.

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If I may paraphrase the statutory language for a moment to describe the practical consequences of these provisions, the director of public health will be responsible for securing improvement in the health of the people in the local authority's area in accordance with the policies that are adopted by the local authority or otherwise apply there as the result of national health policies.

The scope of the function conferred on local authorities, and through them the responsibility on directors of public health, will of course depend on who is taken to be included in the description of "people in the local authority's area". I am taking the liberty of assuming that this may be taken to include the people who actually live there, but of course there are people other than residents there too. My amendment aims to recognise the fact that the resident population in an area of an authority may be matched or even dwarfed by a non-resident population.

As I have already indicated, the example I have in mind is the City of London, where, as your Lordships are aware, the resident population is very small in comparison with the daytime business population. An indicator of relativity is provided by the current parliamentary register of electors, which records around 6,500, against an estimated daytime business population of 360,000, according to the Office for National Statistics in September 2011. My erstwhile constituency mailbag bore witness to that army.

While my focus is on daytime business populations, I acknowledge that other areas may also experience wide variations in what might be described as their permanent residential populations and their temporary ones. The western portion of my former parliamentary constituency, the southern part of the City of Westminster, has a substantial business component but also many tourists and daytime visitors. At an election, if I spoke to someone at random in the street, I had a one in 15 chance of speaking to an actual elector of my own. Seaside resorts have large temporary populations in the summer. The tourist and daytime visitor populations are, of course, more transitory than daytime business populations made up of people who come during the day, week by week, to the same location, and are not simply transitory. Nevertheless, even visitor and tourist populations would seem likely to generate some public health issues, which may prompt similar questions of scope of the public health functions to the one I am raising here.

6.30 pm

I return to the City of London. The City's non-resident population is best characterised as a settled business community. The public health responsibility might therefore be expected to reflect that settled status. The Bill does not, however, indicate whether, or to what extent, the responsibility under the Bill extends beyond resident populations. There are situations in which public health issues might be encountered in people's workplaces rather than at home. Stress-related problems may be one and smoking another. I do not lay claim to a detailed knowledge of workplace public health issues, but noble Lords will, I hope, appreciate the general point of scope which I am making. Scope will, of course,

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in turn ultimately be relevant to the funding demands generated by the responsibility to be discharged by directors of public health appointed under Clause 29.

I should mention in passing that the question of how far local provision should service the needs of daytime as distinct from residential populations has been raised in other health contexts. It is, for example, reflected in the start of trials to open up registration at GPs' surgeries not only to local residents but also to local workers. This trial is being run in the City of London and certain other areas, including Westminster and Manchester.

As to the form of my amendment, the aim is, as I alluded to your Lordships in opening, to make clear that a local authority's public health function extends to those working in its area as well as its residents. This is achieved by an additional subsection in Section 73A of the 2006 Act dealing with the appointment of directors of public health, which is inserted by Clause 29.

I am aware that discussions have taken place between officials in the City and the Department of Health. I should make clear that I make no criticism of those, which I understand have been helpful. I hope, however, that my noble friend will feel able to take this opportunity to say a little more about the application of the public health function to daytime populations, such as the business community in the City.

Lord Turnberg: My Lords, my name is attached to Amendments 121, 122 and 126. I will not repeat the wise and reasonable words of the noble Lord, Lord Patel, who presented the case for these amendments very well. As an honorary fellow of the faculty, I am privy to all its innumerable e-mails and newsletters which set out many of its concerns-and it has many, as I am sure the noble Baroness is aware. These amendments will go a little way to assuage some of those difficulties and they fit very well with the Government's intentions.

The publication of the Department of Health's document, Public Health in Local Government,on the role of the director of public health sets out well the intentions of the Government. They may not be strong enough but they are certainly entirely appropriate. Amendments 121 and 122 go some way to putting in the Bill the emphasis that the Government intend from their own document. I hope that the noble Baroness will see fit to accept these amendments.

Amendment 126 deals with the tricky business of disease outbreaks and the role of the director of public health. Again, the noble Lord, Lord Patel, emphasised with examples the sort of problems that can arise in a situation where responsibility for public health is with local authorities but is also with the health service. I am a former chairman of the Public Health Laboratory Service, which dealt with outbreaks of infections around the country and had a very strong co-ordinating role. For example, leaving aside the two examples mentioned by the noble Lord, Lord Patel, if you have an outbreak of food poisoning in two separate parts of the country, you do not know whether they are connected unless you are able to do the special tests-the special serology-that is done centrally and in a co-ordinated way between directors of public health.

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What is unclear-Amendment 126 goes some way to help this-is that, in emphasising the need for the director of public health to work closely with Public Health England, the documents that have been produced are a little silent on the relationship that the directors of public health will have with Public Health England. That is a key interrelationship that has to be fostered. It should be much clearer. Perhaps this amendment does not do it far enough but at least it leads us in that direction.

Two other areas are not talked about in the document. There is a rather weak statement about the role of the local authority in ensuring continuing professional development and training and education. We have covered training and education in other amendments and the Government have been very helpful in that regard. Here we have a slightly different situation with the local authorities being responsible for the contracts for directors of public health and their staff. There is a role in education and training for them. How that will be achieved is not entirely clear; nor is it entirely clear how the local authorities will be encouraged to ensure that the directors of public health can undertake research, which is an important element.

The documents that the Government have produced make great play of words such as "innovation", "leading the field" and "keeping ahead". We cannot do that without research, so it is important that research comes in here somewhere. I hope that the Government will listen to this.

Baroness Finlay of Llandaff: My Lords, my name is attached to Amendments 121 and 126. I will not repeat the arguments that have already been laid out so clearly by my noble friend Lord Patel. However, as regards Amendment 126, in an emergency clear lines of communication are absolutely essential and must be worked out. Indeed, they must be tested before the event.

We do not need to think only about infections. We need to think about toxins, accidental or deliberate releases of all kinds of chemical substances, and all kinds of contamination that can be a threat to public health. When an emergency arises, the problem is that it is too late to work out those clear paths of communication and access to essential resources. Provision has to be made in national planning.

Baroness Jolly: My Lords, I support Amendments 124, 128 and 152, which are all on issues on which I spoke in Committee. They refer to guidance and I welcome the commitment of the Government to supply guidance to local authorities in these areas. Clearly, we have councils already setting up their shadow health and well-being boards. Local public health directors are already moving into place in the local authorities. In some cases, they are already there because they were a joint appointment with PCTs.

Given that Amendment 124 states:

"A local authority must have regard to any guidance given by the Secretary of State in relation to its director of public health",

organisations which are setting up need to be clear about what is expected. Early guidance would be very welcome on the roles and responsibilities of the DPH in the new world. Is my noble friend able to give any indication when this guidance might be available?

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Lord Walton of Detchant: My Lords, the case for supporting these amendments has been put very clearly by my noble friend Lord Patel and the noble Lord, Lord Turnberg. I do not wish to repeat those arguments but I should like to mention a point or two about history. My reasons for doing so I hope will become clear in a moment or two. When I was a young doctor, medical officers of health in major centres of population were very notable specialists in public health. Indeed, when I was a particularly young houseman, the medical officer of health in Newcastle upon Tyne was John Charles, who later became Sir John Charles and the Government's Chief Medical Officer. He was succeeded in Newcastle by Professor WS Walton-I can assure noble Lords that he was no relation-who later became a very distinguished professor of public health in London.

As the years went by and the National Health Service matured, physicians in public health began to argue that they were actual physicians who, unlike physicians looking after groups of individual patients, were looking after communities. The situation developed until they were no longer directors of public health or medical officers of health. Instead they were transferred into the National Health Service as physicians in community medicine. They became individuals holding consultant appointments, and that was true of doctors and dentists working in community medicine. Eventually the faculty in the Royal College of Physicians grew into the Faculty of Community Medicine. Later it became clear that there were widespread public health functions which were not fully covered by that arrangement and therefore the title reverted to "public health".

The questions I want particularly to ask relate to Amendment 125 about the:

"Appointment of directors of public health".

This amendment seeks to ensure that public health specialists employed,

First, could the Minister go a little further in confirming that medically and dentally qualified directors of public health who are transferred to work in local authorities will retain honorary consultant status in the National Health Service? It is crucial that they should have a formal arrangement whereby they have full access to all the NHS facilities necessary in relation to issues such as the control of epidemics and a whole range of other activities where access to those facilities will be needed.

My other question is one that I have raised before but to which I have not had a satisfactory answer. What is the position of young doctors and dentists who at present are training in the NHS as specialist registrars seeking to become qualified in public health? What is going to be their future? Where will they be employed and how will they continue to undertake a formal training programme if the directors of public health have been transferred into local authorities? This is an important issue that needs to be resolved.

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Finally, the regulation of non medically or dentally qualified specialists in public health is an issue that also has yet to be resolved.

Baroness Masham of Ilton: My Lords, in supporting these amendments, I want just to say that many demands are made on local authorities. If the Bill becomes law, they will have added responsibilities for public health. The control of infectious diseases is vital. We have increasing levels of drug resistance in conditions such as tuberculosis and sexually transmitted infections. We have the problems of alcohol and drug abuse. Food poisoning is always a risk. One never knows what new infection is around the corner-one has only to look at the recent very worrying virus in lambs. We need senior officers of public health because they are the important link between health and local authorities. They need to be in senior positions and to have a clear voice.

Lord Warner: My Lords, I have added my name to Amendment 125, and I had intended to add my name to Amendment 123, but somehow that did not work out. I speak in support of the excellent presentation by the noble Lord, Lord Patel. I am still concerned about whether we will end up in a situation where, in pay and in terms and conditions of service, public health staff at senior levels start to lag behind their counterparts in the NHS. It is a real risk and I am not completely convinced that the way the Government have gone about this is adequate to tackle it.

I also share the view expressed very well by the noble Lord, Lord Patel, that the Secretary of State should give his consent to the dismissal of any director of public health. These posts are exposed when the temperature rises in a particular area over a serious incident, so these directors deserve a bit more in the way of safeguards than are provided in the Government's proposals.

I accept that the Government have moved on this, but I am a little concerned about how government Amendment 128 has been framed. I always get a bit wobbly when I see "may" used in guidance, and I wonder whether that could not be strengthened a little. I accept that Amendment 124 goes a long way towards giving an assurance that local authorities will be required to pay attention to the guidance but, as I read it, there is no guarantee that it will necessarily cover all the areas in the kind of detail that noble Lords have expressed their concerns about in this debate. A bit of strengthening of Amendment 128 would not go amiss unless the Minister can assure us that "may" really does mean that all these topics will be covered in the guidance.

6.45 pm

Baroness Cumberlege: My Lords, I have added my name to Amendments 121 to 125, 128 and 152. Noble Lords will be grateful to learn that I am only going to speak to two of those amendments. I want to reinforce the views that are being expressed, and I too pay tribute to the noble Lord, Lord Patel, on the way he has introduced all these amendments in such a comprehensive fashion-but not the government

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amendments, of course-and other noble Lords who have spoken. I am interested in the situation of the status and accountability of directors of public health. They are going to be very important people. They have access to elected members and senior officers in a new way in terms of recent history. I shall go into that history a little later in my remarks.

Their responsibility is to consult and advise the members and senior officers directly on a range of issues from emergency preparedness to concerns around access to local health services and many other activities, some of which have been mentioned. Acting as the lead officer for health in a local authority and being the champion of health across the whole of an authority's business is very responsible work, along with the day-to-day management of the ring-fenced public health budget, which is going to be delegated to them by the chief executive. They are also statutory members of the health and well-being boards. It is their direct accountability to the chief executive of the local authority and head of the paid Civil Service that I am concerned about.

This is a good measure to be putting forward. I have read the new Public HealthEngland's Operating Model published by the Department of Health, particularly the fact-sheet covering the role of the director of public health. It states that,

So far, so good, but I am not sure that that is actually happening. On this occasion I should like to declare an interest, as I often do, as the executive director of Cumberlege Connections, which is a training organisation. Recently we have been working in an area with a shadow CCG. I had a lot of correspondence after the workshop we ran, particularly from the director of public health. He said:

"It is apparent to me that, especially with organisational development plans in ... Council, as in other councils, it is intended to reduce the number of 'senior' directors at the top table ... in many such instances the director of public health will not be a member of the most senior management team nor report to the chief executive, but report to another director. This is not necessarily the likely model everywhere".

Here he mentions another authority, and says that,

We of course accept that in terms of localism, but there should be some basic principles that all local authorities adhere to, which I believe is the Government's intention. He goes on to say:

"It is also apparent that a number of medically qualified consultants and directors of public health consider that the likely change of status in becoming a local government officer and being made to leave the NHS ... is not what they want".

I can think of at least three directors of public health who have already quit their jobs to return to general practice, to take up a medical director post in the PCT cluster-that seems to be a rather short-term career move, but there we go-or to take very early retirement.

29 Feb 2012 : Column 1354

The Government need to put out some very strong messages about this and we need a monitoring system to ensure that their intentions are being carried out.

A point has been made about the termination of employment of directors of public health. In Committee, we discussed quite fully the position that used to be the medical officer of health-it certainly existed in my council when I was a local councillor. They would be a person of huge character and have great clout within the council and the whole geographical area. One of the reasons for their being able to be so robust and to say how they really saw the health situation within a geographical area was that the only person who could terminate their employment was the Secretary of State for Health-in those days, he was called the Minister for Health. That was a very good safeguard. I know that the Government are keen to involve the Secretary of State, but I would like to know to what degree, and that it is not just consultation via e-mail or a piece of paper but something that is real and is going to make a difference.

Let us suppose that in an area where childhood obesity is presenting a real problem a fast-food company wants to build a restaurant in close proximity to a school. That could clearly conflict with the director of public health's work to reduce childhood obesity. Local authorities, which will have some strong local interests, will be tempted to influence, with local councillors, situations that may go against the professional view of the director of public health. I hope that my noble friend Lady Northover will be able to give me some comfort on these issues.

Lord Rea: My Lords, I apologise to the noble Lord, Lord Patel, for not being here when he spoke to his amendment and for wanting to ask the Minister a question that may already have been covered in the debate. It is on the relationship of directors of public health, who are going to be situated in local authorities, with the clinical commissioning groups, which are going to cover very much the same area-although we still do not know exactly what it is going to be. At the moment, directors of public health work closely with primary care trusts. I imagine they will be largely the same people who move to local authorities.

However, many of the activities of PCTs concern directors of public health. I am not sure that we have yet agreed on whether the local authority director of public health will have a seat on the board of the clinical commissioning groups in the same area. We still do not know whether they are going to be precisely contiguous and/or whether there will be several CCGs in one authority boundary. I would be grateful if the Minister could clarify the relationship between local authority directors of public health and the local CCGs.

Lord Beecham: My Lords, two shows in the West End have taken the theatre-loving population of London by storm in the past year. One of them was "Noises Off", a farce that might be thought of as an apt metaphor for some of the relations on the government Benches; the other was "One Man, Two Guvnors", which is perhaps relevant to the position of directors of public health. I am very glad, therefore, that the amendments

29 Feb 2012 : Column 1355

proposed by the noble Lord, Lord Patel, and some of those which the noble Baroness will propose, reinforce the position and status of directors of public health. It is crucial that they are independent and are employed on conditions that are comparable to those of fellow clinicians in other parts of the health service. Therefore, the Opposition support the amendments of the noble Lord, Lord Patel, particularly in relation to Clause 30 and disease control.

I perhaps have reservations about the requirement for the Secretary of State to consent to the dismissal of a director; it is right that it should be in the form of consultation. It would be a foolhardy authority that ignored the strong views expressed by the Secretary of State. Given the relationship between central and local government, it is right that it should be a question of consultation rather than consent.

I endorse the views of the noble Lord, Lord Turnberg, about the relationship with Public Health England, which is another example of that dual relationship which directors must have. I equally endorse the observations of the noble Lord, Lord Brooke, who seeks to ensure that the responsibilities cover the entire population, resident or working, of the appropriate area.

The Government have moved significantly on some of their amendments. We are on the right track. I hope that they will look sympathetically at the amendments of the noble Lord, Lord Patel, and strengthen further that crucially independent role of the director, who should certainly be a chief officer of an authority and be accountable to the chief executive. It is an important safeguard, which I commend to the Government.

Baroness Northover: My Lords-

Baroness Murphy: I strongly support the stance that the noble Lord, Lord Beecham, has taken on the amendments of the noble Lord, Lord Patel, but I was expecting him to speak to Amendment 163A. I am very disappointed that he has not because it is such a brilliant idea and I was hoping that the Government might listen to it.

Lord Beecham: I am grateful to the noble Baroness for reminding me that I wanted to say a word about that. I was anxious that we should make progress but perhaps a little overanxious. I shall not detain your Lordships' House long on this matter, but the financial side of the arrangements for public health is extremely problematic. At the moment, some £5.2 billion is allocated to public health expenditure out of some £92 billion of NHS expenditure as a whole, of which about £2 billion is directed towards local government. The allocation is based on the existing pattern of primary care trust expenditure, which bears little or no relation to any discernible logic or needs-we heard that at a meeting with the Minister just today.

In addition, there is the new concept of the health premium, which is supposed to be subject to consultation, which has not gone very far and which carries with it a distinct danger that resources will be allocated to areas that can demonstrate an improvement in rather easier circumstances than areas with, for example, a higher instance of poverty, unemployment or other

29 Feb 2012 : Column 1356

factors that militate against an easy improvement. For example, Easington in the north-east would be a very different proposition from Eastbourne in the south.

The purpose of the amendment, which is a probing amendment, is to try to ensure that the system of developing health premiums should be based on principles that are outlined in the amendment and should be subject to adequate discussion before a new system is put in place.

7 pm

Baroness Northover: My Lords, I thank the noble Lord, Lord Patel, and other noble Lords for their contributions. No doubt I shall do so again in a minute.

Lord Wolfson of Sunningdale: My Lords, the noble Lord, Lord Beecham, said that the wording used in Amendment 125 was that rewards and salaries should be "comparable". In fact the actual wording is "no less favourable". The two are entirely different: which wording is being proposed?

Lord Beecham: I shall go along with the amendment. I do not see a distinction of the kind to which the noble Lord refers.

Baroness Northover: I once again thank the noble Lord, Lord Patel, and other noble Lords for their extremely constructive engagement in this important area. I further thank the noble Lord, Lord Patel, for expressing his gratitude to the Government for the changes that have been brought forward.

Noble Lords have welcomed the moving of public health to a more centre stage. The Government have listened hard and have worked to address a number of the issues that have been raised about how this would work. We have brought forward a number of proposals, and I hope that noble Lords will be reassured that the objectives they seek can be achieved by these means.

We agree completely with the noble Lord, Lord Patel, about the need for high-quality, appropriately qualified public health staff, and it remains the case that appointments of directors of public health must be made jointly with the Secretary of State, who will be able to veto unsuitable candidates. To build on that, the Chief Medical Officer and the Local Government Association have written to local authorities on this issue and given advice covering the run-up to April 2013. This advice makes clear that external professional involvement in the recruitment process is the best way of assuring the necessary professional skills and that it should remain a central component of senior public health appointments.

My noble friend Lady Jolly raised questions about guidance, and she and other noble Lords may find the recent letter from the Department of Health and the Local Government Association reassuring. If they read through that letter they will see that on appointing to vacant posts it states:

"External professional assessment and advice provided by the Faculty of Public Health is a central component of senior public health appointments".

29 Feb 2012 : Column 1357

It further states:

"The Faculty of Public Health provides essential advice on the draft job description, draft advert and person specification and we recommend you"-

local authorities-

There are a number of other points in the letter which I hope noble Lords will find reassuring.

Amendment 124 states that a local authority must have regard to any guidance given by the Secretary of State in relation to its director of public health, including guidance on appointment, termination of appointment and terms and conditions of management. The Local Government Association agrees that there should be a direct line of accountability between a director of public health and the chief executive. This issue was of extreme importance to noble Lords, who flagged it up in Committee, and we are taking it forward. It was also mentioned that the director should have access to elected members. We intend to produce guidance that reflects that, and it has already been spelt out in the letter to which I have referred.

In response to the concerns raised here, the Government have announced their intention to require non-medical public health specialists to be subject to regulation by the Health Professions Council. We will discuss the implementation timetable with interested parties and expect that the necessary changes will be made under the powers in Section 60 of the Health Act 1999.

During the helpful debates in Committee on the role of the director of public health we discussed how to ensure that directors have appropriately senior status. This is a vital new role-it provides local leadership on health improvement and protection as well as advising the local NHS on public health-and, in reaction to concerns raised, we have brought forward Amendment 152 to add directors of public health to the list of statutory chief officers in the Local Government and Housing Act 1989. This, combined with statutory guidance, aligns them with other chief officers, including directors of adult social services and children services. We hope that that reassures noble Lords and is what they were seeking. Furthermore, Amendment 128 is intended to give the Secretary of State the power to issue guidance on other local authority public health staff. I hope that that will further reassure my noble friend Lady Cumberlege.

The issue of appointment panels was raised and I can confirm that Public Health England, on behalf of the Secretary of State, will be represented on all appointment panels. Further guidance will be issued on the matter but, again, if noble Lords look at the letter to which I have referred I trust they will find it reassuring.

The noble Lord, Lord Patel, and others raised the issue of the requirements for dismissing a director of public health, and I welcome what the noble Lord, Lord Beecham, said about the need for the right balance of responsibilities. Directors will, of course, have the protection of employment law, and local authorities must consult the Secretary of State before dismissal. This will encourage them to ensure that their case is solid and to deter impulsive action. The Secretary of

29 Feb 2012 : Column 1358

State will now also be able to issue guidance, to which local authorities must have regard, on how the dismissal process works.

Ultimately, of course, it cannot be in anyone's interest for the local authority to be required to continue employing an individual if it believes that it has good grounds for dismissal. The Secretary of State can express his views clearly and robustly, but it is the authority that has the employment relationship with the director and that therefore must make the final decision. However, having regard to what the Secretary of State has to say is obviously an extremely important safeguard. The local authority will need to have very strong evidence to demonstrate why they wish to dismiss a director if they are to carry through their duty properly.

I was asked an important point about an external person on the appointments panel and I have referred to the involvement of the Faculty of Public Health generally. We are actively pursuing the idea of an external person and obviously we will be extremely happy to continue to work with the faculty over this and other issues.

The noble Lord, Lord Patel, and other noble Lords raised the issue of emergency planning and whether there would be an improvement on what exists now. Certainly, in our view, the new arrangements will be a significant improvement on the current ones. For example, in a new pandemic, joint plans will be in place between Public Health England and the NHS Commissioning Board for the important testing and data-gathering that is essential to understand the nature of a new disease in the early stages. The noble Baroness, Lady Finlay, is absolutely right that lines of communication need to be extremely clear and that working out exactly how this is to be done is extremely important. The department is well aware of that and the matter is being taken forward.

The NHS, Public Health England and local authorities will have joint plans in place to establish anti-viral collection points, for example, if needed. Public Health England, as an executive agency, will be able to provide scientific and technical advice and the NHS will have clearly understood mobilisation plans to respond to additional pressures on hospitals and primary care services. Throughout an emergency, the Chief Medical Officer, with Public Health England, will provide the Secretary of State with consolidated scientific advice to inform response and resolution. I trust noble Lords will be reassured by that.

Lord Patel: I am not actually that reassured. The point I was trying to make is that the current arrangements, as specified in the document so far, are flawed. They do not identify a lead person with the local authority who will respond to Public Health England's advice and who also has plans in place not just for a pandemic or national emergency but for a local emergency. I gave two examples. The main problem is the lack of a lead person in charge locally. It might not be solved today but I hope the noble Baroness accepts that there is an issue here.

Baroness Northover: The director of public health has responsibility for what happens locally. One of the important issues here is the nature of the epidemic.

29 Feb 2012 : Column 1359

The response to deal with that will be determined at the appropriate level-that is the key element in this. However, if the noble Lord and the Faculty of Public Health would like to engage further in discussions on this, I am extremely happy to offer that, knowing full well that my noble friend the Minister always has his door open. We look forward to further discussions to make sure that, where we feel it is working well but noble Lords need reassurance, we can address their concerns.

The noble Lord, Lord Walton, brought me back to my history of medicine when he spoke about the history of public health. He emphasised the importance of training and the noble Lord, Lord Turnberg, emphasised education, training and research. I assure noble Lords that all training contracts will be honoured. We are exploring at the moment how public health trainee contracts will be managed in future and are engaging with those who are concerned in these areas. We will set up a stakeholder group of professional bodies, Department of Health policy groups, deaneries, employers and trade unions to develop a framework for supporting public health trainees. I trust that will reassure noble Lords.

I completely agree with the noble Lord that the question of whether directors of public health will hold honorary NHS consultant status is very important and one that we are well aware of. We will shortly publish for consultation a public health workforce strategy to inform decisions on matters such as this.

The noble Lord, Lord Turnberg, asked how directors of public health and Public Health England would work together. Public Health England will have local units to encourage collaboration that will be partners in local planning for public health and will help to join up the system. Public Health England will directly support the public health directors with evidence, guidance and best practice.

I have addressed the senior status of public health directors and the manner of appointments, potential dismissals and emergencies. The noble Lord, Lord Beecham, includes the health premium in his amendment. I realise that he wanted to be extremely brief, so I will be extremely brief in reply and emphasise to him that we intend this premium to support the narrowing of health inequalities. I know-or at least assume-that his amendment is to probe and to find out how we view this. There will be a number of indicators to try to narrow those health inequalities.

We do not want to see anyone disadvantaged by our proposals for conditions of service, and employment law will apply to staff who transfer. Last November, in partnership with employers and unions, we published best practice guidance for staff transfers, followed by further guidance agreed with the Local Government Association. Shortly, we will publish a wider workforce strategy for consultation.

7.15 pm

I thank my noble friend Lord Brooke of Sutton Mandeville for identifying a very important issue that has significant implications for a number of local authorities. The Bill gives local authorities a duty to

29 Feb 2012 : Column 1360

take appropriate steps to improve the health of the people in their areas. As drafted, that duty does not have to be confined to people with a residential address in the area-it could, for example, include a homeless person who is sleeping rough in the area, or, as he says, those who might be working in a particular area such as the City of London.

I can reassure the noble Lord that the current draft of the Bill would indeed allow local authorities to take steps to improve the health of people who work in an area or indeed of any other non-permanent resident. I also reassure my noble friend that we recognise the need for more work on how the needs of temporary populations are reflected in local authorities' funding. We are very grateful for the constructive discussions that the Department of Health is currently having with the City of London, which will continue and will help to ensure that the issue is resolved when final allocations are made.

I hope that I have addressed noble Lords' concerns and am happy for us to have any further discussions, write letters and so on if there is anything else.

Lord Patel: I thank the noble Baroness, Lady Northover, and the noble Earl the Minister, not only for today but for having met me and the faculty in the past. We have come a long way from where we started with public health issues and our long debates in Committee. I think the Government have acknowledged and responded to the need, and I thank them for it. Only two minor issues are left now. She has already alluded to one, about the statutory registration of public health specialists, which it also looks as though we will solve. That leaves one other issue, which we will come to later, about Public Health England, on which I hope the Government's response will be as positive.

Amendment 120 agreed.

Amendments 121 to 123 not moved.

Amendment 124

Moved by Earl Howe

124: Clause 29, page 56, line 40, at end insert-

"( ) A local authority must have regard to any guidance given by the Secretary of State in relation to its director of public health, including guidance as to appointment and termination of appointment, terms and conditions and management."

Amendment 124 agreed.

Amendment 125 not moved.

Clause 30 : Exercise of public health functions of local authorities

Amendment 126 not moved.

29 Feb 2012 : Column 1361

Amendments 127 and 128

Moved by Earl Howe

127: Clause 30, page 57, line 12, after "6C" insert "(1) or (3)"

128: Clause 30, page 57, line 20, at end insert-

"( ) A document published under subsection (1), and guidance given under subsection (3), may include guidance as to the appointment of officers of the local authority to discharge any functions mentioned in subsection (2), and as to their terms and conditions, management and dismissal."

Amendments 127 and 128 agreed.

Clause 31 : Complaints about exercise of public health functions by local authorities

Amendment 129

Moved by Earl Howe

129: Clause 31, page 57, line 36, after "6C" insert "(1) or (3)"

Amendment 129 agreed.

Clause 35 : Procedural requirements in connection with fluoridation of water supplies

Amendment 130

Moved by Lord Hunt of Kings Heath

130: Clause 35, page 64, line 32, at end insert-

"(8) That the funds to meet the running costs of fluoridation schemes covered by legal agreements entered into before 1 April 2013 shall be-

(a) met from the identified fluoridation funds within the ring-fenced public health grants to be made by the Department of Health to local authorities with effect from 1 April 2013;

(b) held by Public Health England on behalf of the responsible local authorities in order to meet the costs incurred by water companies in operating those fluoridation schemes;

(c) accounted for by Public Health England to the responsible local authorities in annual reports on the expenditure incurred on behalf of those authorities.

(9) That the funds required to meet the running costs of new fluoridation schemes covered by legal agreements entered into after 1 April 2013 shall be-

(a) met from additional ring-fenced public health grants allocated by the Department of Health to the local authorities requesting fluoridation of all or part of their areas following a public consultation held under the provisions of this Act and its associated regulations;

(b) held by Public Health England on behalf of the responsible local authorities in order to meet the costs incurred by water companies in operating those fluoridation schemes;

(c) accounted for by Public Health England to the responsible local authorities in annual reports on the expenditure incurred on behalf of those authorities.

Lord Hunt of Kings Heath: My Lords, I shall be brief. I was very grateful to the Minister for a meeting with her and her officials a week ago. I have two concerns about fluoridation schemes. The first is to make sure that where there are current fluoridation schemes, the amount of money being spent on their running costs will transfer to local authorities and that

29 Feb 2012 : Column 1362

it will be recognised in terms of the allocation that is given. I think the noble Baroness will be able to reassure me on that.

The other question I want to put relates to where new schemes come into being. The proposed system seems rather convoluted, with various bodies involved, including Public Health England at a national level but also many local authorities. I just want some assurance that if a local authority or a combination of local authorities decide to go for a fluoridation scheme, the system of financing will be as smooth and easy as possible and that resources will be available to enable those schemes to go ahead. I beg to move.

Lord Colwyn: My Lords, I support everything that the noble Lord, Lord Hunt, has said and declare an interest as vice-president of the British Fluoridation Society. I believe in the efficacy of the fluoride ion, and during my own dental career have seen the beneficial results of this public health measure.

I do not want to repeat what the noble Lord, Lord Hunt, has said, but the Government envisage that, in future, local authorities will be the bodies that consult on fluoridation and decide whether to introduce and maintain a scheme. The issue is about funding for existing schemes and for possible future schemes. The Bill as it stands would mean that on 1 April 2013 the money currently spent by the NHS on existing schemes would pass to local authorities, which would then have to pass it on to the Secretary of State via the new organisation, Public Health England, to pay the bills presented by water companies. This would be a complex, bureaucratic process. If, for example, the money got stuck somewhere, the water company affected would quickly get fed up and stop fluoridating. How much smoother and quicker it would be if the money that the NHS is currently spending went directly on 1 April 2013 to the Secretary of State and Public Health England. This would mean that the organisation that will actually pay the bills will have the money in its account and not be reliant on local authorities transferring it.

The Bill as it stands also means that if any of the new schemes are ever voted for by local authorities when they take charge of consultations on fluoridation, the Secretary of State will look to them to pay for those schemes. Yet local authorities are not responsible for dentistry and have no dental budget. So where would they get the money from? In all probability they would not get it and, as a result, no new schemes would ever be implemented. This amendment means that, although the local authorities will be the decision-making bodies in future, the money for any fluoridation schemes that they support will come from the dental health services budget of the NHS Commissioning Board, the body that stands to benefit from the reduced treatment costs that would follow. The NHS Commissioning Board would transfer funds to the Secretary of State, who would pay the bills submitted by the water companies. I may have got this wrong, but I would be delighted to hear what my noble friend the Minister has to say.

Baroness Gardner of Parkes: Everything that needs to be said has been said; I thoroughly approve of this amendment and ask the Minister to note my support as a former dentist.

29 Feb 2012 : Column 1363

Baroness Northover: I thank noble Lords for that extremely brief and consensual approach to this issue. We debated this in detail in Committee, and I commend all noble Lords for their work in this area.

We certainly agree that the rates of tooth decay in children and adults is an important public health measure. I point noble Lords to the public health outcomes framework, which my noble friend Lord Colwyn might like to have a look at, which is a document to which local authorities will have to have regard.

The noble Lord, Lord Hunt, asked whether, in terms of the public health funding allocation to local authorities, if a local authority has a fluoridation scheme, whether it will be covered within the budget. I can assure him, as I did in the meeting that we had earlier, that indeed it will be covered in the budget, which will look at the public health needs of the area-and that will be reflected in the grant. Those are the current schemes. The noble Lord asked about future schemes. Public health funding is ring-fenced, and the Government look at the needs of the area. However, local authorities will be deciding how they prioritise various issues, so it would not be appropriate for us to say that they must address this issue through a fluoridation scheme. They might be looking at all sorts of other public health issues and seeking to address their responsibilities in terms of dental health in some other way. However, I point out something that I did not know before-and I do not think that the noble Lord knew before-which is that just about all fluoridation schemes currently in place have been initiated by local authorities over their history.

I recognise the commitment of noble Lords to dental health. I appreciate it and realise that noble Lords want to speed it along. I hope that reassurances about the level of funding for current schemes will reassure the noble Lord, Lord Hunt, so that he feels able to withdraw his amendment. We continue to be very keen to engage in this area.

Lord Hunt of Kings Heath: My Lords, I should have declared in moving my amendment that I am president of the British Fluoridation Society. The noble Baroness, Lady Gardner, reminded me by making her own declaration. I am most grateful to the Minister and beg leave to withdraw my amendment.

Amendment 130 withdrawn.

Amendments 131 to 136

Moved by Earl Howe

131: Clause 35, page 66, line 11, at end insert-

"( ) The duty in subsection (3) does not apply in relation to the proposal if the Secretary of State so directs by an instrument in writing."

132: Clause 35, page 66, leave out lines 14 to 17

133: Clause 35, page 66, line 39, at end insert-

"( ) The duty in subsection (2) does not apply in relation to the proposal if the Secretary of State so directs by an instrument in writing."

134: Clause 35, page 66, leave out lines 42 to 45

135: Clause 35, page 67, line 34, at end insert-

29 Feb 2012 : Column 1364

"( ) The duty in subsection (2) does not apply in relation to the proposal if the Secretary of State so directs by an instrument in writing."

136: Clause 35, page 67, leave out lines 37 to 40

Amendments 131 to 136 agreed.

Clause 39 : After-care

Amendment 136A

Moved by Lord Patel of Bradford

136A: Clause 39, leave out Clause 39 and insert the following new Clause-


(1) Section 117 of the Mental Health Act 1983 (aftercare) is amended as follows.

(2) In subsection (2)-

(a) after "duty of the" insert "clinical commissioning group or",

(b) omit "Primary Care Trust or" in each place it appears,

(c) for "such time as the" substitute "such time as (in relation to England) the clinical commissioning group or".

(3) After subsection (2C) insert-

"(2D) Subsection (2), in its application to the clinical commissioning group, has effect as if for "to provide" there were substituted "to arrange for the provision of".

(2E) The Secretary of State may by regulations provide that the duty imposed on the clinical commissioning group by subsection (2) is, in the circumstances or to the extent prescribed by the regulations, to be imposed instead on another clinical commissioning group or the National Health Service Commissioning Board.

(2F) Where regulations under subsection (2E) provide that the duty imposed by subsection (2) is to be imposed on the National Health Service Commissioning Board, subsections (2D) and (2E) have effect as if references to the clinical commissioning group were references to the National Health Service Commissioning Board.

(2G) Section 272(7) and (8) of the National Health Service Act 2006 applies to the power to make regulations under subsection (2E) as it applies to a power to make regulations under that Act."

(4) In subsection (3)-

(a) after "section "the" insert "clinical commissioning group or",

(b) omit "Primary Care Trust or" in each place it appears, and

(c) after "means the", in the first place it appears, insert "clinical commissioning group or".

(5) In consequence of the repeals made by subsections (2)(b) and (5)(b), omit paragraph 47 of Schedule 2 to the National Health Service Reform and Health Care Professions Act 2002."

Lord Patel of Bradford: My Lords, it is with a heavy heart that I find myself speaking here again on this amendment, which attempts to make changes to Clause 39. This amendment is not about politics and is not in opposition to this troubled Bill; it is about the protection of the vulnerable and those in greatest need. I set out in some detail in Committee the reasons and purpose for my amendment, which had the support of not only many Members of this House from all sides but also many leading mental health organisations in this country, such as Mind, Rethink, the Mental Health Foundation, the Centre for Mental Health, the Law Society and the Royal College of Psychiatrists. These are not agencies with vested interests; they do

29 Feb 2012 : Column 1365

not gain anything from fulfilling their core purpose, which is to advocate on behalf of those who are less able to speak for themselves as a consequence of severe mental illness. We are talking about people who have suffered from severe illness-those who have been so ill and at such risk that the full powers of the Mental Health Act 1983 were used to detain them and keep them in hospital.

These are not lifestyle problems; these are not people who could have chosen a different path. They did not choose to be detained in hospital, sometimes for very long periods of time. No-these are people whom the state, in making use of its considerable powers under the Mental Health Act, has a very clear obligation and duty to protect. That protection must go beyond the time spent in hospital to include their aftercare under Section 117 of the 1983 Act. One crucial thing about that section is that it requires primary care trusts and local authority social services to work jointly together in providing aftercare. This could include a variety of necessary things such as visits from a community psychiatric nurse, attending a day centre, administering medication and providing counselling services-or, most importantly, providing supported accommodation within the community.

Under the current law, a mental health patient can expect that their PCT and local authority provide the aftercare package in an appropriate way, including sorting out the funding between themselves. These vital services cannot be taken away until the PCT or local authority are satisfied that the person no longer needs them. I am not suggesting that Clause 39 would stop the provision of aftercare. What I am saying, and what many other experts in mental health and the law are saying is that that will have profound effects on how that aftercare is delivered and paid for, effects that fall down like dominoes with insidious and devastating impacts. For example, the clause removes the duty of co-operation in delivering aftercare services between the health service, the local authority and the voluntary sector, which makes what is a freestanding duty into a gateway provision. As a consequence, it provides a backdoor route by which aftercare services for detained patients will become chargeable.

I am grateful to the noble Baroness and the noble Earl for making time to meet the noble Lord, Lord Adebowale, and me to discuss our concerns. Unfortunately, this has been to little avail since, as your Lordships can see, there is no change to this clause. With the greatest of respect, I have to say that the Minister and indeed the officials in the Department of Health do not understand the full import of the changes that will be brought about by this clause. At least, I hope it is a misunderstanding because I am at a complete loss as to why our concerns have not been addressed.

Let me briefly give some examples of why I believe this clause will be so damaging. I take these from the Local Government Ombudsman, who became involved following several complaints about the application of the current law. I will explain why this is important in a moment, but let me first give your Lordships some of the detail of these cases. The first concerns a woman, Mrs Wilson, who, following a period of detention under the Mental Health Act, required care in a residential

29 Feb 2012 : Column 1366

home as part of her jointly agreed aftercare. Yet despite the clear meaning of Section 117 of the Mental Health Act she was charged by the local authority for this care, resulting in the loss of her home. She was also discharged from a Section 117 agreement without her or her mother Mrs Walton, who was her main carer, being either involved or consulted in the decision, which was yet another breach of the clear meaning of the Act. The ombudsman found that the local authority had failed in its duty to provide aftercare, and in its duty to consult the patient and their carer.

The exact same issue-a failure to involve people in decisions, and inappropriate and illegal charging for services-arose in several other cases, such as with Mr Hughes's sister, who was placed in a care home after being discharged from hospital, again under a Section 117 agreement. She, too, was charged for the costs of her social care and lost her home as a result. Despite clear advice from the Department of Health about Section 117 services being free, the council continued to apply charges. The ombudsman decided that,

It most certainly is required. I could go on and give many examples. The lady in question was being charged £256 a week for her aftercare, even after the legal advisers at the time said that this should have been free. At the time of the ombudsman's decision, Mr Hughes's sister had in fact paid costs amounting to £60,000.

Why are these cases so important? It is because they illustrate, even with the protection of the freestanding duty, that local authorities sought to break their agreements without consultation and did everything in their power to charge the people in their care for services that should most certainly have been free. That is the key to the issue in this argument. If this is how local authorities are applying the current law, what can we expect when they are freed from the duty of this care as Clause 39 seeks to do? They did that in a time of plenty, so what shall we see in the current challenging economic climate? What then for the vulnerable people who are coming out of hospital after having been detained under the Mental Health Act?

My amendment is about ensuring that this does not happen, and that even though it is not perfect we keep the joint duty, so that aftercare can be recognised and responded to in ways that are appropriate and necessary. The Minister has argued that this is about tidying up and aligning the legislation. It is exactly that alignment-that so-called tidying up-that causes the problems. I am reliably informed by legal advisers that introducing reference to the 2006 NHS Act in the way that this clause does will import into Section 117 the power to charge for aftercare services whenever the 2006 Act allows for it. I am in agreement with the noble Baroness, Lady Murphy, who asked in Committee, "What is wrong with the current situation? Why change what are clearly essential arrangements without some serious reasons for the change"?. This does not mean just a tidying up.

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My amendment is simple. It retains a clear and unambiguous responsibility on clinical commissioning groups and local authorities to provide appropriate aftercare services. It will retain these duties on the basis that CCGs and social services authorities must act together jointly. It would also ensure that CCGs continue to arrange for the provision of aftercare services under Section 117, in co-operation with the relevant voluntary agencies. Most importantly, it preserves the judgment of the Law Lords of this House in the Stennett case that this is a freestanding duty, and as such cannot be used for the charging of aftercare services under Section 117.

As I said at the start, I move this amendment with a heavy heart because we should never have come to this point on this clause. I am not making trouble and this is not about making political points, but the Government make their case for this Bill so much harder by refusing to listen to those who perhaps know something more about the impact on people's lives, especially those who are marginalised and at serious risk. The current joint duty is essential, because it means that the patient is more likely to get access to the right kind of integrated health and social care services which they need and, most importantly, that the patient has an enforceable right to those services.

Aftercare under Section 117 is free of charge because the people who need these services are incredibly vulnerable and face a very real risk of relapse or self-harm, and of becoming more isolated and vulnerable as a result of not being adequately housed in an environment that offers them the protection they so desperately need. I will not retreat from this. My duty to those who are in such critical need of our support and my conscience will not let me retreat from this. I move this amendment in good faith and I hope that the Minister, whether it is the noble Earl or the noble Baroness who replies to this debate, will accept it.

Lord Adebowale: My Lords, I support the amendment moved by the noble Lord, Lord Patel. I am grateful to the noble Earl for the time that he generously gave to me and the noble Lord to meet him and the civil servants. However, I was disappointed by the letter that we received following the meeting. I thought that we had driven home the point and had some sympathy from the noble Earl. I understand the need to tidy up legislation, which is an important thing to do, but I find it faintly disgusting that we are going to mess up people's lives. The legislation might be neater but lives will be made much messier.

I have just come from Manchester-from Turning Point's offices there; and I declare my interest as the chief executive of an organisation that will be directly affected by the Bill-where we have a case of an elderly lady who has been with us for 14 months, at a cost of well over £100,000. We cannot get the NHS to pay it because it claims that it is the responsibility of the local authority, whereas the local authority claims that it is the responsibility of the NHS. That is the reality under the current legislation, even with, as the noble Lord pointed out, the provisions of Section 117.

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We are told that, in tidying up, the proposed provisions will allow people who are discharged from mental health institutions to seek a judicial review if they are refused aftercare arrangements in co-operation with health and social services. I was astonished to read that in the letter. I do not know what planet the writer of the letter is on but I would welcome them to join my planet and actually visit and speak to people who are discharged from these institutions, and to talk to their families and friends, and then to come back and tell me whether they are in a fit state to seek judicial reviews against local authorities and the NHS. We must be real when discussing legislation that will affect the lives of real people who may not sit in this Chamber but who will cost us a fortune if we do not get this right.

It is with a very heavy heart that I support the noble Lord, Lord Patel, in his amendment. I hope that, at this late stage, the Government will see the obvious logic. Even in their responses to previous amendments they said that they wished to support the joined-up provision of health and social care. What better example is there of such provision than Section 117 of the Mental Health Act? It is as obvious as gravity. So we must insist-not to make a political point or reference to the Bill, but on behalf of people not in this Chamber who will cost the country dearly if we do not get it right-that the Government accept the logic of the amendment and just say yes.

Baroness Tyler of Enfield: My Lords, I support this important amendment. The whole basis of the Health and Social Care Bill is to place great emphasis on delivering integrated care as part of the needed reforms, and I am sure that we all support that. As the noble Lord, Lord Adebowale, has just said, though, Clause 36 in its current form will remove one of the few examples of genuinely joined-up service provision between local health and social services. A joint duty on aftercare services for these people, some of the most vulnerable in society, is crucial if they are not to have further lapses and become more and more marginalised. We talked earlier about people falling between the cracks, and that is the danger that we are in.

Baroness Northover: My Lords, I realise that noble Lords want to move on to other debates, so it might be opportune if I intervene now. We have always expressed sympathy for what the noble Lord intended in his original amendment. We listened carefully to the points put by the noble Lords when they came to see us, even if it seemed that we were not very responsive to what they were saying. We note the considerable emphasis that they place on retaining the duty of co-operation with the voluntary sector that is set out in Section 117. We realise that the clause removes the duty that is currently there, and that is clearly causing concern.

We do not feel that there is anything in the clauses that will bring in charging for any NHS or social care services that are currently provided free under Section 117, and the Government have no plans to bring in measures that would change the position on charging for Section 117 services. However, sometimes tidying up causes concerns. We are all used to dealing with the section as

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it currently stands and could continue to do so. We are nothing if not a listening team. The Government have therefore decided, and I hope that the noble Lord, Lord Patel, will be pleased, that we will not oppose his amendment. In the light of this, if your Lordships' House agrees and wishes to accept his amendment, the Government will need to bring forward a few technical amendments at Third Reading to make a few consequential changes to the Bill to ensure that the amendment works properly in the amended 1983 Act. I hope that the noble Lord will be pleased that indeed we heard what he and his noble friend were saying.

A noble Baroness: Now you have to go over and give her a kiss.

Lord Patel of Bradford: I was about to take my jacket off-

Lord Beecham: Just stop there.

Lord Patel of Bradford: But a hug is probably more appropriate. That is really good news; I am pleased that the Minister and the noble Earl, who I knew was sincere in all the discussions that we had, have accepted this important amendment. Of course I shall formally withdraw the amendment-

Noble Lords: No!

Lord Patel of Bradford: Sorry, I have lost my flow completely. I meant that I shall formally move my amendment. However, I would like to reserve the ability to see those technical changes and come back if they do not quite achieve what we want.

Amendment 136A agreed.

Amendments 137 to 140

Moved by Earl Howe

137: Clause 48, page 80, line 10, at end insert-

"( ) Subsection (1) does not apply to any function of the Secretary of State of making an order or regulations."

138: Clause 48, page 81, line 6, at end insert-

"( ) Subsection (1) does not apply to any function of the Secretary of State of making an order or regulations."

139: Clause 48, page 81, line 16, at end insert-

"( ) Subsection (1) does not apply to any function of the Secretary of State of making an order or regulations."

140: Clause 48, page 82, line 10, at end insert-

"( ) Subsection (1) does not apply to any function of the Secretary of State of making an order or regulations."

Amendments 137 to 140 agreed.

Consideration on Report adjourned until not before 8.45 pm.

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Welfare Reform Bill

Commons Reason

7.45 pm

Motion A

Moved by Lord Freud

The Parliamentary Under-Secretary of State, Department for Work and Pensions (Lord Freud): My Lords, I am sure that all noble Lords will agree that we have debated this measure comprehensively over the passage of the Bill through this House. Perhaps, though, your Lordships will allow me to take some of our time this evening to explain again why we believe that this change is necessary.

We have been open about the fact that this measure is essential to curb housing benefit expenditure. Left unchecked, expenditure on housing benefit would reach £26 billion by 2014-15. That is unsustainable and unjustifiable, not least because of the current economic climate. As I have said before during our earlier debates on this subject, we do not think that it is reasonable to expect the taxpayer to fund the cost of somewhere approaching 1 million spare bedrooms. At £500 million a year the cost is substantial, and there is no realistic possibility of finding that money elsewhere.

Some in this House, and indeed in the other place, have suggested that we should perhaps abandon this measure altogether as it will not deliver savings if substantial numbers of tenants move into the private sector. I assure noble Lords that if that really were the case, we would not be implementing this change. It is important to look at the bigger picture. If there were movement into the private rented sector, that would free up accommodation in the social rented sector, enabling it to be let to others who may otherwise have been renting privately. Alternatively, it could be offered to people who are currently placed in often expensive temporary accommodation. So, while I can understand how some may conclude that this measure would result in an increase in housing benefit expenditure, I firmly believe that it will achieve precisely the opposite as the effects ripple outward.

During this final stage of the Bill's passage, the noble Lord, Lord Best, has offered amendments to protect some social sector tenants, all of which would reduce the expected savings from this measure. I pay tribute to him for the manner in which he has pursued his amendments and the wealth of knowledge that he brings to bear on this issue. I do not doubt for one moment that these were anything other than well intentioned but the Government have been unable to accept them. Aside from the financial implications, there is an important issue of fairness. We have talked about that a lot in the context of these changes but we must make sure that we recognise the need to be fair to tenants living in the private sector in receipt of housing benefit.

On the face of it, what has been suggested through earlier amendments is an approach that protects claimants in social housing but not those in the private sector. I do not believe that there is a clear rationale to pay

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claimants in the social sector to keep a spare bedroom but not those renting from a private landlord. The Government's clear view is that we do not fund spare bedrooms in the social sector or the private sector. The cost to the taxpayer would be excessive and totally unjustifiable.

Although we have had to take a tough decision to press ahead with these changes, that does not mean we will not protect people in vulnerable situations. As noble Lords know, we are adding £30 million a year of extra help to the discretionary housing payments fund from 2013-14 for disabled people living in significantly adapted accommodation and for foster carers. Local authorities will of course still be able to consider discretionary housing payments for other groups. I realise that the noble Lord, Lord Best, and others would prefer the certainty of specific exemptions for these groups. We understand the arguments for that but do not believe that a blanket exemption is the most effective or affordable approach. Any exemptions would also add complexity to the system, which we want to avoid.

We also have special rules to provide protection for groups such as the recently bereaved, so that they do not see an immediate reduction in their housing benefit. I know that the noble Baroness, Lady Hollis, who I do not see in her place tonight, is concerned about the impact of these changes on those who need care. Therefore, I reassure her once more that we will allow an extra bedroom for those requiring overnight care from a non-resident carer, in the same way as we do for claimants in the private sector.

We have more than a year before these changes are due to come in and we recognise how important it is to prepare for them. It is essential that all those affected by this measure, whether directly or indirectly, understand how the change will affect them so that they can take action well before April 2013. Therefore, we will use this lead-in time as effectively as possible to support local authorities, customers, landlords and others to plan for these changes. I beg to move.

Motion A1 (as an amendment to Motion A)

Moved by Lord Best

3D: Clause 11, page 5, line 21, at end insert-

"(3A) The Secretary of State shall commission an independent review ("the review") of the impact of the provisions of sections 11 and 68 of this Act.

(3B) The review shall assess the impact of those provisions on-

(a) families; (b) the incidence of poverty;(c) the incidence of homelessness;(d) levels of underoccupancy;(e) local authority resources;(f) rent arrears; and(g) any other consequences of sections 11 and 68 of this Act which the Secretary of State or the reviewer consider should be covered by the review.

(3C) The review will commence six months after sections 11 and 68 of this Act come into force (or, if the provisions of sections 11 and 68 comes into force on different dates, six months after the latter of those provisions comes into force).

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(3D) The review will conclude with the making of a report within six months of the review commencing; and shall be repeated one year after it commenced.

(3E) Reports made under subsection (3D) shall be laid before both Houses of Parliament."

Lord Best: My Lords, in response to the Minister's defence of the inclusion in the Bill of this underoccupation penalty, perhaps I could briefly spell out the position that we have reached this evening.

Before Christmas, this House asked the other place to reconsider the idea of requiring several hundred thousand tenants in council housing or housing association homes to move out or pay a fine if they were deemed to have a spare room. The amendment that we sent to the other place would have meant that although the requirement to move out or pay up would still stand for all these households, it would not take effect unless a suitable smaller home to which they could go was available. This would have removed the injustice of penalising people through a reduction in their housing benefit, which they would have to make up from the rest of their extremely low income, when they had no option but to stay put. The fine, or bedroom tax, of an average of £14 per week would have to come out of the tenant's other income-for example, from a single person's income from jobseeker's allowance of just £68 per week-even where they had no chance of escaping this significant reduction in their living standards. Of course, rent arrears will follow, which means evictions and more cost. Long-standing residents in council housing, not least in rural areas, would have to move away over considerable distances to avoid the financial penalties of staying in their own homes.

Despite support from your Lordships on all sides, in the other place this amendment was rejected on financial grounds since the measure was expected to cut the deficit by some £470 million per annum. I put forward a modified amendment, which your Lordships again accepted. Under it, the delay in imposing the penalty charge until an alternative smaller home could be offered would not apply to all the households hit by the underoccupation rule, but only to the most vulnerable, such as disabled people, war widows, those caring for severely disabled people or children under one year-old and others not required or expected to seek work.

On the issue of caring for a disabled relative, perhaps I could elaborate a little on the Minister's comment that a spare room would be allowed for a carer looking after an older relative. This will apply only to a non-family member who is a carer and lives there all the time, exercising their caring duties. However, that spare room is often for the daughter who comes on a temporary basis when her mother comes out of hospital or to look after another member of the family. Having that bit of space can save the National Health Service money as well. Strong speeches were made in favour of the amendment in the other place, including from the Conservative Benches. For example, the particularly acute position in Northern Ireland was highlighted. There was recognition that disabled children often need their own bedroom, as do adults when one of a couple is disabled, and older people for whom an extra room for a family carer who just visits from time to time can be so important. These arguments have fallen on stony ground and the Bill is now back with us.

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So that there are no threads still to be untangled, perhaps I could pick up on a couple more of the points that the Minister made in defence of this measure. He very fairly made the point that an additional £30 million in discretionary housing payments has been found to give the extra benefit back where there are foster children in the home-that is very welcome-or where the property has been adapted and it would be foolish to move people out to somewhere smaller and have to adapt that property, possibly with the adaptations to the previous property going to waste. However, the £30 million that has been found to increase discretionary housing payments in those cases has come from increasing the fine for everyone of £13 per week-the original average figure that we heard in Committee-by an extra £1 per week for everyone who is not exempt. Although the £14 that we now face means that the extra funding will help as many as 40,000 households-I am pleased that it will-the remaining 670,000 households will all pay another £1 a week, which is where that funding has come from.

I turn to the amendment that has now come back to this House. I must say that I was tempted to bring forward an amendment that would lessen the cost to the Government since it is clearly the level of expenditure that has inhibited the Government from going anywhere near my amendments so far. However, frankly, to modify the earlier amendments by taking out yet another group of those trapped by the penalty would become invidious as we try to choose between different categories of highly vulnerable people, and select some but not others for the already limited protection that the earlier amendments would have afforded.

Instead-and I apologise to those who hoped that this House could save the day but will now be deeply disappointed-the amendment that I have brought before your Lordships takes a different tack. It would rely on high-quality research to show the consequences of this measure. The amendment places an obligation on the Government to review the impact of the underoccupation penalty on the families concerned and on levels of poverty and homelessness; to calculate the cost to local authorities and housing associations; to look at whether levels of underoccupancy actually fall; and to consider other foreseeable and unforeseeable consequences. The exercise would begin six months after implementation of the provisions in the Bill. It would be completed within a year and repeated a year after that. My hope is that the Government would prove willing to make some in-flight corrections and to take mitigating action if the evidence shows clearly that the consequences of this measure are dire.

In response to a Motion that I moved on the regulations that introduced earlier housing benefit cuts, the Minister put in hand a thoroughgoing research project on the impact of those changes. I have been delighted by the extent and quality of this research project and I remain very grateful to the Minister for that initiative. I know that he fully understands the value of high-quality research and hope that he feels able to go forward with this amendment. After the long journey we have all taken in pursuit of this matter, that would at least mean that a modest outcome would result from all our deliberations.

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8 pm

Baroness Lister of Burtersett: My Lords, I support Motion A1 as the best outcome we could possibly hope for in the current circumstances. However, I would like to suggest another area that the review should look at in terms of a foreseeable consequence, which is the impact of this measure on social support networks. I was an adviser to a Joseph Rowntree Foundation-funded project carried out by some of the people involved in the review instigated as a result of the noble Lord's earlier intervention: namely, Sheffield Hallam University, which has been looking at the relationship between poverty and place over a three-year period. It produced a report last year which considered these research findings and set them against various explicit and implicit assumptions in government policy. One of the points made in the report was that if forthcoming social housing and housing benefit reforms obliged low-income households to relocate, this might most affect those with the strongest connection to their existing neighbourhood. Surely this goes against so much of government policy. These reforms will make it harder for people to find work because social networks are very important in helping low-income people find work. They will make it harder for those with children to enter or sustain work because social networks are so important in terms of help with childcare. The reforms will undermine the big society. Social networks are the capillaries of the big society. The report suggests that the reforms will reduce people's feelings of security, safety and sense of belonging. I am sure that this is not what we want. I do not know whether the Minister will respond positively to my suggestion. However, if he does respond positively, as he did with regard to the suggestion of the noble Lord, Lord Best, for a review, I hope that he will take on board the impact of this change on social support networks.

Lord German: My Lords, I commend the thrust of this amendment. However, as has been demonstrated, the way in which it is drafted may mean that it does not include everything that we would wish it to include. I would expect the Minister to comment about the way in which a review should be conducted. I do not wish to sound like a well-worn record but I have a long-standing view about the way in which major shifts and changes should be reviewed. It is absolutely essential that any part of the Bill which has profound implications for change should be reviewed in a proper manner. I wish to use two analogies-a route map and a set of milestones. We use a route map to get a sense of direction, find out where we can turn off a route and make diversions, whereas a milestone signifies the distance that we have travelled. Reviews which rely solely on milestones do not necessarily fulfil the point to which the noble Lord, Lord Best, referred: namely, to make changes on route. That is one of the key issues for any form of review of major change.

The Government's principal success in this field was their appointment of Professor Harrington to undertake a series of milestone reports. One of his reports was colloquially referred to as his report number one and a half. He continually places on record what he sees as being the changes which are necessary.

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He has followed different routes and different avenues in looking at the whole issue of the WCA and the way in which it is adopted. That has enabled the Government to make changes as they are going along. I commend the suggestion to the Government that they should think carefully about appointing independent people to conduct a continuous evaluation so that we not only have the milestones when formal reports have to be submitted but changes can be made as the need for them arises. Such a process gives flexibility to the people who are conducting the evaluation to address problems as they emerge.

I make no apologies for returning to the issue of foster carers. I raised it in Committee, on Report and I raise it again today. As we have just heard, the sum of £30 million is intended to support 40,000 households which contain disabled people or foster carers. What analysis has been done of the adequacy of that sum or of whether 40,000 households is the correct figure to cover people who fall into both those categories? I refer specifically to foster carers. We have a distinct shortage of foster carers in our country. Only 65 per cent of children in care are in foster care, which means that many thousands of children who could benefit from this provision if appropriate foster homes could be found for them are missing out. However, it is natural and reasonable that social services departments and fostering services place increasing emphasis on the importance of finding a good match vis-à-vis a child and a foster carer. That has inevitably led to a longer time span in appointing foster carers. Did the Government take that extended time span and the increased demand for foster carers into account when calculating the support that they would make available to the groups I have mentioned? We do not know how many of the 40,000 households include disabled people and how many include foster carers. I should be grateful to my noble friend if he could respond to those points.

In conclusion, I commend to the Minister the review process proposed in the amendment. As has already been pointed out, some noble Lords may think that the amendment should include other matters. Its proposed new subsection (3B)(g) would allow other matters to be taken into account. One might want to refer to the problems caused by disrupted education. I believe that noble Lords have referred to that in previous debates on the Bill. It seems to me that the amendment may not have the right wording but its sense of direction is very appropriate. I hope that my noble friend the Minister will be able to accommodate its main thrust.

The Lord Bishop of Ripon and Leeds: My Lords, I too thank the noble Lord, Lord Best, for the amendment and for his persistence on this issue. He has continually sought to get us to think of ways in which we can provide support for those who may be in need as a result of the Bill's provisions. Therefore, I support Motion A1.

There has been much debate about what effect the Bill will have in practice when it becomes an Act. Some believe that it will result in a very positive change of culture which will be of benefit to all. Others believe that we still massively underestimate the Bill's effect in terms of the number of people

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whose lives will be damaged and who will be made homeless as a result of it. A tremendous variety of assessments have been made regarding how many people will suffer as a result of the Bill, not least the number of children who will suffer.

I spent this morning with staff of a charity called Streetlights, which seeks to support those who are unemployed in the City of Westminster. It is based just round the corner from here in Great Peter Street. It provides food for those who are homeless and at the same time, in seeking to provide holistic support, points individuals and families towards legal and mental health support. Streetlights is backed by the Church Urban Fund, and I was there this morning, partly because of the fund's promotion of today, 29 February, as a "spare day" to encourage volunteering for places such as those run by Streetlights. I was therefore able to talk both to those who run Streetlights and their clients about the effects of homelessness in general and the particular effects that those in charge there envisage as a result of Clauses 11 and 68. They are convinced that homelessness will increase significantly as a result of the bedroom tax proposals and other measures in the Bill. We cannot know whether they are right or not, but it is a real concern among charities that are seeking to find volunteers who will be able to provide necessary support and are pretty unclear as to whether they will be able to do so.

I therefore support very firmly the idea of a review, so that when there is some evidence that we can talk about, we can look at the ways in which we can support and help those in most need. I was very grateful indeed in our earlier discussions on the Bill for the Minister's promise of a review of the impact of the benefit cap as it comes into effect so that we can find out what is actually happening as a result. I very much hope that he will be able to repeat that sort of assurance and promise now. I support the amendment.

Lord Kirkwood of Kirkhope: My Lords, I should like to encourage my noble friend to support at least the thrust of the amendment moved by the noble Lord, Lord Best, as it gives us some reassurance that we will be able to track the changes that will happen as a result of these provisions. I profoundly hope that my noble friend is right to say that rent levels will reduce as a result of the Bill. I fear he is wrong but I will big enough to admit that I was wrong if what he has said turns out to be the case. However, the stakes are quite high. Whether he is right or I am right the Bill will produce effects on the housing of households at the lower income levels in a way that could be dramatic. However, time will tell what the effects will be. I hope that he is right and I am wrong.

I endorse the comments made by others about the persistence of the noble Lord, Lord Best, and the advantage that we have had of his expertise. We owe him a great debt, no matter which side of the argument we are on. I urge him to maintain his persistence because although the review he is suggesting is important, it will come in after the event. Before that we will have a process of regulations to implement some of these provisions. I would encourage the noble Lord to continue with his persistence through those regulations because

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some in-flight corrections may be possible within the envelope that my noble friend on the Front Bench has available to him. If the noble Lord, Lord Best, is prepared to continue his interest and my noble friend on the Front Bench continues the open-door access policy that he has demonstrated to everyone's satisfaction -certainly mine-constructive tic-tac might be achieved before the review is implemented and that would have a positive effect. I would be happy to contribute to any continuing discussions of that kind during the regulations process.

The only other thing I want to say is that I am now convinced that as a result of the housing aspects of the Bill we are dealing with symptoms. We need a fundamental look at housing policy. We cannot do housing benefit like this. We are imposing consequences on an unlucky few who happen to be in the wrong place through no fault of their own. That is very difficult to justify. Of course there is deficit reduction and we cannot wait for housing policy to change. A housing policy change that embraced some of the fundamental core issues facing our nation, as opposed to symptoms, would take a long time, but the journey has to start somewhere. The experience that the Minister has had from this debate puts him in a strong position to go to his colleagues across government to develop housing policy in the social rented sector with rents that people can afford. It will take time and will involve winners and losers. It will also be a tough policy, but at least if it were consistent and done against a background of a wider housing policy, it would be fairer in the long run. If it is the view that we are spending too much on housing support-£20,000 million a year is a lot of money-we must be very careful when addressing the question in the round. I seriously encourage my noble friend, as a result of the consequences of the Bill, urgently to adopt that position within government and with his ministerial colleagues in order to address this issue as soon as possible.

8.15 pm

Lord Boswell of Aynho: My Lords, having listened to this debate and many of the discussions in Committee on the Bill, I commend the amendment of the noble Lord, Lord Best. I hope that the Minister will accept it, first, because the noble Lord has performed a considerable service in bringing his expertise to bear on the issue. I need not go on about that, other than to say that as someone who has no claim to expertise in housing policy I have increasingly come to the view that in many areas of social policy and social advance housing policy is cardinally important because it impacts on all the other areas. Therefore, by extension, the review that the noble Lord proposes will begin to consider some of the ripple effects of these changes on other situations or aspects.

Secondly, perhaps the most relevant analogy that I can make is that we never quite know when we embark on a major element of social change how it will end up. We all have political positions, we ground them in advance, and we then have to sit back and wait for the consequences. Generally, it is unwise to go for the big bang, although Ministers have to do that. I give as an example the changes made in industrial relations policy

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unsuccessfully in the 1970s. They were then brought in successfully and seriatim in the 1980s rather than in one big advance. We are not in that situation today and I can understand where the Minister finds himself.

We need a process and I shall pick up just two points from the debate. One is from my noble friend Lord German who stressed in his very happy analogy of the Harrington report the importance of independence. The amendment specifically states as a rubric that the review should be independent. As a government supporter, I am entirely relaxed about that; we should follow where the argument goes, look at the consequences and amend them.

I also pick up a point made by my noble friend Lord Kirkwood. He talks about in-flight corrections. We have two stages to this process-the regulations to come, which might be called pre-take-off corrections, and the review following the experience of the initial running of the system, which we should look at carefully. The Minister should do that with a measure of flexibility. We know that resources are very limited. The noble Lord conceded that when moving his amendment, but we should be ready. It is very much in the spirit of the discussion that we have had throughout this long saga, in which the Minister and other noble Lords have played a commendable part. We have done our best in limited circumstances. We sort of launch in hope without certain knowledge of where we will go but, given the noble Lord's amendment, with a determination to keep our eyes open as to what is happening and to make such corrections as may be appropriate and just.

Baroness Sherlock: My Lords, I shall say just a brief word. Barristers always say that you should never ask a question in open court unless you know what the answer will be. I fear that Ministers often take a similar attitude to research: do not ask a question unless you know what the answer will be and you know that you will like it. I commend the Minister, because I have had the impression throughout the passage of the Bill that he is not that kind of Minister but is genuinely interested in information. Because of that, I hope that he will feel able to give a generous response to the encouragement of many Members of the House to look for information.

I have two things for the Minister to think about. One is to follow up the point made by the noble Lord, Lord Kirkwood, which is that if the Minister is right and rents change as a result, we will all be interested to learn that. If they do not, we will have learnt something about the market. If that is the case, that creates a question rather than just answering one: what is happening with the state of the housing market and what other levers are available to the state? It would be extraordinarily helpful to the country as a whole if the Minister would use his position in government to commend that set of questions to his colleagues, rather than stopping at that point.

My second point is in response to the comments made by the right reverend Prelate the Bishop of Ripon and Leeds, which concerned the broader effects, particularly on families with children. Many noble Lords will be aware that when the United States engaged in significant welfare reform, one fear expressed

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at the time was that many people would simply disappear from the system altogether. Research was undertaken and that proved to be the case. I have expressed concern at different points during the Bill's passage about what happens to vulnerable children, in particular, and, more broadly, to vulnerable families. Perhaps the Minister can take this opportunity to reassure the House that the Government will do all that they can to track what is happening to individuals so that they do not fall out of the notice of the authorities.

Baroness Grey-Thompson: My Lords, briefly, I commend the noble Lord, Lord Best, on his determination with the amendment and offer him my support. I will not repeat the words of the noble Lord, Lord Kirkwood of Kirkhope, but he is absolutely right when he talks about reassurance. It is so unfortunate at this stage of the Bill that many people who may find themselves in really difficult situations, perhaps through being in the wrong place, will be extremely disappointed that we cannot take this further. As we have read in the press yet again today, many disabled people are being portrayed as benefit scroungers. That causes me great concern as we make some of these changes. The review is vital if we are to ensure that our worst fears are not realised.

Lord McKenzie of Luton: My Lords, we support the Motion proposed by the noble Lord, Lord Best, and I, like others, thank him for the persistence, diligence, precision and passion with which he has pursued this subject from the start of our proceedings. I very much agree with the noble Lord, Lord Kirkwood, who said that this is no way to go about tackling issues of underoccupation; a much broader, more sophisticated approach is needed. It is a pity that we are stuck at this stage with, basically, having to live with what is in the Bill, subject to the review.

We have been told again that the amendment that we sent to the other place is an infringement of its financial privilege. It disdainfully clings to that financial privilege, which it could waive, without regard to the consequences for hundreds of thousands of households who will bear the financial burden of these cuts, in the same dismissive way that the Prime Minister today announced that the Bill would complete its parliamentary passage before noble Lords had even convened to consider it further. They brush aside our amendment, with its protection for families, notwithstanding that for some there are no smaller properties for them to move to; regardless of the fact that, for some, their disability involves them in additional costs which will be more difficult for them to meet and given their housing benefit reductions; and ignoring that many do not have a route to work to mitigate loss of benefit. The noble Lord, Lord Best, was absolutely right not to water down the amendment further and try to pick and choose which of those categories of individual is more deserving of escaping this iniquitous provision than the others.

Throughout the various stages of the Bill, we have sought to press on the Government the innate unfairness of the provisions concerning underoccupation. As we have heard, the arguments advanced have variously included the following. There is the appropriateness of

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adopting the CLG definition of underoccupation-a measure which provides sensible flexibility for households as family arrangements wax and wane, health conditions change, and young children grow older. There is the acceptance that only if there is suitable alternative smaller accommodation should families be expected to move, notwithstanding that that may be totally disruptive to their lives, and that meeting a housing benefit shortfall by getting a job or working more hours should not be insisted on where claimants are simply not able to work.

The losses in housing benefit a week, whether of £12, £13 or £14, cannot be borne without driving more households closer to or into poverty. Most are not sitting on substantial savings to cushion the loss of benefit; if they were, they would be ineligible for housing benefit in the first place. Moving to the private sector is likely to lead to increases in housing benefit costs for the Government rather than reductions. Taking in lodgers to contribute to the housing benefit shortfall will simply not be possible or desirable in many family circumstances. It is a false economy to force disabled people to move from a property which has been substantially adapted. To make it more difficult for those involved in foster caring makes no sense on many levels.

Your Lordships have supported those arguments, but they have been rejected by the Government in Committee, at Report and, now, at ping-pong. The only acknowledgement of the havoc, despair and poverty they will create is a £30 million annual top-up to discretionary housing benefit. Even that, as we heard from the noble Lord, Lord Best, is funded by an increase in the housing benefit reductions for all.

The Government know full well that these clauses will not solve the problem of underoccupation of social housing. They cynically do not want to solve it, otherwise their intended savings will simply not materialise. The offer they make is to move further afield, away from your community, support network, friends and jobs-not a sensible proposition, as we heard from my noble friend Lady Lister-to take a lodger, to use your savings or to earn more money. That is essentially a bogus offer, because most will simply not be able to take it up.

If we cannot persuade the Government, the least we can do is to have arrangements which will confront them with the consequences of what they implement. That is why we support the Motion tabled by the noble Lord, Lord Best, which requires an independent review of the consequences of Clauses 11 and 68. Of course, it will not be just that review which explains what is going on. Local authorities, councillors, MPs, and voluntary and community organisations-and, indeed, the courts-will get the blast from this in little over a year from now, as the cuts begin to bite.

We do not deny the need to tackle the deficit, nor that that means some hard choices, but it is genuinely difficult to understand why this contribution is sought in this way to this extent from this group of people. The alleged cost of our previous amendment, £100 million, is, when we think about it, just 20 per cent of one company's tax avoidance schemes.

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However, that is what both partners in government have chosen to do, and we have not been able to persuade them otherwise. We hope that an independent review will reinforce the points that we have made and still persuade the Government to a different view. If the review concludes otherwise, we can have no complaint.

This is not the end of the matter; it remains work in progress; but this debate marks the conclusion of our deliberations on the Bill, a Bill that we have been able to improve in some respects, but which, in too many ways, imposes unacceptable burdens on the most vulnerable. They are entitled to better from their Government.

Lord Freud: My Lords, let me start with two points. The first is that we plan to move ahead with these changes. The second is that I pick up the point made by my noble friend Lord Kirkwood. I heard very clearly what he said about housing strategy. On this measure, of the 3.3 million tenants living in the social rented sector and receiving housing benefit, only about one in five is expected to be affected by this change. Some will move to more suitably sized accommodation and will get support to do so. However, if social sector tenants choose to stay where they are and meet the shortfall through employment, we will offer them help in doing that. As noble Lords know, this measure applies only to working-age people. The substantial investment that we are making in the work programme and in universal credit will ensure that people are supported to find work and that work really will pay.

8.30 pm

We have already tripled our contribution to the discretionary housing payment budget to allow local authorities to give additional support where they consider it is needed. Perhaps I may answer the detailed questions of my noble friend Lord German on the £30 million extra for the discretionary housing payments fund. As he pointed out, that could assist around 40,000 cases. We estimate that within that number there are 35,000 potentially affected claimants who are also wheelchair users living in accommodation that is being significantly adapted to suit their needs. The other 5,000 are made up of foster carers and, in particular, those between assignments who would potentially be affected by the measure.

The amount that has been added to the discretionary housing pot will be kept under review to see whether it is meeting the level of demand in different areas. If my noble friend Lord Kirkwood would like to classify that as an implied correction, I would not quarrel with him. However, we think that the amount is right. Of course, there are other discretionary housing payments. In total, £90 million a year will be available from 2013-14, and local authorities can spend up to two and a half times their allocation with funds of their own. I know that many noble Lords will point out that local authorities are not exactly flush with funds but that is the technical position.

Clearly, this is a big change-I do not deny that. Effective communication and implementation will be vital and we have already started working with stakeholders on this. We will need to evaluate the measure. I confirm to the noble Baroness, Lady Sherlock, that I believe in

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research and do not necessarily need to know the answer before I read it. We will carry out research on this measure, once it has been introduced, to understand the effects of the changes, but I do not see the need to put that in the Bill.

As noble Lords will understand, I am not yet in a position to provide the full details of that research project, but I can commit to bring forward fuller proposals when the regulations are debated after Royal Assent. I shall also seek to involve the noble Lord, Lord Best. I join other noble Lords in paying tribute to him. I may not have agreed or been able to accept some of the things that he has said but he has said it with precision, knowledge and a genuine understanding that I have learnt from and appreciated. He may not have felt it but he has had an impact. As I said, I shall seek to involve him and other key stakeholders in developing the research proposals, the implementation strategy, and the draft guidance for local authorities and housing providers.

In his amendment, the noble Lord, Lord Best, sets out the groups for whom the impact of the measure should be assessed. I look forward to discussing with him the timing of any evaluation and those whom it covers. Without wanting to pre-empt that discussion, I expect the evaluation to look at the effect on different groups such as families, and any wider effects that it may have on-for example-homelessness. Clearly, vulnerable children are another area. Taking up the point of the noble Baroness, Lady Lister, we should look at social support networks as well, and I undertake to do so.

I close by reiterating that this measure is not about making people move. Rather, people living in the social rented sector, like those in the private sector, will have to make informed choices about where they live and what they can afford. Some may choose to move but for people who do not want to do so there are a number of options to help to meet the shortfall, and we have discussed those over the past months. They include the employment option, increasing working hours, asking others in the household or the extended family to contribute, or taking in a lodger. We have now done this to death and I close by asking the noble Lord to withdraw his Motion.

Lord Best: I am extremely grateful to all noble Lords who have spoken from all sides of the House, including the Bishops' Benches. I thank the noble Baroness, Lady Lister, who made the point that breaking up social networks by requiring people to move or face a penalty that they find very difficult is disruptive. Once it is known that a Member of your Lordships' House is involved in these things, we of course get targeted. One of the most moving e-mails that I received was from a woman who, with her husband, has two rooms and will, I am afraid to say, face a charge of £25 per week. Her husband is partially disabled and they live on a very meagre income. Her mother is a neighbour, living not very far away, and this lady provides a full caring service for her. She has looked into the possibility of moving elsewhere and she can move some miles away. However, she is not going to be able to get back to see her mother twice or three times

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a day. She cannot afford that £25 a week and is going to have to do something. These are the kinds of social network issues that are raised by this measure.

I am very grateful to the noble Lord, Lord German, who spelt out the need for milestones when one brings in new legislation of this kind. To the categories that we ought to look at, he added the disruption of education. Moving children to a different area and taking them out of school can set them back, and that can have life consequences.

I am grateful to the right reverend Prelate the Bishop of Ripon and Leeds, who has talked on children's issues eloquently throughout the Bill. From the intelligence on the ground, he is worried that the level of homelessness will increase, and that is certainly an issue that research would look at carefully.

The noble Lord, Lord Kirkwood, who has throughout on this and other aspects of the Bill been absolutely tireless, makes the point that rents may not go down, as the Government hope. I hope that the Minister does not get the blame when the housing benefit bill does not fall. For example, I received some new figures just this week which show how the number of claimants of housing benefit has gone up recently because of the effects on the economy, with more unemployment and more people having to claim housing benefit. That is not the Minister's fault and I hope that the Treasury does not hold it against him. The housing benefit bill is very hard to curb. The noble Lord, Lord Kirkwood, draws attention to these knock-on effects of everything that one does and calls for a much wider review, which sounds entirely sensible.

The noble Lord, Lord Boswell, to whom I am grateful, stressed the importance of housing more generally and the value of an independent evaluation of the kind that is proposed in this amendment.

The noble Baroness, Lady Sherlock, raised a point to which the Minister responded. I believe that he is genuinely interested in the outcome of an independent review, upon which good policy can be based.

The noble Baroness, Lady Grey-Thompson, highlighted-quite rightly, as it probably has not had quite enough attention in this debate tonight-the fact that very many disabled people are in the accommodation that we are talking about, with fixed incomes and no opportunity to go out to work. They will be particularly badly hit and we must look carefully at that.

The noble Lord, Lord McKenzie, having followed this every inch of the way and to whom I am extremely grateful for his support, made the point that the long list of potential escape routes, such as taking in a lodger or using up one's savings, are not really viable alternatives to having to move or pay out. He concluded that this was going to place unacceptable burdens on the most vulnerable.

I am extremely grateful to the Minister for accepting the necessity for an evaluation and for committing himself to bringing forward full-scale proposals when the regulations come to us. The noble Lord, Lord Kirkwood, made the point that when regulations come before us, we have another chance to look at these matters; we even have a chance to vote on them, and we are able to hold the Minister to account on this.

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I think we will be pleased with what is brought forward, not least because he also committed himself to full consultation on this research project with the stakeholders concerned; to consulting, discussing and working with the stakeholders, including myself, the subsequent action-the strategy and the guidance-that follows from this.

Therefore, I must be satisfied with the Minister's response. He will, he said, be keeping under review the very key ingredient: the level of discretionary housing payments with which local authorities are provided to top up and help people who are in difficult circumstances. I do not think local authorities are going to be very keen to bail out the Government on this one and make up the deficit themselves, but if the Treasury finds, as a result of the research that we do, that there are sufficient hard-luck stories where one cannot really resist having to pay out more housing benefit, the discretionary housing benefit will be one lifeline which could be substantially influenced by research, when it comes along.

At the end of what seems to have been a very long innings on all of this, I thank the Minister for his response and for the courtesy and good humour with which he has approached all aspects of this Bill; I am grateful to him in all those respects. I beg leave to withdraw the amendment.

Motion A1, as an amendment to Motion A, withdrawn.

Motion A agreed.

8.42 pm

Sitting suspended.

Health and Social Care Bill

Report (4th Day) (Continued)

8.45 pm

Clause 51 : Secretary of State's duty to keep health service functions under review

Amendment 141

Moved by Baroness Cumberlege

141: Clause 51, page 83, line 26, at end insert "and its Healthwatch England committee"

Baroness Cumberlege: My Lords, this is a very simple and non-controversial amendment. Under Clause 51, the Secretary of State has a duty to keep under review the effectiveness of key bodies in the NHS. This is a crucial part of the Secretary of State's responsibilities in ensuring that he or she can exercise ministerial accountability for the health service. As this is a new body, through the Secretary of State, we will want to ensure that it is to carry out its functions effectively. Healthwatch England has to undertake certain tasks-for example, making annual reports to be laid before Parliament. Other reports will be at its discretion. These activities will be easy to monitor, but it will be

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much more difficult to assess the quality and the appropriateness of the advice and information or other assistance it chooses to give.

In her letter to noble Lords on 21 December, my noble friend Lady Northover told us that she did not expect Healthwatch England to give the CQC, the NHS Commissioning Board or other bodies an easy ride. She went on to state:

"We fully expect HealthWatch England to raise what at times may be awkward, difficult questions with respect to health ... and to be able to do this publicly".

It is the Government's intention to create not a patsy organisation but one that will be a champion of health and, on occasions, a difficult and awkward companion, focused on improving the quality of care in both health and social services. If it does not, it will not fully represent the voice of patients and service users.

The Care Quality Commission is one body listed in the clause. As the Bill stands, HealthWatch England will be a committee of the CQC. However, as we have discussed in many debates on the Bill-and I believe that more are to come when we come to debate the amendment of the noble Lord, Lord Patel-there will be a need for it to remain operationally independent of the Care Quality Commission. Therefore, I suggest that a review of the Care Quality Commission may not be an appropriate way of fully scrutinising the role of HealthWatch England, and that such scrutiny should be included in its own right in the clause.

That is why I tabled an amendment to add HealthWatch England to the list of bodies that the Secretary of State must keep under review. It would make it clear that HealthWatch England is independently accountable for how effectively it goes about its work, and cannot be overshadowed by-or hide behind-the review of the role of the CQC. I hope that my noble friend will look kindly on this simple and not very earth-shattering amendment. I beg to move.

Lord Harris of Haringey: My Lords, I seek clarification on the amendment. I am sure that the noble Baroness, Lady Cumberlege, means well, but I note that the formulation she used was,

I am sure that it would have been possible to draft the amendment so that it referred simply to HealthWatch England, which would have avoided raising the question that we will come to at a later stage of whether HealthWatch England should be part of the CQC or any other august structure of the NHS. It is an important technical point; I hope that the amendment does not pre-empt any later discussions.

The motivation that the noble Baroness ascribed to the amendment-to demonstrate that HealthWatch England is independently accountable-is extremely important. It is entirely proper that HealthWatch England should be seen to be accountable to the Secretary of State. Certainly it should not exercise that accountability through another body, particularly one which it might on occasions wish to criticise, or about which it might want to raise important concerns or say that it has not done what it might have. Therefore, to demonstrate that HealthWatch England is independently accountable

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is an important objective. My concern is that the amendment may solidify something that at the moment comes later in the Bill, but which I trust will not remain there by the time we have finished Report: namely, the requirement that HealthWatch England is simply a committee of the CQC.

There is also a question about how accountability will work with respect to the Secretary of State. I suspect that the quotation from the noble Baroness, Lady Northover, to which the noble Baroness, Lady Cumberlege, so approvingly referred, about how difficult and painful would be some of the discussions with HealthWatch England, will sometimes apply also to the Secretary of State. When I was for a number of years director of the Association of Community Health Councils, I collected personal denunciations that I had received from successive Secretaries of State. They came from both parties: indeed, the most vehement denunciation was from a Secretary of State from my own party, who perhaps expected more from me than the criticisms that I had raised.

The point is that this will not be an easy relationship. Even the accountability that is envisaged by the reference to "keeping under review" will, I suspect, lead to tensions. However, I do not believe that one can have a body of this nature that is not accountable in some way to the Secretary of State. I simply look forward to the maturity of future Secretaries of State, of whatever party, who will recognise that a body such as HealthWatch England, and local healthwatch organisations, are intended sometimes to be irritants.

Baroness Wheeler: My Lords, I would have liked to debate this amendment in the light of next week's debate on the status, powers and functions of HealthWatch England under Clause 180, when we will fully air once again the serious and continuing concerns across the House about the proposed relationship between HealthWatch England and the CQC, and hear from the Minister how the Government intend to address these concerns as they flesh out their proposals for healthwatch, and as the CQC comes under closer scrutiny. However, we support this amendment requiring the Secretary of State to include HealthWatch England in the organisations specified in the Bill that he or she must keep under review. Obviously we do this in the context of the separate independence of HealthWatch and not as a committee of the CQC.

However, it is also important to make it clear that we do not think that the measure in itself, or combined with other government proposals, for example, on the HealthWatch board membership, will be anywhere near enough to provide the independence that HealthWatch England needs if it is to be the robust and trusted patients' watchdog that is needed-and I emphasise trusted by the public.

The Minister must appreciate that the concerns across the House over the CQC's relationship are not addressed by referring to the close synergies between the two organisations or to the powers and influence of the CQC rubbing off on HealthWatch. In this context it is difficult not to dwell on the recent developments in the commission and the Department of Health performance and capability review of the commission. I say this as a genuine supporter of the CQC and its

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work-for example, last year's excellent special review of stroke services, and the one of residential care-but the department's major findings that the CQC needs to be more strategic, that accountabilities within the CQC are unclear, as well as the strong concern over the blurring of boundaries between the CQC board and executive team, do not augur well for the future relationship between the CQC and HealthWatch.

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