We are told that it is not up to Parliament to redefine marriage. This demonstrates ignorance of our constitutional arrangements and of our history. Parliament can redefine marriage and, as we have heard, Parliament has redefined marriage. It has done so frequently since the Marriage Act 1541, as illustrated by the noble Lord, Lord Pannick. Indeed, as we have heard, that is just as well, otherwise we should still be treating marriage as the transfer of the property of the woman from the father to the husband.

4 Jun 2013 : Column 1096

What are the grounds for saying that Parliament should not exercise its rights to extend the provision of marriage? It is claimed that permitting same-sex marriage devalues marriage. That is not an argument but rather an assertion of moral superiority. It rests in good measure on a rewriting of history—a point well made by the noble Baroness, Lady Neuberger, and indeed the noble Viscount, Lord Colville of Culross—and on biblical text. The Bible has been used to justify all sorts of discrimination that we now regard as morally abhorrent. As the right reverend Prelate the Bishop of Salisbury has noted, the text of the Bible has not changed, but our understanding has. In every sphere of life we are constantly learning, except, apparently, in this one respect, where we cling to a view held 4,000 years ago.

Much of the debate has been conducted as if we were the first nation contemplating the introduction of same-sex marriage. We can learn from what has happened elsewhere. Most of the nations that permit same-sex marriage are signatories to the European Convention on Human Rights. Their churches have not been forced to do anything by the European Court of Human Rights that they do not wish to do. We have heard assertions in this debate that the introduction of same-sex marriage has led to a decline in heterosexual marriage. I have the figures here, which are readily available in the briefing paper produced by the House of Commons Library. Some countries have seen a decline in traditional marriage, notably Portugal and Spain, but in Portugal that was happening before the introduction of same-sex marriage. In Belgium the figures for traditional marriages went up, not down. A study of the Netherlands found that trends in marriage and divorce did not change. In nations where it has been introduced, support for same-sex marriage has increased, and none of the dire consequences predicted as a result of the passage of this Bill appear to have been experienced. Of course, if anyone can show otherwise, they can bring it up in Committee.

The noble Lord, Lord Brennan, said, “What next?” Well, nothing, unless we will it. Things will not happen unless Parliament decides that something should happen. That is a key point. Nothing is suddenly going to translate from this action unless Parliament wants any further action to be taken. It is in our gift.

I end with the words of Paul Parker of the Quakers in Britain:

“For us marriage is not a mere civil contract, but a religious act. While we don’t seek to impose this on anyone, for us this is an issue of religious freedom”.

The principled case for supporting the Bill is, to my mind, compelling.

5.36 pm

Lord Forsyth of Drumlean: My Lords, I will speak very briefly in the gap, of which I have given notice. I think I am entitled to four minutes, which is the time people in the other place—the elected Members—had to talk on a matter of this importance.

I am usually at one with my noble friend Lord Norton of Louth, but when he says that it is up to us to decide I say no, it is not. We can make laws, but they have to carry consent. Next week it will be 30 years since I was first elected to the other place. I have never known a measure—not even the poll tax—that has

4 Jun 2013 : Column 1097

produced such division and concern on both sides of the argument. It is important that we take account of that. What worries me about the Bill is the speed with which it has been whisked through the House of Commons and is now being whisked through here. I am told that we are going to be allowed two days in Committee. As the noble Lord, Lord Brennan, pointed out, the Civil Partnership Bill had far more than that—I think it had five days in Committee. The idea that we can deal with a matter of this importance in two days in Committee when we have had two days on Second Reading is ridiculous. What is the haste? What is forcing the pace of this matter?

On the letters and e-mails we have had, I acknowledge that some people who have written have used quite offensive terms. One of the qualities of the debate that we have had so far in this House has been the civilised and respectful way in which we have listened to the arguments. I would have preferred the House of Commons to have dealt with this matter in the normal way, as we have done on other controversial issues: a Private Member’s Bill, with the Government providing time, and with a Committee of the whole House. Instead, we had a Committee which was stacked and a guillotine—and, by the way, we had a manifesto commitment to end the automatic timetabling of Bills. This Bill, above all others, should not have been subject to a timetable Motion.

In this House we are now faced with the question which I want to address. I will be supporting the amendment in the name of the noble Lord, Lord Dear, because the House of Commons needs to think again. It needs to produce a White Paper or a Green Paper, and the public need to be involved in this discussion so that it carries consent. At the end of the day, consent is the most important thing. Listening to the debate in this House, and to the right reverend Prelate, I believe that consensus can be achieved, but the Bill is no way to achieve it.

The Bill was certainly not a manifesto commitment. My noble friend says that it does not matter. Yes, it does. If it had been, it would have been quite wrong for us to vote for the amendment in the name of the noble Lord, Lord Dear. This House is entitled to vote for the noble Lord’s amendment because the House of Commons has not had an opportunity properly to consider it, and indeed, the Bill would not have come to this place had a deal not been done by the Labour Front Bench with the Government to support the Bill in return for a commitment to consider whether civil partnerships should be extended to heterosexual couples. That is a very important measure that could be taken, but we are told that it is very complicated, it will take a very long time, and they need that time. This is very complicated as well. We are entitled to vote for the amendment in the name of the noble Lord, Lord Dear, and I shall do so, because the process by which this Bill has been handled is inappropriate, and has left the country divided, bewildered and puzzled by something that has come out of a blue sky. That is not a proper way in which to make such a major social reform.

5.40 pm

Baroness Neville-Jones: My Lords, I have also given notice that I wish to speak in the gap and gave notice, and shall do so briefly in view of the length of the

4 Jun 2013 : Column 1098

debate. I did not put my name down at the beginning, because frankly I did not know what I thought about this difficult legislation. I still have great difficulty with this Bill, though I have greatly benefited from the extraordinary quality of the debate.

Marriage is certainly much more than a wedding. As the noble Baroness, Lady O’Loan, pointed out, it has huge ramifications that have not been explored. How could they have been explored in the other place, given the bulldozer that applied? I entirely agree with what my noble friend has just said about the process to which this important legislation has been subjected. I come, however, to a different conclusion about what this House should do about it.

It would not be wise for us to reject this legislation at Second Reading. We have a duty and the right to take it through Committee. That is our function. I beg the Front Bench and the usual channels to afford us more than two days in Committee. If we reject the Bill now, it is a perversion of the function of this House, so I hope and expect that there will be more days available for discussion, given the extraordinary ramifications of this legislation. We need to know that the safeguards that have been claimed are robust. We need to know that the sorts of issues that have been raised can be pinned down and that we have definitions. We may call this thing marriage, but there will be two different categories, and we have to be clear about what the legal position is. I do not support the Bill as it stands, but I will not oppose it going to Committee.

5.42 pm

Baroness Thornton: My Lords, I am pleased to be here and that I heard the noble Lord, Lord Forsyth, coming over the hill as cavalry in aid of the noble Lord, Lord Dear. It is an honour to give the opposition winding speech on this Second Reading debate in your Lordships’ House. I am not envious of the task that the Minister has in answering the substantial and passionate debate that we have had for the past two days. My noble friend Lady Royall outlined most eloquently in her opening remarks the reasons why Labour is supporting this Bill and the Government, but as in the Commons there will be a free vote. I shall not repeat all of her arguments.

When we are contemplating something new, I always think that international comparisons are helpful. Last month this House supported making caste discrimination part of our legislative equality framework. In doing this, and persuading the Government and the Commons that it was the right thing to do, we were blazing an international trail of which we should be proud. Today, we are not being so adventurous, because we are proposing that the UK will soon join those countries that have now signed same-sex marriage into law. They are Argentina, Belgium, Canada, Denmark, Iceland, the Netherlands, Portugal, Norway, Spain, South Africa, Sweden, Uruguay and now France.

I offer my congratulations to Vincent Autin and Bruno Boileau on their marriage last week. It was historic for being the first same-sex marriage to take place in France following President Hollande’s signing of the legislation into law. First and foremost, it was a momentous day for this couple, who on that day made

4 Jun 2013 : Column 1099

a loving and lifelong commitment to one another before their friends and family, just as I and many in this House have done over the years.

The objections to the Bill to bring same-sex marriage on to the statute book seem to fall into two or three categories. There are noble Lords who are uncertain that freedom of religion will be respected by the Bill. To them I say that the Government have built huge safeguards into the Bill, which, it is widely agreed, will do the job. The most reverend Primate and the right reverend Prelates who have spoken have woven brilliant theology and arguments against the principle of same-sex marriage, but as the noble Baroness, Lady Neuberger, my noble friend Lady Mallalieu and others have said, the state’s concept of marriage has been ever-evolving. It has long since diverged from religious teaching. They have not managed to unpick the locks, so to speak.

While lawyers can always find something to disagree about, I would encourage those noble Lords to read back the speeches of the noble Lord, Lord Pannick, and my noble friend Lady Kennedy of The Shaws, who have explained the strong assurances that legal security is provided by the Bill. Some concerns have been raised by noble Lords about the position of teachers and faith schools in reconciling their views of marriage with the new reality. My party is confident that the current law achieves the right balance in securing the right of faith schools to educate pupils in a way that is sensitive to the law of the land and also to students, some of whom may be gay or have parents of the same sex. I may never use these words again, but I agree with the evidence that Michael Gove gave to the scrutiny Committee stage in the Commons. However, it is right that these issues will be tested and scrutinised by this House in Committee, because it is right that these questions and concerns are allayed.

There are those who say that the Bill is in some ways anti-democratic, that it was not in manifestos, that there was no Green Paper—and, they add, let us rubbish the consultation—and they ask why it was not a Private Member’s Bill. The noble Lords, Lord Norton and Lord Kerr, covered the constitutional points, and I agree with their analysis. We have to look at the strength of feeling in favour of the Bill in the Commons. It is remarkable that the majorities at Second Reading and Third Reading were so large. It may serve the opponents’ purpose to suggest that some kind of secret Whip was applied, but I am with the noble Lords, Lord Cope and Lord Bates, about the whippability of such an issue.

Many MPs thought very hard about the Bill and had serious discussions with constituents before deciding how to vote, but each MP made a decision alone about whether to support it, and so must we. Rarely as parliamentarians do we have the opportunity, by the words that we use and the votes that we cast today, to affirm the equal respect that we have for our fellow citizens regardless of their sexuality and the equal respect that we have for their long-term and loving relationships.

We have also had a bit of scaremongering. Scaremongering to further an argument in which you passionately believe is a legitimate debating ploy, but

4 Jun 2013 : Column 1100

noble Lords are wise and experienced enough to recognise scaremongering when they see it. We can safely say that the noble Lord, Lord Tebbit, won the award for this one. In a short and sharp intervention, he managed with his usual skill to provide a scare for almost everything, including compulsory promotion of homosexual marriage and artificial insemination of the heir to the throne.

Lord Tebbit: Clearly, the noble Baroness has the answer to all questions and is going to tell me the answer to the question that I asked about the heir to the throne.

Baroness Thornton: Yes, goal. I am happy to say that it is the Minister who answers the questions here.

The noble Lord, Lord Dear, also did quite well in the old scaremongering field when he said that some 8,000 amendments might be required by this legislation. I thought that that was remarkable and checked whether it is true. I am pleased to reassure the House that this seems not to be the case. The noble Lord seems to have confused the fact that there are indeed 8,000 references to marriage within the total library of legislation, without the need to amend them all. Furthermore, it is clear from discussion with the Bill team and reading the Bill that Clause 11 and Schedule 4 deal more than adequately with his concerns. I am sure that the Bill team will be happy to explain this to the noble Lord in due course.

Other noble Lords feel uncomfortable with what they see as a departure from traditional marriage. I do not doubt that this is how they feel, but I ask them to reflect a little deeper on those feelings. Is it habit and familiarity that make change uncomfortable and unsettling? This was referred to by the noble Baroness, Lady Jenkin. The Minister noted that we all move at a different pace when faced with change. As the noble Lord, Lord Deben, put it so eloquently, major social changes do not happen when the majority align themselves; they have almost always happened when a minority has stood up for what it believes to be right, put it to the public and in the end proved that it is right.

Unfortunately, some who profess to believe in equal rights for everyone, regardless of gender, race and sexual orientation, find it difficult fully to escape prejudices ingrained over many years when homosexuality was said to be at worst an abomination, or at least something to be very quiet and discreet about because it bordered on the shameful. To noble Lords who are finding the idea of same-sex marriage difficult to come to terms with, I make a plea that they should listen to their heart and indulge their generosity of spirit. Having heard the deeply personal speeches of the noble Lords, Lord Browne and Lord Smith, my noble friends Lord Alli and Lord Collins, the noble Lord, Lord Black of Brentwood, the noble Baroness, Lady Barker, and the noble Lord, Lord Carlile, it would be hard not to be moved—and it would be very hard-hearted not to support same-sex marriage.

The noble Lord, Lord Faulks, asked me a direct question: would my Government have brought in this legislation? Given that we brought forward all the

4 Jun 2013 : Column 1101

equalities legislation between 1997 and 2010, and given the presence of my noble friend Lord Alli over my shoulder, how could I say otherwise? It is the personal testimony not just of noble Lords who have faced discrimination and struggle because of their same-sex relationships, but of all noble Lords who have spoken of the love and strength they have found through their partners, civil partners, husbands and wives, that should secure our resolve to reject the amendment of the noble Lord, Lord Dear, and proceed with the Bill. I speak of my noble friends Lady Royall, Lord Brooke of Alverthorpe, Lord Young of Norwood Green and many others.

For many, marriage is the glue—my noble friend Lady Mallalieu called it the superglue—that binds together relationships and gives those in them the strength to face life’s challenges. To have the opportunity to extend this privilege to all couples who want to make that commitment is something that we must now embrace and celebrate as a means to a stronger and more loving society.

I look forward to the Bill receiving a Second Reading today and to getting on with the Committee stage, where I hope we will make progress with many of the issues raised by my colleagues and by noble Lords across the House. We on these Benches will look at pension rights, transgender couples, about which my noble friend Lady Gould spoke so passionately, and humanist marriages, which were referred to by the noble Lord, Lord Birt, and which we are keen to see introduced. Therefore, I urge the House to vote against the amendment of the noble Lord, Lord Dear, and to see the Bill through to its next stage. For the sake of clarity, if noble Lords support the continued passage of the Bill, the Lobby to go into is the Not-Content, and I look forward to seeing many of them there.

5.53 pm

Baroness Stowell of Beeston: My Lords, I am grateful to all noble Lords who have spoken in the debate, and to the noble Baroness, Lady Thornton, for her support. We have had a comprehensive debate that has shown how this House takes its role seriously and is able to deal with controversial and sensitive issues in a measured way that respects differing views. What has come across strongly is that those who support the Bill and those who oppose it essentially agree on one crucial matter: the importance of marriage. We all agree that marriage is a cornerstone of our society that provides stability and brings families and communities together.

It will not be possible for me to refer to all noble Lords who have spoken in the debate, or to respond to all the points raised. I hope that noble Lords will forgive me for that. However, some key themes have emerged, and I will deal with those. A number of noble Lords, particularly the noble Lord, Lord Dear, questioned whether the process that had been followed for the Bill was right. My party was clear about its wish to consider the case of same-sex marriage in A Contract for Equalities, published alongside our election manifesto. The coalition agreement set out the Government’s commitment to push for,

“unequivocal support for gay rights”.

We have conducted the process of developing our proposals in a completely transparent way. We carried out the country’s largest ever public consultation, and

4 Jun 2013 : Column 1102

every response and petition was accounted for and considered with the utmost care. I say to noble Lords who raised questions about petitions that these were not ignored. They were all treated equally, commented on and flagged in the Government’s response to the consultation.

Some noble Lords questioned whether the Bill had had proper scrutiny in the other place. Convention tells us that it is not for this House to comment on how the other House conducts its business. However, it is worth noting that the Committee stage there was completed with half a day to spare. The Bill had two days of debate on Report on the Floor of the House, and was passed by a majority of two to one at Second and Third Readings. As many noble Lords argued, it is now for this House to scrutinise the Bill in detail.

Moving on from process, some noble Lords queried the robustness of the religious protections, including the quadruple lock, whereby no religious organisation or individual minister can be compelled to conduct a same-sex marriage; all will be free to refuse to do so. I say, first, that I am very grateful to the most reverend Primate and the right reverend Prelate the Bishop of Leicester for their acknowledgement of the work that the Government have done to ensure that the religious protections in the Bill are effective. The noble Lord, Lord Pannick, and the noble Baroness, Lady Kennedy, were very clear in their contributions about their view of the robustness of these religious protections. However, it is only right, because in my opening remarks I did not address some of the specific points that were raised by noble Lords in debate, that I should now do so.

The concern was raised that the European Court of Human Rights might order the Government to require religious organisations to marry same-sex couples according to their rites, in opposition to their religious doctrines. To suggest that this could happen is to rely on a combination of three highly improbable conclusions. First, the court would need to go against its own clear precedent that states are not required by the European Convention on Human Rights to provide marriage for same-sex couples, and that they have a wide discretion in this area. Secondly, the court would need to decide that the interests of a same-sex couple who wanted a particular religious organisation to marry them according to their rites outweighed the rights and beliefs of an entire faith and its members as a whole. Thirdly, the court would need to discount the importance of Article 9 of its own convention, which guarantees freedom of thought, conscience and religion. It would be rewriting the rules not just for one religious organisation in England and Wales but for all religious organisations in all 47 states of the Council of Europe.

Some noble Lords raised concerns that the Bill does not deliver equality. Indeed, they suggested that it creates new inequalities and argued that it redefines marriage because same-sex couples cannot procreate. I will return to the definition of marriage after dealing with some of the specific examples that were raised in this part of our discussion. The current definition of adultery has been developed in case law and does not cover relations between members of the same sex. At present, a married man who has a sexual relationship

4 Jun 2013 : Column 1103

with another man is not committing adultery. That would be the case only if he had sexual intercourse outside marriage with a woman. The Bill retains this definition. Like existing marriages, a same-sex marriage can be ended by divorce on the grounds of unreasonable behaviour in such circumstances.

As for consummation, that is not necessary for any marriage to be lawful and indeed not possible in some, which is why we allow for death-bed marriages. As consummation is a historical definition associated with procreation, it would not make sense to extend this concept to same-sex marriages and there is no need to do so. If for no other reason, the opportunity for noble Lords to debate these sorts of things in greater detail is a good reason for this Bill to get more scrutiny. I am sure that they will not be able to resist debating all this in great detail.

The noble Lord, Lord Tebbit, asked about the law of succession and its interaction with the Bill, and in particular whether a monarch in a same-sex marriage could succeed to the throne and whether his or her child, or the child of his or her partner, could succeed. The answer is that the Bill does not change anything in relation to the law of succession. Only the natural-born child of a husband and wife is entitled to succeed to the throne—not adopted children, children born as a result of artificial insemination or children born to only one party to a relationship. That is the position now and it will remain the case.

Lord Tebbit: Is that not discriminatory?

Baroness Stowell of Beeston: It is discriminatory now and we are not changing anything.

Some noble Lords expressed concern about the Bill’s impact on freedom of expression and freedom of conscience. Particular reference was made to whether teachers would be forced to promote same-sex marriage and be dismissed if they criticise it, whether employees will be barred from criticising same-sex marriage and whether registrars will have any choice but to conduct such marriages.

The position of teachers has been the subject of a lot of debate and scrutiny already in the other House. My right honourable friend Michael Gove, the Secretary of State for Education, who would like to think that he has the word “standards” stamped through him like a stick of rock, was clear in the evidence that he gave to the Public Bill Committee that there is a significant difference between a teacher explaining an issue and promoting or endorsing it. No teacher will be forced to promote or endorse same-sex marriage. Any teacher will continue to be able to state their own belief or that of their faith about same-sex marriage. However, teachers and schools will be expected to make clear as a matter of fact in teaching about marriage that the law in England and Wales enables same-sex couples to marry.

We do not consider that the Bill changes anything in this area and we are clear that the existing protections for teachers are sound. As I said yesterday, though, we are continuing to listen to, and discuss these concerns with, religious groups and others to ensure that we have done all we can to make those protections clear.

4 Jun 2013 : Column 1104

As for changing the Bill to ensure that employees cannot be dismissed or disciplined for criticising same-sex marriage, we do not consider that there is any need to do so. Indeed, there could be harm in making such an amendment by raising doubt in other areas, such as criticising homosexuality or civil partnerships. It is lawful to express a belief that marriage should be between a man and a woman, and it is lawful to do that whether at work or outside work. That is a belief that is protected under the religion or belief provisions of the Equality Act 2010, and penalising someone because of such a belief would be unlawful discrimination under that Act. This will still be the position once the Bill is enacted.

None the less, we have been considering what steps we can take to ensure that employers, and particularly public bodies, are completely clear about their responsibilities to respect the rights of people who believe that marriage should be between a man and a woman. With that in mind, the Equality and Human Rights Commission will be reviewing relevant guidance and statutory codes of practice to ensure that the position is completely clear.

On registrars, the Government remain of the view that public servants with statutory duties should not be able to exempt themselves from providing their services for same-sex couples.

Regarding the Government’s position on this important issue of same-sex marriage, at the moment those of us who love someone of the opposite sex can get married, and those of us who love someone of the same sex can be civilly partnered. In legal terms, there is little difference except in the way they are formed and the way they can be dissolved if that sadly becomes necessary. Yesterday I explained why marriage is important to us as a society. Others referred to it as a social good. We all agreed that the institution, the enterprise, the endeavour or whichever word we think best to describe it is a good thing, and that it is important. Some noble Lords, including the right reverend Prelates on the Bishops’ Bench, my noble friend Lady Cumberlege and others, have suggested that gay couples should have their own institution separate from marriage. My noble and learned friend Lord Mackay of Clashfern repeated that today, and made clear that he believes so on the grounds of procreation.

On the question of a separate institution, gay men and women already have their own institution called civil partnership. Like the Bill, the arrival of civil partnerships was a huge change. Unlike the Bill, which has 19 clauses, the Civil Partnership Act had 200 clauses and was contested strongly in debate in your Lordships’ House. After it was finally passed, same-sex couples had access to equal legal rights but they remained different. Marriage remained the preserve of couples made up of one man and one woman. It is the success of civil partnerships that has driven greater acceptance of same-sex couples. In an amazingly short space of time we hear people, including those who used to oppose them, say, “We can’t believe we were all so concerned at the time”. Civil partnerships have led many people—indeed, the majority—to say, “Do you know what? If civil partnership is marriage in all but name, why can’t gay men and lesbian women get married, if that’s what they want to do?”.

4 Jun 2013 : Column 1105

Another institution just for gay couples, as suggested by several noble Lords, is not going to make the demand for them to be able to get married go away. Another institution just for gay couples will not address the fundamental purposes at the heart of this Bill: the acceptance of gay, lesbian, bisexual and transgender people for who they are, and the preservation of marriage itself as a vital institution to our society.

In his powerful contribution, my noble friend Lord Black said that legislation drives social change, and up to now the Civil Partnership Act has been the best example of that. As some noble Lords pointed out during the debate, positive social change, when it favours minority groups, is not by definition about numbers. In 2010 the Government made a commitment to push forward unequivocally for gay rights in the coalition agreement. The fact that three years later we are legislating for same-sex marriage reflects the accelerating acceptance of same-sex couples and the possibility that change is possible.

The Bill does not change the religious doctrine or beliefs of any religious organisation that does not want to change them. The Bill protects and promotes religious freedom. Outside of religion, though, gay couples want to marry and many straight couples want them to be able to. The majority of people are ready to open the door to marriage and to welcome those who want to commit publicly to their partner, because they see that they want to do so for all the same reasons as them.

The right reverend Prelate the Bishop of Leicester asked yesterday,

“Do the gains of meeting the need of many LGBT people for the dignity and equality that identifying their partnerships as marriage gives outweigh the loss entailed as society moves away from a clear understanding of marriage as a desirable setting within which children are conceived and raised?”.—[Official Report, 3/6/13; col. 962.]

That may be a legitimate question for the church to ask itself when or if it ever considers whether to allow same-sex couples to marry. However, I would argue that, outside the church, people already understand that two gay men or two lesbian women marrying each other is the same as a man marrying a woman. They have accepted that it is okay for same-sex couples to marry and that them doing so will not redefine their own marriage, because they understand that gay men and women decide to enter a civil partnership for the same reason that a straight couple decide to marry. Same sex couples and opposite sex couples are different physically, but that which leads them to want the same is not different.

I urge this House to ensure that the protections that allow the church and other faiths to maintain their very legitimate belief in marriage being only between a man and a woman work properly. This House should also debate and scrutinise whether the Bill protects freedom of speech and freedom of expression; that is what we really need to ensure is the case. We need religious belief in marriage to sit comfortably alongside what the state allows in law, just as we already do for divorce, contraception and abortion. It is possible for us to allow something in law that not everyone agrees with and to respect our differences of view. The Bill, which allows same sex couples to marry, is, as I said

4 Jun 2013 : Column 1106

at the very start of the debate yesterday, also about protecting and promoting religious freedom. I say again that, if further changes are necessary to make those protections clearer, the Government will consider doing so.

There have been many powerful speeches but I hope that noble Lords will forgive me, and that my noble friend Lord Jenkin will not be embarrassed, if I say that I thought that his was one of the best. He said better than I ever could that this Bill will not redefine marriage because it will not redefine his own of 60 years, which has provided mutual comfort and support.

Over the past two days, we have heard lots of views about what marriage means and we have all expressed ourselves differently, but we all unite on three points of principle: marriage is a serious commitment between two people; we think that the institution itself is vital to our society; and we respect and must protect religious freedom and freedom of speech. The Bill supports all three principles. I hope that your Lordships’ House, building on its tradition of supporting social change, will wish to affirm that the Bill should have its Second Reading here. I urge noble Lords who support the Bill, and those who remain unsure and so want it to be scrutinised in detail before they decide, not to accept the amendment moved by the noble Lord, Lord Dear. If the noble Lord calls a Division, I urge all noble Lords to vote not content.

The Marquess of Lothian: There was a long discussion about the vote in the House of Commons being an all-party vote. I spent nearly 37 years there, and I know what is euphemistically called an all-party vote. I want my noble friend to assure the House tonight that when we are having a free vote in this House, it will be a genuinely free vote so far as the Conservative Members of this House are concerned, including Front-Bench Members.

Baroness Stowell of Beeston: Of course. I am pleased to confirm that to my noble friend.

6.13 pm

Lord Dear: My Lords, this has been a long and tiring debate, and one that has been a privilege in which to participate. I thank all Members of your Lordships’ House who have spoken, and in particular those who have offered such steadfast support to me, both before and during the debate. I am very grateful. As has just been confirmed, this is a free vote, and Peers across the House have supported my amendment. All of them recognise that it should not be a matter for party politics but a matter of principle.

It is interesting how in the course of this fascinating debate, over two days, the thrust of the debate, or the tide for and against, flowed backwards and forwards. Last night, the first half of that session was more or less in balance, while the second half of last night was discernibly running in my favour, as it were, and today the tide has turned and is running the other way. I make no criticism of that; it is the random way in which the speakers list is put together. Certainly, all of us agree that this is an issue of profound interest and importance and one that will affect every member of

4 Jun 2013 : Column 1107

our society. We cannot escape the fact that the Bill will completely alter the concept of marriage as we know it. The most reverend Primate the Archbishop of Canterbury and the right reverend Prelates, the Bishop of Leicester, the Bishop of Chester and the Bishop of Exeter, the noble and right reverend Lord, Lord Carey of Clifton, and the noble Lord, Lord Singh of Wimbledon, all explained their opposition to the Bill and the detailed practical and theological reasons that underpin their stance.

In the debate over the past two days, it appears to be an accepted fact that the process of the Bill was seriously and unusually flawed. Nobody has really challenged those facts, and I comment very briefly on them because they have been repeated several times already. It is useful to remember that there was no proper consultation or Green or White Paper. There was no manifesto or pre-legislative scrutiny. The Government consultation procedure was, frankly, a mockery, and the result was rigged, because whichever way you look at it the vote was 83% against the Bill. It was heavily constrained in its passage through the House of Commons, with some serious doubts about the process.

Here in your Lordships’ House our debate strangely never came to real grips with the consequences of the Bill should it become law. There was very little examination or comment about the major issues of employment, education, freedom of conscience or the rights and well-being of children, save the one intervention that I noted from the noble Lord, Lord Eden of Winton. Neither was very much time spent on the inevitable impact on the existing legal framework. All we knew for sure was that the Government had admitted that the impact on existing legislation would require at least 8,000 amendments. The noble Baroness, Lady Thornton, has just tried to put that into context.

I hope noble Lords will agree with my very unusual procedure of quoting five lines from my opening remarks yesterday, which can be found in col. 947 of Hansard. I reflected on the fact that the last country to change the law as we seek to do was Argentina, two years ago, and the results are just becoming apparent. A valued commentator in that country said this:

“It quickly became clear that legalising same-sex marriage required a revolution to our internal law. It impacted laws regulating public order, identity, gender, rules of kinship, filiation, marriage, names, marital property arrangements, divorce, alimony, parental rights, succession, domestic violence, adoption, artificial reproductive techniques, surrogate motherhood, liberty of conscience, criminal law, tax law and employment law, among other topics”.—[Official Report, 3/6/13; col. 947.]

Whether there are 8,000 or 800 amendments, that is the sort of change that we must expect as a result of the change in this law.

The major part of the debate that we have had here focused, perhaps unsurprisingly, on aspects of love and acceptance—and who, really, can deny the importance of that? The homosexual community is very small numerically but is none the less just as important and seeks society’s affirmation and social acceptability, which it claims would come from access to, and inclusion in, marriage as we know it. Civil partnerships already give legal equality, as we know; what is now being

4 Jun 2013 : Column 1108

sought is social inclusivity. I, like many others in your Lordships’ House, was moved by the speeches of, for example, the noble Lords, Lord Browne of Belmont, Lord Smith of Finsbury, and Lord Black of Brentwood, and the noble Baroness, Lady Barker. Their ability to speak as they did, and that those views can be accepted in public, was refreshing and commendable.

I have been one of many who have helped in some small way to further the steady growth of full integration of homosexuals into society from a position of illegality, through a phase of tolerance, if you like, into full recognition and acceptability. I am also aware of the very large number of others in society who recognise the huge change that is being sought by this Bill. Balancing the understandable fears and wishes of the majority against the understandable demands of a small minority is a difficult task, but in their haste to force this Bill through Parliament the Government will not satisfy either group. The noble Lord, Lord Alderdice, spoke convincingly of the dangers of forcing legislation on to the statute book without wide consultation and carrying all shades of public opinion with it. I wholeheartedly agree and have cited the current situation in France as one example.

There seems to be, if not general agreement, certainly some agreement that the Bill is in a mess, ill thought through and without proper process or popular mandate. The noble Lord, Lord Dannatt, went so far as to say that the progress of the Bill has to date been tantamount to an abuse of process. He might well be right.

Some argue that it should pass Second Reading and be ameliorated in Committee. We all know that it is constitutionally proper to force a vote at Second Reading. There are precedents for doing so, the most recent being the Health and Social Care Bill only two years ago. We know that such a move was endorsed by the 2006 Joint Committee on Conventions and I recognise and endorse the usual approach in your Lordships’ House to taking care and time to examine a Bill in detail, but not on this occasion. The structure of the Bill is too bad for that and I am certainly not alone in that view. A battery of big guns in your Lordships’ House agreed with me that the Bill is so fatally flawed that it is incapable of sensible amendment and should be voted down now and sent back to the drawing board.

Yesterday, the noble Marquess, Lord Lothian, the noble Lords, Lord Naseby, Lord Framlingham, Lord Tebbit, Lord Mawhinney, Lord Waddington, Lord Anderson of Swansea, and others—all parliamentarians widely experienced in both Houses—supported the move to vote the Bill down now. We have heard the same today from the noble and learned Lord, Lord Mackay of Clashfern, the noble Lord, Lord Brennan, and—in his short intervention—the noble Lord, Lord Forsyth of Drumlean.

It might be a bold move—it probably is—but it is legitimate, it has a precedent and it is appropriate. Who is prepared to drive a steamroller over the address given by the noble Lord, Lord Brennan, himself at one time chairman of the Bar, who asked a series of questions about what the next factors are, whether we should dwell solely on emotion and avoid questions of law, and particularly the fact that Clause 1 of the Bill

4 Jun 2013 : Column 1109

gives no room for negotiation or manoeuvre when it gets to Committee. All the might of government has been thrown at this Bill. Every corner has been cut, yet it is ill constructed and does not have the stamp of democratic legitimacy.

Perhaps I may close in posing a few fundamental questions? Are noble Lords sure that the process has been properly handled? Are they sure that the Bill has democratic legitimacy? Are they sure that all the likely consequences have been thought through—remember Argentina? Are they sure that we know everything about the legal effects of the Bill? Are they sure that there will be no later attempts to widen the definition of marriage further, and are they happy for another Government on another occasion to ram a different Bill through in this way? If not this Bill, when would noble Lords vote against a Bill at Second Reading? If some of the answers are in the negative, I suggest that we vote the Bill down now and do not waste further parliamentary time on it. I suggest that we send it back for proper, mature research, consultation and debate about the whole institution of marriage, taking into account, if you like, civil partnerships for both heterosexuals and homosexuals, because the issue is too important for all sections of society, gay or straight, to be introduced on a whim and handled in so cavalier a fashion.

How can we refuse a Second Reading? Rather, I ask noble Lords: how can we allow it to proceed? I ask your Lordships to agree my amendment and, in doing so, I beg leave to test the opinion of the House.

6.24 pm

Division on Lord Dear’s amendment.

Contents 148; Not-Contents 390.

Lord Dear’s amendment disagreed.

Division No.  1

CONTENTS

Allenby of Megiddo, V.

Anderson of Swansea, L.

Arran, E.

Bell, L.

Birmingham, Bp.

Blencathra, L.

Brennan, L.

Bristol, Bp.

Brooks of Tremorfa, L.

Brougham and Vaux, L.

Browne of Belmont, L.

Browning, B.

Butler of Brockwell, L.

Butler-Sloss, B.

Byford, B.

Canterbury, Abp.

Carey of Clifton, L. [Teller]

Carswell, L.

Carter of Coles, L.

Cathcart, E.

Chester, Bp.

Clarke of Hampstead, L.

Cobbold, L.

Cormack, L.

Coventry, Bp.

Cox, B.

Craig of Radley, L.

Cumberlege, B.

Curry of Kirkharle, L.

Dannatt, L.

Davies of Coity, L.

Dear, L. [Teller]

Deech, B.

Eames, L.

Eaton, B.

Eccles of Moulton, B.

Eccles, V.

Eden of Winton, L.

Edmiston, L.

Elton, L.

Emerton, B.

Empey, L.

Erroll, E.

Exeter, Bp.

Feldman, L.

Flight, L.

Fookes, B.

Forsyth of Drumlean, L.

Framlingham, L.

Gardner of Parkes, B.

Geddes, L.

Glenarthur, L.

4 Jun 2013 : Column 1110

Gordon of Strathblane, L.

Grenfell, L.

Griffiths of Fforestfach, L.

Guthrie of Craigiebank, L.

Hameed, L.

Hardie, L.

Hereford, Bp.

Hooper, B.

Howard of Rising, L.

Howie of Troon, L.

Hurd of Westwell, L.

Hylton, L.

Inge, L.

James of Blackheath, L.

Kalms, L.

Kilclooney, L.

Kirkhill, L.

Knight of Collingtree, B.

Lawson of Blaby, L.

Leach of Fairford, L.

Leitch, L.

Lewis of Newnham, L.

Listowel, E.

Liverpool, E.

Lloyd of Berwick, L.

London, Bp.

Lothian, M.

Luce, L.

Luke, L.

Lyell, L.

Lytton, E.

McColl of Dulwich, L.

Macfarlane of Bearsden, L.

Mackay of Clashfern, L.

Magan of Castletown, L.

Maginnis of Drumglass, L.

Mancroft, L.

Mar, C.

Marlesford, L.

Martin of Springburn, L.

Masham of Ilton, B.

Mawhinney, L.

Mawson, L.

Methuen, L.

Miller of Hendon, B.

Montgomery of Alamein, V.

Montrose, D.

Morris of Aberavon, L.

Morrow, L.

Naseby, L.

Nicholson of Winterbourne, B.

Northbourne, L.

O'Cathain, B.

O'Loan, B.

Oppenheim-Barnes, B.

Palmer, L.

Palumbo, L.

Parkinson, L.

Patel of Blackburn, L.

Patten, L.

Pearson of Rannoch, L.

Pendry, L.

Plumb, L.

Quirk, L.

Rowe-Beddoe, L.

Saltoun of Abernethy, Ly.

Sanderson of Bowden, L.

Sandwich, E.

Sassoon, L.

Scott of Foscote, L.

Seccombe, B.

Sharples, B.

Shaw of Northstead, L.

Sheikh, L.

Simon, V.

Singh of Wimbledon, L.

Skelmersdale, L.

Slim, V.

Stewartby, L.

Stoddart of Swindon, L.

Swinfen, L.

Taylor of Warwick, L.

Tebbit, L.

Temple-Morris, L.

Tenby, V.

Tombs, L.

Trenchard, V.

Trumpington, B.

Ullswater, V.

Vinson, L.

Waddington, L.

Walker of Aldringham, L.

Walpole, L.

Walton of Detchant, L.

Willoughby de Broke, L.

Winchester, Bp.

NOT CONTENTS

Aberdare, L.

Adams of Craigielea, B.

Addington, L.

Adebowale, L.

Adonis, L.

Afshar, B.

Allan of Hallam, L.

Alli, L.

Andrews, B.

Anelay of St Johns, B. [Teller]

Armstrong of Hill Top, B.

Ashton of Hyde, L.

Astor of Hever, L.

Astor, V.

Attlee, E.

Avebury, L.

Baker of Dorking, L.

Bakewell, B.

Baldwin of Bewdley, E.

Barker, B.

Barnett, L.

Bassam of Brighton, L.

Bates, L.

Beecham, L.

Benjamin, B.

Berkeley of Knighton, L.

Berkeley, L.

Best, L.

Bhattacharyya, L.

Bichard, L.

Bilimoria, L.

Billingham, B.

Bilston, L.

Birt, L.

Black of Brentwood, L.

Blackstone, B.

Blair of Boughton, L.

Blood, B.

Boateng, L.

Bonham-Carter of Yarnbury, B.

Borrie, L.

Bottomley of Nettlestone, B.

Brabazon of Tara, L.

Bradley, L.

Bridgeman, V.

Brinton, B.

Broers, L.

Brooke of Alverthorpe, L.

Brooke of Sutton Mandeville, L.

Brookeborough, V.

4 Jun 2013 : Column 1111

Brookman, L.

Brown of Eaton-under-Heywood, L.

Browne of Ladyton, L.

Browne of Madingley, L.

Burnett, L.

Burns, L.

Caithness, E.

Cameron of Dillington, L.

Cameron of Lochbroom, L.

Campbell of Surbiton, B.

Campbell-Savours, L.

Carlile of Berriew, L.

Chalker of Wallasey, B.

Chandos, V.

Chidgey, L.

Christopher, L.

Clancarty, E.

Clement-Jones, L.

Clinton-Davis, L.

Collins of Highbury, L.

Colville of Culross, V.

Colwyn, L.

Condon, L.

Cope of Berkeley, L.

Corston, B.

Courtown, E.

Coussins, B.

Craigavon, V.

Crawley, B.

Crickhowell, L.

Cunningham of Felling, L.

Darzi of Denham, L.

Davidson of Glen Clova, L.

Davies of Abersoch, L.

Davies of Oldham, L.

Davies of Stamford, L.

De Mauley, L.

Dean of Thornton-le-Fylde, B.

Deben, L.

Deighton, L.

Desai, L.

Dholakia, L.

Dixon-Smith, L.

Dobbs, L.

Donaghy, B.

Doocey, B.

Drake, B.

Drayson, L.

Dubs, L.

Dundee, E.

Dykes, L.

Elder, L.

Elis-Thomas, L.

Elystan-Morgan, L.

Evans of Parkside, L.

Evans of Temple Guiting, L.

Evans of Watford, L.

Falconer of Thoroton, L.

Falkner of Margravine, B.

Farrington of Ribbleton, B.

Faulkner of Worcester, L.

Faulks, L.

Feldman of Elstree, L.

Fellowes of West Stafford, L.

Fellowes, L.

Fink, L.

Flather, B.

Foster of Bishop Auckland, L.

Foulkes of Cumnock, L.

Fowler, L.

Freud, L.

Freyberg, L.

Gale, B.

Garden of Frognal, B.

Gardiner of Kimble, L.

Garel-Jones, L.

German, L.

Gibson of Market Rasen, B.

Giddens, L.

Glendonbrook, L.

Glentoran, L.

Gold, L.

Goldsmith, L.

Goodhart, L.

Goodlad, L.

Goudie, B.

Gould of Potternewton, B.

Grantchester, L.

Greaves, L.

Greengross, B.

Grey-Thompson, B.

Grocott, L.

Hamilton of Epsom, L.

Hamwee, B.

Hanham, B.

Hannay of Chiswick, L.

Hanworth, V.

Harries of Pentregarth, L.

Harris of Haringey, L.

Harris of Peckham, L.

Harris of Richmond, B.

Harrison, L.

Hart of Chilton, L.

Haskel, L.

Haskins, L.

Hattersley, L.

Haworth, L.

Hayman, B.

Hayter of Kentish Town, B.

Healy of Primrose Hill, B.

Henig, B.

Henley, L.

Hennessy of Nympsfield, L.

Heseltine, L.

Higgins, L.

Hill of Oareford, L.

Hilton of Eggardon, B.

Hodgson of Astley Abbotts, L.

Hogg, B.

Hollick, L.

Hollis of Heigham, B.

Howard of Lympne, L.

Howarth of Breckland, B.

Howarth of Newport, L.

Howe of Idlicote, B.

Howe, E.

Howells of St Davids, B.

Hoyle, L.

Hughes of Stretford, B.

Hughes of Woodside, L.

Hunt of Chesterton, L.

Hunt of Kings Heath, L.

Hunt of Wirral, L.

Hussein-Ece, B.

Irvine of Lairg, L.

Janner of Braunstone, L.

Janvrin, L.

Jay of Ewelme, L.

Jay of Paddington, B.

Jenkin of Kennington, B.

Jenkin of Roding, L.

Joffe, L.

Jolly, B.

Jones of Cheltenham, L.

Jones, L.

Jopling, L.

Judd, L.

Kakkar, L.

Kennedy of Southwark, L.

Kennedy of The Shaws, B.

Kerr of Kinlochard, L.

Kidron, B.

King of Bow, B.

4 Jun 2013 : Column 1112

King of Bridgwater, L.

Kingsmill, B.

Kinnock of Holyhead, B.

Kinnock, L.

Kirkham, L.

Knight of Weymouth, L.

Kramer, B.

Krebs, L.

Laming, L.

Lee of Trafford, L.

Levy, L.

Lexden, L.

Linklater of Butterstone, B.

Lipsey, L.

Lister of Burtersett, B.

Lloyd-Webber, L.

Loomba, L.

Low of Dalston, L.

Lucas, L.

McConnell of Glenscorrodale, L.

McDonagh, B.

Macdonald of River Glaven, L.

Macdonald of Tradeston, L.

McIntosh of Hudnall, B.

MacKenzie of Culkein, L.

McKenzie of Luton, L.

Maclennan of Rogart, L.

McNally, L.

Maddock, B.

Mallalieu, B.

Mandelson, L.

Manningham-Buller, B.

Mar and Kellie, E.

Marks of Henley-on-Thames, L.

Massey of Darwen, B.

Maxton, L.

Mayhew of Twysden, L.

Miller of Chilthorne Domer, B.

Mitchell, L.

Mogg, L.

Monks, L.

Moonie, L.

Morgan of Drefelin, B.

Morgan of Ely, B.

Morgan of Huyton, B.

Morgan, L.

Morris of Bolton, B.

Morris of Handsworth, L.

Morris of Yardley, B.

Moser, L.

Murphy, B.

Myners, L.

Nash, L.

Neuberger, B.

Neville-Jones, B.

Newby, L. [Teller]

Newlove, B.

Noakes, B.

Noon, L.

Northover, B.

Norton of Louth, L.

Nye, B.

Oakeshott of Seagrove Bay, L.

O'Donnell, L.

O'Neill of Bengarve, B.

O'Neill of Clackmannan, L.

Ouseley, L.

Palmer of Childs Hill, L.

Pannick, L.

Parekh, L.

Parminter, B.

Patel of Bradford, L.

Perry of Southwark, B.

Phillips of Sudbury, L.

Pitkeathley, B.

Plant of Highfield, L.

Ponsonby of Shulbrede, L.

Popat, L.

Prashar, B.

Prescott, L.

Prosser, B.

Puttnam, L.

Radice, L.

Ramsay of Cartvale, B.

Randerson, B.

Razzall, L.

Rea, L.

Redesdale, L.

Reid of Cardowan, L.

Rendell of Babergh, B.

Rennard, L.

Richard, L.

Richardson of Calow, B.

Risby, L.

Roberts of Llandudno, L.

Robertson of Port Ellen, L.

Rodgers of Quarry Bank, L.

Rooker, L.

Roper, L.

Rosser, L.

Rotherwick, L.

Rowlands, L.

Royall of Blaisdon, B.

Sawyer, L.

Scott of Needham Market, B.

Selborne, E.

Shackleton of Belgravia, B.

Sharkey, L.

Sharp of Guildford, B.

Shephard of Northwold, B.

Sherlock, B.

Shipley, L.

Shutt of Greetland, L.

Smith of Basildon, B.

Smith of Clifton, L.

Smith of Finsbury, L.

Smith of Leigh, L.

Soley, L.

Stedman-Scott, B.

Steel of Aikwood, L.

Stephen, L.

Stern of Brentford, L.

Stern, B.

Stevenson of Balmacara, L.

Stevenson of Coddenham, L.

Stone of Blackheath, L.

Stoneham of Droxford, L.

Storey, L.

Stowell of Beeston, B.

Strasburger, L.

Symons of Vernham Dean, B.

Taverne, L.

Taylor of Blackburn, L.

Taylor of Bolton, B.

Taylor of Goss Moor, L.

Taylor of Holbeach, L.

Teverson, L.

Thomas of Winchester, B.

Thornton, B.

Tonge, B.

Tope, L.

Tordoff, L.

Trees, L.

Triesman, L.

Trimble, L.

Tugendhat, L.

Tunnicliffe, L.

Turnberg, L.

Turner of Camden, B.

Tyler of Enfield, B.

Tyler, L.

Uddin, B.

4 Jun 2013 : Column 1113

Vallance of Tummel, L.

Verma, B.

Waldegrave of North Hill, L.

Walker of Gestingthorpe, L.

Wall of New Barnet, B.

Wallace of Saltaire, L.

Wallace of Tankerness, L.

Walmsley, B.

Warner, L.

Warnock, B.

Warwick of Undercliffe, B.

Wasserman, L.

Watson of Invergowrie, L.

Watson of Richmond, L.

West of Spithead, L.

Wheatcroft, B.

Wheeler, B.

Whitaker, B.

Wigley, L.

Wilcox, B.

Wilkins, B.

Williams of Baglan, L.

Williams of Crosby, B.

Willis of Knaresborough, L.

Wills, L.

Wilson of Tillyorn, L.

Wood of Anfield, L.

Woolf, L.

Woolmer of Leeds, L.

Worthington, B.

Wright of Richmond, L.

Young of Hornsey, B.

Young of Norwood Green, L.

Young of Old Scone, B.

Younger of Leckie, V.

Bill read a second time and committed to a Committee of the Whole House.

Care Bill [HL]

Bill Main Page

Committee (1st Day)

Relevant document: 1st Report from the Delegated Powers Committee.

6.48 pm

Clause 83 agreed.

Schedule 5 : Health Education England

Amendment 1

Moved by Lord Hunt of Kings Heath

1: Schedule 5, page 104, line 28, leave out sub-paragraph (1)

Lord Hunt of Kings Heath: My Lords, it is a great pleasure to open the Committee stage debates on the Care Bill. Schedule 5 relates to the establishment of Health Education England as a non-departmental public body. Schedule 5 is concerned with the membership of Health Education England and other matters to do with its establishment. As this is the start of Committee stage, I declare an interest as chair of an NHS foundation trust, and as a consultant and trainer with Cumberlege Connections.

The education and training of staff in the National Health Service is of course a critical responsibility, on which patients depend for good outcomes of care. The UK has traditionally enjoyed a very high reputation for the quality of our training and educational institutions and for the standing of the professional staff who come into the National Health Service. However, we should also acknowledge that there are a number of challenges facing the UK in ensuring that we continue to produce the right kind of people, in the right specialties and in the right numbers, taking into account the long-term challenges we face, not least that of an ageing population.

We received lots of briefings for this part of the Bill, for which I am most grateful. I was particularly struck by the briefing I received from the Royal College of Physicians, which points to trends in medical education

4 Jun 2013 : Column 1114

and training. On demography, it points out that by 2033 there will be 3.2 million people above the age of 85, with the prevalence of dementia expected to double. On social trends, people have more choice and higher expectations. On efficiency, the economy of course will shape services substantially and we know that, in the short term at least, the NHS faces unprecedented austerity.

While the Royal College of Physicians believes that many elements of the current training structure are excellent, there is a need for change too. Many more physicians must train in internal medicine to meet the new needs of patients across hospitals and community services. There is an emerging view that too many consultants specialise too soon and that there is a need to focus more on general physician consultants if we are to meet some of the problems that hospitals are facing. A&E is a symptom of the need for hospitals, in particular, to change the way they are often organised in order to recognise that their key client group are frail, older people who probably need the attention of generalist physicians as much as speciality doctors. The RCP points out that the doctor-patient relationship is evolving and that this needs to be reflected during training. It says that there should be more flexibility for time out of training and career progression between different grades which meets the changing needs of the health service.

Every royal college and many trade unions and patient groups have made similar comments about the need to look at the training and education of our professionals. We know that there are formidable challenges with regard to nurse education. The Francis inquiry identified a number of these. There is a real worry that newly-qualified nurses are not well prepared to take on full nursing responsibilities. The excellent independent report of the noble Lord, Lord Willis, commissioned by the RCN, contains some very important messages for us in our debates. There is a debate among the public and in Parliament about whether the caring aspect of nursing has sometimes been neglected. There is also the issue of whether healthcare support workers lack mandatory training and registration. I have no doubt that we will also debate those matters.

The connection between this and Schedule 5 is that Health Education England will be faced with many interesting and difficult issues. I can say to the noble Earl that we support the establishment of HEE in statute and I am very glad that Sir Keith Pearson has been appointed as chair of that organisation. The noble Earl will know that he was previously the distinguished chair of the NHS Confederation and an NHS trust. He brings to the job a wealth of experience.

The amendments in this group are designed to enhance the ability of Health Education England to understand the pressures that the service is under in relation to staffing and to ensure that our education and training is flexible to the rapidly changing face of health and social care. There are three amendments concerning the membership of Health Education England, as set out in paragraph 2(1) of Schedule 5, which states:

“The members of HEE must include persons who have clinical expertise of a description specified in regulations”.

4 Jun 2013 : Column 1115

Amendment 1 seeks to delete that but I hasten to add that it is a probing amendment. I have no problem at all with people of clinical expertise being on the board—far from it. However, I seek assurance from the noble Earl that one of the members appointed will be a registered nurse. This relates also to Amendment 3.

I need hardly speak to the House of the importance of nursing issues to the workforce and to the work of Health Education England. I remind the noble Earl of recommendation 204 of the Francis report into Mid Staffs. It states that all NHS bodies,

“should be required to have at least one executive director who is a registered nurse, and should be encouraged to consider recruiting nurses as non-executive directors”.

I hope that the noble Earl will be able to respond positively. The nursing workforce is so important to the quality of care that it is crucial that Health Education England has nurses around the board table both on the executive and non-executive sides. Every time there is a restructuring of NHS boards, often there will be people who try to exclude nurses from those boards. They are mistaken. I do not think that boards in the NHS can do without nurses around the top table.

My noble friend Lord Turnberg will of course speak to his own amendment but I support its thrust, which is to appoint one or more members with expertise in research and one or more with expertise in medical education and training.

I also hope that recognition will be given to the needs of those staff who are not professionally registered. My Amendment 4 refers to that point. How are the needs of healthcare assistants going to be met if there are not people around HEE who understand the constraints and pressures under which they work?

Managers in the health service, many of whom are not qualified in the traditional sense of being professionally registered, have a crucial role to play. I had hoped that Health Education England would be concerned about the identification and development of those managers. I remind the noble Earl that there is a big problem in recruiting chief executives to NHS bodies, perhaps because their length of stay is almost as bad as that of football managers. That tells it own tale about the job. I hope that Health Education England will consider that it has some responsibility to look at how the managerial cadre can be developed and trained, and how they can be given some security in their jobs and reassurance about what will happen to them if they need to move on from one organisation to another.

7 pm

My Amendment 5 deals with the appointment of the chief executive of Health Education England. Can the noble Earl tell me why the Secretary of State has to give his approval to the appointment of the chief executive? We have debated this matter before. If the Secretary of State appoints the chair and the non-executives, why can he not trust the chair and the non-executives to do an effective job? I point out to the noble Earl that in Clause 79, in relation to the CQC, there is a provision that actually excludes the Secretary of State from appointing the CQC chief executive. Why it is different for the CQC as opposed

4 Jun 2013 : Column 1116

to Health Education England? Am I to take it that Health Education England is considered to be less independent than the CQC?

I also ask the noble Earl to consider my Amendment 5, which would subject the chief executive appointment to Health Select Committee scrutiny. I know that current scrutiny by Select Committees tends to be of the chairs of organisations but, in view of the importance of the work of Health Education England, would it not be worthwhile for the Health Select Committee to be able to undertake scrutiny of that appointment? It would be an effective substitute for the Secretary of State’s role.

My next amendment, Amendment 6, concerns paragraph 8(1), which states:

“HEE must pay its employees such remuneration as it decides”.

Is it intended that HEE employees will be engaged on NHS terms and conditions? I certainly hope so. Indeed, given their role in the education and training of staff, it would be rather puzzling if the staff of Health Education England were not covered by the same terms and conditions as NHS staff.

My final amendment, Amendment 7, concerns paragraph 12(2). It is really a probing amendment. It concerns the status of Health Education England’s property, which is not to be regarded as property of, or property held on behalf of, the Crown. I looked to the Explanatory Notes for an explanation but, alas, all the Explanatory Notes do is to repeat what is in the Bill. I should be grateful if the noble Earl could explain the thinking behind that.

Overall, as I have said, the Opposition welcome the establishment of Health Education England as a statutory body. It has a very important role to play but I think that its governance arrangements could probably be improved. I beg to move.

The Deputy Chairman of Committees (Viscount Ullswater): My Lords, I must advise your Lordships that if this amendment is agreed, I will not be able to call Amendments 2 and 3 because of pre-emption.

Lord Turnberg: My Lords, I will speak to Amendment 2. Before I do so, I should explain that I have heard from the noble Lord, Lord Patel, who cannot be in this place this evening because of illness in the family. I strongly support the amendments of my noble friend Lord Hunt, in particular the idea of a nurse on the boards; I also very strongly support his ideas on trying to attract good managers to stay in the service for as long as possible.

Amendment 2 is the first of several amendments that I have tabled emphasising the need for Health Education England and the local education and training boards to pay particular attention to the maintenance of standards and quality in education and training. I express my interests here as someone who has spent many years trying to raise standards of medical education in my previous jobs as dean of a medical school, the president of the Royal College of Physicians and, perhaps of equal significance, as president of the Medical Protection Society, where I was brought face to face with what happens when standards fail or are allowed to slip.

4 Jun 2013 : Column 1117

This amendment specifically concerns the membership of Health Education England and the need for it to include at least one person with expertise in research and another in education and training. I will save my remarks on research until we debate later amendments, but so far as education and training are concerned, my fear is that in the drive to meet workforce requirements and staffing numbers we will lose out on standards and quality. This amendment simply makes more explicit the need for input on the board of someone who has particular expertise about education and training, and the maintenance of standards.

I will make another point now to save making it later. I believe that there is a conflict, not easy to resolve, between the desire to provide sufficient numbers of trained staff locally—as determined, quite rightly, by local providers—and the need to maintain national standards. For example, in medicine it is vital that a cardiologist, orthopaedic surgeon, general physician or trained nurse is trained to a national standard that is recognised everywhere. It is not acceptable for a local provider to decide what training should consist of, but they want someone whom they can rely on. It is vital that there are national standards and hence there is a need for someone at the Health Education England level who has the expertise to look at how those standards can be set.

So far as national workforce planning is concerned, I have lived through innumerable efforts at medical workforce planning and found them to be fraught with difficulty, largely because it takes so long to train doctors: five or six years as undergraduates, then another five or 10 years of specialist or general training. Predicting need for different types of doctors 10 or 15 years downstream is far from straightforward. The noble Earl kindly sent around a document on a mandate from the Government to Health Education England. However, I fear that the section entitled “Excellent Education”, with its emphasis on training multipotential individuals working in teams across all health sectors—important though that is—de-emphasises the need for specialists. That prospect fills me with apprehension—that five years downstream we will have a health service lacking essential parts. I fear that the right balance between the need for general across-sector care and specialist care may be tipping too far in these particular aspirations. In any event, for the moment, I will press for the placing of relevant education expertise on the board of HEE, as suggested in this amendment.

Lord Willis of Knaresborough: My Lords, in the Second Reading debate on the Health and Social Care Bill, now an Act, I made the point that while we were talking about structures until the cows came home, the things that really mattered were the education and training of the staff within the NHS and the research element that gave those staff the very best tools in order to be able to care for patients and have good patient outcomes.

I compliment not only my noble friend, but the whole House, and indeed the whole Parliament, on the way in which it got behind the proposal in that Bill which is now in this one to create Health Education England as a way forward. The appointment of

4 Jun 2013 : Column 1118

Sir Keith Pearson, who knows the supply side very well and has the ability to bring people together to listen to what he has to say and to be able to develop Health Education England as a real force for good, is quite outstanding. My worry is that we will start to bind the hands of Sir Keith and Health Education England, and we must not do that. What is required now is an organisation that is given sufficient flexibility and power to be able to grasp the key issues that are facing the NHS and to move forward.

I support very strongly the amendment in the names of the noble Lords, Lord Turnberg and Lord Patel, to include on the board people with relevant expertise. I am pleased that the noble Lord did not go on to say exactly who should be on that board, because I believe that that would be a step too far. But to have somebody with a real background in training, education and medical research would bring great strengths to the board.

I also support Amendment 3 in the name of the noble Lord, Lord Hunt. Indeed, I support virtually all the amendments tabled by the noble Lord and compliment him on the way in which he introduced this part of the Bill. Having a registered nurse on the board is so important. If we do nothing else in terms of the Francis report, the one thing that shines through is that you need somebody within the organisation who brings to the board those issues of quality care at every level. That is really quite exciting. I hope that my noble friend will listen to the wise words of the noble Lord, Lord Hunt, and others, and ensure that nursing is given a real place at the table, because quite frankly for generations it has not been. Nurses are no longer the handmaidens and “handmasters” of other professionals. They are in fact equals.

Baroness Emerton: My Lords, I support the noble Lords, Lord Hunt, Lord Turnberg and Lord Willis, in their recommendation that a registered nurse should be on the board.

An issue that Francis picked up after the report is that the nursing voices are not strong. He said he was disappointed in the response from the nurses. We now have to ensure that the nurses on the board are equipped with the knowledge and expertise to be able to speak out and hold their own. The training of senior nurses in standing at the board table and making their voices heard and understood on quality, safety and the patient experience is going to be very important. Therefore, it links very much with the leadership training, which we also need to address, in terms of their preparation. Perhaps the noble Earl will comment on that.

Lord Warner: My Lords, I support these amendments. I will pick up the point made by my noble friend Lord Hunt about managers. The public sector needs all the quality management it can get and many of its problems rest on the fact that we do not have a cadre of managers to take many of our public services through the difficult years ahead. The NHS is no exception.

For too long—and my own party has been guilty of it in the past—we have dismissed managers as men, and indeed women, in grey suits who are dispensable. We have to give some strong messages to HEE that if

4 Jun 2013 : Column 1119

the NHS is to develop and evolve and cope with the problems ahead, we need a strong cadre of managers and we have to develop them over time. It is not too early to start now because we have a real problem not just in staffing chief executives now but in staffing the next cadre of chief executives and the middle management and development programmes for that. The Government would do well to give some strong messages to HEE and possibly even consider strengthening the legislation on this issue because it would be a missed opportunity if we do not strengthen that body of people to help us run the NHS in the coming decades.

Baroness Finlay of Llandaff: My Lords, I will briefly add my support, particularly to the amendment in the names of the noble Lords, Lord Turnberg and Lord Patel. I will draw the House’s attention to the wording, that it is,

“expertise in medical education and training”

that is being asked for, not just medical education, and that the expertise in research is not tied to medicine.

I understand the arguments that HEE must not be too tied or have a board that is too rigid, but if it is to meet the enormous challenges that it faces—and it has come from many, many discussions—to be able to have questions asked at board level about education and training will be essential if we are to have a workforce that can adapt rapidly as new technologies and new ways of providing care come along. It will need to have people with expertise and understanding of the most efficient and effective ways to upskill the workforce in particular areas, because there are enormous unknown challenges ahead.

7.15 pm

Baroness Masham of Ilton: My Lords, I, too, support having a nurse on the board. It is vital because the nursing workforce is the biggest of all the professions, and training and recruitment is sometimes the problem that has to be faced.

The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): My Lords, we begin our Committee proceedings with a series of amendments that take us to the heart of the theme that permeates this Bill. The driving principle of reforming the education and training system is to improve care and outcomes for patients. Excellent health and healthcare require a training system that will deliver a highly skilled workforce, working together with compassion and respect for people.

Noble Lords will remember our debates of last year when, recognising the importance of education and training in the NHS and public health, we inserted into the Health and Social Care Act a clear duty on the Secretary of State to ensure that there is an effective education and training system. This Bill delegates that duty to Health Education England. This means that Health Education England will be clearly accountable to the Secretary of State for ensuring that there is an effective education and training system in place for healthcare workers in England. Health Education England will provide national leadership for workforce planning,

4 Jun 2013 : Column 1120

the commissioning of education, training and development activity, and the quality assurance of the education and training that is delivered.

The backdrop to all that is the changing face of healthcare provision. The way health services are provided is expected to change significantly over the next few decades, with more care provided in the community and an increased emphasis on public health. This cannot happen unless we equip the workforce with the skills and knowledge to do this. To do it successfully, the local and national infrastructure needs to be in place to plan and commission effectively. That is why the creation of Health Education England and the local education and training boards is so important.

It is vital that the board of Health Education England has the necessary skills and experience to oversee the delivery of its important functions. In recognition of this, the Government have already strengthened the Bill, following pre-legislative scrutiny, to place an explicit requirement, in paragraph 2(1) of Schedule 5, on Health Education England to recruit members with clinical expertise. The specific nature and description of the expertise and specified numbers are to be set out in regulations. That amendment has been well received by stakeholders such as the Royal College of Surgeons. A similar requirement has been placed on local education and training boards to have members with clinical expertise.

The noble Lords, Lord Hunt and Lord Turnberg, have tabled a number of amendments relating to clinical expertise on the board of HEE and the LETBs. I realise that Amendment 1 is a probing amendment. It may be helpful to explain our thinking around the Schedule 5 requirement. This sub-paragraph was added to the Bill following pre-legislative scrutiny to place an explicit requirement on Health Education England to ensure that there is clinical expertise on the Health Education England board. It also responds to responses to the consultation on the Bill, which touched on the importance of Health Education England having access to professional leadership. This will give Parliament and bodies representing the professions the necessary assurance that the Health Education England board has access to the appropriate knowledge and understanding in making decisions that impact on professional education and training. It also provides the basis for a clear duty in the Bill for both the Secretary of State and Health Education England to make appointments of clinical experts, which can be developed subject to regulations. For example, the regulations will specify what we mean by “clinical expertise” and allow greater flexibility to specify any detailed requirements. It will also allow changes to be made to those requirements as Health Education England matures, should circumstances demand it.

Amendments 3 and 4 seek to extend the requirement for members with clinical expertise by expressly requiring Health Education England to include in its board membership a registered nurse and someone with experience in staff groups that are not professionally registered. Similarly, Amendment 2, tabled by the noble Lord, Lord Turnberg, seeks to extend the requirement for members with clinical expertise by expressly requiring Health Education England to include

4 Jun 2013 : Column 1121

one or more members with expertise in research and one or more members with expertise in medical education and training in the Bill.

It is undoubtedly important for Health Education England to have access to professional expertise, but having said that I need to make clear that the Government do not believe that it is appropriate for the Bill to mandate requirements for certain professions or particular areas of expertise. That is better suited to be set out in secondary legislation, as it may change over time, and Health Education England will need greater flexibility to recruit the expertise it requires and to specify any detailed requirements as circumstances demand.

One of the great strengths of Health Education England over previous arrangements is that it has a remit for all the professions, bringing a strengthened approach to multi-professional education and training. Although medical and nurse training, and an understanding of the importance of research, are extremely important elements of its functions, HEE has a much broader focus. It may be helpful to the Committee to have a sense of how the new organisation intends to do justice to that broad remit.

First, HEE will employ a director of education and quality at board level who is responsible for ensuring a co-ordinated multi-professional approach to education and training. Within the Health Education England special health authority, that post is filled by a doctor, and is supported by a medical director, a director of nursing, and other professional advisers for dentistry, pharmacy, healthcare science and the allied health professions.

Secondly, Health Education England has established professional advisory groups, bringing together employers and national stakeholders, to focus on profession-specific education and training issues covering medicine, dentistry, nursing, pharmacy, healthcare science and the allied health professions. These advisory boards will support HEE and its board in the decisions they make that impact on health professional education and training. It should also be remembered that Health Education England employs many health professionals that support the activities of the LETBs. In these ways it has direct access to a wealth of knowledge and expertise on the planning, commissioning, provision and quality assurance of education and training.

The Government understand the importance of considering the support workforce that is not professionally registered. Health Education England, with the networks of employers working through the LETBs, will provide a wider leadership role in the development of the whole workforce engaged in the delivery of healthcare and public health. This is emphasised in the Government’s mandate for the Health Education England special health authority. In making non-executive appointments to the Health Education England board, the Secretary of State will source the skills and expertise that are required to ensure the Health Education England board can function effectively. The chair and non-executive directors will do likewise in making executive appointments to the board. That approach has worked well for the recruitment of the current HEE special health authority board, which has three members with clinical expertise, including a

4 Jun 2013 : Column 1122

doctor. I should also mention that two non-executive appointments are still to be completed. In recruiting for those, we are looking for a further clinician with experience of equality and diversity issues, and someone who can bring a strengthened focus on the patient perspective to support the development of education and training.

In the light of what I have said, I hope noble Lords will feel reassured that the Health Education England board is suitably clinically informed, and that they will feel able to withdraw those amendments.

I now turn to Amendment 5. The Bill already requires the consent of the Secretary of State to the appointment of the chief executive of Health Education England. That approach is in line with the appointment of other chief executive officers across the health system and seems proportionate for a body of this size and nature. In addition to approving the appointment of the chief executive, the Secretary of State will appoint the chair and non-executive directors of Health Education England. This approach has worked well for the HEE special health authority, which has a board with a good blend of experience and expertise.

As for the role of Parliament, the Bill makes provision for Health Education England to report to Parliament on an annual basis, with the requirement to publish an annual report setting out its achievements and to publish annual accounts. I am sure the Health Select Committee will rightly continue to take a strong interest in education and training and will have the opportunity to discuss progress with Health Education England whenever necessary. I hope that will reassure the noble Lord on this amendment.

Ensuring that non-departmental public bodies have robust governance and accountability arrangements in place is clearly essential. Schedule 5 to the Bill makes provision for the constitution of Health Education England and deals with the exercise of its functions and its financial and accounting obligations. A number of amendments in this group fall under that broad heading.

Amendment 6, which again I realise is a probing amendment, poses a question about the terms of remuneration of HEE’s employees. In establishing HEE as a non-departmental public body, it is important that it is given the appropriate levels of autonomy and independence to carry out its important education and training functions without day-to-day interference from Ministers or the Department of Health. Yes, it needs to be held accountable for the use of its resources, and the Government are committed to holding it to account in an open and transparent way, but I hope noble Lords would agree that it is important for a body of this nature to have the ability to determine the pay and remuneration rates for the people it recruits and employs, including its executives. That does not mean that it will not be subject to any constraints. I can reassure the Committee that as an arm’s-length body of the Department of Health, HEE will be subject to the rules and controls covering the use of its budget, and to procedures applicable to senior appointments and levels of remuneration. These are the very same rules that apply to other arm’s-length bodies and to all government departments.

4 Jun 2013 : Column 1123

The noble Lord, Lord Hunt, asked me whether HEE employees will be engaged on NHS terms and conditions. In fact, HEE employees are currently employed on NHS terms and conditions and there are no plans to change that when HEE becomes an NDPB.

Amendment 7 is another probing amendment. The provision which the noble Lord has questioned is important. It clarifies that Health Education England’s property is not to be regarded as property of, or held on behalf of, the Crown. This is a standard provision that applies to other arm’s-length bodies in the health system. It allows Health Education England to make arrangements for its own property and office needs. It needs to do so to support the staff it employs nationally and across the local education and training boards. It would not be practical for any other body to hold this responsibility. Of course, Health Education England will work with other bodies to look for savings on estates, information technology, human resources and in other areas. It is already doing that as part of the shared services programme which the Department of Health and all its arm’s-length bodies are signed up to.

Part 2 of Schedule 5 imposes a very clear duty on Health Education England to exercise its functions effectively, efficiently and economically. Part 3 of Schedule 5 sets out how the Secretary of State will fund Health Education England and includes restrictions on the use of resources. These are consistent with provisions made for other bodies in the healthcare system such as NHS England.

I make the same point as I did a minute ago—that HEE needs to be held accountable for the use of its resources—but it is right to give it direct responsibility for how it operates and manages its day-to-day business, including the ability to make arrangements for its own property and accommodation. In the light of that, I hope the noble Lord will feel sufficiently reassured to not press his amendment.

7.30 pm

Before I sit down, I want to cover the issue of managers. The current HEE board includes people with a healthy cross-section of experience of NHS management and training, higher education and clinical roles. I cannot make any specific commitment about the future board of HEE once it becomes an NDPB, but I have registered strongly the cogent point made by the noble Lord about managerial skills.

The noble Lords, Lord Hunt and Lord Warner, asked specifically about the training of managers. Health Education England will work with the NHS Leadership Academy, which supports the development of managers and will take an interest particularly in the development of clinicians as managers. We are the first to agree with the noble Lord, Lord Warner, that managerial skills in the new NHS, as in the past, will be crucial if we are to deliver what we all want, which is a health service that is efficient, effective and delivers good outcomes for patients.

Baroness Cumberlege: Perhaps I may comment on what my noble friend has said in reply to the debate. I understand that under secondary legislation he is

4 Jun 2013 : Column 1124

considering putting a registered nurse on the board. Some assurance on that would be very helpful. In my experience working with clinical commissioning groups, when they were appointed there had to be a nurse on the board, and the last person to be appointed in many cases was the nurse. There was a feeling that it was hard to find a nurse who would make such a contribution. Some very talented young nurses are coming on-stream, but when one talks about a clinical presence on a board, so often, it is interpreted as a medical person on the board. We seek to ensure that a working nurse will be on those boards. If my noble friend can reassure me that he will consider that very carefully when drawing up the regulations, I will be very pleased.

I am so sorry. I should have declared an interest. My interests are on the Lords’ Register.

Earl Howe: My Lords, I listened with care to my noble friend, whose experience we respect greatly. I can tell her that Health Education England’s board will need to have access to a cross-section of clinical expertise, as it does at the moment. Nursing representation will of course be very important. I assure her that we will prioritise that issue in developing the supporting regulations on membership. That is probably as far as I can go, but I recognise the force of everything that my noble friend said.

Baroness Emerton: On a point of clarification, the Minister used the term multi-professional education in relation to integrated services. We have concentrated on medicine, nursing and clinical expertise. Because we are going to be looking across the boundaries into social care, is Health Education England going to have anything to do with the social care aspect of the training of clinical specialists? We have not mentioned social care, and I wondered whether we should.

Earl Howe: My Lords, Health Education England will have responsibility for the NHS workforce, but not for the social care workforce. We will reach a group of amendments that bear closely on the issue of integration, where I am sure that we can explore the relationship that Health Education England will have with those bodies charged with delivering the social care workforce. The noble Baroness is absolutely right: there needs to be co-ordination and joined-up thinking in those areas. If she will allow, we can wait until we reach that group of amendments before debating the issue further.

Lord Warner: Let me assure the noble Baroness that I shall be in good voice on the subject of social care on Amendment 13.

It was helpful to hear what the Minister had to say about advisory committees and advisers. I listened carefully. I did not note anything about those advisory committees or an adviser for what I might call the sub-professional group. I am sure that the professions will be extremely well looked after in HEE, but the groups which we often have the most problem recruiting and ensuring are properly trained are those below the professional level. Can the noble Earl say a little more

4 Jun 2013 : Column 1125

about those unsung heroes working at the sub-professional level and what kind of advisory capacity HEE might have in that area?

Earl Howe: It will certainly be open to the board of HEE to establish an advisory committee that specialises in unregulated professions. Although, again, I cannot make a firm commitment about that, the very fact that we are dealing with a workforce of substantial size on which the NHS crucially depends—I am now talking about healthcare support workers—means that it would be very surprising indeed if the board were not to have some form of specialist advisory service to inform its decisions.

Lord Willis of Knaresborough: Before we finish debating this group of amendments, will my noble friend reflect on what he has just said about regulation? One of the traps we fell into with the Health and Social Care Bill—I do not think that it was intentional, it just happened—was that so much was promised in regulation that it was not until we started discussing the regulations that we saw what we had not done in the Bill. Perhaps it would be helpful to produce draft regulations as we go along before Report, so that we know what we are including in the regulations.

Earl Howe: It may not surprise my noble friend to know that I asked my officials the self-same question, because I anticipated an appetite for draft regulations. I am, unfortunately, not in a position to make that promise, much as I would like to do so, because there may not be the necessary time available for the regulations to be drawn up in draft. However, I will take back the strength of my noble friend’s request and see whether there can be any reconsideration of that point.

Lord Hunt of Kings Heath: My Lords, it has been a very good debate, and I am grateful to the noble Earl and other noble Lords for taking part. It is the role of noble Lords always to ask the Government for draft regulations but, alas, I fear that we may not see them. If we cannot, perhaps we could at least get a sense of instructions that might be given on policy direction.

First, let me say that the Government’s reflection on the Joint Committee’s recommendation with regard to clinical expertise, and the change that has been made, is welcome. I listened with care to the noble Earl when he said that the needs of Health Education England and the education and training of staff may change over time, which is why that is best left to regulation. That makes sense, but I cannot believe that there will ever be a time when research and nurse representation will not be important. I ask the noble Earl to give that further consideration.

I will just reflect on the comment of the noble Baroness, Lady Emerton, that this has been a consistent theme of restructurings over the years. The noble Baroness, Lady Cumberlege, and I have lived through many restructurings and they always start with the premise that there will not be a nurse on the board. Then, after argument and sometimes experience, it is discovered that you need to have a nurse. I would have thought that the Francis report, at its heart, focused a

4 Jun 2013 : Column 1126

lot on nursing experience and leadership. I ask the noble Earl to give this further consideration. It would be a very visible sign that the Government are listening to this point and that they actually set out in primary legislation that a registered nurse should be appointed.

I am glad that the noble Earl picked up the point about non-registered staff and managerial staff. It is not just in the health service. In the further education sector there is a similar problem, with only a limited number of people applying to be college principals. We need to think very hard about what we can do to give greater support and encouragement to bright young people coming through so that they aspire to take on these top jobs. No one should underestimate the pressures that those leaders are under, but we really want good people. I endorse the noble Earl’s reference to clinicians. We need to encourage more clinicians to take on leadership roles.

I was very interested in the contrast between the desires of the noble Earl not to give autonomy to the board to appoint its own chief executive, but to give it autonomy when it came to the salaries of its staff. I ask for some consistency here. If the Secretary of State appoints the chair and the non-executives—which is absolutely right—he or she should then have confidence in their judgment to allow the board to appoint a chief executive.

Finally, on the intervention of the noble Baroness on integration, it might help our future debate if the noble Earl could confirm that Clause 88, on matters to which HEE must have regard and in which subsection (1)(h) refers to,

“the desirability of promoting the integration of health provision with health-related provision and care and support provision”,

answers the point that the noble Baroness raised—that in effect HEE does have to have an understanding of the needs of those providing social care because of the contribution that they can make to integrated services.

Earl Howe: I can answer that immediately by saying yes, it does mean that; indeed, it is that particular provision to which I think the amendment of the noble Lord, Lord Warner, is attached.

Lord Hunt of Kings Heath: My Lords, I am very grateful. Having said that, I beg leave to withdraw my amendment.

Amendment 1 withdrawn.

Amendment 2

Tabled by Lord Turnberg

2: Schedule 5, page 104, line 28, after “expertise” insert “including one or more members with expertise in research and one or more with expertise in medical education and training”

Lord Turnberg: I will not move this amendment but I want to make one brief comment. If we are to rely on the regulations to interpret what clinical expertise really means, it is unlikely, however, that expertise in education and training will not be essential. I hope that comment will be borne in mind.

4 Jun 2013 : Column 1127

Amendment 2 not moved.

Amendments 3 to 7 not moved.

House resumed. Committee to begin again not before 8.44 pm.


Global Fund to Fight AIDS, Tuberculosis and Malaria

Question for Short Debate

7.44 pm

Asked By Lord Fowler

To ask Her Majesty’s Government what action they are taking to support the global fund on HIV and AIDS, tuberculosis and malaria.

Lord Fowler: My Lords, this short debate is about the importance of the global fund. I saw the global fund at its beginning, when Richard Feachem was the director. Over the past decade it has developed into one of the chief means of combating HIV/AIDS, tuberculosis and malaria around the world. It has helped in the dramatic progress that has been made, particularly in the past five years, and that progress has been truly dramatic. In HIV, the number of people on anti-retroviral treatment worldwide has increased from 1.4 million in 2007 to 4.2 million today. In 2007, there were almost 3 million TB cases detected and treated; today the total is 9.7 million. In 2012, a cumulative 310 million nets were distributed, compared with only 46 million five years ago.

The result is that, with all three diseases, a record number of people are now receiving treatment. To give the example of HIV/AIDS, which I know best, well over half of the people in sub-Saharan Africa who need anti-retroviral treatment are now receiving it. Incidentally, that is probably a bigger proportion than for some countries now in eastern Europe—it just shows how the balances change—whereas for TB in sub-Saharan Africa, the figures for those being successfully treated are higher than for HIV.

Not all these improvements, it should be underlined, can be put down to the global fund. National Governments make a massive contribution themselves. I was in Cape Town a month or two ago and, to take South Africa as an example, it finances much of its own programmes. The years of neglect have been followed by an inspired effort by the South African Department of Health. The result is that, over the past five or six years, life expectation has already improved and increased by something like five years. Furthermore, we should never forget the massive contribution that the United States makes bilaterally through the President’s emergency fund—a fund started, incidentally, not by Bill Clinton but by George Bush, which will stand as a tribute and lasting memorial to him. If it was not for the United States, I think that the world would be in a terrible mess as regards these funds. So we can say, so far so good.

However, there is another way of looking at the figures. We can also look at the death toll from these diseases now, and we can look at the new infections that are taking place every day throughout the world,

4 Jun 2013 : Column 1128

not just in Africa. The most recent figures show 2.7 million deaths from AIDS and TB-related causes, and 660,000 deaths from malaria and related causes. By any standard, that is a devastating loss of human life. Here we come to the crunch point. I pay tribute to the increases in financing that there have been, but if financing continues just at its present level, the prospect is that there will be many more new HIV infections and fewer TB patients receiving care. In other words, we risk going backwards. One reason for that is the growth taking place in the world population; another is the particular nature of HIV. For some diseases it is possible to give a course of treatment, for a patient to recover and for his place to be taken by a new patient; but HIV is not remotely like that. There is still no cure. It is a lifelong condition. Patients stay on that treatment and, other things being equal, the cost will rise as new cases come forward for treatment.

That is not to say that we should not seek further efficiencies in programmes. We should certainly do that. Incidentally, as far the global fund is concerned, in spite of some of the criticism that it has had, it actually has a very good record in this area. I remember seeing an example of that in Kiev in the Ukraine, where the global fund took the decision that the Government should hand over their responsibility in various aspects to an NGO, the HIV Alliance. The result was a dramatic reduction, an economy, in drug costs. The costs of the antiretroviral drugs which were being bought came down by something like 25 times.

We also need to persuade national Governments to increase their direct contributions to their own epidemics. It is certainly not enough for some countries to rely as heavily as they do on outside finance. Of course, when that happens it is fuel for those who argue—wrongly, in my view—that international aid should be cut back, but let us remember that this is not the easiest time to make that case and to ask Governments to add to their aid programmes. The fact is that however you look at it, it is very much in everyone's interests that the budget for the global fund is increased. The fund is a vital part of the world’s fight against three killer diseases. If we start to go backwards, that obviously affects the lives of millions of people around the world but, more, it also means that the epidemics continue to spread. That in its turn will mean even more money to combat them and bring them under control.

The global fund has estimated that over the next three-year period of 2014-16, it will need something like $15 billion—a substantial increase, certainly, on what is now being spent. However, if the result can be a decisive and irreversible improvement, that is a very considerable prize indeed for the world. No one seriously doubts the global fund’s figures; most significantly, they are not challenged by the United States, which is by far the biggest donor in the fund. That was confirmed to me last week when I was in Washington talking about these things.

What we in this country therefore now await is the British Government’s response. When I was Health Secretary, I harboured an ambition to make the United Kingdom a model of how a nation should respond, particularly, to HIV. We have made progress along that road but I think that no one would say today that it is a model. We spend, for example, far too little on

4 Jun 2013 : Column 1129

prevention and on publicising not only the threat of HIV but the way in which it can be combated. However, we have maintained a good record in our contribution to the global fund. I hope that the Minister will now be able to put some more flesh on those bones. The US has set an example; we need also to set an example.

I have two last points. First, I very much hope that the global fund will continue to support the efforts to develop a vaccine for both HIV and TB. We have seen what a vaccine can achieve on polio and there are some encouraging signs, as in Thailand, that the prospect of developing a vaccine is not as far-fetched as some critics argue. The problem is that the development time for a vaccine is far in excess of the lifetime of any Government or three-year programme. It is nevertheless a goal which is most certainly worth pursuing. I say that in particular because of my second point. What stands in the way of so much progress in these areas is stigma and discrimination. A further effort is most certainly required there. Stigma infects gay and lesbian people, those with HIV and those with TB. It means that many people around the world are reluctant to come forward for testing. A vaccine would cut through all that. It is therefore, again, a goal which is worth pursuing.

If I may say so, tonight there has been a historic vote in this House. We have sent out a clear message that we in this country believe in equality of treatment for all. That was a massive message, which was underlined by the majority. I believe also that we are united, irrespective of which way we voted on that debate, on the criminalisation of homosexuality being abhorrent. I hope that that message goes out equally strongly, but I put it to the Minister that it would be even better if tonight she could set out the British Government’s plans to help the global fund fight one of the most important health battles that the world now faces. That is a historic battle and this country could make an important and valuable contribution to it.

7.55 pm

Lord Chidgey: My Lords, I congratulate my colleague and noble friend Lord Fowler, first, on securing this debate and, secondly, on the remarkable way in which he set out the problems which we face.

I first came face to face with the scourge of HIV/AIDS about 10 years ago, in Soweto in South Africa. I was taken to a hospice and clinic run mainly by volunteers and funded by donations from the local community. At that time, victims of HIV/AIDS whose illnesses had reached their final stages were being cast out into the street and left to die. The hospice volunteers went out into the townships each and every morning to bring in the abandoned and the dying, and to provide them with clean beds and nursing care during their last days and hours in the comfort of the hospice. I recall standing by the bed of a desperately ill young woman, possibly still a teenager, searching for some words of comfort or solace. Beyond speech, she just looked up with despairing and frightened eyes. It was yet another human tragedy unfolding.

The clinic attached to the hospice had the main task of mobilising the community, particularly those from the families of HIV/AIDS victims, to be trained in basic healthcare procedures. The concept was to

4 Jun 2013 : Column 1130

provide a core of basic healthcare support for HIV/AIDS victims in their homes. At that time, the clinic had trained over 350 volunteer community healthcare practitioners, working with the families in the townships. During the same visit, we met with the leaders of the Johannesburg chamber of commerce to be briefed on the impact of AIDS on the economy. The heaviest toll was being taken in the extractive and heavy haulage industries, where the death rate was so high that employers had to expect a complete replacement of their workforce every four years. A lack of education and of access to antiretroviral drugs and a reluctance to be clinically tested all added to the difficulties in attempts to contain the epidemic. As the noble Lord, Lord Fowler, said, South Africa has made great strides since then but, as he also pointed out, the drugs are not a cure.

A little later, with a delegation to Botswana, I visited the local research centre in Gaborone, established and funded by the Gates foundation as part of a multimillion dollar project to combat the spread of HIV/AIDS. At that time, I recall that more than 35% of the population in Botswana were infected by the disease. The project was having some success, particularly among the young in the more remote areas of the country. A problem was that as their health improved under the Gates drug regime, there was a trend to return to a pattern of unprotected casual sex, in the mistaken belief that they were now cured, so the educational aspects of the programme had to be revisited.

The United Kingdom has been a major supporter of the global fund since 2002. The coalition Government have maintained the commitment to £1 billion over the period 2008-15, with annual commitments in line with this pledge. It is to DfID’s great credit that it has played a key role in supporting the fund, following the cancellation of the 11th round of funding, by bringing some payments forward—meaning that the £1 billion pledge is likely to be met a year earlier.

In 2011 the global fund was rated “very good value for money” in DfID’s multilateral aid review, or MAR, the same as the GAVI Alliance—the former Global Alliance for Vaccines and Immunisation—which, however, received a substantial increase in investment in that year. Since the MAR, DfID Ministers have repeatedly said that they will significantly increase or even double the UK’s contribution with a further £1 billion. However, a strong pledge is needed now, ready for the 2014-16 replenishment. Will the Minister provide the strongest possible indication of when the Government intend to honour their pledge?

There is no doubt that investments through the global fund and other partners in the treatment of AIDS, TB and malaria have produced dramatic results. AIDS deaths have declined by 24% since 2005, as millions have gained access to the treatment. Half of the malaria-affected countries are on track to reduce cases by 75% by 2015. The global goal to reverse the spread of TB has been achieved ahead of schedule. Nevertheless, donors must be vigilant in detecting financial abuse or incompetence. Last October, the global fund found that in Djibouti over one-third of the $23 million grant had been misused or gone missing. Six months on, what action has DfID taken with the global fund to establish how this happened, and what steps have been taken to prevent a recurrence?

4 Jun 2013 : Column 1131

The global fund sees this replenishment year of 2013 as critical for the future, with the need to raise $15 billion to tackle the three diseases in the period 2014-16. The three diseases, AIDS, TB and malaria, face an historic turning point. We now have the tools and the knowledge to curb the trajectory of all three epidemics, but we can achieve this only with an ambitious funding scale-up in the coming years.

8.00 pm

Baroness Masham of Ilton: My Lords, I thank the noble Lord, Lord Fowler, for having secured this debate on the global fund. I declare an interest as a member of all-party parliamentary groups on HIV/AIDS, tuberculosis and malaria.

The global fund has been supported by the UK, which knows how important the fight against these and other emerging diseases is. Recently, the funding model of the global fund has been made more flexible on timing, better on engagement with partners and more predictable on the level of funding available. The new funding model allows countries to better plan over time, to increase domestic funding as global fund financing decreases. The World Health Organisation states that there are 440,000 new cases of multidrug-resistant tuberculosis every year, causing at least 150,000 deaths. Many of these people will also have HIV.

There is an urgent need for rapid diagnostics for killer infections. An expert in respiratory tract infections, Alimuddin Zumla, tells me that the absence of rapid, accurate diagnostic tests for pulmonary tuberculosis was further compounded by the widespread inability to screen for drug-resistant bacteria. An ideal diagnostic test for RTIs should be rapid, cheap, easy to use, sensitive and specific and should screen for many micro-organisms and their antibiotic resistance. The diagnostic platform should be transferable, robust and, ideally, run on solar power for use in the remote healthcare settings in developing countries. I am pleased to say that I have a cousin who is a professor of microbiology in Australia. His team have developed a mobile unit that is called a “lab without walls”. They take it to projects in developing countries, so it is exciting that progress is being made by dedicated people. However, to achieve this across the world, physicians, scientists, biotechnology companies, funding agencies and Governments need to work together to drive the development of improved diagnostic tests for both developed and developing countries.

MDR-TB and extensively resistant TB are an increasing problem in Asia, Africa and eastern Europe. Global fund money is only for supporting programmes in developing countries. There is a need for part of this money to be used for research. Good research would result in better treatment outcomes—money well spent, rather than just supporting programmes. Without research, progress will not be achieved. The global fund has done much to help. I hope that it will continue to do so with renewed efforts from our Government and other countries to increase this valuable work. With modern travel, many people have access to the world. Health infections should be everyone’s business.

4 Jun 2013 : Column 1132

8.05 pm

The Lord Bishop of Derby: My Lords, I too want to thank the noble Lord, Lord Fowler, for his persistence and commitment to this very important work and for his prophetic leadership.

I want to focus on TB, which, as we know, is preventable and manageable but needs the right resources. I commend the enormously impressive work of the global fund and, as mentioned by the noble Lord, Lord Fowler, the importance of national Governments. I want to particularly remind us of the importance of the global fund’s aspiration to work with what it calls civil institutions: partnership with people on the ground. To explore what that might mean and to encourage the Government to take that aspiration seriously in the way that we offer funds and seek accountability, I want to talk a little about Peru, which is recognised as among the countries with the highest TB burdens in the western hemisphere. If I understand them correctly, the indicators show that TB control in Peru may actually be deteriorating.

My second reason for talking about Peru is that I am privileged to be a friend of the Bishop of Peru. He and his family come from Chesterfield in my diocese and he visits us when he is in this country. This year, we have in our diocese of Derby a harvest appeal fund to help him build a school, a clinic and a church on one site where there will be proper provision from the system, civic society and education. That is a model of partnership. Last week, I spoke to Dr Townsend Cooper who is running a project for the diocese in Peru. He describes the working of all these efforts from the point of view of civil society—the church on the ground—as “filling in holes”. They do not have a sense of working in partnership; they feel they are running round filling in holes.

I will give one example of a case that he is treating at the moment that he discussed with me last week. They are helping a 13 year-old girl in Ventanilla who has cerebral palsy from a birth injury and was recently diagnosed with TB of her spine. The existing system swung into action: she was admitted to hospital and had surgery and medicines. Then, of course, she was sent home to complete the treatment, and home for this 13 year-old girl is one room on the back of a family property that she shares with her mother. She was discovered in this place by one of the visitors from the diocesan medical team. She was unable to go to hospital by bus because the surgery on her back made that journey virtually impossible. Taxi drivers refused to take her because, as the noble Lord, Lord Fowler, said, there is a stigma about having TB and she is regarded as dirty. Quite frankly, she would not have the money for a taxi anyway. The diocesan medical team picked her up and began to visit her. They did very simple things: hygiene, transport, education for her and her mother about management of the treatment and co-operation. What the doctor calls a very small amount of targeted help has transformed the situation, and the initial investment in the treatment is now again beginning to bear fruit.

That is just one little story, but I share it because it shows the problems of people of good will and faith on the ground who are trying to fulfil the aspiration to

4 Jun 2013 : Column 1133

work with civil society. It alarms me that the director of this project says they feel like they are filling in holes. It is not a comprehensive enough system of outreach, partnership and co-operation so that the good work being done by the fund and national Governments is not biting as much as it might to make the difference.

I would like to make two points. First, I support the request for the Minister to comment on the Government’s pledge to increase investment in this fund. I also want to ask what the Government might be able to do to encourage the fund to take seriously its aspiration to work with civil society, and how to bed that in better so that those on the ground trying to fulfil this part of the complex response to TB do not feel that they are just filling in holes but are part of a more joined-up and coherent system.

8.09 pm

Baroness Chalker of Wallasey: My Lords, it is a pleasure to speak in this debate, which was initiated by my noble friend Lord Fowler. I, too, commend him on his energy, commitment and his determination to keep HIV/AIDS and other diseases at the forefront of debate and always to remind my old department, now DfID, that it has to keep up to the mark. As noble Lords will know, my interest in the health of people in the developing world has gone on for a very long while. I spent more than 10 years at the Liverpool School of Tropical Medicine, six years chairing the Medicines for Malaria Venture and eight years chairing the London School of Hygiene and Tropical Medicine, so I have particular interests.

I hope that we can hear from the Minister and the department a strong pledge to the global fund, which is already operating in 151 countries. I also ask the department to look hard at what more can be done to enhance the training of rural health workers, particularly in prevention. The Touch Foundation, at the moment only in America, works in Tanzania, supported also by the Vitol Foundation in this country. The work to prevent disease and to get early diagnosis has meant a much better use of the resources that we get from the global fund. We can be very grateful to the Bill and Melinda Gates Foundation for the $650 million that it has given since 2002, and it has now given a promissory note for another $750 million. However, we can make the money work only if we have people on the ground to communicate with those who do not understand why these diseases develop so strongly.

In the new funding model of the global fund we have a real opportunity. I understand that it is to be piloted in nine countries, which have not yet been disclosed. It will try to get a greater alignment with country schedules and their priorities and to focus on the countries with the highest disease burden and lowest ability to pay. It will make it simpler for the implementers and the global fund, will mean greater predictability of process and financing and will have a real ability to elicit full expressions of demand and to reward ambition. The global fund can do that. However, the new funding model will work only, first, if it is financed, and secondly, if there is a translation of what you can do with the money through the people

4 Jun 2013 : Column 1134

on the ground. That is why I make an additional plea to the department that it should consider those organisations that can help in prevention and, particularly, in early diagnosis.

My main interest is clearly in malaria and in trying to beat the mosquito in spreading falciparum and vivax. However, we can have success with new drugs only if those on the ground know when, how and in what quantities to apply them, as well as using the nets that for so long the global fund has provided. I therefore ask the Minister two things. First, that we have early notification from the department of what it can give to the global fund but, secondly, that we now focus a lot more on local-level training, maybe through non-governmental organisations such as the Touch Foundation and other good organisations such as AMREF—I can mention many others, but I will not go on. It is no good just putting the money in unless we motivate the people to do the right things.

8.14 pm

Baroness Jolly: My Lords, I, too, thank my noble friend Lord Fowler for securing this well informed and timely debate. I realise that I am a newcomer to this field, and recognise that I am among experts with a wealth of experience. However, I hope that what I lack in both experience and expertise I can make up for in strength of feeling and enthusiasm.

I will take this opportunity to build on what the other speakers have said and emphasise the importance of the global fund in the fight against tuberculosis. Ninety per cent of international donor funding to fight TB comes through the fund, mainly because it is such an effective institution but also because TB does not get the profile or attention warranted by the devastation it causes. It is a disease closely associated with poverty, and 90% of cases are in developing countries. In 2011 there were almost 9 million cases of TB and the disease killed 1.4 million people. That is scandalous when you think that the majority of cases are curable with a course of cheap antibiotics. There are 22 high TB-burden countries in the world today, of which six are totally reliant on funding from the global fund, while two-thirds of the budget for the other 15 comes from global fund financing. Let us be clear: for many countries there would be no response to TB without the global fund’s support.

Last summer I was lucky enough to visit one of the projects supported by the global fund in Zambia. We visited St Luke’s Mission Hospital in Mpanshya, which serves a population of over 30,000 people and receives funding from the Churches Health Association of Zambia, or CHAZ, for its work on malaria, TB, HIV/AIDS and preventing mother-to-child transmission of HIV. CHAZ receives a grant from the global fund and is one of two principal recipients of such funding in the country. Through the grants that the global fund has distributed, CHAZ has brought about catalytic change in Zambia. Global fund-supported programmes have diagnosed and treated 44,000 new cases of TB, distributed 1.6 million bed nets to protect families from malaria since 2003, and provide lifesaving antiretroviral treatment to over 450,000 people living with HIV.

4 Jun 2013 : Column 1135

On our visit we heard from community health workers who included TB and HIV treatment supporters, traditional-birth attendants and former TB patients. These comments also reflect the observation of the right reverend Prelate the Bishop of Derby, because these people were church-based workers. They were based at this religious foundation, some 200 kilometres east of the capital. They carry out their work entirely voluntarily, covering long distances on foot in order to reach patients. Their commitment to improving the health of their communities was truly inspirational; but this is only one part of the global fund’s portfolio. It really brought home to me the important work that they do and the hope that the projects that they support brings to millions.

It is essential that this work continues in Zambia but also elsewhere. This replenishment year is critical for the future of the fund’s work. It announced in April that it will need $15 billion to tackle the three diseases for 2014-16. Speaking about the call for new pledges, the executive director of the global fund said:

“Innovations in science and implementation have given us a historic opportunity to completely control these diseases. If we do not, the long-term costs will be staggering”.

These costs are not just financial; they are costs in lives.

If this goal were achieved, it would mean that 17 million patients with TB and with multidrug-resistant TB could be treated, saving over 6 million lives over the three-year period; I cannot do the sums, but per day those numbers run to four figures. Some 1.3 million new HIV infections could be averted each year and 196,000 additional lives saved from malaria.

Of the money needed by the fund, the United States has signalled that it could pledge an unprecedented $5 billion. However, according to US law it cannot donate more than one-third of total contributions to the Global Fund. For the US contribution to become a reality, other donors must increase their contributions to commit the remaining funds. I echo the comments of my noble friend Lord Fowler: the UK Government have a key role to play. They can exert leverage on other donors by demonstrating their continued support for the Global Fund with an increased contribution of £1 billion for this replenishment period. An early summer announcement of increased UK funding at this key moment would lay down a marker for other Governments to follow.

This is just not my view. It was shared by the International Development Select Committee last year when it urged the Government to do all possible to commit funds early, and at a time that raises the most amounts of money from other donors. I urge my noble friend the Minister, for the reasons that I have just outlined, to do all in her power to ensure that the Government bring forward this anticipated increased contribution, ahead of the Summer Recess.

8.20 pm

Lord Lexden: My Lords, we are fortunate that my noble friend Lord Fowler has brought these immensely important international health issues before the House today. My noble friend has been a tireless champion of

4 Jun 2013 : Column 1136

the global fund, whose crucial role he has underlined once again. The fund embodies a remarkable international partnership, bringing together Governments and private-sector organisations and uniting them in an unrelenting campaign to overcome the world’s pandemics.

We are united this evening in believing that the fund can be even more successful in the future than in the past. There remains so much for it to do, as we have heard from speakers in this debate. It is a matter of considerable pride that our country, under both the previous Government and this one, has been the third largest contributor to the global fund. Like all those who have taken part in this debate, I look forward to hearing what my noble friend the Minister has to say about our future contribution.

I hope that she will be able to allay widespread concerns that government support for research into new treatments and advances in prevention is about to be cut significantly. Continued funding is essential if recent scientific progress is to be carried forward steadily by those involved in highly regarded, not-for-profit public/private partnerships, such as the International AIDS Vaccine Initiative. This works with more than 50 academic, industrial and governmental organisations around the world to research and develop AIDS vaccines. There could be no more important work.

At the same time, it is accepted by the global fund and by all those who back it that at a time of severe pressure on the public purse everywhere, contributions from individuals, corporations and private foundations must be encouraged. That point was made forcefully in a recent report from the influential Center for Strategic and International Studies in Washington. It needs strong emphasis in this debate.

If the global fund is well equipped and resourced, as we hope strongly, as a result of a combination of public and private support, it will still labour under a formidable handicap. However successful the fund and the efforts of the vast numbers of people working to end the pandemics may be, they will not be able to reach and relieve all the suffering with which they contend. That is because homosexuality is a criminal offence in some 78 countries. Where homosexuals are criminals, HIV cannot be fully relieved or curtailed. The statistics are stark. In Caribbean countries where homosexuality is not against the law, of every 15 men who have sex with other men, one is infected with HIV. In Caribbean countries where homosexuality is criminalised, the rate of infection is one in four. So we come back to the deep-seated problem of criminalisation, which is and always should be a prominent feature of our debates on these issues.

We naturally direct our concern principally to the countries of the Commonwealth. In 42 of the Commonwealth’s 54 member states, homosexuality is a criminal offence. The Commonwealth’s collective institutions produced clear evidence in 2011 that where homosexuality had been decriminalised, HIV infection had fallen. To the infinite sadness of us all, that has not led to a widespread acceptance of the case for decriminalisation. In some countries the situation has got worse. Last week the Nigerian Parliament passed a harsh anti-LGBT Bill that is bound to fuel prejudice and hatred in other countries.

4 Jun 2013 : Column 1137

On moral as well as on health grounds, the Christian churches in Commonwealth countries ought to be at the forefront of efforts to stem the tide of oppression and extend basic human rights to all LGBT people. In fact, as we know well, all too often the churches are to be found in the forefront of militant antigay activity. The Church of England, which is my church, has great influence in many Commonwealth countries. I end with a fervent plea that it should consider issuing a strong public statement utterly condemning the criminalisation of homosexuality. If it did that, it would confer an inestimable boon on those working, through the Global Fund and other remarkable, selfless organisations, to end the pandemics that so disfigure the world today.

8.25 pm

Lord Collins of Highbury: My Lords, I, too, thank the noble Lord, Lord Fowler, for initiating this debate. I thank him also for his lifetime commitment to the battle against HIV and AIDS, and, more importantly, against the prejudice that all too often hinders treatment and prevention. His contribution to the earlier debate made me feel proud of this House and of all the people who have supported equality.

The Global Fund to fight AIDS, Tuberculosis and Malaria has, since its inception, saved an estimated 8.7 million lives, disbursed antiretroviral drugs to 4.2 million people, treated 9.7 million cases of TB and distributed 310 million insecticide-treated bed nets. Like the noble Lord, Lord Chidgey, I very much welcome the fact that the coalition Government have maintained the previous Government’s commitment of £1 billion to the fund.

I also recognise the key role that DfID has played in supporting the fund through a turbulent period. In 2011-12, following the cancellation of the 11th round of funding, the UK acted and, with the support of DfID, brought forward some payments during this period, which means that we are likely to reach the £1 billion pledge a year early, in 2014. Since these difficulties, we have seen, as the noble Baroness, Lady Masham, said, a radical restructuring. Simon Bland, a leading DfID civil servant, was appointed chair and has overseen the implementation of reforms at the fund. These have refocused resources and efforts on effective grant management, while remaining true to the organisation’s vision, mission, principles and values. As we heard in the debate, the fund received the highest possible value for money rating in DfID’s multilateral aid review.

Since the publication of that review, DfID Ministers have repeatedly stated that the UK will significantly increase its contribution to the fund. The previous Secretary of State for International Development said that the UK would up to double its contribution to the global fund. In these circumstances, and like many noble Lords in the debate, I ask the Minister clearly to signal that the Government will double their contribution to the global fund. As the noble Baroness, Lady Chalker, said, an early announcement on this, in June or early July, would provide the impetus for other countries to make their commitments, providing the global fund with certainty on how much of the next replenishment it is likely to achieve.

4 Jun 2013 : Column 1138

Like the noble Lord, Lord Fowler, I acknowledge the role and commitment of the United States Government. As the noble Baroness, Lady Jolly, said, that is critical for the future of the fund’s work. A $15 billion contribution to the global fund would see close to 90% of the global resource needs to fight these diseases met. However, for the US contribution to become a reality, other donors must increase their contributions. If we meet that goal it would mean that 17 million patients with TB and multi-drug resistant TB could be treated, saving over 6 million lives over the three-year period, and 1.3 million new HIV infections could be averted each year. As we have heard from the noble Baroness, Lady Jolly, 196,000 additional lives could be saved. These are real objectives and I welcome the Minister’s response in making sure that we can make that doubling-up contribution.

8.30 pm

Baroness Northover: My Lords, I, too, thank my noble friend Lord Fowler for securing this important debate and, like others, I pay tribute to his leadership in this field. Both he and the noble Lord, Lord Collins, are right to say that this debate follows a stunning endorsement of our commitment to equality and fairness for all. The noble Lords, Lord Lexden and Lord Fowler, and others flagged the difficulty of tackling disease and explained how stigma, criminalisation and lack of equality hold us back.

The United Kingdom Government are strongly committed to the fight against these three diseases, which represent some of the leading causes of mortality and morbidity in developing countries, posing the largest threat to achieving the health-related MDGs. They also slow economic activity, widen inequality and cause severe financial and emotional strain on affected households. We heard from my noble friend Lord Chidgey and the right reverend prelate the Bishop of Derby about the individual human impact of these diseases.

As we have heard, the global fund plays a key role in the fight against these diseases, and we recognise that its results to date have been very impressive. In a little over 10 years it has enabled a significant and sustained response that has changed the course of these diseases around the world, as my noble friend Lord Fowler highlighted. Thus, Bangladesh has seen a 92% reduction in malaria deaths. In Cambodia, TB prevalence has declined by 43% and malaria deaths have declined by 80%. In South Africa, life expectancy has risen for the first time in a decade from 51 years in 2005 to 60 years in 2010. In HIV there have been huge gains, as my noble friend Lord Fowler and others noted, with 700,000 fewer infections globally in 2011 than in 2001.

Challenges remain, however, such as the growth of drug-resistant TB and HIV epidemics driven by drug injection, as the noble Baroness, Lady Masham, pointed out. From 2001 to 2010, the number of people living with HIV rose 250% in eastern Europe and central Asia, again a problem flagged by my noble friend Lord Fowler.

We are currently the fund’s third largest contributor. As the noble Lord, Lord Collins, pointed out, in 2007 the United Kingdom committed up to £1 billion from 2008 to 2015 for the fund. Europe generally is also

4 Jun 2013 : Column 1139

an active supporter. Taken together, the European Commission and the EU countries that contribute to the fund account for well over 40% of its receipts.

A year ago, my right honourable friend the previous Secretary of State Andrew Mitchell confirmed to the International Development Committee that the United Kingdom would contribute £128 million to the fund in the years 2012 to 2014. He also said that the United Kingdom would consider increasing that commitment depending on progress with the fund’s crucial reforms, to which the noble Lord, Lord Collins, referred.

DfiD Ministers have indeed increased or accelerated our funding to help the fund through short-term difficulties. In 2010, we advanced a payment so that all the proposals under the fund’s 10th round of applications could be approved, and in 2011 we brought forward another payment so that these same grants could be signed off. Because of this, we are on track to meet in full and one year early our £1 billion pledge, even before any increase. The United Kingdom also continues to be an active and engaged member of the fund and its committees in Geneva.

At country level, the United Kingdom provides a range of complementary funding and other support to national plans and global fund-supported programmes, as well as through in-country governance bodies, most notably the country co-ordinating mechanisms that manage global fund grants. However, as noble Lords have flagged, there have been some recent challenges; the noble Lord, Lord Collins, referred to this. The fund invites scrutiny and is a highly transparent organisation. In 2011, the Global Campaign for Aid Transparency ranked the fund fourth in their “Publish What You Fund” data, and in 2012 the global fund ranked joint third. That is very encouraging. As my noble friend Lord Chidgey and others have noted, we rated the fund as providing very good value for money in the multilateral aid review.

However, press reports in 2011 claiming fraud and corruption caused the fund to examine its systems and procedures. It became apparent that the reports were exaggerated and extrapolated from audits that the fund itself had published. None the less, they triggered a series of events, including the cancellation of the fund’s 11th round of applications for funding. A high-level independent review panel was established to look at the fund’s fiduciary controls and oversight mechanisms. The panel concluded that the fund’s purpose was right and that it had achieved significant results, but that it had outgrown its original structures and was in urgent need of reform, including changes to its business model.

The fund responded in full to the panel’s recommendations. Subsequent reforms have been rapid and far-reaching. It has changed its business model and practices and made significant and strategic senior appointments so that the senior management team is even stronger than before. It has redirected staff towards active grant management and working more closely with high-burden countries.

My noble friend Lord Chidgey asked about an incident in Djibouti. We and the fund take a zero tolerance approach to fraud and corruption, which he will not be surprised to hear me say. We have supported the fund in appointing a chief risk officer, undertaking

4 Jun 2013 : Column 1140

a grant-by-grant and country-by-country assessment of risk and strengthening the secretariat to manage risks better. The fund is further improving its audit investigation units, and recovery of any and all fraud is being vigorously pursued.

A new funding model, intended to ensure that the fund improved its performance and better met the needs of poor people affected by the three diseases was agreed late last year. I reassure my noble friend Lady Chalker that the secretariat is focusing in particular on the 20 high-impact countries in Africa and Asia that account for 70% of the burden of the three diseases and 54% of the fund’s grants. We are very glad that the global fund appears to be back on track and even stronger than before. On 28 February this year, it allocated £1.9 billion to 50 countries to test its new funding model, and on 15 May we learnt that the first five country concept notes have passed their review stages and will be recommended to the board for funding later this year.

I was asked a number of questions, and I shall go through some of them. The right reverend Prelate the Bishop of Derby asked about civil society involvement and emphasised the significance of that, and of course that is right. Roughly 33% of global funding grants go to civil society recipients in parallel to Governments. My noble friend Lady Chalker asked about the training of health workers. As she probably knows, the global fund supports health workers, including through general health system strengthening and through the countries’ own national programmes. She was concerned that there should be better targeting on prevention, which the noble Lord, Lord Fowler, emphasised, and we agree. Clearly, the 310 million bed nets—again the noble Lord, Lord Fowler, referred to this—are a demonstration of what can be done.

Various noble Lords emphasised the reduction of stigma, including my noble friends Lord Lexden and Lord Fowler. My noble friend Lord Fowler interestingly linked that to vaccines. We agree that the support for the development of vaccines is very important and we have increased funding. As part of a package of interventions, even an inefficient vaccine can have its uses.

My noble friend Lord Lexden suggested that we needed to work closely with private sector foundations and individual contributors, and we agree. We are doing that generally across DfID. He will note that Bill Gates will be joining us on Friday and Saturday at the hunger summit, for example, outside this debate.

The noble Baroness, Lady Masham, asked about diagnostics. I assure her that DfID is providing £6.5 million to the Foundation for Innovative New Diagnostics to develop new diagnostic tests for a range of diseases. She is absolutely right about the importance of that. She and my noble friend Lady Jolly emphasised the importance of TB research and taking this forward. DfID supports a range of research, including £23.3 million to the Global Alliance for TB Drug Development and various other projects.

We liaise closely with our colleagues on the fund’s board, including those from the United States, France, Germany, Japan and the EC, and—I hope this reassures the right reverend Prelate—with those from civil society. We recognise President Obama’s request to Congress

4 Jun 2013 : Column 1141

of $1.65 billion for 2014 as a strong vote of confidence in the fund and its reforms. Like the noble Lord, Lord Fowler, we pay tribute to the United States’ record here.

Our own reform priorities are to reduce transaction costs levied on recipients and on partners, as flagged by my noble friend Lady Chalker; to gain even better value for the money spent; to continue the focus on the poorest and most vulnerable; and to develop the longer-term sustainability of global fund-supported programmes. Clear, positive developments have already been made and we are seeing early signs of the impact of these reforms. The multilateral aid review update for the global fund, which will be published in the summer, will help to provide further important evidence.

I welcome the interest of all noble Lords in this area. The focus is to make sure that in a period of global austerity, when we all face major health problems, such as those resulting from HIV/AIDS, malaria and TB, resources are used as effectively as possible. The global fund has an impressive track record and it is vital that such international players, whose reach is far wider than that of individual countries, are as efficient as possible as we seek to combat poverty and disease around the world.

8.43 pm

Lord Fowler: My Lords, I thank the Minister very much for what she has said. I particularly thank everyone who has taken part in the debate. It has necessarily been a short debate, but the speakers have brought in virtually all the areas of the global fund: AIDS, tuberculosis and malaria. In addition, the point has been made very strongly about the stigma that attaches to a number of these areas and which stands in the way of testing and is therefore totally counter- productive.

I thank the Minister for her reply. I think I will need to look at it with a little more care. She went very rapidly at one stage when I thought she was getting to the point of pledging herself to doubling the contribution, but I do not think that quite came. I thought she made the case entirely for doubling the contribution, so I was not sure why she did not go that final bit, but there we are. I live in optimism.

In all seriousness, the pledge has been made a number of times and it is getting just a wee bit dog-eared. I do think it is rather important that if the Government want to set an example, get some credit for what they are doing and have some influence, they should make a firm pledge and make it stick. However, I thank the noble Baroness for her reply and I thank everyone who has taken part.

Care Bill [HL]

Bill Main Page

Committee (1st Day) (Continued)

8.45 pm

Amendment 8

Moved by Baroness Wheeler

8: Schedule 5, page 107, line 22, at end insert—

“( ) HEE must exercise its functions consistent with the promotion of a comprehensive health service, giving equal consideration to the importance of physical and mental health.”

4 Jun 2013 : Column 1142

Baroness Wheeler: My Lords, I shall speak also to Amendment 10. These two amendments seek to make sure that Clause 84 and Schedule 5 specify the responsibility of Health Education England to ensure, throughout its work, the promotion of a comprehensive health service which gives equal consideration to the importance of physical and mental health and the health of people with learning difficulties. This parity of esteem, putting mental health on a par with physical health, must be a key principle carried through HEE’s work and in the education and training of healthcare workers, and it is important that the Bill specifies this. Why is that? It is because the lack of parity continues to have a massive impact. The most recent psychiatric morbidity surveys show that, despite theoretical parity under existing legislation, only a minority of those with a mental disorder in England receive any intervention, in stark contrast to other disease areas, such as cancer, almost all of which have some intervention.

Labour is proud that it introduced the NHS constitution and is pleased that it now has widespread support. However, we acknowledge that it did not go far enough in ensuring that parity of esteem was entrenched into the constitution. This is especially important as the growing number of NHS bodies and organisations established under the Government’s NHS reforms are all required to take the constitution into account in all they do.

Noble Lords will recall that parity of esteem was a hard-fought-for, last-minute inclusion in the Health and Social Care Act. It is vital because it is important to do everything that we can to ensure that this key NHS objective is taken seriously and is underlined at every stage. We welcome the steps in the HEE mandate recognising HEE’s leadership role in this, including a focus on the mental health workforce to ensure that there are sufficient psychiatrists and other clinicians and specialist staff working to build the values and skills to facilitate continuous service improvement, developing training programmes which ensure that all staff have awareness of mental health problems and how they may affect their patients, and ensuring that the mental health needs of people with long-term health conditions are addressed concurrently and not as an afterthought.

We particularly welcome HEE’s leadership role in providing, through LETBs, training programmes to support staff in diagnosing the early symptoms of dementia so that they are aware of the needs of patients, carers and families. Building skills among GPs is especially important in this respect, as we know that patients often go undiagnosed for years. The target for Health Education England of 100,000 staff undertaking dementia foundation-level training by 2014 is a challenging one but it must be achieved if the current appalling level of undiagnosed cases is to be reduced. While focus on dementia is welcome, we must also ensure that other debilitating mental illnesses are addressed with equal vigour.

The lack of parity of esteem for mental health under the current system is widely recognised and acknowledged. The website of the mental health charity, Mind, sums this up well in reporting on the experiences of people with mental health problems. As it says:

4 Jun 2013 : Column 1143

“One person told us they get immediate attention for slightly high blood pressure, but face indifference and long waits about their mental health needs unless they are suicidal. Others have told us that they experience far better treatment in A&E for physical symptoms than when they need emergency help in a mental health crisis or for self-harm injuries. This is not acceptable—an emergency is an emergency”.

My noble friend Lord Patel of Bradford reminded us during the debate on the Queen’s Speech that only 13% of NHS funds are devoted to the treatment of mental health issues. Against this backdrop we strongly welcome the Royal College of Psychiatrists’ report, Whole-person Care: From Rhetoric to Reality, commissioned by the Department of Health and the NHS Commissioning Board last year. It sets out how progress on achieving parity of esteem can be made by,

“changes in attitudes, knowledge, professional training, and practice”,

and makes key recommendations to apply across the NHS on equivalent levels of access and waiting times for mental health services, specifically in emergency and crisis mental healthcare.

The RCP report has a number of recommendations relevant to HEE’s remit and role. These include how HEE should as a priority support the development of core skills and competences in health and public health professionals; the need for the General Medical Council and the Nursing and Midwifery Council to review medical and nursing study and training to give greater emphasis to mental health; and integrating mental and physical health within undergraduate medical training. I would welcome the Minister updating the House on what action the Government plan to take on this important report, the timescale for the Government’s response, and how any of the report’s recommendations will be fed into the Bill.

Whole-person care is Labour’s agenda for the future. It would bring together physical health, mental health and social care into a single service to meet all of a person’s health needs. Ed Miliband, in announcing Labour’s commission on whole-person care, emphasised that:

“In the 21st century, the challenge is to organise services around the needs of patients, rather than patients around the needs of services. That means teams of doctors, nurses, social workers and therapists all working together”.

In his landmark speech on mental health last year at the Royal College of Psychiatrists seminar, he acknowledged mental health as the biggest,

“unaddressed challenge of our age”.

He went on to say:

“We have to confront the unspoken discriminations too. Like the vast inequalities in funding for research. Like the lack of training in mental health of many NHS staff – whether in GP surgeries, outpatient clinics or A&E. Eight out of ten primary care professionals say they need more training in mental health than they have”.

Amendment 12 underlines the importance of HEE working,

“with persons who provide health services to ensure an adequate provision of continuing professional development for health care workers”.

That is particularly important in view of the recent findings in a member survey by the Royal College of Nursing, which pointed to a worrying decline in CPD

4 Jun 2013 : Column 1144

training. The noble Lord, Lord Patel, has an amendment on CPD under the provisions for LETBs, so we will pick up this issue then.