To call attention to the Government’s public health agenda; and to move for papers.

My Lords, I would like to make it clear at the outset that those of us who criticise the NHS are not for one moment ignorant of, or unappreciative of, the great amount of good, even brilliant, treatment that so many patients receive. It must not be assumed that because we draw attention to the undeniable fact that some patients are very badly treated and beg for deficiencies to be remedied we are condemning the whole NHS. We certainly are not. But there are thousands of cases where clear proof of bad, even inhumane, treatment has resulted in suffering and death. We have a duty to bring those cases to public attention and to try to put things right, which is appallingly difficult.

Since 2002, I have been trying to ensure that hospital patients are routinely given food and water. In 2003, my Patients’ Protection Bill put forward some solutions; for instance, asking relatives and friends if they could come in and feed or give a drink to helpless patients, which is quite common practice in many European countries. That and other suggestions fell by the wayside. The Bill was allowed no further than Second Reading. Six long years later it is reported that patients in Stafford Hospital are so desperate to have a drink that they pull the flowers out of the vases and drink what is left. It is also reported that many have become severely dehydrated. I cannot bear to think of the suffering that they must have endured, nor that if warnings had been heeded and acted on, that suffering need never have happened.

The past six years have made no difference for the patients who do not get fed either. Only last month, figures came out showing that almost 30,000 hospital meals are thrown away uneaten and untouched every day. Is that because they are inedible or because some are not fed to patients? Or is it because the plate was put too far away for the patient to reach and whipped away with no help offered in either reaching or feeding, which is extremely common? Some hospitals throw away more than one-third of prepared meals. Some are even worse: the Middlesbrough primary care trust threw away 43 per cent of all prepared meals. What a wicked waste.

When asked about this, a health Minister in the other place blithely commented that no one should be concerned and that the situation merely reflects the need to give patients a choice. But I understand that those meals had already been ordered by the patients. They had made their choice. That excuse will not wash: figures released show that more than 8,000 people left hospital last year clinically malnourished. More than 240 people die in hospitals and care homes in England from malnutrition every year, which is truly shocking.

It is very wrong that there are still instances of MRSA, C. difficile and other killer bugs in our hospitals. Great efforts have been made to make the wards clean. Billions of extra pounds have been spent, but 24 trusts still fail basic hygiene tests. Wards are too crowded, with beds often packed tightly together. Nurses go out and about in the towns nearby, still wearing their uniforms. They pick up germs everywhere and go straight back to deal with patients in the same uniforms—which matron would never have allowed. Some hospitals allow too many visitors.

I am extremely concerned to have heard from several sources that the true numbers of deaths from these bugs are deliberately hidden and that death certificates often state the cause of death to be something other than MRSA et cetera. Trusts do not want the true cause known. No questions are asked if a person dies of pneumonia or a heart attack, but they do not want to let it get out that people are still dying of MRSA. Surely falsifying a death certificate is illegal.

Replacing matrons with managers was a mistake. I am sure that many hospital managers could run businesses brilliantly. But a hospital is not a business. One needs to have some medical knowledge in the task. Managers are not matrons. The former cannot be expected to run a hospital as efficiently as the latter.

I have raised other cases of bad treatment. For example, some patients are left in a cold ward with windows wide open and no warm coverings. Their deaf aids are taken or lost, which can make them seem confused and subnormal, and stricter discipline can be enforced. Ignoring repeated cries for help in getting to the bathroom is also common. A dossier of 25 cases, all of which I checked personally, was submitted to Ministers in this House. Those Ministers were helpful. They listened and the details were passed to the trusts concerned—where they met a blank wall. The allegations were either ignored or denied. Some of them were not investigated at all. The only thing that came out of the exercise was the introduction of a mysterious thing called a red tray. No one explained what it was, how it was proposed to use it, or what instructions to staff went with it. The noble Baroness, Lady Wall, kindly told me of her own personal experience, but none of the officials explained. So we never got far with the dossier.

The big question is whether this new body, the Care Quality Commission, will do better. Well, it is not exactly a new body, more a grouping together of three old bodies. The trouble is that, none of them, individually, has managed to right the wrongs that exist. In the introductory papers about the new body there is no admission whatever that there ever were any wrongs. The document says that the CQC will build on the good work of the existing commissions. That is the same old refusal to admit there is anything at all amiss—no hint of acceptance that improvements are needed. Sack the whistleblower: ignore the evidence.

Another quote from the document that the CQC put out says,

“our job is to make sure that providers continue to meet … quality standards”.

What does it mean “continue”? What quality are we talking about? It has not even started.

The setting up of the CQC will hardly improve matters, since the lady named as chief executive is the very same person who was responsible for checking the standards of care at Stafford Hospital, to which I have already referred. That has a dreadful record. It is reported that hundreds died there needlessly because standards of healthcare were so bad. It is reported that the number was somewhere between 400 and 1,200. That does not sound as if her checking was up to much. Whatever excuses may be made, whatever denials or apologies, the Government cannot expect that this chief executive, with this record at Stafford Hospital, comes into her new job with any confident backing.

That excellent organisation, Help the Aged, is currently campaigning for sick and elderly people in hospitals to be treated with dignity. It has my strong support, especially its demand for an end to mixed wards. There is no dignity, and small protection, for those finding themselves in the next bed to a stranger of the opposite sex at night, when there are not many staff about, and the ward is dark and undersupervised. Ministers seem to have given up on the problem. They say the sexes cannot be separated. Why not? They always were. Unless we are talking about intensive care and patients who are unconscious, mixed wards are an abomination.

There is no dignity in being left to lie for hours in a soiled bed. On 31 March, the BBC reported the case of a pensioner who snatched her elderly husband from a Stevenage hospital. She was so upset at his bad treatment, including being left in a wet bed, that she resolved to take him away—and she did. There was a row with the staff, who threatened her with the police. That should never have happened, but it has happened since. The staff have no right to threaten such people with police action and give them a police record. That is appalling. Since then, that lady’s husband has been fine, much more comfortable and happy. I understand that following the programme, the BBC was deluged with listeners who knew from experience exactly why the wife was determined to take him. His was not an isolated case. I could mention other wrongs, but time is short and others wish to speak.

How sad that, while medicine and pharmacology have made such enormous strides, the standards of care and respect for patients as human beings has declined almost past belief. Our brilliant surgeons can do heart, liver and kidney transplants—soon they will be doing whole face transplants, apparently—and our marvellous scientists can produce drugs that can combat almost every known disease. We have thousands of excellent nurses, but we can no longer ensure that people who go into hospital will receive the most basic care or keep their dignity. Does the Government’s public health agenda include any resolve to tackle these problems?

My Lords, I congratulate the noble Baroness, Lady Knight, on her determination to follow through on a subject that she so clearly cares passionately about. I have chosen to concentrate on a different aspect of the public health agenda, which is that of trying to get people to help themselves through encouraging them to exercise. I often feel that I have to talk by myself on this subject and that people do not relate to me, but now I have the happy experience of being able to refer to an NHS document. I shall give the full title: A Systematic Review of the Evidence Base for Developing a Physical Activity and Health Legacy from the London 2012 Olympic and Paralympic Games. What the document shows as you go through it is that there is a huge public health benefit to be derived from getting people to take exercise. That is not a revelation, but the fact is that we should exercise because it is one of the most effective forms of, let us say, self-maintenance.

The problem is that the Olympic Games have gone from being a dream to a cure-all in many fields. The document goes into how things should be implemented and lists local authorities, primary care trusts, schools, colleges and stakeholders. Later it mentions local government, LOCOG, national stakeholders and so on. Noble Lords will get the idea. I have spoken about the benefits of exercise before, which has produced interesting exchanges. I have often asked the noble Lord, Lord Davies, which department is responsible for increasing the take-up of exercise. He has responded by saying that it is the NHS or the Treasury. When I ask who will do it, one or other of those two departments will be quoted, but how do they work together and where is the guidance?

I suggest that in encouraging people to take exercise and play more sport, we should note the difference between what is exercise and what is sport. It is rather odd. Sport is something that you decide is a sport. Going for a run can be thought of as a sport, but people may regard it as a way of trying to keep their waistline down because the doctor told them to or they want to fit into last year’s clothes. Is running a sport or is sport something that needs a different type of support structure?

Having indulged myself for a few minutes, I come to the essence of what I am trying to get at today. How are the Government going to support both the Olympic movement and other bodies that work with sports at the participation level, where we are not talking about elite athletes? How is the Department of Health encouraging people to get involved? For instance, is the department going to develop a policy of naming and shaming local authorities that do not provide sufficient parks in which to take a pleasant walk? That is basic exercise rather than playing a sport. A good walking strategy for each town centre should be provided because it certainly would cover an exercise agenda. Will we make sure that local authorities have to comply or, if they do not have to, will we shame them if they do not? Are we going to ensure that there is sufficient open space to walk dogs, for example? The great excuse for taking exercise in our society is walking dogs. In rural areas, will we ensure that all footpaths are open? Will this be monitored? Will this be driven forward? If the Department of Health is not doing it, who will do it? The big beasts of the departments are involved here. Sport lives in the Department for Culture, Media and Sport, but I would have it transferred to the Department of Health. There is disagreement in my party about this, but I like to nail my colours to the mast.

The question here is how we will achieve this aim. The document about the Olympics gives examples of how it might be achieved. However, the fact that we have a huge event that people watch on television will not guarantee greater participation, although it may encourage it in a few areas. It became blindingly obvious to me when it was pointed out that it may encourage people to take sport more seriously and push on to the next level but it will not necessarily encourage people to take up sport. This may be because it is discouraging to see the world’s best when you are wandering around without the basic skills.

How will the Government tap in and allow greater participation? Will the Department of Health make sure that there is better funding for basic-level coaching? This could be about movement and the ability to participate in sport occasionally. If you occasionally play five-a-side football and keep yourself fit enough to do so, exercise and sport will combine.

Do the Government have a definitive method for counting the increase in exercise? The same applies to interest in sport. If there was such a measure, at least we could tell whether we were succeeding or not. There is no guarantee. If the Government turn round and say, “Our gains are more successful than anyone’s in the past for increasing participation”, we will have a good excuse for bringing to account the relevant Minister, because this is the first Olympics where the Government have said that this is one of their goals. We must have realistic, minimum targets.

I now turn to a matter for which the Department of Health must bear sole responsibility: the provision of sport and exercise medicine. I asked about this a couple of weeks ago—the exact date escapes me—and the Minister pointed out that in 2005 the Government gave a commitment to provide enough consultants in sport and exercise medicine. The figures that I have are that there are eight trained individuals, whereas it is reckoned that we need 72 as a basic requirement. In the medical system, consultants are required to pass on information and to make sure that people have the necessary support.

There is a movement to replace certain kinds of drug therapy with exercise therapy. That relates to the obesity strategy and so on, but I will not go into that. The noble Baroness can take as read my criticism of the body mass index as a guide to obesity. The index fails to take into account that someone may be heavier built and that muscle per volume is much heavier than fat. My favourite statistic relates to Pinsent and Redgrave. When they won their last medal, they were simply heavily overweight as opposed to obese. The body mass index is a blunt instrument, which does not apply to anybody who is taking exercise that allows an increase in muscle mass. People can get heavier and fitter. This kind of exercise does not apply to this chart.

Why is it important that we have this extra guidance? One of the younger Members of this House—he is not in his place—who along with me is regularly required to compete with another place at various silly events, damaged his knee. It was a muscle tear—nothing serious. The doctor told him not to exercise for six weeks. If you leave a muscle not working for six weeks, it gets weaker, the tendons and ligaments around it are left in worse shape and, when you go back to using it, it is more likely to be damaged. That is a basic level of ignorance that is shocking in a doctor. How can we get people at the top who will ensure that when this occurs, if the doctor does not know what to do, he will consult on up—or indeed sideways, for physiotherapists?

We need people in place. If we take into account that these doctors are necessary for the implementation of the strategy, what are we doing to make sure that they are there? We have provided the training posts—usually by shifting funds around, or so I am told—but we are not providing the consultancy posts. People have dropped out of the training because there is no end place for them. If you are a registrar and you want to train, you might think, “I’ll further my career—oh, there’s nowhere to go, so I’ll stop doing the training”. That is perfectly natural in that situation; I am sure that if any of us was in a similar one, we would do the same. What are we doing about this?

I see that my 10 minutes are up. I suggest to the Minister that we need answers on this. Without them, much of what the Government are doing here becomes simply meaningless.

My Lords, I thank the noble Baroness, Lady Knight, for giving us the opportunity with this debate to raise issues of public health that are sometimes rather difficult to get into that context. I shall concentrate entirely on the issue of prison healthcare because although it is not currently in the public health agenda, I submit that it should be. Prison health is a public health issue.

When I took over as Chief Inspector of Prisons in 1995, I was surprised to find that, in the whole of the United Kingdom, only prisons were not part of the NHS. Prisoners were in the NHS before they went into prison and when they left prison they went back into the NHS, but while they were in prison they disappeared from the NHS radar. Prison Service healthcare used to claim equivalence with the NHS for maintaining this, but how could that be when only 10 per cent of prison medical directors were qualified to act as GPs in the NHS?

There was no properly structured nursing force, particularly for psychiatric nursing, not least because there were no career opportunities for people to develop careers inside such a small organisation as prison healthcare. There were therefore far too many short-term agency nurses, employed at great expense, which did not contribute to consistency or continuity of improvement, if such a thing was possible. What is more, prison doctors did not have access to notes on people before they came into prison, nor did doctors, after someone had been released, have access to notes made in prison almost without going to the trouble of getting an affidavit.

There were particular problems with the lack of professional oversight from all the NHS arrangements for such oversight that exist in hospitals and elsewhere. The only oversight was from my own inspectors, among whom I had a doctor and a nurse, but then we inspected only every five years. That was not good enough for overseeing the whole system.

Why is this a public health issue? Because every single prisoner, with the exception of about 30, is going to come out. The physical and mental health of that person is therefore a matter of interest for the public among whom they are going to be released. They may have physical ailments that, unfortunately, flourish in the prison environment, such as varieties of TB and all the blood-transmitted viruses such as HIV and hepatitis C. People age in prison; indeed, they age much more quickly in prison than they do outside. Children in prison can stay with their mothers until they reach the age of 18 months.

Then, there are the dreadful mental health statistics, with at least 70 per cent of prisoners suffering an identifiable personality disorder and about 500 requiring transfer into secure mental health accommodation because their condition is such that prison is wholly inappropriate as a place to hold them. Thankfully, since 2004, prisons are part of the NHS and healthcare provision is offered by primary, secondary and mental healthcare trusts. This is not the place to comment on the patchy nature of that provision, particularly in mental health, but it is important to have an overall direction and strategy for how healthcare is delivered. There is a great danger that unless you have consistent oversight of what is done, particularly for those with mental health problems, they will come out of prison worse than they went in. That is avoidable and inexcusable.

I say as an aside that I have always thought that one reason why prisons should be regionalised—as the noble and learned Lord, Lord Woolf, recommended in his report following the Strangeways riots in 1990 and as picked up by the only White Paper on prisons, Custody, Care and Justice, published in 1991—is to avoid prisoners having to leave their own region. That would give regional NHS authorities an opportunity to have some control over what is done with and for their own people, whose treatment will be their responsibility on release. Prisoners should have a proper physical and mental health assessment when they enter prison and plans should be made to treat anything discovered while they are there, taking the opportunity of the sentence to make real progress. For people with mental health problems, that can include the development of a sustainable lifestyle with the clear understanding that what is established should be carried on elsewhere. This is where I believe that public health clicks in. It would be irresponsible to do less than I have outlined. It would be irresponsible to the public to whom the prisoner is returning.

Today the Bradley review on diversion was published. It concentrates largely on people in prison who have mental health problems. It contains 82 recommendations, and the Government have announced that they accept all of them in principle. However, there is obviously work to be done. I was fortunate enough to speak to the noble Lord this morning but I have not yet read the report. I asked him particularly whether his report contains signposts suggesting that public health authorities need to get on to what he is proposing and make it their responsibility for carrying it out. He said that it does. One of the things that he has recommended is a national programming board with an advisory board to serve it. That national advisory board will not achieve anything unless there is a part of the NHS which is responsible and accountable for seeing that those recommendations are delivered.

Prison healthcare is comparatively new to the NHS, and many different trusts are involved in contract work in different prisons, but what matters is that one part of the NHS should be responsible for overseeing the consistency of that treatment, wherever it is given. Oversight of the provision from these various trusts also is needed to ensure that every prisoner has the assessment needed to ensure that this opportunity is not missed. It makes absolute sense for public health authorities to be given that responsibility. I urge the Minister to pursue this matter with her department after this debate.

My Lords, I am very grateful to the noble Baroness, Lady Knight, for her perceptive intuition in inspiring this debate at this crucial moment when the press is dominated by the possibility of a flu pandemic which would challenge considerably our public health agenda. I want in that context to draw attention to the Department for Communities and Local Government paper issued this week on Faith Communities and Pandemic Flu. I thank Monsignor John Devine and the Faith Communities Consultative Council for their input, and I stress the crucial importance of faith communities in any pandemic.

I am very grateful for the measured government response to the current flu threat, both in calling for vigilance and in combating irrational panic. It is crucial that, should there be a pandemic, anyone infected stays at home. It is equally crucial that those not infected continue both to work and to support those who are ill. Basic respiratory and hand-hygiene standards, such as the use of tissues and careful hand washing, are key to our care for one another. That fits in closely with the issues raised by the noble Baroness, Lady Knight, about hygiene in hospital. It applies also to hygiene within our communities and would do so very particularly were there to be a pandemic.

I also welcome and affirm the ethical framework of the DCLoG document: that in a pandemic all people matter equally. In that context, the prayer and worship of faith communities matters crucially. That would provide support for those who are ill and strength for those not infected to provide help for others. I particularly commend, from that document and elsewhere, the development of flu-friend networks which can be based in churches, mosques or other faith communities or elsewhere whereby there is organised provision to collect antivirals for vulnerable people. That is something that can be set up locally—it must be set up locally; it cannot be set up in any other way—and would provide a structure whereby help can be provided in the event of a pandemic.

Imaginative ways of contacting people with prayer and support need to be developed locally, including internet prayers and phone numbers advertised alongside those provided through the NHS. It is also important that faith communities consider how to adapt their own ceremonies should a pandemic arise, such as, in the Christian community, the receiving of communion in bread alone without the use of a common cup during such a period.

I remain haunted by that government assertion that everyone matters equally. There are many in this country for whom it does not feel like that. This Sunday, I shall be worshipping at St Hilda’s, Cross Green, in Leeds, where there is a particular ministry to asylum seekers, some of whom are terrified by fear of the authorities. In a situation such as that of a pandemic, there will be a particular responsibility on faith communities both to affirm that ethical affirmation of DCLoG and to care for those who often feel themselves to be rejected by others.

I also want to make a quite different contribution to this debate. If the threat of a pandemic is an immediate concern—and it is, and the public health agenda needs to deal with it—so there is the longer-term threat to our public health of alcohol abuse. How are the Government developing their policies to combat such abuse? In the city of Leeds alone, the cost to the local economy of alcohol-related harm is estimated at £275 million a year. The cost to the NHS is vast. The cost to individuals, both temporary and long term, is encountered in damaged lives. I suggest that this is one of the most significant current threats to public health and that we have developed a culture of alcohol abuse that needs determined combating.

I take noble Lords, as I have been, to the accident and emergency department of St James’s Hospital in Leeds. A chaplain has been called to support a family where the grandfather has just died; a precious moment of farewell and commendation that we have all experienced in one way or another. It is Friday night, and this is the casualty unit in a large city, so that farewell takes place in the context of staff struggling in a battlefield, responding to the needs—the genuine needs—of intoxicated strangers. It is not a farewell that I would wish on anyone.

Those who work as professionals in public health are in my experience convinced that action must be taken to limit easy access to cheap and destructive alcohol. The Government seem to have turned their back on Sir Liam Donaldson’s call for significant price rises in this area, but it is not clear to me what other strategy will be able even to begin to deliver us from the human and financial costs being incurred. Responsible drinkers would be little affected by price changes. For those given to abuse, there needs to be a progressive impact to encourage a speedier return to personal health and stability. We have found ways—we could probably find better ways—of doing that for tobacco. Perhaps amendments to the Health Bill on Report will strengthen our response to that particular problem. There needs to be a similar strategy on alcohol.

So much of the human tragedy in our society has alcohol abuse as an element within it, whether it is domestic violence; whether it is increasing numbers of people going to prison and therefore becoming subject to the issues that the noble Lord, Lord Ramsbotham, has raised; whether it is to do with broken relationships, or with our ability to take that exercise that the noble Lord, Lord Addington, so ably advocates. There needs to be local work involving primary care trusts and faith communities. There also needs to be government action to promote behaviour that serves the community and to foster personal responsibility. The Government are rightly determined to do that in the case of a pandemic. I look forward to similar commitments on the much longer-term damage of alcohol abuse.

My Lords, I thank the noble Baroness, Lady Knight of Collingtree, for introducing this debate on public health, which could not be more topical. I do not think that the debate was planned to take place in the very week when the world is plunged into the vital need of public health across the globe due to swine flu. It may be better referred to as Mexican flu, named after the country of origin, as were Spanish flu and Hong Kong flu. This is a complicated virus, containing pig, fowl and human viruses. The fight to control a flu pandemic will involve many professional bodies, and the public should be kept informed with the correct information and guidance to take the necessary precautions.

Having visited Mexico some years ago and having succumbed to Montezuma’s revenge, resulting in the most violent diarrhœa and sickness, I wonder whether Montezuma has done something to make this virus worse in Mexico. When I flew over Mexico City, there were miles of shanty town on the outskirts of the city and a cloud of pollution hung all around. Many of the so-called houses were tin shacks, and many people were living in poor conditions. Poor housing often contributes to poor health.

The virus seems most complicated. I have a few questions for the Minister, as we did not have the planned Statement yesterday. Does the virus have a window of about three weeks when a person may be infected, but the test does not show positive? Does the manufacture of the quantities of vaccine needed not require thousands and thousands of eggs? Do we have enough eggs? Does Tamiflu have a sell-by date? If so, is our stockpile still in date?

The fourth report of the 2005-06 Session of the Science and Technology Committee, Pandemic Influenza, asked the Minister whether the Health Protection Agency, responsible for frontline management and the emergency strategy on the flu pandemic, will have enough funds and capacity as some of the agencies have been merged. Is it adequately equipped to manage if the pandemic spreads? Will there be enough testing capacity? Will more people be drafted in to help, and will funds be made available to cope? What are the plans for distribution of antivirals?

For some years, the World Health Organisation and our Chief Medical Officer have been telling us that there will be a flu pandemic. The world is now on full alert. The importance of public health and other organisations coming together and working for the good of society is absolutely vital. There must be good communication with the public and honest, transparent networking.

As a precursor to my Question on 13 May about the cases of Panton-Valentine Leukocidin—PVL—positive staphylococcus aureus, I am concerned that this public health matter which can come in from the community and affects young, fit people and children who pick it up from playgrounds, sports halls and military camps, can be missed through a lack of knowledge by GPs and hospital doctors. The symptoms are flu-like. The body’s immune system packs up and white cells stop fighting. If not treated, victims can die in a few days. The last case that I heard about was that of a student from Harrow School a few weeks ago, who became very ill with PVL MSSA. This has been a serious problem in the USA. There needs to be very good surveillance and awareness, as there are so many different strains of MRSA. Another concern is that of pigs infecting humans in countries such as Holland. Does the Minister agree that there should be a close working relationship between veterinarians and microbiologists? There should also be close co-operation over the serious problem of variant CJD and blood safety.

Public health is of huge importance in our prisons, as my noble friend has said. With conditions such as HIV and tuberculosis, prisoners need to be on courses of medication. There is no guarantee that they will continue treatment or seek medical care once they are released into the community, especially if they are homeless and have multiple diagnoses. Prisons have different systems that do not communicate with each other, making it difficult to establish an offender’s medical history. Only a few prisons use online systems. On a recent visit to Pentonville prison, which has a high incidence of tuberculosis, it was good to meet a dedicated nurse specialising in TB, who works between prisons. She told us that multidrug-resistant TB was a great concern. With the homelessness and chaotic lifestyle that many prisoners have on discharge, that is a serious public health risk. Drug and alcohol misuse is also a huge problem. When asked how the prison contains an infection outbreak, they recommended that screening within 24 hours of arrival is crucial to safeguarding the prison against the spread of infection.

For many years, I have felt that there should be a good, all-round health education in all of our schools. Children should learn that healthy eating and exercise will give them the best chance in life. They should learn about the dangers of type 2 diabetes and how to avoid it, about the result on their health if they smoke, and about sexually transmitted diseases and substance misuse. There should be more testing in the community for conditions such as venous thromboembolism, or VTE, which accounts for more than 25,000 deaths in England alone, and for so many others which, if detected in time, will save people from having long-term conditions as well as from dying early. Prevention of illness is so important.

I shall end on a positive note. On Tuesday, I went to an exhibition at the Design Centre, “Design Bugs Out”. The Design Council, the Department of Health and the NHS Purchasing and Supply Agency brought designers together with clinical specialists, patients and front-line staff to test an innovative approach to procurement. They should be congratulated on that excellent initiative. There was equipment there such as bedside cabinets, a commode with rounded edges and disposable pan, a patient bedside system, a patient’s chair and a porter’s chair—all with curved, smooth edges—an intelligent mattress with an inbuilt early warning system, which allows soiled mattresses to be identified and replaced as soon as they become contaminated. There was also equipment for doctors and nurses, such as blood pressure cuffs and a cannula time tracker. All were easy to clean, to help overcome health-associated infections such as MRSA and C. difficile. This is to promote good clinical care. Equipment is likely to be cleaned properly if it is easy to clean. This exhibition will be taken around the country and I hope that orders will be placed.

I am pleased to learn that the National Institute for Clinical Excellence is increasing its public health promotions. If public health is neglected, it will be at our peril.

My Lords, if persistence is deemed to be an Olympic sport in 2012 I will be there when the noble Baroness, Lady Knight of Collingtree, picks up her medal. I thank her for giving us the opportunity to have this wide-ranging and absorbing debate.

As the daughter of a Methodist minister who was also a chaplain, I found the right reverend Prelate’s speech most perceptive and very moving. The question asked by my noble friend Lord Addington on sport and health prompted me to think that, if you were to ask three different government Ministers what a boxing match was, you would get three different answers. The Department of Justice would say that it is a means of reducing youth offending; the DCMS would probably describe it as a noble art; and the Department of Health would point out its potential for causing sub-cranial neurological trauma and consequently the necessity for it to have a risk management programme attached to it.

A few weeks ago, a fast-food chain announced that it would create 6,000 jobs. At the same time my colleagues on Leeds City Council explained that they were going to make about 300 staff redundant. When they were challenged on the “PM” programme, they explained that a number of their sources of funding and revenue from central government had been cut but that they were also suffering other losses of income, including loss of revenue from their swimming pools because people cannot afford to use them. That is a deeply depressing symptom of a recession, but I want to stress the importance of the public health agenda now and in the future.

The Faculty of Public Health defines public health as:

“The science and art of preventing disease, prolonging life and promoting health through organised efforts of society”.

To that one can add that the politics of it all is about providing the means to do so. At times of economic recession, it is easy to see public health as a soft target and an easy place in which to make cuts. However, I want to try to persuade the Minister that to do so would be false economy. I do not want to repeat at length the details of the Budget. I am sure that noble Lords will have absorbed all that for themselves by now. However, I should point out that for the next two financial years Department of Health funding will stay broadly the same. People in the NHS have breathed a sigh of relief about that. However, we should encourage them to see those two years as a very short window of time within which they, as health professionals, should work with the Government to reorient the NHS to be a major bedrock of public health development. If they do not, in about four or five years’ time we will be left with the remnants of a health service that may well have been fit for purpose in times of affluence but is not so in times of recession.

In February 2009 the Health Select Committee in another place produced a fascinating report on health inequalities. It is a fair report and acknowledges that the Government have attempted to tackle health inequalities, have bravely set themselves demanding public health targets and have targeted resources at areas of deprivation. However, one of the most striking and compelling points made by the committee is that there is a lack of evidence with which to judge the effectiveness of the programmes that have been funded and their cost-effectiveness. The report says that, all too often, the Government rush in with insufficient thought and do not collect adequate data from the beginning. Frequently, objectives are unclear and policies are changed or implemented with such short timescales that meaningful evidence cannot be gathered.

If anything, the Health Select Committee understated the case. The ability to evaluate public health interventions and the lack of an evidence base for doing so not only affects the NHS and other government departments but hampers the work of the voluntary sector. I point out to noble Lords that the great bulk of public health and preventive work is carried out not by the NHS, or even by the state, but by charities and the voluntary sector. Their work is also seriously impeded by the lack of an evidence base.

Politicians of all parties are under no illusions whatsoever that, in future, public services will be under increased pressure. There will be an imperative to make sure that funding of services goes to the most efficient and effective. I particularly ask whether the Government agree with the Health Select Committee that Professor Sir Michael Marmot’s forthcoming review of health inequalities is an ideal opportunity to introduce new evaluation methods that are ethical and economical. Do the Government also accept that Sir Michael’s review should include work on inequalities in secondary care and, therefore, should review the payment-by-results framework?

The Government have done a tremendous amount of work on such matters as coronary heart disease and cancer. Not to acknowledge that would be churlish. We need from that work the evaluation data that enable us to see how the NHS can become more productive in future. My noble friend was right: the majority of work on public health is not done by the NHS at all; it is done by other government departments. The WHO Commission on Social Determinants of Health recently stated:

“Communities, neighbourhoods and cities that ensure access to basic goods, that are socially cohesive, that are designed to promote good physical and psychological well-being, and that are protective of the natural environment are essential for health equity”.

Social reformers since the 19th century have been trying to persuade Governments of just that.

My colleagues in another place, Vince Cable and Nick Clegg, have stated repeatedly that a key part of our economic recovery will be investment in green technology and in such matters as environmentally sustainable housing. If there is to be a silver lining—and I am not Pollyanna, by any means—it will be that Governments rise to the challenge of making radical changes to the planning system and infrastructure development to bring about communities that have better health outcomes and reduce health inequalities.

In the short time available, I will mention one further matter. The Healthcare Commission, under the leadership of Anna Walker, ceased to be at the end of March. Its final report was on mental health and older people. It is an excellent report, which I commend to the House. I mention it because it is a public health matter to which very little attention is paid. As with other services, there is a lack of data, but the Healthcare Commission found in its research that, for older people, access to mental health services—and particularly to crisis and emergency mental health services—is wholly inadequate, just because those people are aged 65 and over. In times of recession, it is understandable that Governments put the bulk of their resources towards those members of the community who are most economically active, such as younger adults. However, older people are the biggest users of public services. I hope that the noble Baroness will encourage the department to look at the report’s recommendations, which are not really for large-scale further public funding. They are for better data and systems, so that existing services can be made better.

In 2004, Derek Wanless pointed out in his report on the National Health Service that, for the health of the nation to be drastically improved, public health and the awareness of individuals about what they could do to lead healthy lifestyles would be important. Five years on from that and standing as we are on the brink of a recession, it is even more important that his message about the priority of public health should be taken up by the Government.

My Lords, my noble friend Lady Knight is to be congratulated on her customary wise and incisive speech introducing this important topic. I am grateful to her for giving us the opportunity to debate it because, far-reaching as it is, public health is an area of policy that tends to receive less than its fair share of discussion in your Lordships’ House.

When defining “public health” to myself, I tend to go back to the words quoted by the noble Baroness, Lady Barker. Those words originated with the former Chief Medical Officer, Sir Donald Acheson, who, I remind the House, spoke of public health as,

“the science and art of preventing disease, prolonging life and promoting health through the organised efforts … of society”.

That definition has been tweaked by the present Chief Medical Officer, who has brought in the more current subject headings of health inequalities, clinical governance and the management of risk. The distinguishing feature of public health is surely that it relates to initiatives that reach across populations and groups as opposed to the curative treatment of individuals. One could range far and wide to topics such as housing and education, even taxation, and still not stray off the subject of public health, but I should like to focus today on issues that fall directly within the Minister’s purview and on one in particular about which we have heard this afternoon: health inequalities.

If we seek to identify improvements in public health over the past 20 years, we can point to a number of successes. On what might be called the big ticket issues, life expectancy across the population is improving and infant mortality is falling. The rate of improvement is not as great as it is in some other western countries, but it is still an improvement. Among the major targets in public health policy, we can look with some satisfaction at the trends in smoking prevalence and the consumption of salt in the diet where, taking the bald averages, both are both going down.

However, there are other areas of public health where success has been more elusive. Sexual health is one, dental health is another and the one about which we hear quite a lot, obesity, is proving a very difficult nut to crack. The evidence on these three areas is that they are much more of a problem among lower socio-economic groups. That is the reason why part of the Government’s public health strategy has been to target specific areas of health inequality—that is to say, disease areas that affect certain subsets of the community most damagingly.

Health inequalities are a stark measure of a Government’s success in delivering good public health, so it is welcome that the Health Select Committee in another place has recently subjected this aspect of the topic to close scrutiny. Its report makes fascinating and sometimes depressing reading. Over the past 10 years, health inequalities have in fact widened, not only between the rich and the less well-off but also between the population as a whole and other sectors of the community who are seen as being harder to reach: ethnic minorities, those with mental health problems and the elderly. To call the Government’s record a failure because of the widening gap in inequalities would perhaps be overly harsh, because it is a tough test, but unfortunately the charge of failure begins to stick when we look at the committee’s findings elsewhere.

The committee’s most damning criticism relates to the Government’s whole approach to policy in this area. I would describe it as a lack of intellectual rigour. It is a story of eye-catching initiatives which are poorly designed and rushed into being without proper baseline information or clear objectives. Evaluation of these initiatives too often consists of simply examining the processes that have taken place and asking people what they thought of them. To compound the sin, there has been short-termism—changes of direction and a failure to maintain policy long enough to know whether it has worked. The net result, in the words of one witness, has been that,

“we have wasted huge opportunities to learn”.

Indeed, large amounts of money have been poured into initiatives such as health action zones, healthy towns, healthy schools and the expert patient programme. What we get at the end of them is a series of inputs, throughputs and customer satisfaction measures. None of them has produced results that tell us what we need to know, which is what interventions actually work. Professor Ken Judge of the University of Bath put it quite brutally when he said:

“We end up with rich descriptions of what people are trying to do. These ... are then used as evidence of good practice because we do not have anything else and we slide inexorably from setting these things up essentially to the production of propaganda”.

The committee was uncompromising in its conclusions. It said:

“Such wanton large-scale experimentation is unethical, and needs to be superseded by a more rigorous culture of piloting, evaluating and using the results to inform policy”.

Of course, much of the public health agenda is delivered locally through PCTs, but here again there is cause for concern. The committee found that strategic health authorities and PCTs are not providing satisfactory leadership in public health. The number of senior public health specialists is falling. We have seen funds for public health siphoned off into other areas during times of budgetary pressure. My own view is that we need to look again at the idea of ring-fencing a goodly portion of the public health budget to prevent the same thing happening again.

More than that, when tackling health inequalities, there is a perception that many PCTs are simply unsure of how to spend their funding allocations to the best effect. If that is true, it again reflects poorly on the quality of leadership, not least national leadership. There is a drive by the Government to improve access to GP services, which is welcome. Equally welcome is the intention to rebalance the QOF towards public health goals. But other things have suffered. I am thinking particularly of early years intervention with mothers and young families, where the scope to combat health inequalities is considerable; yet the number of health visitors and midwives—the very professionals best placed to deliver help—has also been falling. NHS dentistry has been one of the Government’s stated priorities; yet, again, reality belies the rhetoric. Access to NHS dentists has gone down since the introduction of the new contract. None of this is exactly a story of stunning success.

Central to much of the effort in this area are health promotion campaigns. We have seen a succession of such campaigns over the years, a lot of them related to healthy eating. On the plus side, there is evidence that some of the key messages are getting through. As a nation we are eating more fruit and veg than we used to and taking more exercise. Our intake of alcohol is going down. But the key issue here is not the averages; it is whether enough of the right people are permanently changing their behaviour. The Minister will be aware that the King’s Fund has levelled some serious criticisms on exactly this point. It and others have stressed that one-off advertising campaigns cannot hope to change deep-rooted attitudes and behaviour. It would be helpful to hear from the Minister how the latest TV campaign, “Change4Life”, hopes to overcome that criticism.

The rise in obesity continues, as does widespread alcohol abuse among teenagers. More than two-thirds of adults still do not know what exercise they should be doing, what amounts of alcohol are unsafe and even what a portion or fruit and veg consists of. If we are aiming to create, in the words of the Secretary of State, “a lifestyle revolution”, what can make us confident of doing that? In the final analysis, if we cannot improve public health, we will not be able to afford the NHS. That is why this debate is vital and why, in one form or another, we shall return to it over the months and years ahead.

My Lords, it is with great pleasure that I respond to this debate and to the opportunity provided by the noble Baroness, Lady Knight, to highlight the Government’s public health agenda. I congratulate her and other noble Lords on an interesting debate. She has drawn attention to issues of which the NHS is aware and is acting on, from matrons to the organisation of wards and infection control, which are of course of great importance.

I do not accept the failures in regulation alleged by the noble Baroness, given that in the past there was virtually no accountability for doctors and other medical professions at local level, which is why we have focused during the past 10 years on giving our regulators a wide range of toughened enforcement powers and have enabled the new commission to take direct and independent action against service providers that fail to meet essential levels of safety and quality which people are entitled to expect.

I entirely agree with the noble Baroness that we need to deal with mixed-sex wards. The Government have never denied that. The Secretary of State announced in January a six-month drive to eliminate mixed-sex wards in hospitals. Three cornerstones underpin the programme: a £100 million privacy and dignity fund; improvement teams established to help those hospitals with challenges in this area; and working to establish financial covers in the context of the contracting framework between PCTs and hospital trusts.

The Government’s approach to public health cannot be described simply by a list of initiatives. It is about how we deploy our health resources and the leadership that we provide in this area. Our leadership is a response to our passionate belief that good health is a shared priority from the bottom to the top of the nation. Our starting point was that in 1999, only 1.8 per cent of total health expenditure went on prevention and public health. We now spend more than 3.6 per cent—double that spent 10 years ago.

Not everyone sees that as a good thing. Earlier this year, my right honourable friend Dawn Primarolo, the Minister for Public Health, pointed out that there is a school of thought that there is no such thing as public health. According to that view, any intervention in public health and any act to give individuals or groups support, guidance or safeguards is somehow an attack on their liberty. She rejected that argument, and so do I. Choice and control can be an illusion when you are very poor and in ill health. For those living in such communities, it is practical, tailored, focused support that makes the difference. That is our aim. For example, the health of communities collaborative programme is working in 28 sites among the most disadvantaged communities to raise awareness of the signs and symptoms of cancer and cardiovascular disease and to encourage people who may have those symptoms to seek help early. It is a community-based approach to public health that can be tremendously successful.

We believe that we have come a long way towards our aim to provide services that reflect changes in people's lifestyle, habit, environment and society. We believe that our campaigns are now much more sophisticated than they were in their targeting and their understanding of people's motivation to change. For example, the smoking campaigns funded by the Department of Health have been widely acclaimed by marketing experts in both the public and private sectors. However, as noble Lords have mentioned, those campaigns cannot work on their own. That is why Change4Life is rooted in research about people's behaviour and how they change their lives. It tells people how they can make positive changes as well as warning of the dangers of obesity. Clearly it is up to individuals what they eat, drink or smoke. It is not the Government’s intention to intervene unnecessarily or stand at their shoulder in the kitchen, as it were.

Our sexual health campaign has generated almost 1 million visits to the Condom Essential Wear website. More than half of 16 to 24-year-olds say that they are more likely to have a check up for a sexually transmitted infection as a result of seeing the advertising. We have already heard from the public and the media of lives saved following our stroke awareness publicity. Some may remember that I described FAST in your Lordships’ House, with visual aids. One clinician in Kent has reported seeing around 200 patients as a result of the campaign’s message. We estimate that the new cervical cancer vaccine will save the lives of up to 400 women a year.

There are other campaigns aimed at informing, supporting and empowering individuals and families to make healthy choices. These include seasonal flu immunisation, pandemic flu preparedness—I will refer to that again in a moment—stroke awareness, sexual health, HIV and having an NHS life check. All our major campaigns are evidence-based and subject to evaluation.

The noble Lord, Lord Addington, raised the issue of sporting and physical activity. Change4Life, launched in January 2009, focuses on pregnant women, parents of babies and toddlers and parents of pre-school and primary school children. In future years, we will see the development of programmes targeted at young people and adults. For example, £140 million was invested in our free swimming programme. The walking your way to health scheme, led by the Department of Health, Natural England and the British Heart Foundation, delivers nearly 2,000 walks to more than 30,000 people each week. We are determined that as part of our legacy for the Olympic Games, 2 million adults should be more active in 2012. This will include active travel, dance, gardening, and active conservation. We are measuring the activity that contributes to this target of 2 million people through an extended version of Sport England’s active people survey.

The noble Lord kept asking me who is responsible for this. It is a cross-government activity. It can only be delivered across government. The Department of Health, for whose activities I am partly responsible for, has its part to play, as do all the other departments mentioned by the noble Lord. He also mentioned the sports and exercise consultants. We had an exchange about the importance of the provision of sufficiently qualified medical experts for the Games and about establishing consultants and medical facilities as part of the legacy of the Games.

The noble Lord, Lord Ramsbotham, made an eloquent comment about health in prisons. Like him, I am looking forward to reading the report of my noble friend Lord Bradley. I know that the Government will look very carefully at his recommendations. The challenge that we have—the noble Lord will be only too aware of this—is that, since 2006, all prison health services have been transferred to the NHS; we are mainstreaming their services. Therefore, our target is that prisoners receive the same standard of healthcare as we would expect in the rest of the community. However, we know that that is easier to say than deliver. Indeed, there is a great deal more to do.

My Lords, are we going to hit the number of 72 consultants in sports and exercise medicine within the NHS?

My Lords, the noble Lord knows that part of the 2012 delivery is that there has to be a sufficient number of sport and exercise medicine consultants. If I recall correctly, that is two medical experts per event during the Games. I will write to the noble Lord again about this if he so wishes, but I am not going to go into it in detail now. We have every intention of delivering both the legacy and the Games properly medically equipped.

I thank the right reverend Prelate for being so on message about the Government’s work in these uncertain times of the threatened pandemic. I take on board his comments about the need to be aware of the challenges of the asylum-seeking communities and other communities at this time of uncertainty. I also thank him for his support for our forthcoming debate on point of sale for tobacco. We take very seriously the issues of alcohol raised by the right reverend Prelate. There is good evidence that cheap alcohol is linked to people drinking more and subsequent harm to their health. It is important that any Government intervene to reduce harm without, as the right reverend Prelate said, unduly impacting on the majority of responsible drinkers. We are looking to develop the evidence base on that issue.

The noble Baroness, Lady Masham, raised the threatened influenza pandemic. All NHS organisations have comprehensive plans which they are now bringing into action at the appropriate level. Every resilient forum in England has validated pandemic-specific plans, which were outlined by my noble friend on Tuesday in the Statement and yesterday in answer to a Parliamentary Question. I will not go into a great deal of detail. I am quite happy to give the noble Baroness and all noble Lords the latest briefing on this matter. But I can refer her to the website, which is very informative and is being kept up to date. I assure her that we will return to this issue and will keep the House fully informed about any developments during this uncertain time.

The noble Baroness, Lady Barker, made a very good point about how we will use the next two years, and about the importance of investment in the public health agenda. We are considering the Marmot review and taking it very seriously. I agree with her that the Healthcare Commission’s final report was very important. I undertake to follow this through and to make sure that it is given proper consideration.

The noble Earl, Lord Howe, raised a variety of issues about healthcare, public health targets and the various programmes that we are undertaking. The health and equalities targets were deliberately set to be ambitious and some progress has been made, although there is a great deal more to be done. We believe that there is a lot of headroom within the system for improvement. Our focus now is to provide tailored, intensive support to deal with issues such as high infant mortality, new GP practices in the most deprived areas, additional support for the early presentation of cancer and CVD, the take-up of vascular checks in disadvantaged areas and programmes to support communities, such as the improvement development agencies, healthy communities and communities for health.

One of the noble Earl’s colleagues in another place criticised Change4Life as a campaign that was an attack on the video games industry. Would the Conservatives spend more or less than Labour on public health information campaigns and do they support the Change4Life campaign, or does the noble Earl agree with his honourable friend that this is just a campaign against video games and that they are bad for you?

Finally, some time ago my right honourable friend Alan Johnson, the Secretary of State for Health, said that we are committed to examining what the future of public health policy should look like. We have a good record of success. We continually try to improve. Throughout my response I have highlighted some obvious examples of how we are making a difference to people’s health and well-being. We are investing in health; we are concerned about what health means and what public health is all about. I am grateful that we are able to continue this shared debate and look forward to hearing from colleagues in the future about this matter.

My Lords, this has been an interesting debate. Although we have not had many speakers—perhaps that is not surprising on the last day before a bank holiday weekend—all the points made have been varied and very interesting.

The point of the noble Lord, Lord Addington, that aspirations must be achieved, was a good one. He asked whether they will be achieved and whether we are sure that they can be achieved. There are doubts in many places about that matter. The House was most interested to hear from the noble Lord, Lord Ramsbotham. From his great experience he made a strong case for some fundamental changes in the way that sick prisoners are treated and under whose ambit they should come. I hope that his remarks will be taken on board, because they were thoughtful. Springing as they did from experience, they were worthy of great concentration and thought.

The right reverend Prelate the Bishop of Ripon and Leeds drew attention to something that no one has mentioned until now: the work and the willingness of faith groups. That is an important point that we often miss. I hope that the Minister will bear in mind the amount of good will and good intentions to help difficult areas in the health service. The noble Baroness, Lady Masham, talked not only about the pandemic but about the education that was necessary. I thought that that was a different and important point in the area of healthcare.

I listened with great interest, as I always do, to the noble Baroness, Lady Barker, who made some wise suggestions about the importance of directing finance. I hope that those comments will be listened to.

My noble friend Lord Howe talked about health inequalities. That is a subject on which he or I could speak for a very long time. It concerns us, and I hope that the Government have taken on board the worrying statistics that he gave us.

The Minister talked about mixed wards. I hope that we shall not be put off in the way that we have been in the past by saying that mixed wards have changed. At one point the Minister told me that 92 per cent or 93 per cent of all patients were not in mixed wards. I found out that the truth was that they were not in mixed wards because the name of the ward had been changed to an assessment ward. So one could say that they were not in mixed wards, but the wards were mixed: men and women were there together. They were not intensive care wards.

I thank most warmly everyone who has taken part in the debate, and I beg leave to withdraw the Motion for Papers.

Motion withdrawn.