House of Lords
Wednesday, 16 November 2011.
Prayers—read by the Lord Bishop of Norwich.
Unemployment: Young People
The most recent forecast from the independent Office for Budget Responsibility is for unemployment to level out and then fall from the second half of 2012. There is no separate forecast for youth unemployment, but this would be expected to follow a broadly similar trend.
Am I to understand, when thanking the Minister for that Answer, that the Treasury does not look specifically at youth unemployment when considering its policies? Is it the case that no Minister in the Treasury, no official and none of its excellent economists or statisticians has a view on when the rate of increase in unemployment, especially for young people, will become a rate of decrease?
Well, my Lords, the forecasts have now gone to the Office for Budget Responsibility and are the basis for planning. Clearly, the forecast that I have just given noble Lords is somewhat out of date and we are looking to have another later this month. Clearly, the implication of what the Governor of the Bank of England has just said is that growth will, on his forecast, run at 1 per cent this year and next, and this will be built into those kinds of forecasts.
My Lords, faced with the tremendously high rate of youth unemployment, is it not time that both parties accept that under both of them youth unemployment has increased? Is it not time that we put by party differences and had a united effort to tackle the problem of youth unemployment?
Is it not the case, particularly in old industrial areas, which have found it very hard to attract new private sector investment, that by withdrawing public sector expenditure too fast and abandoning regional development strategies, the Government are condemning young people to continuing unemployment?
My Lords, of course we are not withdrawing regional support. We have put in a £1.4 billion growth fund and have a series of programmes designed to help young people. We have help in terms of work experience, the sector-based work academies and the work programme, which will together provide support for 350,000 youngsters over the next two years.
My Lords, I am grateful to the Minister that he refused to adopt a false optimism in his reply. We all know from previous recessions that the impact on young people, particularly their morale and self-respect, lingers long after the recession is ended and creates ongoing social problems. Would the Minister agree that, instead of decimating youth services at this time, the Government should be seriously investing more in such work so that we have some chance of avoiding the loss of a whole generation to cynicism and hopelessness?
My Lords, I was very impressed, as I am sure many noble Lords were, with the report by Professor Wolf on what has been going wrong for young people. Her conclusion was that there are four things that young people need: a job, proper educational qualifications, apprenticeships or work experience. This Government are trying to concentrate on really effective solutions for young people.
My Lords, the Government inherited falling youth unemployment, yet this is the eighth consecutive monthly rise in unemployment and precedes the eurozone crisis. This crisis is down to this Government’s decisions to scrap the EMA, to cut post-16 education funding and to scrap the future jobs fund, and an austerity plan that has choked off growth. How bad will it get before the Government realise that you reduce the deficit by growing jobs, thereby cutting the cost of benefits and increasing tax receipts? When will we get a credible jobs plan, or will it take another million youngsters on the scrapheap before the Government finally get it?
No—let me tell you the real figures. The total number of unemployed and inactive youngsters went up from 1.4 million in 1997 to 1.45 million now and 1.39 million last year. That was an increase during the longest boom that this country has ever seen. Why did that happen? That was not cyclical, it was structural.
My Lords, my noble friend will be well aware of the even higher youth unemployment rates in Europe, particularly in Spain. He will also be aware of the comparatively low youth unemployment rate in Germany. Is there not a great deal that we can learn from the Germans in this?
Indeed, my Lords. The Germans have had a long tradition of apprenticeships and that is something that we need to copy and build on. We have put in money to fund an additional 250,000 apprenticeships over this spending review; we had 442,000 apprenticeships starting last year, an increase of 50,000; and we are putting in measures today to encourage smaller firms to take on apprentices.
Supreme Court: President
My Lords, the noble Lord will be aware that this is one of the matters being considered by the Constitution Committee of this House under the chairmanship of the noble Baroness, Lady Jay. However, the Government are committed to implementing the recommendations of the Advisory Panel on Judicial Diversity, which was chaired by my noble friend Lady Neuberger, including the recommendation that no judge should be directly involved in the selection of their successor. We are considering this issue along with the evidence presented to the House of Lords Constitution Committee and will shortly start a broader consultation on the matter.
I am grateful for that very helpful answer. Does the Minister appreciate that there is some urgency about this because the president of the Supreme Court, the noble and learned Lord, Lord Phillips of Worth Matravers, is retiring next summer? I think that the Minister is saying that he agrees that it is highly undesirable that a retiring judge, however distinguished, should play so significant a role in the appointment of his successor. Can he please indicate that there will be some urgency in the way in which the Government deal with this?
My Lords, perhaps I may say how much we on the opposition side welcome the Minister’s response to the noble Lord, Lord Pannick. If the Government will act urgently on the point that the noble and learned Lord, Lord Phillips, has spoken about, we will do everything that we can on our side to make sure that such a matter goes through Parliament as quickly as possible. Perhaps I may ask briefly about judicial diversity, in which I know the Minister has a particular role. Are the Government satisfied that they are doing enough to make sure that our judiciary is diverse enough? Many judges at all levels have spoken about this in recent weeks and it is a matter of considerable concern.
I thank the noble Lord for his initial remarks about co-operation, which will again help with the sense of urgency. On the question of judicial diversity, one of the most encouraging things in recent days is the way in which members of the senior judiciary have been going public on the need for urgency on the matter. It is a fact that four members of our 161 judges in the High Court are of black, Asian and minority background. In England and Wales, four out of 42 members of the Court of Appeal are women and we have one woman on our Supreme Court.
Yes, my Lords. This is often called the “tipping point” criterion: whether, if there are two candidates of absolutely equal merit, the one from the black and ethnic community or the woman should be given the post. I go back to the point made by the noble Lord, Lord Tebbit, that the aim should be to get the best person for the job. That is something that I believe in but, if there are two candidates of absolutely equal merit and one is a woman or from the black and ethnic minorities, you might take into account that they have had a greater struggle to reach that point of merit. That may come into your final conclusion.
May I question the Minister’s view that diversity has been sufficiently practised by the Government and is being pushed in the way in which it is being pushed in discussion in this House? The most recent appointments to the UK Supreme Court were of two men: one came up the usual route from the Court of Appeal and was promoted; the other has not had any full-time judicial experience but is a distinguished Queen’s Counsel. Those are the most recent appointments, yet, as the Minister himself said, there are several women members of the Court of Appeal. Are they being sidelined?
My Lords, do the Government acknowledge that the combination of high tuition fees and the cuts in legal aid will have a very bad impact on diversity at the young end of the legal profession, especially the Bar, and that there will be less diversity in years to come unless it is made possible for young people of all backgrounds to get a start at the Bar?
We will be debating in the near future the cuts in legal aid. Where I do share concerns is that to get into the legal profession, whether as a barrister or a solicitor, requires a financial commitment that could have an adverse effect on social mobility. That is something that the Government will have to address.
My Lords, on hearing of the sentences imposed on the medical and nursing professionals by a Bahraini special tribunal on 29 September 2010, my right honourable friend the Foreign Secretary led the international criticism by issuing a statement of the UK’s deep concern at the disproportionate sentences. He called on the Bahraini judicial authorities to follow due process carefully and transparently. The Parliamentary Under-Secretary of State, Alistair Burt, also called the Bahraini ambassador in London the next day to reiterate our concern, and the UK’s national security adviser also raised the case of the medical staff during his recent visit to Bahrain.
I thank the Minister for that reply. I hope he will agree that when we condemn the violation of human rights, we should do so with all countries that do that. Will he do his best to use this country’s influence with Bahrain to ensure that when the trial of these people comes about it is fair and transparent and is witnessed by observers from different countries?
Yes, we will certainly do that. One can draw some cautious optimism from the fact that the retrials are by civilian courts. The military courts have been closed and certain detainees have been released—not in this case, of course. A substantial commission report on human rights is about to be published next week that will cover all aspects of the kinds of concerns that we have and the noble Lord rightly has about what has been going on in Bahrain.
My Lords, on the subject of the international commission of inquiry, which is due to come out on 23 November, will my noble friend tell the House whether he has complete confidence in the impartiality of this commission? He will know that the opposition parties in Bahrain were very concerned at the delay in the publication of the commission’s report and fear that there had been external pressure for the commission to revisit its findings?
I believe my noble friend’s concerns to be unfounded. There were delays. It is a massive report and there were sheer technical problems in getting it forward in due course. As for impartiality, it is by all accounts—we have not seen the full detail yet—a substantial report that has gone into everything in great detail. One of the members is the distinguished British jurist, Sir Nigel Rodley, and there are other distinguished jurists and impartial members on it as well. I am fairly confident that this will be a very substantial report. It will be published at the same time as it is presented to the authorities in Bahrain and I think it will carry matters forward substantially.
My Lords, the United Kingdom has urged the United States to pay its assessed contributions to UNESCO until at least the date of Palestinian accession to UNESCO was decided. It is not yet clear which programmes might be affected by the US decision to withhold its assessed contributions to UNESCO.
My Lords, does the Minister agree that it is simply morally wrong potentially to withdraw funding from UNESCO projects that may save thousands of lives in future tsunamis, educate people about the Holocaust and foster free media in some of the newly emerging democracies of the Middle East in retaliation for others simply disagreeing with the United States about Palestinian membership of UNESCO? Does the Minister think that we should tell our friends in the United States that this is the way to lose friends and fail to influence people?
We do think it wrong—and we have raised this with our United States colleagues—that the United States should not merely consider withdrawing its contribution for the future, which, it is argued, is necessarily triggered by existing law in the United States, but should stop the contribution that was already due this year and on which UNESCO has already made spending plans. Obviously, the sudden withdrawal of commitments that have already been made will cause grave difficulties. A lot of people will lose their jobs and UNESCO has had to freeze all new plans. That is wrong; I agree with my noble friend. We raised this matter with the State Department and the point is being debated. Of course, the matter will be put to Congress, which is the driving force in this issue, but the general point that my noble friend makes is quite right.
Does the Minister recall Britain’s withdrawal from UNESCO for a long period in the 1980s, which unfortunately was part of the continuing use of UNESCO as a political and ideological tool? Can pressure be brought to bear on UNESCO to do something about Syrian behaviour, given Syria's recent speech to UNESCO about the importance of youth and women's education and so on, which seems a bit odd in the current circumstances?
The kind of pressure that can be brought to bear on UNESCO, and may have to be brought to bear as it faces the huge cut of 22 per cent in its budget, is to suggest that it should streamline and improve its administration. There have been improvements; it has made progress, and it is focusing on some very valuable programmes, as my noble friend pointed out. On the specific issue of Syria and Syrian projects, I cannot comment as I have no details. I will look into the matter. Broadly, there is now a British member on the UNESCO board, and we believe that UNESCO, which had some difficulties in the past, is improving and can focus on valuable things, of which the tsunami warning programme is a very good example.
Does my noble friend accept that as UNESCO's new Secretary-General is attempting to put it on to a much more streamlined and efficient path, the shortfall in funding will only undermine her position? Have the UK Government been in touch with other Security Council members to see whether they, as well as the G20, might be able to assist in making up the shortfall, at least on a temporary basis until UNESCO can revise its budget?
It is early days for that. We will have to see whether the United States follows through on what appears to be its intention not merely to withdraw future funds but current funds as well. A very large number of countries—107—voted for Palestine's membership of UNESCO. There were 52 abstentions and 14 countries voted against. Therefore it was a fairly solid commitment to Palestinian membership. On the question of funding, we will have to wait and see how the matter turns out. Certainly there are major difficulties to be faced and resolved.
My Lords, noble Lords on this side of the House all share the concerns about the future of UNESCO and agree with the Minister’s comments. The fundamental issue behind this question is how strongly we are prepared to make clear to the United States our difference of view on the recognition of Palestinian statehood. While the Government’s position was sympathetic, it was ultimately a decision to have no position—to vote neither for nor against. How does this advance the peace process and the cause of a two-state solution, given the present stalemate and Israel's very recent decision to announce further settlements that will be deeply counterproductive? Should we not be more robust on these issues?
That is, of course, a broader question. The noble Lord is absolutely right that the question of Palestinian statehood lies behind the question of whether partial arrangements, as it were, for statehood should be made by Palestine applying to various UN organisations, of which UNESCO is one. It is the judgment and view of Her Majesty’s Government that the way forward must be by negotiation for the emergence of the Palestinian state. We reserve the right to recognise the Palestinian state at the moment of our choosing. We take the view that a fragmented application to UNSECO and other bodies is probably a mistake and will delay negotiation. We also take the view that, if the matter is to go to the Security Council—I say “if”—and if then, as is almost certain, the Americans vetoed it, that, too, would set back negotiation very substantially. It may be rather limited now but it is going to be even more limited—indeed, it will screw it up completely—if that course is followed. There are plenty of ifs and buts in the future. Beyond that, there is the possibility that it might go to the General Assembly as well, but all these matters have yet to be decided.
I have absolutely no idea. The world is not like that. It is not a question of representations. Obviously there are discussions in the corridors at multinational meetings on who is going to subscribe to what. That is perfectly natural, but we make our own decisions in the end.
My Lords, is not the real issue that, given that no sensible negotiations are taking place, the Palestinians have very few options left and that their bid to become members of the United Nations, and initially of UNESCO, is the only way forward for them? If we keep talking about negotiations when they are not happening, are we not simply saying, “Let us leave it as it is”?
I am not sure that the noble Lord has got that right at all. It is perfectly true that Mr Netanyahu is not, or does not appear to be, a great proponent of negotiations at the present time, but the quartet is proposing some views. We think that there are pressures that can carry negotiation forward and we are not at all convinced that the Palestine statehood idea, if it went to the Security Council and produced the veto and the freezing up of negotiations all round, would be much of an improvement on the situation. I agree with him that it is not good, but it would certainly be very much worse in our view if we followed this course.
My Lords, in terms of acts that could be considered to be threatening to any future peace talks, surely there can be no equality between on the one hand the Palestinians wanting full membership of UNESCO, which is a fairly benign movement in its way, and on the other hand a profoundly aggressive movement: the continuing extension of settlements in the Occupied Territories? There really is no equality, surely, between those two acts.
No, none whatever. We regard the continued expansion of settlements as illegal, most unwise and highly provocative. That is part of the broad scene, and that must halt as part of the move forward to the negotiation that will bring Palestine to its full and rightful statehood. I agree. I am not quite sure what point the noble Lord is making. There is no comparison at all.
Local Authorities (Contracting Out of Community Infrastructure Levy Functions) Order 2011
West Northamptonshire Development Corporation (Area and Constitution) (Amendment) Order 2011
Motions to Approve
Business of the House
My Lords, given the pressure of business in this House and the lack of business in the other place, all noble Lords are anxious to know when this longest-ever Session of Parliament will end. I would therefore be grateful if the noble Lord the Leader of the House could confirm the information given by his right honourable friend the Leader of the House of Commons on Thursday 10 November, at col. 454 of Hansard, that the Queen’s Speech will be held in May.
My Lords, the noble Baroness the Leader of the Opposition quite correctly gave notice of her question to my office just before Question Time, and I am very grateful to her.
I have not had time to consult my right honourable friend the Lord Privy Seal, Sir George Young, and neither he nor I wish to mislead either House in any way. However, I have now had his words drawn to my attention, and I have read them, so perhaps I can give some context and perspective to the words he used. He was answering a question from his opposite number about the desirability of autumn versus spring State Openings. He was referring to a Statement that he had made on 13 September, when he said that State Openings,
“will, in future, ordinarily take place in the spring, rather than in the autumn”.—[Official Report, Commons 13/9/10; col. 34WS.]
That is very much what he intended to say. The context of this is the new Fixed-term Parliaments Act under which Sessions will run after general elections in May, and from May to May. That was what he was trying to say.
My right honourable friend may also be taking a very pessimistic view of the progress of business in this House. I think that the usual channels have a plan to deliver this Session in a timely manner, and I hope that we can do better than that.
Can the noble Lord clarify one bit of his answer? This has not only been a very long Session; it has now also become about the most boring Session of my 25 years in this House. Is he saying that the facts of the matter are that the Government have not made up their mind at all about when the Queen’s Speech will be?
My Lords, I wonder whether it would be helpful to the House if, rather than explaining the context in which Sir George Young made his Statement in the other House, we actually repeated the words that he used. He said:
“I made a statement, I think, last year on the fact that the Queen’s Speech will be held in May to coincide with the fixed election dates of every five years”.—[Official Report, Commons, 10/11/11; col. 454.]
That promise—and I think that I can put it in those terms—was repeated endlessly during the passage of the Fixed-term Parliaments Bill by, I think, the noble and learned Lord, Lord Wallace of Tankerness. I even put down an amendment to try to ensure that there would be a fixed date for the Queen. Given the Government’s obsession with fixed-term Parliaments—which I oppose, but the Bill has been passed—there should be fixed Sessions. Surely there is a logic to that. Frankly, if the Queen’s Speech is not in May of next year, it will be very close to breaking faith with the clear undertakings given during the passage of the Fixed-term Parliaments Bill. I therefore ask the Leader to do more than just consult his colleague down at the other end—perhaps they should try to get their acts together.
My Lords, we will make an announcement in the first part of next year about when the actual date will be, and we are very happy to stick with spring. It is true that this Session has been very long, for reasons which I think will be readily understood. However, we believe that from the start of the next Session, we will go towards annual Sessions that will aim to finish around April or May.
My Lords, is it not becoming rather ridiculous that we still have not had a debate on the crisis in the eurozone? Perhaps the expression “fiddling while Rome burns” would be appropriate in this context. The usual debate on the Chancellor’s normal Statement is not really a substitute for a debate on the crisis in the eurozone. We need to debate both.
My Lords, returning to the Queen’s Speech, in all seriousness, is this uncertainty not causing tremendous problems for people planning ahead—not just Members of the House of Commons but Members of the House of Lords, all those involved in the State Opening and, not least, Her Majesty the Queen? Is it not incumbent upon the Government to say now when the State Opening is going to be held so we know exactly how to plan ahead for next year?
My Lords, the noble Lord, Lord Foulkes, does a good job of righteous indignation on this subject. I assure him that in past years it has been entirely normal to announce the date of the Queen’s Speech about four or five weeks in advance, and we aim to do precisely the same this year.
I admire the Leader’s ability to put this in perspective. I have to say, it is easier to get things in perspective if you do not have to stand on your head. Is not the reality behind this that actually, as Members on all sides of the House have said, the problem for the House is the quantity and quality of the legislation being brought before it?
My Lords, I have already answered many questions on this. The quantity is no greater than similar Sessions after a general election, and of course Parliament is trying to improve the quality by putting amendments and occasionally defeating the Government.
Health and Social Care Bill
Committee (6th Day)
Relevant documents: 19th report from the Delegated Powers Committee, 18th report from the Constitution Committee.
My Lords, I rise to intervene on this Motion today with a very heavy heart—and empty-handed, because the Government have refused to release the risk register on the implementation of the Health and Social Care Bill, as instructed in the judgment of the Information Commissioner last Friday. I am grateful to the Minister for his letters to me and other noble Lords explaining the Government’s position on this matter. Thorough explanations are helpful but they do not make this a right or just position for the Government to take. The Government inform us that they need 28 days to consider this issue. I would just make the point that the Department of Health has had a whole year to think about this issue.
Noble Lords may recall that I drew this important matter to the attention of the House on Monday and specifically asked the Minister to assist the House in its deliberations by making the risk register available. I am most grateful that the noble Baroness, Lady Williams, supported my appeal. Since Monday, it has become clear that the well respected Conservative MP, Dr Sarah Wollaston, made the same plea to her own Secretary of State in a letter to the Evening Standard.
I beg the leave of the House to say I have nowhere else to raise this important matter. I do not wish to delay the House but I want to make two points and ask two questions of the Minister. There is a precedent that I urge the Minister to consider. In 2008 the noble Earl’s then honourable friend, Miss Justine Greening MP, recently promoted to the Cabinet, used an appeal to the Information Commissioner to get the release of the risk documentation on the Heathrow third runway. I am sad to report that my own Government did not cover itself in glory in this matter, refusing to part with the information for more than a year. However, the key difference between then and now is that of course the third runway was not the subject of a very large piece of primary legislation that aims to bring radical change to our NHS and that the information we are being denied could be very relevant to our deliberations.
I have already written to the noble Earl about this matter and intend to follow the same route as my right honourable friend John Healey MP by putting an FOI request in for the most recent risk register about this matter. I urge other noble Lords who share my concern to do the same. The reason I am doing this is because the Secretary of State suggested yesterday that the version of the risk register that my right honourable friend John Healey asked for would now be a year out of date. I regard that as both a glib and disrespectful remark.
The Minister told the House on Monday that most of the information from the risk register is included in the impact statement that was published when the Bill arrived in the House. Can the Minister say exactly how much of the risk register is contained in the impact assessment and how much is not? Perhaps the Minister might assist the House by publishing the information that is not contained in the impact assessment but is in the risk register. The Government say that this is a very secret document, but also that it is available. I am sure that the House would like to know which it is.
Finally, there is a course of action open to the House, which is to refuse to resolve itself into a Committee on the Bill as an expression of its concern about this matter. I have discussed this course of action with several noble Lords, and we have a genuine dilemma here. Many feel that it is a very serious error to refuse to place this information at the disposal of the House when we are considering this important Bill. On the other hand, we are all aware of the amount of work that there is to be done on this Bill. I do not intend to divide the House today, but I reserve the right to come back to this issue if it is not resolved at least within the time allotted by the judgment of the Information Commissioner. The Minister may also need to arm himself with the information contained within the risk register, because I, for one, will be asking him, at all the appropriate moments in the debates to come, whether that issue is mentioned in the risk register and what it says.
My Lords, before the noble Earl responds, may I offer him a little piece of advice, as a former Health Minister who had to take controversial legislation through this House? I would say to him that if I had been confronted with this situation, I would have gone to my boss, the Secretary of State for Health, and asked him to facilitate the passage of this legislation through the House by making this information available to the House.
My Lords, I, too, wish to ask the Minister one additional question. Can he give any idea of how quickly the proceedings that he mentioned in his recent letter to Members of the Committee will take? He showed in that letter that there needed to be discussions with other ministries and that there needed to be consideration of whether an appeal should be brought. I know that he appreciates, as much as the rest of the House does, that our debates in many areas would be very much affected by knowing what is in the risk register, and in particular, perhaps, those parts of it that the noble Baroness, Lady Thornton, suggests could be made available. Can he give the House any idea of the probable timetable, as we are all conscious of the fact that the debates might have to be repeated all over again if the information in the risk register is relevant to the things that we are talking about?
My Lords, I read the report the other day and it seems to me that the Government are refusing to publish because they have got something to hide. We want to read this document. The Information Commissioner’s report is a fascinating document which repeatedly, under a number of paragraph headings, states that the Government should publish this document and act in a transparent way in the public interest. That phrase is repeatedly referred to in the course of the document. It is quite incomprehensible that the Government should have taken this very silly decision—a sort of ostrich in the sand approach to these matters.
My Lords, I fully appreciate the strength of feeling that noble Lords have on this matter and I hope that the House will accept my assurance that I have no wish to be, or to appear, unnecessarily obstructive over the release of data which your Lordships may feel should be in the public domain.
However, I should bring the House up to date. The ruling of the Information Commissioner carries with it very significant implications, not only for my department but for every department across government. The risk register is a basic tool for the management of policy implementation. It is a working document which informs advice to Ministers. Publication of departmental risk registers, were this to become routine under the Freedom of Information Act, would fundamentally affect the day-to-day working of government. In this context we are of course looking carefully at the issue of precedent, and I am grateful to the noble Baroness for having raised this.
The Government, as a whole, must therefore consider whether or not to appeal the Information Commissioner’s ruling. Officially, we are allowed 28 days from the date of the ruling in which to do this. Consequently, I regret that I cannot make any specific commitment on these matters today. I emphasise that the Government’s wish to take some further time to consider the way forward is in no way an attempt to string this matter out in a needless or obstructive manner. We intend to act with maximum speed. If a decision is taken not to appeal the Information Commissioner’s ruling, we will proceed to comply with it immediately.
I hope, however, that noble Lords will understand the Government’s view that it is reasonable to allow time in which to take a decision on a matter that is both complex and important. Meanwhile, I am very willing to consider the noble Baroness’s constructive suggestion that I should examine whether there are any risks covered in the Department of Health risk register which have not already been placed in the public domain and which could be provided without further ado. I shall give a progress report to the House on these issues at the earliest opportunity.
Clause 7 : Clinical commissioning groups
60A: Clause 7, page 4, line 18, at end insert—
“( ) Each clinical commissioning group has the function of safeguarding the comprehensive provision of NHS services.”
My Lords, this group of amendments brings us to the general function of clinical commissioning groups. New Section 1F to be inserted in the National Health Service Act 2006 under Clause 7 states:
“Each clinical commissioning group has the function of arranging for the provision of services for the purposes of the health service in England in accordance with this Act”.
I suppose that, in many senses, clinical commissioning groups are the flagship of the Government’s reforms, but that those functions are not particularly inspiring. I would have thought that the Government would have wished to set out a rather more ambitious remit. My amendment seeks to do that and is quite specific that the clinical commissioning groups should have the function of safeguarding the comprehensive provision of NHS services.
It is very important that words to that effect are in the Bill in order that clinical commissioning groups are under no misapprehension that they have an obligation to ensure that patients receive comprehensive services. Recently, the Secretary of State has felt it necessary to intervene with primary care trusts because there has been evidence that in order to balance their books, they have been putting restrictions on treatments both in terms of the actual treatments but also in artificially delaying access to non-urgent treatment for a number of weeks. The Secretary of State has ruled that this is unacceptable.
The question that arises is: if that situation arose with clinical commissioning groups, what is there to be done to ensure that CCGs are reminded that their job is to ensure that their patients receive comprehensive health services? Essentially, that is what my first amendment is about. It is of course linked to Clauses 10 and 11. As we have already generally agreed, Clause 10 is one of the essential parts of the Bill’s intention to change the foundation of the NHS. The clause would remove the Secretary of State’s duty under Section 3 of the NHS Act 2006 to provide key listed health services to meet all reasonable requirements throughout England and, crucially, would remove the area-based responsibilities of primary care trusts.
In Clause 10, we see in their place the clinical commissioning groups—the bodies responsible for persons on lists and other persons usually resident in unclear and potentially non-contiguous areas. As far as I can see, those specified services would clearly have to be provided for everybody except, arguably, emergency care. In addition, Clauses 8 and 9 would in effect remove from Section 3 public health functions such as immunisation, screening and health promotion, so these PCT services would not have to be covered by clinical commissioning groups. I have to say that the provisions of Clauses 8 and 9 are particularly opaque, and the interface with Clause 10 in unclear. I would also point out to the noble Earl that new charging powers are proposed in Clause 47 for those services that are free at present, although I think that the noble Earl has suggested that they would be commissioned by local authorities and would not be part of the National Health Service. My Amendments 76 and 77 would delete Clause 10 entirely, retain Section 3 of the 2006 Act in its entirety and add a new clause that would give clinical commissioning groups the duty to arrange provision for all persons usually resident in their area and, as regards emergency care, for everybody present in their area.
I was going to put a number of questions to the noble Earl, but he has written a letter that relates both to the pilot schemes to make it easier for people to move between GP practices and, if they move, to stay on with their old practice if they are likely to return to their former residence. That would apply, I suspect, to people such as students. He has also given some details about the general responsibilities of the national Commissioning Board in relation to patients who cannot find a GP who will take them on. That is helpful, and I certainly think that there will be time later on to discuss this in more detail. On the pilot schemes, one of the issues will be the approach taken when patients turn up at one of these GP practices and ask to go on its list. We know that reception sometimes can be a very good experience and sometimes not so welcoming. That factor should be kept in mind.
A second issue arises from the noble Earl’s letter, particularly about the allocation of patients on GP lists. As the NHS Commissioning Board will hold the contracts of GPs—it would be deemed a conflict of interest if clinical commissioning groups held them—the Commissioning Board itself will be responsible for allocating patients to lists if they cannot get on a particular list. How on earth is this practically going to happen? Does this not make it inevitable that not only will the NHS Commissioning Board have to establish regional offices, but, given the size, it will need local offices so that the public can get in touch with it? Presumably that means, too, that the NHS Commissioning Board will oversee the system for complaints made against GPs in terms of their primary care delivery function. So there are quite a lot of difficult issues here about how practically the NHS Commissioning Board will carry out its duties. As for the allocation of patients, what will happen about patients with severe learning difficulties or complex mental or physical health problems, or asylum seekers and the homeless, those of no fixed abode who traditionally have often found it difficult to get on a list? How will the NHS Commissioning Board know what to do about this unless it has some kind of local presence? I do not believe it can be done from the headquarters of the Commissioning Board in Leeds—or at least it would be very difficult to do so.
I know that we have discussed the issue of the clinical commissioning groups not being area-based, and I will come back to that. The noble Earl’s maps are very instructive. I would point out that the Heart of Birmingham PCT hardly covers the catchment area of the Heart of England NHS Foundation Trust. That is a matter of great regret to me because it currently has a thumping great surplus, unlike the PCTs that serve my own foundation trust. I can no doubt look to the noble Earl for a helpful intervention in that—or perhaps not.
There are lots of questions here that stem from, first, the guarantees that clinical commissioning groups will provide a comprehensive service for their patients; and, secondly, the allocation of GPs to lists, moving away from area-based commissioning and some of the practical difficulties that will come from that.
My Amendment 78 continues the theme. Currently, Clause 11, at line 6 on page 7, says that,
“Each clinical commissioning group may”—
“arrange for the provision of such services … that relate to … physical and mental health … or … the prevention, diagnosis and treatment of illness”.
Again, why is it only “may”? Surely those services would be part of any comprehensive provision. Would the noble Earl agree to a gentle amendment to make it “shall”? That would be a visible sign that CCGs are there to provide comprehensive services—or to make sure that their patients receive them.
Some of the considerations are relevant to the duties of the national Commissioning Board itself. My Amendment 81B is designed to ensure that the Secretary of State will require the board to commission services for rare conditions. If devolved to clinical commissioning groups, I think it unlikely that they would commission rare services. This has been a problem in the past, even with primary care trusts, because they are not used to such rare services. If a patient goes to a GP needing them, there is no precedent or protocol for obtaining them. I would be interested in any thoughts that the noble Earl has on rare services. In a sense, it is parallel to the orphan drug issue that the NHS also faces.
My Amendment 82 focuses on how the board’s performance in commissioning services is to be performance managed. Will the noble Earl say—or write to me—about how, in commissioning plans, the board will seek to consult health and well-being boards? This is a rather general group of amendments. I am conscious that we have a usual channels agreement to finish 12 groups today before we rise. If there are some points that the noble Earl would seek to write to me about, that would be very good. I beg to move.
My Lords, I speak to Amendment 79 in my name and those of the noble Lord, Lord Patel, who unfortunately cannot be here today, my noble friend Lady Pitkeathley and the noble Baroness, Lady Murphy. Our purpose is to focus clinical commissioning groups on the needs of the 18 million of our fellow citizens with long-term conditions.
We spend an awful lot of time and money in our healthcare system preoccupied with acute hospital care. Indeed, 50 per cent of NHS expenditure goes on acute hospitals. However, day in, day out, week in, week out, the bulk of NHS activity—some 75 per cent of it—goes on good, bad and indifferent treatments for people with long-term conditions. Of course, some of these people have acute episodes, often because their routine care has been neglected. For example, 10 per cent of NHS expenditure goes on people with diabetes. The number of people being treated with diabetes is rising. We know how best to look after people who suffer with diabetes but too often we neglect basic, routine care and maintenance of the condition, seemingly waiting for the inevitable crisis to occur.
The scale of long-term conditions is, in my view and that of the colleagues who signed this amendment, sufficient to draw particular attention to their needs in the Bill. That is what the first part of Amendment 79 does by adding the words,
“especially persons with long-term conditions”,
to Clause 11 at line 12 on page 7. However, we want to go further. A very high proportion of those with long-term conditions need help, both from the NHS and from adult social care services. That is why the second part of that amendment specifically requires clinical commissioning groups to pay attention to their need to secure improvement in the integration of health and social care in the delivery of services. Of course, we have already had one discussion on integrating health and social care services at the point of delivery, including specifying a definition and I suspect that we shall come back to integration on a number of occasions as the Bill progresses. I shall certainly return to this issue on Report.
In the mean time, I hope we will receive a more constructive response from the Minister to this amendment, placing a clear responsibility on clinical commissioning groups from the outset to focus on securing improvement in the integration of health and social care in the commissioning of services. We need to move from the rhetoric of integration to requiring it to happen in legislation. I beg to move.
I wish to speak to Amendment 80. I wonder how many noble Lords are aware of the historic nature of the proposed insertion into the 2006 Act of new Section 3B(1)(c). It is the first time that mention has been made in a Bill of the requirement on the Secretary of State for Health to provide services or facilities for those detained in a prison or in other accommodation of a prescribed description.
When I was appointed Chief Inspector of Prisons in December 1995, I had to give up the chairmanship of Hillingdon Hospital National Health Service Trust because I could not guarantee the time required, but during my chairmanship I was particularly grateful that my extremely able director of mental health insisted that I trained as a lay assessor so that, in his words, I could be of some use to the hospital. What neither of us realised at the time was that he was enabling me to appreciate, at once, the full and avoidable horror of the situation that I found during my first prison inspection of Holloway, during my second week in post. He educated me about both the complex requirements of those suffering from mental health problems and what it was possible to provide for them.
That understanding fuelled my fury at finding that none of what I had been accustomed to at Hillingdon was present in the largest female prison in England in 1995, despite the appalling numbers of women with varying degrees of mental health problems. When I remonstrated about that, I was told that uniquely in the country, prison healthcare was not, and never had been, the responsibility of the NHS but had been retained by the Prison Service. I was then told that the director of prison health, a doctor, was not responsible for the provision of healthcare, merely for advising the prison’s board, which was actually responsible. When I asked how many of the prison’s board had medical experience or qualifications, I was told none.
So I set about trying to change this nonsense, writing a thematic review of the situation in 1996, entitled Patient or Prisoner?, in which I recommended that the NHS takes over responsibility as soon as possible. I quoted the vast well of psychiatric morbidity, exacerbated by the treatment of and conditions for prisoners being wholly unsuitable for those suffering from mental health problems, which invariably made them worse. I simply could not understand how this situation had been allowed to continue since 1947, not least the continued failure to include the needs of the 500 or so prisoners whose transfer to high or medium-secure hospital accommodation was recommended each year in National Health Service estimates. That meant that provision was always a matter of chance because of competition with funded community needs. Years of lack of NHS budgetary provision for any aspect of prison healthcare, including the additional expense that released prisoners add in the community, remain a millstone around the NHS neck.
It seemed abundantly clear to me that prison health was a public health issue, because every single prisoner except, for the very small number, sentenced to natural life was going to come out and the state of their mental and physical health when they did so was a matter of public interest. Not only was offender health not regarded as a matter of public health, but GPs had to fight to get information from prisons about any medical treatment a prisoner had received. That was of doubtful quality, because we found that only 10 per cent of prison medical officers were qualified to act as GPs in the NHS. In other words, not only did anyone going into prison disappear from the NHS radar screen, but the authorities seemed to disregard the fact that imprisonment—paid for by the taxpayer—presented a priceless opportunity to identify and initiate, or pick up and continue, essential mental and physical health treatment. This could then be continued on release to the benefit not just of the prisoner but also of the community into which he or she returned. It all seemed unbelievably short-sighted and, frankly, stupid.
In the event, the NHS was made responsible for prison healthcare in 2003—seven years later, or longer than World War Two; so much for the speed of governmental decision-making. Since then, there has been considerable improvement, particularly when good primary care trusts have taken very seriously their primary care contract responsibilities with individual prisons. The same has not been so true of mental health contracts, largely because provision has in no way been able to match demand. I shall never forget speaking to members of the first mental health in-reach team to go into Wandsworth. They had expected to have to deal with a few very serious cases; instead they found that they were swamped by the 70 per cent of the prison population who were suffering from one or more identifiable personality disorders. It did not make them sectionable, but suggested that there was something affecting their behaviour that, if identified, could be mitigated. However, as the resources to carry out the identification were, and are, lacking, mitigation was, and is, denied—a process that should be of public concern.
My reasons for spelling all this out are to explain why my proposed amendment is an appeal to the Minister to withdraw the words, “other accommodation of a prescribed description”, and substitute detailed descriptions of that accommodation. I say that because the Secretary of State is required to commission services for a number of entirely different places of detention with very different requirements. Public and privately run prisons require primary, secondary and mental health contracts appropriate for their population type, whether man, woman or child. Privately run secure training centres and local authority-run secure homes require child-centred services. Privately run immigration and removal centres, about whose healthcare provision there have been many complaints, require a range of services, including specialist knowledge of tropical diseases. In addition, if the Government adopt the diversion schemes recommended by the noble Lord, Lord Bradley, there must be appropriate psychiatric and nursing provision in both police and court cells, in which people may have to be held until moved to appropriate NHS accommodation.
The Department of Health is very fortunate to have an able director of offender health, Mr Richard Bradshaw, who can provide the necessary descriptions very quickly because he is well acquainted with the differing needs. I therefore ask the Minister to accept this amendment in the spirit in which it is meant, which includes trying to ensure that the dreadful situation that I have described is never allowed to reoccur in any prescribed place of detention.
My Lords, I shall speak to Amendment 83 in my name and that of my noble friend Lord Patel. This amendment proposes that:
“Regulations must require the Board to commission services for veterans who have lost limbs”.
The purpose of the amendment is to ensure that those who have served our nation and who have quite rightly received the highest standards of care—both in theatre in the battlefield at the time when they sustained horrific injuries, then during their immediate aftercare back here in the United Kingdom and thereafter while remaining members of the Armed Forces receiving ongoing rehabilitation—can be certain that, once they are discharged from the services and return to civilian life, they are able to avail themselves of the necessary specialist services for years and decades hence. There is no doubt that what is achieved in battlefield salvage is quite remarkable, and those who sustain horrific injuries that some time ago would not have been survivable are now saved and can continue, from a young age, with the prospect of a good quality of life. However, the injuries, particularly the limb losses and multiple limb losses that they have suffered, will require ongoing specialist care.
Her Majesty’s Government have recognised the importance of this area and the noble Earl’s honourable friend the Member for South West Wiltshire, Dr Andrew Murrison, has recently published a report, A Better Deal for Military Amputees, in which he reviews both what is achieved acutely for these brave servicemen and what their ongoing clinical and other needs may be. He makes a number of important recommendations in the report. He suggests that a nationally commissioned service for veterans is the best fit for service-attributable amputees and, of the options he puts, looks at the option most likely to deliver the most for the wider amputee community. He goes on to make a specific recommendation that:
“Ministers should take appropriate powers to provide for national commissioning of specialist prosthetic and rehabilitation services for amputee veterans through a small number of multi-disciplinary centres in England, adequately resourced and determined through a tendering exercise”.
He puts the question that:
“Ministers will have to consider the extent to which existing legislation and the Health and Social Care Bill which is currently before the House of Commons”—
it was at the time—
“permit the national specialist commissioning of special provision for amputee veterans, tabling any necessary secondary legislation or amendments to Clause 11 in the Health Bill”.
So there is a broad recognition by those who have been commissioned by Her Majesty’s Government to look at this issue. The commissioning of specialist services for amputee veterans to ensure their long-term good clinical outcomes—that they may avail themselves of advances in the future, which are going to be dramatic and important in the decades hence and which could have an important impact on their ability to function—and that they have a high quality of life will only be achieved through national specialist commissioning of amputee services.
The Prime Minister, in his response to the report, stated the following:
“I am passionately committed to our Armed Forces. As a country and as a Government we have a particular duty to servicemen and women injured on operational duty. This report maps out a clear strategy for ensuring that those brave people can be confident they will receive the same levels of access to prosthetic limbs and specialist care from the NHS as they do at Headley Court. They deserve nothing less. Based on the recommendations in this report, this Government will make the resources necessary to meet that need”.
This amendment provides an opportunity to ensure that those needs are met. I strongly believe that only through the specialist commissioning of these particular services will the long-term interests of our brave service personnel, who have lost multiple limbs and who have to contend with that in their veteran lives, be properly secured. I hope very much that Her Majesty’s Government and the noble Earl will consider this amendment seriously.
My Lords, having put my name to Amendment 79, I support the powerful case made by my noble friend Lord Warner for the inclusion of long-term conditions and integrated services in the Bill. I particularly draw your Lordships’ attention to those long-term conditions that can be fluctuating as well as progressive. While it may be progressive in an overall sense, an illness such as multiple sclerosis has periods of varying intensity, when needs are different, and even periods—sometimes quite long periods—of remission. It is very important, therefore, that services are not only commissioned across health and social care—it is very important that there is a whole package of support; that is of such significance to users and their families—but also that those packages of care are flexible enough to cope with the varying progress of these illnesses.
The last thing that an MS sufferer, for example, wants when a period of remission suddenly ends with a fresh attack, as it frequently does, is to go back to square one on clinical commissioning, especially as far as the integration of clinical and social care commissioning is concerned. They do not want to go back to starting the assessment process or back to judgments about need and the abilities of their families to care for them, and so on, with all the delays and distress associated with reassessment and all the unnecessary expense that these processes involve. That applies very much also to those with certain mental health conditions, which are also fluctuating in their intensity. So proper care across integrated services not only prevents acute episodes but also helps to support caring families to participate in care effectively, as they wish to do, thus saving scarce resources as well as meeting the needs of those who are suffering.
I shall speak to Amendment 81B, to follow on from what the noble Lord, Lord Hunt, said. Brevity will be my watchword, of course, because we do not wish to drag out proceedings. This is a particularly important amendment, referring as it does to commissioning for rare conditions. There are many such rare conditions that people suffer from, but I refer particularly to one called arthrogryposis, which my wife has suffered from from birth to today. As with many people who have struggled with a rare condition from childhood to the age she is now, it has been difficult to get not just treatment but diagnosis. She was originally not diagnosed with this condition, which is associated with the nervous system and the muscles and mobility. Throughout her life she had the difficulty of being misdiagnosed, and then when she was diagnosed she had difficulty getting treatment. I welcome the amendment for that reason.
Many people have that struggle to get the treatment that they need appropriately in their area. For example, we recently went to Birmingham, where they have done some research work. It is so important to get research work done for rare conditions, to establish where they came from and whether people were born with them. I so much welcome—as my wife and others with her condition will welcome, as well as those with other conditions of various sorts—the fact that we are drawing attention to the need for commissioning for rare conditions. You could say that only a small proportion of the public has each rare condition but, when you add all the rare conditions together, there is quite a proportion of people with those problems.
I draw to a close on that basis and hope that the Minister will consider this very carefully, as we and many other people have had experience of rare conditions, with the difficulty of diagnosis and treatment and of getting it recognised throughout their lives.
My Lords, this is an interesting group of amendments about how prescriptive the powers and duties should be for CCGs and about dividing up who should do what between the groups and the board. We have to be careful about how prescriptive we want to be, because it may vary in different areas according to the board’s confidence in the ability of groups to commission. However, I take the point that there are some fundamental principles which we would like to see in each of these groups. That was why I added my name to the amendment tabled by the noble Lord, Lord Warner, and others, about the need to strengthen the co-ordination of health and social care. This is fundamental to the care of so many people. In my view it is a requirement, not an option, that it should be in the forefront of commissioners’ minds.
I am sympathetic to the amendments on special conditions and rare conditions, but—coming back to what the noble Lord, Lord Warner, said—the areas where we need most improvement include everyday, ordinary, complex multiple conditions of older people and simple but common surgical emergencies. It is the ordinary, everyday things that we need—ensuring that we have the right commissioning groups at the right level and that they concentrate on these broad responsibilities relating to the population.
I support the question that underlines Amendment 82, in the names of the noble Baroness, Lady Thornton, and the noble Lord, Lord Hunt of Kings Heath. This is about how agreement will be made between health and well-being boards and the commissioning intentions. We need some understanding of the ground rules which will underpin those negotiations. My experience of negotiating contracts in the NHS is that they can be an awful long time in coming and being finalised unless you have some clear ground rules. I wonder how far the Government have got in thinking about that.
I wish to speak to Amendment 178 on behalf of the noble Earl, Lord Sandwich, and the noble Lord, Lord Mancroft, neither of whom are in their place today. This again is about clinical commissioning groups’ awareness. Amendment 178 is a plea that commissioning groups should take into account—particularly into financial account—what is already being provided for voluntary organisations. Often these provide a more cost-effective and responsive service to client groups. In the noble Lords’ minds particularly were services for those who misuse drugs or alcohol, but there are also services in mental health or in specially targeted support and rehabilitation for specific ethnic groups. For example, a support worker from the same ethnic community can be so vital in establishing mutual trust and compliance with a care plan.
I very much hope that commissioning groups will take into account what is already being provided when they commission. Of course, I understand that alcohol and drug misuse services will be commissioned largely by local authorities. This is entirely positive because they often have a greater understanding of the involvement of voluntary organisations in being able to contribute to a wider service than the NHS often does. Nevertheless, this is an important amendment.
My Lords, I wanted to intervene on this group of amendments because I have been trying, without success, to find out how to table an amendment relating to how the new architecture will deal with the most chronically excluded. Some of them will require alcohol services, which we shall come to later, but many of them will require other medical services. In addition, many of them will not have a fixed abode or will not have a fixed abode for very long. Therefore, they will be moving around.
When I asked the chief executive of the Commissioning Board who would deal with these people, I was rather concerned to be told that it would be clinical commissioning groups. CCGs might do so, but I am not convinced that they necessarily will. First, CCGs may well not be very aware of the numbers involved, particularly if they are not inner-city commissioning groups, and they may well not be aware of the complexity of response that such people will require. These will be people who require some medical intervention as well as other forms of intervention and support.
At the moment, much of the medical attention that these people receive is fragmented and is often not the appropriate intervention, and they can be a real nuisance in places such as A&E. The Government need to listen to those in the voluntary sector who say, “We need a new approach to how we work with people with these multiple conditions and we need to make sure that we get it right”. However, the NHS has a responsibility—it does not stand outside this—and this matter will need to be looked at on a wider and more expansive level than simply that of the CCG.
In this country we assume that, because we have GPs, people will automatically be registered with them and will be looked after. However, my experience of working with these most frequently disturbed and disadvantaged people has been that they fall through the net again and again, and somehow we have to make sure that that does not happen. Due to work that I have done in the past and because I am currently involved with a voluntary organisation, I have previously discussed with the Minister ways in which that can be achieved effectively. I do not pretend that it will be easy or that we can simply lay something down in legislation and it will all happen. However, somewhere in the middle of that there is a way forward.
I hope that in considering the amendments—particularly those of my noble friend Lord Hunt—the Government will work on this issue and come back with clarification that this group of people will not fall through a net in the new architecture.
My Lords, I want to pick up on a point that I made on Monday. We are discussing the role, duties and powers of CCGs, and I want to talk about commissioning services. Where contracts are negotiated with existing providers—whether they are within the National Health Service, the voluntary sector or the private sector—it is fairly clear to see how the system will operate. However, I am not clear—and perhaps the Minister can enlighten me—about the role of CCGs in promoting and creating new services or facilities within the NHS.
The example that I particularly want to refer to concerns the provision of new health centres in my own area of east Lancashire. These are new significant capital schemes but they are not the direct responsibility of the hospital trust. Where the responsibility is that of the hospital trust, it will no doubt be responsible for the provision of new capital schemes. Here we have facilities that will be partly occupied by GPs; they may well be occupied in part by community-based services that are now the responsibility of the hospital trust. The hospital trust may wish to make use of the facilities as outreach facilities for day patients, and so on, but they do not fit neatly into the hospital trust. At the moment, they are the responsibility of the PCT. The existing primary care trust in east Lancashire has now approved in principle the provision of three health centres in three towns—Great Harwood, Clitheroe and my own town of Colne. Because of the changes and the fact that the PCT is not responsible in the future, it has now been passed to the cluster of PCTs, which is at a Lancashire level, and will have to be approved by the strategic health authority.
These are all bodies that in future will not exist. Who will be responsible for this kind of capital project within the NHS in future? It is not just a question of commissioning within an existing landscape of provision in different sectors, but a question of commissioning new services and new capital projects that do not fit into the hospital trusts. Will that be done at a national level? Will it be the responsibility of the CCG? Who will be responsible for the provision of finance for this kind of project?
My Lords, this group of important amendments illustrates that good care for all is what is needed. I shall say a few words on Amendment 79 on long-term conditions. As has been said, there are many long-term conditions, and there is great anxiety all over the country because of the change. What the Minister says today will be very important and may allay some of the distress. There is a shortage of district nurses, which is an important issue for people who need dressings for leg ulcers, for example, which can last for a long time.
On a positive note, there is telecare and telehealth and other new technology for monitoring. People can be monitored in their own homes. If something goes wrong, people can call emergency services. Scotland is doing much better than England, and other countries in Europe, such as Poland and Holland, are using the system a lot. England could do a lot better for people with long-term conditions.
All the amendments in this group are exceedingly important and I am glad that my noble friend Lord Ramsbotham mentioned prisons and people in cells. When I went to see prisoners being processed, a GP was trying to fathom out what to do with a really serious alcoholic. I asked, “What are you going to do?”, and he replied, “If only I had some rehabilitation services for alcoholics, I wouldn’t have to send him to prison. What will happen is that he will be in and out all the time”. Many things can be made better, and I hope that the noble Earl will give us some hope when he responds.
My Lords, I rise briefly to support Amendment 79 moved by the noble Lord, Lord Warner, although he should not have moved it at this stage perhaps; he should have just spoken to it.
As the Minister knows, I am concerned about people with CFS/ME. They are the most neglected, denigrated and discriminated-against group in the country and there are some 60,000 of them who are severely ill, which means that they are homebound and bed-bound. They have multi-system symptoms, which are far too often neglected. They have co-morbidities—one person that I know of, who has had ME since she was 15 and is now 30, has severe gynaecological problems but because she has ME they are not going look at those. Also, she gets no social care. It is very important that these services are thoroughly integrated and that people understand that because you have ME it does not mean to say that all you need is a little bit of CBT and GET and you can get up and go. We have got to provide for people who are severely ill. So I support the noble Lord, Lord Warner, and the noble Baroness, Lady Pitkeathley.
My Lords, CCGs will be under a duty to arrange for services to meet the reasonable requirements of patients for whom they are responsible. This is the language of the current duty on the Secretary of State in Section 3 of the 2006 Act and will remain one of the fundamental principles in the future. Additionally, under their discretionary power in new Section 3A inserted by Clause 11, CCGs will have the power to arrange the provision of services and facilities for the people for whom they are responsible where that will improve physical and mental health or improve the prevention, diagnosis and treatment of illness in those people. However, CCGs do not have commissioning responsibility for all services—for instance, those that the NHS Commissioning Board will commission. For that reason, Amendment 60A would be inappropriate. However, the Bill is already expressly designed to ensure that the comprehensive health service is maintained and that patients’ needs are meet.
Amendments 76 to 78 seek to revise the commissioning responsibilities of CCGs, as set out in Clauses 10 and 11. In effect, Amendment 76 would give each CCG responsibility for commissioning for everyone normally resident in its area, removing the link between the provider of primary medical services with whom a person is registered and the CCG responsible for commissioning services for them. We think it is important to maintain this link. PCT responsibilities currently include people who may be registered with a GP in that area but who live outside the geographic boundaries of the PCT, so this is not something new. Clause 10 also includes some necessary provisions for the Secretary of State to clarify the responsibilities of CCGs in regulations—for example, when a CCG has ongoing responsibility for a patient’s care even if they are no longer a registered patient of a member of that CCG, which is an important element of the policy of continuing healthcare, and when somebody might be excluded from their responsibility, which might apply to patients registered with a GP in England but living in another part of the United Kingdom.
Amendment 78 would change the discretionary power that CCGs would have under new Section 3A into an obligation. That would go much further than the current discretionary powers of the Secretary of State. It would place CCGs in the situation of being legally obliged to arrange any services that it felt were appropriate to meet a patient’s needs. This would conflict with their duty under Section 14P to exercise their functions effectively, efficiently and economically, and could leave them open to challenge. These are judgments that commissioners, as now, need to be able to weigh up themselves in order to achieve the best possible services for their patients with the resources that they have available.
The same arguments apply to Amendments 177 and 178. On the latter, the noble Baroness, Lady Murphy, made an excellent point about the key role that the voluntary sector can play in providing high-quality and cost-effective services. The noble Earl, Lord Sandwich, is a great advocate of services for those addicted to prescription drugs. I pay tribute to his work, about which I have spoken to him, and I hope he will be reassured that this area of care is not forgotten and that the voluntary sector has a major role to play.
If I had to single out one area where I expect to see a step change in the quality of care delivered to NHS patients as a result of the creation of CCGs, it would be long-term conditions. However, it is unnecessary, as Amendment 79 proposes, to emphasise that the power in new Section 3A applies to securing improvement in the health of persons with long-term conditions, because the new section covers all those for whom a CCG has responsibility, regardless of their health needs. Neither is it necessary to make additional provision for integration, important though that is.
New Section 14Y in Clause 23 would require CCGs to exercise their functions with a view to securing integration. We covered integration in earlier debates. Rather than focusing on integration as an end in itself, the duty under new Section 14Y rightly focuses on the outcomes that we want to deliver through the provision of integrated services. When that duty is considered in conjunction with the power of CCGs to do anything calculated to facilitate the discharge of any function conferred on them, it is clear that the Bill already achieves the intention behind the amendment.
I fully agree with the noble Lords, Lord Ramsbotham, Lord Kakkar and Lord Hunt of Kings Heath, that the services covered by Amendments 80, 81B, 82 and 83 should be commissioned by the NHS Commissioning Board. It would be very difficult for me to take issue with the powerful points that they advanced for the care of those in the criminal justice system, Armed Forces veterans and those with rare and specialised conditions. However, it is our firm view that it is better to provide this detail through regulations, which will give the Secretary of State flexibility, as the services that the board commissions and the settings in which they are provided will no doubt change over time. This will also provide greater flexibility over when the board takes on these responsibilities, to allow co-ordination with the other agencies involved.
The noble Lord, Lord Kakkar, made an extremely compelling speech about amputee veterans. The Government accepted the recommendation in Dr Andrew Murrison’s report, A Better Deal for Military Amputees, that Ministers should take appropriate steps to provide for the national commissioning of specialist prosthetic and rehabilitation services for amputee veterans. Clause 12 already includes provision for the Secretary of State to require in regulations made under new Section 3B of the 2006 Act that the NHS Commissioning Board should commission certain other services not specified in the Bill. I confirm today for the first time that we intend to make provision for amputee veterans under those regulations.
In the context of Amendment 82, the noble Lord, Lord Hunt, asked how the board would involve health and well-being awards in its commissioning plans. The NHS Commissioning Board will be required to appoint a representative to attend local health and well-being boards in certain circumstances. It will thus have an active role in the preparation and development of joint strategic needs assessments and joint health and well-being strategies. It will have a duty to have regard to those strategies in exercising its commissioning responsibilities. However, it would not be appropriate to require commissioning plans to agree with health and well-being boards, or for the boards to have a right of veto. The Local Government Association agrees with us on this.
Clearly it is also important that the board develops its responsibilities in a way that complements and supports other local health and social care commissioning. As I have said, the board will have regard to joint health and well-being strategies. It would confuse lines of accountability, and would actually be unworkable, if we forced a duty on the board to agree its commissioning plans with health and well-being boards. Clause 20 also enables the Secretary of State to specify in the mandate to the board matters by reference to which he will assess the board’s performance, including in the services it will commission.
The noble Lord, Lord Hunt, asked how the board will be able to manage its primary care responsibilities effectively. Sir David Nicholson has set out his expectation that the NHS Commissioning Board will have a local field force, which is likely to be based—at least to begin with—on the areas covered by the PCT clusters. The field force would manage those aspects of primary care commissioning that require local expertise. There is a very informative section in the document, Developing the NHS Commissioning Board, published a while ago, which talks about this. It refers to Sir David’s aim to have,
“dedicated teams performing the range of functions”,
that make up the relationship with clinical commissioning groups. I direct the noble Lord’s attention to page 23 of that document, and hope that he will find it helpful.
The noble Lord also asked me what would happen if a CCG refused to commission a service. I reassure your Lordships that, first of all, CCGs will be under a statutory obligation to arrange for the provision of care to meet the reasonable requirements of the people for whom they have responsibility. I have covered that point. The board will have a duty to perform an annual assessment of how well each CCG has fulfilled its duties in the previous financial year, and that will include in particular an assessment of how well it has taken account of assessments and strategies under new Section 116B(1) of the Local Government and Public Involvement in Health Act 2007, inserted by Clause 190. It is intended that the NHS Commissioning Board, supported by NICE, will develop a commissioning outcomes framework so that there is clear, publically available information on the quality of healthcare services commissioned by CCGs, and CCGs must have regard to the commissioning guidance that must be published by the NHS Commissioning Board. Where a CCG chooses not to commission a service, it would have to be satisfied that it was not necessary to do so in order to meet the reasonable requirements of the patient population.
My noble friend Lord Greaves asked about the role of CCGs in setting up new services. I wish to be clear: CCGs will commission services, they will not provide services. A key commissioning function for CCGs will be securing the provision of services in their area to ensure effective provision of such services. If a new service is required, a CCG could choose to factor capital costs into the contract when commissioning the services.
In the example that I provided, it is not a service that I am talking about; it is a facility—a new building that hosts a series of services, some of which will be GP services, some of which may be commissioned by the CCG, and some of which may be hospital services. Who, in future, will be responsible for deciding to build a new building in, say, Clitheroe, and commissioning the contracts and so on in deciding to do it?
I am grateful to my noble friend, and I apologise that I did not cover that point. There are, of course, capital budgets. These exist at the moment and will continue to exist. The Commissioning Board will hold them. Where a capital project such as a building needs to be pursued, that money—as opposed to revenue money, which of course funds the commissioning of care—will be used to finance projects that are shown to be cost-effective and necessary to meet the needs of patients in a local area.
I would like to get to the bottom of this while we are talking about it. At the moment, those capital funds are provided either through the PCT or by the PCT from the money it has in the bank. In future, who will hold the funds to fund those capital projects?
They will be held in the first instance by the NHS Commissioning Board. I anticipate that if a CCG or a group of CCGs wishes to establish a new service that involves a new building, a dialogue will take place with the board to bid for the necessary funds.
The noble Baroness, Lady Armstrong, put a very important question to me about the needs of the homeless. As I have indicated, CCGs will have responsibility for meeting the reasonable secondary care needs of the homeless. CCGs are responsible for unregistered patients in their area as well as those who are usually resident. Primary care for the homeless will be, as now, accessed through GP practices, either as registered or temporary patients, or through open-access GP services, such as GP-led health centres or bespoke services for the homeless. It is important that the needs of the homeless are factored in to the plans not only of CCGs but of the joint health and well-being strategies formed at local authority level. Clinical commissioning groups will participate in formulating them.
Just to clarify the point I made to my noble friend Lord Greaves, I perhaps should have made it clear that the Commissioning Board could in practice allocate capital budgets to a CCG or a group of CCGs. I hope that was implicit in what I said. I re-emphasise that clinical commissioning will deliver better outcomes only if we allow clinicians the autonomy to identify the needs of their patients and communities and to make the key decisions about how best to meet those needs. With that in mind, I hope I have provided sufficient reassurance to the noble Lord for him to withdraw his amendment.
Can the noble Earl help me, before we get to Report stage, on the issue of the integration of services? He used the same argument he used previously, which is essentially that integration is a process and what we should be concerned with in the future is the outcomes framework. The problem for those of us who want to see something more on integration in the Bill is that we cannot quite see how we can change the culture on integration without having something in the Bill. Outcomes frameworks deliver results later on in the process. We see in the future what has happened. The difficulty many of us have is that we do not believe that that future will arrive unless we are more vigorous in this legislation about specifying some requirements on integration. Will the Minister write to a number of us before Report stage to explain how the outcomes framework will deliver that change of culture without words in the Bill about integration, particularly integration between health and social care? I do not expect an answer today, but I would like a clearer answer than the noble Earl has been able to give to satisfy us that we do not need some words in the Bill.
I understand the point the noble Lord is making and I will be happy to write to him and other members of the Committee. The Bill already provides a framework of powers and duties which will support more integrated approaches to meeting patients’ health and social care needs, ranging from requirements to ensure that use is made of research in the health service to the close relationship between commissioners and the local authority and the health and well-being board. We ought not to forget that the NHS Commissioning Board guidance under new Section 14Z(6) could well cover the exercise of this function of integration. I accept the noble Lord’s point that in large measure it is a matter of changing cultures and one cannot achieve that through the written word in a Bill that goes through Parliament. However, I would be happy to put some flesh on the bones for noble Lords in writing and I hope that that will be helpful.
My noble friend has given a careful response, as always, to the points made. However, will he accept that there is a very special need for focus on rare conditions and the struggle to get both diagnosis and treatment? I hope my noble friend will take note of this because I can attest, through my wife, that there is a lifetime struggle from childhood to get these issues addressed. I hope that will be borne in mind.
I am grateful to my noble friend and I did mean to make specific reference to his speech, which I found very impressive. He is of course absolutely right. There is no doubt that the commissioning of specialised services in recent years has improved in many areas but it is still variable. I do not believe I am misrepresenting those who champion the cause of patients with rare conditions by saying that they welcome the fact that the commissioning of specialised care will now fall to the NHS Commissioning Board. In other words, the commissioning will be done once and not, as at the moment, very frequently 10 times at strategic health authority level. It is absolutely clear that for all sorts of reasons greater consistency and better quality need to be injected into the commissioning of specialised care. The points my noble friend made were ones that we certainly subscribe to.
When the noble Earl was talking about the relationship between health and well-being boards and the local commissioning groups, he said that consultation would be expected but that in the last analysis if there was no agreement there would be no question of the health and well-being board having to approve of the CCG’s plans. In the event of a serious difference of opinion, for example, about provision for the homeless or provision for special needs in a community, would there be any possibility of referring the matter up to the board or would it just be left to them to try to reach the best agreement they could?
Part of the function of the board is to support decision-making at a local level if that is ever required. If there were a serious disagreement of the kind my noble friend describes, I envisage that the resources of the board could be made available to the decision-makers at local level to try to find a way through whatever disagreement had occurred.
My Lords, I am grateful to the noble Earl, Lord Howe, for his response. Essentially what he is saying is that the reasonable requirement duty based on current legislation, together with the discretionary power in Clause 11, is sufficient to ensure that clinical commissioning groups will commission in a comprehensive way and deal with the many specific issues raised by noble Lords in this very interesting debate. He went on to assure us that if they are not doing that, the annual assessment based on outcomes alongside clinical commissioning guidance will make sure that CCGs are kept up to scratch.
My concern as to whether that is going to be sufficient partly comes because of the attitude of some GP practices to what one might call “difficult to reach” patients; for example, homeless people or people with mental health problems. We have heard about the rare disease issue. I am sceptical that the views of GPs in their surgeries are somehow going to be translated into a much more comprehensive vision the moment they step inside the door of the clinical commissioning group. That, at heart, is where people’s concerns are. I agree that framing an amendment to satisfy this point will not be easy, but I suspect that we will all want to come back at Report to try to button this down.
My noble friend Lord Warner referred to the question of interventions, which is relevant to this. I am still not clear. The Secretary of State has been right to intervene with PCTs on the question of artificial waits for treatment but CCGs will do the same because they will have the same problems with resources. We were told last week that we have got this cancer fund, about which there will be no option. Ministers will make other promises in the future and yet money is being taken out of the health service. There is bound to be tension around the CCG board table. What if it decides that the 18-week wait is no longer important to it or it has a rule that if it is not urgent, a patient has to wait for a certain amount of time—because it is a way of controlling its costs? Where, then, is the intervention going to be?
My final point is about this whole question of the mechanism of health and intervention. I have not picked up the local field force yet—this is an innovation. However, it is quite clear that the NHS Commissioning Board, at a local level, will have to be a local player. It has the right of attending health and well-being boards, and presumably, if we do not get integrated health and social care, it will have to take advantage of that presence. It will hold the contracts of all GPs, so I assume that it will deal with complaints. The local field force will have to deal with the allocation of patients to practices where GPs are refusing to accept them. I am left with a sense that, in fact, there will be quite a large bureaucracy at the local level; the difference being that now it is under a proper public board. In the future it will be an outpost of a massive organisation based at the centre. I question whether that really is an improvement on what we have.
This has been a good debate. I sure we will want to come back at Report stage on the reassurance we need about comprehensive commissioning by CCGs, but, at this stage, I beg leave to withdraw the amendment.
Amendment 60A withdrawn.
Clause 7 agreed.
Clause 8 : The Secretary of State’s duty as to protection of public health
60B: Clause 8, page 4, line 23, after “protection” insert “and promotion”
My Lords, we now come to the important area of public health. This is the time for your Lordships’ House to dip its collective spoon in the good part of this curate’s egg of a Bill. I have to say that, of course, in the context of this Bill, “good” is a relative term, but I very much welcome the reversal of the 1973 reorganisations—the splitting off of public health from local government—and the recognition, implicit and indeed explicit in the Bill, of the need for the closest possible relationship between public health services and the wide range of local government services which contribute to the promotion and improvement of the public health of individuals and whole communities.
In this context, of course, it is critically important to recognise the need for a high degree of professionalism, and in particular to ensure that public health specialists are thoroughly engaged at a senior level within local government and that they have a considerable measure of independence, both at national and at local level. There are amendments that we will be discussing—not necessarily in this group but as we go through the Bill—that address those particular issues.
One amendment in this group that I will not be moving or speaking to today is Amendment 94A, which relates to the making of Public Health England into a special health authority. By the vagaries of grouping, Amendment 267, in the name of the noble Lord, Lord Patel, relates to a later part of the Bill, although it could have been grouped with my amendment. It would be discourteous of me to anticipate that debate, given that the noble Lord’s amendment is down for future discussion. In general, we need to examine the role of government and their capacity either directly or through any of the other bodies created by the Bill to deal with the broader issues of public health at the local and national level.
Amendment 60B is the first amendment in my name. It simply incorporates the concept of promotion of public health as well as protection and improvement of public health in the rubric to Clause 8. It strikes me as a more positive and perhaps wider responsibility, which is echoed in some of the amendments we will discuss in this group about promotion through information, publicity and the like. It also perhaps has slightly less of a strictly medical connotation than the original rubric contains.
More significantly, Amendments 67A and 75ZZA relate to the proposed requirements on the Secretary of State to produce annual reports in dealing with the public health impact of budget changes and, as regards Amendment 75ZZA, in respect of finance generally. As ever, there is a significant issue around finance, which cannot be dealt with in terms of the context of the Bill. But it is critical that the reform is carried through with a workable system of financing the new arrangements. Considerable concerns about that have been voiced in response to the consultation documentation about funding the public health service from a number of quarters, including local authorities, the Faculty of Public Health and other organisations.
The difficulties of course are that at the moment public health is funded through the PCTs. It is by no means clear what the total quantum will be defined as in terms of the money to be redistributed direct to local authorities—ring-fenced, as we know it will be—let alone how that quantum will be distributed by way of formula. In addition, there is the new concept of the public health premium which will be used to reward those authorities which achieve an improvement in the public health of their area.
These are difficult matters. The Select Committee suggested that the public health impact of financial changes should be the subject of report. Both amendments simply follow the recommendations of the Health Select Committee of the House of Commons. I hope that the Minister will be able to agree them or at least agree to consider them and come back on Report.
I have been looking into this issue with the Local Government Association and this morning I received some advice stating:
“We are no nearer an announcement on the distribution formula or quantum after the third trawl for data. We remain concerned that it may be dealt with in isolation from wider issues about the design of the wider systems and the role and cost of Public Health England”.
Clearly, the finance will not be dealt with in the Bill but we need to know as we go through the Bill and approve—I hope improve—the proposed structures, how the financial system would work. Perhaps in reply the Minister could give an indication of when it would be expected that the financial framework will be explained and judgments might then be made about the adequacy or otherwise of those arrangements because they will impinge heavily on the eventual outcomes that we are all seeking.
Amendment 69ZA will extend to local authorities the duty to have regard to and promote the health equalities agenda, which we have discussed previously in relation to the national Commissioning Board and the national players, as it were. It seems to me sensible that there should be a matching requirement for local authorities to have particular regard to that issue.
Amendment 89A is a suggestion, really, that the provision in the Bill conferring on CCGs the responsibility of arranging vehicles for residents who need them could also be a concurrent function of local authorities, some of which, I think, currently operate such schemes. Given the arrangements that local adult services and, indeed, children’s services of departments already have for supporting people with conditions requiring such mobility, it would seem sensible to permit those to be included in the arrangements.
I hope that the Minister will respond sympathetically to these amendments, and indeed to others that other noble Lords will be making in the debate this afternoon. If he cannot reply in detail today, as time is pressing, I would quite understand if written communication were made later.
I apologise to the House for my enthusiasm to get in to this debate on public health, which I regard as a key part of this Bill. I am extremely supportive of much of the thrust of the Government’s approach. I rise to speak to Amendments 62, 64, 65 and 68, which are in my name and in the name of the noble Lord, Lord Patel—and, in the case of Amendment 62, also in the name of the noble Lord, Lord Walton. Unfortunately, neither of those noble Lords can be with us today. However, I strongly support the remarks made by my noble friend Lord Beecham.
These amendments to Clause 8 are aimed at strengthening the Secretary of State’s duty on the protection of public health. Let me make clear that, as I said, I very much welcome the Government’s emphasis and commitment on public health and support the thrust of their changes. It is time for us to give much more prominence to public health if we are to relieve the pressures on the NHS in the coming years. However, I believe that we could go further than the Government have in terms of the Secretary of State’s duty, as currently expressed; hence these amendments.
Amendment 62 requires the Secretary of State, when taking steps to protect the public from disease or other dangers to health, to do so on the basis of,
“using the best scientific and other evidence available and without regard to special interests”.
The first prong of this amendment is to cement evidence-based policy into the discharging of the Secretary of State’s duty to protect public health, and to make clear the use of science in doing so. All Governments like to claim that their decisions are evidence based—nothing surprising or new in that—but all too often they are not. For example, it has been a very long haul getting all government departments to have chief scientific advisers. Even now, the Treasury has only recently appointed its first chief scientific adviser.
Your Lordships’ Science and Technology Committee, of which I am privileged to be a member, is currently looking at the experience of chief scientific advisers in different departments, and it is very clear that their status and influence vary considerably. In the area of public health, it is absolutely clear that using a strong scientific evidence base, including the social and behavioural sciences, is very important indeed. Nowhere was this more important than in the controversial issue of banning smoking in the workplace and in public places. The dangers of second-hand smoke were discounted until the scientific evidence made that position untenable. If I may say so, we are now seeing a rerun of that debate over the issue of smoking in cars and the danger to children of second-hand smoke. Without going into particular issues, I want to emphasise the importance of Health Secretaries—of all political persuasions—making public health policy and taking decisions on the best scientific evidence available, and of requiring them to do so in statute.
The second prong of Amendment 62 is something of a belt-and-braces approach, requiring the Secretary of State to not be overinfluenced by special interests. There have been long-running concerns about the influence of the tobacco, food and drink industries on successive Governments over public health policy. I am not making a party political point here. All Governments have been subjected to pressures by those particular special interests when they have tried to deal with protecting public health. I will not go over the ground in detail because it is well documented and in the public arena.
However, the issue has been given a new burst of life because of this Government’s attachment to nudging public behaviour in the right direction rather than legislating. Again, the Science and Technology Committee of your Lordships’ House, under the chairmanship in this case of the noble Baroness, Lady Neuberger, produced a report recently on this issue. While the nudge approach can be useful in changing public behaviour, that it is a sufficient remedy in many critical areas, such as obesity, is not supported by good evidence. The result is that powerful interests backed by skilful marketing can still defeat important public policy advances.
Lobbying by powerful special interests is a feature of all western democracies, and a potentially dangerous one in the sphere of public health. We should take the opportunity of this Bill to require future Health Secretaries in this position not only to pursue science-based policies but to resist the blandishments of special interests. Amendment 64 is a simple substitution of “must” for “may” in terms of the steps that the Secretary of State should take in carrying out his duties set out in new Section 2A(2).
Amendment 65 extends the final item of that list of steps, so that services made available assist the public to take,
“responsibility for improving their health and well-being, including access to their own medical records”.
Many of the pressures placed on the NHS result from lifestyle choices that we all make that can damage our health. We need to make it a central tenet of public health policy that we should assist people to take more responsibility for their own health and well-being, rather than simply expecting others to bear the cost of treating them when they become ill. Obesity is a good example. In most cases, the solution lies literally—if I may put it this way—in our own hands. Accessing and probably holding our own medical records would reinforce that personal responsibility. This Government, like the previous one, rightly emphasise personal responsibility alongside rights. In the sphere of public health, Amendment 65 gives a push to that approach. I hope that the Government will accept it in the spirit in which it is proposed.
Finally, Amendment 68 extends Clause 2A(4) to give the Secretary of State a bit more help in carrying out his duties to protect public health. This amendment requires the Secretary of State to appoint an independent standing advisory committee on public health of no more than 15 people to provide advice on a regular basis as well as when the Secretary of State seeks it on a particular issue. The reports of that committee will be available to Parliament and the committee can report to the Secretary of State on any matters of concern that it has about the state of public health. I would envisage this committee being a major focus for the provision of scientific evidence to underpin public policy in this area under Amendment 62. I think that Amendment 68 is self-explanatory and its benefits self-evident in an area as important as public health.
I hope that the Minister will see these amendments as constructive strengthening of the Government’s ambitions on public health and enabling a helpful legacy to be left to the next Health Secretary whenever this current Health Secretary chooses to leave his job. I believe that these amendments go with the grain of the powerful, recent report on public health by the Select Committee, which proposes further strengthening of the Government’s powers. I hope that the Government will be sympathetic to these amendments and to Amendment 95, in the name of the noble Lord, Lord Patel, to which I have added my name.
My Lords, I wonder whether my noble friend could help me with something that seems to be implied in his very eloquent deliberations about the amendments. I agree with him entirely that, in the public health arena, political leadership—the role of Governments of whatever party—is enormously important, particularly, as he said, in resisting the blandishments of external lobbies and so on. Does he see a potential conflict between the additional powers which he is advocating for the Government and the Secretary of State in this area, which I would entirely support, and the decision of the Government to reduce the powers of the Secretary of State in general for health services, healthcare and the promotion of general health matters in the way in which the Committee has discussed at some length on earlier clauses?
My Lords, my noble friend raises a very important point. I can see some differences of approach here. Today, I am speaking on the rather narrow issue of helping the Secretary of State to be a powerful influence in improving public health. Of course, it is for your Lordships' House to debate further, as we progress through the Bill, whether we want Clause 1 to go a little further than the Government seem to want in terms of the Secretary of State’s responsibilities. I have sympathy with my noble friend in seeing a slight confusion on the part of the Government in some of these areas.
My Lords, I wish to express strong support from these Benches for the amendments spoken to by the noble Lord, Lord Warner. Perhaps I could mention one or two points. It is clear that the emphasis on public health, important as it is at the national level, must also be reflected at the local level. I say again, therefore, that the amendments about expecting clinical commissioning groups to have at least one board member with public health experience are important in reflecting the kind of things about which the noble Lord, Lord Warner, has spoken.
I also believe that the noble Lord has put forward in Amendment 68 a very interesting idea that ought to give a higher profile to public health advice on how to deal with diseases and illnesses in the population as a whole. Obviously I share the views expressed by the noble Baroness, Lady Jay, on the importance of putting the Secretary of State squarely behind these issues, and I shall give one example of that. The Bill provides for extensive redress on issues related to smoking and alcoholism, and perfectly properly so. People are perhaps more reluctant to point the finger in relation to some of the serious public health issues arising from the food industry, issues which have great implications for the food industry's relations with the overall economy. There has over many years been a very slow response to growing evidence that certain foods, particularly foods directed at children and young people, have a substantial impact on health. If one looks at the ways in which those foods have been advertised, with an emphasis on how attractive they are, not only so that people will taste them but so that there will be a certain addiction to them, one will see an issue on which there should be a major consultation between the Department of Health and that industry. So far that has largely been limited to issues such as labelling, which is sometimes so complex that the ordinary consumer would not easily pick it up.
There is a continuing emphasis on, for example, foods that attract young children but which contain high levels of salt, sugar and so on, which is all the more serious in a country such as ours which, sadly, has a growing problem of obesity. I strongly suggest that the Government should look closely at Amendment 68 and the idea of establishing a standing advisory committee on public health. I would also point out the importance of assigning responsibility all the way up to the Secretary of State to ensure that these negotiations with industries and special interests which are crucial to the nation's health are conducted at the highest level and that public health is recognised as a full companion to all the other aspects of health. In that respect, I am very pleased indeed that the Government have put emphasis on the independence of the public health area and allowed public health to be taken out of the Department of Health and given its own status. That is a very long step forward.
My Lords, I have some amendments in this group to which I would like to speak. The first is Amendment 62A, a probing amendment which seeks a government response. This amendment would require the Secretary of State to report annually on the steps taken in relation to the duties listed in the Bill. Currently we have the Chief Medical Officer’s annual report, which is excellent and provides an enormous amount of information particularly on matters relating to public health. However, given this Bill and the dramatic changes we will see in the delivery of healthcare across England, it seems important that we should have regular annual reporting that can be tracked from year to year against a specific set of headings. Over the years this would create comparators that could be used to see whether the quality and health improvements on which the Bill is focused are being achieved.
Similarly, I have amendments about undertaking an audit of healthcare providers’ processes and outcomes in terms of how they improve public health and implement the public health advice they receive. Amendment 71A, another probing amendment, suggests changing the wording of the provision so that there is an obligation to consider diagnosis and treatment rather than diagnosis or treatment, as the Bill currently provides. I tabled this amendment because I was somewhat horrified to see that the Bill provides a requirement to consider treatment but not to ensure that the diagnosis guiding the treatment is correct. Treatment for the wrong condition will result in morbidity and mortality related to the treatment plus progression of the underlying condition. I wonder whether that might not be a drafting issue which the Government might be inclined to look at again.
I have taken further advice on my Amendment 69A and have decided not to press it. I can therefore spare the Minister the trouble of trying to respond to it.
However, perhaps I may give a little evidence in support of this pressure to require reporting and audit at every level. There is high-powered and strong evidence from public health itself. Public health is a competency set, not a separate discipline. All public health practice needs epidemiology, biostatistics and a commitment to organisations and community understanding, with a focus on prevention and the implementation of evidence into practice. Evidence is not just a matter of, “Yes, there is evidence”, or, “No, there is not”. There is a hierarchy of scientific evidence in relation to public health.
It is important to understand that there are five criteria in relation to the reporting requirements that I am asking for. First, there may be evidence of no benefit. Secondly, there may be no evidence of benefit. Thirdly, there may be uncertain evidence of benefit. Fourthly, there may be evidence of efficacy. Fifthly, there may be evidence of both efficacy and effectiveness, which means that these interventions would incontrovertibly improve efficacy and seem feasible for large-scale implementation based on effectiveness trials. So that is very high-level evidence, and the others are hierarchies right down to the first I listed, which was a reason for decommissioning and stopping the use of an intervention.
Perhaps I may give some examples of where that hierarchy has influenced clinical practice and the reason why public health cannot be divorced from clinical practice. Even though this has been put on local authorities and will have a strong influence, I hope it will not become divorced from clinical practice. It needs to be linked to commissioning by GPs for the following reasons. First, it has been demonstrated that general practitioners and clinicians can save money if they provide advice on health in the consultation as well as dealing with the presenting complaint. Secondly, involving clinicians in detecting alcohol problems as part of a routine consultation has been shown to save money and lives. Thirdly, in nurse-led clinics there is evidence of cost-effective secondary prevention when they are used for targeted areas such as coronary heart disease. They can be extremely effective. Fourthly, drug treatment is a public health issue and there needs to be close working in the clinical setting to make sure that the use of drugs in conjunction with the appropriate use of pharmacy advice can maximise health benefit. Fifthly, primary care itself is more effective where public health is involved in the way that primary care is delivered. A very powerful trial conducted in the USA has shown that to be the case. Last but not least, high-tech interventions that at first sight might seem expensive, when properly evaluated in public health terms, have been shown to save lives and money, so they become an investment for savings.
Those are just some of the examples of why we need public health right at the heart of the changes, but we also need the monitoring that public health can bring to ensure that things that should happen are happening.
My Lords, from the outset the noble Lord, Lord Warner, and my noble friend Lady Williams have hit the button on this debate. Like the noble Lord, Lord Warner, I am a sceptic about nudge theories and think that they need to be investigated. I thought that the House of Lords committee under my noble friend—my former noble friend—the noble Baroness, Lady Neuberger, interrogated the issue extremely well. We are in an obesity crisis. We are expecting 50 per cent of adults to be obese by 2020 and I believe that we are going to have to do something rather more drastic than simply nudge people. Personally, I am quite attracted to the idea of a fat tax. Let us see the evidence of whether a nudge is going to prevent us from facing a major obesity crisis by 2020 that is even greater than the one that we already have, or whether a fat tax is the only way that we are going to get there. The spirit of the amendment moved by the noble Lord, Lord Warner, is absolutely correct in that respect.
Very ingeniously, the noble Lord has introduced the idea of patient control over their own records. I do not know whether this is the right place in the Bill to be debating this issue, but I do know that it is an extremely important suggestion. Patients should have control over their own records, which should not be simply under the control of the local GP. It is increasingly important for pharmacists to have sight of a patient’s records—with the consent of the patient; that is the essential control—and that other healthcare professionals should do so. There should not be a monopoly on the sight of patients’ records for general practitioners. With the consent of patients, other health professionals should be able to see them. We will then have proper integration of healthcare without expecting GPs to be the gatekeepers for all an individual’s healthcare needs.
I do not know whether we are starting the debate that was referred to at Second Reading, but this is an important area which I hope will be discussed further during the course of the Bill.
My Lords, I should like to make a short intervention to ask my noble friend one or two questions. When I was a Minister I was responsible for the Health of the Nation policy, which I much enjoyed. At the time we introduced the five-a-day programme. That was 21 years ago, so we can see how long it has taken to get that message deep into the psyche of the British people. There is something about promoting good health and habits of living to the population—it takes a very long time.
I want to speak to Amendments 62, 65 and 68. I was very much hoping that we would have a debate on Amendment 94A, which is about Public Health England. But courtesy is the hallmark of this House and, as the noble Lord, Lord Patel, is not here, it is absolutely right that we should not debate it today.
On Amendment 62, on scientific and other evidence, from the noble Lord, Lord Warner, it is the “other evidence” that I want to ask my noble friend about. As my noble friend Lady Williams said, other evidence is something that you build up, and I am quite concerned about how we are going to get this evidence into health and well-being boards and how we will ensure that the Government have enough evidence that builds from the bottom up. One problem is with access to data; if we are going to have joint needs assessments through the health and well-being boards and strategies, and if that information on the ground cannot be shared, it will be very difficult to ensure that we have joint needs assessments. The GPs have those data and share them with other people in the National Health Service, but I do not believe that at this time they can share them with local government. That will be a very important issue because, although they are anonymised data, if you are going to run a public health programme on obesity you really need to know exactly in what geographical area that obesity is at its worst so that you can target it. When you are looking at the needs of individuals, you may have information about the numbers of people who have diabetes or coronary heart disease, but it is when you link those diseases to individuals that you get back to the previous debate that we were having on long-term conditions. Linking some of this stuff together is absolutely critical, and maybe my noble friend could think about that in the intervening time and write to me—and to other noble Lords, if they are interested.
I agree with my noble friend Lord Clement-Jones that this may be not quite the right moment to discuss medical records, but I really cannot resist it, although I will be brief. Some 21 years ago, in this House, from the place where my noble friend now sits, I made my maiden speech on medical records, so it is something that I have quite an interest in. When I produced a policy document on changing childbirth, one recommendation was that women who were pregnant should hold their own medical record, sometimes known as hand-held maternity notes. That has had an enormous impact; it has made those women feel that they are very important—they are pregnant and they are going to have a child and a whole readjustment to family life. That is a very important time in a woman and her partner’s life, and it acted as a sort of passport to them. Bearing in mind that 30 per cent of women who are pregnant are obese, which has a huge impact on the next generation, it seems to me that having hand-held records or access to or ownership of your own records is terribly important. Of course, we have the red book that women get about their children so that they can share that information with health professionals.
My last point is on Amendment 68 and the standing advisory committee. I absolutely understand why the faculty of public health and other people like that idea. I am not sure whether that advisory committee, as has already been suggested by the noble Baroness, Lady Finlay, will make an annual report. That is possible. We will have the Chief Medical Officer’s report annually, as she said, which is a very brave and independent document; the Chief Medical Officer says how it really is, and I know that it is very often extremely uncomfortable for the Government.
When we have Public Health England, will it make an annual report? I am concerned that we do not get too confused. Some of these standing advisory committees have been extremely effective, such as the Joint Committee on Vaccination and Immunisation. When I left the Government, in our last year we did not have a single case of home-grown measles. That was a tremendous achievement and my hero is Professor David Salisbury, who has worked in this field for years. However, if one individual like Andrew Wakefield comes along, it can destroy the herd immunity for years. So, although advisory committees are helpful, they will not necessarily prevent that sort of thing from happening.
In addition, advisory committees breed. It is absolutely extraordinary. Yes, you want to keep the good ones. There are others that I have set up and given a time limit to complete a task within two or three years. Then you try to get rid of them. It is so difficult, because they get dug in, they love the work they are doing and many get paid for it. In the end, they become not so much a help but more of a nuisance. So I have some reservations, but when we get to the debate on Public Health England we will see how some of this knits together.
My Lords, I am also pleased that public health receives such a high profile in this Bill. I speak to Amendment 60B and one or two others in this group. There seem to be several aspects to the public health parts of this Bill being probed by these amendments. However there is one area of public health that might fall between too many bodies and where we might usefully explore how we can arrange for them to be better co-ordinated. The area is child and maternity services.
As I understand it, local authorities will be responsible for child public health services; the Commissioning Board for health visitors and immunisation services; and clinical commissioning groups for child health and maternity services. That will require all sorts of collaborations to be set up, and that is always a recipe for some problems. I hope that the noble Lord can give us an idea of how these sets of services can be rationalised in some way.
I shall now speak to Amendment 62 and some others. Clause 8 describes the Secretary of State’s duty to protect the public’s health. It details a number of specific responsibilities which, it so happens, are currently undertaken by the Health Protection Agency. I would like to comment on them. I have extolled the virtues of the HPA on a number of occasions, having observed it closely as the chairman of its predecessor, the PHLS, some years ago. Incidentally, the hero of the noble Baroness, Lady Cumberlege, is an employee of the Health Protection Agency. It is a remarkable organisation and the envy of the world. It jumps on outbreaks of infection very rapidly and has prevented many an epidemic. There are many examples of that.
I reiterate this because the HPA is to be swept up into a new arrangement, as we have heard, much more directly under the influence of the Secretary of State. Thank goodness it will not be within the Department of Health, but it will be very close to it. My fear is that we will weaken something of great value to the country. I have some specific questions for the noble Earl.
First, is it expected that all the current functions of the HPA will be taken on board, or are we to lose some? The list is pretty comprehensive but it may leave things out. If so, what would be lost and what would be preserved? Secondly, is it intended that all the staff will move across? They currently work as a very efficient and effective team—a lean, mean team—and any break-up will have an effect. Thirdly, is funding to be affected in the changeover? Will the new organisation have access to external research grant income? That is very important if it is to keep ahead of the infections, which keep changing every day. I have mentioned this before and the noble Earl has responded, but I should like him to respond again more forcefully on whether the organisation will have access to the Wellcome Trust grants, the Medical Research Council and others outside of the NIHR. One of the duties of the Secretary of State is to take steps that include,
“the conduct of research or such other steps as the Secretary of State considers appropriate”.
Finally, will the body have the degree of independence that will allow it to give advice to the Secretary of State unfettered by Civil Service restrictions?
I hope that the noble Earl can help us with these questions, because there is considerable unease in the HPA at the moment.
My Lords, I should like to speak very strongly in support of Amendment 65 in the name of the noble Lord, Lord Warner. Were the noble Lord, Lord Patel, here today, I am sure that he would also speak strongly in support of it because he raised the issue of patient records yesterday when we had a meeting with Professor Steve Field of the Future Forum. We were discussing information provision for patients and the use of computer records. He said that for many years when working in maternity he had given patients their own notes, and in all that time he could remember only two occasions on which the notes had gone missing. On one occasion, the patient reported that a dog had eaten the notes and, on the other, the notes were left on a bus and shredded, someone having recognised that they were important. Therefore, only two sets of notes were lost over a period of some 20 years. Patients are perfectly capable of looking after their own notes. When I was a surgeon in Ghana in 1974 it was certainly quite common for patients to come to the clinic with their notes, which often would otherwise have been lost.
The final message that came through was that we have spent billions of pounds on creating paperless records and computer records and are about to spend even more. The information that we were given yesterday at the Future Forum was that we should be looking at what can be done locally, bearing in mind that GPs have a computerised system of records. We heard another anecdote about an old lady who went to the out-patients’ clinic for her appointment and the consultant said, “I’m terribly sorry but we’ve lost your notes today”. She put her hand into her handbag and came out with a memory stick, saying, “Doctor, it’s all on here”.
I hope that the Minister will take note of Amendment 65 because I feel that it may well stimulate us to look again at patient records and the use of technology. We are, after all, in the 21st century and, although paper records are wonderful for us to have as a tactile instrument, they do not always contain the information that we need.
My Lords, given that my hard-working noble friend Lord Howe deserves at least a short break, I shall be addressing these amendments. If I do not cover them sufficiently comprehensively, given the time, I shall be very happy to write to noble Lords.
This is a very large group of amendments covering Clauses 8, 9, 14 and 19, which together set out the fundamental legislative basis for the new public health system. I thank noble Lords for their general welcome of these provisions, which of course put public health very much front and centre in the new system.
The Public Health White Paper sets out the Government’s commitment to protecting the population from serious health threats, helping people to live longer and to enjoy healthier and more fulfilling lives, and to improving the health of the poorest the fastest. At a national level, there is a clear rationale for accountability for health protection to rest with the Secretary of State. The nature of various threats to health are not, of course, always amenable to individual or local action. They require a clear line of sight from the Secretary of State down to local services.
Clause 8 inserts new Section 2A and gives the Secretary of State a new duty to take steps to protect the health of the public in England. In practice, Public Health England, the national component of the new public health system, will play a key role in health protection, bringing together a fragmented system and strengthening the national response on emergency preparedness. It is our intention that it will be an executive agency of the Department of Health. Public Health England as an executive agency will have an operational distinctiveness that will allow it to build and maintain its own identity. Agency status will support the ability of scientists in Public Health England to give expert, objective and impartial scientific advice, which noble Lords have called for, to both the Secretary of State and more widely. I entirely share the view of the noble Lord, Lord Warner, that we must make use of the best scientific and other evidence available. We intend to set out clear proposals shortly on how the Secretary of State and Public Health England will receive professional advice. I am confident that those proposals will at least match the intention of the noble Lord’s amendment.
I hesitate to interrupt the noble Baroness on her debut at this point, but does she understand that by its very nature an executive agency is within a government department and does not have the same level of independence as a non-departmental public body? We are seeing played out in the public arena at present some of the consequences when there is disagreement between people in an executive agency and a Minister. That concerning the Home Office is currently being played out on the front pages of our newspapers. Does she agree with me and, I think, my noble friend Lord Turnberg, that having scientists in an executive agency fetters their freedom compared with in a non-departmental public body?
The noble Lord flags up a concern that has been expressed about the independence of the new organisation. I would point out the example of the Met Office, which is arranged in a similar way. What it does on climate change may not always go down well with the Government of the day, yet it has no reluctance in coming forward with the evidence that it has.
It is extremely important that it should have that expert advisory position. That is why it was moved out of the Department of Health, which was the original proposal. The noble Lord will know that it was going to be within the Department of Health, but the Future Forum flagged up that concern and the decision was taken that it be arranged in this way, to address the points that the noble Lord has raised.
Coming back to what I was saying about the Health Protection Agency, I remind noble Lords that Clause 53 abolishes that agency and repeals the Health Protection Agency Act 2004. That is central to the Government’s plans for unifying national health protection activity and creating a more transparent and accountable service under the Secretary of State. In so many ways the Health Protection Agency has done an outstanding job, and we certainly pay tribute to those who have worked within it. It has established an outstanding international reputation, as the noble Lord, Lord Turnberg, pointed out. Public Health England will be able to build on that recognised expertise not only from the Health Protection Agency but from other organisations that we can draw into our public health system. There was talk about whether this should be a special health authority. The noble Lord, Lord Beecham, said that he wished to address this later on, so no doubt we will come back to this and to the points the noble Lord, Lord Warner, made about independence and why we are not proposing to do things in quite that way.
Clause 50 requires the Secretary of State to publish an annual report. Noble Lords wanted to know about the reporting mechanisms. This annual report covers the performance of the comprehensive health service in England. I wish to highlight that the content of the report will include public health. The noble Lord, Lord Warner, was right to emphasise the importance of good evidence. This will be key to the analysis and taking forward of effective policy. I understand exactly what he means by “special interest”. However, the drafting of his amendment might have the unintended consequences of people not being able to consult groups that they might wish to consult—such as the royal colleges, which might be regarded as being special interest. The key thing here is not only the commitment to rely on scientific evidence but also transparency. That is essential. If you have transparency over where information is coming from and who is meeting whom, that should help to allay some of the concerns that the noble Lord has expressed.
We have heard a certain amount about medical records. The Department of Health’s information strategy, which will be published this winter, will include consideration of the benefits of greater transparency of provider performance and outcome information as well as setting out how increased transparency and greater access to information can support improvements in care, giving people greater access to and control of their care records. A number of noble Lords raised the point about their medical records. This has been a long and ongoing debate over generations, almost. I hope that noble Lords will be encouraged by what comes forward.
Clause 9 inserts new Section 2B into the National Health Service Act 2006, giving local authorities a new duty to take steps to improve the health of people in their areas and the Secretary of State the power to take steps to improve the health of England. There has been a bit of a debate as to the balance here. As noble Lords will recognise, there is undoubtedly a shift in the devolution of the responsibility to local authorities. We welcome the enthusiasm that has been shown by local authorities and the Local Government Association in taking on this responsibility, which belonged to local authorities in earlier years and made such a dramatic improvement, particularly in the 19th century in terms of sanitary reform when it was at local authority level that enormous change took place. It is easier to see the joining-up of all the areas that need to be joined up, as shown in the Marmot report, if public health is seen as a local authority responsibility. Giving this role to local government opens up new opportunities for community engagement and for developing holistic solutions to health and well-being by embracing the full range of local services. Crucially, unlike primary care trusts local authorities are also directly accountable to the local electorate for their performance. Directors of public health will lead this work as the principal advisers on health to the local authority.
I hear what the noble Lord, Lord Beecham, says in regard to inequalities. However, I hope to reassure him that our reforms will give all levels of the public health system key roles in tackling health inequalities. The shift to local authorities should help in this regard. As these changes take effect, we would expect them to have the largest and earliest impact on those communities with the worst public health by joining up services in that way and because the public health budget will be ring-fenced for local authorities and therefore will be less likely to be raided by the rest of the health system.
The Secretary of State for Health will publish a public health outcomes framework that will set the strategic context for the system from local to national level. The framework will set out the broad range of opportunities to protect and improve health across the life course and to reduce inequalities in health. As I mentioned, from 2013-14 the department intends to allocate to local authorities a ring-fenced public health grant, targeted for health inequalities. We are also developing a health premium to reward communities for the improvements in health outcomes that they achieve.
The noble Lord asked when funding for local authorities would be made. We expect to announce a baseline figure for 2012-13 very shortly, which will allow local authorities to plan ahead for 2013. Our estimate of the global figure, as he will know, is in excess of £4 billion.
Amendments 69A and 60B would effectively give the Secretary of State a duty in relation to health improvement. In drafting Clauses 8 and 9, we took care not to duplicate duties, as this could inadvertently create confusion over whose responsibility it is to act by giving two agencies a duty to take similar steps. This is an area that the noble Lords, Lord Beecham and Lord Warner, and others probed. I hope that this clarifies that we are devolving responsibility to local authorities, with certain responsibilities for the Secretary of State and Public Health England.
In addition, there have been a number of amendments in relation to the steps that may be taken under parts of new Sections 2A and 2B. We have avoided defining health protection or health improvement in a restrictive way. Instead, these steps illustrate the nature and extent of the functions by listing a number of steps that the Secretary of State or local authority may take. In some cases, we have also selected the steps to remove any doubt as to whether they could be taken in the exercise of the new functions.
Clause 14 transfers responsibility for a number of public health activities from the Secretary of State, including the transfer to clinical commissioning groups of the Secretary of State's responsibility for the supply of wheelchairs. This issue has not come up; noble Lords seem to be relatively content. I hope that, if they are concerned, they will make contact in time.
Clause 19 allows the Secretary of State to delegate by arrangement his public health functions to the NHS Commissioning Board, clinical commissioning groups or local authorities. Where the Secretary of State enters arrangements under new Section 7A, the function will remain that of the Secretary of State, but it will be exercised by the body that is under and subject to those arrangements. When a local authority, the Commissioning Board or a clinical commissioning group exercises the Secretary of State's public health functions, it will be liable for its own acts or omissions. However, the Secretary of State will remain responsible for the function in the sense that he will be accountable to Parliament and will have to check that continued delegation is appropriate and that the function is being exercised appropriately.
The noble Baroness, Lady Finlay, spoke about “and” and “or”. I assure her that the provision is expressed in a non-excluding way. I know that “chair and table and desk” appears to mean that you have everything, but if you put in “or” it makes it easier: if you have a chair and table, you are not ruled out if you do not have a desk as well. I hope that the noble Baroness is reassured. When I sought explanation about when to use “and” and “or”, it was explained that having “or” makes a provision more inclusive than having “and”. Therefore, the noble Baroness can be reassured that we are not going down the line of wanting treatment with no diagnosis. I cannot imagine that the medical profession would agree to that even if we were to propose it.
I am grateful for the reassurance that the noble Baroness does not see any way of uncoupling diagnosis from treatment. I am not terribly comfortable with the furniture analogy. Pieces of furniture are not as complex and integrated as human bodies.
I have a feeling that carpenters might disagree. Nevertheless, I take on board what the noble Baroness says, and I hope that I have reassured her.
Where was I? I think that I have covered the points spelled out by various noble Lords on research and evidence. Research and evidence would rightly run right the way through these arrangements, and I would have expected noble Lords to flag this up. It is absolutely crucial that evidence underpins the work that is done. I heard what was said about nudging, and so on. The Select Committee itself said that it welcomed the exploration of new ways of doing things, provided that they do not dislodge other ways of assessing things. It is extremely important that, in all these areas, you assess what the impact of something is. I hope that noble Lords will be reassured. We will come on to this in a minute.
I hear what the noble Lord says. To judge so quickly something which has only exploded on to the agenda relatively recently does not seem to me to be terribly scientific. As a former social scientist, I do not think that that is giving quite enough time to assess it. However, the Government absolutely hear what the noble Lord says. We need a range of ways of exploring things. If people suggest ways of probing and investigating areas, then all those areas need to be assessed properly, and given due time to take effect.
I was about to come on to the point that, in this Bill—noble Lords have flagged this up—there is provision for continuing to measure children even though that public health responsibility has gone over to local authorities. It underpins our understanding of the extent to which we have obesity among children. It is extremely important that it is carried forward, and I think that that bears out the Government’s commitment to continued research.
I have covered patient records. The noble Lord, Lord Turnberg, asked about child services. I know that my noble friend will be coming back into full view in a minute, and will address some of these areas, so maybe that is best covered then. We are extremely concerned to make sure that, across all areas, these matters are properly co-ordinated.
I have addressed the point raised about the separate annual reports. The Secretary of State is reporting generally, across all these areas. I hope that I have not missed out any key areas. There was a question from the noble Lord, Lord Turnberg, about Public Health England. It will indeed be able to receive research funding from the majority of sources from which the HPA is currently receiving research income. This was a key point that was flagged up by noble Lords last night, and it has been confirmed. Research is clearly vital for the specialist expertise required in Public Health England.
I appreciate noble Lords’ probing on all these important areas, but I hope that at this stage the noble Lord will be happy to withdraw the amendment.
My Lords, I am grateful to the Minister for her reply, although I shall resist the temptation to follow her into the realm of rearranging the furniture or even the deckchairs on the NHS “Titanic”. She rather missed the point of Amendment 69ZA, which adds to the provision in the Bill that will require each local authority to,
“take such steps as it considers appropriate for improving the health of the people in its area”,
the duty to take such steps as are appropriate to tackle the problems of health inequalities. That is the point that the amendment seeks to enshrine in the Bill. It is a duty that will lie on the Secretary of State for national purposes, but not for local purposes.
I am sorry that the noble Lord feels that I did not adequately deal with that. The point I made is that moving public health to local authorities will join up a lot of the other factors—housing, the environment and so on—for which they have responsibilities. As the Marmot review highlighted, that should help to address some of those areas.
It is also worth bearing in mind that the Equality Act introduced by the previous Government is relevant across all these areas and in terms of the groups with protected characteristics. Many of those who suffer from particularly bad health would be covered by that.
My Lords, it is surely clearer to have in one place the responsibility for reducing health inequalities. The amendment simply adds to the Bill:
“and shall, in doing so, take such steps as are appropriate to reduce health inequalities”.
That is the right place to have it when one is delegating that responsibility. The noble Baroness referred to the ring-fenced grant, which will, of course, apply to the public health function but, as she has just said, the public health function is not confined to what might be described as health expenditure. This duty to reduce health inequalities as part of local government’s new responsibilities should be embodied in statute, to ensure it in the consideration of the rest of local authorities’ functions and budgets.
I noted the remarks of the noble Baroness, Lady Williams, who is not in her place. She seemed to think that the Government have given independence to public health bodies. I hope she is right in her inference, but I am not so sure. We will return to this matter when we discuss Public Health England and other aspects of the Bill, including the role of public health specialists and directors of public health within local government. There are amendments that reinforce the independence of such postholders which are necessary additions to the Bill. I accept that the Government’s aspirations may be in line with that, but it seems to me that the Bill does not go far enough in providing them.
I want to return briefly to my amendment, which I do not think the Minister referred to, which is based on the recommendations of the Select Committee report on the public health impact of budget changes for the national level of public health, which affects Public Health England and the local authorities. I refer to the observations of the Select Committee:
“The Department of Health must also make clear how the actual level of funding for public health will relate to the historic baseline. We seek reassurance from the Department that, in setting the public health budget, it will take account of objective measures of need. This must apply in respect of both the national budget and allocations to local authorities”.
The next paragraph says:
“Although the Department of Health states that, in the current reduction of NHS management and administration costs, frontline public health services are being protected, we have heard evidence to the contrary. Furthermore, the Department has failed to give a convincing account of its distinction between frontline and non-frontline spending in public health services. Unless it can do so, the suspicion will remain that it is an arbitrary distinction and that public health services are suffering, and will suffer, in consequence of the cuts that are being made”.
In relation to the health premium, which as yet we have barely explored, the committee said:
“We are concerned about the proposed introduction of the Health Premium. We believe there is a significant risk that, by targeting resources away from the areas with the most significant continuing problems, it will undermine their ability to intervene effectively and thereby further widen health inequalities. Although many witnesses welcomed the proposed ring-fencing of public health budgets … and the Committee understands the short-term attractions of this approach, it does not believe it represents a desirable long term development”.
After further analysis, the committee said that,
“the ring-fenced public health budget should operate for no more than three years”.
I am sorry that the noble Lord thought I did not cover the first point. I did not make myself clear. With regard to the total figure for the health premium, which I mentioned briefly—and the Department of Health will be publishing something shortly—there is consultation on that. There is always controversy over how best to do that. I recognise what the Health Select Committee says about not wanting to have an inadvertent removal of money from where it is most needed to an area that might need it less, which appears to have done better and so on. These things are clearly very complex, as the noble Lord will know, and there is consultation on how best that should be taken forward so that it is most effective and does not have that unintended consequence.
Of course there is consultation going on. It has been going on for an inordinate amount of time and we need to see the outcome of that—as indeed does local government—during the passage of this Bill, I hope. These are critically important matters which at the moment remain opaque, to put it mildly. Of course there will be a report in due course, but the financial aspects of that report must be consistent with the thrust of the policy, and on that we are clearly not in a position to make a judgment. This is a matter to which we will clearly have to return, possibly in conjunction with the Bill, possibly separately. If local authorities are to undertake these increased responsibilities, there will have to be a satisfactory system to make possible the operation of the machinery that the Bill is creating.
Having said that, I acknowledge that these are all probing amendments. I hope that the Government will look at some of them with a view to possibly adopting them in future. On that basis, I beg leave to withdraw the amendment.
Amendment 60B withdrawn.
Amendment 61 not moved.
62: Clause 8, page 4, line 26, at end insert “using the best scientific and other evidence available and without regard to special interests”
My Lords, I do not wish to prolong this debate. I was very grateful for all the support that I got around the House for some of the ideas in these amendments. I wish to give notice to the Minister that I remain unconvinced by what has been said so far—that the Secretary of State’s duty will be exercised in a way that guarantees he takes account of independent scientific evidence. We will return to that later in this debate, but in the mean time I will not move my amendment.
Amendment 62 not moved.
Amendments 62A to 65 not moved.
65A: Clause 8, page 4, line 37, at end insert “in particular, public information and advice campaigns, especially those aimed at improving the levels of early diagnosis of serious conditions”
My Lords, each of the four amendments in my name is a probing amendment. All the amendments refer to one particular aspect of NHS activity: public health information and advice campaigns. The Department of Health has a long and distinguished history in deciding which issues need such campaigns, and actually running, funding and monitoring the campaigns. In this area there is a very large body of experience and expertise that resides in the Department of Health. Many of these public health campaigns have been very successful. Thousands and thousands of lives have been saved as a direct outcome, and these campaigns are an established and key part of the public health armoury.
The most obvious part of many public health information and advice campaigns is often the mass media component, but there is always much more to it than that. In June 2004, the Health Development Agency noted that these campaigns typically also involve the mobilising and supporting of local agencies and professionals who have direct contact with the campaign target, bringing together partnerships of public, private, professional and voluntary organisations, and encouraging local and national policy changes so as to create a supportive environment in which people are more able or willing to change their behaviour. Devising and managing these campaigns is a demanding and difficult job. The Department of Health has been doing this job very well for decades. Importantly, it has been doing this job centrally. This is not just a reflection of the current NHS architecture. For the public health and information campaigns to work efficiently, simple direction and control is a necessary requirement.
The Department of Health is running a national obesity campaign and a national dementia campaign. In January there will also be a national campaign aimed at raising awareness of the symptoms of bowel cancer. Each of these campaigns builds upon a solid foundation of knowledge and experience of the issues, and of what it takes to run a successful campaign—knowledge and experience held, not exclusively, but very largely, in the Department of Health. Each of these campaigns can reasonably expected to be directly responsible for saving thousands of lives, and for improving the efficiency of the NHS.
The success of the original and groundbreaking HIV/AIDS campaigns in the 1980s, under the direction of my noble friend Lord Fowler, is well known. That success continues. Recently, regional pilots of dementia and bowel cancer campaigns have shown, for bowel cancer, a 48 per cent increase in the number of people visiting their GP with symptoms, and for dementia, 63 per cent of people aware of the campaign said that they would visit their GP if they saw any possible symptoms. There is a long-standing and proven ability of public health information and advice campaigns to generate early awareness and early action, both things absolutely critical for dealing effectively with some of the more serious medical conditions.
Success rates in cancer treatment are a prime example of this. We know that England’s cancer survival rates are currently poorer than those of many comparable countries. I know that we are part of the International Cancer Benchmarking Partnership to try to understand why this is, but without waiting for a definitive answer, it is quite clear that early diagnosis is an absolutely critical factor. In Improving Outcomes: A Strategy for Cancer, published in January of this year, the Department of Health notes that improving public awareness of the signs and symptoms of cancer and encouraging people to visit their GP when they have these symptoms, is a key ambition. That is why the Department of Health last year provided £9 million to support cancer awareness campaigns. It is a crucial feature of these campaigns, and most others, that they are very largely given priority, direction and funding centrally by the Department of Health.
My concern, and the point of my amendments, is that in the new architecture of the NHS, this central direction and funding will disappear, either suddenly, or more likely, gradually, as current and planned campaigns reach the end of their lives. I entirely accept that the Government understand the merit of public health information and advice campaigns and would want them to continue. I am much less certain, however, that they will continue in any effective form if responsibility for them is diffused throughout the system and central control and funding vanishes. It is not of course that I think that there will be local objections in principle to public health information and advice campaigns, but in hard-pressed localities there may well be a temptation to assign lower priorities and less funding to them. Even if the local need for such campaigns is acknowledged and acted on, making sure that the campaigns are properly devised, properly run and properly integrated will present difficulties without clear central oversight.
The first three amendments are aimed at making explicit the Secretary of State’s central responsibility for public health information and advice campaigns, and explicitly require him to consider the desirability of such campaigns when he draws up the mandate. The final amendment requires the board to include public health information and advice campaigns in its duty to promote education. These are all probing amendments, which are looking, essentially, for two things. First, they seek an assurance that large-scale public health information and advice campaigns will continue to exist and will be an important part of the public health armoury. Secondly, they seek an explanation of how in future public health information and advice campaigns will be originated, how they will be driven and how they will be controlled, funded and assessed. I beg to move.
My Lords, I support these amendments, which are so relevant to recent proposals in the Select Committee report on HIV/AIDS. The Bill calls for the Secretary of State to take steps to promote public health in England from disease or dangers to health. Without a doubt the most effective way of achieving that aim is through the provision of public information, advice and awareness-raising campaigns, first, in respect of prevention and, secondly, in respect of early treatment and care.
That proposal would mean the promotion of early testing as well as testing for the estimated 22,000 people who have HIV but do not know that they are infected and who, as a consequence, are likely to transmit the disease further. It would also ensure the availability of testing. At the moment the venues for testing are fairly restricted but the Government are considering proposals by the HPA and NICE to widen the range of settings where testing might take place, particularly in areas of high prevalence. We await the Government’s decision on those reports. The need to raise awareness of early testing is crucial to prevent onward transmission of the disease. There is no better example than the evidence obtained from antenatal clinics which have had campaigns and have given information to pregnant women about mother-to-child transmission and where the number of such cases is now extremely low. That advice should be taken by the Government.
I raise these points specifically because the Government’s response to the Select Committee on the need for awareness-raising campaigns did not give the assurances that we might have hoped for. While there are campaigns currently targeted at those most at risk of HIV—we hope that they will continue, but we are not certain that that will be the case—it was very short-sighted that there was no guarantee of the inclusion of HIV on any national sexual health campaigns, if in fact there are to be any. This amendment would be helpful in making that happen. There was a complete rejection of campaigns directed at the general public. Those were not considered to be necessary, yet we know that there is a growing diversification of HIV into other communities. For those people, early diagnosis is essential.
There was, however, a welcome for a web-based campaign run by the National AIDS Trust, which is specifically designed to get prevention and awareness messages to the general public. In a sense, therefore, we have a little contradiction in the need, and the process does go round in a circle. Lack of awareness by the public is one reason why the stigma of HIV persists and why there are so many mistaken beliefs about HIV. It is often the fear of that stigma that deters people who might be at risk from going for HIV testing or even STI testing. Effective awareness-raising campaigns would overcome some of those difficulties and are essential if we are to promote early testing and reduce the levels of HIV, which are growing each year, and thus reduce the levels of transmission.
It seems to me that not to have those campaigns is not only poor health practice but economically short-sighted. The HPA suggests that, if we had prevented the estimated 3,800 or so HIV infections acquired in the UK in 2010, we would have saved over £35 million annually, or £1.2 billion over a lifetime of cost. Treatment is very expensive. That seems to me an enormous amount of money when compared to the cost of running effective and regular public awareness-raising campaigns. Surely common sense tells us that the campaigns should continue.
My Lords, these amendments relating to campaigns are very important. My question is: who will be carrying them out? I would like to highlight the problems of late diagnosis of HIV/AIDS, tuberculosis, hepatitis B and C, and meningitis.
Many people are living with HIV/AIDS who do not know that they are infected. There needs to be sensitive targeting of campaigns. If diagnosis is late, the condition is much more difficult and expensive to treat, as has been said. There are often co-infections of HIV/AIDS and tuberculosis. Late diagnosis in TB is very dangerous. Along with the growing problem of drug-resistant TB, there is extensively drug-resistant tuberculosis, which is very dangerous and much more expensive to treat and takes much longer.
I would like to mention the effective and important work of the group Find & Treat, which goes out to find homeless and other people who are difficult to find, who may have TB, and test them. The group now wants to test for co-infections, which would be much more effective and less expensive in the long run. This type of infection is on the increase. There is a fear that, unless local authorities and the National Health Service work together, there may be fragmentation, and these people, who should be treated early, may fall through the net. Find & Treat needs all the support that it can get to carry on this very important work.
Hepatitis B is very infectious, but there is now a vaccination, which is good. However, there is no vaccination for hepatitis C. Both types of hepatitis have been found to be a huge problem in prisons. There is a problem of liver disease with hepatitis C. Early diagnosis is important for all infections. In the case of meningitis, there have been far too many tragedies because of late diagnosis. The public—and doctors—need to be reminded continually how important this issue is by means of campaigns and guidelines. My GP always waits for guidelines from the Department of Health.
My Lords, I speak in support of these amendments tabled by my noble friend. I strongly welcome the provisions in this Bill that ensure that the NHS and local governments work together on public health. I believe that these provisions are long overdue. However, as my noble friend said, we need to ensure that central responsibility and control is retained to be able to have high-profile, national public health campaigns.
I am the co-chair of the All-Party Parliamentary Group on Hepatology and I participate today from that perspective. I wish to speak especially about hepatitis C. In the summer, the group produced a report emphasising the points that I am making about the importance of national public health campaigns. The current proposals will affect those suffering from this disease and will improve the response at a local level. However, they will also ensure that we need a national response. Hepatitis C is a preventable and curable cancer-causing, blood-borne virus. The main groups affected are intravenous drug users, or those who have been, and certain ethnic groups from south Asia who were also badly affected because, very tragically, they were immunised in childhood during mass immunisation campaigns using dirty needles.
As has been said, a stigma is attached to hepatitis C, as it is to HIV/AIDS. As a result of that stigma, it has largely been ignored by government ever since it was first identified in the late 1980s. Deaths from the disease are rising; mortality has risen by between 39 and 45 per cent since 2005 and the number estimated to be affected is between 250,000 and 466,000. I say “estimated” because the majority of those affected are undiagnosed. That is the key point in relation to public health campaigns.
The picture in Britain is not the same as the picture in most of the rest of Europe. Elsewhere deaths from the disease are falling because there have been high-profile public campaigns and strategies to deal with the disease. As a result, diagnosis has been very much earlier. I said that the majority of people suffering from the disease are undiagnosed, but why is that? They are undiagnosed because it is a tricky disease. It remains asymptomatic for 10, 20 or even 30 years, and by the time the symptoms occur it may be too late for a cure. It is certainly very possible that any attempts at treatment are very complex and expensive. That outcome can be a result of the stigma, but it can also be a result of ignorance because we have had no big public health campaigns. There is ignorance on the part of clinicians and the public. Delayed diagnosis costs not just lives but a great deal of money. There is a range of clinically effective and cost-effective treatments for the disease that can cure and that are recommended by NICE, and more and better treatments, due to go to NICE in the near future, are in the pipeline.
That is the background. As I see it, that is how the Bill will help, but it needs to be improved in order to help even more. The local government NHS LINk will enable local public health campaigns to focus on local needs. Given the list of at-risk groups that I have described, it is obvious that an area with a high population of those from south Asia, for example, will be enabled to target their health messages appropriately. An area that is aware that it has a particular problem with drug use will do the same. Of course, many people will be affected by the disease who do not live in those target areas, and they need to be screened and treated in the same way, so local campaigns need to supplement and bolster national information campaigns, not replace them.
We have already heard from my noble friend reference to the dementia campaign that is currently being run, and there has been reference to the AIDS campaign. I would say very strongly to the Minister that we need a hepatitis C campaign of similar impact. Without the proposals in these amendments, I believe that there might not be sufficient obligation on the Government to co-ordinate these campaigns. I very much look forward to Minister’s response on this issue.
My final point is that successful national and local campaigns will inevitably have a knock-on effect on commissioning services. More patients will be diagnosed, and that will mean more needing treatment. In the long term, of course, there will be a fall-off in the demand for treatment because of higher public awareness and, one hopes, very much safer behaviour as a result. That fall-off will take years, however, and it is essential that GP services, hospitals services and, for example, drug and alcohol action teams all have the increased capacity brought into line at the same time as such campaigns take place. It is therefore even more important that there is the central control and direction to which I referred. That is just one example; other noble Lords have given similar examples, and I urge the Minister to give this serious consideration.
My Lords, there is no provision on the Order Paper for debates on Clauses 8 or 9 to stand part. Rather than risk taking up the time of the House by necessarily opening such a debate, I wanted to make a few general remarks under the heading of this group of amendments because it touches on Clauses 8 and 9.
All of us in this Committee are very concerned about public health. It is a priority for anybody in public life and really must be. Some telling points have been made both this morning and this afternoon, and I particularly retain the remarks about the importance of addressing the threat of obesity, which we know causes an awful lot of medical conditions, and the very important issue of tobacco smoking. We have made tremendous progress in public health by bringing down smoking. The results are already clear in the reduction of the incidence of some of the cancers. It is also important to address the threat of sexually transmitted diseases, and some very good and sensible things have been said about AIDS and hepatitis B and C. To that list I would add chlamydia, which does not normally have fatal consequences but has very sad consequences for infertility. It is far too widespread at the present time.
There are a number of other areas about which we should all be concerned. One that concerns me is the introduction into this country of tropical diseases by airline passengers and the great importance of making sure that clinicians are properly trained to identify the symptoms as rapidly as possible and to deal with them. The facilities are there to quarantine where necessary people who have highly infectious tropical diseases.
Another public health risk that we ought to be aware of is the danger of strains of bacteria emerging that are immune to antibiotics, very largely as a result of the excessive and irresponsible prescribing of antibiotics—sometimes quite disgracefully as a placebo—and a lack of discipline on the part of patients in completing a course of antibiotics. That is a serious issue that has not been addressed by any public campaign, as far as I know.
All of us are concerned about the danger of a viral epidemic in the form of some new strain of flu or something of that kind. We are very much aware of it because the media talk about it a lot. That has not gone away; we must not get complacent about that. I am glad that in the area of the protection of public health, the Government have made it clear that, unlike in the area of the provision of clinical treatment, the Secretary of State has a clear responsibility stated explicitly and unambiguously in the Bill.
However, the Government have missed an opportunity to simplify and rationalise the bureaucratic structures and lines of accountability. That would have been very desirable. What is emerging here is an extremely complex structure of responsibility. The Secretary of State uniquely has responsibility for taking necessary measures for the protection of public health but shares that responsibility with local authorities in the area of improvements to public health. The Bill makes it clear that the Secretary of State “may” and local authorities “must” take measures in this area, so there is the prospect of a highly undesirable situation in which the Secretary of State takes such action but that duplicates what local authorities are doing. I do not think we have heard in the course of the debate exactly how the Minister envisages the relationship between Public Health England, the Secretary of State and local authorities with their new medical officers developing. I almost called them “medical officers for health” because I think this is a revival of that old concept, and they did a wonderful job in their time. However, I believe that they are going to be called “directors of public health” and are to be established under Clause 9 by all local authorities.
We need to understand what the relationship between these bodies is going to be. The noble Baroness, Lady Northover, said earlier that the Health Protection Agency is to be abolished. That is what it states in the Bill, but I understand that actually it is going to be subsumed more or less in toto into Public Health England. We need some transparency on that. I would like to know how many people are going to be involved in the agency because these bodies can be extremely expensive. We want to make sure that we are getting proper value for public money.
I am particularly concerned about the suggestion in Clause 19 that the Secretary of State may devolve on to clinical commissioning groups or the National Commissioning Board his responsibilities in the public health area. So there we have another bureaucracy that has the potential to become involved without being clearly defined. There is a frightening element in that clause which provides that any liabilities arising as a result of the involvement of the National Commissioning Board or clinical commissioning groups in the public health area will accrue to those bodies and to no one else; in other words, not to the Secretary of State. The Secretary of State is not delegating his authority; he is not using the National Commissioning Board or clinical commissioning groups as his agent under his direction, which would be an appropriate thing for him to do; but rather he is abandoning his responsibility to this completely different set of bodies whose main job is in the area of diagnosis and treatment. Again, that is a very confusing picture.
The proliferation of bodies and lack of clarity about bureaucratic responsibilities should be a matter of concern to us all for at least three reasons. The first is that it makes it very difficult for the general public. I find it difficult to understand exactly what the hierarchy of responsibility is. Human beings never give of their best unless their responsibilities are clearly defined and demarcated so that they can be held responsible for those areas for which they really are responsible. They are simply hopeless if other people might be equally responsible. We have not talked about the health and well-being boards. What have they got to do with public health? It is quite unclear to me, but presumably they have some role in this area. It is very confusing and I think that that is very undesirable.
The second reason is the matter of cost. Anybody who has dealt with the NHS as a Member of Parliament, as a business or in any other context knows that one of the great troubles with the NHS is that whenever a decision needs to be taken, there are around 26 people in the room from at least 12 different departments and agencies. That is extremely bad from the point of view of clear decision-making. It means that all decisions take a long time and the costs go up indefinitely. It seems that we have a formula in the area of public health for the replication or even the aggravation of that problem.
The third reason why we should have clarity of responsibility in this area is because people do not perform if they can simply get out of any kind of sense of responsibility by saying that it is someone else’s fault. We are providing endless opportunities for excuses to be made and for people to avoid their responsibilities. I would be very relieved if the Minister could reassure me that these fears are groundless and give clear reasons why that is so.
My Lords, I shall speak briefly about the importance of information in an early diagnosis. I have two areas to focus on. First, people with learning disabilities often get a late diagnosis and suffer terribly because of it, with an earlier death as a consequence for many. Often that is because of a lack of accessible information. I speak as the executive chair of a social enterprise, called Beyond Words, which designs pictorial information to try to bring health and social care information to people who cannot read. Any public health information campaigns need to remember that not everybody can read information easily; it has to be designed to be inclusive.
Secondly, I have a question about how the accessibility of information about the bureaucratic structures of the NHS will help with early diagnosis. This is to do with the current “choose and book” system. Something that has happened to a close relative of mind in the past few weeks made me realise that I do not know how the Bill is addressing the whole issue of better choice for patients. I will briefly tell noble Lords the story. It is about somebody who needs an early diagnosis for what seems like a serious, rare, long-term condition and who has been referred through the choose and book system to four different hospitals to see four different specialists in different areas, where those specialists cannot easily communicate with each other because their hospital systems do not speak to each other. The person concerned chose the hospitals that offered the earliest appointments, which is what most people do and what choose and book offers you. You take the first appointment because you are worried, but the hospital consultant is unable to refer to a consultant in the same hospital with whom they would be able to consult. The patient has to go back to the GP and back through the choose and book system. It is not working.
There is something about information and early diagnosis here as well. I could not see where, apart from under information, I could raise this issue. I look forward to hearing a response from the Minister.
My Lords, Amendments 65A, 71ZA, 97A and 133A seek to raise the priority within the Bill of public health information advice designed to encourage the early diagnosis of serious conditions. Improving early diagnosis is an important objective across the whole health system, which includes the new public health system. I am very grateful to noble Lords for raising such a significant issue.
I completely agree with my noble friend Lord Sharkey as to the important role of information advice campaigns. I hope that I can reassure him that the changes to public health will not see the end of such campaigns. Where such campaigns work, we want to see more of them. We know how important early diagnosis is in treating cancer, for example. Thus, people coming forward for bowel cancer screening can be diagnosed at a stage where the disease is totally curable.
The noble Baronesses, Lady Masham and Lady Gould, emphasised other areas in which treatment is more effective earlier but also where there is a risk of infection, such as HIV, TB, hepatitis and meningitis. The noble Lord, Lord Davies, flagged up other STDs, among other issues. We are well aware of the importance of these areas. This is also where local authorities’ involvement in public health should assist rather than detract. The noble Baroness, Lady Gould, rightly flagged up this issue in relation to HIV/AIDS. No doubt we will return specifically to the points that she has raised when we debate HIV/AIDS on 1 December, World AIDS day, a debate to which I am responding. I look forward very much to our discussions then.
We will no doubt come back later to wider discussions of Public Heath England and the directors of public health, to which the noble Lord, Lord Davies, referred. Perhaps his notions can be revisited then when attached to the appropriate amendments.
As I outlined in the debate on the previous group of amendments, Clause 8 sets out the Secretary of State’s new duty to take steps to protect public health. It illustrates this duty with a list of steps that would be appropriate for the Secretary of State to take. That list includes the provision of information and advice. Amendment 65A would amplify that to specify that this could include information in campaigns around early diagnosis. I should explain that the list in Clause 8 is neither prescriptive nor exhaustive. The amendment would not therefore either require or give the Secretary of State a new power to do anything that the clause does not already accommodate.
Similarly, Amendment 71ZA would have the equivalent effect on a list of steps that local authorities may take under their new duty to improve public health. As we have already said, local authorities’ new responsibility will include behavioural and lifestyle campaigns to prevent serious illness and they will be funded accordingly. The Department of Health is also working with stakeholders from the NHS, local government and voluntary and community sectors to finalise the operational design of the new public health system. We expect to publish proposals shortly and they will set out how we expect to promote early diagnosis through the system.
Of course, the NHS will continue to play an important part in public health, a point emphasised by the noble Baroness, Lady Finlay, earlier. The Bill allows the Secretary of State to mandate or agree particular services that will be the responsibility of the NHS Commissioning Board. Amendment 97A seeks to ensure that he will consider early diagnosis campaigns when he does so. I hope that the noble Lord, Lord Sharkey, will be reassured that this is something which we are already considering. I can also reassure noble Lords that the objective of Amendment 133A is already met by the clause as drafted. Where the Commissioning Board is engaged in early diagnosis campaigns, then the duty to promote the integration of services would automatically apply to those campaigns just as they would to any other health, or health-related, services.
I emphasise that we especially expect advice and information to continue to play a major role in early diagnosis and local authorities will be able to contribute to that. Meanwhile, Public Health England, too, will be able to manage and support effective national campaigns. We will be publishing further detail shortly on how the different levels of the system will work.
In short, I believe that we are in total agreement with noble Lords about the principles underlying their amendments and with what noble Lords have said in the debate. We share their desire for improvement in this area. We all know what huge potential early diagnosis offers and the vital importance in this of public health campaigns. The Bill as drafted offers all the necessary support for that ambition. I therefore hope that the noble Lord will accept that and withdraw his amendment.
My Lords, as we are in Committee, I can repair my omission in failing to anticipate the Minister’s response to what has been a very good debate. I congratulate the noble Lord, Lord Sharkey, on tabling these amendments. I take issue with him slightly over one matter he mentioned: the relative performance of this country in terms of cancer survival rates. Recent reports make clear that they have improved substantially and are now beginning to outstrip those of other comparable health services. However, that does not detract at all from the thrust of the amendments.
The Minister referred to bowel cancer screening. That is but one example of the importance of early diagnosis, and public information can certainly assist in that context. As some of your Lordships may recall, I have some personal experience of this because my wife died of colon cancer last year. Her symptom was constipation, which is not a predominant symptom. Relatively speaking it is a less frequent symptom, but even now it is not something that some of the literature and material produced by cancer charities refers to. That is an illustration of the need for clear information to be given. There has been a very successful campaign about stroke, which was temporarily halted and then resumed. There is clearly a role for that kind of campaign. I should have thought that the Government could accede to the request for these duties and responsibilities to be included in the Bill.
Although I certainly strongly support the amendments, there are perhaps two riders that I might add. The first is that information, which of course can be in many forms, is not of itself necessarily enough. For example, information in labelling on food does not convey very much to people. This is an example of nudging not being enough. In some cases what is needed, apart from information, is action, and I hope that, as part of their public health agenda, the Government will take a rather firmer line in making requirements of the food industry and others concerning what goes into the nation’s diet.
The other rider relates to the efficacy of some kinds of campaigning. This does need to be measured. Some campaigns—noble Lords have referred to them—have been extremely effective; others, less so. The rather dramatic advertising about HIV and AIDS in the early days was not thought to have been particularly effective. It seems to me that in the interests of effectiveness and efficiency—that is, in terms of the expenditure involved—we need to evaluate what sort of campaigning and publicity works.
With all those qualifications, such as they are, I strongly support the noble Lord’s amendments. I hope that the Government will take another look at whether sending a very clear signal by having these kinds of amendments made to the Bill would assist what we all agree across the House is a prime responsibility and a prime opportunity for the Government to advance the public health agenda.
My Lords, my apologies if I leapt up far too soon. I caught the noble Lord’s colleague’s eye and it looked as though no one would be speaking from that side of the Chamber. However, I am incredibly glad to hear what is in fact cross-party support for this kind of campaign. The noble Lord is absolutely right: the part that charities play and have played in many of these campaigns is absolutely critical, not the least of which is Cancer Research UK and its various campaigns. Therefore, I thank the noble Lord for his contribution.
I thank all noble Lords who have spoken to the amendments and I thank the Minister for her response. I should also like to register the propensity of all Governments to make sudden cuts to public information campaigns. Last year, the Government announced a freeze on their £540 million annual publicity budget. On 29 May this year, they announced a partial thaw, with expenditure of £44 million on four campaigns in England. This followed the publication of a Department of Health report called Changing Behaviour, Improving Outcomes, which found that, for example, after the cessation of campaigns, calls to the Change4Life information line fell by 90 per cent, calls to the FRANK drugs line fell by 22 per cent and visits to the NHS Smokefree website fell by 50 per cent.
All that illustrates my continuing concern that it is too easy to cut public health information campaigns and that it might be even easier in devolved organisations. Therefore, notwithstanding the Minister’s helpful response, I continue to believe that we need safeguards against such cuts written into the Bill. I look forward to discussing this again on Report. I beg leave to withdraw the amendment.
Amendment 65A withdrawn.
66: Clause 8, page 4, line 38, at end insert—
“( ) providing services for the prevention and treatment of harmful drinking and alcohol dependence.”
My Lords, I hope the Committee will agree that it would be more convenient to discuss the spirit of this amendment when we come to the later group of amendments that focus on issues around alcohol—the group beginning with Amendment 71 —and that the other amendment in this group, Amendment 74B, warrants a short debate in its own right. I beg to move.
My Lords, I thank the noble Baroness. This small amount of grouping and degrouping was partly to do with having everybody present and correct for a good debate on alcohol and its dependency.
However, Amendment 74B in my name and that of my noble friend Lord Beecham raises an important issue. I was heartened to hear the Minister say that there is a list in Clause 8 that was not exclusive, because this amendment is about a list that is not exclusive that we want to put in the Bill.
I start by marking the fact that today is national COPD day. It is appropriate that when discussing public health, we should mark the fact that millions of our fellow citizens have chronic obstructive pulmonary disease, and many of them have it as a result of their lifestyle choices that they made possibly when they were very much younger. It is very appropriate that in this debate about public health, what leads people into chronic conditions should be part of it. I also mention the fact that today—not unrelated to this—the British Medical Association issued its call for a ban on smoking in cars and an extension of tobacco regulation, which also merits some consideration.
Amendment 74B places in the Bill a by-no-means-exclusive list of matters that are important for the improvement of public health. We are trying to tease out whether and how a comprehensive approach to public health, which takes account of all pertinent matters, becomes possible in the framework that the Government are outlining for the promotion of public health. For example, the list includes issues such as employment or the lack of it, poor quality housing and its effects on health, air and water quality, and so on. They all concern the improvement of public health.
One of the reasons behind the amendment, and its place in the Bill, is that it also concerns the disbursement of grants and loans in Clause 9(4). As has already been said, we are also exploring what the Secretary of State and local authorities might, and could be expected to spend their funding on. I return to the question raised by my noble friend Lord Beecham about the public health premium. If we apply the proposed list in the amendment to my home town of Bradford, where there are very high indices of deprivation, how will the areas with the most severe and serious deprivation qualify for a public health premium when they are starting from such a very low base? I am sure that there is an answer to that question but I would like to have it on the record.
Evidence was given by the Association of Directors of Public Health to the Health Select Committee when precisely that point was raised. I hope that if the Government cannot answer my question now, they will be able to address it when they respond to that excellent report.
My Lords, it is interesting that there is not a universally accepted definition of public health. There are, however, broad domains of public health, be they health improvement, health protection or health services. The Faculty of Public Health defines public health as:
“the science and art of promoting and protecting health and wellbeing, preventing ill-health and prolonging life through the organised efforts of society”.
That is a very broad definition. It could almost include every range of local government services. It seems to me that there is a need for some guidance on what aspects should be included in the ring-fenced budget. We have previously been told that there will be no breakdown of the budget within that ring-fencing, which makes it even more important that some guidelines are laid down. The frequent reply from the Minister has been that we leave it to each local authority to determine what public health is. But while I appreciate that there will be a variation in needs between different authorities in different areas, some guidance and priorities might be useful to them.
I am delighted that my noble friend has highlighted sexual health as being important because there is a great deal of concern that sexual health will not be a favoured issue for many local authorities. Furthermore, as regards HIV for instance, there is no understanding that there is all too often a relationship between the required long-term care and other aspects of local government services. There is also concern that, unless it is highlighted, there will be a lack of understanding by local authorities of the divide within the commissioning arrangements for HIV and contraceptive services between the National Commissioning Board’s responsibilities and their own—for prevention and testing in the case of HIV and for the establishment of clinics for special cases in the case of contraception. Guidance would give local authorities greater clarity of their roles and responsibilities and the fact that they are a key player in this process of integration. I am sorry to refer again to the response to the Select Committee report on HIV and AIDS, but it is so topical. The Government identify that integration where possible—whatever that means—will be by the NHS Commissioning Board, clinical commissioning groups and health and well-being boards. That will apply to all health services so there is no need to have a special duty applying to the integration of specific services, such as sexual health and HIV. However, I think that is a misjudgment. Having some identification priorities would give guidance as to which areas require special duties.
At Second Reading, the Minister referred to the Advisory Committee on Resource Allocation, which is an independent expert committee that has been asked to advise on a public health formula to inform the distribution of the public health grant across local authorities, saying that it intends to publish further detail later this year. So I appreciate that we are not going to get the detail for which I would have asked on the distribution of that grant. If we could get some detail, that would be very helpful, but perhaps I may remind the Minister that there is only two months left this year and I hope that we will get that response before the end of it. The calculation of spend on public health, including sexual health services, must be based on robust and accurate data, so can the Minister identify how that can be achieved without a specific definition of what it should include? I appreciate that the Minister has so far always rejected the idea of coming up with a definition and he certainly might not agree with the list that is before him. Nevertheless, I would be grateful if he could rethink this. There needs to be some principle laid down to make sure that local authorities understand what public health actually means.
My Lords, Amendment 66 would add alcohol services to the list of examples that the Secretary of State may take under his new duty to protect health and Amendment 74B would add a number of steps, including one on alcohol, to the equivalent list of steps for local authorities to take up under their new duty. I appreciate the decision by the noble Baroness, Lady Finlay, to regroup and we will discuss her amendments a little later. However, the noble Baroness, Lady Thornton, followed by the noble Baroness, Lady Gould, decided that the group should stay in place.
Adding to the Bill's list of steps that may be taken may highlight an issue but would not materially alter the situation. The noble Baroness, Lady Thornton, with her governmental background, is clearly extremely familiar with the function served by these indicative lists. I appreciate her indication that she is probing on this. Obviously it is extremely important in these different areas.
I also note the definition of public health that the noble Baroness, Lady Gould, quoted. I scribbled down the part about the science and art of promoting health and well-being through the organised efforts of society. That illustrates that this is an evolving and moving area. We hope that it will evolve and move because public health has now been put with local authorities. By joining up all the different areas we wish to join up, we hope that the field of public health will move along. Therefore, it is not appropriate to put in the Bill such a definition, which is set at a particular time, because of the evolution that I hope will expand in a way that the noble Baroness—who clearly is not satisfied—will be happy with.
We are talking about a ring-fenced budget; we are not talking about a general local government budget. Therefore, there must be some guidance on what should go into that budget. I do not mind whether it is a definition in the Bill or guidance, but something must be done to make sure that we know what is in the ring-fenced budget.
The noble Baroness is absolutely right. This is not simply philosophy. Therefore, regulations will provide that guidance. In the mean time, I say that this is an issue on which we have spent considerable time working. She is probably aware of the July 2011 update to the public health White Paper. If she is not, I suggest that she looks at it. Paragraph A.10 on page 27 contains a list of the areas in which we expect local authorities to engage. I am sure that the noble Baroness, Lady Thornton, will be pleased that the list starts with tobacco control. The noble Baroness, Lady Finlay, may note that the second item is alcohol and drug-misuse services. Other issues that noble Lords have mentioned are also listed, such as obesity and community nutrition initiatives. The list is long.
I can see the temptation. The list in the Bill is indicative. These lists are always subject to much debate about what goes in and what stays out. I fully understand why the noble Baroness wishes to add her list. However, we would resist adding to the list in the Bill, which is, as she knows, indicative. We appreciate people's contributions to what needs to be covered in these areas. I point out to her that the list—no doubt we will spend many hours debating the regulations—includes all sorts of things, such as mental health services and dental public health services. I will not read out the whole list. If noble Lords think that something is on it that should not be there, or that other things that are not on it should be, I am sure that we will consider those points as we debate the regulations.
I noted a response to the noble Baroness, Lady Hollins, but I think that I may be referring to a previous debate. She is absolutely right to emphasise that we have to make sure that everything we do is patient-centred. All the changes must focus on that. It is a challenge for everybody. Perhaps people have tried to do it before. No doubt we will have problems trying to do it ourselves, now and in the future, but that has to be the focus. Therefore, we have to remember the diversity of the patients that we are talking about. I am sorry; that answer belonged in an earlier debate.
I know that we will return later to debate alcohol. I hope that noble Lords will not press the amendments in this group.
Amendment 66 withdrawn.
Amendment 66A not moved.
67: Clause 8, page 4, line 38, at end insert—
“( ) The Secretary of State shall appoint a Chief Environmental Health Officer for England.
( ) The Chief Environmental Health Officer for England shall give advice to and report to the Chief Medical Officer for England on all such aspects of environmental and public health as are relevant to the public health functions referred to in this section and the duties referred to in section 2B of this Act.
( ) The Secretary of State shall report to Parliament annually on the work of the Chief Environmental Health Officer for England.”
My Lords, this is a brief probing amendment that is mirrored by my noble friend’s Amendment 75A, which is identical. I originally thought that I had tabled this as a new clause and it had appeared as an amendment. I would like to take the opportunity, by the way, to apologise to the House for being missing when a couple of the amendments that are in my name were moved by other noble Lords. My absence was unavoidable.
The reason for the amendment is straightforward: it is to test the views on the creation of a chief environmental health officer for England. Historically, of course, there has been a chief environmental health officer position since the days before 1974, when I was elected to the other place. It was abolished, I think, on 1 April 1974 during the massive reorganisation that year. That was the last time local authorities had the lead responsibility for public health services. Each local authority had a medical officer of health in those days—in Birmingham, in fact, we called them the chief medical officer of health.
Today, England has a Chief Medical Officer of health, but not a chief environmental health officer. The amendment, and my noble friend’s new clause, proposes that the Secretary of State should appoint a chief environmental health officer for England. In Wales, there is a chief environmental health officer in post. In Scotland and Northern Ireland, there are arrangements that are similar to that. Indeed, there are things happening in the devolveds that are streets ahead of what is happening in England. I have to say that my experience is that Westminster, in the centre, is completely unaware of it all, mainly because, regretfully, there is not a degree of communication. The respect agenda is not actually being played out in practice. Nevertheless, these things are happening elsewhere and there is a good case for making similar arrangements in England. This would recognise the role played by environmental health in promoting health and well-being and the importance of assuring environmental health input into policy-making at the highest level. That is part of the key issue: to get it involved at the highest level.
There are some other amendments, for a further debate, that relate to the complications—again, unique in England—of two-tier local government. This issue does not arise in Wales, Scotland and Northern Ireland. There is a complete mishmash in England. The way in which we inherited the current two-tier local government structure was not planned. That actually highlights some of the difficulties with environmental health, which cannot be done and is not done at county level, of course, although I will save that point for other amendments.
England currently lacks this input into policy-making at the highest level. The appointment of a chief environmental health officer would assist in that area. I am very guided in this by the Chartered Institute of Environmental Health. It has made some very positive remarks about the Bill and given some input into this part of the Bill, in no way to whinge or criticise but rather to strengthen the Bill.
It is envisaged that the chief environmental health officer will focus on a preventive approach to achieving good health outcomes, and in particular on the wider determinants of good health and well-being. The postholder will be able to review the relevant data and advise the Department of Health, Public Health England, NICE and the Chief Medical Officer. It is envisaged as part of the package of proposals and amendments that the chartered institute has proposed that the chief environmental health officer answers to the Chief Medical Officer to have that input into preventive strategies and the wider determinants of health, in the widest sense that the public understand it, and to oversee the development of good practice within local authorities and their partner organisations.
There is a real impact on local government because of the way in which the Bill moves aspects of what I will call the NHS into local government. It is crucial that people in local government, particularly environmental health officers, working as they are in a multitude of areas of activity for local government, feel that there is a head of profession to develop good practice, provide leadership at the very top and have input into policy and policy-making at the very highest level. An annual report to Parliament by the chief environmental health officer for England would not go amiss.
This is a probing amendment to test whether the Government have thought about this. It would be interesting to know what discussions they have had with local government. It would be very interesting indeed if the Minister could explain and show the House the benefit of any discussions the Government have had with Wales, Scotland and Northern Ireland about ideas of difference. Devolution means that things will be different. I make it absolutely clear that I am not arguing for things to be the same, but there are benefits that you can learn from discussion, and I am not clear that there have been such discussions. At the moment, England will be the loser, in particular because of the mishmash of two-tier local government, without the central leadership that a chief environmental health officer could provide. I beg to move.
My Lords, I hope that the Government will be able to give some assurance that environmental health will be recognised in the new public health services that will be established. I became acutely aware of the importance and contribution of environmental health when I chaired the House of Lords Science and Technology Select Committee inquiry into allergy. Environmental health officers were most helpful on issues around climate change, air quality, diesel particles and the hyperallergenic effect of high levels of diesel in making pollen more allergenic.
When I chaired the inquiry into carbon monoxide poisoning, I had a great deal of help from the Chartered Institute of Environmental Health on gas safety and gas regulation. It brought its engineering and architectural expertise to inform that inquiry. It is important to be aware that although these professionals are called environmental health officers, they come from a broad range of backgrounds and bring in engineering, architecture and what you might broadly call environmental physics to inform the health debate. They are complementary to but not duplicated by the provisions in standard public health medicine.
I echo everything that the noble Baroness, Lady Finlay, has just said. The noble Lord, Lord Rooker, has raised some extremely important issues and hit some serious problems at the heart of the Bill. I am not sure that his solution is the right one, but it needs discussion. I am sorry that the noble Baroness, Lady Gould, in not in her place because she made the important point that the meaning of the phrase “public health” has evolved over the years. The core Public Health Act 1936 was about the role of local authorities in relation to public health and what we now call environmental health.
In the 1974 local government reorganisation, public health functions were split. Half went to the health service, the other half remained with local government, and the phrases “environmental health” and “environmental health officers” were largely invented at that time to distinguish the new environmental health service from what had previously been public health. Of course, in two-tier authorities environmental health is a function of the lower-tier authority.
The noble Lord, Lord Rooker, made a very important point. We have some amendments coming up, probably in a few hours’ time, when we will discuss this, so I will not say a great deal more about that now except to make the basic point that it is very important indeed that environmental health functions, which already rest with unitary authorities but in county and district areas will rest with district authorities, are properly integrated with the rest of the public health function.
As the noble Baroness, Lady Finlay, said, the things that environmental health officers and departments do are astonishingly varied. If a problem is clearly a public health or environmental health problem, they will find the expertise, go out and get expert advice if it does not exist within that authority, and tackle it. It is a very important function indeed. However, at the national level, environmental health, as defined in the Local Government Act 1974, rests with the Department for Communities and Local Government, not with the Department of Health. It probably ought to rest with the DCLG because it is very clearly a local government function, but again, at the national level, the Government need to take action to integrate it into the new, very important public health functions of the Secretary of State.
My Lords, as my noble friend Lord Rooker has said, I have an amendment in this group that is precisely the same as his, except that it was directed at a different point. My noble friend has made a strong case for this particular dimension of addressing environmental health issues, but there is also the wider issue of the lacuna in the Bill, as has been touched on. There is one major shift that the White Paper, the post-pause White Paper and now the Bill are driving for: the shift of public health, including environmental health, to local authorities. However, the Bill itself reflects very little of that. The noble Baroness, Lady Thornton, in response to the group of amendments before last, referred to the fact that work was being done on it and said that she hoped this would see the light of day fairly soon.
The establishment of Public Health England as part of the department-cum-executive agency is hardly reflected in this Bill at all. The issues that relate to the respective role of the local authorities, to which my noble friend Lord Greaves has referred, are not reflected in this Bill at all. We have a major shift, going back to pre-1974, that makes public health the responsibility of local authorities. We have a recent history in which all the expertise in environmental health departments has been seriously squeezed because the requirements are mostly non-statutory. EHOs have been diverted on to other issues. We are coming into a further famine of local authority funding. The local authorities will be receiving this new public health responsibility at a time when their total resources are being squeezed and restricted and other priorities are impinging.
Before this Bill completes its course, we need greater clarity on how public health and environmental health responsibilities are to be carried out; what the structure of them is going to be; what the co-ordination among local authorities, and from the centre to the local authorities, is going to be; what the exact role of Public Health England is going to be; and, frankly, at least some broad indication of how that is being resourced.
The noble Lord raised the question of funding. Does he agree that this will perhaps be exacerbated in two-tier areas because the ring-fenced public health funding will go to the top-tier authorities, whereas the environmental health functions will remain with the lower-tier authorities—which indeed are extremely squeezed on their funding because this is what we call “other services”, which are not regarded as a priority—and finding a way of getting some of that funding down to the lower-tier environmental health authorities is a question that needs to be looked at?
My Lords, perhaps I may intervene now to ask the Minister to say, when he is winding up, what happens if the local authority does not do what it is supposed to do? It is not impossible. In fact, there is a great variety, as we sit here today, in the performance of local authorities. They are managed by elected members, who want to please their electorates, so there are all sorts of arguments for thinking that not every local authority is going to be very enthusiastic about these additional objectives.
My Lords, I will leave that question for the Minister, because it clearly raises wider issues. I totally agree with the noble Lord, Lord Greaves, that one of the most acute effects of all this will be at the district level, where the funds are less protected, and where there is already some difficulty and some serious variability in performance and resourcing.
Given the Government’s support for the establishment of a chief environmental health officer at the centre to help co-ordinate all these issues and—if you like—to punch the weight of environmental health in the other range of priorities which the Department of Health has to pursue, I would ask the Minister this. Will the assessment of public health and the ongoing process she described in trying to defend the Bill from not spelling this out in great detail, lists or no lists, be available to us before we complete the consideration of this Bill, the exact timescale of which looks ever lengthier? Nevertheless, before we reach final conclusions on this, we need to have greater clarity on the direction in which the Government are going on public health, and, I would argue, on environmental health in particular.
I shall mention one other issue that relates to this. The abolition of the HPA also has significant implications in this area. I intend to come back to this at a later stage, but some of the functions of what are currently statutory authorities are going to go to Public Health England, as I understand it, and there is some confusion there as to how that will be carried out, what authority those roles will have and what their local manifestations will be. Under the new structure we will have health protection units around the country. So that is just one more complication here. By Report we ought to have some greater clarity in the strategy of the Government. I ask the Minister to give us an indication of that.
My Lords, I had not intended to intervene on this amendment, but just from memory, I can think of several areas where the presence of an environmental health officer at the centre would perhaps have speeded things up. The noble Baroness, Lady Finlay, alluded to air quality, but there are other examples as well. I am old enough to remember the smog of 1951 and the enormous benefit of the Clean Air Act which followed a few years later. I was also in your Lordships’ House when lead-free petrol was debated, and when that became law nationally. There is also the question of food safety—the noble Lord, Lord Rooker, will know all about this—particularly the BSE epidemic, when it became necessary to ban animal-sourced feed for ruminant animals. Again, that required national legislation. Local environmental health officers, who do a fantastically important job, would not have been able to deal with these things on a local basis.
My Lords, in my youth—your Lordships might think it a rather sad youth—I was, at age 25, opposition spokesman on Newcastle City Council on a pre-Seebohm health committee, which had two remarkably effective and powerful chief officers. One was the medical officer of health, and the other was the chief public health officer. That was the designation of what I suspect we would now call environmental health officers. They were a very powerful combination and very influential within the council. But the point is that they were working together, which is precisely what my noble friend’s amendment seeks to achieve at national level. In later debates we will undoubtedly discuss the role at local level. It is absolutely right to identify this as a core function.
The noble Lord, Lord Rea, referred to one aspect of the role of such officers in environmental issues affecting public health. Perhaps I may revert for a moment to the previous debate and my noble friend Lady Thornton’s proposal to list some matters for inclusion as public health issues in the scope of the duties of local authorities and the Government. Several of those—including nutrition, air and water quality, adequate housing standards, fuel poverty, and possibly even occupational health—will fall within the domain precisely of this kind of appointment. It therefore seems to me that working alongside the chief medical officer of health, or reporting to him—a position of the kind covered by my noble friend’s amendment— would be entirely appropriate and effective. That binary combination or approach would ensure that, across the range of public health issues, there would be the best leadership and the best advice would be available to Ministers at national level and, similarly, at the local level. If it were to be matched, as I hope it would be, that advice would be available to local authorities.
The noble Lord, Lord Northbourne, referred to variations in the practice of local authorities in terms of the resources they devote to this topic. That was undoubtedly true in the past and will no doubt be true in the future, but it is also true at present. The practice of primary care trusts in terms of the way that they allocate budgets is by no means uniform, although I am not necessarily suggesting that it should be. But that is precisely one of the difficulties that I suspect we will encounter when the Government are forced to determine how much is currently being spent, how much perhaps should be spent and how much is to be allocated through any formula-based system under the ring-fencing scheme to be pronounced.
Individual authorities will have different ways of applying core funding, but that does not represent a substantive change from what we have now. Indeed, I would hope that, given greater public accountability, we will have a better outcome than we have had in the existing pattern. I warmly endorse my noble friend’s amendment.
My Lords, I thank the noble Lord, Lord Rooker, for giving me the opportunity to highlight the outstanding work that environmental health officers carry out in district councils as well as in the private and voluntary sectors. The Chartered Institute of Environmental Health, to which he referred, also does an excellent job in presenting the issues nationally and in liaising with central government. They will all continue to play a crucial and developing role in public health.
The noble Lord has long been a doughty fighter on environmental issues. I remember my astonishment when, as a Minister, he granted an amendment which I had tabled that he had been refused permission to grant. I therefore feel very mean in suggesting that I will not be reciprocating today. However, when the noble Baroness, Lady Finlay, raised her points, I was rather glad that, when acting on the Energy Bill in relation to the point for which she fought on preventing carbon monoxide poisoning, I was at least able to grant something there, although I know that that was more limited than what is being sought now.
I should stress that environmental health officers, along with other local authority staff, will be very much inside the group of professionals and practitioners in local government who will form part of the wider public health workforce. Consequently, we expect many opportunities for them in the future to contribute to and to shape local plans and priorities. Surely that will help transform this area, because public health, as I indicated, needs to be defined widely. In its new location it will change in order to have the effects that we wish to see. The noble Lords, Lord Beecham and Lord Rea, are right to urge working together, especially given the history of these officers.
At the national level, the Chief Medical Officer will have a central role in providing impartial and objective advice on public health to the Secretary of State for Health and to the Government as a whole. She will be the leading advocate for public health within, across and beyond the Government, advocating the design of policies that improve health and well-being. We are clear that this role includes advising on environmental health issues as well, and that the Chief Medical Officer will in turn continue to be able to seek such advice on environmental health and other issues whenever necessary just as she can do now. The Government believe that, as valuable as environmental health expertise is, this makes the post of chief environmental health officer unnecessary.
The noble Lord is of course right to urge discussion across devolved areas in all fields, as we can learn from each other. He might be reassured that the Chief Medical Officers of the various Administrations meet regularly, and that Public Health England, like the Health Protection Agency, will in some ways have a remit that extends beyond England and thus offer the chance to learn from the experience of others. We remain confident that Ministers will receive high-quality advice from the CMO on environmental health. I stress that we also need to look internationally and draw on research and experience very widely in this field. We can learn a lot from that.
The noble Lord’s amendment calls for the Secretary of State to,
“report to Parliament annually on the work of the Chief Environmental Health Officer”.
We agree on the need for transparency and believe that the Secretary of State’s accountability for public health at the national level is a major strength of the new system. This is why Clause 50 of this Bill requires the Secretary of State to publish an annual report to Parliament on the working of the comprehensive health service as a whole, which will include his and local authorities’ new public health functions.
The noble Lord, Lord Whitty, asked what the Government are going to do about ring-fencing the budget. Some of the issues that he raised were discussed in the first grouping on public health. I do not know whether he was in his place at the time. If he was not, he should be reassured that his noble friend Lord Warner intends to flag up some of the concerns that he raised in a later grouping, and we have various other groupings in which his concerns will no doubt be flagged up. I point out in relation to our discussion on the previous group that we will be using regulations to set out what essential services local authorities have to provide. Noble Lords can also see what is in the White Paper.
I want to clarify what will be covered in regulations so that if I was not clear in the last grouping, I can be clear now. Essential services that we think need to be delivered consistently across the country—for example, dealing with local emergencies—will be included in regulations. We will use publications like the updated White Paper, which I quoted earlier, to set expectations about the totality of services to be covered by the public health ring-fence. I hope that that provides clarification.
My noble friend Lord Greaves talked about the co-operation between different councils—county councils, district councils and so on. District councils have local insight and expertise. In many cases they will have the lead on key services affecting health and well-being, such as housing and environmental health. Health and well-being boards will play a big part in local health improvement activity and must find themselves able to involve local councils so that they work most effectively.
The noble Lord, Lord Northbourne—sorry to startle the noble Lord—wondered what would happen if local authorities do not carry out their duties. The Secretary of State does not have a conventional performance management role with local government—I am sure that those in local government will be pleased to know. However, he does have the power to intervene and ensure that particular services are provided if a local authority fails to do so. Local authorities will also have to account for their use of their ring-fenced grants, and the power exists to recoup money if the conditions attached to the grant are not met. I hope that that reassures the noble Lord.
In summary, it is very clear that environmental health is and will continue to be a very important component of the public health system, which will be led locally by directors of public health. I hope that the noble Lord is prepared to withdraw his amendment.
My Lords, I am grateful to the Minister for her reply, and particularly for reminding me about the favour that I did her. It proves that Ministers can make policy at the Dispatch Box. I accepted her amendment against advice; I used the excuse that there would have been a government defeat if I had not. She cannot use that tonight because I shall not press the amendment anyway, but I am very grateful that she remembered that.
I do not want to make a long speech. The Minister said that the work of environmental health officers is absolutely fundamental. They are the unsung heroes of policing a system in this country for our citizens on a whole range of issues, whether food, air quality or other matters. The public are aware of them only when things go wrong. I am reluctant to go down this route, but I declare an interest of chairing the board of the Food Standards Agency, which is a government department, and that is why I do not speak on it in this House. Environmental officers are unsung heroes and they deserve our support. They provide a 24/7 operation and they go into areas where, by and large, police officers would go in only pairs. Late at night they visit takeaway enterprises and so on. They do an enormous amount of work.
I also hear what the Minister said in answer to the point about discussion between the four Governments in the UK. If the only link between the four UK Governments on the respect agenda is between the four Chief Medical Officers, we are in dead trouble. Although that is important, it is more important that Ministers in the four Governments who have similar responsibilities talk to each other. Devolution means that things will be done differently—we are not looking for a one-size-fits-all situation—but it is crucial that there is co-operation, consultation and information. Major changes take place without any contact whatever with other Governments and it is the same in this area. There is no doubt that that causes problems. I am sure that we will turn in more detail to the issues relating to local government in regard to other amendments and we may or may not come back to this on Report. In the mean time, I beg leave to withdraw the amendment.
Amendment 67 withdrawn.
Amendments 67A and 68 not moved.
Clause 8 agreed.
Clause 9 : Duties as to improvement of public health
Amendment 68A not moved.
68AA: Clause 9, page 5, line 13, after first “the” insert “physical and mental”
My Lords, since I set down these amendments a good deal of water has passed under the bridge. Fortunately, that will enable me to be briefer than I otherwise would have been. The first and most important thing that happened was the excellent debate on Amendment 11 in the name of the noble Baroness, Lady Hollins. I do not wish to reopen that debate this evening but I want to draw attention to two rather more fundamental matters in addition to what was mentioned in that debate.
The main one is what we mean by health. Do we believe, and do the Government believe, that health means simply freedom from illness or disability, physical or mental? Or do we believe that health can and should mean more than that? I dare say the noble Lord, Lord Layard, if he were in his place—he certainly spoke on Amendment 11—might have supported me in suggesting that health relates both to physical and mental well-being and that we should be doing much more to promote mental well-being, a subject on which the noble Lord, Lord Layard, has written an excellent book. I quote in this context the Childcare Act 2006, which defines well-being on page 1:
“In this Act ‘well-being’, in relation to children, means their well-being so far as relating to—
(a) physical and mental health and emotional well-being;”—
emotional well-being is an important one—
“(b) protection from harm and neglect;
(c) education, training and recreation;
(d) the contribution made by them to society;
(e) social and economic well-being”.
The important thing is physical, mental and emotional health and also such things as self-confidence and self-esteem. I should like to ask the Government to define what they mean by “health” in the Bill. I should also like to ask the Government to place more emphasis in this Bill on prevention—on services and policies to prevent a lack of health rather than focusing mainly, as the Bill does at the moment, on trying to repair the damage when things have gone wrong.
I am not sure whether technically I should withdraw those two amendments or whether I should do so at the end. I will now go on to Amendments 71ZAA, 72A and 97ZA. These amendments are intended to probe the Government’s intentions on two further issues which I consider to be very important. The first is my concern about whether the Bill will effectively and adequately address the health needs of children. That concern is also raised by the noble Lord, Lord Ramsbotham, who unfortunately is not in his place, in an amendment which I support, Will it provide the services that children need? In that context, why does the Long Title of the Bill specifically refers to “adult social care services” but makes no mention of children’s care services?
My second concern relates to the role of parents in securing the physical and mental health of their children. I doubt whether this Bill shows enough concern for the role of parents, especially in the very early years, in promoting good mental and physical health for their children. The Bill’s emphasis seems to be more on clinical interventions to treat ill-health rather than on preventing it in the first place. Only last week, the NSPCC published new research showing that more than 20 per cent of babies born today have mothers who are either dependent on drugs or alcohol or who are subject to domestic violence. How will the Bill address that problem? Too many mothers and fathers today cannot give their children the care and education they need because they themselves have never experienced a happy, supportive home life. Today, we as a society have done very little to help those parents to help their children. How will the Bill help in that situation?
Recent research shows that the majority of a child’s brain development takes place in the last months of pregnancy and in the first two years after birth. This is the time when nearly all children spend most of their time in the care of a parent. Children are learning from their environment every hour of every day. The lessons they learn are often hard to dislodge. What they learn in those years is crucially important if they are going to progress smoothly and confidently into nursery school, reception class, primary and secondary school and on to a healthy adult life. Yet, as far as I can see, the Bill makes little or no mention of the preparation of parents for their important role in developing the physical, mental and emotional health of their child. Parental responsibility in that context ought to be deeply embedded in the Bill because healthy children grow up to be healthy adults who themselves are more likely to have healthy families. Research shows that, from the financial point of view, early intervention is extremely cost-effective. In the context of the Bill, what is the Government’s policy on preventing ill health? On that note, I should like to withdraw the amendment.
The noble Lord cannot withdraw the amendment until he has moved it. The Question is whether Amendment 68AA shall be agreed to.
My Lords, I am not quite sure whether the amendment is before us or not, but I shall make a brief assumption that it is and then I will allow the noble Lord to decide whether to sustain or withdraw it.
As we all know, the noble Lord has made a very distinguished contribution to the whole issue of the status and well-being of children and it is fair that we should recognise that. In particular, he has gone to a great effort to underpin the importance of early education and such things as the Sure Start programme. I want to add two points. The first is that, as a former Secretary of State for education, I remember working very hard to try to persuade my colleagues in the educational world that there should be an emphasis on education in parenting.
It is perfectly true that the early stages of a child’s life are vital, but as the noble Lord, Lord Northbourne, has pointed out, research shows that the link between what a child becomes and its parental inheritance is very close indeed. One of the more disturbing pieces of recent research shows the close link between an abused child and an abuser. Many young people who are abusive parents are in fact the children of abusive parents. Tragically, this dreadful tradition can move on from generation to generation. I simply want to make the point that it is not just a case of Sure Start for the child, it is also a case of proper education and training for the parents.
I have often felt that we should try to link sex education with parental education to bring out above all the extraordinary responsibility that a human child is because it takes so long to grow up compared with the young of most other species. A human child is dependent for many years, and I believe that we should put more emphasis on that than we do. However, it is not fair to make the Department of Health the sole responsible power for addressing this difficult subject. It requires a degree of working between departments, including education and other departments. I simply want to put on the record before the Minister replies the importance of securing co-operation between the Department of Health and the Department for Education, and for that matter social care on this particular set of issues.
My last point is quite straightforward. One of the aspects of training children in parenthood is to allow them to see what it is like to care for a young child. Some teenagers at school will not necessarily have younger siblings. Long ago when I was the prisons Minister—I should have talked about this when the noble Lord, Lord Ramsbotham, was in his place—I introduced a group of offenders, all young boys, to the task of helping in the care and support of children with Down’s syndrome. That relationship had an amazing effect on both parties. The young offenders suddenly realised that they were responsible for someone much younger than themselves who was dependent on them, while the Down’s syndrome children suddenly had older brothers who were devoted to them and to whom they could address their huge capacity for affection. There is a lot of room for bringing young people together with children and teaching them something more than we know now about what it is to be a parent and the huge responsibilities involved in that role.
I should just say how pleased I am that the noble Lord, Lord Northbourne, has brought his great experience and commitment to the children and the family into this debate. I urge him to remain in his place for the debate that we are going to have very soon on children.
My Lords, as the noble Lord, Lord Northbourne, mentioned, the two amendments in this group, Amendments 68AA and 69AA, are essentially dealing with the same matter on which we had considerable debate on an earlier day. Both seek to make an explicit reference in the provisions of the Bill to improving the physical and mental health of the population. I can well understand that the noble Lord with his extensive knowledge and experience of child health in particular should have tabled these amendments. The other amendments to which he spoke are in a later group. I shall respond briefly to those, but I hope that he will forgive me if I do not do so at length, because I think that there will be other noble Lords when we get to that group who will want to expand even more fully on the issue of children’s health.
I shall not dwell again, if the noble Lord will forgive me, on issues raised in the course of the earlier debate, on 2 November, but I reassure him that all references to illness throughout the Bill relate to both physical and mental illness. Illness is defined in the 2006 Act to include mental illness. Equally, it is not for nothing that we have chosen the name health and well-being board to refer to the mechanism at local authority level to define the health needs and priorities of a local area and set a health and well-being strategy to guide commissioners. That sense of well-being is to be at the forefront of commissioners’ minds. The Bill does not provide an explicit definition of health, but I assure the noble Lord that it recognises that well-being means more than the absence of illness and needs to be addressed separately. The approach in the NHS Act and other legislation is that health is simply given its ordinary definition and is not redefined.
The noble Lord, not for the first time, spoke compellingly about the importance of parents in supporting both the health and well-being of children. I could not agree with him more. The whole spirit of the measures set out in this Bill is to give more control and empowerment to patients. For children, that includes their parents. As such, I ask the noble Lord not to despair by reason of the lack of words in the Bill on this topic, as the intent is most certainly there. It is not for nothing, either, that the Bill places duties on the Secretary of State and other bodies in the Bill to exercise their functions with a view to securing continuous improvement in the quality of services. The agenda set by the noble Lord, Lord Darzi, in the last Government runs through this Bill like a thread, and it is our ambition for clinical commissioning groups that the prevention agenda should be centre stage for them, as it already is for practice-based commissioning groups, which are looking at what we call the QIPP agenda—quality, innovation, productivity and prevention—as a way of driving efficiency and better quality care into primary medical services. I am sure that all noble Lords’ ambition is that the NHS should not just be a national treatment service; it should be a national health and well-being service in the fullest sense.
On the public front, I am sure that the noble Lord will have noticed that in Clause 8 new Section 2A is inserted into the 2006 Act. I draw his attention to subsection (2)(d) in that new section, which refers explicitly to prevention in the area of public health.
We will come to the other amendments spoken to by the noble Lord when we come to a later group, but I will just comment very briefly on them at this point.
As regards Amendment 71ZAA, our general approach is not to specify particular services in the Bill. It already allows the Secretary of State or local authorities to take steps to improve the health of the people of England or the people in the local authority’s area. Once again, it is a case of making that general provision. Bear in mind that if we specify one group of people, it carries the implication that we are excluding others, which of course we do not want to do.
The same point applies with Amendment 97ZA. Strictly speaking, Amendment 99A is unnecessary. The mandate is clearly relevant to other government priorities. There are already established mechanisms for ensuring that policy is consistent across government and therefore we would fully expect the Department for Education to provide input on any relevant parts of the mandate. I hope that the noble Lord will be reassured by my brief comments on this matter. His comments are well taken; equally in the light of what I have said, I hope that he will feel able to withdraw the amendment.
My Lords, I might add that Amendments 68A and 69A refer back to Clause 1 and the Secretary of State’s duty to promote a comprehensive health service,
“designed to secure improvement … in the physical and mental health of the people of England”.
Of course, I support the amendments and note that their purpose is different from the purpose of my own extensively debated and supported amendments, which sought to ensure improvement in the quality of services for people with illness. I specify both mental and physical illness. Rather than speaking about mental health, I actually speak about illness. Instead of detaining the House now, perhaps I could speak to the Minister at a later date.
My Lords, I should be happy to speak to the noble Baroness on this topic. I have been reflecting on it since our debate some days ago. I do not suggest that the amendments tabled by the noble Lord, Lord Northbourne, are designed to do exactly the same as those of the noble Baroness, however they draw our attention to a similar definitional issue.
I am most grateful to the noble Earl for giving so many excellent assurances on the questions that I asked him. I apologise profoundly to the noble Baroness, Lady Williams, for nearly cutting her out of the debate. For some reason I was confused about the procedures. I beg leave to withdraw the amendment.
Amendment 68AA withdrawn.
Amendments 68B to 70 not moved.
71: Clause 9, page 5, line 17, leave out “may” and insert “must”
My Lords, I am grateful to the House for being so accommodating in moving the amendments slightly so that we can discuss alcohol now. The reason for this group of amendments is because of the ever increasing problem and toll on our society from alcohol misuse. These amendments are designed to ensure that alcohol misuse is a national priority for the Secretary of State and a priority for local authorities and clinical commissioning groups. Amendments 328, 329 and 331 ensure that local organisations have levers in their responsibility to promote integration; and that health and well-being boards and health and well-being strategies take into account alcohol misuse and are devised with appropriate expertise in alcohol misuse.
Turning to the individual amendments, we passed over Amendment 66 briefly for convenience, but it links to Amendment 71, which changes the duty on the Secretary of State from “may” to “must” because of the danger to health that alcohol poses. Alcohol is a major and growing public health concern. Alcohol misuse affects 4 per cent of the population and more than 10 million people drink above the recommended limits. The prevalence of liver disease, to which alcohol is the major contributor, is growing and is set to overtake stroke and coronary heart disease as a cause of death in the next 10 to 15 years. This is set out in the Department of Health’s document on developing a national liver strategy, published last year.
Last year, more than 1 million hospital admissions were due to alcohol misuse. This represents a doubling in the number of admissions over eight years and the rise is becoming exponential. The estimated cost of alcohol-related harm to the NHS in England is £2.7 billion based on 2006-07 prices. However, the overall cost to the nation from all aspects of alcohol abuse is £20 billion. The Exchequer gets back only £13 billion from tax on alcohol, so there is a £7 billion gap. We just cannot leave that unaddressed. Amendment 72 would insert a new subsection to state that one of the steps that local authorities and the Secretary of State might take to improve public health is,
“providing services for the prevention and treatment of harmful drinking and alcohol dependence”.
In Clause 9, local authorities will take new responsibilities for public health. As PCTs and strategic health authorities are abolished and their responsibilities are transferred to clinical commissioning groups and the Commissioning Board, there is a need to make sure that nothing falls through any gaps. Local authorities’ new public health responsibilities will be supported through their ring-fenced budget of £4 billion, which we have already heard about. However, at present they are unaware of how much funding they will actually receive, and there is a real danger that, with a squeeze on local government’s finance, the budget may be used to fill other gaps within the increasing number of responsibilities that local authorities will be taking over.
The Bill does not specifically state that local authorities will have responsibility for alcohol services, but those of us who have put our names to these amendments are keen to see that in the Bill. It has to become a statutory responsibility, given that the problem is evergrowing. The Department of Health’s consultation on commissioning and funding routes for public health stated that the commissioning of treatment, harm reduction and prevention services for alcohol and drugs will be the responsibility of these local authorities.
The public health outcomes framework includes outcomes on the rate of hospital admissions per 100,000 for alcohol-related harm, and the NHS outcomes framework includes a measure of the mortality rate among the under-75 age group from liver disease, based on a set of conditions where alcohol contributes to 50 to 60 per cent of liver disease overall in the country.
The voluntary sector providers of alcohol services risk a disinvestment in their services if they are not given sufficient priority. They find that their services are already often marginalised and stigmatised because they are dealing with a marginalised and stigmatised group. Some alcohol services that are currently funded by the National Treatment Agency for Substance Misuse will be integrated into Public Health England, and the future of its funding is unclear.
Alcohol services have tended to be a Cinderella in public health, with smoking and illegal drug misuse tending to be prioritised over alcohol. I completely welcome the emphasis on smoking cessation and tackling illegal drug misuse but I regret that alcohol has slipped past and the problem has escalated in the process.
To put this into perspective, on average £136 is spent on dependent drinkers, compared with more than £1,300 on dependent drug users. Yet we know that the social toll on the health, particularly of children in families where there is a problem drinker, can be as great as the toll where drug abuse is going on. The cost of smoking has been estimated to be £2.7 billion a year, which is the same as the cost to the NHS of alcohol. The problem is no smaller than smoking.
The wording in Amendment 202 is designed to ensure that clinical commissioning groups have a duty to make reducing alcohol-related harm a priority. General practitioners have a crucial role to play in identifying, assessing and referring people with alcohol use disorders. General practitioners have tended to under-identify alcohol misuse and, unfortunately, GPs identify only about one in 67 males and one in 82 females who are hazardous and harmful drinkers. Detection in general practice is currently woefully inadequate. Less than one-third of GPs use an alcohol-screening questionnaire.
The Government have indicated that 15 per cent of QOF funding will be assigned to public health and primary prevention indicators from 2013. All the proposed public health indicators are focused on smoking, and the indicator for screening for alcohol misuse has to date been rejected. There is strong evidence that brief intervention and advice in primary care can lead to one in eight people reducing their drinking to sensible levels, so it becomes a very cost-effective and clinically effective intervention. That has been demonstrated in 22 randomised control trials, so there is a very high level of evidence for this clinical intervention.
Amendments 238 and 239 are designed to ensure that the joint health and well-being strategies takes into account the drinking levels in the local population and, in preparing those strategies, that the people who have experience in alcohol services are involved. The joint strategic needs assessment must include an examination of levels of hazardous, harmful and dependent alcohol use in the population and must widen the scope of the local authority with its partner clinical commissioning groups in preparing the health and well-being strategy to include alcohol service representatives.
These joint needs assessments will be very important in underpinning the overall direction taken with funding and commissioning services. That is why Amendment 331 requires health and well-being boards to include expertise in alcohol and drug services in the preparation of reports and strategies on the health and well-being boards. It is worth noting that the criminal injury compensation from alcohol-related injury alone is substantial and is a cost that we are handing on to the next generation. There is also a cost to the private sector from alcohol abuse, which comes completely outside any health costs, such as when premises are damaged, sometimes very severely and set on fire in alcohol-fuelled criminal activity.
Overall, integration is essential. If we are going to spend £400 million per annum on dealing with alcohol-fuelled injury that results in hospital admissions and violent woundings, one must remember that that is only the cost of those that have been recorded by the police. The actual cost just from injuries and woundings is possibly twice that. With an overall cost of £21 billion to the public purse from alcohol abuse, I suggest that this cannot be ignored in the Bill. I beg to move.