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Lords Chamber

Volume 768: debated on Thursday 14 January 2016

House of Lords

Thursday, 14 January 2016

Prayers—read by the Lord Bishop of Rochester.

Social Housing Sector


Asked by

To ask Her Majesty’s Government whether their plan to limit housing benefit in the social housing sector to the Local Housing Allowance rate will apply to those living in supported housing.

My Lords, the introduction of local housing allowance limits to the social sector will apply to both housing benefit tenants and recipients of the housing element of universal credit from April 2018, but only where new tenancies have been taken out or renewed after April 2016. The department has jointly commissioned an evidence review with DCLG to look at the size and scope of the supported housing sector. The research results will guide our consideration for future policy development.

My Lords, I welcome what the Minister has said, but it is really not enough. Only the inclusion of specified accommodation will solve the problem and protect the most vulnerable from an unintended consequence of the proposed legislation. I cannot stress enough the need for urgency. Supported housing providers have to decide in the next few weeks whether or not to continue to support those developments, so there is a real urgency on this issue. I remind the Minister that the LHA cap was announced in the Autumn Statement without either consultation or an impact assessment. It may be an unintended consequence but, now that it has been highlighted, can the Minister please assure the House that it will be addressed quickly and before the Report stage of the Welfare Reform and Work Bill?

The measure will come in in 2018 and there will be regulations within that timescale. As I said, we have this major review—the first really substantial review—and we have been working on that for more than a year now. That will inform our whole policy approach to what is a very important sector, and I hope it will put it on a much sounder footing than it has been.

We are collecting evidence about the size of the sector, who it supports, where the funding flows are coming from and how it is supported. There are various support sources, including the Supporting People fund and RR. We look to publish this report later this year.

My Lords, the review to which the Minister refers is extremely welcome. Has he heard the news that the major housing associations providing extra care housing for older people, which saves the state an enormous amount of money in hospital and residential care fees, have put their programmes on hold awaiting the outcome of this review? If he has heard that news, could he respond to the urgency of the situation?

We are talking to the relevant supported housing associations—it is a variegated sector. There are a couple of issues that are concerning them at the moment, and this is one of them. We are looking, as we develop a dialogue, to get a policy that works for this sector as soon as we possibly can.

My Lords, the other issue that is probably concerning the sector is that the Welfare Reform and Work Bill is forcing all housing associations to cut their rents by 12% over this Parliament—money that will almost all go directly to the Treasury. It is a double whammy. I spoke this morning to the head of Depaul UK, a small charity that houses 700 young homeless people in the north-east and around the country, dealing with kids who have come out of prison or have escaped abuse and exploitation. It has already absorbed cuts of 30%. If this policy goes through, the support workers who teach the young people how to live, cook, pay the rent and go to work and get them ready for independent living simply cannot be paid for. If this goes ahead, Depaul will pull out of hostel provision altogether. Is that what the Government want?

As my noble friend Lady Williams made clear on Monday night, this area is under active consideration within the timetable of the Bill.

My Lords, I declare an interest as the chair of Housing & Care 21, one of the housing associations referred to by the noble Lord, Lord Best. Can I ask the Minister whether he really understands the urgency of this issue? He talks about 2018, but the housing associations involved will have to start telling people in the next few weeks what they can expect under the current government policies. The review has to be quick. How quickly can the Minister respond in order to help housing associations that are currently delaying their decisions?

We are aiming to develop our policy on the back of the information that we get in the spring, and we will be working with the whole sector to develop policy. As for the other issue that the sector is concerned about, which I discussed in the last question, that is within the timetable of the Bill.

My Lords, does the Minister appreciate that there is a complete difference between ordinary tenants and tenants in supported housing? These are people coming out of prison or with learning difficulties and all kinds of other handicaps. They require hand-holding and mentoring before they can reintegrate with the rest of society.

I thank the noble Lord for that question, because I absolutely understand the substantial distinction between standard provision of housing and supported housing, which in the context of the actual payments is now specified allowances.

For the purposes of clarification, can the Minister confirm exactly what is supported housing and clarify that it in no way involves aids for disabled people in housing of any variety?

This is a variegated sector, which is exactly what we are discovering now. Supported accommodation or specified accommodation, using the other definition, effectively looks at the services that are provided to support people. I suspect that some of them will supply aids of some kind, but the real thing is the actual service elements that are provided for people.

My Lords, perhaps the noble Lord could ask his noble friend Lord Strathclyde to do the review. That might speed it up.

Education: Unregistered Schools


Asked by

My Lords, we are taking robust steps to tackle unregistered schools. We are working closely with Ofsted and are pleased that it has agreed to take forward prosecutions in relation to settings operating illegally as unregistered independent schools. We have also consulted on introducing a new system to regulate out-of-school education settings which teach children intensively, and we will intervene and impose sanctions where there are safety or welfare concerns.

I am grateful for the Minister’s reply. He will be aware of the unannounced inspection of the premises of three unregistered schools in Birmingham, where some frankly appalling practices were found, including health and safety issues, safeguarding issues, homophobic and misogynistic material et cetera. First, can he assure us that the advice letter from the chief inspector in which he suggests that there should be an urgent meeting between Ofsted and local authorities to review policies and procedures will be followed through? When that meeting has taken place, can the results be shared with Members so that we can see that this matter is being put right? Secondly, can the Minister indicate how we should deal with Sunday schools and communion classes, which may fall into the category of unregistered provision?

On the first point, I assure noble Lords that we are working very closely with Ofsted and I would be very happy to write to the noble Lord about it. We do not propose to regulate institutions such as Sunday schools and one-off residential settings which teach children for a short period every week. We are looking specifically at places where children receive intensive education, which we think will be defined as more than six to eight hours a week.

My Lords, are the Government looking at madrassahs that teach fewer than 12 children? I gather that 12 is the number which means that some inspection can be done but, as the noble Lord will know, many madrassahs have fewer than 12 children.

We are not specifically looking at madrassahs but we will be covering institutions such as those to which the noble and learned Baroness referred in our call for evidence, which has just closed. We will consider all this in the legislation we propose to bring forward in relation to institutions teaching above six to eight hours a week.

My Lords, my noble friend is looking for bad conduct. Does he agree that he is also seeing a good deal of very valuable instruction given to children who need to be integrated into our society and are handicapped in many ways because of their ethnic or geographic origin?

We are concerned about the point my noble friend makes and about isolated communities, which is an area that Louise Casey has been asked to look at to see how we can improve integration. We are very active in our whole-school approach to making sure that children are brought up to understand enough about the different religions and beliefs in this country that they can be prepared for life in modern Britain.

Will my noble friend ensure that independent schools that intend to become members of one of the independent schools associations do not have registration procedures that are unduly burdensome, while at the same time providing for the full inspection that is required?

I assure my noble friend that we have no plans to change the regime for full-time education. We have been consulting on part-time education of more than six to eight hours a week.

Are there plans to review the arrangements for home education to ensure that they cannot be exploited in order to avoid registration?

We are concerned about some institutions where the rules on home education may be exploited and we are looking at that. But we have no plans to alter parents’ rights to educate their children at home.

Mental Health Services: Serving Military Personnel


Asked by

To ask Her Majesty’s Government what assessment they have made of the support available to serving military personnel with mental health problems, and what plans they have to establish a 24-hour mental health helpline for serving soldiers.

My Lords, the Ministry of Defence is absolutely committed to looking after the mental health of our Armed Forces and provides a range of community-based healthcare in line with national best practice. Out-of-hours care already includes the free 24-hour mental health helpline run by the charity Combat Stress, which receives funding from the MoD, and the Big White Wall, which is a 24-hour online community. There are therefore no plans to provide an additional helpline.

I thank the Minister for his Answer. Will he say whether the Government consider it satisfactory that serving Armed Forces personnel are currently having, and under current plans will continue to have, to rely on support from the charitable sector for urgent mental health issues which occur outside of Monday to Friday normal office hours? With the very best will in the world, those charities will not have access to the in-house mental health records, know about their situations or the medication that they are taking.

My Lords, there is no point in duplicating a service that already works very well. We work in close partnership with Combat Stress, which provides an extremely effective service, and, if necessary, signposts the individual to the right service according to need. There are helplines available for veterans as well, which we run on a 24-hour basis, but we do not see the need and there is no evidence that we should be looking at duplicating that service.

My Lords, do the Government accept that, as a result of operations over the last decade and more, there are many more potential and actual mental health problems among serving personnel? The Minister suggests that this can be helped by charities, but what information is given to serving personnel that these charities are available? It seems to me that there is not enough information available to serving personnel on this issue.

The noble and gallant Lord raises a very important issue. I do not believe that there is any shortage of information available. Personnel are given briefings and advice on whom to contact if they think they need help. These are reinforced by publicity material such as posters and leaflets in all unit primary care centres. Information is also available online on the MoD’s area of the GOV.UK website. Similar guidance can be found on the NHS Choices pages. I believe that there has been a significant improvement in the provision of this kind of information in recent years.

My Lords, when many of our young men, who are little more than teenagers, are being hounded by public interest lawyers, the Iraq Historic Allegations Team and the Iraq fatalities investigation unit, is it fully appreciated that they may have been under intense pressure in combat—even in a state of panic and mental stress—when they have been involved in individual incidents? Is this not what happens when we send young men and women to war?

My Lords, as someone who has returned to being a Defence Minister after a break of 20 years, there is no doubt in my mind that the Armed Forces have come a very long way in that time. They take the mental health of their personnel extremely seriously. As one would expect, the model adopted is one of best practice, prevention, early detection and the ready availability of evidence-based treatments. This applies not just during a deployment but pre-deployment and post-deployment as well.

My Lords, I am sure that the whole House would welcome the improved understanding of mental health issues in the Armed Forces, and, indeed, the improved provision for those who, sadly, develop mental health issues. But would my noble friend agree that most of the Armed Forces are not affected by mental health issues when they are serving and that there is a danger, by concentrating on this, that serving personnel are undermined because they feel that they are being pitied, rather than respected for the excellent work that they do?

I hope that service personnel do not feel that way, and rather that they feel well supported, but my noble friend is right. It is notable that incidence of post-traumatic stress disorder, for example, is extremely low in the UK Armed Forces in numerical terms. One can attribute that, in very large measure, to the services and support that are now available to Armed Forces personnel, both in this country and on deployment.

My Lords, my noble friend Lord Campbell-Savours is absolutely right: it is outrageous that we are chasing, many years later and in an open-ended way, the men and women who have tried to protect us. Can we not carry out an urgent investigation into firms of solicitors that I know use agents in Iraq—and no doubt will in the future in Afghanistan—effectively to ambulance chase to get cases? We are constantly seeing these cases, which cost immense amounts of money and cause mental anguish to our men and women, so they affect the issue we are talking about. We really need to get a grip on this.

As the noble Lord rightly points out, there has been extensive coverage and publicity on this very issue in the press in recent weeks, and I share his concern. The fact of the matter is, though, that it is not the Government chasing our armed services personnel. Every time a complaint is raised, we have a duty to investigate the complaint. It is not a matter of hounding Armed Forces personnel but rather of trying to get to the bottom of the complaint as quickly as possible. Indeed, many of these complaints have been found to be without foundation, but I share his concern about the behaviour of certain law firms.

I am sure that the Minister and many other Members of the House will be aware of the excellent work done by the organisation Combat Stress. In a well-researched report published recently, it revealed that there had been a fourfold increase in the number of veterans who had asked for help for mental health conditions over the last 20 years. Its research suggests that this will continue. The good news is that Combat Stress has treatments that work, but it needs additional funding to deliver them. Has the Minister’s department had discussions with Combat Stress about this need for additional funding and, if it has, what is the outcome?

My Lords, yes, we do have regular discussions with Combat Stress, with which we work very closely in partnership, as I have already indicated. It is interesting that, while the number of military personnel assessed with a mental disorder has risen steadily in the past couple of years, the level of mental illness remains broadly comparable with that of the general population. Although it may sound strange to say it, I think the rise could indicate good news rather than bad news, in that the more we address stigma in mental illness, the more we encourage people who need help to come forward. I hope that is attributable to the better services that are available.

Will my noble friend tell me when last we had a thoroughgoing investigation into what other forces do in this area? Is this not surely something about which we could learn a great deal from, and teach a great deal to, others who are concerned with what must be a universal problem among the major forces of NATO? A comparative piece of work might very well be valuable.

My noble friend hits on an extremely important point, which is why, in 2003, the Ministry of Defence commissioned the King’s Centre for Military Health Research, which is part of King’s College London, to conduct a long-term research study following a cohort of more than 20,000 members of the Armed Forces. That study continues with the same cohort. In so doing, comparative information is emerging about the performance of other armed services around the world. We can take credit for the fact that the incidence of mental illness in our own armed services compares very favourably indeed with that of some other armed services around the world.

My Lords, men and women seeking this sort of support require anonymity and are anxious about that, as, indeed, they are about quality. Therefore, will the Minister explain to the House whether anonymity is protected, how this service is regulated and when it was last quality tested?

The noble Baroness is quite right that anonymity is important to many people and, of course, record-keeping is scrupulously observed in that sense. At the same time, some people feel that it is important to identify mental illness when it occurs. That is why peer support among a unit, for example, features very large, particularly when armed services personnel are on deployment. Anonymity in that sort of instance is difficult to achieve by the very nature of the support that we wish to see personnel give to their peers.

Hong Kong: Kidnapping of British Subjects


Asked by

To ask Her Majesty’s Government what discussions they have had with the Hong Kong and Chinese authorities regarding the kidnapping of British subjects from Hong Kong.

My Lords, my right honourable friend the Foreign Secretary raised our deep concerns about the disappearance of British citizen Mr Lee Bo with the Chinese Foreign Minister on 5 January. We have requested further information from the Hong King authorities and are pressing the Chinese authorities for consular access. We continue to call on both the Hong Kong and Chinese authorities to protect Hong Kong’s high degree of autonomy and the rights and freedoms of its people.

I thank the Minister for that reply. As he knows, Mr Lee Bo was the fifth person to disappear from Causeway Bay Books in the past three months. Given that the 1984 Sino-British joint declaration guarantees free speech as well as Hong Kong’s judicial independence until 2047, are the Government engaging with other partners—Australia, the United States and other countries, as well as the Hong Kong authorities—to secure his release and are they planning to raise the issue at the Security Council if they do not gain any comfort from the Chinese authorities?

My Lords, the noble Baroness mentions a number of important points. I should first say that my right honourable friend the Foreign Secretary told the House of Commons earlier this week, on 12 January, that if these allegations of Chinese security agents taking Mr Lee Bo out of Hong Kong are proven, it would be an “egregious breach” of the joint declaration. Perhaps the noble Baroness would also like to hear about a press conference held by the Chief Executive of the Hong Kong SAR, Mr CY Leung, on the afternoon of 13 January, in which he said that, because there had been reports of mainland authorities arresting or abducting the person in Hong Kong, if that were the case, it would not be acceptable under the principle of one country, two systems—Hong Kong people ruling Hong Kong with a high degree of autonomy—and would not be acceptable under the basic law.

My Lords, as I understand it, it would be not just a breach of the agreement between Britain and Hong Kong but a breach of China’s own laws if people were kidnapped by members of their security forces—the police, particularly. I understand that there is an element of double standards in what the Chinese Government are saying and what they may be doing, but has this been taken up with the Chinese Government? If police officers who serve in China are involved in kidnapping citizens in other territories, is it not against China’s own law and should that not be put to the Chinese?

The noble Lord, Lord Soley, is quite correct in what he says and if I have anything more to add on this I will write to him. It is also quite correct that other countries were involved; a citizen of one of the Scandinavian countries, who is part of this publishing group, has also gone missing.

My Lords, we have obviously condemned the abduction of South Koreans into North Korea and some of us have condemned rendition for other purposes by other countries. Are we now giving different advice to British citizens of Chinese origin about travel to both mainland China and Hong Kong, if they have been involved in any form of political activity?

I do not think that we are at present, but what also concerns us is what is happening in Hong Kong in the media and the publishing sector, where books are being published that could perhaps be deemed critical of the Beijing leadership. There is a certain amount of self-regulation going on, which cannot be a good thing.

My Lords, obviously our thoughts are very much with those who have disappeared and, in particular, for their welfare, but at least one of them is a British citizen. What does the Minister think the implications are of the Chinese Foreign Minister’s statement, in which he said that, based on the basic law of Hong Kong and Chinese nationality law, the person in question is first and foremost a Chinese citizen? China does not and will not recognise dual nationality of its own citizens, so what are the implications of that statement in the light of this case?

My Lords, perhaps there are two things that I can tell the House and the noble Lord. First, with respect to this individual case an initial report was made to the police by the wife of Mr Lee Bo. She later withdrew that complaint but the police are still carrying out the investigation. In addition, Mr Lee holds a British passport and, in line with this, we stand ready to offer consular assistance to him and his family.

My Lords, these are very troubling cases, particularly that of Mr Lee. Does the Minister agree that the rule of law is vital for the prosperity of Hong Kong and the peace of mind of its citizens, and that it is in everybody’s interest—including that of mainland China and Hong Kong—that the rule of law, which up to now has been maintained very effectively, should continue properly?

My Lords, with all his experience on this subject, the noble Lord is quite right about the importance of the rule of law and the relationship between the United Kingdom, Hong Kong SAR and the Chinese people. It was only in the recent past that we had the state visit of President Xi to the United Kingdom. It should be noted that both Her Majesty the Queen and President Xi mentioned Hong Kong in their speeches.

Business of the House

Timing of Debates

Moved by

That the debate on the motion in the name of Lord Turnberg set down for today shall be limited to 3 hours and that in the name of Lord Campbell-Savours to 2 hours.

Motion agreed.

National Health Service

Motion to Take Note

Moved by

That this House takes note of the ability of the National Health Service to meet present and future demands.

My Lords, I am extremely grateful for the opportunity to open this debate and delighted that so many noble Lords have agreed to speak. I very much look forward to the maiden speech of the noble Baroness, Lady Watkins of Tavistock. I am only sorry that speakers have only three minutes to express their views.

It seems entirely possible that one or two noble Lords might draw attention to the parlous state of funding of the NHS. They may even echo Matthew Parris when he wrote:

“Our health service is heading, if not for the rocks, then for the sandbank of chronically sub-optimal performance and monthly threats of insolvency”.

It is tempting to say that this cannot go on. But of course it always does, because of the people in it—the nurses, the doctors, the physios, the porters and so on—who work their socks off to do their very best, despite the lack of resources. They regard it as a privilege to work in a service that aims to care for people and their ills, as indeed did I during most of my working life. When the NHS works well, there is nothing quite like it and the public know that. But when staff morale is at a low ebb, as it certainly now is, and when we have a Secretary of State who seems quick to lay blame but is quite incapable of showing the least sign of appreciation of the staff, then that impacts directly on patient care.

I would not want to be ungrateful for the bit of light relief provided by the Chancellor in the recent spending review, even though that was partly achieved by robbing the budgets for public health, education and NICE. It is hard not to feel, as do the Health Foundation and the Nuffield Council, that this is just another emergency bailout—a temporary fix—when the basic underfunding continues apace as the NHS tries to cope with an ever increasing demand. Having said all that, I hope that I do not disappoint the Minister if I say that I will not be taking that line, at least not yet. What I want to do is to lay out what would be an ideal system for providing total care for the population in the community and in hospital. None of what I say will be entirely foreign or original. Perhaps you know what they say about originality: it is the art of concealing your sources. My sources will be obvious.

The ideal service would have to be completely joined up, with social services, general practice and hospital care integrated. That is so often talked about but rarely achieved because it requires the integration of management and, often, the budget. The silos of primary and secondary care would disappear as GPs were able to work as a team across the divide, in and out of hospital, perhaps even under the same management. This may be a pipe dream, and many—perhaps most—GPs would object, but enough may see the advantages, especially now when they are under such unsustainable pressure that so many are thinking of giving up. Health visitors and district nurses, as well as social workers, could be employed by the hospital so that they could be completely integrated. They would be able to see their patients in hospital as easily as in general practice and the community, without this delaying referral system we have set up.

We had a debate before Christmas about the problems of the care home sector. A number of significant private providers are threatening to go out of business with the potential loss of a large number of care home beds. Currently, about one-third of acute hospital beds are already occupied by patients who would be better cared for in the community. Even more pressure may be put on those beds as care homes are lost.

Would it not be much better if hospital trusts opened their own care homes? A bed in their care homes would cost them about half what a hospital bed costs them, and the trusts would save money and beds—a no-brainer, you might think. Your Lordships may ask where these care homes might come from, but most trusts have obsolete stock that could be rescued, and what about the homes that private providers may vacate? It would need a little capital, but the potential rewards are enormous.

What about those isolated mental health services? At the moment they are far from providing the equity of esteem with physical illness services that everyone talks about. Would they not stand a better chance if they were more joined up with other health services?

There are two other elements in this brave new world that I should touch on briefly. First, why do patients who need to be checked up from time to time by their consultant always have to spend hours travelling to and from the hospital and waiting to be seen? Consultants and patients have telephones, for heaven’s sake. We could do much more if we could get round the tariff system that rewards hospital trusts for out-patient visits but not for telephone calls. The noble Lord, Lord Prior, and I have discussed this before. We are making nowhere near enough use of IT, the internet, remote monitoring devices built into vests and so on. Patients deserve much better.

The other area I should briefly mention is medical research. I should express my interest here as scientific adviser to the Association of Medical Research Charities, which puts around £1.3 billion a year into research. Research should underpin our integrated NHS, and we must take advantage of our excellent basic research capacity and link it with our unrivalled access to the whole NHS population. It is worth remembering that about 50% of our increasing lifespan is the result of advances gained from research.

I suspect that noble Lords will have noticed that much of the full integration I have described requires local authorities and hospital trusts to agree to a single management system and, where possible, a merged budget. That is something that has eluded successive Governments for ever, it seems. What about the idea of patients being given their own personal budgets, which could ease the transition? Perhaps the Minister could say where we have got to with that.

It is not difficult to see why there is resistance. Social services and GPs are reluctant because they see their precious limited resources being used to prop up the hospitals, while the hospitals have historically seen themselves as providers of acute care and only reluctantly as having a responsibility to the community. It does not help when both are financially squeezed. So is it an impossible dream? It seems to me that we do now have an opportunity to go some way along that route, with increasing recognition by all parties that they cannot go on as they are. It will be difficult, but I did not just dream up these ideas.

We have had excellent example of good practice around the country in Torbay and a number of other places for ever, it seems. But most of my ideas have emanated from Salford Royal Hospital, where David Dalton, its chief executive, has already set up much of this integration and has agreement for more. Here I must admit to some pride in speaking about that hospital, because it is where I spent most of my working life as a professor and consultant. It used to be called Hope Hospital, and has obviously taken advantage of my leaving to do great things.

The hospital trust has been employing its own health visitors for some time. It even has two general practices in its employ, one providing out-of-hours services and the other with responsibility for looking after all the residents of care homes in Salford—both in addition to their normal practice.

Incidentally, all 49 of the other general practices in Salford are linked into the hospital’s electronic case records system. The hospital is now virtually paperless, and GPs and hospital staff have access to all the clinical information about their patients wherever they are. From April this year, agreement has been reached between the trust and the local authority that adult social care, including domiciliary and residential care, will come under the trust’s management with a merged budget—remarkable. Perhaps equally exciting is the fact that the mental health trust will in April be contracted through the new single integrated care organisation, a chance to see much better cohesion between mental and other services.

Salford Royal no longer sees itself as simply a hospital but as part of the community for which it provides for the health and care of all of Salford’s 250,000 residents. All those remarkable developments have been possible only because of inspired leadership in both the trust and the local authority, and it has taken many years of patient negotiation between them, and much legwork with the GPs. Salford is of course a nice, circumscribed, if deprived city which sees itself as progressive, and it has the big advantage of having just one CCG.

None of that has required another health Bill to reorganise or, as Ray Tallis has put it, to redisorganise the service. I have lived through no fewer than eight NHS Bills during my 16 years in this House; that is one every two years, and we certainly do not need any more. I have spoken about the Salford experience because that is what I know best, and it may well not be replicable everywhere else, but Sir David Dalton’s report for the Government of a year ago presented a series of different ways in which closer integration has been able to occur. It does not have to be the hospital trust that manages the budget. It could, for example, be some form of unified joint management system. Much more important is inspired and inspiring leadership—not available everywhere, I fear. It has been that leadership that has produced the essential elements of team-working together, with all members feeling appreciated for doing a good job. That is something that the Government could take to heart.

We have heard about the 25 so-called integration pioneers that NHS England talked about last year. Can the Minister update us on them, and on the pilot schemes in east London announced recently? Then there is the much heralded devolution of budget to Greater Manchester, of which Salford is of course an important part. That is clearly the route that the Government want to take, but therein lies the rub. First, in devolving responsibility, the Government get themselves off the hook if things go wrong. That is what devolution means.

Secondly, merging two inadequate budgets by itself may improve efficiency but is unlikely to be sufficient. It would be a huge blow to the Government’s devolution agenda if Greater Manchester failed for lack of funds. It would mean a big step back for the integration that we desperately need and would put off anyone else thinking of taking the same route. It is inevitable that money must come into it, and, to their credit, the Government have recognised that and have now agreed to provide transitional funding for Greater Manchester of £450 million over four years—just over £100 million a year. Whether that will be sufficient remains to be seen, but it is undoubtedly helpful and should be welcomed.

Although it is good to know that the Government are aware of the need for some temporary funding, there remains the more serious, longer term sustainability of the NHS and, in particular, social care. Almost everyone recognises that the UK spends one of the smallest proportions of GDP on health of almost all European countries: about 6.5% of GDP, compared to an average within the EU of about 9% or 10%. Social service funding is even worse off. All of that is in the face of increasing demand from an ageing population and a frightening increase in the number of patients with dementia. Almost every day we read in the papers of yet another failure or crisis.

We can become more efficient, and I have tried to indicate one way that we might be able to do just that, but short-term injections will not be the solution. We must find a way to provide a more sustainable level of funding to bring our services up to the standards of our neighbours in Europe. It is true, as Mark Britnell describes in his book, In Search of the Perfect Health System, that nowhere in the world has a perfect system, and many Governments struggle. But that is no excuse for starving our own service and having to accept an increasingly inadequate level of health and social care. If we are to gain the advantages of integration that we can clearly see in a few places, we must have the sustainable resources to do it. Of course, there is a separate debate to be had about how we fund our health services, which is something for cross-party discussions, royal commissions and so on, and I do not want to get into it today, although I suspect that other noble Lords may do so.

Meanwhile, the Government must get into the habit of valuing their staff and not blaming them; they must try to show that they are supporting and not confronting nurses and doctors all the time. I am sorry to end, as I started, by decrying the low level of government funding and criticising their attitude to NHS staff, but I do so only against the background I described of what it is possible to achieve by an efficient system of integration. Mark Britnell in his book finds that the most important reason why people are proud to be British is the NHS. Its fairness and accessibility to everyone, regardless of ability to pay is a precious resource, and we must not let it fail.

My Lords, I did not agree with everything that the noble Lord said, but I congratulate him on how he set out the pressures that the health service faces and will face in future. As he forecast, it is for reasons like that that I advocate a royal commission to examine the future financial—and I emphasise financial—requirements of the health service and propose ways in which that demand can be met. My proposal has absolutely nothing to do with the current industrial dispute. Indeed, I suspect that the BMA would not be a natural supporter of such an independent investigation. Basically, I want a commission to investigate how we can continue to afford a National Health Service providing care irrespective of income, which is what everyone in all parties wants, while recognising the financial challenges of an ageing population and the extra cost involved in medical advance. At the same time, we must recognise that public spending on health should not crowd out all other areas. I also want to see good education, a strong police service and—if noble Lords are interested, we are debating this subject next Thursday at about the same time—better prisons. If this is not an intrusion into private grief, I want a strong defence policy as well.

It is against that background that I would set out four requirements for a royal commission. First, it should be absolutely independent; it should be neither a political body nor an insider body. Secondly, it should look at how we finance the health service, otherwise there is absolutely no point. What we want are the best ideas on financing a service that we all value, irrespective of party, and we should re-examine old policies—for example, policies such as prescription charges, which mean at the moment that 90% of prescriptions are prescribed free. Thirdly, a royal commission should look at all the options; it should certainly examine experience, particularly in other countries of Europe, but it should investigate the potential of a health tax—a ring-fenced contribution to the costs of healthcare, which would have the advantage of connecting the taxpayer much more closely to the cost of the health service that they finance.

Fourthly, and lastly—and personally I regard this as crucial—a royal commission should investigate the long-term savings and benefit of better public health. Both Governments have failed here. The national health basically remains a sickness service, not because that is what Health Ministers want but because that is what the Treasury allows. The Treasury will try to provide resources for treating the casualties, but it is very reluctant to invest in preventing those casualties. It says that you cannot show that it will work, when the evidence is clear that prevention policies can and do work, not least in the 1986 AIDS campaign, which reduced not only HIV but all other sexual diseases at the same time. Even worse than this general failure is the fact that the Treasury has now chosen public health as the one area in the whole of the health field where spending is to be reduced, which is an entirely retrograde step.

There is a vast amount to do, and what we do now has implications for years to come. I believe that a royal commission has the potential to provide a proper base on which to face the financial challenges and to win public support.

My Lords, I am indebted to my noble friend Lord Turnberg not only for securing this debate but for his long-term contribution to health debates and the development of health policy in your Lordships’ House. Like him and many noble Lords speaking today, I am greatly committed to the NHS. In fact, I owe my life to it. No price can ever be put on that, and no acknowledgment is enough.

Many statistics will be traded here today but I am not going to engage in that. I shall focus on the wording of the debate so far as future demands are concerned and offer my thoughts on what the NHS needs in order to be the institution we know, love and admire into the next century.

In my view, there are two essentials. First, to have a viable health service you have to have a social care service which works. We are all familiar with the reasons why the post-war settlement set up different systems of care: men died at 66—one year after retirement—and women at 68 or 69, so you did not need much social care in those days. Now, with our ageing population, the contrast between a health service free at the point of use and a social care system which is means-tested and publicly funded only for those with heavy needs results in a lottery, so the type of ailment you have will determine the financial support you get to cope with its effects. There is no equity. Moreover, efficiency is hampered by a lack of integration in organisation as health and social care are separately commissioned. Look at the 3,000 hospital beds today occupied by people fit to leave but stuck there because funding or assessment has not been resolved. The economic cost of this is huge but to it must be added the cost of the human misery caused by this situation.

We simply must move to a single, ring-fenced budget for health and social care which is commissioned in one place and within which entitlements are understood. We hear constantly that health and social care are becoming better integrated. In the 18 years I have been in your Lordships’ House, I have lost track of the number of times I have heard that assurance from Ministers on all sides of the political divide, but progress is piecemeal at best. We have to hope that somewhere, sometime and soon we will have a Government with enough vision and courage to disregard the five-year focus of any Government and propose a proper reassessment of the post-war settlement to reflect the current and future needs of our ageing nation. It can be done with vision and commitment, as my noble friend has shown us in Salford.

The second thing the health service needs—here I echo the noble Lord, Lord Fowler—is to focus not so much on curing illnesses but on the prevention of illnesses. Statistics are legion about the illnesses which are debilitating to the individual and expensive to the NHS, and the obvious way of tackling them is to prevent them arising in the first place—for instance, diabetes, so associated with obesity; strokes, so associated with high blood pressure; and lung diseases, so associated with smoking and lack of exercise. Yet time and again we hear that nowadays prevention programmes run statutorily or by the voluntary sector are being cut because they are long-term investments and may not pay off, so to speak, for as much as 10 or even 20 years, so they make easy targets. Does the Minister agree that this is short-sighted? We are at a point where only far-sighted, perhaps controversial, but courageous actions will preserve for the long term our much-loved and much-admired NHS.

My Lords, I, too, thank the noble Lord, Lord Turnberg, for securing this important debate. I also want to thank all the people who work in the NHS at the moment. We need to recognise that much of it works very well, despite the pressures which I am sure we will focus on during this debate.

My starting point is that the world is changing. With the demographic time bomb, a large increase in the older population and the conditions associated with that, comorbidities and the changes in the technology delivering medical services, our NHS is facing perhaps the biggest challenge of its time. That is before we even start to look at the financial allocation.

I, too, want to focus on public health. There are concerns about the £200 million in-year cuts which are impacting on the ability to help the public prevent their own need to call on the health service.

I congratulate the noble Lord, Lord Fowler, on the fantastic AIDS campaign. We need a public campaign on how to use the health service now. The number of people who bypass the GP and go straight to A&E, despite what has been done on this subject, is still appalling. Talk to any emergency doctors and they will tell you that there are plenty of people who they should not be seeing there.

The noble Lord is not the only person asking for a commission; my colleague Norman Lamb in another place has also said that we should have one on the entirety of health and social care, for all the reasons that noble Lords have mentioned. We have been talking for years about full integration, and I shall come on in a moment to an example of where I see one particular small project working very well.

Our NHS faces a much bigger crisis, and that is staffing—both nurses and doctors. Not only are we exporting a large number of them—over 5,000 doctors applied for certificates to work abroad, and many of them have gone—but I am not sure whether noble Lords are aware that UK doctors make up only 63.5% of doctors currently registered in the UK. That means that over one-third of our doctors have been foreign-trained. Some 91,000 of our nurses at the moment have trained abroad—that is, one in seven. It is an enormous number. We may have separate debates on how we do not train enough and how 10,000 nursing places have been lost. We have been thinking on a very short-term basis about medical education over the past five years, specifically since the removal of the SHAs. It is vital that we start to plan longer-term. Hiring doctors from abroad may work in the short term but often causes problems in their own areas and countries. While some trusts work closely with other countries—such as the West Hertforshire trust, which works with nursing schools in the Philippines—that is not universal.

My final point is about good integration. Hertfordshire is launching the Sloppy Slipper Swap this month, funded by the county council and the CCG. Some 4,000 people in Hertfordshire have trips and end up in hospital. Most of those are at home and are caused by poor footwear, so it is great to see a fully integrated campaign run by the libraries to ensure that people have access to education and a free pair of slippers, as well as advice about winter warmth. That is the sort of project that we need to see replicated throughout the country.

My Lords, I thank the noble Lord, Lord Turnberg, for this extremely important debate. I declare an interest as chair of the Centre for Ageing Better, a new What Works Centre that does what it says. I will focus on the implications for the NHS of an older population and I shall seek to look 10 years forward, as I think it is essential that we do so in order to address this question.

The starting point is that we are living longer, and this is a cause for enormous celebration and thanks. There are people in this Chamber and in our society who are alive now who would not have been without the changes and successes of medical science. So we should address this as a fantastic opportunity to consider how we benefit from longer lives, rather than seeing it as a disastrous crisis.

Nevertheless, we have to face up to the scale of change and challenge. The ONS tells us that in 10 years’ time there will be 40% more people aged 85-plus. We know what that implies for the NHS in terms of demand and cost. We know that it means many more people with long-term conditions—there are some estimates in Ready for Ageing? if noble Lords want illustrations—and we know from the five-year forward plan that long-term conditions drive 70% of NHS costs. So one way or another there will be a major increase in the proportion of GDP that we spend on health and social care over the next 10 years. Wanless estimated about 11% of GDP; the King’s Fund report by Barker estimated about 12%. Those give us the scale of increases in GDP spending that we are likely to make by one means or another.

What should we do? I agree with the noble Lord, Lord Fowler; it is not the model that is wrong. The model of the NHS is fundamentally equitable and relatively efficient and low-cost compared to others. The question is essentially: how do we fund an NHS and a social care system to address this?

Prevention is critical; it has been talked of, so I will say only two sentences on it. Wanless said in 2002 that unless we address prevention we will hit a crisis; the NHS Five Year Forward View said that we have now hit that crisis because we failed to address prevention properly. At present there is no ambition, plan, leadership or social debate about how we will make the major shifts in personal attitudes and behaviours that will avoid self-inflicted damage and cost to individuals and the public purse later on. Many lives are poorer because of that, so we have to address it, and although it will be slow to make change, it is fundamental to success.

In conclusion, on how we as a society pay for between 11% and 12% of our GDP on health and social care to benefit from longer lives, the question is clearly how we do it in a way that is fair to all people. We need to recognise that many of today’s pensioners are better off than ever. Pensioner poverty has been largely eradicated, and pensioners have a very privileged tax and benefit status—I celebrate that personally. However, in truth the question is: what is the political agreement with the public? Is it essentially, “We will protect you in a privileged tax and benefit position” or “We will commit as a society and as politicians to protect the quality of health and social care that you will need in an equitable way in our society so that you will benefit from your longer lives”?

My Lords, I join noble Lords in thanking the noble Lord, Lord Turnberg, for this debate and I look forward to the maiden speech from the noble Baroness, Lady Watkins. With regard to debates, I put on record that it would be very useful for this House in particular each year in the late autumn to debate the draft mandate that the Government give to NHS England. That is the primary basis upon which the accountability through the Secretary of State to Parliament should be exercised. It was not debated here or in the other place, and it should have been.

I am very proud that, as my party’s spokesman over nearly 10 years, we made unambiguous and absolute our commitment to the values and constitution of the NHS, as my noble friend Lord Fowler equally made clear, and that we made a commitment to increase the budget of the NHS in real terms. Frankly, in the last Parliament it was 0.5% in real terms on average per year; the long-term average has been something over 4% in real terms per year, so the pressure on NHS budgets is unambiguous.

I agree with the noble Lord, Lord Turnberg, that the only reason that in 2014 the Commonwealth Fund could say that we had the best healthcare system among leading economies was because NHS staff deliver a superb service with modest resources. Over the last five years, they continued to deliver substantial efficiencies; in doing that they met the so-called Nicholson challenge of delivering £20 billion. We did it in part not least because—my noble friend the Minister and his colleagues hid this away on 21 July last year—the reform process cost £1.4 billion but delivered £6.9 billion of direct savings during the course of the last Parliament.

However, we need to do more in the future. Time does not permit me to do more than list the things we need to do. We need an NHS digital infrastructure that is user led and that delivers what the Wanless report called for but which did not happen. We need a preventive system. In the creation of Public Health England, the responsibilities of local authorities and the public health strategy in the White Paper of 2010-11 there is a strategy, but it needs to be funded, as my noble friend said, and as Wanless recommended, it needs to be delivered. On commissions, Wanless is a cautionary tale. To agree that a large amount of money should be available for the NHS does not necessarily deliver the preconditions for the success of that service in using that money effectively. We also need new models of care—integrated and personalised care—and better procurement, on which I look forward to hearing from the noble Lord, Lord Carter of Coles. We need the Dilnot report on social care to be implemented, as we heard in the debate before Christmas. Not least, we need tariffs for the acute sector to be realistic, even if challenging in terms of quality and efficient care.

Finally, we need a long-term future for the NHS, and I am not just referring to the next £20 billion of efficiencies over the next five years. There needs to be an understanding that, while there is a requirement to continue to be efficient, there is light at the end of the tunnel and that when we get to 2020 and beyond, the NHS budget, having gone down from 7.8% to probably 7.1% of GDP, does not go down any further and prove unrealistic in relation to rising demand. From that point onwards, for the subsequent five years, NHS England can then build a vision around a commitment to a sustained level of NHS funding relative to the income and wealth of this country.

My Lords, in my three minutes I will concentrate on one section of the NHS Five Year Forward View, published 18 months ago, headed “Getting serious about prevention”. It makes the point that we are reaping the consequences of failure to prevent chronic diseases that would be largely avoidable if only suitable changes in behaviour could be made. The former Chief Medical Officer exhorted people to change their so-called “lifestyles” and live more healthy lives—I think we know the list.

The five-year view does not emphasise sufficiently that these diseases are all strongly related to social conditions. As Sir Michael Marmot has shown, there is a gradient in both mental and physical health through all socioeconomic groups from the top to the bottom. Health education messages to change behaviour are, however, less effective in the lower part of the spectrum. Poverty and inadequate housing may make it more difficult to give up harmful habits such as smoking, drinking or comfort eating, which can give momentary relief from economic and social pressures. Changing behaviour where it matters most is therefore the most difficult; powerful underlying pressures, some from the tobacco industry and parts of the food industry, are pulling in the opposite direction.

Professor David Gordon and his colleagues at Bristol University have drawn up an alternative list of desirable health behaviours to those advocated by the CMO. They take a rather different approach, which goes like this: “1. Don’t be poor. If you can, stop; if you can’t, try not to be poor for long. 2. Don’t live in a deprived area. If you do, move. 3. Don’t work in a low-paid, stressful manual job. 4. Don’t live in damp, low-quality housing”. There are six others, which I am afraid time precludes me from listing.

Those suggestions all have a direct bearing on health and longevity, but they lie outside the remit of the NHS and are mostly the responsibility of local authorities and other departments of state. If they were adequately funded, a great load could be lifted from the NHS, which at present is carrying a burden for which it is not really designed. I suggest that the continuing financial crisis of the NHS will not be solved until it is properly funded and other departments of state whose responsibilities have a bearing on health are enabled to carry their full share of maintaining the nation’s health and well-being.

My Lords, I add my thanks to the noble Lord, Lord Turnberg, for putting this debate on the table. In dealing with this question, I consulted the army of doctors, specialists and carers who enable me to be here today and to function. I asked them, as well as my colleagues in the department of health economics where I used to work, what kind of solutions they thought would deal with the problems that we face.

The general response was the suggestion that is already on the table—that you cannot have good health without having good preventive care at the very beginning, without having good food at schools, without having timetable slots for gym sessions and exercises, or without enabling the next generation to grow up healthy. The problem with the NHS is that people like me are now surviving and are costing a great deal. I am constantly in a variety of hospitals, being pumped and tested and put together. We are expensive—but I hope that we render some services.

On the other hand, what is absolutely required, more than care, is preventive measures. Also, my colleagues from health economics pointed out to me that, in terms of state funding, the NHS has been improving faster than the input to it, year after year since 2010. Essentially, efficiency is increasing; unfortunately, the burden that is put on that efficiency is increasing faster.

We cannot deal with that by looking at the National Health Service simply in terms of health and medication. We absolutely need to prevent people rushing to the NHS because their GPs are overstretched and they cannot get easy access to them—calling an ambulance ensures that they do get access to the NHS, whereas getting themselves to the GP is often costly and time-consuming and involves a great deal of waiting. So what is needed is to enable patients to have better access to GPs.

I do not think that that is served by having round-the-clock services in hospitals. I had dinner with a group of GPs last night. Many of them said to me, “It doesn’t matter whether you get your toenail removed on a Monday or a Saturday”. Hospitals perform a great many functions that do not need to be provided on a seven-day basis. We need to be able to separate what needs doing now, how we do it, and, particularly, how we secure the next generation’s health.

My Lords, I am very grateful for the opportunity to speak in this debate. Much of what I was going to say has been said and I do not intend to repeat it. I have surveyed some of the National Health Service foundation trusts in my diocese and there are common threads, both of opportunity and concern: financial, operational and clinical. Yet it ought to be said that some of the administrations of these health services are doing heroic work at a time of enormous complexity and constraint. Again, as has been said about the need to raise morale among staff, we should at least thank and congratulate those who are making the system work despite the challenges.

As demands rise, constraints are harder to deal with. I will throw into this that questions around PFI will have to be addressed at some point because of the deficits that some of our trusts are facing. One obvious issue here is that collaboration across key organisations at a system or place level is made difficult when each is bound by an independent regulatory regime and independent internal governance arrangements.

The relationship between health and social care was raised earlier. Social care is means tested. If you want to shift people out of acute beds in hospitals and into social care, there has to be a smoother route for doing it; obstacles should be handled or dismantled.

Finally, in relation to questions about the future, I will raise the question of chaplaincy—not as a bit of special pleading but because chaplaincy recognises the holistic nature of the care of people. In a debate such as this, we very easily talk about money, finance constraints and administration systems, but looking at the whole needs of people, so that they cease to be just medical cases or numbers or bed throughput, will be increasingly important.

My Lords, I hope that the right reverend Prelate the Bishop of Leeds will forgive me for my intemperance. Normally, I do not interfere with the bishops, except when I am playing chess. I also apologise, if I may, to the Minister, the noble Lord, Lord Prior. I feel very deeply about what I am going to say, and it will be uncomfortable. I want to assure him of my respect for him and my recognition of his commitment to the National Health Service. However, what I have to say is important.

According to independent international observation, we have the best National Health Service in the world, often funded at a lower level than almost any other equivalent in Europe. However, I am not sure that it can remain so after the 2012 Act, which of course was introduced by the noble Lord, Lord Lansley, whose idea it was.

The one thing that makes our National Health Service as good as it is, is the quality of academic medicine and research that goes on in our universities. Jeremy Farrar has pointed out that the reason he became such a good doctor is that he did research. In spite of the ludicrous boasts that we are doing more research in the NHS and that every patient will be part of research, sadly, this is really not happening. As Professor Geraint Rees, the notable neuroscientist at UCL has said, the culture of the NHS has become increasingly inflexible and actively hostile to clinical academic training. Why do I say that? It is because it is inflexible in allowing research-oriented doctors to move to different regions to get experience. The system makes it difficult for research-oriented doctors to return to clinical training, and the career that I had would now be impossible. Doctors wanting to do research find it extremely difficult to persuade seniors and managers that they should spend time doing this, and the current problems doctors face are a shocking example of what is happening.

The fact is that research takes time: it takes time to read, to reflect, to discuss, to think, to write, to publish and to talk to patients to explain why the research is so important. I see prospective medical students in schools all over the country and they show one thing: they cannot get into a university to do medicine unless they demonstrate their altruism and an understanding that they will need to be ethical, their commitment to justice, and the notion that they are going to have to be extremely diligent. As you see, they go through medical school with all those principles—the notion of justice, public service and, above all, diligence—drummed into them at every stage in every university.

But what have the Government done? I congratulate the current Secretary of State on one thing. He has certainly united the most diligent, altruistic, committed, intelligent and well-trained workforce in the country; they have gone on strike almost unanimously. The fact is that the attitudes that are being pushed on to the doctors are, ultimately, extraordinarily destructive, and the Government have a major responsibility for that. The future of our NHS is imperilled by this change of attitudes.

My Lords, these are challenging times for the population’s health and the healthcare system, for reasons already set out very clearly in today’s debate. What some commentators have called a near existential crisis of the social care sector has brought some services close to breaking point.

The much-heralded greater efficiency and productivity improvements in the NHS, very important as they are, are being pushed to their limits and will not close the projected £30 billion funding gap. At best, they are like sticking a plaster on a health and care system that needs major surgery. As we heard the noble Lord, Lord Turnberg, set out so eloquently, for a sustainable and long-term approach we need to set up a totally new model of integrated health and social care.

We all know that the NHS is not only a public good but a top public priority. The Government have acknowledged this priority in the recent spending review, and the commitment to an £8 billion increase in NHS funding by 2020 is very much welcomed. But frankly, that is only going to stabilise NHS services in the short term, and a lot of it will be taken up with addressing the growing deficit facing NHS trusts and foundation trusts. Critically, it will not, in my judgment, allow the implementation of the seven-day services requirement nor the much-needed investment in new care models.

We also need to understand where this £8 billion is coming from. Cuts to other parts of the Department of Health budget will clearly have knock-on implications for the NHS. So it is of real concern that other health spending, such as public health, education and training, and capital, is expected to fall by more than £3 billion. My key point today is that it is critical that the additional money does not come at the expense of funding for mental health or, indeed, social care. The coalition Government pledged a transformation in mental health services with almost a £1 billion investment, something that the Prime Minister made much of in a carefully packaged re-announcement earlier in the week. While this investment is hugely welcome, it still does not properly address the fundamental disparity between the ways in which physical and mental healthcare are funded and delivered.

The NHS England five-year forward plan had many good things to say about new and more joined-up models of care. These models are fundamentally about abolishing long-standing boundaries between GPs and hospitals, between physical and mental health and between the health and social care sectors. There is so much more to do as well joining up the community services, prevention and public health.

As has already been mentioned by my noble friend Lady Brinton, my right honourable friend Norman Lamb has recently proposed the creation of a cross-party commission on the future of the healthcare system. I strongly support this. The work needs to explore the various tax and fiscal options as part of the solution to the funding gap—something, frankly, which politicians of all stripes have long shied away from. I hope the Government will welcome this initiative.

My Lords, I thank the noble Lord, Lord Turnberg, for tabling this debate, in which it is a great honour as a Member of this House to make my maiden speech.

My career started in 1973 as a nursing student in close proximity to this House at Westminster hospital where, on a more personal note, I was fortunate to meet my husband, a surgeon. I thank him for his support and encouragement in embracing my appointment to this House. Although I do not mean to be controversial today, I can assure your Lordships that this is difficult for me, having extensively argued the merits of investment in nursing versus medicine, surgery versus mental health, and acute care versus community care throughout the 40 years’ experience I have as a nurse and regular practice with a surgeon at home. In turn, this led me to a deputy vice chancellor role at Plymouth University, with responsibility for student affairs, including a range of health programmes. I have more recently been involved in chairing academy schools, working as a non-executive director in the NHS and the Aster Housing Group. I also undertake charitable work in drug treatment centres and in the care of older people.

I thank noble Lords on all sides of the House for the warm welcome that has been extended to me since my arrival and all the staff of the House for the assistance they have given me. I also thank my two supporters—my noble friend Lady Emerton and the noble Lord, Lord Kestenbaum—and my mentor, my noble friend Lord Patel, who tells me that he is watching this from India.

The vision for the NHS is for a modern, efficient and sustainable NHS where care and compassion matter. It has been argued that an integrated approach could both improve the quality of care for patients and improve productivity. Numerous studies have shown that an increase in the number of registered nurses in hospital and community settings is associated with clear benefits for patient mortality rates and other key metrics. Patient outcomes are enhanced if care is co-ordinated and, where necessary, delivered by registered nurses. If hospital admissions are to be reduced, rapid assessment in patients’ own homes from a range of healthcare professionals is vital. Yet are we doing enough to ensure that we are training sufficient numbers of healthcare professionals to achieve and sustain integrated care as outlined in our strategy?

In the early 1980s, as a “nursing officer for change”, I worked in a large mental hospital where over 1,000 beds were closed and replaced with community-based services. The key to the largely successful project was that all clinical staff were provided with further education and development to prepare them for the changes in their role. Community care is now the norm for those who have mental health and learning disability challenges, and most care is successfully delivered in a range of health and social care settings. I would argue that we are not so successful in providing acute healthcare intervention in people’s own homes, as evidenced by increasing admission rates to hospital, yet other countries successfully provide more care in the community. We hardly have an ideal situation at the moment.

Key to successful community care for people with the most acute medical problems and long-term conditions is the number and kind of nurses that are available to work in a range of settings, yet we know that we have an international shortage of qualified nurses which is estimated to be at least 20,000 in the UK alone, resulting in increased agency staff costs and, perhaps more important, reduced continuity of care. Happily, the number of nursing places in universities is set to rise this year, but for the next three years we will have the lowest output of registered nurses because of previous short-term cuts. The noble Lord, Lord Willis of Knaresborough, has indicated that we need to put training at the very heart of the NHS agenda, and that lifelong learning is essential. If we want a thriving healthcare structure, we must ensure that we have a workforce that is provided by the voluntary, social enterprise and independent sectors as well as the NHS. We need to recruit, train and retain care assistants, who provide support for individuals in their homes working with registered nurses.

In a recent letter to the Times, the noble Lord, Lord Hunt of Kings Heath, concluded that the NHS is currently remarkably robust considering the level of investment. I agree, yet as others have said today, funding remains relatively stable in real terms and the only way to resource the future is to redesign our service to meet future challenges. Nursing is pivotal to this. In the current situation, the role and complexity of nursing is poorly understood, especially the role of the registered nurse with a degree. I can assure noble Lords that degree-level nurses are not too posh to wash, but can do so only if they have enough time to do it with care and compassion, as well as overseeing others who can deliver care well. The Guardian recently suggested that NHS leadership is ailing, but pointed to the Florence Nightingale leadership scholarships as an area of good practice. We must provide more opportunities for leadership development to ensure a supply of competent leaders who are able to respond to changing demand and lead the redesign of services for a sustainable NHS.

I have argued that registered nurses are pivotal to greater NHS productivity. This will require valuing and investing in the profession not only in terms of education and opportunity but by demonstrating for tomorrow’s care workers kindness and compassion in employment terms, so that this, in turn, is reflected in the care they give not only to us in this House but to society at large in the four countries of the United Kingdom.

My Lords, it is my great privilege to welcome the noble Baroness, Lady Watkins of Tavistock, to the House and to extend warm congratulations to her on her most excellent maiden speech. It is an indication of the expertise that we can look forward to in her future contributions.

I thank the noble Lord, Lord Turnberg, for the opportunity to debate this important topic, which is to see how the NHS can be turned from a national sickness service back into a national health service. The rapid development of scientific knowledge, the growth of technology and research into the etiology of disease have led to valuable treatments for many conditions, and continue to do so, but at the same time the concentration on public health that was a priority at the inception of the NHS—preventing disease and promoting the health and well-being of the population—has decreased, although it remains a very important ingredient. Highly technical treatments and shorter hospitalisation now are appropriate but, because of the lack of community support, hospital beds become blocked.

As a retired nurse with 62 years’ experience, I am aware that the intent has always been to preserve the place of public health, but it has been overshadowed by the more exciting treatment side. The well-being of patients remains a requirement for nurses in the nurses’ code of conduct. A few lines refer to the fact that well-being in public health and care standards should be included in the syllabus of the nursing degree.

The NHS constitution also includes well-being as a responsibility of all staff. However, it is recognised within the Five Year Forward View that public health remains in urgent need of revival. That is for several reasons, the most important being the health of the population and the cost-effectiveness of a healthier population. Recently, Simon Stevens said that we cannot put more on the overstretched NHS staff. Healthcare professionals are the key to the future of the National Health Service. Unless they take a lead in promoting health and prevention of disease, nobody else will have the knowledge or the skills to take that forward. I do not refer just to doctors and nurses but to social services and all charitable contributors.

There is an in-built resistance to breaking down professional and organisational barriers but we must have the right leadership—leadership has been mentioned several times this morning—to take forward the health service so that it is not only a sickness service. It should be possible to influence and persuade lateral thinking and bring the holistic culture to health. It should start with the promotion of health, the prevention of disease, the treatment of disease and the well-being of the population, which should provide an evidence-based and cost-effective service.

The idea of the royal commission is good but, my goodness, a royal commission takes a long time. This is an urgent need and perhaps we may ask the Minister for a full debate on public health quickly.

Perhaps I may remind the House that this is a time-limited debate. Although most speeches have finished when three minutes is still showing on the clock, speeches have reached their permitted limit when three minutes first shows on the clock.

My Lords, the wording of our debate in part says,

“the ability of the National Health Service to meet present … demands”.

I think we all agree that when it meets present demands, it does so in an exemplary way. The problem is that it does not meet all demands and the failure to meet demands is increasing. I picked four important points at random and was interested that, at least in part, they overlap those inadequacies to which the noble Lord, Lord Turnberg, drew attention.

There is very little integration between health and social services. We are sad about that at the community level but is it realistic to expect that to happen if, at the government level, there is not integration between health and social services? Perhaps the time has come to reverse the decision to separate them that was made some years ago. Thousands of people urgently need hospital treatment who cannot get it because beds are blocked by frail, elderly, blameless people who cannot otherwise be cared for. That is a failure in demand.

All around us, GP surgeries are closing, some of them permanently. I think 20 closed permanently in the county of Northamptonshire just last year. No one knows how many are being shut on a short-term basis because we cannot get the GPs to keep them open. It is a failure of demand when two or three weeks elapse before you can see your GP and when your chances of dying are 16% greater if you happen to be admitted to hospital over the weekend.

One of the problems with the NHS is that it is embedded in politics. That is not a new phenomenon: it was true when I was on the Front Bench doing my thing 25 years ago; it remains the case. Any chance to change the structure for the future has to deal with that political problem. Maybe a royal commission is the way forward, or something smaller, independent, with public consultation could lead the way. I can think of no place better than your Lordships’ House, which is full of expertise, common sense and vision, to lead the way to make it possible to engage the politicians who now lead us, on both sides of the House, to look at the possibility of a better future.

My Lords, I, too, thank my noble friend Lord Turnberg for securing this important and timely debate, and join in the welcome of the noble Baroness, Lady Watkins of Tavistock. It is good that we have another nurse in this House. In my memory it is the first time in some 16 years that we have had three nurses speak in quick succession in a debate. If anyone with any influence out there is listening, we need even more nurses in this place.

It goes without saying that unless we have a highly skilled and well-educated nurse force there are implications for the future of the health service. But now, without any consultation whatever with the Royal College of Nursing, the Royal College of Midwives or UNISON, we are hit with the Chancellor’s CSR announcement. It is the same sort of attitude that my noble friend Lord Winston referred to so far as the medical profession is concerned. There was no reference whatever to the nursing and midwifery professions about the changes to the pattern and funding of nurse education. That announcement has come out of the blue and provides that, from 2017, student nurses, midwives and others will have to pay their university tuition fees and that, at the same time, their bursaries will be scrapped. Thus will end free education for nurses and midwives. The justification is to allow more applicants to get into university—to allow more to get past the so-called cap on places. Listening to the Chancellor’s announcement, you would have thought that the dreaded cap was nothing whatever to do with the Treasury and the restrictions on funding for university places for student health professionals.

There are few, if any, graduate professions as ill rewarded as nursing, so I am not sure how the Chancellor thinks that his plans can work if potential nursing students are to be faced with what for many will be career-long indebtedness of perhaps up to £50,000, to be paid back immediately on qualification from a miserable starting salary of about £21,000. Quite clearly the Chancellor and the Department of Health have been seduced by the Council of Deans of Health and Universities UK because the whole plan seems to be more about income for universities and, at the same time, savings for the Government than it ever has to do with workforce planning and the alleged possibility of more university places.

In a Written Answer to me the Government admitted that they do not collect data on how many student nurses leave university because of financial reasons, yet they now pray in aid the fact that there will be more money available from loans, as if the bursary system was a primary retention problem. To look at the figures, if the present percentages at universities are replicated, then many of the 10,000 so-called extra places will go to increasing numbers of midwifery and other health profession students. It will leave probably 6,000 extra places for nurses—2,000 per annum. Unless my maths is badly wrong, we will potentially have some 22,000 nursing students per year. That is the better part of nearly 3,000 fewer places than we had under Tony Blair’s Government of some 10 years ago. As with so much, we had the numbers right then, and we need to get back to that Labour figure if we are serious about tackling nurse staffing in the NHS.

Very close to home, a member of my family who has a number of degrees, is a skilled practice educator and teaches at university from time to time was until very recently still paid as a staff nurse. That is not a reward for 30 years’ continuous practice and education that will encourage nurses to take on a huge debt to come into our profession. With the greatest respect to the Minister, for whom I have the highest regard, we have either to start to pay nurses properly for their duties and responsibilities or else we have to do a quick U-turn if we are to get more students into university. We have to look carefully at what we are doing here and we have to work with those who represent the nursing and midwifery professions, which at the moment the Government have manifestly failed to do.

My Lords, this is a very important debate and I wish there were more time for it to be conducted. I thank the noble Lord who initiated it. However, we are living in a fairyland in which we are talking about further improvements in the NHS, most notably a 24/7 service, at a time when the existing structure is under the most desperate threat. As we all know, another £200 million is to be cut from preventive measures but no one has so far mentioned the £22 billion of savings that the NHS is supposed to find through productivity agreements over the next five years. The ideal that we all share of bringing together social care and the NHS is largely vitiated by the Treasury’s inclination to continually cut local authority spending at a time when we are talking about improvements in, for example, preventive measures. That shows we are still denying the harsh facts in front of us.

It will be a great advance if we can even keep the NHS together for another couple of years. The noble Lord, Lord Winston, rightly said that it is being preserved at present through the extraordinary dedication and commitment of its badly paid staff, whose work is inadequately recognised. We owe them a great deal for keeping the NHS going but we simply cannot continue to think that we do not have to address the central issue of steady, consistent and adequate funding. We are nowhere near doing that.

In listening to the comments of the noble Lord, Lord Fowler, I remembered the very detailed study of the Barker commission published in October 2014, which was drawn up with the aid of the King’s Fund but has still not been discussed in this House or anywhere. It proposed that spending on health and social care should reach a figure of between 11% to 12% of GDP by 2025. We are still not discussing that proposal and still pretending that it does not exist. The noble Lord, Lord Fowler, rightly mentioned two difficulties. First, can a royal commission provide an adequate response within a year, or even less, because it is crucial that it does? Secondly, it is absolutely essential that any measures adopted are supported by all parties. We have to have an all-party response for which we all bear responsibility and we must not invent new ways to spend money that we do not have. If I may say so, in the noble Lord, Lord Prior, we have the kind of person who can go to the Treasury and say, “It is no good taking away with one hand what you give with the other because that simply leads to extreme frustration and even to desperation”.

We need a royal commission that conducts its business much more rapidly than is usually the case. We also need to debate the Barker report. However, we must recognise that, more than anything else, we need sustainable, steady and consistent funding, including funding drawn from taxation, because without that we will not be able to save the NHS.

My Lords, except to congratulate the noble Baroness, Lady Watkins of Tavistock, on her excellent maiden speech, our restricted time means that I will skip the usual niceties and nuances and concentrate on the absence of a credible funding system.

We are in the middle of a decade when we expect the NHS to cope with substantially increased demand and service expectations on an annual budget increase of roughly 1% a year in real terms for 10 years. Before this decade, successive Governments provided the NHS with a real-terms annual increase averaging 3% to 4%. It is virtually impossible, I suggest, to retain a good-quality labour force, meet rising demands, improve quality, and redesign service delivery on a 1% annual real-terms increase for a whole decade, ending up with 7% of GDP, roughly, being spent on our NHS.

By 2020, the combined health and care system will face a funding gap, I would suggest, of some £35 billion a year, with the 2015 spending review closing that gap, on the most favourable interpretation, by about £10 billion. The rest of the money comes from our old friends: pay restraint, new ways of working, and better productivity. I accept that the NHS could use its existing resources much better but, even if the NHS delivered all the proposals of the noble Lord, Lord Carter of Coles—a very big “if”—it would not close the funding gap. The 2015 spending review totally fails to deliver a credible funding strategy and actually makes a bad situation worse by failing to provide any kind of viable funding system for publicly funded adult social care or public health. The NHS and social care are confronted not with a managerial or professional failure but with a failure by politicians across the political spectrum to engage with the public on how we fund a sustainable, integrated health and social care system over the longer term.

To have good-quality and readily accessible health and care services, largely free at the point of clinical need, the public have to be helped to understand that they must pay for them, whether through more taxation, some form of co-payment, or a combination of the two. To get to grips with this rather politically unpalatable truth, we need an authoritative, independent inquiry that will work quickly to examine the possible options for new funding streams to provide some buoyancy and future-proofing. The Front Benches in both Houses need to get behind the ideas of either the noble Lord, Lord Fowler, or the Liberal Democrats, outlined by Norman Lamb in his 10-minute rule Bill. We need to start acting now to future-proof the NHS’s funding.

My Lords, I congratulate my noble friend Lord Turnberg on obtaining this timely and wide-ranging debate. I declare my health interests as shown in the register. I will concentrate my short contribution on mental health, which I believe has never been higher on the public’s agenda.

The NHS currently spends only about 13% of its budget on mental health treatment and support, including GP time, prescriptions and secondary mental health services. However, evidence from prevalence surveys shows that only 25% of people, including children, with common mental health problems receive any treatment. There has been a great deal of talk in recent years of parity of esteem between physical and mental health and I welcome recent announcements of additional funding for mental health services, but the funding gap is still huge.

The King’s Fund and the Centre for Mental Health identified that a third of people with long-term physical conditions—4.6 million people in England—have a co-morbid mental health problem, most commonly depression and anxiety. The cost of care for this group is 45% extra and more still for those with multiple conditions. This adds up to an additional cost of £10 billion nationally each year. The extra costs are for a variety of reasons, including poorer self-care and condition management. This can increase the cost of prescriptions, cause or lengthen the hospital admissions and dramatically increase both morbidity and mortality.

At least £1 billion more is spent on the cost of staff mental health in the NHS, at least half of which is likely to be hidden, as staff present at work but may be struggling to do their jobs as well as they would wish. A significant part of the £14 billion cost of untreated mental health care could be saved while offering better healthcare. For example, liaison psychiatry in acute hospitals has been found to save £3 to £4 for every £1 invested, cutting costs by an average of £5 million per hospital.

Crucially, earlier intervention is vital in all areas of mental health care. There is clear evidence that investing in perinatal mental health care, parenting programmes to help families to manage children’s behaviour, treating childhood depression, anxiety and conduct disorder, promoting mental health in schools and early intervention in psychosis all generate savings far in excess of their costs.

I hope that the Government will also invest in liaison and diversion services and that the Treasury will shortly approve the business case for mainstream funding of these services. Huge savings can be made here in the criminal justice system and the health service. By investing wisely in mental health support, the NHS may be better able to sustain itself. Reaching out to people with physical conditions and symptoms whose mental health needs are unmet will improve health at a lower cost. I hope that such integrated proposals will be pursued by the devolution of health and social care in Greater Manchester, building on the work of Salford that my noble friend Lord Turnberg so well described.

My Lords, I am glad to congratulate the noble Baroness, Lady Watkins, on her maiden speech. Due to the pressure on time, I want to focus on one very small area, which has been alluded to by various noble Lords but which I want to develop a little. It is the pressing and vital need to reboot the concept of a social contract, which lay at the heart of the national health system as envisaged by Beveridge and which balanced rights and responsibilities, not least against the background of living in a time when people have increasingly emphasised rights and perhaps downplayed the sense of duty and responsibility.

In 2013, PricewaterhouseCoopers produced a report on the 65th anniversary of the NHS, which identified two key factors that would be essential for the future of the NHS. One of them was the extent to which people took personal responsibility for their own health and care, and that of their families. Then last year, when the independent research published by the Commonwealth Foundation revealed the UK’s health system to be at the top of the league among nations in the developed world, the one area where we did not score highly was in the prevention of illness. That report highlighted the particular problem of large numbers of people in this country with unhealthy lifestyles.

It is deeply concerning that so many illnesses are caused by addictions to alcohol and smoking, while we have the highest rate of child and adult obesity in Europe. Estimates of their cost vary but just those three areas could well be costing as much as £17 billion per annum. To address these issues requires a deep cultural change across our nation, along with a renewed emphasis on personal responsibility for our health and for exercise, for people of all ages. But of course these sorts of changes are some of the hardest to make. The need for a new social contract between citizens and the NHS is urgent, with a much greater emphasis on what we need to do in response to what the NHS provides. Indeed, this message needs to be reinforced every time anyone comes in contact with the NHS.

While laws and taxation have a contributory factor, we need to create a climate which celebrates health and people taking responsibility for it, for them and their families. There is a great deal of evidence that one of the most powerful factors in bringing about such behavioural change is the influence of peer groups. We need to work consistently with health campaigns, sports and leisure clubs, statutory and voluntary youth and children’s groups, schools, colleges, churches and everybody from the Mothers’ Union to the WI and the University of the Third Age to think how we can celebrate the need for personal responsibility. It needs to be undertaken over the long term; we are talking in terms of decades. If we are to see significant change then the evidence of the campaign to reduce smoking, which has halved since the 1970s, shows that it can be done but will take time and consistency.

My Lords, I declare my interest as a now fully retired dental surgeon with over 40 years’ experience and a fellow of the British Dental Association.

All too often when we speak about our health system, oral health is conspicuously absent from the debate, and this morning is no exception so far. Both the Government and Opposition seem united in seeing a more integrated approach to delivering health and social care services as the key to ensuring the future sustainability of the NHS. It is essential that dentistry is factored in and included in any wider health strategies, and that the interplay between oral health and general health, and dentistry budgets and other NHS budgets, features in any discussions on healthcare provision.

An excellent report published by the Faculty of Dental Surgery reveals how much further we need to go in our fight against tooth decay. A third of five year-olds in England are still suffering from caries, and within that group the average child has at least three teeth affected. It is simply shocking that in this day and age tooth decay—an entirely preventable condition—continues to be the most common cause of hospital admissions among five to nine year-olds, with 500 primary school-age children requiring hospital treatment every week. This not only causes the children and their parents unnecessary stress and pain but is also a complete waste of NHS resources, costing the taxpayer over £30 million a year.

A fifth of five year-olds eligible for school meals have severe or extensive tooth decay, compared with just one in 10 among those from more privileged backgrounds. The situation is particularly alarming considering that approximately 90% of dental problems are preventable and the damage they cause is cumulative and costly. We must also raise awareness of the risks of tooth decay, especially of the impact of sugar consumption on children’s teeth. I fully agree with the BDA that no option should be left off the table in the efforts to end Britain’s addiction to sugar. Possible measures range from lowering the recommended daily allowance, through action on marketing and labelling, to possible sales taxes.

I also urge the Minister to consider investing in a national oral health programme to drive improvements in children’s oral health in England, following and learning from the success of such programmes in Scotland and Wales. I once again urge the Government to consider the overwhelming worldwide scientific evidence which clearly points to fluoridation being a safe and effective way to fight caries and narrow the significant inequalities in children’s oral health across the country, and to encourage local authorities that do not yet use this resource to introduce water fluoridation schemes.Noble Lords will all agree with me that a shift in focus from treatment to prevention is crucial if we are to ensure the NHS will be able to face the challenges of the future. This statement is as true in the area of dentistry as it is elsewhere in our health system.

My time is up. I was going to say a few things about oral cancer and the importance of the dental team in the new tobacco control strategy, and was going to bring your Lordships good news of a dental treatment that does not involve drilling.

My Lords, I thank my noble friend Lord Turnberg for securing this debate and declare my interest as an engineer and chairman of the Warwick Manufacturing Group at the University of Warwick. I also run the Institute of Digital Healthcare jointly with the medical school.

Two years ago, I was treated for pneumonia at the Queen Elizabeth Hospital Birmingham, a fantastic new hospital led by an outstanding former nurse, Dame Julie Moore. The care I received was immaculate, and I understood then why the NHS is sometimes called our other national religion. However, I see it as our national science. After all, it is the subject of many experiments and is constantly being tested.

One current test is higher care standards, which requires more medical staff on wards. As a result, agency staff costs have soared. Monitor expects the bill to be over £4 billion this year, blaming a fundamental mismatch between supply and demand for medical staff. A lot of companies have made very good profit exploiting this, and it is rather ironic that Ministers are now proposing a cap on rising bills as the answer. The truth is that, whether in energy or agencies, price caps are a short-term fix. The solution is to increase supply.

Several medical schools, including Warwick, offer four-year medical degrees for graduate entrants. Such graduates do very well both academically and in their career. Warwick graduates are currently second only to Cambridge medics in gaining specialty training places. Shorter courses also mean qualified students can contribute to the NHS earlier. Four-year graduate entry degrees broaden access, attract quality applicants and give faster returns on public spending. It would be ludicrous to close such programmes. Yet medical schools could be forced to do so, as EU legislation demands that medical qualification takes five years. Currently, the fifth year for graduate entrants is the first-year foundation programme. During this time, graduates are provisionally supervised under the GMC before full registration as an independent practitioner is granted.

However, after the Greenaway review, the Government proposed merging degree graduation and full registration. This would unintentionally make four-year courses impossible, as removing the year under provisional registration would leave graduate entry courses short of the EU demand for five years’ training. To resolve this, graduate entrants could continue to do their first foundation year under provisional registration, and I understand the GMC may favour such a solution. We must innovate to attract outstanding medical students, then get them working as soon as we can. To achieve this, I urge the Government to pledge that future graduate entrants will retain the option of a four-year medical degree.

My Lords, I also thank the noble Lord, Lord Turnberg, for this important debate. I have my own recent family reasons for having the deepest gratitude to wonderful NHS staff, who deploy life-saving skills. I also have a niece who is a junior doctor.

However, I want to concentrate on diabetes. There is huge potential—it is a no-brainer—to spend more wisely. Four million people live with diabetes, and they cost the NHS £10 billion a year—£1 million an hour—which is 1/10th of its budget. The total cost to individuals and society is £24 billion and rising fast. My particular focus is on those who are insulin-injecting, predominantly with type 1 diabetes. I have some, albeit second-hand, experience of this, having been with my husband for the 40-odd years since he was diagnosed. The NHS has never included me or learnt from me; for example, when it comes to coping with hypos. I should mention that my husband already has access to the technology I will refer to, that he is chairman of a health trust and that he was, for several years, chairman of the UK branch of the Juvenile Diabetes Research Foundation.

NHS England’s Five Year Forward View last summer referred to diabetes only as a preventable illness resulting from,

“the nation’s waistline … piling on the pounds”.

This completely ignored and insulted those with type 1, whose diabetes is not caused by obesity. As well as the integration of services, I urge an “invest to save” approach to both research and care. Around 400,000 people have type 1 and although they account for only one in 10 of those with diabetes, they consume, on some estimates, half of the £10 billion that diabetes costs the NHS annually. As much as 80% of the cost of treating people with type 1 is spent on avoidable complications. Two reports from the National Audit Office, and one from the Public Accounts Committee of the other place—a second is in progress—have been scathing about NHS care failures.

How do you invest to save? First, you do it in research. The glittering prize is a cure. JDRF and the researchers it funds do excellent work, but the UK Government spend only £6.5 million a year—10p per head of population—on diabetes research, backed up of course by crucial EU funding that Brexit could put at risk. This spending is puny and inexplicable.

Secondly, you invest to save in devices for self-management. The key to keeping type 1 diabetics well and avoiding debilitating and expensive complications of organ damage is good blood glucose control through self-management. Insulin pumps and continuous glucose monitors have proven benefits in the management of type 1 diabetes, and NICE guidance attests to their cost-effectiveness. Testing without finger pricks now exists, and NICE needs to look positively at this. Yet only 7% of people with type 1 in the UK have a pump, compared to 15% in Germany and 40% in the US. Only 1% or 2%, mostly self-funded, have a CGM.

I conclude by saying that spending to save on diabetes is an easy win; there is no excuse not to do it.

My Lords, there are some excellent specialist units doing exceptionally high-quality work with good leadership and splendid teams of skilled staff which are world-class, and patients are grateful for their correct diagnoses and care, but there are also hospitals which have inadequate equipment, lack of staff and leadership and poor morale. Patients are often misdiagnosed and have a poor standard of care, causing concern and lifelong problems. There should always be good communication, honesty and transparency. Patients should feel safe and have faith in those people looking after them.

The big question is how this can be achieved across the country when demands are growing and we have to rely so much on staff from other countries. It is refreshing when one finds keen, enthusiastic doctors who love their job. The present situation with dissatisfied junior doctors is very concerning. A satisfactory solution must be found.

Patients who have had an operation and are in need of rest and recuperation should not be subject to a noisy and stressful environment. They need a well-organised, peaceful ward with a responsible sister in charge, so many people say, “Bring back matron”. Many people across the UK are anxious about the money spent on agency staff, who cost a monumental amount of funds and may not have the necessary commitment. This situation is milking the NHS.

It is vital that infection control is treated as a priority in the NHS. It will come to the fore as antimicrobial resistance comes to dominate acute hospital care. The UK had the global lead in infection control, appointing the first specialist infection control nurses. If they suffer cuts, it will be a disaster.

Worldwide, the lives of billions of people are affected by zoonosis, diseases transmitted from animals to humans. This is an immense public health problem. Bush meat, which is meat that comes from wild animals captured in developing regions of the world such as Africa, was the origin of HIV and Ebola. Thousands of tonnes of bush meat are coming into the UK each year. It is illegal to bring bush meat into the United States of America; it is very strict. Should we not do likewise? One never knows what dreadful diseases are around the corner.

My Lords, I, too, thank my noble friend Lord Turnberg for securing this debate and congratulate the noble Baroness, Lady Watkins, on her excellent maiden speech. I also declare my interests as being those on the register.

We have heard that the public value the NHS so greatly, and we know from the Commonwealth Fund studies that we rank very highly in healthcare systems in the world, yet something is clearly wrong. We need to address the question of funding, but in this brief speech I should like to focus much more on what we need to do now in the short term to equip the Minister to go back to have those necessary arguments with the Treasury to secure the correct level of funding.

The interesting thing is that we have a great system. Somebody said the other day that we have done everything right once. What we have failed to do is build on the great experience that we have built up in a number of areas. If we look at quality or use of resources, we see unwarranted variances right across the system. The noble Lord, Lord Lansley, asked about procurement. The fact is that in some hospitals we are sometimes paying double and using twice as many staff to get the same outcomes. We need to work on a national system which delivers consistency, not only in quality through the CQC but in the new arrangements that are being put in place through the NHS improvement agency, to make sure that everyone is doing the same thing right. We have not learnt from the great achievements that we have in many places in the system.

The second area is one on which many people have spoken: the whole question of the right care in the right place, the flow through the hospitals—people call it workflow in industrial situations and increasingly in healthcare. One big thing that has emerged from the speeches of other noble Lords is the whole question of discharge from acute hospitals. There are 130,000 acute hospital places in England, and probably 10% of them are blocked, so 13,000 beds are being used inappropriately.

The third point is collaboration. Others have talked about integrated care. Salford is a wonderful example. Northumbria proves what we can do: integrated acute, community and social care. We know how to do all this; we do not need to look to consultants to tell us. The NHS knows that what we have to do is organise to deliver it. Critical to that will be the 1.4 million people who work in the NHS. I think it is equalled only by the Chinese army and Indian railways in size of workforce—and possibly Walmart. I suggest that the other three have a high degree of leadership. We probably need to get away from leadership by bullying to leadership by leadership, so that the system can actually deliver.

I repeat that we need to equip the noble Lord, Lord Prior, to go back with those right arguments. Those of your Lordships who read the Guardian on Monday may have noted Matthew D’Ancona’s little piece. I end with this quotation:

“The custodian of the NHS”—

we are all custodians, I suggest—

“who truly seeks to safeguard its future must fight for internal efficiency, restless reform and the changing needs of patients, as well as for extra cash”.

My Lords, this debate is about present and future demand and how we best manage it. In doing so, we need to include all rare disease, not just the big killers. Individual rare diseases may not kill many, but collectively they are a significant part of the disease burden.

Mesothelioma is such a disease. In the recent mesothelioma debate, the Government confirmed that 60,000 are expected to die from that terrible disease over the next 10 years. An international comparison by the Eurocare group shows that the UK survival rate at one year is 36%. Sweden’s is 46%. In other words, one in 10 patients more dies here than in Sweden, or 6,000 lives over the next 10 years. The disease is identical and the treatments identical. This is therefore a matter of care quality management.

We see this pattern across cancer. The British Journal of Cancer published the latest international performance assessment. Here is a sample of the one-year survival rates for 2005 to 2009. In lung: Sweden 41%, England 31%. In colon: Sweden 82%, England 73%. In ovarian, Sweden 79%, England 64%. This sounds remarkably like the England football team’s latest performance against Sweden. Perhaps, as in football, we should turn to Sweden for management advice.

Sweden has driven improvements in its service not by chucking more money at the problem but in the way it manages the service. Hospital quality is published at a granular level, not some meaningless general level. Patients with a specific disease know which hospitals to avoid. Some of your Lordships will recall the Colchester cancer scandal. What did not come out in the media at the time is that the East of England Cancer Registry foresaw such an issue many years before in research showing that smaller centres had worse outcomes than larger ones. They may still do, but who is to know without the data?

Yesterday I tabled a number of Written Questions for the Minister on the data that the Minister already has in the National Cancer Intelligence Network in Public Health England, which could help patients to get better care if it was published, such as cancer-specific hospital performance data. I am sure that the Minister would agree that these are important issues, and that the reasons they are not being published should be investigated. Once these investigations have happened, will the Minister agree to meet me—I would be grateful if the Minister could reply on this point in his wind-up—to see how these results could be put into the public domain? I believe that these figures are an important component in seeing improvements in cancer care.

My Lords, I thank my noble friend Lord Turnberg for initiating this debate and congratulate the noble Baroness, Lady Watkins, on her wonderful maiden speech.

It is quite a while since I have spoken on health or social care matters, but I am fearful for the future. The ingredients of broken promises on social care funding, inadequate funding of the National Health Service, increasing demand and creeping privatisation mean that the pressure cooker may one day explode. The Government seek to avoid blame by making doctors and nurses subsidise our health provision, and finding a scapegoat in local government for the failures of social care. Student nurses are paying for their own training and working for nothing in the NHS for half their time; their pay has been capped and they are paying for their lodgings; safe staffing ratios have been scrapped; and nurses are doing even more outside work for the privilege of working up to 70 hours a week. That does not create a positive climate for the future.

The Government need to take a step back on the junior doctors dispute, which has been badly handled. The overwhelming vote of 98% on a 76% turnout is not just a problem for the Government; it places an enormous responsibility on the doctors’ leaders, because any settlement is going to look like a comparatively poor deal. It is important to allow ACAS to get on with its job. I read a very moving letter in the paper from the father of a junior doctor, who said of his son:

“He regularly works weekends and nights, and spends much of his ‘free’ time adjusting his sleep patterns. He almost always works between one and three hours extra daily because of understaffing … His social life is almost nonexistent due to exhaustion and antisocial hours”.

All that is on a basic pay of £28,000 a year, and he is paying for his own insurance fees as well as very expensive examinations.

Finally, the recent hasty announcement to devolve health budgets to five London boroughs is not genuine devolution. It is more like being persuaded into a life raft only to find the substantial figure of Boris Johnson jumping in at the last minute. Apparently, he is going to oversee the process—clearly, part of the “Keep Boris Busy” campaign. The massive funding gap for social care will be slightly narrowed at the expense of healthcare, and the London boroughs will take the flak. These piecemeal experiments will lead to more complex structures, more contracting out and huge dividends for management consultants, who will hope to increase their £600 million a year income. The losers will be patients and the elderly. I really am fearful for the future of the NHS.

My Lords, the National Health Service is facing its most serious financial crisis since its birth. The Health Foundation estimates that there will be a £6 billion funding gap by 2020, which I suspect is likely to be an underestimate, given the growing number of hospitals unable to stay within their budget.

I very much support the proposal of the noble Lord, Lord Fowler, supported by others, too, for a royal commission, but if there is no royal commission there should be strong support for Norman Lamb’s proposal, supported by two former Secretaries of State for Health, Conservative and Labour, for a powerful independent commission. One of its recommendations should be to fund health and social care through a specially earmarked, hypothecated tax. The Treasury hates hypothecated taxes. I believe that I am the only former Treasury Minister speaking in this debate, although that was a long time ago, when Roy Jenkins was Chancellor. But the health service is a very special case; its need for funds is greater and grows faster than almost any other public service, and much faster than GDP. At the same time, it is Britain’s most cherished institution. People would be prepared much more readily to pay for its needs than through general taxation if there were a special tax for the health service. The obvious special tax would be a reformed, progressive system of national insurance contributions, which in their present form have neither rhyme nor reason and should either become part of income tax or, much better, finance a special NHS fund.

I have one final, more general point. The needs of the National Health Service are, perhaps, one of the clearest illustrations of why we should reject the Government’s strategy on making us a low-tax, low-spending country, with public spending reduced to 36% of GDP, the lowest in the major countries of the European Union. Health and social spending are already the lowest. Low tax and low public spending societies are the most unequal and dysfunctional; they lower the quality of life of their citizens in numerous ways, as convincingly argued in that seminal book, The Spirit Level, and in Joseph Stiglitz’s splendid volume, The Price of Inequality. One of the main tasks of opposition parties in this Parliament should be to expose the dire consequences for our society of the Government’s declared central aim to shrink the state. One of its most notable casualties would be the National Health Service.

My Lords, in the time I have today, I am going to concentrate on a very specific area, that of wheelchair services. I declare an interest as chair of the National Wheelchair Leadership Alliance, which was set up after NHS England supported two national summits, and a huge weight of academic evidence and case studies offered a compelling case of why action was needed. A 10-point charter was developed which received significant support from the public, Members of both Houses, CCGs, the industry, wheelchair services and charities, to name a few.

It is simply not understood how important the right chair is. In our campaign, I sat in a wheelbarrow. I am not proposing this as a cheap solution to wheelchair services, but in a few minutes it became very painful and it provided a shocking image. We chose a wheelbarrow because it may have a seat, wheels and handles but it does not give independence. That is what the wrong chair means.

During this work, we have seen some dreadful cases, including long waiting times and people dying before they received their equipment. No one is trying to do a bad job—quite the contrary—but it is a Cinderella service and a complete postcode lottery. A cushion can cost £250, while a pressure ulcer from the wrong cushion can cost £100,000 to fix.

The mandate consultation came at a perfect time, and I am delighted that we merited mention in the response. I understand that the mandate is a strategic document and is not meant to be prescriptive, but the response dismisses a focus on individual services. This contradicts the Government’s aim for integrated healthcare, because wheelchair services may be a single service but the outcomes have an impact on every government department. Because of having the wrong chair or not having a chair, children are missing school and people are missing work; it is costing the NHS significant amounts of money through injury and harm. If disabled people cannot get to work, how can Her Majesty’s Government hope to halve the employment gap for disabled people? One person told me that through access to work she would have five-sevenths of her specialised chair funded, but she had to leave it at work at the weekends because it was not for personal use. That is totally ludicrous—how could she get to work in the first place?

I know we have limited time, but I have a few questions for the Minister. Will he elaborate on whether further work has been done on the cost-benefit of providing the right wheelchair? Will he provide an update on the work of NHS England’s data dive and tariff, which is very welcome and crucial to moving this debate forward? Will he confirm that the number of responses to the mandate consultation in this area was among the highest received? Why have the wider benefits of providing the right wheelchair not been taken into consideration? I am not asking for more money; I am just asking for a genuinely integrated approach. Finally, as we are limited for time, can I meet the Minister, as this has been a problem for 30 years and affects millions of people?

My Lords, we are tight on time. May I give a further reminder that in the final stages of this debate, Back-Bench speeches should be concluded when three minutes first appears on the clock?

My Lords, I, too, thank the noble Lord, Lord Turnberg, for bringing this debate to the House. There are demands on our health service, and it is clear that a rapidly ageing society puts great pressure on our NHS in many different ways. My contribution to this debate will focus on local efforts to support these services.

As noble Lords will be aware, responsibility for public health now rests with local authorities, and that is working well. Councils now play a pivotal role in looking at what can be done to care for people in their own community. Integrated care is essential to meet the needs of the ageing population, to transform the way that care is provided for people with long-term conditions and to enable people with complex needs to live healthy, fulfilling and independent lives.

Locally we are delivering the better care fund programme to ensure a transformation in integrated health and social care. For example, in North Lincolnshire, we have joint senior management at clinical commissioning group and local authority level. We recognise that an enhanced out-of-hospital model, enabling health and social care professionals to provide more joined-up services closer to people’s homes and communities, should form the basis of any system-wide model of care. We connect local areas to local GP practices to offer new ways of working with social care, community healthcare, mental health services, voluntary and community organisations and other key stakeholders. We have local teams to enhance existing community services and have already delivered, as I have mentioned before in the House, five well-being hubs, which are fully operational, and are currently developing satellite hubs. These hubs target the most vulnerable people and provide interventions on a one-to-one basis. They actively work with hospital teams to create support links for service users admitted to hospital, helping with discharge. We are also looking at ways to work differently with the intermediate care services. We engage with users to make sure they have the confidence to access services and work, in order to reduce any delays in processing care which could damage that confidence. We are also piloting the healthy and active passport, which will give citizens access to services and schemes aimed at improving health and well-being.

We simply cannot ignore the impact of an ageing population and the pressures it puts on healthcare, both local and national. The current efforts to address projected pressures offer a way to a brighter future for older and vulnerable people, and I welcome the Government’s initiatives to support local areas. They are fundamentally about moving away from a sickness service and towards a system that enables people to live independent and healthy lives in their own communities. We must create wellness, not just treat illness. Through hard work, imagination, commitment, and not working in silos but together, we can meet head on the challenges presented by our increasingly elderly population and aspire to make this country the best to grow old in.

My Lords, I, too, am grateful to the noble Lord, Lord Turnberg, for promoting this debate. I am also grateful to the NHS for keeping me alive when I had cancer, and for the maiden speech of the noble Baroness, Lady Watkins. I look forward to hearing more from her in future.

I shall quickly say something on personal responsibility, public health policy and corporate social responsibility, which I do not think has been touched on so far. On personal responsibility, as leaders, we have to be much more courageous, honest and open about the need for individuals to understand and accept that they are ultimately personally responsible for the state of their health. We need stronger campaigning. As was proved by the noble Lord, Lord Fowler, when he dealt with AIDS, if people are willing to be honest, open and courageous, we can carry all levels of the country, be they poor or rich. People need to be given many more facts about their lifestyles and the damage that arises from some of what they are eating and drinking. Those of us who use the health service should learn the cost of the services that are being provided. Each time I go to the health service, I should be told the cost of the medicines. If there is a combination of all that, we will start to raise awareness and knowledge and to create a different approach to personal responsibility. I will say no more on that because the right reverend Prelate the Bishop of St Albans more than fully covered it.

Linked to that is progress on policy on Public Health England. It is an outrage that £200 million has been chopped from its budget when we face so many problems with the increasing number of people going to the health service for treatment. Fortunately, it was one of the successes of the 2012 reorganisation, with its evidence-based recommendations on sugar taxes and alcohol abuse, for example. We need to co-ordinate policies at different levels to avoid the clash of one organisation trying to reduce alcohol, and the Chancellor then cutting taxes on alcohol last year, meaning that we now have more people drinking than before. We need to get the co-ordination of policy right. This is being addressed by Public Health England.

Deep down, most politicians believe that what they are saying is correct and that they need to take action, but regrettably, we too frequently run away from putting such things into practice. We have too many knee-jerk reactions, such as we had from the Prime Minister on the question of a sugar tax.

In the light of our experience with the responsibility deal, there needs to be a radical review of people’s relationship with the private sector. Retailers, especially supermarkets, food and drink manufacturers, producers and distributors need to accept that they have greater social responsibility than they have been prepared to accept so far for some of the health-related problems in this country. They have to face up to the fact that they need to embrace that change in culture and accept more responsibility for those problems. The Government have failed to achieve real progress with them on a voluntary basis. They should be faced with legislation if they will not move.

My Lords, I draw the attention of the House to my entry in the Register of Lords’ Interests. Last autumn, the Chancellor secured some good headlines by promising an extra £10 billion in real terms for NHS England by 2020, representing an annual increase in NHS spending of 1.75%. But beneath those headlines, NHS cost and demand rises by 3.5% to 4% a year. When trying to explain the problems of the rising cost of pensions and healthcare, I often begin by saying that when I was at school, 40 years ago, male life expectancy was just 67. A man approaching retirement then might well have worked and paid taxes since he was 15. After 50 years of contributions, he would retire at 65 with a pension and the health service would have to provide for him and look after him for just two years. A man who retires this year at 65 will probably live another 20 years. His state pension will have to be paid for from general taxation for 20 years, not two years, and towards the end of his life there will be, on average, a period of eight years when he will be in poor health and in need of greater health and social care support.

In providing for women and men like him, the NHS delivers good value for money compared to healthcare systems in other countries. We achieve a lot by spending just 8.5% of GDP on health compared to the OECD average of 8.9%, but our figure is due to fall to 7.8% by 2020.

If we want a better health service, we have to look at the fact that France, Germany and Holland all spend about 11% of GDP on health. We will certainly never match those levels if the Chancellor is to succeed in his aim, set out in the Autumn Statement, of reducing the overall level of government spending from about 41% of GDP to just 37%. It would, however, be a very brave politician who argued for more than a very modest increase in the basic rate of taxation, even though it is now 15p in the pound lower than in 1975-76, 10p in the pound lower than in 1979-80, 5p in the pound lower than in 1988-89 and 2p in the pound lower than in 2000-01. It may be politically unacceptable to reverse those income tax reductions, made for political advantage, but the time must have come for a hypothecated health and social care tax. I hope that this idea will be considered further by the cross-party commission being launched by Norman Lamb.

My Lords, as a professional economist—the only one speaking in this debate—I should say that any service that is free at the point of use will perpetually suffer from excess demand. The NHS is no different; more or less since its founding, it has faced a continuous demand for more money and the public fisc has been unable to quite meet it, so we have had a history in which it is perpetually in a funding crisis. At the same time, though, there is a great deal of satisfaction with the service, so we need to understand how it works.

We have to be careful about the fact that the percentage of GDP spent on health is not a good measure of outcomes; it is a measure of inputs. As someone has said, we have one of the best-ranked health services, despite not being the highest-spending nation. The highest-spending nation is probably the United States, which has a lousy health service.

Having said that, we need to make the user more aware of the costs of the service, as my noble friend Lord Brooke said. In many previous debates, I have suggested that every user of the NHS be given an annual return showing what they have used it for and how much that has notionally cost the NHS. They should be made aware that even if they miss an appointment it costs money. Whatever they have had, somewhere it has been paid for. They do not have to pay for it themselves, but they ought to be made aware that there is a cost to each thing that they do or indeed do not do. At the same time, we ought to provide people with another sheet of paper showing how the total NHS money is spent, just for information. People ought to understand what their money goes on. Right now they do not understand, and they take it for granted.

I shall say just one more thing because my time will be up very soon. We have made all sorts of predictions about what proportion of GDP should go on health. I can more or less tell the House, with all the certainty that I can command, that the era of high growth is over and that for the next 10 or 15 years the GDP growth rate will not be high, and nor is inflation. Whatever we do, we will have to find ingenious ways to achieve efficiency, perhaps by nudging users to be more economical with their use of the NHS, and somehow changing behaviour so that we do not always take for granted that there will be more money, and if there is not more money, it is someone’s fault. One of the last—no, I do not think I have any more time.

My Lords, I, too, thank the noble Lord, Lord Turnberg, for securing this debate. He and other noble Lords have spoken with much wisdom, expertise and experience. My only qualification in this area may be that I was a board member of the North West Thames Regional Health Authority, a member of the Solihull Family Practitioner Committee and a board member of SCAR, the Sickle Cell Anaemia Relief charity.

As a schoolboy, I attended a university open day as a precursor to studying for a medical degree. I recall that we had to walk through a laboratory where some experiments were being carried out on dead bodies donated for research. It is still vivid in my memory. I passed one corpse that had been drained of all body fluids and dissected lengthways, so that I was looking at a half-body. I recalled that in the Bible Lazarus had been raised from the dead, but I thought to myself, “But that Lazarus was not cut in half; this guy is going nowhere”. I decided at that point that medicine is a special calling, and perhaps it was not calling me. So I have every admiration for members of the medical profession. I just hope that the BMA and the Government can reach an agreement. With the prospect of two further doctors’ strikes, it is surely the patients who will suffer.

It is said that some 40% of diseases are related to lifestyle. Smoking and alcohol abuse are major problems. As the saying goes, Bacchus has drowned more men than Neptune. We need an effective national plan for preventable illness, otherwise the impact of lifestyle-related diseases and longer lifespans will put even greater strain on resources. This may have to be a part of an open, independent inquiry or commission charting the way forward, as the noble Lord, Lord Fowler, stated. It could include an international comparison of the way that other countries deal with these issues, especially the means of funding the service. The inquiry needs to examine a more holistic approach to health, involving health promotion, sickness prevention, mental illness and social care. We have excellent health foundations, such as the Nuffield Trust and the King’s Fund, that can help with this.

The third Gospel was written by Luke, who was a doctor of medicine, but, as a Greek, he was a non-Jew, a foreigner. I mention that to highlight the tremendous contribution made by ethnic minorities to our NHS. Some 37% of doctors and 27% of nurses are from black and minority ethnic backgrounds. In London, 40% of the NHS workforce are from BME communities.

In my student days, my idea of a balanced meal was a biscuit in each hand. Since then, I have had to learn the value of healthy nutrition and exercise. There is nothing permanent in life except change, and there has to be change in our approach to the NHS in order for it to meet its present and future demands. As John F Kennedy once said, our task now is not to fix the blame for the past but to fix the course for the future.

My Lords, I thank my noble friend Lord Turnberg for introducing this debate with great wisdom and erudition. While I entirely agree that the principle underlying the NHS is noble and widely acclaimed, in practice it leaves much to be desired.

Noble Lords have concentrated on funding and other things but I want to concentrate on the more elementary aspect of some of the practices that characterise the NHS. It is very striking, for example, that doctors are inundated with paperwork so that they have hardly any time to talk to their patients or spend much time with them. It is also striking that when a GP refers a patient to a consultant, the consultant’s letter does not arrive until about two or three weeks later, either because—so I am told—he does not have the typing facilities or because he would not use electronic devices to communicate with the GP. I cannot understand why this sort of thing should go on in this age.

As we have talked about our ageing population, it is worth bearing in mind that more and more of our people suffer from Alzheimer’s, dementia and other conditions. The result is that they forget to take many of the medications prescribed for them, or for some reason they take it earlier when they feel ill and stop when they begin to feel better. It may be a good idea to remind them in some way from time to time that they have forgotten to take their medication. I gather that some experiments are being done, and there is no reason why the NHS cannot be technologically more imaginative. Why can blister packs, for example, not be devised so that they warn patients at the appropriate time that they should be taking their medication? Or, for example, why should chemists not be able to monitor whether a particular medicine has been taken by a patient and, if necessary, ring them up and tell them they should be taking it? Therefore, technologically, we ought to be able to produce smarter and more sophisticated packages of medication than we do.

My third point has to do with some of the infrastructure of our surgeries, some of which are located in old terraced houses. Doctors would love to provide all kinds of services but they are unable to do so because of the cramped environment in which they have to function. I cannot see why local authorities and other bodies cannot provide purpose-built medical facilities where GP services can be housed. This would mean that GPs could provide the kind of services they would like to and patients would not be cramped and would feel much more comfortable.

My last point has to do with the way the Government have treated junior doctors. Doctors remain our main asset, and if they are alienated and feel resentful they may leave in large numbers, which would be no credit to our society.

My Lords, I will begin by making an appeal to those who arrange these matters in this House. A three-minute time limit in a debate such as this is absurd, and it is certainly absurd to allow a maiden speaker—we heard a very good one this morning—only three minutes. When times are allocated, a little could be taken off the Front-Benchers to give a little more for a maiden speech. I also endorse the plea made by my noble friend Lord Lansley for a proper annual debate—I do not refer to the Queen’s Speech—on the National Health Service.

Time allows me to make just two points. The National Health Service may indeed be the best in the world. If it is, that is because it is the creation of all political parties, and it is very wrong for any politician to seek to make a political football out of it. Your Lordships’ House sets a much better example than the other place when it comes to debating the NHS.

My second point is very simple. My noble friend Lord Fowler made an eloquent plea for a royal commission. I was privileged to take part in a debate that was instituted by the noble Lord, Lord Turnberg, just over a year ago, when I made for the third time a plea for a commission or an inquiry. I repeat that plea again today and endorse what my noble friend Lord Fowler said. It is important not only that we take the NHS out of the party political arena but, as the noble Baroness, Lady Williams, said in her excellent speech, we have to look to the future because the health service is in crisis. A sticking plaster is not the solution. To lurch from one financial crisis to another does not only the NHS but the whole nation a disservice in the process. As I have said before, we must have a plurality of funding. Whether that comes from taxation—hypothecated or not—compulsory insurance, extra charges such as penalties for those who do not keep appointments or from a combination of all three, we must have a plurality of funding and take away this continual crisis.

We are all beneficiaries of the National Health Service and we will all depend on it in the future. I therefore urge the Minister to give some indication that he has sympathy for the idea of a commission and, at the very least, I should like some sympathy for my noble friend Lord Mawhinney’s plea for a body to be set up in this House, where there is a greater accumulation of expertise on this subject than anywhere else in the country.

My Lords, like the noble Baroness, Lady Ludford, I too will concentrate on diabetes, which absorbs 10% of the national budget—some £10 billion—which will inevitably grow as we move from the current figure of 3.5 million diabetics to some 5 million in 2025. We have epidemics of type 1 and type 2 diabetes. I report from the front; as a high-risk foot person with diabetes I attend a monthly podiatric clinic. Those lists are now being slimmed, including for diabetics. The clinic tells me that it is as worried as anything because future problems, which inevitably arise from diabetics with poor feet, will not be identified. Similarly, I stand here today because I benefit from the shoes that are made for me in Liverpool to protect my feet because of the neuropathy I have—I have no feeling in my feet. That enables me to stand here today and enables other people to be economically active. We must not contract these services, as is now happening, with delays falling upon delays.

Diabetes UK has identified that four out of 10 diabetics do not get the necessary care processes. It has identified that some 135 amputations as a result of diabetes take place every week, when four out of five of those amputations are preventable. What are the Government doing about that startling statistic? The Diabetes Think Tank also recognises that 95% of diabetic care is self-administered, and we should concentrate on this area. However, in January two years ago for some reason the Government gave up the Patient Experience of Diabetes Services survey, which had been so useful in analysing what diabetics felt about the services they received. I therefore invite the Minister, as I did when he first came in, to attend the Diabetes Think Tank, and I hope that he will be able to attend it. I commend what my noble friend Lord Turnberg said in introducing this debate, that there are enormous opportunities in sharing best practice with our colleagues within the European Union which we are about to neglect.

I finish on an optimistic note. When I was declared a diabetic in 1969, they said, “You’ll get a medal after 40 years if you survive that period”. I can now report that I have long been past the 40-year mark, but an 88 year-old type 1 diabetic has recently received the HG Wells medal—he was a diabetic—for surviving for 80 years.

My Lords, like other noble Lords I thank the noble Lord, Lord Turnberg, for securing this debate and for the wise speech which he gave in introduction. I will address one issue only: the cost to the NHS of litigation arising out of cases of alleged medical negligence. Of course this is not a new problem. For at least five years, those who seek to join the UK Register of Expert Witnesses have been told that alternative dispute resolution—ADR—is becoming an increasingly important adjunct to litigation, and in significant parts of the UK this idea has taken grip. None the less, it is hard to believe today that all opportunities for early resolution are being taken in the NHS. There are still cases on treatment issues that may have lasted over decades, which involve hundreds of documents that cover several years. This is obviously very difficult for the patients and inevitably involves a drift of financial resources out of the NHS toward the legal profession.

Finally, in the same context it is important to draw attention to a change in the guidance for experts in such cases. In 2007 there was a total ban on payments to experts that depend on the outcome of the case. This was softened in 2014 but is still greatly discouraged. This is a surprising development and not consonant with the need to protect at all cost the resources of the NHS financial position, which, as every speech in this House today has indicated, is inevitably difficult, and is likely to be for some time to come.

My Lords, first, I thank my noble friend Lord Turnberg for securing this debate. He is not only my noble friend but a personal friend. Few have committed more to the NHS than him. To the noble Baroness, Lady Watkins, I can say, “It’s over. You can relax, and you did really well”.

I speak as a parent of a junior doctor who qualified at the University of Nottingham and now is a resident doctor at NYU medical centre in New York. It might be interesting if I were to compare and contrast aspects of the two systems as seen through his eyes.

The first aspect is the teaching. At NYU each resident receives around 14 hours of high-powered classroom teaching each week. The regime is free food, phones off, high concentration. Lectures are given by specialist consultants. As he puts it, “Every day I lunch with giants”. At Nottingham he was lucky to get two hours per week.

As for attitude, at NYU he feels a valued member of the team; in the east Midlands he and all his colleagues felt underappreciated. Most NHS medical staff were disgruntled and demotivated. Of his colleagues in Nottingham, a third either left the profession or went to work abroad. Each one had cost the NHS £300,000 to train but, when they left to go elsewhere, no one noticed, no one took responsibility, there was no exit interview and no one cared.

Then there is the pay. In his final year in Nottingham, he earned about £40,000. It is true that his basic pay was £23,000 but, with unsocial hours banding, the pay soon mounted. At NYU he earns $60,000—exactly the same amount—but in the United States almost all junior doctors carry student loans in the region of a quarter of a million dollars, and repayment starts immediately.

Finally, there are the hours. Last month in New York, he worked 80 hours per week, as he has done every month. He works six days every week, including many weeks on night shift. Even on daytime shifts, he leaves home at 5 am and often gets home at 8 pm.

The American junior doctors are the ones with really unsocial working hours. They are the ones who struggle to make ends meet and the ones who should be complaining, but there are no picket lines to be seen on First Avenue and 32nd Street. The question is why? Let me hazard a guess. In much of the UK, junior doctors—indeed, even senior doctors—are treated as objects: cogs in the wheel or items on the spreadsheet to be moved here and there at will. There seems to be little realisation that to get the best out of people you have to encourage them, you have to integrate them as part of the team and, most of all, you have to make them feel valued. It is called leadership. Looking at this junior doctor crisis, there seems to be little of that in evidence in our NHS but it is what we really need.

My Lords, we are on the last lap. I thank the noble Lord, Lord Turnberg, for telling us about the enlightened approach of Salford Royal Hospital. It has obviously made great progress since I worked in Manchester and it was known as the “No Hope Hospital”.

It is no coincidence that the London Olympics highlighted the NHS in its very creative opening ceremony. We are all very proud of it, particularly the staff, but it would be stating the obvious to say that it has numerous problems. At a time when it faces unprecedented increases in demand, the NHS has been given its most challenging funding envelope ever. The future of the health service is in jeopardy unless we do something radical. As the noble Lord, Lord Rea, said, it cannot get out of this hole by itself.

That is why my right honourable friend and former Health Minister Norman Lamb introduced a Private Member’s Bill in another place a week ago. He called for the establishment of an independent commission to examine the future of the NHS and social care system, to take evidence and to report its conclusions to Parliament. I pay tribute to those on the Conservative Benches who have called for something similar, but I think that a royal commission may take too long and that something quicker is required.

Norman Lamb was supported by two former Secretaries of State for Health, Members from all parties and the chief executives of more than 40 organisations in the sector. I join with his call today in this debate, along with many of your Lordships. When you get agreement from so many from all sides of health and social care, it is clear that you are reflecting a real need. The purpose of the commission would be to consult widely to find solutions to the massive challenges that face the health and care services, and to establish a sustainable—a crucial word—new settlement which takes into account present and future demands.

In order to calculate future demand, we need no crystal ball—we have a lot of evidence to help us. We know that since the Second World War demand has gone up by about 4% every year. For example, thanks to successful new diagnostics, treatments, drugs and surgical procedures, half of people diagnosed with cancer now survive the disease for 10 years or more compared with only a quarter 40 years ago. Other chronic conditions are also now managed better than ever. We should celebrate all this while being realistic about what it means.

We have heard about the predicted gap of £30 billion in NHS funding by 2020 unless something is done. The Government have committed to providing only £8 billion of this and expect the NHS to find the other £22 billion through efficiencies and new models of care. However, experts involved in the process are unconvinced that this can be done.

The King’s Fund’s Quarterly Monitoring Report, published in October 2015, included a survey of NHS finance directors’ views on their ability to achieve 2% to 3% productivity gains per year, which would be needed to achieve that saving. The vast majority were sceptical to say the least. Eighty-four per cent of NHS trust finance directors and 88% of CCG finance leads felt that there was a “high” or “very high” risk of failing to achieve the target. Here are a few respondent comments:

“I feel strongly that the low-hanging fruit has been taken. The modus operandi needs to change fundamentally”.

“When plans are not credible then it is impossible to enthuse people”.

“Increased national pressures/tying of hands … make it difficult to achieve big savings”.

“The £22 billion challenge requires productivity gains significantly over what has been achieved over the past few years”.

“Unless there is a national debate about what the NHS can provide then there is no way that the NHS can deliver within the financial envelope”.

Jim Mackey, chief executive of the hospital regulator, NHS Improvement, put it in colourful language—and I quote him verbatim—saying that the efficiency targets set by the Government are,

“unachievable and, frankly, bloody stupid”.

That is what he said, my Lords.

Given that the recently announced increases in funding will be swallowed up mostly by paying for the £2.2 billion of deficits in NHS and foundation trusts, increases in payments to pension funds, apprenticeship levies and the new minimum wage, it is pretty clear that this extra money will do nothing to address future increases in demand. Meanwhile, social care funding has been cut in real terms and faces a funding gap of £6 billion by 2020 according to the Health Foundation, but this does not take into account the effect of the new minimum wage in a sector where so many workers are on the minimum wage. The LGA estimates that this will add a further £1 billion to the gap. Now Ministers have decided to stop the £1 billion payment-for-performance element of the better care fund and, instead, have mandated local targets for the reduction of delayed transfers of care. So the Government give with one hand and take away with the other.

Did the Chancellor provide the answer to these problems in the autumn spending review? I think not. The new provision for councils to raise a 2% social care precept would provide only an extra £1.7 billion by 2020 if every single council did it. In poor areas the ability to raise significant extra funds in this way is in inverse proportion to the need—not a very clever solution.

The increase in the better care fund will not come until 2019. Sadly, this will mean that the better-off will be able to pay for good care and the poor will get either no care at all or a substandard package—the best their poor stretched local authority can manage—adding further to our appalling health inequalities. The inevitable pressure that these cuts to social care will put on the NHS is obvious and has been clearly outlined by Simon Stevens, the head of NHS England. So current and projected NHS funding does not allow the service any chance of fulfilling the mandate, mentioned by the noble Lord, Lord Lansley, put upon it for the next five years by the Government themselves. Beyond 2020, it will just get worse if nothing is done, and our precious NHS will no longer be the envy of the world. Mention of the mandate reminds me to endorse the call of my noble friend Lady Tyler and the noble Lord, Lord Bradley, on mental health. We need to find new answers.

All Governments pledge themselves to protect the NHS, yet our spending as a proportion of GDP is low, as we have heard, compared to that of other developed countries. According to the Office for Budget Responsibility, it will decline further by 2020. The position of social care is even more dramatic.

What is the point of growing our economy if we do not spend the money on the things that most of the population would like it spent on—and what they vote for? Given what we know about rising demand, it makes no sense at all. The consequences of the Government’s failure to address this are very serious and completely contrary to what they say they want according to the latest mandate. Standards will not rise, new technologies will be unaffordable and services will not be able to address our health inequalities—an absolutely top priority in my book.

The silly thing is that nobody really believes in the ability of the system to fill the gap through efficiency savings and new models of working, desirable though they may be. Money is so tight at the moment that many parts of the system are struggling with crisis management, let alone improvements. To make things worse, there are numerous financial disincentives. For example, where is the incentive for acute hospitals to work with local services to keep patients out of hospital when they rely on the payments for activity when they come in?

The social care system is living on borrowed time. Eligibility criteria are getting tighter every day. Will the Government face this crisis head-on, take politics out of it and support my right honourable friend’s call for a commission to bring together all the evidence, the brains and the expertise available?

I think it boils down to five simple questions. How much should we be spending as a country and how should it be raised? How can we spend it better and have all services reach the standard of the best? How can we end the artificial divide and conflicting incentives between health and social care? How can we minimise future demand by avoiding preventable diseases? How can we reduce health inequalities? It is time for a new Beveridge commission.

My Lords, if the Minister is going to have any time at all, I should cut my contribution short. First, I declare an interest as president of the Health Care Supply Association and the barcoding association GS1, because I want to comment on the remarks of my noble friend Lord Carter on efficiency.

I very much welcome this debate. I was very taken with my noble friend’s description of the ideal world. I wonder if noble Lords think, as my noble friend Lord Carter does, that elements of that are in existence in the NHS at the moment, and that the issue is how to get that going in every part of the NHS. That is one of the essential conundrums.

I will focus also on the very important contribution of my noble friend Lord Winston, who talked about the risks to our medical research. Our medical research has always been one of the best in the world. On it our whole life science sector has depended. The fact is that we in this country have always had a very strong, innovative pharmaceutical and diagnostic industry. When my noble friend says that all of that is at risk, we need to listen.

There is no doubt—I pick this up consistently—that there is a hostility in the NHS to the kind of time that is needed for doctors to practise in research, and even to take part in Royal College activities. This has really got to stop. Seeing the noble Lord, Lord Lansley, here, I have to say that the introduction of NHS England does not help, because, for all the fine words that are in both the mandate and what NHS England says, I do not see any commitment in NHS England to these kinds of issues.

I will raise one further issue in aid of that. Our record on the introduction of new, innovative medicines in this country is a disgrace. We have some fantastic inventions, but the NHS is pathetically slow in introducing them. The noble Lord probably knows very well that we have an accelerated access review under the chairmanship of Sir Hugh Taylor. The word on the street is that it is simply not going to get anywhere because the NHS is not going to play ball and is not going to insist that NHS bodies invest in these medicines. A whole sector of our economy is at risk because of this. I know that the Minister is as concerned as I am and I hope that he might say something.

I come to the issue of junior doctors—not to talk about the dispute but because both my noble friends Lord Winston and Lord Mitchell raised the issue of why junior doctors are so disengaged. Anyone who has met them will know how angry they feel. It is partly about the Secretary of State’s manipulation of statistics—which, frankly, given the brightness of junior doctors, was always going to be very unwise. It is also about their distrust of management. Part of the problem is that they just do not believe that, locally, NHS employers will do the right thing.

My noble friend is right. Why are junior doctors treated so abominably by NHS employers? Why can they not get access to decent hot food at night? Why are the junior messes not in places where they can go and meet? I do not know what can be done to get this home to the NHS. Anyone who meets our juniors knows that they are the brightest of the bright and are hugely committed—yet, somehow, we seem to have made them wholly disenchanted with the NHS. It is a very serious issue.

This brings me to the issue of leadership, which my noble friend mentioned. In June last year, the noble Lord, Lord Rose, produced an excellent report on how to enhance and improve leadership in the NHS. He asked the Government three questions. How do we get better leadership? How to we recognise it? How do we find and mature the people who are needed to lead the NHS? I am afraid that there has been virtually no response to this from the Government. That is very disappointing. In fact, all that has happened is that the turnover of chief executive officers has continued at an alarming rate. Again, as one of my noble friends said, we have got to get rid of leadership by bullying. There is a bullying culture throughout the system and it is having a corrosive impact on the ability of people locally to lead organisations.

Of course, funding is very important. I do not need to repeat all the arguments that noble Lords have put forward. Essentially, they concern growing population and demographic pressures. We in this country spend less on health than any comparable country. The OECD figures that came out just before Christmas were very convincing on this. The Government’s claims in the Autumn Statement frankly do not ring true. We know that they are front-loading some of the money for the next five years, but the annual increase from here to 2020 will be 0.85%— even less than the average increase from 2010 to 2015.

At the same time, we know that half of that extra money has come from raiding the budgets of Health Education England and Public Health England, from capital funds and from the cost of pension payments. At the same time, what do Ministers do? They pile on more pressure. Not a week goes by without another press release from the Department of Health or an announcement by the Secretary of State that something else has got to be done. No wonder his credibility is shot in the NHS.

Of course, the gap between the money that is going in and the £30 billion per annum that it is generally believed will be required by 2020 is huge. I pay great tribute to my noble friend Lord Carter, because obviously he is helping the NHS to see if it can close part of that gap. I am sure that is right and that, on procurement in particular, a much more cohesive national approach is needed—but at the end of the day, there is still going to be a gap.

Should there be a royal commission? I cannot help repeating Harold Wilson’s famous diktat that royal commissions take minutes and waste years. That is, of course, when they are used simply to postpone a decision. I understand why noble Lords want some kind of neutral and impartial commission to look into those issues. However, we have already had the Barker commission, and I doubt whether anyone is going to improve on that. In the end, it is a matter of political will. I say to the Minister that, at the very least, what we seek is some honesty from the Government: admit that the financial gap is not going to be met and stop piling on the pressure.

I apologise to the noble Lord, but there is a question that is central to this: would he and his party be prepared to take part in an all-party commission, possibly a parliamentary one, in order to get the quickest possible effective answer for the terrible crisis that has been outlined in this debate?

My Lords, this is a time-limited debate and I want to leave the Minister a little time to respond. I would certainly be very happy to discuss the issues with noble Lords here—I like the idea of a group of politicians in this House looking at it. On the subject of a royal commission, I do not think I can go as far. In the end, we sometimes have to have the courage of our convictions and come up with proposals to sort this out.

My Lords, first, I thank the noble Lord, Lord Turnberg, for bringing this debate, and I thank the 45 people who have contributed to it. That shows that the noble Lord has touched an important nerve. The future of the health service and of social care in this country is hugely important.

The noble Lord, Lord Turnberg, talked about his experience at Salford, where they have a fantastic hospital with a joined-up system. This shows that it can be done. Around the country, there are hospitals and healthcare systems that are doing it; they are doing a fantastic job by good standards. Of course, that requires great leadership, and leadership is not something that can be cloned; there just are not that number of great leaders in any system. However, in Salford, under David Dalton, they have a great leader.

The fact that it can be done lies behind the work that the noble Lord, Lord Carter, has done. Hospitals around the country are achieving great performance. However, the noble Lord, Lord Carter, has uncovered a huge amount of what he would call “unwarranted variation”; that could be unwarranted clinical variation, operating variation or any other kind of variation. That has to be addressed, and the noble Lord, Lord Carter, has given us a methodology for doing that. He, along with other noble Lords in this debate, points out that unless we can crack delayed discharges in hospitals and delayed transfers of care, many of our hospitals are going to struggle.

I also pay tribute to the noble Baroness, Lady Watkins. In her maiden speech she very properly reminded us of the importance of training and community-based services. Her mentor, the noble Lord, Lord Patel, who was watching as she gave her address, is no doubt watching me from India as I speak to the debate.

I want to mention two particular contributions. The first is the speech by the noble Lord, Lord Winston. The noble Lord, Lord Hunt, picked up on his point about academic medicine. That is a crucial issue and one that I cannot address head-on today, but perhaps we might have a meeting involving others, including Hugh Taylor, to talk about it further. The second is the contribution by the noble Lord, Lord Mitchell, about the contrast between his son, who is a junior doctor, working in England compared to working in New York. I thought that that was a very revealing contribution, if I may say so.

I want to preface all my remarks by paying tribute to not just junior doctors but to all those who work for the NHS and in social care. They do an extraordinary job and have a true vocation, and many noble Lords have experienced the benefit.

This is the third general debate that we have had on the NHS since the election. The first was introduced by the noble Lord, Patel, and the second by the noble Lord, Lord Crisp. In that debate, we talked very much about prevention. We could be here for many hours talking about prevention. The noble Lord, Lord Rea, talked about the importance of housing and employment, and there are so many other issues that we could talk about in the context of prevention. Therefore, I hope that noble Lords will excuse me if I do not address prevention as much as they might like me to.

I want to go back to June 1948 for a minute, and to Nye Bevan talking to the Royal College of Nursing. He said:

“We shall never have all we need. Expectations will always exceed capacity. The service must always be changing, growing and improving—it must always appear inadequate”.

The noble Lord, Lord Desai, made the point that when you have a service that is free, demand will always exceed what we can provide. Nye Bevan saw that back in 1948, and it is important to hold on to that when we look at our funding situation at the moment.

We do have a plan: the NHS Plan. The NHS Five Year Forward View was produced by Simon Stevens of NHS England and supported by all the arm’s-length bodies. It is not the Prime Minister’s plan, it is not my plan and it is not the Secretary of State for Health’s plan. It is the NHS’s plan. It called for £8 billion of real investment over that five-year period, and the Government have given the NHS that amount of money: it is £16 billion in cash terms and £8 billion, or arguably £10 billion, in real terms. This is broadly what the NHS wanted.

The NHS is actually doing quite well. I will come back to some areas where it is not doing as well as we would like but, broadly speaking, it is doing quite well. The Commonwealth Fund said that it is first overall compared with other OECD countries, scoring highest on quality, access and efficiency and second on equity. In the recent Economist review looking at end-of-life care, we came out top. However, that is not perfect. The noble Lord, Lord Freyberg, pointed out that our cancer outcomes are not as good as they should be. The noble Lord, Lord Bradley, talked about mental health, and clearly we can do better there and in other areas too. There is too much variation in what we do. However, if we look at medical research, the quality of our education in most of our medical schools, medical publications and clinical outcomes, the NHS can still be regarded as a world-class health service.

Other noble Lords have already made the point that we do this at very low cost. In America, they spend 16% of GDP on healthcare; we spend around 8% and most of Europe spends around 10% or 11%. We do it at very low cost and we get very good results. On that basis, when people say that it is not affordable—an issue my noble friend Lord Fowler and others have raised in this debate—I say that it is affordable. We are doing it at 8% of GDP at the moment but we could choose to spend 10% or 11%: the country can afford good healthcare. I would argue that we are providing good healthcare at the current level of spending.

There is no evidence that a tax-funded system is any less efficient or effective than other systems of funding healthcare. Indeed, I would argue that, on the contrary, the NHS, for the reasons that I have given, is an efficient system. The OECD made a more neutral comment, saying that,

“no broad type of health care system performs systematically better than another in improving the population health status in a cost-effective manner”.

Therefore, I do not think there is an argument for questioning whether we can afford a good healthcare system in this country.

I turn to the various questions that were raised. Is it affordable? Yes, it is affordable, and we are demonstrating that. Is a tax-funded system viable? Yes, it is viable, and I will go further and say that there is evidence to suggest that it is more viable than any other way of funding a healthcare system. Do we have a viable plan in this country? Yes we do, and I will come to that in a minute. Do we need another plan or another commission? I do not think we do. It would be an enormous distraction at a time when we have a five-year forward view. At a time when the whole of the health service is committed to that view, there would be immense concern if we embarked on yet another review or commission of any kind. We would go through a two-year hiatus waiting for that report and would not be able to get on and deliver what we have at the moment.

What is that plan? It falls into two parts. First, can we make the existing system more efficient? The answer is: of course we can. We have some of the best hospitals, wards, clinics, laboratories and specialties in the world in the NHS. Our problem is that there is so much variation across the system—clinical variations, staffing variations, property utilisation variations, procurement variations, pharmacy and medicines utilisation variations and back office costs variations—all of which have been identified, as shown by the extremely important work done by the noble Lord, Lord Carter, assisted by clinicians such as Professors Tim Briggs and Tim Evans. They have given us an improvement methodology based on transparency which will deliver huge improvements over the next five years. A great deal of their work is mirrored on commissioning through the use of the Right Care programme and the Atlas of Variation that has been developed largely by Dartmouth in the USA.

The second part of our plan concerns the new models of care—an issue raised by the noble Lord, Lord Turnberg—and we have already seen these operating effectively in Salford.

This is a move from institutions to systems. We are now trying to develop a place-based care, a population-based care. Although there were many benefits from foundation trusts—I believe wholly in the principle of earned autonomy—one of their unintended consequences is that they have created a fortress mentality in some parts of the country. The King’s Fund has used the analogy of the tragedy of the commons, where everyone is looking after their own interests rather than the interests of the wider system. It has also left patients having to navigate a complex, unjoined-up series of different organisations. We will see over the next four or five years the emergence of new systems of care, including PACS and MCPs, and the Accountable Care Organisation, ACO, will become increasingly familiar to us.

We will also see different outcome-based payment systems and incentives as we move to integrate with social care. There will be many cynics and sceptics because some people, as the noble Lord, Lord Turnberg, said, have seen all this before. We have been talking about integrated care for 20 odd years. I think it is different this time—but I would say that, wouldn’t I?

We have to ask why change is so difficult in healthcare—and not only in the NHS. Why has there been such dramatic change in car manufacturing and retailing across the world, when healthcare systems have proven much more difficult to change? Interestingly, in the 2000 NHS plan, echoed in the five-year forward view, were two comments: that we have a 1940s system delivering care to a 2016 population with entirely different needs to the population of 1948; and that healthcare has been slow to move, not only in the NHS but around the world. Changing that system will be difficult but very important.

Why am I optimistic about it? First, we have a narrative. The five-year forward view gives the whole service a very powerful narrative around which it can combine and work together. Secondly, the architecture of the system is not perfect—I know that the noble Lord, Lord Lansley, is sitting behind me—but it is serviceable. We do not need another top-down reorganisation. We can work with the bodies created through the last reorganisations, and NHS England is now building resources and a team of people who can truly deliver on its plan. The new purpose of the NHS is based around improvement and learning rather than regulation, which is important, and the independent CQC.

There are two other reasons for optimism. Transparency will be a much better improvement mechanism than targets, regulation, competition and the command and control structures that we have had in the past. The financial crisis we have gone through has made hospitals look more radically at how they can change their models of care. Finally, we have not spoken in the debate today about the huge impact that technology will bring in empowering patients to look after themselves and take greater personal responsibility, as other noble Lords have mentioned.

I have to conclude. I thank the noble Lord, Lord Turnberg, for introducing this fascinating debate, which has raised important issues. I look forward to reading it in the cold light of day over the weekend.

My Lords, it has been a fascinating debate and I am grateful to all speakers who have participated in it. It is amazing how much information people can pack into three minutes. It has been very helpful. I was bowled over by the maiden speech of the noble Baroness, Lady Watkins.

There is no way in which I can summarise the debate in no time at all but one or two themes have emerged. Everyone agrees that we should focus to a greater extent on prevention. That makes it seem even more ridiculous that we are cutting funding for public health at this time. Most people agree that there is a need to integrate services across the social care/hospital divide, and most people feel that we should begin to appreciate our staff to a much greater extent than we do. To alienate them at a time when we need them so desperately is counterproductive.

On the point that we are seeing a rise in demand and the costs of healthcare, I detected more than a hint from the noble Lord, Lord Prior, that he might believe that the spreading of good practice—there is all sorts of good practice around—and increasing efficiency will solve the funding crisis. I suspect he is the only speaker in the debate, on either side of the House, who believes that. It focused the minds of most people on how we fund the gap.

If one thing has come out of this debate it is that we have begun to think about how—

Motion agreed.

Flood Management

Question for Short Debate

Asked by

To ask Her Majesty’s Government how they intend to review their long term strategy for flood management, particularly in rural areas that do not qualify for large-scale flood defences.

My Lords, I am grateful for the opportunity to put to the Government the Question before us. If there was a sound track to this debate it would probably include Phil Collins’s “In Too Deep”.

It is important to note the destructiveness of the recent flooding, given that the news agenda moves on very quickly and communities which found themselves at the heart of a sympathetic nation quickly feel themselves to be forgotten. For some of the communities in my diocese, the recent floods come in the wake—almost literally—of other occurrences in recent years. For them the need for longer-term and more joined-up measures is obvious.

I pay tribute to civic leaders, emergency services, public service workers, members of the Armed Forces, the Environment Agency and local volunteers, many of whom sacrificed holidays and family time over Christmas to support victims of this appallingly destructive flooding. Churches in many of the affected communities offered refuge, sanctuary and practical support in providing meals, clothing and the distribution of emergency resources. In places such as Kirkstall in Leeds, Bingley, Ilkley, Mytholmroyd, Hebden Bridge and Sowerby, people got stuck in. The Sikh charity Khalsa Aid helped in Hebden Bridge, and I know that Muslims worked hard to provide relief and help in Cumbria as well as affected parts of Yorkshire and Lancashire. These impressive stories demonstrate that perhaps the parable of the Good Samaritan still echoes through this generation in the costly and practical support of one’s neighbour. It is also appropriate here to salute the insurance companies, many of which have been praised for the speed and nature of their response to those flooded. Affected churches have greatly valued the service of the Ecclesiastical Insurance group in particular during recent weeks.

The Government’s response to the latest flooding in Yorkshire and Lancashire has involved repeated use of the word “unprecedented”. Of course, by definition a unique event is unprecedented, but it is of no comfort to people who have lost their homes or businesses that an event is unprecedented, nor does it help when the enormity of the immediate flooding happens to be greater than the last time, which also ruined homes and businesses and in some cases left people uninsurable—hence the Question in this debate.

I shall give some numbers. Around 16,000 properties have been affected in northern England and Scotland. At the end of December, KPMG estimated that the total cost of flood damage would exceed £5 billion. The Association of British Insurers estimates that claims will total £1.3 billion. The average domestic claim will amount to £50,000, up from an average of £31,000 in 2013-14. Around 3,000 families are now living in alternative accommodation while their homes are being repaired. In Calderdale alone, flooding hit 2,500 homes, nine schools and 1,250 businesses, and as many as 40% of those businesses could be uninsured. Infrastructure damage is estimated to be at least £20 million. Damage to homes and businesses also has a knock-on impact on the wider ability of the local economy to recover and function.

There is still the possibility that more flooding could be on the way because the winter is but young. Understandably, the Government are moving into recovery mode. Almost £200 million has been made available for investments in recovery, including money for repairs and upgrades to existing defences, money for local authorities to repair infrastructure, grants to home and business owners for the improvement of personal flood resilience, and grants for farmers whose land has been flooded and crops destroyed. All this is welcome. However, the much-publicised Flood Re scheme, which will help to provide flood insurance to at-risk homes, will be launched only in April. This will guarantee affordable premiums, as many homeowners cannot afford the current premium levels in high-risk areas. But Flood Re is not going to be available to small businesses or buy-to-let properties, meaning that they will almost certainly face an increase in premiums. The fact that Flood Re is not yet in force means that many people will not have been insured for damage caused by the December floods, potentially those who would have been waiting for Flood Re to come into effect before securing insurance. The Times reports that up to £1 billion of damage will have been sustained by uninsured people.

No rational person believes that all risk of flooding can or should be eliminated. But people do not always understand why, when following one disaster a case is made for enhanced protection, yet that protection is quickly scaled back once memories begin to fade. During the recent flooding in Leeds, the Lord Mayor of Leeds went as far as to question whether this would have been tolerated in London, and whether England’s third city deserves the same level of investment as its first. Furthermore, in this context it is clear that swingeing cuts to local authority funding must inevitably diminish the ability of such authorities to respond effectively to local disasters and recovery from them. It is claimed that northern metropolitan councils have faced disproportionate cuts which have then had an impact on the maintenance of bridges, drains and other essential infrastructure. We are also seeing the threatened closure of local front-line services at the same time as emergency response needs are evident.

Two immediate points must be addressed by all parties to the debate about planning for future flood protection: first, the amounts that have already been spent, and which might have to be spent in the future in reactive recovery, should not be counted against the resources needed for long-term protection planning; and secondly, the insurance costs and access to adequate insurance by people and businesses in what are now vulnerable areas must be managed in a way that allows both recovery and a future for those affected. Surely the changes to weather patterns in recent years indicate that similar events can be expected in the future and we need to be building resilience to address them. Prevention might be financially expensive, but it will certainly be cheaper than the cumulative costs of non-prevention over, say, a decade or two.

However, the finances only hide the human costs: businesses closed or lost, homes ruined, families and children forced into temporary homes with all the consequent disruption to schooling and the best circumstances for learning and growing. These costs go beyond pounds and pence. So questions remain about how the Government will address these challenges in the longer term, and no doubt other speakers will touch on other aspects of this matter. But noble Lords might well seek reassurance that the recently instigated national flood resilience review, chaired by Oliver Letwin, will pay serious attention to the strengths and weaknesses of current worst-case-scenario planning in the light of the future impact of climate change, recent substantial cuts to the Environment Agency in the form of a 15% funding cut and the loss of 1,500 staff, along with the need for whole-catchment approaches to flood prevention and water management.

Rural communities are particularly vulnerable where funding decisions are driven by a return-on-investment calculation which means that many schemes will not be considered cost-effective on paper. I hope that this debate will touch on such challenges and urge Government to take long-term views in future planning. I look forward to hearing how the Government intend to review their long-term strategy for flood management, particularly in rural areas that do not qualify for large-scale flood defences.

My Lords, I congratulate the right reverend Prelate on securing this debate and I echo his thanks to all concerned in the recent floods which particularly affected North Yorkshire, rural areas in Cumbria, and parts of Leeds and Lancashire. I refer to my interests in the register, in particular that I am a vice-president of the Association of Drainage Authorities. I would like to answer the right reverend Prelate’s question directly by saying that to tackle the long-term strategy, we should simply work more with nature. I shall draw on the example of a project that I was particularly closely associated with while in another place as the Member of Parliament for the constituency that includes Pickering.

I believe that the Pickering pilot project was a partnership approach that could be used in other places, particularly those that feed into catchment areas around Leeds, Cumbria, Lancashire and York. We have to accept that there is no one-size-fits-all solution, so we have to adopt a mix-and-match attitude to land management. We should drain where drainage is appropriate, dredge where dredging is appropriate, desilt and clear away weeds where that is appropriate. Working with nature is less capital intensive and less physically engineered. It allows water either to slow down, as we did in the Pickering scheme, or speed up so that it moves away from flooded areas, whichever is appropriate. In adopting a full catchment management system, or in the case of Pickering a sub-catchment management system, that is precisely what we did. We took a smaller reservoir, which was less engineered and therefore less costly, and I am delighted to say that the scheme really stood the test of the recent floods in North Yorkshire.

Farmers have a role to play in this by temporarily storing water on their land but hopefully without falling foul of the reservoir safety Act. I believe that the European Commissioner in Brussels, Phil Hogan, is keen to reward farmers through the new system of basic farm payments for the public good that farmers provide by retaining water upstream and taking it away from areas downstream, be they farmland, towns and villages, or even cities like Leeds and York, thus keeping them safe.

The key is to work with nature and to adopt a full capital management system. As regards funding, perhaps I may say that there is no bottomless pit. We have to lever in private sector funding. The Pickering approach was exemplary. It was a partnership approach involving the county council, Ryedale District Council, the town council of Pickering, the Environment Agency and the Forestry Commission, all planting new trees and cutting down existing ones, creating dams and, indeed, taking 200 years to create a new peat bog. I believe that Pickering shows the way forward. It does so also by merging the total spending budget and having a capital spend that is the equal of £2.3 billion and matching that with maintenance. I think that that answers the right reverend Prelate’s question.

My Lords, I declare an interest as a former chief executive of the Environment Agency who did, along with my chairman, turn up when there were floods. I am also chairman-designate of the Woodland Trust. Flood prevention, of course, is not about flood defences or inappropriate development in the flood plain: it is much wider than that.

I want to make two points. First, to echo the noble Baroness, Lady McIntosh, it is about managing land at a catchment scale for resilience against the increasingly frequent warmer and wetter winters, and more extreme events, that we are likely to see. It means better soil management by land managers to avoid compaction, bare ground and run-off. It also means appropriate planting of trees in the upland upstream areas to help alleviate flows.

I commend the Environment Agency in working with the natural processes programme, which is looking, among other things, at the right trees in the right place and on the right scale; tree cover in the flood plains in riparian woodlands; cross-slope woodland; tree shelterbelts; gully woodlands; and the restoration and creation of increasing numbers of wet woodlands. We cannot say that this is a single-bullet solution—planting trees will not solve the entire problem. But tree cover in the appropriate place can reduce flood peaks by up to 40%. Infiltration of water on the ground is 60 times more effective in treed areas than in grazed areas.

I urge the Minister to ensure that all regional flood and coastal committees consider how natural flood risk management can best be deployed in their areas. The Environment Agency and the Forestry Commission opportunity maps showing where trees and woods are most likely to reduce flood risk in England should be promoted more widely to help projects use them across the country. I also urge that the new Countryside Stewardship scheme’s first-year arrangements are closely watched to make sure that they are having an impact in supporting woodland planting in areas where it is likely to reduce flood risk. I also commend to the Minister the Woodland Trust’s report, Stemming the Flow, about the role of trees and woodland in flood protection. Indeed, I commend the Pickering experiment, which the noble Baroness clearly described.

Secondly, floods do not just happen in flood plains. Surface water flooding is becoming an increasing problem. We need to build resilience into new buildings and to retrofit property-level protection measures in existing buildings, which means waterproof surfaces, resilient electricity supplies and individual housing flood defence remedies. The measures are known to pay for themselves after simply one flood. In flood-risk management, the cost of remediation of floods is almost directly proportionate to the degree of heartache. Such measures are the least we can do for those recently flooded and those who, without such measures, will be flooded again in the future.

My Lords, I remind the House of my registered council interests. This is a tale of two small towns and what happened on Boxing Day. Barnoldswick and Earby are twin towns in that part of the Lancashire district of Pendle which used to be in Yorkshire. They are both prone to flooding. Water rushes down from the surrounding moorlands on to a glacial plain where they are built and the two towns straddle the Pennine watershed at its lowest point. Both have suffered from periodic, catastrophic flooding over the past 150 years. This year, on Boxing Day, the heavens opened.

Barnoldswick, which is locally known as Barlick, escaped this time for two reasons. The first is a series of local works over the past 20 years and more which were mainly the initiative of the local district council and local people. I pay tribute particularly over that time to the work of my colleague, Councillor David Whipp, whose decades of work in this area have been heroic. At the danger point, when it happened, a small estate called Ghyll Meadows turned out to be the most vulnerable point. Early on Boxing Day morning, David went out to inspect the defences and decided that they were not going to hold. He called on what I can only call a heroic local community to turn out, particularly using social media, networks and contacts which had been built up for this purpose over the years. More than 200 people turned out. They built a new barrier with sandbags provided by the district council. Improvised sandbags came from all sorts of places. A local builder’s yard opened to provide material and a local farmer provided machinery. Legions of people swept away the water that was seeping through the new improvised barrier.

Unfortunately, they were not so successful in Earby. They managed to withstand Storm Desmond but then came Storm Eva. Earby had the same history and the same storms in December. On Boxing Day, the local becks overflowed. More than 50 houses and local businesses were badly flooded. Earby has a local scheme ready and waiting to go. It has been agreed by staff at the Environment Agency but is waiting for funding. It is not the district’s responsibility but the district council has £168,000 in the bank account towards it but it is waiting for the rest.

The problem of Earby is unique. It is part of Lancashire. Therefore, it is part of the north-west Environment Agency. In all ways, its administration and representation of councillors and others is with Lancashire and the north-west. But, unlike the rest of Lancashire, the water in Earby drains eastwards. It joins the great River Aire and flows through Leeds. No doubt, some of the Earby water joined the rest of the water to flood Leeds this year. It is part of the Environment Agency in Yorkshire. It comes under the Yorkshire Regional Flood and Coastal Committee and is in direct competition with the rest of Yorkshire and the horrific events that happened there.

But east is east and west is west. Earby is stuck between the two on the Pennine watershed. Will the Minister spend a little time looking at Earby and working out how its problems can please be funded?

My Lords, I thank my right reverend colleague for today’s debate. Due to the shortage of time, straightaway I shall focus a little more on whole-catchment flood management. A renewed focus on this approach has been one of the notable outcomes of the current flood crisis, helped of course by the exemplary work of the Pickering slow-the-flow scheme, which the noble Baroness, Lady McIntosh, described so eloquently.

The potential of whole-catchment approaches—for example, using meandering rivers, planting trees and building permeable dams to slow water in upland areas and reduce peak flow further downstream—is enormous. In the long term, it provides a cheaper, more environmentally friendly method of flood management, which works, as a number of people have already said, with natural processes rather than constantly trying to hold back the tide. Such approaches also have the benefit of being effective across a catchment, rather than simply focusing on one or two high-value areas, and so can help to lower the flood risk in rural hamlets and villages that might otherwise not qualify for flood protection.

Yet, generally, Governments and local authorities have been slow to embrace such proactive approaches, for a number of reasons. First, the whole-catchment approach will help to mitigate the risk of small and medium-sized floods but there is little evidence that they will protect homes from floods with the highest levels of water. For towns and villages to be protected from the heaviest flooding, some form of flood defence barrier is usually needed. It would generally be cheaper for the Environment Agency to build that barrier a bit higher than to invest in both a barrier and a whole-catchment approach to flood management.

If the Government are serious about a whole-catchment approach, Defra and the Treasury need to look again at how they value those projects and be willing to take into account a wider range of factors—for example, environmental benefits—when they make those valuations. Will the Minister assure the House that a review of how the Government value measures such as this will be included in the national resilience review?

Secondly, a proper whole-catchment approach to flood management will require reconsideration of how we currently approach planning and development, not just on flood plains but in upland areas, too, where increased run-off can raise flood levels further downriver. According to the CEO of the Environment Agency, 13% of housebuilding is currently being undertaken in flood plains and that percentage is increasing. Will the Minister inform the House whether the Government will consider giving the Environment Agency new powers to properly regulate developments across at-risk catchment areas?

Finally, dialogue with farmers is vital if we want to take more proactive approaches to slowing the flow of water off upstream land. Redirecting subsidies to incentivise farmers to plant more trees in key areas, to build temporary reservoirs that can hold floodwater back, and even to allow their land to flood in instances of high flood risk, are all things that I hope the Government will look at closely.

My Lords, to people who have recently suffered flooding, as we have just heard from the noble Lord, Lord Greaves, or who are fearful that they may well experience flooding in future, it is no consolation at all to know that the science of flood prevention is not wholly agreed on or resolved in every area all of the time. That is a very important point. Secondly, many of the ideas that will lead to flood mitigation over the years, which both right reverend Prelates have highlighted—it is good to see the Anglicans here en masse this afternoon talking about flooding issues—will take many years to take effect.

On the first point, if you put a bunch of hydrologists, geologists, geomorphologists, soil engineers, arboriculturalists and others into a room and ask them what can be done to mitigate flood problems in different areas, such as both right reverend Prelates have pointed out so clearly, you will sometimes find very different answers coming forward. Mr Rory Stewart, the responsible Minister in another place, who is very far-sighted and has great clarity of mind, has pointed out that we do not have a settled scientific agreement in some areas. We need to work very hard to bring that about. We have to be open about that to flood-prone and flood-threatened areas.

The second point is that many suggestions can be made about how we can get rid of or stabilise water flow. My noble friend Lady McIntosh pointed out that we can reinstate bogs, but also that that can take a century or more to have an effect. Even reinstating peat bogs where there are some remnants of them can take many decades. While it is a very good piece of rural housekeeping to ensure, whether it is local authorities or farmers with their bridges and culverts, that pinch points are clear on a regular basis on a very local scale, it is also clear that we need to look at longer-term suggestions, such as letting rivers meander more once riparian interests are taken into account. You cannot just tell a river to get meandering: it takes 10, 20 or 30 years before meandering takes any effect.

Lastly, I entirely agree with the noble Baroness, Lady Young, that tree planting is very good at anchoring the soil, as it also is when you can persuade farmers not to plough or plant uphill or downhill in rows. There is great debate about tree planting: what sort of trees should be planted, their effects on the landscape, and the interrelationships with natural habitat. There is no doubt at all about it: whatever else, whether you plant little whips or bigger standards, it takes a while—sometimes decades again—to get the trees coming up to the right height to do this.

It is very important that we are honest and open as a Chamber and across the party-political divides that these things cannot just be fixed overnight and that we need long-term, integrated strategies, as was again pointed out by both right reverend Prelates. I am absolutely sure that my right honourable friend Mr Oliver Letwin, the Cabinet Minister responsible, will take that fully into account in his far-sighted review that is coming down the track towards us.

My Lords, I believe that the House should be deeply grateful to the right reverend Prelate for having had this debate. I can say with practical experience of some years as director of Oxfam that the real challenge is to keep the focus when the reality of the long-term consequences of what has happened are being felt by the people in the front line. That is when our support and interest becomes vital.

We are faced with an immediate, immense humanitarian economic and social crisis, but also with another example of an inescapable wake-up call of the relevance and importance of what happened at Paris. We must not allow that to become empty rhetoric or a self-congratulatory exercise in successful diplomacy. We have to make a reality of the aspirations of Paris and we should be judged by what happens and how soon it happens.

Meanwhile, we cannot ignore the size of the problem. I live in Cumbria. Bridges are down all over the county and communications disrupted. Yes, mountains, at least in part, actually shifted. Families are broken and incomes ruined for individual families and for communities. All this must, of course, have immediate remedial action, but immediate remedial action cannot be allowed to become the enemy of the strategic priorities. I mentioned Paris, but more practically on the ground—I am glad to note that some of these points have been mentioned in the debate—is the attention to tax structures that encourage flood defence work by all those who want to undertake it.

This means recognising the inescapable link between the uplands, the flood plains and those in the front line. I live on a fell side. I look down on the flood plain below me. It fills with water. Of course, we in the local community say, “Where does all this water go?”. It does not get rid of the water. That is why a far greater range of upland activity is necessary. Tree planting, upland reservoirs, farm reservoirs, the rest: all this must be looked at.

I conclude simply by saying that, in this situation, amelioration can become the enemy of strategy. We have to be as firm on the strategy as we are on the practical immediate action. Paris could too quickly become a gigantic historical irrelevance.

My Lords, I declare an interest in this debate as a trustee of the Tyne River Trust. I know that I speak for us all when I say that our thoughts and prayers are with all those affected by this dreadful flooding. I am very grateful to the right reverend Prelate the Bishop of Leeds for proposing the debate. I firmly endorse his comments on Flood Re.

We would be naive to think that this will not happen again or that it is as bad as it gets. We need to ensure that the UK has a long-term flood management strategy in place to prevent damage to property, farmland, roads and disruption of people’s lives. I recognise and commend the swift action taken by the Government in response to the flooding crisis, but the problem is that we need to cease being reactive and instead put in place a long-term strategy that will help prevent events such as this.

The floods that affected Cumbria also affected Northumbria, where I live. Here, the flood barriers that were reinforced and rebuilt 10 years ago were not breached; the water just overflowed. To build ever- higher flood defences is not the solution. We would simply demolish the bridges if we did that.

I stress the seriousness of the situation for the farmers who have been affected by this. While it is very welcome that funds have been made available—the charity sector in particular has been very helpful and made significant impact; I am a trustee of the Prince’s Countryside Fund which has been delighted to help in this crisis—my deep concern is how difficult it may prove to be to access these funds. The application for funds during the Somerset flooding proved to be too arduous and complex for many farmers to benefit. For busy farmers trying to clear their land and cope with the stress of the experience, it was far from helpful. Will the Minister ensure that the system is as simple as possible, while still of course adhering to public sector requirements?

A further issue is that farmers can claim the support only after the funds have been spent. This policy fails to recognise the massive cash-flow problems that farmers will experience off the back of this bad winter. The fact that some have still not received their BPS payments is a major concern. Some have had stock losses. Therefore, the cash-flow issues are serious. I hope that the Government will look at changing this policy to consider advancing payments—either 50% or 75% of the payment—to allow farmers to carry out the work and invest as proposed. What we need—this has been reinforced this afternoon—is a policy for flood risk management that is integrated with other land use. Reliable and evidence-based policy is needed to inform both the practitioners and the policymakers to design appropriate solutions.

A balance needs to be struck between the interests of environmentalists while not being detrimental to the livelihoods of farmers. It is clearly inappropriate to dredge every ditch, stream and river. Precious environment would be lost if we did so. Neither should we rule out carefully selected targeted dredging where it is appropriate. We need to see much more integration between the range of bodies that have responsibilities within individual river catchments, not just the Environment Agency but Natural England, the river trusts, national parks, local authorities and so on—the LEPs and others. One size does not fit all. Not for the first time we often see individual bodies operating within silos. Farmers need to be compensated for the work they do in holding water to protect urban areas downstream. At present this service is unrewarded and comes with great costs. Clearly, we need to include that within integrated solutions.

My Lords, as I think many of your Lordships may know, I am a Cumbrian. At the outset, I declare the interest that I am making a claim in respect of flood damage. Somebody put it to me: do you think you have to declare property currently under water? I have also been a member of the North West Water Authority’s regional land drainage committee. However, I must emphasise at the outset that I am a great deal less badly affected than many of my neighbours. I pay tribute to my local MP, friend, neighbour and Floods Minister, Rory Stewart, for the way he has led the Government’s response.

In thinking about flooding, it is terribly important that we all recognise that, despite being within the national jurisdiction, the British weather does not recognise parliamentary sovereignty. If it is getting wetter for whatever reason, and regardless of those reasons, we have to deal with the consequences of that. Against that background and what seems to be the likelihood of future flooding, we need as a country to be absolutely clear about what is a public responsibility, and what flows from that both administratively and financially, and what is a private responsibility and the same consequences that might flow from that.

I was very pleased that the right reverend Prelate talked about insurance, because it seems to me that the role of insurance in this area is of considerable importance. For example, I heard tell locally—this may be apocryphal for all I know—of a person who has been flooded more than once. His insurance company said, “Yes, we shall certainly give you some more insurance but, of course, the first loss is half a million”.

Something very important that has not been touched on is the attitude and role of the banks in the context of their corporate and social responsibility when their customers get into financial difficulties because of this kind of thing. As an individual, I believe that it is important that we respond to these general problems by working with nature, but there is a whole series of nuts-and-bolts issues that need to be thought about and clarified. Do you canalise water or let it spill out over open land? How should we deal with, and respond to, problems directly caused by earlier mitigation flood defence works? How do we respond to problems caused by people constructing buildings, living in houses or working in premises that are known to be liable to flooding? In extreme cases, should we approach these premises as we approached slums in the old days and simply demolish them? Reference has been made to future building on the flood plain. Should we allow it and, if so, under what conditions to mitigate any possible disaster that may ensure?

It is of paramount importance that we are clear about all these things, because unless and until we are clear, we will never have a sensible, long-term policy about flooding and all we can do is do what we have done recently, which is clear up the mess. In the longer term, the only way of making sure that we do not have a mess is to have a good long-term policy.

My Lords, in July I spoke in the Moses Room, warning of imminent flooding. The right reverend Prelates might be amused that I joked that my Hebrew name, Abram, should be changed to Noah. In biblical times, it seems that he was the only human who knew what was coming. Today, we all know that the changes in climate mean that floods are more likely. I shall not talk about this global effect of human activity now. I want to bring to the notice of the Minister the causes of flood damage resulting from our inability in this country to apply proven community methods of river management, working with the water cycle to manage rivers so that they do not flood.

As the noble Baroness, Lady McIntosh, said, many recent trials have shown the success, affordability and financial effectiveness of natural catchment measures in the UK. For this to happen on a larger scale, we need to encourage the buy-in and engagement of the whole river community, develop financial support for these projects from bottom up and arrange long-term financial backing, and we need to allocate a small proportion of land, both private and public, to create natural interventions. The Flow Partnership is a social enterprise and charity that is known and respected by the Government and has long-term experience in India, Sweden, Slovakia and here in the UK in dealing with both floods and droughts in this manner. It can help Her Majesty’s Government, first, to create practical examples of what works at low cost and then to form a long-term strategy that would address these difficulties and save millions of pounds in future damage liabilities.

Employing natural catchment measures has multiple benefits. As well as climate change mitigation, it involves the whole community working together, increases biodiversity, improves river quality and, of course, prevents flood damage. Her Majesty’s Government ought to see the diversity of landscapes—wetlands, forests and ponds—as an interconnected system of the whole water cycle. Working with it communally could build for us a resilient future and make the population safer from floods.

In December, I wrote to the Prime Minister’s office about the way flood defences are mistakenly financed and contracted by the Government and fall into the trap whereby the construction companies are judged by output, not outcome. A huge structure is built. Yes, it is on cost and on time, but it does not work. That is why the Flow Partnership is developing a strategy of community-funded natural catchment measures. These measures are effective and relatively easy to put in at a 10th of the cost. They increase the storage capacity of the river catchments and can be implemented widely. Its methods have been successfully trialled in Belford, Northumberland, and three other catchments by the Environment Agency. Despite the success that such trials evidence, the work is at the moment stalled due to the lack of appropriate funding sources. A river and landscape bond—an enterprise bond—which could be created if backed by the Government, would attract local and business investment and would reduce flood risk in the riparian areas of the UK at a fraction of the cost, time and effort than is now the case. I suggest that the Government should meet the people involved, allocate a small budget for them to work, say, on the River Dearne, and enable them to put the river and landscape bond into place. This would be a way for us to make safe 100 rivers in the UK, and perhaps even to export this methodology in future as a benefit to the world and, of course, to the UK. Thank you.

My Lords, I, too, pay tribute to those who have assisted those who have been devastated by the recent floods and commend the Government for the level of financial assistance supplied so far to those local authorities. However, on that point, is the Minister now in a position to answer the question I asked in this House on 7 December—namely, given that it is a time-limited application, will the Government be applying to the European Union Solidarity Fund for assistance that can be given to local authorities to invest in new infrastructure?

It is clear from what colleagues have said that we need a comprehensive review of our ability to manage flood risk in the future, first because of our need to adapt to climate change. We need only consider the extremes of weather in December and the fact that already nearly 2.5 million homes are at between one to 100 years’ risk in the UK. On that point, it is disturbing to note that in Defra recently the staff of the climate change adaptation team have been reduced from 38 to six. That is an extremely worrying indication of the Government’s priorities in this area. I hope that the review looks at staffing levels as well as overall resources elsewhere.

I wanted to briefly cover two points. First, the current conventional approach to flooding that has been taken by both the Environment Agency and the Treasury focuses very much on project-specific approaches and, as the right reverend Prelate the Bishop of Leeds said in his opening remarks, on a cost-benefit ratio, which does not help those in rural areas in particular, where the numbers are far less than in urban areas. We have therefore seen political pressures from Members down the other end, and rightly so, for more concrete measures to be put in places where they can be seen. While it is welcome that £2.3 billion has been spent on concrete proposals and flood defences, we cannot see that there has been any real forward movement to ensure that natural capital is taken into consideration in the decisions about where flood defences can be put, particularly, as others have said, around the upper catchment areas.

Under the coalition Government, the Natural Capital Committee was established, which made it quite clear that although, as the noble Lord, Lord Patten, said, there is underlying uncertainty over some areas of the science, in three areas there was a clear economic rationale for where money could be spent and benefits could be seen: woodland planting, peat restoration, and wetland restoration. At the moment, the national infrastructure plan seems to stand in splendid isolation, with no consideration of any forms of natural capital. It merely looks at hard, concrete forms of roads, flood defences and other infrastructure. I would hope that the review would look at the national infrastructure plan.

Secondly, as other noble Lords have said, the scale of housing that this Government are looking to move is incredible. I do not doubt their commitment to achieving that, but we have to ensure that the review also looks at the planning implications of this massive increase in housing and infrastructure.

My Lords, I am extremely grateful to the right reverend Prelate the Bishop of Leeds for promoting this debate and to all noble Lords who have taken the opportunity to look beyond the short term. I apologise that I cannot refer to all the excellent contributions but, in the limited time that I have, I would like to raise the following points.

First, it would be helpful if the Secretary of State would acknowledge, unequivocally, that the unprecedented rain and flooding we are confronting today is the result of climate change. It is not an unusual freak of nature; it is part of a trend. It was predictable that climate change would make the UK warmer and wetter and that is exactly what has happened. This is why, as my noble friend says, the outcome of the Paris talks is so important.

Secondly, we welcome the Government’s announcement of a national flooding review. It is crucial, however, that it is based on the best independent research and evidence about river flows and catchment management—I take the point, of course, that this is a developing science. We know, for example, the advantages of reafforestation in upland areas in absorbing excess water, but we need better scientific advice on where to locate new plantations of trees and woods to maximise their impact. Equally, sustainable drainage systems have a role to play, for example, in reinstating lost wetlands and providing essential flood relief. They also have the added advantage of providing social and environmental benefits.

Every time we add something new to the landscape, or interfere with natural water flows, we risk unforeseen ecological consequences and potential conflicts. All the evidence so far suggests that leaving rivers and streams to meander—with wood and vegetation accumulating as natural obstructions—will slow the river flow and limit flooding. Yet the Secretary of State announced last week that farmers are to be given greater powers to dredge and clear water courses to prevent their fields flooding. Apart from the adverse impact of speeding up rivers and streams, this seems to contradict a previous Environment Agency report, which concluded that rivers that are artificially dredged silt up more frequently and the only real solution is to tackle the creation of silt upstream. What independent advice was received before this announcement?

I do not pretend that managing the sometimes conflicting interests of farmers and urban communities is easy. Flooding fields may be necessary; farmers need to be properly compensated and we need to properly evaluate the effects on food production. Surely, though, we also need to take a stronger stance on clearing land, for example, for grouse shooting, which has little public benefit and has been identified as one of the sources of the recent flooding above Hebden Bridge.

Finally, these conflicts underline why the government resilience review needs to be free from the influences of vested interests, transparent in its work and authoritative in its recommendations. I hope that the Minister can reassure me on these issues in his response.

My Lords, I am most grateful to the right reverend Prelate for securing this debate. Across the United Kingdom, many people have endured their homes and businesses being flooded and devastated. I echo what other noble Lords have said today in expressing my deepest sympathies to all affected. December last year was the wettest on record and the wettest calendar month since records began in 1910. In relation to what the noble Baroness, Lady Jones of Whitchurch, said about climate change, the view is that the recent heavy rainfall is consistent with this general picture, but it is not possible—and many scientists will say it is not possible—to say that any individual event is directly caused by climate change.

The impacts were, undoubtedly, particularly severe in Yorkshire, Cumbria, Lancashire, Greater Manchester and, more recently, in Scotland. Our thoughts are with all those who suffered and we must now use all our energies to help them to recover from this dreadful experience. We clearly owe an enormous debt of gratitude to all those who served during this extremely difficult time, including the fire and rescue service, police, military, Environment Agency, and local authority workers. I also echo what the right reverend Prelate the Bishop of Leeds said about what churches and other faith groups did and what the noble Lord, Lord Greaves, said about the many volunteers in his part of the world. It shows that we have a great country where the good Samaritan is at large.

Recognising the threatening weather forecasts, the Government held daily COBRA meetings, allowing all necessary resources to be deployed early and ahead of the flooding. The emergency services, Environment Agency, and military were on the ground and able to provide immediate help. Supporting assets, including high-volume pumps and rescue boats, were made available to local commanders in all areas. Indeed, the right reverend Prelate the Bishop of Leeds has referred to this. The Government have committed almost £200 million for recovery in addition to our significant, ongoing investment. This funding includes £50 million to rebuild and improve damaged flood defences and £40 million for transport infrastructure. A community recovery scheme for councils to spend on local priorities will provide grants of up to £5,000 for resilient repairs to properties and funding will provide help through rebates on council tax and business rates. Farmers will be able to claim up to £20,000 to restore damaged agricultural land. The noble Lord, Lord Curry of Kirkharle, spoke of his support and, clearly, we need to ensure that support is engaged in a user-friendly manner.

The noble Baroness, Lady Parminter, asked about the EU Solidarity Fund and I will write more fully to her on that. However, the UK taxpayer would still pay for the majority of the funds received, because we would pay more into the EU budget and it would reduce our rebate. We feel that we needed to act quickly; the support packages we have already announced are designed to deal with the urgent needs of those affected.

In terms of investment in flood infrastructure, the Government have committed to spend £2.3 billion on a six-year capital programme to 2021. That means that we will be investing £2 billion in flood defences over this Parliament—a real-terms increase on the £1.7 billion invested in the last Parliament and a real-terms increase on the £1.5 billion spent between 2005 and 2010. Our six-year capital programme gives communities a much clearer view of when schemes will be built. It is intended to reduce the flood risk for over 300,000 households and around 420,000 acres of agricultural land, while avoiding more than £1.5 billion worth of direct economic damages to farmland and securing 205 miles of railway and 340 miles of roads. In addition, government investment will be supported by a further £600 million of partnership funding—£250 million has already been secured, with sources for the other £350 million identified.

The right reverend Prelate’s Question is about how we can help rural areas which may not qualify for large-scale interventions. My noble friend Lady McIntosh of Pickering referred to partnership funding, an approach which means that some rural locations that previously had little prospect of any government funding could now be eligible for a share. The Stroud rural sustainable drainage project is an example of successful rural schemes going ahead with partnership funding. While capital schemes increase the number of people protected by flooding, we know it is also vital that we keep our existing flood defences in good condition. That is why the Government have also committed to protecting the £171 million per year spend on maintenance in real terms over this Parliament.

Partnership working is a key part of flood risk management. I welcome the work of the 118 internal drainage boards, or IDBs. These locally funded and operated public bodies, based predominantly in rural areas, manage water levels and reduce flood risk for local communities. The noble Baroness, Lady Jones of Whitchurch, asked about dredging and the noble Lord, Lord Curry, also referred to this matter. Dredging will be effective in some areas and inappropriate in others. My right honourable friend the Secretary of State’s announcement about making it easier for landowners to dredge relates to agricultural ditches in low-lying areas, where maintaining the flow of water is important to lowering flood risk in the local area. This bears out the fact that different scenarios will work in different parts of the country by having, for example, different trees and uses of contours, as has been said. It is all about the flexibility that we now need to have.

In many places, however, the IDBs are now working on behalf of the Environment Agency to the benefit of the local community. There are numerous examples where this approach is working well. In Lincolnshire, for instance, the excellent partnership of the Environment Agency, IDBs, local authorities and others has produced a strategy for flood risk management across the county. After the dreadful flooding in Somerset, moreover, the Somerset Rivers Authority was established to give local people much more control and power over flood risk.

In Cumbria, my honourable friend Rory Stewart has worked tirelessly as Flooding Minister—that is an absolutely non-partisan thing to say. Those in the locality have echoed this. My noble friends Lord Inglewood and Lord Patten also referred to it. My honourable friend will chair a new floods partnership, bringing together local expertise to publish an action plan this summer. The partnership will consider improvements to flood defences, review upstream options for slowing tributaries to key rivers and build stronger links with the local community. My honourable friend Robert Goodwill is also acting as flood envoy to Yorkshire. Such partnerships are to be encouraged across the country, led by groups of local people who know the flood risk in their area and what should be done about it, with government playing a key role in strengthening and facilitating them.

The noble Baroness, Lady Jones of Whitchurch, and other noble Lords asked how we intend to review flood risk management. Recent events represent an important opportunity to assess our approach and there are undoubtedly lessons to be learned from what has happened. My right honourable friend the Secretary of State has announced the national flood resilience review, to which my noble friends Lord Patten and Lord Inglewood referred. This is to be set up to ensure that the country can deal with its increasingly extreme weather events. Work to consider forecasting and modelling, the resilience of key infrastructure and the way that we make decisions about expenditure has already begun. It is expected to conclude this summer.

That review’s work complements the Natural Capital Committee; I think this was the point that the noble Baroness, Lady Parminter, was taking us towards. The committee is already developing the catchment-based approach, including slowing the flow upstream. Many of your Lordships referred to this. I listened very carefully to the points that the noble Lord, Lord Stone of Blackheath, made. My noble friend Lady McIntosh of Pickering spoke of the Slow the Flow project in Pickering, which is working with the natural environment to reduce flood risk. The noble Baroness, Lady Young of Old Scone, spoke of the range of opportunities for working with and enhancing the natural environment. That is a way forward for us to ensure that we are in a much better position and was echoed by the right reverend prelate the Bishop of St Albans.

We all have an extremely interesting and valuable range of reviews in prospect. I very much hope that we are now into a period of recovery, where we can look to help those affected back into their homes and businesses—although, as the right reverend Prelate the Bishop of Leeds said, we are clearly in a position where the winter and its floods could continue. We should all be very grateful for what the emergency services, the military, the fire service and volunteers may have to do. However, our aim in government is to ensure that long-term investment will help to make our country more resilient. Partnership funding has already made many more rural schemes viable and through working in partnership, and with the active engagement of local communities, we can help to manage flood risk. I assure your Lordships that I will take all the comments made today and share them with my ministerial colleagues, and that the Government and Ministers will be using all the energies that we have to ensure that the whole country is as well protected as possible.

Identity Documentation

Motion to Take Note

Moved by

That this House takes note of the potential use of identity documentation in dealing with the challenges of assuring the identity of individuals.

My Lords, it being a Thursday afternoon, I have received many apologies from Members unable to attend this debate, for which we are all grateful. The issue of identity cards is the issue in British politics that refuses to go away; it haunts political debate. It is not that it is the unique preserve of any political party. Identity cards have wide support in both Houses of Parliament, across the political divide and in the electorate.

The Labour Government did at least try to develop a scheme. They started in 2002 with a national consultation under the heading Entitlement Cards and Identity Fraud: A Consultation Document but, following legislation, the whole programme was plagued with arguments over whether it should be a national identity card or an entitlement card. This finally led to a climbdown as it was moved from a compulsory to a voluntary scheme. The 2010 election then killed the whole programme. The national identity register, a crucial component in the scheme, was then destroyed on 10 February 2011. The personal details of everyone issued with a card under the pilots were also destroyed. We are now left with biometric residence permits for non-EEA foreign nationals, but only because Europe requires them and the system of national insurance cards is completely out of control. The coalition effectively destroyed the whole programme, leaving us exposed to an explosion in identity fraud and crime that permeates every aspect of our national life.

Nevertheless, to be fair to the Government, they have recognised the need to tackle the issue, in particular on the internet. With that in mind, the Government’s identity assurance programme, IDAP, was launched. Under the IDAP model, people assert their identities to government via a series of private sector identity providers. I understand that PayPal, Cassidian, Experian, Verizon and a number of others have at some stage been in the frame. However, although they build relationships with HMRC, PAYE, the DVLA and other departments or agencies, they lack access to the necessary biometric data such as fingerprints, digital iris recognition and facial digital photographs. Their programmes are undermined, despite the “hub”, by the lack of a national identity register to underpin the process of identity assurance. I sense that this approach is born of the mistaken assumption that it will save money. What it fails to heed is that public confidence in identity assurance cannot rely on private provider systems preoccupied with profit and shareholder value. Such identity assurance programmes will fall down as disastrously as did Vodafone, PA Consulting, EDS and others, all of which have lost data over recent years.

Card opponents tell you that the state equally stands accused of sloppy data handling. They quote HMRC’s loss of two CDs in 2007, leaving millions at risk, along with other examples. They did happen. But Germany has built a secure system with a reputation for impenetrability based on a range of biometrics. The system leads the way in Europe, and if they can do it, we can do it. Germany is leading a whole group of European nations, including Austria, Belgium, Croatia, Cyprus, Finland, Estonia, Denmark, the Czech Republic, Hungary, Greece, Gibraltar, France, Italy, Latvia, Luxembourg, Malta, Spain, Slovenia, Portugal, Poland and Holland. Most of those regimes require a passport or a card holding data which we refuse to hold. They are all building systems of identity assurance in which their publics can have confidence. Why can we not do the same? That is the background to the debate.

What do we want? Charles Clarke, former Home Secretary, summed it up perfectly in 2006 when he said that we want,

“a universal scheme for everyone legally resident in the UK”.

His scheme required a fingerprint, a photograph and a signature. I would go further, with iris recognition or even DNA added. If whatever data are finally approved were not to be stored on the card itself, the card could secure, through a protocol and a strong process of authentication and tiered authorisation, access to data, perhaps under three headings: “generally available”, “sensitive” and “highly sensitive”. The accessible information on the chip would relate to information held on the national identity register. The chip would have different layers of defence against physical attack, fault attack and side-channel attack. To compromise a properly designed system, you would have to manipulate the national identity register, which I would say is an impossible task. Again, the German system shows the way. I understand that EU passports are already common criteria evaluated, which means they already achieve best practice for attack resistance.

At this point, I thank Professor Keith Mayes of the Information Security Group at Royal Holloway University for helping me to understand the complexity of such systems. The issue for many of us is whether you hold the data on the card or whether the card authorises access to the national identity register. I believe that the cards should be an access tool to a server, enabling the card to establish basic ID as simply as possible.

What is the purpose of the card? We know that the CBI believes that a single source authenticating personal data would be the best protection against fraud. It foresees reduced costs in maintaining back-up systems. A recent government report entitled Future Identities highlighted that people often have several identities, on and offline. We are told that this, among other factors, is now costing us nearly £30 billion a year in fraud. National identity cards with sophisticated biometrics would help combat that fraud. You might compromise a photograph or a signature, but digitised information is hard to replicate. You certainly cannot have two iris patterns on one eye, two different fingerprints on one finger, or even two different types of DNA.

The purposes of a national identity card fall under four headings: to reduce fraud; to establish entitlement to services; to provide security assurance; and to check identity more generally. In defining the benefits, I have consolidated all three tiers and levels of access I previously referred to—generally available, sensitive and highly sensitive. I see the benefits coming as follows: when using banking or financial services, including credit or debit cards; when buying or selling property and vehicles; when making mortgage applications; when making credit transfers; when entering credit, rental, hire or leasing agreements; when boarding aircraft and other forms of public transport; when accessing public buildings and the workplace; when sitting exams and driving tests; when seeking to reduce HMRC’s tax collection costs; when voting; when establishing identity during police inquiries; when tracing the identity of someone who is deceased; when verifying “fit and proper” in the professions; when carrying out checks on workers at airports and in the caring professions, in particular when early decisions are required; when establishing proof of identity; when tackling impersonation, whether in examinations or, as I have said, driving tests; when tracking the background of false accusers; when tracing bail abscondees; when tracing persons engaged in road traffic offences; when dealing with illegal subletting; when accessing public services, public benefits and pensions; when challenging disability fraud; when dealing with council tax and housing benefit fraud; when establishing on-street identity—if I had longer, I would go into that in much greater detail; when establishing entitlements to concessionary travel and relief from congestion charges; and when investigating organised crime, including money-laundering and trafficking.

The card would be of particular benefit to the Government in checking entitlement to European Union health cards and access to national health services, including hospital treatment. It would give the Government the opportunity to sort out the disaster over the allocation of national insurance cards, and the problem of multiple passport irregularities. It would also bring us into line with other states whose cards already substitute for a passport.

Following the Government’s decision to legislate on illegal working, we should also not underestimate the benefit of the card for the private sector—for landlords checking on illegal tenancies, and for insurance companies in dealing with insurance fraud. The scheme should be tailored to allow them sufficient access at the lowest tiers to establish basic identity in carrying out both statutory and non-statutory duties. The scheme would be particularly helpful to the Director of Labour Market Enforcement proposed in the Immigration Bill. It would underpin his work. Most interestingly, the card would be useful in the enforcement of human rights, particularly for that group of women—invariably in the ethnic minorities—who, with tightly controlled family conditions, are denied basic human rights and even their identity.

I now come to the final benefit, which is crucial. Income tax collection in the UK is not without its problems. It is not helped by the system of self-assessment and reductions in revenue and personnel. Many people in the UK live outside or on the margins of the tax system. They pay no or little tax, yet they often earn substantial incomes while drawing extensively on public services. We who pay our taxes resent the freeloaders, be they foreign or UK nationals. We believe that the state should act to stop this abuse. It is costing the country billions. A national identity card with relevant biometric data would be a powerful tool in ensuring that people pay the state for the services they receive.

I recognise that at first glance, the list of benefits I have identified may appear onerous or perhaps even intrusive, but it is a pick-and-choose agenda which can be tailored to conditions nationally at any particular time. It is an agenda whereby identity today is verified with bank cards, passports, driving licences, utility bills, bank statements, council tax demands, national insurance cards and even marriage certificates—all sources of identity information today. We have all been asked for them at some stage in our private lives. All of them have their weaknesses, causing public concern.

The consultation originally carried out by the Labour Government not only recorded a majority in favour of national identity cards but, astonishingly, found that 75% were in favour of providing all three types of biometric data—fingerprints, a facial digital photograph and an iris digital photograph—such was the level of concern at the time. Today, the cry for reform is greater than ever, and I want this whole debate reopened.

My Lords, I congratulate the noble Lord, Lord Campbell-Savours, on initiating this debate and salute him for his persistence in pursuing the issue. I also thank Mary Santo for her typically helpful and informative Library Note.

My strong support for the introduction and general use of identity cards stems from my time on active service in Northern Ireland when commanding my battalion in west Belfast in 1974 and the Belfast brigade from 1978 to 1980. In 1974, whenever we wanted to prove the identity of someone we had stopped, we had to carry out what was called a P-check, which meant contacting the company base in the area in which the person stopped claimed to live and asking for their identity to be confirmed by checking the P-cards that were held on everyone known in the area. Often, this took some time, and I well remember being increasingly nervous when having to wait for 45 minutes for a check to be carried out in another battalion’s area while standing on a street on which the IRA was very active.

In 1979, it was decided that the whole system should be automated, all the old P-card data being transferred to a computer database. This process proved the inefficiency of the old system, one person being found to have 13 different spellings of his name on 13 different cards. Within days, the operational value of almost instant response had proved the spend-to-save value of the cost of automation.

In 1974, it was almost impossible to persuade members of the public to talk to us, largely because of their resentment of internment without trial, which, fortunately, was ended in 1975. When I returned in 1978, that situation had changed somewhat, with more people being prepared to talk, but the overt presence of armed troops on the streets was an impediment to normality, many people citing frequent P-checking, particularly when newly arrived regiments were getting to know their areas, as a particular irritant. My RUC opposite number often used to say how much easier it would be, for both police and Army, if everyone had to carry an identity card, not least in countering false identity—which sentiment I note with interest quoted in the Library Note as being felt by many policemen today. In consequence, I have always thought that human rights are more likely to be protected than breached by identity cards, because they can be used to prove both who someone is, or is not.

I am not going to go into the technicalities of how this can be done with an identity card, because I know that the noble Lord, Lord Marlesford, will discuss biometrics, for example. Instead, because time is limited, I want to mention another practical use of identity cards of which I have long been in favour, not least because of its value in countering false identity. Every time someone is received into prison, they are given a new prison number, which is inefficient because it denies automatic access to previous records without a considerable amount of checking and comparing data. After prisoners are released, they have to apply to a jobcentre for any benefits to which they may be entitled, which takes time, during which they have to try to live on their £46 discharge grant.

When I inspected the prisons in the UAE for an extradition case, I found that prisoners were given identity cards, using the same number as their national identity card, which they could then use for many purposes such as access to medical provision, use of the library, or to record canteen purchases. But staff told me of the immense value of no longer having to carry out much time-consuming bureaucracy. How much simpler it would be on our prisons if an identity card number could also be used as a prison number, an NHS number and a national insurance number, all of which is perfectly possible given the power of current computer systems. Not only would this make life easier for the overstretched staffs of our overcrowded prisons but it would enable automatic access to medical records and transfer of records of treatment during imprisonment. A prisoner’s entitlement to benefits could be processed in prison, obviating avoidable temptation to reoffend in order to survive.

I dispute the Government’s continual refusal to consider the introduction of identity cards—largely, it would appear, on grounds of cost. I invite the Minister to consider that, from the point of view of many public servants, their introduction would be a spend-to-save measure.

My Lords, I too am grateful to my noble friend Lord Campbell-Savours for giving us the opportunity to debate this extremely important topic. I was shocked to discover the other day that it is slightly more than 40 years since the first episode of “Fawlty Towers” was broadcast on television. I am sure that many remember that first episode, which introduced Basil Fawlty to the nation; he was a hotel owner, as many probably remember. He comes across a person describing himself as Lord Melbury, with whom he naturally forms a sort of fawning relationship, believing everything that he says. Lord Melbury, of course, as those who have seen the episode will know, is a con man. Because Basil Fawlty has no means of verifying the identity, he gets taken for a ride with all the ensuing consequences.

The principle of enabling citizens to verify each other’s identity is actually an extremely important one, and has become more important in the 40 years since then. It is a matter of considerable regret to me that the last Labour Government attempted to mis-sell the concept of identity cards and identity assurance in that way. I am quite clear that identity cards would not have been a magic bullet against terrorism, or serious or organised crime, but it would have been an assistance; it would have made things easier for the police and security services, and would have saved time in verifying, but it would not have solved those fundamental problems. But that simple idea of having an identity register and connecting oneself to it would have enabled citizens to prove who they were and—as the noble Lord, Lord Ramsbotham, has just told us—who they were not, very quickly. It would have been tremendously easy. At the moment, when we have to verify our identity, we are required to produce a passport or driving licence. I do not have a driving licence, simply a passport, which I have to find and not lose. You are then required to produce a recent utility bill, sometimes two, at a time when the utilities are trying to get us all to manage our accounts online, so we do not have that piece of paper which signifies our name and address. In my case, at least one utility has my name wrong. It is mis-spelt. That does not matter in the provision of the service concerned, but it is a pain in the neck when I am trying to prove I am who I think I am.

We are now increasingly reliant on being able to demonstrate who we are and to satisfy other people about that. It is more necessary than it ever was. It is becoming increasingly important online, so some mechanism which would span this and enable us to identify ourselves online is crucial. It is a protection for business—as in the case of Basil Fawlty—and for the public. Who am I dealing with online? Who am I dealing with face to face?

Concerns expressed about the idea of a state-run identity system are either about cost—and as the noble Lord, Lord Ramsbotham, has already indicated, they are not very convincing—or are something to do with civil liberties. Let us be clear that if the state does not take on this function, others will. In fact, I am surprised that we have not yet got a series of major commercial operations offering us an identity service of this sort. Some of them do so on a fringe basis, but there is nothing that is comprehensive and effective. Would that be any less scary if you are worried about your personal privacy than the Government providing the service?

We already give out an enormous amount of information, such as via supermarket loyalty cards. One such scheme identified that a woman was pregnant before her family knew and started sending her material about pregnancy, which caused a certain degree of embarrassment. There are phone data and payment cards. Until I switched it off, my mobile phone, in a rather obscure location, produced a map of my favourite places. For all I know, it still does. Certainly, that data may well reside or be updated on a regular basis on a Californian server. It tells them—or me, if I did not know it already—where I spend a large amount of my time. If you looked at the map, you would find I spend a large amount of time at this end of the parliamentary complex. I try to confuse it by spending a lot of time in Portcullis House, but it was still clear. That gave one marker, as far as I was concerned. It demonstrated that I spend most nights in north London on the borders of Haringey and Islington, another marker. When I was heavily involved in the Metropolitan Police, it would demonstrate that I spent a lot of time just opposite St James’s Park Tube station. You are beginning to get a pattern, but what is the significance of being told where I go for my morning coffee on my way to work? We already have all sorts of things managing our identity and intruding on our privacy. Would it not be better if we had a simple system on which everyone could rely that was run on our behalf by our nation state?

My Lords, I am basically on the same side as the noble Lord, Lord Campbell-Savours, on this matter. However, I approach it from a slightly different point of view. The key words in the Motion are,

“assuring the identity of individuals”.

Why is this Motion so opportune and sensible at the moment? It is because the Government of this country are faced with a huge challenge to their most basic responsibility: to assure the safety of individuals. That is of course a challenge faced by all EU Governments. The threat of Islamist terrorism, although quite different, is as great as that which the West faced during the Cold War, and certainly far greater than that which the UK faced during the Irish Troubles. This is a moment when the acceptance of the balance between privacy and national security has shifted, and must shift, dramatically.

“Identity documentation” is no longer the key phrase; rather, it is “identity verification”. There has been a tendency to assume that the value of identity documents, whether passports, driving licences or ID cards, can be enhanced by the inclusion in them of biometric data. Indeed, that may be the case in the majority of instances. Where it really matters, though, in serious crime and above all in terrorism, it is a dangerous illusion. For the sophisticated criminal or terrorist, it is not a problem to replace on any document the biometrics of the legitimate holder with those of the person who is carrying the document. The biometrics will match so that when you produce the document, yes, it matches and you are who you say you are, but you will not be.

The only secure method of identification is for the biometrics of the person to whom an identity document has been issued to be matched online with biometrics stored centrally at the time of issue. For that, what we need is not a secure document but merely a secure number. What is urgently needed in the UK is the abolition—the abandonment—of the chaotic multiplicity of identity numbers and the introduction of a single identity number. This should be used for passports, national insurance and tax, driving licences and other state permits, as well as for the National Health Service. It would of course be the primary number used for the security, police and prison services, as the noble Lord, Lord Ramsbotham, said. It would be possible for the standard number that everybody had to have an added prefix, or something added on after it, to separate it according to its use, and of course to build in all the necessary safeguards so that access to the fundamental data could be restricted according to the authorisation of the person applying to get the information, so it would all be stored and very safe.

Over the years I have asked Parliamentary Questions on what I have just described as the chaos, and, frankly, I have had the most absurd answers. With regard to travel documents, the Government still lack records of what other passports a British passport holder possesses. Not surprisingly, we have had the dangerous absurdity in increasingly numerous cases of terrorist suspects on bail skipping out of the country, either because they have failed to surrender their passports or because they have had second or third passports that no one knew about. I am putting down an amendment to the Immigration Bill once again, for the third time, to deal with this. It should of course be standard practice to cancel any passport electronically so that the actual document is unusable.

The Government do not even know how many national insurance numbers there are in use and say that it would be too expensive to find out. Non-British nationals can obtain our national insurance numbers even if they only have time-limited visas. The Department for Work and Pensions does not cancel the numbers when they expire; it just keeps them, so there must be millions more than the entire population. To give the House an example of that, there are approximately 72 million live NHS numbers in England and Wales, while the population of those two countries is 56 million. Presumably, some 16 million non-residents are on the books of the NHS. Can we really afford this?

I believe that the survival of European civilisation, which historically has been based on democracy, Christianity and the nation state, is today under challenge from the jihadists of Islamic State. We must act to defend it, and I hope that the Government take this debate as a starting point for urgent action.

My Lords, I, too, thank my noble friend Lord Campbell-Savours for obtaining this debate and for the excellent way he introduced it. I hope the noble Lord, Lord Marlesford, will not mind if I do not follow him directly down that route, but I can inform him that I believe his suggestion is very close to what the Government intend to propose at some point in the near future.

I will take this debate one stage if not several stages further. We are living through a technological and scientific revolution that has changed the world more in the last 50 years, and will increasingly do so in the next five or 10 years, than has ever happened before in the history of mankind. That is the world we live in. I want to move from the idea of an ID card to what I would call a smart card for all. Such a card would of course do all the things my noble friend said as regards introducing security, giving people the right to know what is on it, and so on. However, I want that to be a smart card which enables people to put on to it all the information we hold.

Every one of us in this Chamber and probably in the Houses of Parliament as a whole has a form of identification. I hang it around my neck, because I do not assume that the policemen at the gate automatically know who I am. At the end of the day, that is an ID card. It opens doors—I have only to put that on to a door and I can open it. I have a driving licence in my wallet, a passport at home, bank cards and a whole series of membership cards for different organisations. Why should I not just have one card, with some form of identification on it—a fingerprint or an eye scan, or whatever it might be, or even DNA, as my noble friend suggested? That would mean that I could get rid of all the various forms of ID I have at present because I would have one card. I accept that people might say, “But you might lose it, so maybe we should have three or four cards”. Despite what the noble Lord, Lord Marlesford, says, people will not find it easy to reproduce it, so even if you lose it, it will become just a piece of detritus that you can leave. Eventually, however, there will be a chip in the back of your hand, all the information will go on to that, and you will put that on to things.

Turning to the commercial aspect, the Government are talking to the banks about the idea of them paying for some of this. Banks and those who deal online, such as travel agents, or people who sell online on Amazon, will increasingly want some form of ID—a way in which they can establish the identity of the person who buys their goods or who goes to the bank machine, and know that that person is who they claim to be. Therefore, the banks may in the first instance put an extra slot in the bank machine so you can put in your ID card and then your bank card. It would be even better if the bank could put its banking services on to that single card, so you put one card in the machine, put your fingerprint on it or let it scan your eye, and then the bank could say you are the right person.

That is the world we live in. The technology is already there. I am sorry to have to say this to my noble friend Lord Harris of Haringey, but the fact is that the Apple iPhone 6 is available with a fingerprint control, and you can bank with it and buy almost any goods with it. So we already have the technology. You have to use some form of card—although, I accept, not an ID card—on London Transport buses because they will not allow you to use cash any more. Cash will be a thing of the past—in the next 10 or 15 years it will have gone. Cheques are already going and cash will go next.

That is the world in which we live. If this place does not keep pace with that technology, we will be in very grave danger of not keeping up with what is going on in the world outside, and if that happens, we will start to lose democracy itself.

Perhaps I may tell the noble Lord that in York, none of the machines taking cards would work because of the awful floods, and people could not buy food from the supermarkets. They needed cash.

My Lords, I, too, thank the noble Lord, Lord Campbell-Savours, for initiating this debate. However, I am going to break the cosy coalition of those who believe that the state is the sole, and safe, guardian of my identity. I say that because I have listened to the debate and am still not clear what the problem is. It is not for me, as somebody who does not believe in ID cards, to defend the status quo; it is for those who want a change to prove that there is a problem and that ID cards are the effective solution.

Let us look at the real world outside this cosy Chamber and see what is happening in the countries that have ID cards. Many noble Lords have mentioned different countries, such as Germany, Spain, Italy and France, in talking about crime. Can any of those noble Lords or those yet to speak who wish to have ID cards point to a direct correlation between a reduction in crime levels and the citizens having ID cards? We need proof, not general statements. Those who suggest that ID cards will reduce the incidence of crime should give the statistics that show a correlation between ID cards and a reduction in crime in Germany, Spain and France.

It is also said that ID cards will somehow be effective in reducing terrorism. I remind noble Lords of the horrific attack and terrorist atrocities in Jakarta this morning and the appalling attacks that we have seen just across the water in France. Indonesian citizens carry ID cards, as do the citizens of France. Have those cards made them any safer? If noble Lords can show me a correlation between identity cards and a reduction in terrorism in those countries, I will support them.

We also hear about identity fraud. Again, I would like to see statistical evidence that there is more identity fraud in this country than in countries that have ID cards. I ask noble Lords to show me the facts. Most identity fraud now occurs online, and in the countries that I have just talked about national ID cards are not used to prove your identity in commercial transactions.

Benefit fraud and taxation fraud, which the noble Lord, Lord Campbell-Savours, talked about, have been given as reasons for bringing in ID cards. Most people do not lie about their identity in such cases; they lie about their financial circumstances. So, again, I ask noble Lords who support the introduction of ID cards to give me the facts which show that in countries with ID cards there is less taxation fraud and less benefit fraud.

Perhaps I may put it to the noble Lord that, if the nature of the population of a particular country changes for whatever reason, his argument falls apart because one is not comparing like with like.

My Lords, I am comparing like with like, because those who argue that ID cards work are suggesting that somehow the problems that they have suggested will be reduced. The noble Lord next to me made it very clear that he did not believe that they would wipe out these problems, but I am asking for the evidence that shows that they will reduce them: that is all I am asking for. I accept that they will not wipe them out or get rid of them, but I wish to know whether there is scientific evidence in those countries that shows that these problems have been reduced—because if there is not, we do not have a problem and our system works in a comparable way to that of other nations.

The last thing I will say on this issue, because I do not have time to go into the civil liberties argument, is that it is really important for British civil liberties and freedom. Part of what makes us British—the British values that some go on about—is freedom, and the state not having overall control of our identity. In dealing with this issue—and particularly crime and terrorism, where recently this debate has come up most—we would be undermining the very British values of freedom and civil liberty, and the criminals and terrorists would have won, if we were forced to have compulsory ID cards.

My Lords, a few days ago I listened to an interesting item that is a matter of concern to many people. So far in this debate, noble Lords have covered a number of subjects concerning identity cards. I will address just one problem. If somebody wishes to work with children or if they want to foster or adopt a child, there is a strict process that must to be completed, with a DBS certificate being issued. This involves the Disclosure and Barring Service—the DBS—which was previously the Criminal Records Bureau. A criminal record check is required for types of work known as “regulated activity with children”—and this covers people who do not even meet children frequently.

Having read a little about this matter, I have to say that I am astonished at the number of acts which are covered. An incredibly large number of people apply for a job for which the employer is required to request a DBS check and has to wait for a certificate. This is sent to the applicant, and the employer has to ask for visual confirmation of approval. The time it takes to complete the necessary check depends on the level of the check, the details provided by the applicant wanting to work with children and, finally, which police forces need to be involved in the check. Generally, it takes about eight weeks to get a DBS check. It must be remembered that a lot of people wanting to work with children are unemployed and might want to work as soon as possible.

However—this is why I am raising the matter—the current process that is meant to take eight weeks rarely achieves that, and there are those who are still waiting after three or four months. Why? The programme indicated that this delay was due to the number of applicants and to the police force involved, and it was said that there were approximately 120,000 people waiting in the Metropolitan Police area—which gives an idea of the number of people who want to work with children.

There has to be something that will overcome this problem. How about a special identification card for everybody to carry which can be updated when necessary, specifically for those who want to work with children? Would this not be an easy and cheap way out of these difficulties? It would be much cheaper than the current system.

My Lords, I, too, thank the noble Lord, Lord Campbell-Savours, for introducing this debate. I take the view that ID cards are an idea whose time has come and I support exactly what the noble Lord, Lord Harris, said about an increasing number of people—a more and more rapidly increasing number of people—living a lot of their lives online and being quite prepared to give up information freely online. ID cards—state ID cards—are a natural extension of this process. My expertise, such as it is, is in security, and it will be on that aspect in the main that I will talk briefly.

False identities are an absolutely staple terrorist tactic. In answer to the questions from the noble Lord, Lord Scriven, in these troubled times it is not so much about the prevention of terrorism but its investigation. The police and the security services have an increasingly desperate concern in long-term inquiries, and sometimes in emergency inquiries, to establish the identity of individuals.

Is it not the case that, following the two major terrorist attacks in the UK, particularly the one in London, of the 99 recommendations given, quite a lot of those were about people already known and the security forces not acting on the data that they knew? It was not about a lack of data.

I am sure there were some recommendations like that, but perhaps when I have finished the noble Lord might see the opposite side of the coin.

It is this search for identity that lies behind the troubled development of the DNA database. The same reason lies behind the coming forward of the investigatory powers Bill and the question of ID cards.

I remind the House of two names: Kamel Bourgass and Manfo Asiedu. Bourgass was convicted in 2003 of the murder of Detective Constable Stephen Oake in Manchester. He was sentenced for that and other terrorist offences to 25 years in prison. Manfo Asiedu was the fifth bomber in the failed London attacks of 21 July 2005. He ran off across Wormwood Scrubs, throwing his device to the ground. He received 33 years’ imprisonment as a sentence. The thing that connects these two men is that at the time of their conviction we did not know who they were. As far as I can accept, we still do not know who they are. We know that the names they have given are not their right names. This is simply absurd. The links that we might have been able to establish to other plots and other people had a system of ID cards been in place are pretty obvious.

I need to make one issue clear, and here I disagree with the noble Lord, Lord Ramsbotham: nobody I know in the police or security services who has considered this seriously sees a need for people compulsorily to carry identity papers in the street. This is not a question of a police officer demanding papers from somebody walking down the road. However, in the case of serious crime and terrorism, the police need, as soon as possible, to establish identity. These days, it would not be difficult to create a system that would not be intrusive but would be of huge assistance in those inquiries.

As the Foreign Secretary said today, speaking about Jakarta, these are troubled times. These troubled times are on our very doorstep. I speak now to the Minister: I never understood why, as far back as the 2005 general election, the Conservative Party resisted the idea of ID cards. After Paris, after Istanbul, after Jakarta, I do not think the public will understand why the Conservative Party is still resisting the idea. It is an idea whose time has come.

My Lords, I want to focus on some of the issues that I have been investigating in my work to try to encourage more rail freight, passenger services and other traffic across the channel, the pretty disastrous camps that have been created in Calais and the pressure that is on many people who want to come to this country.

Before I do that, I would like to reflect on something. We have been talking about the different identification required for different events, including people going into buildings and so on. More and more, organisations require that but, on the other side, nobody is required to carry any ID at all. A couple of years ago, I was invited to go and visit Prince Charles in Clarence House to advise him on rail freight. I turned up on my bike and the security guard said, “Where’s your driving licence?”. I told him that I did not need a driving licence because I was on a bike—I did not have one anyway. “Where’s your passport?”, he said. I am afraid that I then said, “Are you a foreign country?”. I offered my House of Lords pass, but that was rejected out of hand. There needs to be some consistency. It is lovely being amateur like this but, given today’s problems, it is pretty ineffective.

I have talked to a lot of people about the problem in Calais. It is dramatically affecting cross-channel traffic, including businesses, passenger services, freight services, lorries, cars, trains and so on. It affects not only France but Germany, Italy and other countries.

As to what documentation people need to show the authorities, I agree with my noble friend Lord Campbell-Savours that the Germans have got it right, for many reasons. They still have a terrible fear of what the Stasi did to them over 25 years ago and are keen to have data that do not leak everywhere. We should try to get all the different immigration and other services together and come up with a common approach which would allow you to go on a train from, say, Germany to London without getting off at Lille and wasting two hours while you have to go through security again. The fact that they cannot reach agreement means you have to go through this 19th century procedure.

One of the issues that arises in many discussions is: why do people want to come to this country? Clearly the Government do not want too many people here, unless they are going to be useful and work and so on, and so they are stuck in Calais. We have had many debates as to the reasons. Clearly one is that we speak English and, like most of the rest of the world, the country they come from probably speaks English as a second language. If they have family and friends here, one can understand why they want to come here.

The evidence I have gathered from talking to a lot of people is that one of the great attractions in getting here is that you can survive without any ID. You can work cashless. Whether that is in the restaurant or café trade, agriculture or anything else, there are a lot of places where you can get by without having to pay tax or declaring anything. You do not need any social security identification but you can probably still be treated in hospital if anything goes wrong. If you visit a hospital in France as an emergency, you will be treated. Otherwise you will have to show an ID, a passport, an insurance card(?) or something.

Having an identification requirement in this country—I am not expert but other noble Lords have provided good information about it—would reduce the pressure on us. We should not think that this problem will go away because, if the Calais situation is tightened up, which the Government are quite good at doing, all that will happen is that people will go round the coast, to the west and to the north, and choose other ways of getting in. As we saw in the press, one of the Paris bombers apparently came into this country and out again without being detected. So detection must be properly carried out.

We need some form of identification in this country together with enforcement. I notice that there is a clause in the Immigration Bill that allows the Government to take away driving licences from people they do not like, but what else can they take away? It would be better if the system were co-ordinated because eventually the message would get back to people who are trying to come here that we are no better or more attractive than any other part of Europe. We hope that you will think carefully before trying to come to this country because you think you can work here on the cheap, without paying tax and without having any ID.

My Lords, I am grateful to the noble Lord, Lord Campbell-Savours, for introducing this fabulous debate.

In answer to the noble Lord, Lord Scriven, the problem is that we do not have one clean, reliable identity database. Can any noble Lord, or anyone inside or outside the Chamber, tell me why we get so excited about DNA profiling? My DNA profile is a matter of fact: I cannot alter it; it will not change with my age; it is not a choice that I have made. One of its beauties is that it can be boiled down to 70 characters of 16 groups plus a gender marker. This could be put on to a computer database which can easily be searched.

To verify every citizen’s identity à la the old ID card system is an exceptionally time-consuming, intrusive and expensive process, which is why it was binned in a former Parliament. It is also a pointless exercise because most citizens are honest and have a driving licence that is reasonably accurate. We have similar problems with Criminal Records Bureau checks because essentially they are trying to establish identity. We could give every citizen access to the driving licence system, even if they do not have the ability to drive, and then put more effort into cleaning up the relevant database. I agree with much of what my noble friend Lord Marlesford said because the advantage of the driver number is that it is easily determined from one’s name and date of birth.

But I would go further. I would capture the DNA profile and fingerprints of every UK citizen and link them to what is currently the driver number. The DNA profile would be loaded into the national DNA database with its current very strict access controls. The fingerprint data would have broadly the same availability as the data collected for the biometric residence permit, with some facility for banks and building societies to verify a card. One’s DNA profile and fingerprints are both matters of fact, and of course there is no need to carry a card because authorities can test fingerprints with mobile equipment. Having a card is simply a convenience; it is about the underlying reliable identity system.

Much more sensitive, I think, is who a citizen has been communicating with and where in the UK he or she has been, a point made by the noble Lord, Lord Harris of Haringey. I will deal with some of the most obvious DNA worries. The first is genetics. My understanding is that the DNA profile does not have enough information in it to identify a genetic disorder or predisposition to a particular illness. In any case, my second point is that the national DNA database will check only if a profile from a crime scene matches a subject profile. It will not generally provide a subject profile to law enforcement authorities or anyone else, and there is no need to do so.

My third point is that an innocent British citizen abroad would be disadvantaged if he is matched to a crime scene profile because the local law enforcement agencies could become lazy and think that they have “got their man”. Actually, the current system has this weakness. Let us take as an example a 25 year-old British lad on holiday who had been involved in a punch-up in the UK five years previously. He would be in the same unfair situation. This would not happen if all UK citizens were on the database without any discrimination. In the event of a nasty incident with a crime scene DNA profile available, it would not be so remarkable if a Brit matched the crime scene profile.

Finally, there is the argument that central government is incapable of managing a big IT system. The fact is that the Home Office is successfully managing the DNA database. As I understand it, only around 40 officials can actually access it, and presumably there is only one normal point of access, while the records hardly ever need to be edited or updated because of their nature; they are matters of fact that do not change. That is rather different from other records such as health records. In my view, public and political opinion on the use of DNA profiling is governed by fear and misunderstanding rather than logic. We should give all citizens a reliable system of identity rather than go for an intrusive and bureaucratic process of trying to verify everyone’s ID.

My Lords, I, too, thank my noble friend Lord Campbell-Savours for introducing this debate. I always thought that it was a great pity that the last attempt by the Labour Government to have identity cards was abandoned on the grounds of research by, I am ashamed to say, the LSE that it would be too expensive. As noble Lords know, India has just instituted an almost universal identity card system called Aadhaar, which 900 million people have already got.

The Aadhaar card has been extremely useful for transactions with banks, claiming subsidies and accessing the welfare state, especially for very poor people who normally do not have proof of identity. The fact that they have very easily provable identity—I think because of the biometric data—has not only liberated a lot of people but reduced costs across both private and public transactions. If we are going to have this, could we ask the Indians to do it for us? They would probably do it for one-tenth of the price of anyone else and they are very good at it.

Let us not demand too much of such a card. First, having a universal identity card in everyone’s possession shows universality of membership of a community. It is very important that we are all part of the same community. Secondly, in relation to what the noble Lord, Lord Scriven, said, everything about me is known. It is not possible for me to have my individuality hidden and under just my control. As many noble Lords have pointed out, Walmart and Google know it. Recently I was writing a book and I was told that my book had to be more interesting because someone reading a book on a Kindle reads only four paragraphs at a time. Therefore, every fifth paragraph has to be exciting. Any time I use a phone or a Kindle, or do anything, somebody has mapped me. So I am not a free citizen.

We need first of all to make quite sure that our different numbers—our national health number, our national insurance number and so on—are co-ordinated. If we are to use a driver’s licence, people like me who do not drive will have to get one. We need some form of identity with a photograph and biometric identity information. It should be universal, and be able to be used for all bank transactions and any purchases, including bus travel and so on. If we do that, the saving in transaction costs would be enormous. The World Bank has admitted that just having these cards is saving India $1 billion per year, which is a great saving.

There will be terrorism anyway. In terms of separating people, those who have identity cards might be easier to map and those who do not have them definitely can be treated as suspects. The use of ID cards will not get rid of terrorism but it will ease our lives in many other ways, which is why we should do it.

My Lords, I am pleased to speak in this debate. If ever I wondered about the need for a Liberal party, I do not wonder after hearing the comments today. I was proud to be part of the coalition Government in 2010 who repealed the Identity Cards Act 2006 and who ordered the destruction of the national identity database. I am also proud that my party has been consistent throughout its history in opposing national identity card schemes. Indeed, it was the only party that opposed from the outset the Labour Government’s attempts to impose identity cards in 2004. I am also pleased to follow my noble friend Lord Scriven in opposing the suggestion again today.

There are many reasons, both of principle and practicality, why a national identity card scheme is a very bad idea. The most important issue of principle is that it would fundamentally alter the relationship between the state and its citizens. It violates the fundamental traditions of Britain that have kept our liberties safe.

We need to be really clear about what a national ID card system, with a national ID card database, actually means. For the first time in our peacetime history, the state would have the power to demand information from every person in the land, not in order for them to travel or gain an internationally recognised travel document—a passport—or to prove that they have complied with the driving test, or even to gain access to a public service, but simply because they exist. For the first time in peacetime, every person in this country would be compelled to attend a designated place, to be fingerprinted and to have their biometric data taken from them. On every occasion that a citizen moved house the state would have the right to know. More than that, every citizen would be under a duty to inform the state, and a penalty of severe fines, if they moved their premises.

An ID scheme is being discussed here as if it is just some administrative system. It is a fundamental departure from the way we operate in this country. I can think of no other common-law country in the world that operates a national identity scheme—none. Indeed, we have heard comments from noble Lords telling us how popular a national identity system would be. I wonder about that, because there are two common-law countries that thought about introducing such a system: Australia and New Zealand. They backtracked pretty rapidly because as soon as the public actually knew what it meant they changed their views on it rather quickly. Indeed, I can think of no other democracy in the world that operates a national ID scheme that does not offer its citizens the protection of a written constitution and a Bill of Rights.

Does the noble Lord not think that India is a democracy? Does it not have a written constitution? It has an identity card: 900 million people have such cards.

But does the noble Lord not believe that India is a democracy? He said that no democracy has it, but India is a democracy.

India has a written constitution. I said that no democracy in the world operates a national identity system that does not have and does not afford its citizens the protection of a written constitution, which India does, and a Bill of Rights, which India also does. The noble Lord makes my point rather clearly.

I will rapidly wind up my comments, but I want to address a couple of specific things. The noble Lord, Lord Blair, told the House about circumstances in which the police and the security services did not, and still do not, have information about who somebody actually is. He also said that the police would not need to stop people and demand papers from them, but in those circumstances it is not clear to me how he could be absolutely sure that the people he refers to would have had documents. If the police are not checking for them, it would certainly be possible for people to avoid that.

The noble Lord, Lord Campbell-Savours, had a lot of faith in biometric data, but as we have heard evidenced, 10% of French biometric passports have been found to be forged. The noble Lord, Lord Berkeley, spoke about illegal workers and tax evasion, but as we know, places such as Italy, France and other countries with ID cards still have to deal with those problems.

A national identity card system would not protect us from terrorism, or stop illegal immigration or illegal workers. But above all, it would violate the fundamental principle that, in this country, it is the state that accounts to the people; it is not the people who have to account to the state.

My Lords, I join those who have congratulated my noble friend Lord Campbell-Savours on initiating this important debate and, indeed, on his powerful speech.

I am one of the dwindling number in your Lordships’ House who carried my identity card during the war when I went to school. I had no problem with that: indeed, I was rather proud to have an identity card. Now, of course, the argument is made that that was wartime. Make no mistake, we are currently in a de facto war situation. Call it ISIS, call it Daesh, call it what you will, but the growing number of terrorist groups means that we are at war. In these circumstances, we have to use every instrument we can to try to protect ourselves.

The noble Lords, Lord Scriven and Lord Oates, have elevated the carrying of identity cards to some great principle and say that it is quite wrong that the state should be involved. They have argued that identity cards do no good at all. No one in this House has argued that the use of identity cards is a silver bullet and will solve the problems we are experiencing—of course they will not. However, they are a necessary tool which I believe must be used.

The second argument is the civil liberties one. Again, the noble Lords, Lord Scriven and Lord Oates—perhaps according to the script—promote that argument. Civil liberties are not absolute; they cannot be absolute. No organised state can operate on the basis of vanity. The noble Lords say that the state does not demand this and does not demand that. How far do they take that argument? Are they saying, for example, that it is wrong for the state to say that, if someone wants to drive, they must have a driving licence? Is that the case? No, of course not. That is the trouble with taking things to ridiculous extremes. To say that identity cards pose all sorts of challenges is quite mistaken. It is the duty of a state to protect civil liberties. Indeed, I would be the last to allow the state to infringe my civil liberties. However, civil libertarians have a right and a duty to defend and nurture the state and the society which make those civil liberties available. That is where I part company with the Liberal Democrats in particular as they do not recognise that those of us who are involved in society in this country have a right to defend ourselves and, indeed, to make things better.

Of course, there are many different identity schemes around. For example, I carry a driving licence, as do many people. I also carry a bank card, two supermarket loyalty cards and my Automobile Association membership. I say “Automobile Association membership” in case saying AA membership is misunderstood. I also carry my Labour Party membership card and an organ donor card. People ask why it is necessary to carry anything else. It is vital that we understand that although these different cards cover a broad spectrum, it could be argued that the cards I carry are perfect cover for someone who is up to no good. It just depends how you look at it.

We have to understand that all cards currently in use are vulnerable to one extent or the other. Of course, the use of biometric passports is improving the situation. However, the fact is that there is concern about cards being used in counterfeiting. In the dangerous world in which we live, it is necessary to defend ourselves and at the same time protect our civil liberties. A discussion about identity cards is valuable. Today’s debate will not solve everything but I hope that it will reignite the campaign to introduce identity cards.

My Lords, I want to look at this from a practical point of view. Will the ID cards or a national database work? The first thing I want to know is what is it for? People think that it will help with payments and with fraud but what I want to know is that someone has paid their bill, I do not really need to know who they are. With travel and passports, is this a great reliable thing with the Government issuing it? In 2007, it was admitted that there were 10,000 fraudulently obtained but real passports issued by the Passport Office, because even it cannot protect against everything.

In terms of access, we have House of Lords passes to get in here; we do not really need an ID card especially for that. On medical and NHS matters, we have a number for that. Could it be amalgamated with something else? The problem is that expatriates go abroad; that is why there are more NHS numbers than we have people. All those expatriates can come back here at any point and demand services.

You might want to prove your qualifications; you have a driving licence for that. I suppose you could try to amalgamate things into one card but would you have to change the card every time you got a different qualification? Actually, everything is online now—all they do is look you up. You are not even going to have the paper part any more that says what your speeding offences are and so on.

The other thing such a document could be for is collecting tax, with the NINO, or the national insurance number—but, “Oh, there are far too many of those”. Foreigners working here receive entitlements by paying in and if they come back here to work later on, they are entitled to benefits. If they come and retire here they are entitled to their past history. We have lots of people on the system who may come back. It is not one-to-one so we should not want it linked to ID cards.

So the ID card is going to identify the bad guys—great. Will it work? Does it say “terrorist” or “crook” on it? What does the CRB check, as it used to be called, tell you? What it says is that you have not been caught yet. This is the trouble with these things. The 2004 Madrid bombers, for instance, were stopped by the police, who had no idea that they were terrorists and let them go. Does a card tell you where the bail-jumper is? It does not have a special tracking device on it to tell you who is a bail-jumper; it does not do anything like that.

I point out that 35 million tourists come to this country every year, for eight days each on average—that is just the tourists; there are also all the businesspeople. That is an awful lot of foreign identity documents, issued by all sorts of places which I do not think I had better name; let us call them Ruritania in general, although I can tell you that an awful lot are issued by states that have no interest in helping us whatsoever. How do you check that a document belongs to a particular person, otherwise it is just a flash-and-go card; you look at the picture and maybe it looks sufficiently like the person: “You’ve grown a beard, okay, I won’t worry”? There are portable biometric readers but the trouble with biometrics is that they change with age; even DNA can change a bit but I do not know enough about it to know whether all or just a critical bit changes. What I do know is that, within the limited accuracy of laboratory test results—because they are always reduced to a set number of points that can be compared electronically—you will find that you have duplicate thumb or finger-prints, which, visually, you might be able to see are different. It is the same thing with a portion of DNA; usually it is said to be a one-in-6-million match. That means that, with that level of accuracy in the testing, there are 10 people in the UK with the same DNA as you. Given that most of the population are in the south-east, it means that quite a few of them are close to where you are. So, by coincidence, quite a few people could be stopped who might be mistaken for you.

Another big problem is false negatives. You stick your cash card into the wall to take out some money and you stick your ID card in alongside, you put your thumb on the reader and it then says you are not you. But you have a bill to pay or you have to pay a chap who is trying to do you for dropping litter on the ground—with all these new police powers or local authority powers we are getting. You cannot take out the money so you have to spend the night in jail because it has said that you are not you. The false negatives are very difficult; the moment you try to eliminate them, you lessen your biometric uniqueness. You have to blur it a bit more, because there are huge problems around that.

What I really worry about, which has been mentioned already, is the Gestapo/Stasi issue. Whenever the state has had a huge amount of knowledge about us, it has used it for its own ends. I will mention that at the very end.

It also helps fraud if you have a single number. The US experience of having a single tax number to link all your details makes it much easier. If you can get that off someone plus a couple of other bits, you get everything on them. It is much easier to impersonate them there. Here, it is much harder to get everything and there is therefore friction between the different silos, when something does not quite match if you catch the crooks. They have half your information but not all of it. Of course, if we link up all the databases it will be a magnet for the crooks and spies. The first thing I would do as a foreign agency would be to have someone in there to get the details so that I could put in implants, create identities and so on. It will only give us a false sense of security.

You can actually get a good feel for how someone is by building up a profile of what they do online. Their digital footprint is probably much more critical nowadays. With online feedback and references, you can discover whether people are good or bad by other people in the community telling you whether they are all right. That is how we do things in real life: we get references about people.

To finish off, I recommend a very good miniseries of “Doctor Zhivago” that was done in 2002. Interestingly, it was nothing like the old David Lean romance but all about how a powerful apparatchik with access to information can control a family for his own nefarious ends. We should just be careful that we do not end up with a J Edgar Hoover in the UK starting to control things because he has access to the databases. I am not entirely paranoid but, just because I am, it does not mean to say that they are not out to get me. Another thing I do not want to see is cordon and search to trawl for illegal immigrants or bail-jumpers, for example—how else are these people to be found?—because of the ID card. All I can say is that if you are eating your dinner and the waiters at your great occasion have all been hauled off for checking but did not have the right ID cards, you are going to be pretty cross.

My Lords, first, I add my thanks to those expressed already by so many others to my noble friend Lord Campbell-Savours for securing this debate. It provided us with a real trip down memory lane to be reminded by my noble friend Lord Harris of Haringey of an early episode of “Fawlty Towers” and then to be fascinated by hearing about his favourite places.

As my noble friend Lord Campbell-Savours said, both Conservative and Labour Governments, and the Home Affairs Committee in the other place, have at differing times expressed an interest in, or introduced, identity cards. In May 1995, the Conservative Government published a Green Paper on identity cards. In 1996, the Home Affairs Select Committee in the other place concluded in a report that the balance of advantage to the individual citizen and to the public as a whole was in favour of some form of voluntary identity card, subject to a number of provisos. The committee also stated that only a compulsory card, or one that carried details of immigration status, would have an impact on preventing illegal immigration. The Queen’s Speech of the 1996-97 parliamentary Session then included a commitment by the then Government to publish a draft Bill on the introduction of voluntary identity cards.

In 2004, the House of Commons Home Affairs Committee published a report, following its own inquiry and the publication of a draft Bill by the then Government, which concluded that the Government had made a convincing case for proceeding with the introduction of identity cards. The committee said that the test should be whether the measures needed to install and operate an effective identity card system were proportionate to the benefits such a system would bring and to the problems to be tackled, and whether such a proposed system was the most effective way of achieving this goal. It also expressed the view that the scheme proposed by the then Government would represent a significant change in the relationship between the state and the individual—a point raised by the noble Lord, Lord Oates, who was opposed to going down the road advocated by my noble friend Lord Campbell-Savours.

The Labour Government then passed the Identity Cards Act 2006, which created a framework for national identity cards in the UK and a national identity register. The rollout of compulsory ID cards for foreign nationals began in November 2008 and the rollout of the identity card to UK residents began on a voluntary basis in November 2009. The then Government argued that the Act would achieve less illegal migration and illegal working, enhance the UK’s capability to counter terrorism and serious and organised crime, reduce identity fraud and lead to more efficient and effective delivery of public services. That was not a view shared by the incoming 2010 Conservative-led coalition Government, who immediately passed an Identity Documents Act cancelling identity cards, which ceased to be a legal document for confirming a person’s identity in January 2011 and ceased to be a valid travel document. However, as has been said, the UK Border Agency continues to issue biometric residence permits to non-European Economic Area foreign nationals staying in the UK for more than six months to provide evidence of the holder’s immigration status in this country.

In his speech, my noble friend Lord Campbell-Savours made his case for identity cards in his typically powerful and persuasive manner, and raised a number of points which require a full answer from the Government if this debate is to have any meaningful purpose and not simply turn out to be little better than a talking shop. On previous, very recent occasions when the issue of identity cards has been raised, both in this House and in the other place, the Government’s response has been that they considered money that would have been spent on identity cards had been and was being more usefully spent on better equipping security forces and better securing our borders.

There are two points on that. First, to suggest that we have improved and are improving control of our borders by using money not being spent on identity cards seems a rather doubtful claim from a Government who are nowhere near achieving their own declared objective of net migration in the tens of thousands, who apparently have large numbers of asylum seekers whose claims they have rejected still in this country without even knowing where they are, and who have no real idea how many people are in this country with no authority to be here.

The second point is that the Government appear to see identity cards as an inferior option to investing in other means of improving security and control rather than as potentially another complementary string to the bow. If that is the Government’s argument and I have not misrepresented it, they have to make their case, including by responding in detail to the specific and clear points made by my noble friend Lord Campbell-Savours about the potential wide-ranging benefits of identity assurance and an identity database. As has been said, many other European countries have identity card systems in one form or another in which they appear to have confidence, so it is not some revolutionary, untested idea.

As my noble friend Lord Harris of Haringey and others have said, we also live in a society where, in the light of technological developments, the amount already known about an individual, or which can relatively easily be found out about an individual, by both commercial and other organisations and the state is considerable and seems to expand by the year. As a result, the extent to which it can be claimed that an identity card system and an identity register represent some further unacceptable intrusion into privacy is one on which there are likely to be very different views.

In the House of Commons earlier this week, the Government were asked by both a Conservative and a Labour Member to reconsider the question of ID cards in the light of issues concerning immigration and the identification, detention and deportation of illegal immigrants, as well as the introduction of digital services, national security and the protection of UK citizens from terrorism. In his speech, my noble friend Lord Campbell-Savours laid emphasis on how he considered the benefits of identity assurance went way beyond those areas and into addressing the increasingly worrying area of identity fraud.

I have to say that this is a Government who are prone, on occasions, to making hasty decisions on security and border control issues. There was the issue of control orders, which the Government decided they could not countenance but then found they had to bring back in all but name. Then there was the Government’s determination to opt out of EU directives on justice and home affairs issues, only to find, when reason prevailed, that it was in the national interest to opt back in to the key matters. Perhaps this was when the Government finally appreciated that Europe and co-operation were not the causes of security issues and other problems, but rather the potential solutions to them.

Given this Government’s track record in this area of, on occasions, acting first and thinking second, the issue raised by my noble friend Lord Campbell-Savours deserves not to be hastily dismissed as it has been on previous occasions. Instead, the case that my noble friend has made today deserves to be considered carefully in the light of the current situation—particularly in respect of increasing identity fraud, the need for identity assurance, the threat of terrorist activity and apparent levels of illegal immigration—and given an evidence-based response, irrespective of whether the Government decide they are going to change their approach or not.

I hope that that is what the Government’s line will be today: that, without any commitment to change their current stance, they will nevertheless set up a review of the advantages or otherwise of the introduction of an ID system giving identity insurance, including looking at the position in other countries that have such systems and the benefits or otherwise that those systems actually bring—an issue raised by the noble Lord, Lord Scriven.

In today’s environment, all measures that might further enhance security and address other significant problems and issues, including identity fraud, merit careful and full consideration of their advantages and disadvantages so that decisions made on what measures it is in the interest of our nation and our citizens to adopt are clearly evidence-based.

My Lords, I, too, thank the noble Lord, Lord Campbell-Savours, for securing this debate and continuing an exchange which we had when he raised his Question in your Lordships’ House recently.

At the outset, let me say that I may well disappoint the noble Lord by the nature of my response, because the Government’s position is that identity cards as described—and certainly as introduced by the previous Labour Government—failed essential tests in that they were expensive. I realise that the sums talked about— £85 million—may not in the current scheme of things seem large, but back in times of austerity in 2010 they were very significant. Where something was not delivering the expected benefits, the decision was made to use that funding elsewhere.

I totally agree with the noble Lord’s analysis of a growing problem. We need to look at it very carefully. A number of noble Lords spoke about the changing nature of commerce and the way the state interacts with citizens, which raise a number of serious questions about how we establish our identity and keep services and information safe. That is why the Government issue a number of identity documents at present. Some 54 million people—84% of the population—have a passport. Increasingly, those passports carry biometric data, which can be used at special e-border gates that are being introduced. Sixty per cent of the population carry a photo driving licence. I understand that that does not apply to the noble Lords, Lord Berkeley and Lord Harris, but a large proportion of the population does.

Several noble Lords rightly pointed to the fact that, outside of identity cards, there is an EU agreement that all people coming from outside the EEA into that area for a period in excess of six months should be required to have a biometric residence permit. So far, 2 million of those documents have been issued. Moreover, there is a similar European requirement for an application registration card for those claiming asylum in any EEA member country. That applies in this country as well.

I should say at this point that I fully support the point made by the noble Lord, Lord Rosser, about collaboration with our European colleagues on security grounds being critical to the safety and security of people in this country. I shall come to some of the measures to which he referred later.

The first point is that there are already a large number of established and robust identity documents. The British passport is recognised as a gold standard in the international community, in terms of its ability to frustrate the fraudsters and those who would seek to copy these documents. Then there is the legislation we introduced just last year on specialist printing presses, which ought to be clamped down on—and the penalties should be increased.

So we have, first, already a large number of identity documents that could be called upon in certain circumstances to establish and verify people’s identity.

Would the Minister confirm that there are no biometric data in the form to which I referred in my contribution for those 600 UK citizens who have gone to join ISIS and who may well return to the United Kingdom in the near future to carry out terrorist offences? Would he confirm that we do not hold biometric data on those persons, unless they committed a crime in the United Kingdom in the period before they left to go to Syria or Iraq?

In the strict way in which the noble Lord poses the question, of course, the answer would be—

Well, in one way, of course, that would be the answer. But let me unfold this, if I can. First, as a result of the counterterrorism legislation that we introduced last year, the Government are now able to intervene and seize someone’s passport before they actually leave the country. Secondly, as a result of that legislation there is the ability to have a controlled or managed return for the individual to this country. Additional passenger name recognition registration information needs to be supplied in advance, and since April, we have introduced exit checks for people leaving this country. Therefore, those people would have needed genuine passports, which would have been checked at the border.

We do not know the specific type of passports they were travelling with in that instance. But additional elements have been introduced to improve our security, and I may just go through a few of them. Certainly, the passenger name records directive was agreed at the Justice and Home Affairs Council following the Paris attacks last year. We have the biometric residence permit, the application registration card, and the Prüm requirements for the exchange of databases. We are part of the Schengen information-sharing system with our European colleagues, and we are going to be part of the second-generation Schengen system. We are part of the European criminal records information system for sharing data across borders. Of course, I appreciate that people will feel that additional information is required, which is one reason why we are introducing the Investigatory Powers Bill. We are also investing heavily in our border security: £380 million of investment is going into the borders and immigration citizenship system, and the digital services for the border security programme, to which we have committed. We have committed an additional £64.5 million to the Channel ports to improve security there, and we have announced a further £1.9 billion to be spent on intelligence and security matters.

That is a lovely list of what is happening and what he is doing, but did the Minister read the piece in the Guardian on Monday, which I briefly referred to, which said that two of the terrorists came and in out through Dover without being checked? I remember that some time last year before the election, when the noble Baroness, Lady Kramer, was a Minister, I complained that lorries and cars were not being checked going into Dover, and her answer was that if we checked everyone we would cause a traffic jam. That is a pretty bad reason.

In the wake of the terrorist attacks, we have introduced 100% border checks at scheduled arrival ports in the United Kingdom. I cannot see how that assertion would stack up with the evidence.

What matters is the proportion of people who are checked when they arrive and leave. What is the figure in each case now—not what is planned, not what is hoped for, but now?