Motion to Approve
I beg to move that the draft Greater Manchester Combined Authority (Public Health Functions) Order 2017, which was laid before this House on 20 July 2017, be approved.
The draft order we are considering today, if approved and made, will confer local authority public health functions on the Greater Manchester Combined Authority as agreed in the devolution deals, and support Greater Manchester’s programme of public sector reform.
The Government have, of course, already made good progress in delivering their commitment to implement the historic devolution deal with Greater Manchester. Since agreeing the first deal with Greater Manchester in November 2014, we have passed the Cities and Local Government Devolution Act 2016, followed by a considerable amount of secondary legislation for Greater Manchester, including: establishing the position of an elected mayor; new powers on housing, planning, transport, education and skills; transferring fire and rescue functions and assets; and setting out the operation of the police and crime commissioner function, which transferred to the mayor on 8 May.
The draft order we are considering today provides a further significant step for Greater Manchester. Greater Manchester has identified public sector reform and population health improvement as priorities. This draft order provides for the conferral of certain local authority public health functions on the combined authority. Once the order is made, the combined authority will be able to exercise those public health functions concurrently with the 10 metropolitan district councils in its area.
The main new function is conferral of a local authority’s duty to take such steps as it considers appropriate for improving the health of the people in its area. The effect of the order will be to treat the combined authority as if it were a local authority, with the same duty to improve population health and the same consequential requirements to comply with guidance and the NHS constitution, and with the ability to enter into partnership arrangements with local authorities and NHS bodies.
Conferral of local authority public health functions will enable a Greater Manchester-wide strategic leadership approach to the delivery of agreed public health functions and commissioning responsibilities—for example, public health intelligence, health needs assessment and health protection. It will support a Greater Manchester-wide approach to tackling health inequalities, variation in quality and service improvement to promote fair and equitable access and to achieve an upgrade in health outcomes for the population of the wider city. It will also support strengthened collaborative decision-making for population health through the identification of city- wide commissioning priorities and intentions, underpinned by shared principles and common commissioning standards —for example, commissioning for whole-system sexual health and substance misuse services. Finally, it will enable population health to be embedded across the city’s health, social care and wider public services through the Greater Manchester strategy and the population health plan.
Noble Lords will want to know that the statutory origin of the draft order before us today is in the governance review and scheme prepared by the combined authority in accordance with the requirement in the Local Democracy, Economic Development and Construction Act 2009. Greater Manchester published this scheme in March 2016 and, as provided for by the 2009 Act, the combined authority consulted on the proposals in the scheme.
The consultation ran from March 2016 to May 2016, in conjunction with the 10 local authorities in its area. The consultation was primarily conducted digitally, including promotion through social media. In addition, of course, respondents were able to provide responses on paper, and posters and consultation leaflets were available in prime locations across Greater Manchester. As statute also requires, the combined authority provided to the Secretary of State in June a summary of the responses to the consultation, and the Secretary of State concluded that no further consultation was necessary.
Before laying this draft order before Parliament, the Secretary of State has also considered the other statutory requirements in the 2009 Act. He considers that conferring these functions on the Greater Manchester Combined Authority is likely to improve the exercise of statutory functions in the area, and he has had regard to the impact on local government and communities, as he is required to do. Also, as required by statute, the 10 constituent local authorities and the combined authority have consented to the making of this order.
In conclusion, the draft order we are considering today, if approved and made, will confer local authority public health functions on Greater Manchester Combined Authority, enabling it to play a key role in improving the health of the population in Greater Manchester. I commend the draft order to the House.
My Lords, first, I thank the noble Lord for his explanation of the order. As I am going to touch on oral health in Greater Manchester, I declare an interest as president of the British Fluoridation Society.
The order is unexceptional and we support it. It takes a sensible approach, enabling the combined authorities in Greater Manchester to undertake public health duties which at present fall just to individual local authorities. The Greater Manchester Health and Social Care Partnership has published a very interesting population health plan, which has a lot of very good things in it, and I commend the local authorities and the combined authority for what they are doing.
I mentioned my interest in oral health. It is well known that Greater Manchester has very poor oral health. It is also well known that, at a stroke, this could be dealt with by the introduction of fluoridation in the water supply in the north-west. All I would ask is that when the order has gone through, Greater Manchester be gently urged, through the Minister’s good offices, that an improvement in oral health be one priority that the combined authority—and indeed the mayor, who I know is a passionate believe in fluoridation—might take on. I hope the Government will encourage them in the right direction.
The order proposes that for some interventions, there can be reductions in visits to urgent care, a reduction in the number of people with chronic conditions, and that 700,000 people will be able to manage their chronic conditions more effectively. But of course, this takes place in the context of a very rocky position for the NHS and social care. The funding gap and the demographic pressures on the health service are severe. Inevitably, this is going to impact on the effectiveness of what Greater Manchester can do on health and social care as well as public health.
A few moments ago at the NHS providers’ conference, the chief executive of NHS Improvement talked about the rocky ride the health service will undertake over the next few years. I would also mention the direct consequence of the reduction in funding in public health that has taken place. At a time when we need greater public health interventions, it is deplorable and regrettable that public health has been cut. I shall give the Minister one example. At the weekend it was revealed that 52 local authorities—more than one-third—have closed contraceptive services in the past 12 months. Can you conceive of a more stupid decision by a local authority than to cut its contraceptive services? I certainly cannot. The Government have presided over this, and the decimation of public services. What is going to be the consequence? It will be more unwanted pregnancies and more abortions. What on earth could lead a local authority to think that this is a cost-effective approach?
Yet we know that the Government are preventing Public Health England making strong interventions in the affairs of local authorities. I say to the Minister that it is all very well bringing this order—I am quite happy with the order itself—but when are the Government going to get a grip on the public health agenda? At heart, that is the issue we should really be discussing today.
I am very grateful to the noble Lord who has just spoken for setting out the fluoridation situation. I have written to the Mayor of Manchester on this very issue and sent him copies of all the Hansard replies over the years when I have asked what the difference is in health patterns between Manchester and Birmingham. The answer is always the dental situation. The general health in both the area that is fluoridated and the one that is not indicates no difference whatever. People who claim that fluoridation might be damaging to health have no foundation for that when the situation is the same in both cities.
What really alarmed me was when I read that Manchester was so desperately short of national health general anaesthetic beds for children in particular that it was having an effect on the whole bed supply, because so many children in Manchester required full clearance under general anaesthetic. It is hard to believe that it has reached a point where it is preventing other people having necessary operations. We also must not overlook the fact that those children will have been suffering considerable dental pain at the same time.
Another big pro for Manchester is that its water system is controlled by one large area, since it is large enough for that to be the case. In other local areas it might be that some very small local authority prevents the whole thing because its water would be taken into account when it was done. Greater Manchester is big enough to do this, though, and I hope it will. I am very pleased to hear that what the Minister said today is going to happen, and I am glad of the support of the Front Bench opposite.
My Lords, I declare an interest as a member of Newcastle City Council and of its health scrutiny committee. I have served long enough to recall the original reorganisation of local government, combining public health services with social care, in the early 1970s. I congratulate the Government, the Mayor of Manchester and the combined authority on taking the issue forward in the way that the Minister described. Perhaps I should also declare a rather unfortunate interest as I myself am suffering from some oral problems—not, however, as a result of any lack of fluoridation in the north-east. In fact we have a very good record on that; it is one area in which we somewhat lead the way.
My noble friend referred in passing to funding. The public health budget is under great pressure. I hope that the Minister will be arguing the toss with the Chancellor for the forthcoming Budget and the following announcement of the local government finance settlement, which will come no doubt on Christmas Eve or thereabouts. It is crucial that this innovative approach by Manchester, but also the work done by authorities up and down the country under the present system, is adequately funded, and there is a real risk of serious problems arising unless that occurs.
In congratulating Manchester and the Government on this step, however, I ask the Minister what progress he anticipates being made on the rather more difficult area of combining health and social care provision in the way envisaged by the agreement and advocated by the Government across the whole policy field. That will be much more difficult than what is being carried through in Manchester under the terms of the order. The NHS structure is so complicated that it is difficult for local authorities to deal with it adequately now in one local authority area, let alone across a wider area. I cite as an example the difficulties that my authority and the area I represent in the city are having with the clinical commissioning group, which is a big, powerful body, one of several separate powerful bodies within the NHS, and has decided to close a surgery in an area of considerable social need, quite a distance down the hill, as it were, from other surgeries and where there is a growing population on a new housing development in the area.
This suggests that any further development of the combination of health with local services will need a review of how all the partners to that manage to co-operate. It will be very interesting to see what Manchester manages to achieve in that regard. My advice to my colleagues in Newcastle would be, frankly, while exploring options to wait and see what happens in Manchester and how it works out when that stage is reached. I appreciate that we are not at that stage yet, but it is necessary to flag up some of the potential difficulties that might have to be faced if we are to have really effective collaboration across the whole field of health and social care.
My Lords, perhaps I may take this opportunity to question my noble friend on the fluoridation programme. I must declare an interest. I cut my legal teeth as a devil and an apprentice with Simpson & Marwick, and my devil master was the junior advocate in the fluoridation case brought by a pensioner who had dentures—she had none of her own teeth. She objected to the fluoridation programme to be carried out by Strathclyde regional council in the early 1980s. She won her case and Strathclyde regional council did not fluoridate the water supply at the time on the grounds that compelling evidence was led by the petitioner, Mrs McColl, to prove, among other things, that fluoride could be a carcinogen.
Has the Minister taken the time to consider such evidence, and can he assure the House that the level of fluoridation in the public water supply will not be such that any such fears will be raised in the fluoridation programme to be carried out by Greater Manchester council?
My Lords, perhaps I may ask the Minister about infectious diseases and express my interest as a past chairman of what was the Public Health Laboratory Service and as a Mancunian. Infectious diseases know no boundaries, and it is important with any infectious disease outbreak, which may occur anywhere in the UK, that information is spread very easily to epidemiological centres and central laboratories, so that such outbreaks can be traced and checked. Is there anything in this agreement that will ensure that there is association, collaboration and co-operation with the central laboratory services?
I thank noble Lords for their contributions and for their broad support for the order before the House today. As I outlined, it represents another significant milestone in the Government’s devolution agenda and I am glad that that has been welcomed across the House. I will try to respond to the various points that noble Lords have made.
Like the noble Lord, Lord Hunt, we support the idea of the population plan, which will clearly differ from place to place where there is this kind of devolution. I stress that an important and distinctive part of this plan is that it confers on the combined authority the same powers and responsibilities as a local authority. It is therefore about them acting concurrently, rather than in an overbearing way, or seeking to override.
I have been in your Lordships’ House long enough to know that fluoridation is an area of particular interest. I wonder only why it has taken so long for me to have to answer a question on it. This is a devolution deal, and it is therefore about those powers being taken locally and acting in concert. I do not think it is consistent with the idea of devolution for me to urge any combined authority to point in one direction or another, and it sounds like my noble friend Lady Gardner has been doing plenty of urging already. Any such move would have to be made in concert by all 10 of the local authorities and the combined authorities and be done through the usual processes of consultation and so on, with regard to all the responsibilities that attend on those public health powers. I hope that provides some reassurance to my noble friend Lady McIntosh.
After the Strathclyde case and the ruling from Lord Jauncey, the then Conservative Government took legislation through both Houses of Parliament to make sure that fluoridation was legal and above board. That was based on evidence that has not been undermined since.
I am trying to make the point that there is an established regulatory framework around such proposals. As noble Lords can tell, I am trying to avoid coming down on one side of the argument or the other. In the end, this is an issue both for local areas and for clinical opinion and research. On the broader position of public health, difficult decisions had to be made about local authority budgets as a consequence of the financial crisis and the deficit which it brought about. It is still the case that local authorities are getting £16 billion to spend on public health over the five years from 2015 to 2020. Alongside that, power and decision-making have been devolved to local authorities on using that money and combining it with other functions that have an impact on public health. One of these would be housing, the quality and condition of which has a huge impact on the public health of local people. You cannot both welcome devolution and say that local authorities should not have the power to act in different ways, so long as they comply with their statutory obligations. From that point of view, local authorities should not act outwith those obligations, whether in the case of contraception clinics or any other public health responsibility.
The noble Lord, Lord Beecham, asked about integration: I stress the point about pooling of budgets. As he will know, a chief officer for health and social care has been appointed in Greater Manchester. That person is an NHS England employee, because the NHS is a national health service and NHS functions have not been devolved. We are clearly trying to achieve greater integration of services, through the sustainability and transformation programme. We hope that doing this at a level where there is a degree of integration by the relevant local authorities will be fertile ground, and that it will provide evidence for and leadership in the move towards accountable care systems, which NHS England is now leading through its five-year forward view.
On the final point about information being spread to epidemiological centres, I again stress that this measure confers the powers of a local authority on to a combined authority, so it will absolutely have the responsibility to share data. Indeed, it will not be able to assume responsibility for any functions if the 10 local authorities do not want it to do so. Obviously, we hope that they will. Indeed, by committing to support this order, they have signalled their intention to do so. I reassure the noble Lord that there is absolutely no risk that these kinds of responsibilities will be watered down as a consequence of this order.
In conclusion, I hope that I have answered noble Lords’ questions and inquiries about the impact of this order on fluoridation and many other issues. It is an important order and I hope that all—
I am sorry to intervene again but I have just reflected on what the noble Lord said about fluoridation. He seemed to say that he was not prepared to come down on either side. That sounds to me like a new statement of government policy, as traditionally government has been in favour of fluoridation.