Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 5 months ago)
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Baroness Thornton
“Power to regulate clinical physiologists in England
(1) Section 60 of the Health Act 1999 (regulation of health care professions) is amended as follows.
(2) In subsection (1) after paragraph (b) insert—
“(ba) regulating the clinical physiology profession in England,”.(3) In that section, after paragraph (bb) insert—
“(bc) regulating clinical physiologists in England who appear to require regulation in pursuance of this section,”.”
Baroness Thornton
My Lords, I shall speak also to Amendments 338ZB, 338F and 339ZB. We return to a regulatory issue. Amendments 338ZA and 339ZB are new clauses relating to the power to regulate clinical physiologists in England. Amendment 338ZB is a new clause requiring clinical physiologists to be registered by the Health Professions Council. Amendment 338F says that the Health Professions Council, in exercising its functions, shall co-operate with the regulation of clinical physiology in England and with the provision, supervision or management of services of people engaging in clinical physiology in England. The noble Baroness, Lady Finlay, has an amendment in this group and we support what she is proposing.
I am sure that other noble Lords have received the helpful briefing note from the Registration Council for Clinical Physiologists, which highlights that the Government’s current approach—a preference for voluntary registration, as the Minister outlined in the previous debate—has been applied to clinical physiologists, despite a recommendation from the Health Professions Council in 2004 for statutory regulation. The RCCP has a substantial amount of evidence suggesting that, in the case of clinical physiologists, voluntary self-regulation is not as effective as statutory regulation.
In the Command Paper Enabling Excellence: Autonomy and Accountability for Health and Social Care Staff, the Government stated that statutory regulation would be considered for those professions where a compelling patient safety case could be made and be supported by an evidence-based cost-benefit risk analysis. Ten months later, though, no such risk assessment has been undertaken, and the RCCP continues to believe that clinical physiologists should be statutorily regulated.
The disciplines that are covered by clinical physiology are audiology, cardiology, gastrointestinal physiology, neurophysiology and respiratory physiology. Clinical physiologists work directly with patients, performing sensitive procedures such as assessments of pacemakers, testing lung function and assessing and diagnosing hearing loss. Many of the procedures performed by clinical physiologists in the UK are performed by statutorily regulated professionals in much of western Europe and by clinicians in the United States.
A body that I have mentioned, the Registration Council for Clinical Physiologists, maintains a voluntary register of clinical physiologists in the UK and Northern Ireland. It has more than 5,000 registrants across a number of different disciplines in clinical physiology. These professionals play an integral part in the process of diagnosis and treatment, undertaking procedures such as ECGs, which pose significant risks to patients. That, really, is the point here.
Baroness Northover
My Lords, these amendments seek to extend compulsory statutory regulation to physicians’ assistants in anaesthesia and clinical physiologists and to make changes to legislation to further provide for the compulsory statutory regulation of clinical physiologists.
I make it clear at the start that healthcare scientists such as clinical physiologists play an important and highly valued role as part of clinical teams, and this is also true of physicians’ assistants. It is a testament to their professionalism that the Department of Health is not aware of any general concerns about the standards of practice of either group. Furthermore, we need to be absolutely clear that the purpose of regulation is to protect the public, not to support the development of a profession.
Given the wider systems of assurance in place such as the Care Quality Commission’s registration requirements, and the vetting and barring scheme, the Government do not consider that the case for compulsory statutory regulation of these groups of healthcare scientists not already subject to regulation, and physicians’ assistants, has been made. However, we agree that there need to be processes to ensure high standards of care, and assured voluntary registration overseen by the Professional Standards Authority for Health and Social Care has the potential to provide this. It will ensure that there are robust standards of conduct and training. It will be open to employers and commissioners to insist on only recruiting staff on voluntary registers. Those doing so would secure many of the benefits of compulsory regulation. Both healthcare scientists and physicians’ assistants already have established voluntary registers and would be well placed to seek accreditation from the authority.
The noble Baroness, Lady Thornton, asked why we were not taking forward the regulation of clinical physiologists as recommended by the Health Professions Council. The recommendations of the Health Professions Council were not based on an assessment of the risk presented by a profession, but rather on whether that profession had already developed processes of assurance which prepared them for professional regulation. There is therefore no evidence that compulsory statutory regulation is necessary to mitigate the risks posed by the professions recommended for such regulation by the Health Professions Council. This is probably why the previous Government did not decide to regulate, although this is an issue that has been flagged up for a number of years. The professions recommended by the Health Professions Council for compulsory statutory regulation will be well placed to join the system of assured voluntary registration that we are proposing.
The noble Baroness, Lady Thornton, asked about research in terms of regulating clinical physiologists. We are not planning on commissioning research into the case for regulating them, but we will review the case for introducing compulsory statutory regulation for clinical physiologists and, obviously, others in the light of experience of assured voluntary registration, and the evidence about risks available.
Baroness Thornton
Perhaps the Minister could tell us what sort of timescale she envisages for this, or whether it will have to wait until an accident happens like the noble Baroness, Lady Finlay, recorded and then the Government will deal with it.
Baroness Northover
The noble Baroness will be fully aware, because she was a health Minister, that if there is no evidence of there being a risk then you do not choose to regulate. That is presumably why the previous Government chose not to.
The noble Baroness, Lady Finlay, flagged up the position of anaesthetists’ assistants. I had interesting discussions yesterday with an anaesthetist and an anaesthetist’s assistant, and it was very enlightening. As the noble Baroness will know, the anaesthetist is of course ultimately responsible. Assistants must always be supervised by a consultant who needs to be available within two minutes. The issue that the noble Baroness raises is one of quality assurance. As she knows, the Royal College of Anaesthetists runs the training and the registration for those assistants. After they have done a science degree, generally it is 27 months of practice. If the Royal College of Anaesthetists judges that that is inadequate, on the basis of the kind of concerns that the noble Baroness raises, then it is clearly for it to say that there are risks, it has encountered risks, and that needs to be addressed. If this system comes under the quality assurance system that I mentioned earlier, there will be another body looking at whether that kind of training, assurance and registration is adequate. However, there have not been cases flagged up as causing concern. I also point out that there are few anaesthetists’ assistants. They are more generally used in other countries, I gather, but not so much in the United Kingdom. The noble Lord, Lord Alderdice, asked why there is not more statutory regulation. In some ways I think I have addressed that. Although compulsory statutory regulation is sometimes necessary, one has to look at the risks and at what is proportionate.
Baroness Thornton
The health Minister Anne Milton said that those professions in which a patient safety case can be made, including that of clinical physiologists, will be considered for statutory regulation subject to a cost-benefit risk analysis. Will the Government carry out that analysis and, if so, when and in what time? I do not particularly want an answer about what my Government may or may not have done or may or may not have decided. The noble Baroness’s own Minister has pronounced on this matter since the general election so it seems to me that she needs to answer the question: when will they do the risk analysis?
Baroness Northover
I have already mentioned to the noble Baroness—she is probably totally familiar with this—that the Department of Health does not have evidence of there being a risk in this regard. Clearly, as I mentioned on the earlier group, these issues will always be kept under review. If the concerns that she has flagged up and if the association, which is particularly encouraging the regulation of clinical physiologists—that is fine; it is all part of professionalisation—flags up particular concerns that emerge from other evidence, then of course the department will take that very seriously. However, things need to be proportionate.
Baroness Northover
I am very happy to take away what the noble Baroness has said and to discuss the situation further with her.
We expect the assured voluntary registration to be up and running by 2012. Therefore, afterwards that would need to be assessed to see whether anything further is required, as noble Lords have figured might be the case. We are hoping to see how it all works.
The noble Lord, Lord Walton, flagged up various groups which were regulated and he could not quite see why others were not. Given that I used to bump into the noble Lord, Lord Walton, in the Wellcome Library for the History and Understanding of Medicine, I think he will fully understand that the way in which regulation has grown up has not necessarily been logical or consistent. Therefore, I flag up the 2005 Hampton review on regulation which says that it should be proportionate to the risks that it seeks to mitigate and various other provisions. That is what we are seeking to do. Of course, we shall keep under review what we are doing to see whether it is adequate. In the mean time, I hope that the noble Baroness will be willing to withdraw the amendment.
Baroness Thornton
My Lords, I thank the Minister, but this is not yet a satisfactory situation. We might be moving towards one but we are not there by any means. If I were on the register of clinical physiologists I would find it slightly offensive for the Minister to suggest that I was asking for statutory regulation as a kind of professional development of the organisation. Physiologists are very clear in all of their briefings that they think that this is important for patient safety. That is why they want statutory regulation and that is why we need to listen to them very carefully.
Baroness Thornton
I thank the noble Baroness for that. The noble Baroness, Lady Finlay, made a graphic and powerful case. I thank my noble friend Lord Rea, the noble Baroness, Lady Masham, and the noble Lord, Lord Walton, for their support for the amendment. My noble friend Lady Pitkeathley and the Minister are coming at it from a different point of view. It is entirely possible that an arbitrary decision was taken, quite possibly by my Government, that there was enough statutory regulation. It is possible that this Government need to think that that was an arbitrary decision in the history of regulation and that exceptions need to be made.
There are questions about the limits of assured voluntary registration. Do clinical physiologists carry out invasive procedures that could harm patients? Yes, they do. Are clinical physiologists incentivised to join the voluntary register? No, they are not. A small number of NHS and private employers notionally require applicants to be on their register but there is no mandatory requirement for this. Are professionals incentivised to maintain the voluntary register? No, their activities are carried out on a voluntary basis by the chair and other officers. Does the voluntary register empower patients to make formal complaints? No. While the Health Professions Council operates a system whereby anyone can make a complaint about the fitness to practise of a professional on its register, in most instances members of the public are not aware of the existence of voluntary registers. Finally, does the voluntary register have any powers of enforcement? No, it does not. The RCCP operates a disciplinary code and procedure but it cannot protect patients from continuing to be treated by practitioners who have not been registered and who are potentially unfit to practise. I beg leave to withdraw the amendment.
Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 5 months ago)
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Baroness Jolly
My Lords, I wish to add something on Clause 51 stand part. I am sorry that it is not where we expected it, but that is absolutely fine. We are in a place of unintended consequences, because without a PCT there is no home for this particular service. Also, post-Shipman, there is a need for sharpening up clinical governance on death certificates. Therefore, there is no disagreement with any of that, but the unintended consequence is that local authorities have a serious problem in that, as I understand it, funeral directors no longer wish to be a part of the mix, so local authorities are being tasked with implementing a system in which something will have to be collected—somewhere in the order of £150 per certificate to cover the costs. The call for the system to be set up came in 2009; the previous Labour Government asked us to look at regularising the system of certification of deaths not only for cremations but for burials. It was to be revenue-neutral, which poses another problem for the local authorities.
The timing of this for somebody who is bereaved is really difficult. If you lose somebody, you can neither bury them nor have them cremated without the death certificate. Being charged something in the region of £150 could be really awkward, difficult or maybe even impossible. If they paid into an insurance plan, it will not have paid out; after a few days, probate is just not in the right place at all. I would like the Minister to consider two things. First, the cost is anticipated to be somewhere between £40 million and £60 million. I cannot think of anything else on which the taxpayer actually pays for the collection of government data. I would like the Government to consider whether it is appropriate to pass on these fees when certificates for births, marriages and deaths are currently less than £20. Secondly, failing that, would my noble friend commit to working with the Department for Communities and Local Government and the Ministry of Justice to devise a sensitive system that does not call for a sizable payment up front on collection of the death certificate? They should pay attention to the pilot data alluded to by the noble Baroness, Lady Finlay; the pilots are not running absolutely smoothly.
Baroness Thornton
My Lords, what links the two parts of this debate are the unintended consequences and the need for second and third thoughts about things. My noble friend Lord Patel, the noble Lord, Lord Adebowale, and the noble Baroness, Lady Hollins, expressed concern about this clause. That is frankly good enough for me. It has been suggested elsewhere in the way of things that some enthusiastic civil servants, in the process of tidying up this Bill, have actually brought about what could be serious unintended consequences. The noble Baronesses, Lady Murphy and Lady Barker, also have some important points to make about the amendment in the name of the noble Baroness, Lady Barker. This House spent many hours constructing the architecture through the Mental Capacity Act and the Mental Health Acts, not all of it right. I do, however, remember the duty of co-operation being an important part of those Acts; those rights, protections and duties are very important and we need to check that we have not damaged them through the construct of this Bill.
On Clause 51 stand part, we on these Benches are pleased to support the important amendment put down by the noble Baroness, Lady Finlay, about the problems that might occur when the responsibilities of primary care trusts for the certification of deaths are transferred to local authorities. I do not intend to read out the whole of this note because the noble Baroness, Lady Jolly, has referred to most of it, but we are very concerned that these proposals will mean delay and an increase in cost when people are at their most vulnerable and least able to withstand that. I do not think that anybody in this House would want that to happen. I suspect that the Government would not want to place in jeopardy the trust and confidence in the system as it is, and I think there is a danger that Clause 51 does that. We on these Benches support the amendments in this group.
Baroness Northover
My Lords, noble Lords have spoken passionately about the need to support patients who are particularly vulnerable. These are complicated areas, and I am happy to write to noble Lords to clarify what is intended in the Bill and to address their specific questions if I do not answer them in what I say here.
The Bill makes a number of essentially consequential amendments to the Mental Health Act 1983. The Government are also taking the opportunity to remove a few redundant powers and to make a small number of changes to that Act. That is the intention. This is not a major shift; these are meant to be tidying-up changes. However, if they have unintended consequences, it is important that they are flagged up, and I hear what the noble Lord and other noble Lords said.
The principal changes are the change in the responsibility for commissioning independent mental health advocates from the NHS to local authorities and the change in the requirement that a second opinion must be given even where patients on supervised community treatment consent to their treatment. This condition does not apply to patients who are detained in hospital and is contributing to the major difficulties that the Care Quality Commission is experiencing in managing the second opinion appointed doctors service.
The Government are also taking the opportunity afforded by the Bill to make a number of changes to the Section 117 of the 1983 Act. The first amendment in this group, which was tabled by the noble Lord, Lord Patel of Bradford, addresses that. The main change is to transfer the duty on primary care trusts to commissioning consortia, but the clause also takes the opportunity to align the duty in Section 117 more closely with mainstream NHS legislation. That is the intention. For example, it gives the Secretary of State the power to make regulations that say which consortium is to be responsible in any given case. That will allow us to end the current anomaly that sees some PCTs responsible for Section 117 aftercare for patients whose other needs are the responsibility of a different PCT.
Regulations could also say that, in particular circumstances, the NHS Commissioning Board is responsible rather than the consortium. That would allow us to prevent consortia ending up having to commission services that are normally commissioned by the board just because the patient happens to qualify under Section 117. The noble Lord, Lord Patel, spoke very persuasively about the need to avoid this clause having unintended side effects, and I can confirm that that is certainly not the Government’s intention. I am very happy to meet the noble Lord to discuss these issues further.
On co-operation with the voluntary sector, we need to consider consistency with other services that CCGs will commission in order not to give in some way a distorted picture of when CCGs should work closely with the voluntary sector. Nevertheless, I am happy to have further discussions on this point.
On charging, which is clearly a significant concern of the noble Lord, the Bill does not change the current situation. Patients will not have to pay for any care under Section 117. I hope that I can reassure the noble Lord on that point.
The second amendment in this group was tabled by my noble friend Lord Marks and is about access for children who come under the 1983 Act to the services of an independent mental health advocate. Section 130C of the Mental Health Act 1983 already gives the same right of access to such an advocate to all qualifying patients, including children. Making special provision for minors might give the impression that other qualifying patients should have lower priority for access to such services. Our aim is that every vulnerable person who comes under the major provisions of the 1983 Act and wants the support of an advocate should have one. That should, of course, include every child and young person, but it should also include everyone else as well. The current law not only supports the aim of this amendment in respect to children but does so for all vulnerable people of all ages.
Baroness Thornton
“( ) In exercising functions under subsections (1) and (2), the Secretary of State must set out how the performance of the Board in relation to these functions will be managed, and how the Board must agree any arrangements for provision with the appropriate Health and Wellbeing Boards.”
Baroness Thornton
My Lords, this small group of probing amendments concerns itself with primary care services and the directions that would provide for those primary care services. I will briefly outline each of the amendments and ask the Minister's reactions to them.
On Amendment 239, if directing the board to exercise the Secretary of State’s functions relating to the provision of primary medical services, the Secretary of State must set out how the performance of the board in relation to these functions will be managed and how the interaction with the appropriate health and well-being board will occur. How will that be supported and how will it occur?
On Amendment 239ZZA, the Secretary of State may not direct the board to exercise the Secretary of State’s functions in Section 114 of the 2006 Act, which relates to dental services and the provision of accommodation. Amendment 239ZZB is very similar. It relates to ophthalmic services. Amendment 239ZZC relates to pharmaceutical services. The Clause 205 stand part debate relates to the list of performers of pharmaceutical services and particularly addresses the question of how the Government would intend to support the provision of community pharmaceutical services in the future through the Bill. That is another probing amendment.
I want to hear what the Minister has to say about how local services being commissioned nationally will work in terms of relationships with the health and well-being boards and in terms of the provision and support of community pharmaceutical services. I beg to move.
Earl Howe
My Lords, Amendment 239 raises the issue of performance management of the board. Noble Lords will recall the debate on Clause 20, in which I sought to reassure the Committee that new Section 13A of the National Health Service Act 2006, introduced by Clause 20, already enables the Secretary of State to specify the manner in which he proposes to assess the performance of the NHS Commissioning Board. It is not appropriate to set out performance management processes in respect of each and every direction issued to the board by the Secretary of State. I agree about the importance of the NHS Commissioning Board developing its commissioning responsibilities in a way that complements and supports other local health and social care commissioning, as the amendment proposed by the noble Baroness seeks to ensure. As I have indicated previously, the NHS Commissioning Board will be under a duty to have regard to joint health and well-being strategies. It would confuse lines of accountability and would actually be unworkable if we forced a duty on the board to agree with the health and well-being boards on how it will deliver its functions. I hope very much that your Lordships will agree that it is right that health and well-being boards do not have a right to veto plans for the provision of those primary medical services, which the Secretary of State has determined are necessary for patients. The NHS Commissioning Board will also have responsibility for commissioning primary dental services, primary ophthalmic services and pharmaceutical services.
Directions from the Secretary of State—usually of a technical or administrative nature—are currently made to primary care trusts and others in respect of primary care services under existing powers in the 2006 Act. So the provisions in this part of the Bill are not new powers; they are replacement powers adjusted to reflect the new organisations created by the Bill. These amendments would remove essential administrative and operational flexibility to enable those primary care services to continue to be provided efficiently and effectively for the ultimate benefit of patients. I realise that they are probing amendments and that the noble Baroness has no intention of pressing them, but clearly they are not appropriate.
Clause 205 enables regulations to be made that require the board to prepare, maintain and publish performers lists of pharmacists and pharmacy technicians on the abolition of primary care trusts. It replaces those provisions of the 2006 Act that currently relate to fitness to practise for pharmaceutical services performers. It also amends the Act so that, where a performer of local pharmaceutical services is included in a local pharmaceutical services performers list, they can be automatically included in an assistants list of performers and vice versa. We have yet to take a view on implementing performers lists for local pharmaceutical services performers and for those who assist pharmaceutical contractors in the provision of pharmaceutical services. We expect to do so during the coming months. In the mean time, this clause is needed to ensure that, if we do decide to introduce them, the primary legislation will adequately enable this.
The noble Baroness asked how, logistically, the board will manage approximately 8,300 GP contracts. We recognise that the NHS Commissioning Board could have difficulty in appropriately managing primary medical services contracts throughout England without help. The proposals to establish a significant field force as part of the board’s establishment will assist, but it will remain the case that the board’s ability to undertake this task will be enhanced if it can utilise the important local expertise and knowledge that will be available to the clinical commissioning groups. We have put in the Bill an explicit duty for all clinical commissioning groups to support and assist the board in securing continuous improvement in the quality of primary medical services. That is in new Section 14R in Clause 23. Alongside this, direction-making powers in Clause 46—
Baroness Thornton
The Minister mentioned field forces that will help to make this work, and I can see that that will almost certainly be the way to do it. But would there be an intention to have expertise in each of the different areas or across the piece? The Minister does not need to answer the question now; he can write to me. But the community pharmaceutical industry would be interested in an answer on how that would be delivered.
Earl Howe
I would be happy to write to the noble Baroness in the interests of time, but I was about to explain that as regards primary medical services the direction-making powers that I mentioned will also enable the board to arrange for clinical commissioning groups to carry out some contract monitoring functions and limited commissioning functions on its behalf should it so wish. So the board can enlist the help of the clinical commissioning groups themselves to do some of the monitoring function. That will not alter the board’s overarching responsibility for commissioning general practitioner services and holding their contracts. But I will write to the noble Baroness, as she asks.
Baroness Thornton
I thank the Minister for that answer. We will return to discuss issues about the community pharmacies, possibly not in Committee or on Report but outside the Chamber, because there are some areas of concern where clarification is required. I thank the Minister for his answer and beg leave to withdraw.
Health and Social Care Bill
Baroness Thornton Excerpts(12 years, 6 months ago)
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Baroness Thornton
My Lords, I rise to intervene on this Motion today with a very heavy heart—and empty-handed, because the Government have refused to release the risk register on the implementation of the Health and Social Care Bill, as instructed in the judgment of the Information Commissioner last Friday. I am grateful to the Minister for his letters to me and other noble Lords explaining the Government’s position on this matter. Thorough explanations are helpful but they do not make this a right or just position for the Government to take. The Government inform us that they need 28 days to consider this issue. I would just make the point that the Department of Health has had a whole year to think about this issue.
Noble Lords may recall that I drew this important matter to the attention of the House on Monday and specifically asked the Minister to assist the House in its deliberations by making the risk register available. I am most grateful that the noble Baroness, Lady Williams, supported my appeal. Since Monday, it has become clear that the well respected Conservative MP, Dr Sarah Wollaston, made the same plea to her own Secretary of State in a letter to the Evening Standard.
I beg the leave of the House to say I have nowhere else to raise this important matter. I do not wish to delay the House but I want to make two points and ask two questions of the Minister. There is a precedent that I urge the Minister to consider. In 2008 the noble Earl’s then honourable friend, Miss Justine Greening MP, recently promoted to the Cabinet, used an appeal to the Information Commissioner to get the release of the risk documentation on the Heathrow third runway. I am sad to report that my own Government did not cover itself in glory in this matter, refusing to part with the information for more than a year. However, the key difference between then and now is that of course the third runway was not the subject of a very large piece of primary legislation that aims to bring radical change to our NHS and that the information we are being denied could be very relevant to our deliberations.
I have already written to the noble Earl about this matter and intend to follow the same route as my right honourable friend John Healey MP by putting an FOI request in for the most recent risk register about this matter. I urge other noble Lords who share my concern to do the same. The reason I am doing this is because the Secretary of State suggested yesterday that the version of the risk register that my right honourable friend John Healey asked for would now be a year out of date. I regard that as both a glib and disrespectful remark.
The Minister told the House on Monday that most of the information from the risk register is included in the impact statement that was published when the Bill arrived in the House. Can the Minister say exactly how much of the risk register is contained in the impact assessment and how much is not? Perhaps the Minister might assist the House by publishing the information that is not contained in the impact assessment but is in the risk register. The Government say that this is a very secret document, but also that it is available. I am sure that the House would like to know which it is.
Finally, there is a course of action open to the House, which is to refuse to resolve itself into a Committee on the Bill as an expression of its concern about this matter. I have discussed this course of action with several noble Lords, and we have a genuine dilemma here. Many feel that it is a very serious error to refuse to place this information at the disposal of the House when we are considering this important Bill. On the other hand, we are all aware of the amount of work that there is to be done on this Bill. I do not intend to divide the House today, but I reserve the right to come back to this issue if it is not resolved at least within the time allotted by the judgment of the Information Commissioner. The Minister may also need to arm himself with the information contained within the risk register, because I, for one, will be asking him, at all the appropriate moments in the debates to come, whether that issue is mentioned in the risk register and what it says.
Baroness Thornton
My Lords, I thank the noble Baroness. This small amount of grouping and degrouping was partly to do with having everybody present and correct for a good debate on alcohol and its dependency.
However, Amendment 74B in my name and that of my noble friend Lord Beecham raises an important issue. I was heartened to hear the Minister say that there is a list in Clause 8 that was not exclusive, because this amendment is about a list that is not exclusive that we want to put in the Bill.
I start by marking the fact that today is national COPD day. It is appropriate that when discussing public health, we should mark the fact that millions of our fellow citizens have chronic obstructive pulmonary disease, and many of them have it as a result of their lifestyle choices that they made possibly when they were very much younger. It is very appropriate that in this debate about public health, what leads people into chronic conditions should be part of it. I also mention the fact that today—not unrelated to this—the British Medical Association issued its call for a ban on smoking in cars and an extension of tobacco regulation, which also merits some consideration.
Amendment 74B places in the Bill a by-no-means-exclusive list of matters that are important for the improvement of public health. We are trying to tease out whether and how a comprehensive approach to public health, which takes account of all pertinent matters, becomes possible in the framework that the Government are outlining for the promotion of public health. For example, the list includes issues such as employment or the lack of it, poor quality housing and its effects on health, air and water quality, and so on. They all concern the improvement of public health.
One of the reasons behind the amendment, and its place in the Bill, is that it also concerns the disbursement of grants and loans in Clause 9(4). As has already been said, we are also exploring what the Secretary of State and local authorities might, and could be expected to spend their funding on. I return to the question raised by my noble friend Lord Beecham about the public health premium. If we apply the proposed list in the amendment to my home town of Bradford, where there are very high indices of deprivation, how will the areas with the most severe and serious deprivation qualify for a public health premium when they are starting from such a very low base? I am sure that there is an answer to that question but I would like to have it on the record.
Evidence was given by the Association of Directors of Public Health to the Health Select Committee when precisely that point was raised. I hope that if the Government cannot answer my question now, they will be able to address it when they respond to that excellent report.
Baroness Thornton
The Minister is giving a list—and there are at least two further lists in Clauses 8 and 9. I cannot see why my list should not be in there, too.
Baroness Northover
I can see the temptation. The list in the Bill is indicative. These lists are always subject to much debate about what goes in and what stays out. I fully understand why the noble Baroness wishes to add her list. However, we would resist adding to the list in the Bill, which is, as she knows, indicative. We appreciate people's contributions to what needs to be covered in these areas. I point out to her that the list—no doubt we will spend many hours debating the regulations—includes all sorts of things, such as mental health services and dental public health services. I will not read out the whole list. If noble Lords think that something is on it that should not be there, or that other things that are not on it should be, I am sure that we will consider those points as we debate the regulations.
I noted a response to the noble Baroness, Lady Hollins, but I think that I may be referring to a previous debate. She is absolutely right to emphasise that we have to make sure that everything we do is patient-centred. All the changes must focus on that. It is a challenge for everybody. Perhaps people have tried to do it before. No doubt we will have problems trying to do it ourselves, now and in the future, but that has to be the focus. Therefore, we have to remember the diversity of the patients that we are talking about. I am sorry; that answer belonged in an earlier debate.
I know that we will return later to debate alcohol. I hope that noble Lords will not press the amendments in this group.
Baroness Williams of Crosby
My Lords, I am not quite sure whether the amendment is before us or not, but I shall make a brief assumption that it is and then I will allow the noble Lord to decide whether to sustain or withdraw it.
As we all know, the noble Lord has made a very distinguished contribution to the whole issue of the status and well-being of children and it is fair that we should recognise that. In particular, he has gone to a great effort to underpin the importance of early education and such things as the Sure Start programme. I want to add two points. The first is that, as a former Secretary of State for education, I remember working very hard to try to persuade my colleagues in the educational world that there should be an emphasis on education in parenting.
It is perfectly true that the early stages of a child’s life are vital, but as the noble Lord, Lord Northbourne, has pointed out, research shows that the link between what a child becomes and its parental inheritance is very close indeed. One of the more disturbing pieces of recent research shows the close link between an abused child and an abuser. Many young people who are abusive parents are in fact the children of abusive parents. Tragically, this dreadful tradition can move on from generation to generation. I simply want to make the point that it is not just a case of Sure Start for the child, it is also a case of proper education and training for the parents.
I have often felt that we should try to link sex education with parental education to bring out above all the extraordinary responsibility that a human child is because it takes so long to grow up compared with the young of most other species. A human child is dependent for many years, and I believe that we should put more emphasis on that than we do. However, it is not fair to make the Department of Health the sole responsible power for addressing this difficult subject. It requires a degree of working between departments, including education and other departments. I simply want to put on the record before the Minister replies the importance of securing co-operation between the Department of Health and the Department for Education, and for that matter social care on this particular set of issues.
My last point is quite straightforward. One of the aspects of training children in parenthood is to allow them to see what it is like to care for a young child. Some teenagers at school will not necessarily have younger siblings. Long ago when I was the prisons Minister—I should have talked about this when the noble Lord, Lord Ramsbotham, was in his place—I introduced a group of offenders, all young boys, to the task of helping in the care and support of children with Down’s syndrome. That relationship had an amazing effect on both parties. The young offenders suddenly realised that they were responsible for someone much younger than themselves who was dependent on them, while the Down’s syndrome children suddenly had older brothers who were devoted to them and to whom they could address their huge capacity for affection. There is a lot of room for bringing young people together with children and teaching them something more than we know now about what it is to be a parent and the huge responsibilities involved in that role.
Baroness Thornton
I should just say how pleased I am that the noble Lord, Lord Northbourne, has brought his great experience and commitment to the children and the family into this debate. I urge him to remain in his place for the debate that we are going to have very soon on children.
Earl Howe
My Lords, as the noble Lord, Lord Northbourne, mentioned, the two amendments in this group, Amendments 68AA and 69AA, are essentially dealing with the same matter on which we had considerable debate on an earlier day. Both seek to make an explicit reference in the provisions of the Bill to improving the physical and mental health of the population. I can well understand that the noble Lord with his extensive knowledge and experience of child health in particular should have tabled these amendments. The other amendments to which he spoke are in a later group. I shall respond briefly to those, but I hope that he will forgive me if I do not do so at length, because I think that there will be other noble Lords when we get to that group who will want to expand even more fully on the issue of children’s health.
I shall not dwell again, if the noble Lord will forgive me, on issues raised in the course of the earlier debate, on 2 November, but I reassure him that all references to illness throughout the Bill relate to both physical and mental illness. Illness is defined in the 2006 Act to include mental illness. Equally, it is not for nothing that we have chosen the name health and well-being board to refer to the mechanism at local authority level to define the health needs and priorities of a local area and set a health and well-being strategy to guide commissioners. That sense of well-being is to be at the forefront of commissioners’ minds. The Bill does not provide an explicit definition of health, but I assure the noble Lord that it recognises that well-being means more than the absence of illness and needs to be addressed separately. The approach in the NHS Act and other legislation is that health is simply given its ordinary definition and is not redefined.
The noble Lord, not for the first time, spoke compellingly about the importance of parents in supporting both the health and well-being of children. I could not agree with him more. The whole spirit of the measures set out in this Bill is to give more control and empowerment to patients. For children, that includes their parents. As such, I ask the noble Lord not to despair by reason of the lack of words in the Bill on this topic, as the intent is most certainly there. It is not for nothing, either, that the Bill places duties on the Secretary of State and other bodies in the Bill to exercise their functions with a view to securing continuous improvement in the quality of services. The agenda set by the noble Lord, Lord Darzi, in the last Government runs through this Bill like a thread, and it is our ambition for clinical commissioning groups that the prevention agenda should be centre stage for them, as it already is for practice-based commissioning groups, which are looking at what we call the QIPP agenda—quality, innovation, productivity and prevention—as a way of driving efficiency and better quality care into primary medical services. I am sure that all noble Lords’ ambition is that the NHS should not just be a national treatment service; it should be a national health and well-being service in the fullest sense.
On the public front, I am sure that the noble Lord will have noticed that in Clause 8 new Section 2A is inserted into the 2006 Act. I draw his attention to subsection (2)(d) in that new section, which refers explicitly to prevention in the area of public health.
We will come to the other amendments spoken to by the noble Lord when we come to a later group, but I will just comment very briefly on them at this point.
As regards Amendment 71ZAA, our general approach is not to specify particular services in the Bill. It already allows the Secretary of State or local authorities to take steps to improve the health of the people of England or the people in the local authority’s area. Once again, it is a case of making that general provision. Bear in mind that if we specify one group of people, it carries the implication that we are excluding others, which of course we do not want to do.
The same point applies with Amendment 97ZA. Strictly speaking, Amendment 99A is unnecessary. The mandate is clearly relevant to other government priorities. There are already established mechanisms for ensuring that policy is consistent across government and therefore we would fully expect the Department for Education to provide input on any relevant parts of the mandate. I hope that the noble Lord will be reassured by my brief comments on this matter. His comments are well taken; equally in the light of what I have said, I hope that he will feel able to withdraw the amendment.
Lord Rea
My Lords, as a former GP, I echo the words of my noble friend Lord MacKenzie. Screening for alcoholism should be added to the QAF measures in view of all the reasons that have been eloquently adumbrated by other people. I want to raise a fairly basic problem which is the cost of alcohol services. At the moment, a lot of these are funded as outreach programmes by PCTs, and those are going to be transferred to local authorities. They will have to be paid for out of the index-linked £4 billion-odd that is going to be given to local authorities for this purpose. Perhaps the Minister could say whether the actual cost of running these alcohol services is being taken into account when considering how that £4 billion is going to be calculated. There are also plenty of other services being transferred to local authorities.
Baroness Thornton
My Lords, I rise to comment on these excellent amendments, and to support my noble friend Lord Beecham who has his name against Amendment 71. Amendment 71 is one of those very small amendments that changes “may” to “must” but it is actually at the heart of this discussion. What we are talking about here is how national campaigns will be linked to local action, and how they will be funded.
I start by reminding the Committee of some of the key components of this Government’s health policy on the harmful use of alcohol: banning the sale of alcohol below cost price; reviewing alcohol taxation and pricing to ensure that it tackles binge drinking without unfairly penalising responsible drinkers, pubs and important local industries; overhauling the Licensing Act; local authorities having more powers to remove licences and refuse grants that are causing problems; allowing councils and police to shut down establishments; doubling the fines for underage alcohol sales; and local councils being able to charge more for late-night licences.
My noble friend Lord Brooke put his finger on it, as did my noble friend Lord Turnberg, when he expressed scepticism as to the efficacy of these when you link them to the responsibility deal pledges on labelling. As part of the public health responsibility deal agreed with the Government in March 2011, UK alcohol beverage companies have pledged—that is an interesting word to use in this context—to implement a health labelling scheme to better inform consumers about responsible drinking. This pledge is in line with the industry’s response to the Department of Health’s consultation in May 2010 on options for improving information on the labels of alcoholic drinks to support consumers in making healthier choices in the UK. I do not think this is going to work.
Will the Government be reviewing their national campaign on alcohol and the misuse of alcohol in the light of this Bill? We have a national policy and a campaign, presumably run and directed by the Secretary of State for Health through the public health agency within the department. We have to look at what will actually happen on the ground and indeed address the dangers or risks that are posed by this Bill. A key question is the distinction between primary prevention and secondary prevention, which is complex in relation to the prevention of alcohol misuse. It is a concern when interventions cannot be clearly delineated as primary and secondary prevention. It seems that the reforms being proposed here will make that worse, not better.
Multiple commissions across one therapy, such as alcohol misuse, may cause uncertainty over who is responsible for funding services considered for both primary and secondary prevention. The worst case scenario is that neither the directors of public health nor the GP consortia commission secondary prevention services because the directors of public health are focused on primary prevention, awareness and information, the GPs are focused on treating the physical complications and harms relating to alcohol, and the hospitals are mopping up the people who turn up needing treatment for alcohol abuse.
If we are to tackle the fact that the number of hospital admissions was over a million in the last year, and that it is estimated to cost the NHS £2.7 billion a year—almost twice the equivalent figure for 2001, with the costs to society being even greater—there has to be co-ordination between national and local, and some direction about how these programmes will be carried through at local level. On these Benches we are therefore very sympathetic to what we see as a series of rather modest and focused amendments. We hope that the Minister will be able to look upon them with some sympathy.
Baroness Northover
My Lords, Amendments 71, 71A, 72, 74A, 202, 328, 329 and 331, make alternations to local authorities’ new duty for public health. In introducing this group, the noble Baroness, Lady Finlay, has made a very powerful case, as one would expect from somebody who has campaigned for a very long time in this area. Clearly, the harm caused by alcohol is unacceptably high, and everyone has to play a role in reducing its harmful use. She is absolutely right in her campaign on this. As she says, 1.1 million hospital admissions were alcohol-related, out of a total of 14 million admissions, at a cost of £2.7 billion. It is of course extremely striking that 13 per cent of 11 to 15 year-olds reported drinking in the last week. I am acutely aware of the particular vulnerabilities of children and young people in this regard. The British Crime Survey suggests that alcohol is linked to half of all violent crime, so you can see the significance of what we are talking about here.
Can I assure the noble Baroness, Lady Masham, that indeed, we are very acutely aware of how many prisoners have alcohol problems, as well as drug and mental health problems? As a Whip in the Ministry of Justice, I can assure the noble Baroness that we regard this as extremely important and that we are seeking to tackle it.
Local directors of public health in local authorities will have a key role in tackling alcohol harm. Can I assure the noble Baroness, Lady Finlay, that this will need to be addressed at every level of the health service and public health? That is why it receives such prominence in the paper that I referred to earlier. Again, I refer to the fact that public health, itself in the past very much a Cinderella service, is now at the front and centre of these changes. We hope that the involvement in local authorities will help to change this.
There are a number of steps that need to be taken; I would like to flag up some that the Government are taking at the moment. The noble Baroness, Lady Thornton, made reference to a number of these, and we are fully aware that this is a range of things, and that neither this Government nor the previous one, in all the range of things that we have undertaken so far, have made a dent in this problem. We recognise that this problem is driven by economic and social change, and it needs to be addressed in that regard, and understood very fully. In terms of relevant things which are happening, local directors of public health and local authorities will have a key role in tackling alcohol harm. We know that engaging with those drinking above the lower risk guidelines early on, and providing advice or referral for treatment for those who need it, does work, and that that is helpful.
While the health services have made improvements, much more needs to be done to identify consistently early signs of drinking above the lower risk guidelines, and to offer advice whenever and wherever the opportunity arises. I know how difficult this is with teenage children.
The coalition’s programme for Government, to which the noble Baroness, Lady Thornton, referred, committed to a ban on the sale of alcohol below cost. It also committed to review alcohol taxation and pricing to ensure that it tackles binge drinking. The Treasury published its review of taxation on 30 November 2010 and set out changes to duty on beer.
I hope that the noble Lord, Lord Turnberg, will be reassured that we will bring together the Government’s approach in an alcohol strategy, which is to be published towards the end of this year. We are reforming the Licensing Act via the Police Reform and Social Responsibility Act to enable local communities to ensure responsible retailing of alcohol. Also mentioned was the consultation on the public health outcomes framework.
Baroness Northover
I note what the noble Lord has said in regard to his Government. I would be astonished if those working on this strategy were not bearing that in mind, but I will check. I can assure the noble Lord that, in the unlikely event that they are not, I will bring the review to their attention so that they can factor it in.
The noble Lord, Lord Rea, asked whether the current spending on alcohol is included in local authorities’ funding for public health. I can assure him that that is the case and that what is being spent by PCTs on commissioning alcohol services will be reflected in the resources transferred to local authorities.
Amendments 66 and 72 would add,
“providing services for the prevention and treatment of harmful drinking and alcohol dependence”,
to the list of steps that the Secretary of State and local authorities may take under new Sections 2A and 2B. However, the Bill already gives the Secretary of State and local authorities the ability to take appropriate steps to address harmful drinking. The new public health responsibilities in this Bill give local authorities a ring-fenced grant to ensure that local authorities have the resources to deliver their public health responsibilities, including alcohol misuse services. Obviously, there was discussion of that ring-fence grant previously. I think it is a move forward that, instead of public health being part of the overall NHS and subject to being raided, there will be a ring-fenced grant.
Clinical commissioning groups are already under a duty—under Section 3 of the NHS Act, as amended by Clause 10, and under new Section 3A—to commission services as they consider appropriate as part of the health service or to secure improvement in the physical and mental health of their population. Given the scale of the problem, it would be astonishing if that was not part of how they see their responsibility.
I can further reassure your Lordships’ House that the importance of services which reduce alcohol-related harm will not be overlooked. The Secretary of State will set the strategic direction of the NHS through the mandate to the NHS Commissioning Board. This should be the route for highlighting priorities for the health service and I have no doubt that debates in Parliament, such as this, and in the wider sphere will help to influence that.
Amendments 328 and 329 would require joint strategic needs assessments to include an assessment of alcoholism in the local population and the involvement of representatives from alcohol services in the preparation of the joint health and well-being strategy. While we fully support the principle that the joint strategic needs assessments need to be comprehensive, we do not feel that it is necessary to include this amendment in the Bill. The scope of this assessment will naturally include the needs related to harm from alcohol. However, we have retained the power for the Secretary of State to issue guidance on the preparation of the joint strategic needs assessment. We will ensure that it covers the need to consider alcoholism, which I hope will reassure noble Lords.
Amendment 329 would require local authorities and clinical commissioning groups to,
“involve representatives from alcohol services”,
in the preparation of the joint health and well-being strategy. While there is no representative of alcohol services in the local area on the health and well-being board, it would still be able to involve experts as appropriate or invite them to be members of the board. On Amendment 331, which would require health and well-being boards to include,
“a representative from alcohol and drugs service”,
the same point applies: they could be a member of the board or their advice could be sought. The legislation sets out a minimum membership for these boards—
Baroness Thornton
I am slightly disturbed that so far the Minister has given us lots of coulds and maybes and “there is no reason why they should not”. Given the scale of this problem, I think that the Government need to look carefully at what goes on the face of this Bill and what is put in regulations about the problem of alcohol abuse.
Baroness Northover
I think that that point comes through loud and clear from this debate. I note what the noble Baroness said about what goes into the Bill or in regulation. She will know, from her experience of government, that generally speaking you do not put this sort of thing into the Bill. However, I take on board very much what she said about regulation, and I will take that back to the department.
The noble Baroness rightly focused on the joint strategic needs assessment and analysis of the current and future health and social care needs of an area. This would include the health and social care needs that are alcohol-harm related. Health and well-being boards would be able to involve people as necessary. As I said, noble Lords have made a very strong case for tackling alcohol abuse, which is very much economically and socially driven by the changes that underlie why this has come about. I have no doubt whatever that this issue will continue to dominate our debates, whether over regulation or over the Secretary of State’s mandate. This is a difficult area to tackle, as we know and as the previous Government knew, and it is best tackled as a cross-party attempt.
If only putting such matters into the Bill was a panacea. However, I am sure that the noble Baroness recognises that that is not the case. We realise that a range of measures must be taken, and I can assure the noble Baroness, Lady Thornton, that we constantly review the effectiveness of what we do. If we did not, I am sure that noble Lords would ensure that we did. I hope, therefore, that the noble Baroness will agree to withdraw her amendment.
Baroness Finlay of Llandaff
I have added my name to one of the amendments in this group but support many of the others. The key issue is that children often need accurate diagnosis but do not get it. It is the way in which you detect learning difficulties of all sorts—sensory impairment and motor impairment. The need for a range of services integrated to support children is critical because as they grow up, unless their needs are addressed early they become greater; they do not decrease.
I shall illustrate that. A little girl, whom I shall call Emily, is eight. She was born prematurely but by the time she is eight, having had a stormy neo-natal period, she has epilepsy, cerebral palsy and swallowing difficulties. She is wheelchair-dependent, partially sighted and has communication difficulties. For her ordinary care, like other children, she needs her GP, district nurse and health visitor. For her hydrocephalus she needs paediatric neurosurgery. For her complex epilepsy she needs paediatric neurology. She needs physiotherapy because of the cerebral palsy and cramps. She needs speech and language therapy to help her learn to swallow efficiently and occupational therapists who help her to manipulate her communication device through which she communicates with her family who love her dearly and want to do the best for her.
That is one example and we have hundreds of children in our country who need integrated co-ordinated care. Perhaps Emily was lucky because she got the interventions that she needed and they were brought together. But, we also have a lot of children, as referred to in this debate, who are being missed on the way through because they do not have such clear-cut presentations. That is why, unless we use this as an opportunity to really change the way that we look after our children in health and social care in the broader context, we will be failing them.
Baroness Thornton
My Lords, this is a very important debate and the first opportunity we have had to look at the proposals affecting children. The Government’s plan is that public health services for children under the age of five, including health visiting and the family-nurse partnership, will initially be commissioned by the NHS Commissioning Board. To facilitate its plans to increase the health visiting workforce by 4,200 over a four-year period from 2011, the intention is that eventually this responsibility will pass to local authorities, which from the outset commissioned services for children between the ages of five and 19, including the Healthy Child Programme for school-age children. Maternity care meanwhile will now be undertaken by CCGs, although it was originally intended that this would be undertaken by the NHS Commissioning Board. The board will still be responsible for specialist neonatal services.
In the very helpful public health report recently published by the House of Commons Health Committee, Councillor Rogers of the LGG told the committee that the initial split of commissioning children’s public health services,
“doesn’t make sense. There is obviously a serious risk of a gap developing around the age of five, and it doesn’t make sense for school nursing to be in one place and health visiting to be in another”.
The Government’s response to the Health Select Committee was that,
“we believe that the commitment to raise the number of health visitors by 2015 is best achieved through NHS commissioning and thus will retain our existing proposal that the NHS Commission Board should lead commissioning in this area in the short-term”.
Baroness Whitaker
It is the same question. In the noble Earl’s very comprehensive answer, did I miss whether speech, language and communication problems were within public health? I do not recall hearing him answer that question.
Baroness Thornton
While the noble Earl is collecting questions that we feel were not answered, I asked specifically about the risk register, whether it is 100 per cent of children and where the weighing and measuring is taking place.
Earl Howe
My Lords, I will have to write to the noble Baroness on that question, and indeed some of the other questions that she posed in her speech. I hope she will allow that. As regards speech and language therapy, rather than give the noble Baroness an answer that may turn out to be incorrect, I may have to drop her a note. I will write to her.
Health Professionals: EEA and Non-EEA Citizens
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Baroness Thornton
My Lords, I thank the noble Viscount, Lord Bridgeman, for bringing this important matter to your Lordships' House. Although this is a short debate, it is none the less of huge importance. I am very keen to identify these Benches with the need to resolve this matter. A Health Select Committee report last year looked at the death of David Gray as a result of Dr Daniel Ubani and said then that this is a matter of great importance and urgency. How much more so now? That report stated that if the GMC had been able to carry out language and competence tests on EEA doctors wishing to practise as GPs then that life and perhaps other lives would have been saved. The Select Committee was keen to see the issue resolved then.
We know that the Government need to press for change to the relevant EU directive to enable the GMC to test the clinical competence of doctors and to undertake systematic testing of languages. I was very pleased to see that Sub-Committee G of our European Union Committee has taken evidence on this matter and will be reporting. That helps to strengthen the case. It would possibly have been helpful if it had reported before the deadline for the Green Paper, which is 21 September, but the fact that the evidence that has been given to it has been made public is very important. I knew that it was considering these matters, but I read with alarm some of the reports about the evidence that it had received. Dickon Weir-Hughes said to our Select Committee that the Nursing and Midwifery Council had to operate a two-tier system because of EU rules on the free movement of workers. In evidence to the same inquiry, the GMC revealed that a foreign doctor’s husband had contacted it on her behalf to register her for work because she could not speak English. It went on to report that the Nursing and Midwifery Council is now admitting people who have not been near a patient for 20 years, as the noble Lord, Lord Hunt, said in his speech.
We know that the GMC and the NMC have huge responsibilities for patient safety and we know that we must listen to them about this problem because this is about risk to patients. The problem we face is that this directive is an overarching document based on the principle of freedom of movement in the internal market and applies to several hundred professions, not just to those in the healthcare sector. While we on these Benches of course support the principle of freedom of movement and recognise the positive contribution of European Union nurses, midwives and doctors in the provision of healthcare in the UK, as the noble Viscount said, freedom of movement should not take precedence over patient safety. That is the challenge facing the UK Government in these negotiations.
I hope that this debate will help the Minister in his representations to BIS on behalf of the Department of Health about why this review is so important and why we have to stand firm on it. I join other noble Lords in urging BIS to continue to reflect our concerns in its submission to the Green Paper consultations and I urge the Government to continue their support when the draft legislation changes are made later this year for the consideration of the European Parliament and Council of Ministers.
We also know that the wheels of European directives move exceedingly slowly, which is why the points made by the noble Lord, Lord Kakkar, and others about addressing this issue in the mean time, if we possibly can, are also important. I would also like to identify these Benches with the call to do that.
Socioeconomic Equality Duty
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Baroness Verma
My Lords, as the noble Lord knows, I try to answer as honestly as I can. I simply reassure him that we believe firmly in the Equality Act. We supported the then Government to ensure that it got through, and we have put into place as many protections as we can for the vulnerable and the low-paid.
Baroness Thornton
I am not surprised that a Conservative Government are rolling back this aspect, as they told us that that is what they would do. I am surprised at the extent to which the Liberal Democrats roll over again from pledges and promises that they have made to the electorate—on NHS reorganisation, tuition fees and so on. We are getting used to it. For the record, will the noble Baroness say what other measures in the Equality Act the Government intend either not to implement or to delay? I would be pleased to see on the record what those are.
The noble Baroness and the Government are confusing two things: first, putting money in to help the vulnerable—we will see whether or not that works, although many people have their doubts—and, secondly, the issue of equality. The point of this duty was to ensure that somebody in the public sector was paying attention to, for example, the socioeconomic prospects of groups such as Muslim women, Travellers, the Jewish community, girls in sports, the Dalit communities and older Afro-Caribbean communities. Somebody was to pay attention to those communities and their socioeconomic prospects. Are the Government saying that they do not care about that duty? How will they ensure that those communities are taken into account? That was the point of the socioeconomic duty. If the Government want to get rid of that duty in the Equality Act, why are we not having a debate and a vote?
Baroness Verma
My Lords, I will repeat it yet again. We supported much of the Equality Act. If local authorities are worth their weight in gold, they are already doing all the things that the noble Baroness is hoping for. While 90 per cent of the Act has been in force since 1 October, further announcements will be made in due course. The noble Baroness will just have to wait and see.
Health: Cancer
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Baroness Thornton
My Lords, I join other noble Lords in congratulating the noble Baroness, Lady Finlay, on initiating this important debate. We have had a debate of exceptional quality, but that is only to be expected in your Lordships’ House on this subject. I also join others in congratulating the noble Lord, Lord Howard, on his maiden speech. I am sure that it is the first of many sparkling contributions to your Lordships' House.
I shall start by echoing the remarks of the noble Baroness, Lady Finlay, on tobacco regulation. This seems to be a question that I ask every week. What exactly is happening to the implementation of vending machine bans and point-of-sale tobacco regulation?
The timing of this debate is most appropriate. It is a snapshot of where we are after the previous Government’s work and investment, which have so improved the prospects for cancer patients, and of what still needs to be done. It is also an acknowledgement that change is coming, and poses questions to the Government about what that will mean for cancer patients and their families. It has also provided some suggestions for inclusion in the refreshed, new Cancer Plan.
I was moved by many of the speeches, not least that of my noble friend Lord Beecham, who I am delighted to have as a member of our small but perfectly formed opposition health team. My noble friends Lady Pitkeathley, Lord Kinnock and Lady Morgan made contributions that were enhanced by personal experiences, and my noble friend Lord Wills brought to the House’s attention his forensic ability, which I am sure we shall benefit from as we move forward.
We know that the most effective way of improving cancer survival rates is through prevention and early detection. That is why as a Government we invested in improved cancer prevention and diagnostic services. Breast screening for women, for example, means that 14,166 cases were diagnosed in women aged 45 and over—a figure which is similar to the one the previous year and nearly double that of 10 years previously. The Labour Government also rolled out the NHS bowel screening programme, the first screening programme targeted at both men and women. As a result of cancer screening and the two-week requirement for a specialist to see the patient, survival rates for breast cancer, as for bowel cancer, are improving for those getting this early screening and diagnostic.
The premature mortality rate for cancer is the lowest ever recorded, saving nearly 9,000 lives in 2006 compared with 10 years previously. A recent study by the International Agency for Research on Cancer found that breast cancer mortality rates in the UK were reduced by 30 per cent during the period 1989 to 2006, more than in any other European country. We are on the right trajectory, and it is important to keep moving in the direction in which we have started.
I should like to make a related point to the Minister. It is important to stop allowing this issue to be used as a political football. Andrew Lansley’s continued suggestions that the previous Government somehow failed cancer sufferers is not appropriate. I would be the first to admit that this was work in progress and that there was much more to do, but Mr Lansley does not need to attack the previous Labour Government to justify keeping cancer high on the healthcare agenda.
The Government have, for example, recently used data from EUROCARE that compare UK survival rates of patients diagnosed between 1995 and 1999 and between 2000 and 2002. The data show that the UK has lower survival rates for the most common cancers—lung, breast, prostate and bowel—than other countries with a similar health experience. However, there are two problems with this comparison. Few other European countries have the fully comprehensive cancer registry—referred to by the noble Baroness, Lady Finlay—that England has. Cancer data in Germany, for example, relate to only 1 per cent of the population. This information comes from the King’s Fund. It is also worth keeping in mind that there is a five-year time lag associated with five-year survival rates and that, at the end of this Government, EUROCARE will be measuring the experience of patients diagnosed during the early part of Labour’s Cancer Plan 2000. We know that five-year survival rates for the 21 most common cancers improved for both sexes between 2003 and 2007, compared with the period between 2001 and 2006.
The noble Baroness, Lady Finlay, raised some important questions about the cancer fund. I am still unclear about how the decisions to use this fund will be made and about what will happen if it runs out of money, as it surely will. There are various estimates about the inadequacy of the fund to meet the need. The British Oncology Pharmacy Association has estimated that the real cost of funding treatments will be £85 million this year and £120 million in a full year. We have to ask questions about the fund, which are linked to questions about NICE.
Can the Minister tell us which is likely to save more lives—investing in early diagnosis, or in cancer drugs not approved by NICE? Linked to this is the Government’s intention to downgrade NICE’s work in this area. It is extraordinary that the Government are removing NICE’s authority. It is the one outfit designed to prevent the Secretary of State having to take responsibility for unbearable rationing decisions. As the Guardian reported recently, and as the Minister said, NICE will become “somewhat redundant”. That week we saw the Daily Mail crowing about victory for its campaign. Under the headline “‘Penny-pinching’ NICE stripped of power”, the article stated:
“The scandal of patients being denied drugs just because the NHS rationing body decides they are too expensive will end”.
There is a serious problem here because, regardless of whether the NHS budget is increasing, it is vital to preserve NICE’s integrity and to ensure that the use of all drugs and treatments on the NHS is approved on an equal and fair basis while ensuring that they are cost-effective to the taxpayer. I do not understand why NICE cannot be the body that undertakes the new value-based system which the Government have been outlining. At the end of the day, if the changes go through, how will the Government help those GP commissioners who will be targeted in local campaigns by newspapers and patient groups to prescribe expensive drugs for rare conditions?
I shall return to the issue of waiting lists which I raised in an Oral Question to the noble Earl in the past couple of weeks. I asked about the lengthening of waiting lists for diagnostic tests and its impact on the diagnosis of cancer. Waiting lists for diagnostic tests have almost doubled since Andrew Lansley got rid of the 18-week target. Those are the Government’s statistics, not mine. I clearly did not put my supplementary question to the noble Earl correctly because he told me that I was completely misinformed and wrong. I was pointing out that if diagnostic tests are being delayed, it seems likely that cancer patients will be in that cohort, and that the two-week target—which I am not disputing; I am glad that the Government are keeping it in place—therefore begs the question: how will the Government monitor the consequences of increasing waiting lists for cancer patients and other conditions? Is it acceptable for waiting lists to be lengthening in this manner? How will GP commissioning deal with this issue, and how will the two-week target be maintained under the new regime?
I shall conclude with two questions, one of which picks up on the remarks of the noble Baroness, Lady Hussein-Ece, about people with cancer in the workplace. I am also grateful to Macmillan Cancer Care for sending me a briefing which calls for a set of initiatives to deal with people who want to work and who have, or are recovering from, cancer. Will such initiatives be included in the new Cancer Plan? Macmillan is calling for every patient who wants to work after cancer to be given back-to-work information; explicit outcomes on cancer patients remaining in and returning to work to be included in domain 3 of the NHS outcomes framework; vocational rehabilitation services to be included in cancer quality standards and the NHS Commissioning Board's guidance; and the Department for Work and Pensions to promote employers' awareness of the employment provisions of the Equality Act and their impact on disabled people, in particular those affected by cancer.
Finally, I return to an issue that I have raised before with the noble Lord, namely, the impact of excessive hospital parking charges for those with cancer and other conditions. The average cancer patient pays £325 in travel costs and hospital car parking charges while travelling 53 times to hospital in the course of their treatment. We know that the department's guidance is not working because it is not enforced. Around 60 per cent of cancer patients still have to pay the full price for parking during their treatment, even though DH guidance recommends that hospitals offer free or concessionary rates. Excessive car parking charges are too often the final straw that breaks the camel's back during a highly stressful, emotional and financially challenging time for the patient and their loved ones. We have had a full and fascinating debate and I look forward to the Minister's response.