Health and Social Care Bill

Baroness Thornton Excerpts

Wednesday 16th November 2011 Lords Chamber

[Earl Howe]

That the House do now resolve itself into Committee.

[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.

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[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.

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[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.

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[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.

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[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.

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[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.

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[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”.

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[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.