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Sir Robert Smith (West Aberdeenshire and Kincardine): I caution the hon. Gentleman against being trapped into stereotypes. Research has shown that those beyond a certain age have a statistically greater ability to survive some treatments than younger people, who have yet to be hit by a range of illnesses. People who do not survive those illnesses will not reach an older age. It is important that there is no prejudice in that clinical judgment.

Mr. Hammond: I accept the hon. Gentleman's words of caution. The issue is not just the ability to survive a treatment. When considering the allocation of health care resources to different priorities, Ministers, the National Institute for Clinical Excellence or whoever is responsible will want to consider what benefit the patient will accrue from the treatment as well as the cost. Such a consideration may introduce legitimate and clinically justifiable discrimination on the grounds of age in certain circumstances. I raise that issue to distinguish between discrimination in the pejorative, everyday sense and discrimination that is backed by clinically justifiable reasoning.

If the Government overcame their taboo on talking about rationing we could address the issues. We would find that part of the debate about discrimination, particularly age discrimination, merged into the debate on rationing. We would then be able to identify the discrimination in the system--I accept that there is some unjustifiable discrimination--and focus on tackling it. We could do that within the health service structure that the Minister and his colleagues have put in place by imposing a further permanent duty on CHIMP, as proposed in amendment No. 172. I acknowledge that new clause 7 is well meaning, but amendment No. 172 would be a better way to address the problem if primary legislation was considered necessary.

Mr. Denham: Equal opportunities for those who work in the NHS and for those who need its services has been an important and recurring theme in our debates on the Bill in Committee and in another place.

The new clause and amendments pursue that theme in the context of some of the new developments in the Bill: primary care trusts in amendments Nos. 78 and 79; the duty of quality in amendments Nos. 83 and 80; and CHIMP in the other amendments. I have explained why that piecemeal approach to legislation, bolting specific provisions about aspects of equal opportunities on to some parts of the NHS framework, is not the best way forward.

If we are to legislate, we should address the NHS in the round. However, such an approach requires careful consideration and would need to look beyond the NHS, taking account of developments across Government and the importance of a consistent approach across the range of public services. For example, we are working closely with the Home Office on planning the way forward on race equality in the light of the recommendations of the

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Macpherson report on the Stephen Lawrence inquiry. On that front, the Race Relations Act 1976 would provide the route for legislative change. Such issues must be taken seriously.

I am happy to reaffirm our commitment that there must be no place in the NHS for discrimination on grounds of age, gender, race, religion, sexual orientation, or disability. That is more than just a statement. We shall continue to scrutinise the NHS's performance against that commitment as an employer and in the service that it offers to patients. I shall set out in a moment the areas in which there has been activity. Looking back over the debates in another place and especially in Committee, it seems that there has been a tendency for the suggestion that we are doing nothing to go unchallenged--that would be my fault--whereas that is clearly not the case.

8.45 pm

The new clause proposes an independent review to consider these issues. I am not sure that such a review is the right next step; indeed, there is a real risk of putting practical action on hold while efforts are diverted to support what would inevitably be a massive and all-embracing review. Equal opportunities and work against discrimination must be embedded in our total way of working, rather than being treated as a separate and one-off activity. What matters is that our total programme for the national health service should reflect the drive to eliminate discrimination and promote equal opportunities that has been the theme of this short debate.

Let me outline some of the steps that we are taking. On employment, our human resources framework for the national health service, known as "Working Together", sets action on equality in the workplace as a priority. By April 2000, all local employers will need to have policies and procedures in place to tackle harassment by staff and service users and they must also make progress on family-friendly policies.

We are carefully considering our whole approach to equality following the Macpherson report. We are working with the Home Office and other Departments to ensure a systematic response across Government. Last year we commissioned and published a survey of all national health service trusts in England to examine progress in equal opportunities so that we could establish a base-line against which to measure progress and set targets to raise standards.

Since coming to power, we have launched an NHS-wide development programme, known as "Positively Diverse", which is encouraging recruitment and development of staff from local communities. That has been underpinned by an audit covering about 76,000 staff from the organisations concerned, to provide valuable information about their experience and to help to inform local action plans.

We have signed up the national health service to the Commission for Racial Equality's leadership challenge programme. Forthcoming guidance will cover positive approaches to the employment of disabled people. The national health service is a member of the Employers Forum on Age and two thirds of national health service trusts specifically include age in their equal opportunities policy statement. We intend to publish an equalities

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framework document later this year to ensure that equality and diversity are mainstream issues for the national health service. That will be supported by equality indicators so that the activities of the national health service as an employer can be kept under constant review.

Both the hon. Member for Southwark, North and Bermondsey (Mr. Hughes) and the hon. Member for Runnymede and Weybridge (Mr. Hammond) spoke about access to health care. Action on inequalities is a central theme. We are facing up to inequalities in health. We are the first Government to do so in a long time. We launched the Acheson inquiry on health inequalities, which we shall draw on in the public health White Paper, "Our Healthier Nation", which we shall publish shortly.

We are committed to ensuring fair access to consistently high standards of service, in accordance with need. As part of the comprehensive spending review, we commissioned a systematic review of the research into equality of access in the national health service. That research concluded that evidence of systematic discrimination is relatively limited, but that there are some areas of health care in which access has not been equal.

It will not surprise a well-informed gathering this evening that those areas include primary care services in the inner city; mental health services, in which there is evidence of particular problems for black and Asian people with mental health needs; and coronary revascularisation, in which people were less likely to be referred for treatment if they were poorer, older, female, or black or Asian. That work is further evidence of our commitment to understanding the problem and taking action.

Tackling such inequalities is a key issue for the new health action zones, for health improvement programmes and for primary care groups and, in future, trusts, as they begin to look in depth at the needs of their populations and better align their resources with those needs. The first national service frameworks will set national standards for coronary heart disease and mental health and will enable a rigorous approach to tackling inequalities. The next national service framework will cover older people and will of course need to tackle the important question of access to services.

The Commission for Health Improvement will look carefully at the issue of access to health care, within its overall remit for monitoring and supporting the NHS's progress in improving quality of care. I would expect that to be an important theme as the commission reviews action on the national service frameworks, for example, and the development of clinical governance. One issue would be whether groups within the population are receiving the sorts of treatment that the evidence suggests they should. That is an important issue, because fair access is one of the six themes of the NHS performance assessment framework. The framework recognises

That is one of the six criteria by which the NHS's performance will be assessed in future.

Mr. Hammond: Given what the Minister has just said, would not accepting amendment No. 172, and thus including a specific duty for CHIMP, send an important and valuable signal?

Mr. Denham: I have considered the amendment carefully, but I concluded that it was not necessary. As I

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have said, several of the normal aspects of the commission's work in reviewing the development of clinical governance will require to consider issues of access. That will apply especially to its consideration of the national service frameworks. It would be within the power of the Secretary of State to request the commission to carry out a specific study of access issues, should that be necessary. However, to introduce a standing requirement would be unnecessary in the context of the way in which the commission will work.

We are committed to implementing section 21 of the Disability Discrimination Act 1995 in the NHS and will shortly issue to the NHS a report on that by Disability Matters, including a proposed action programme for the NHS that will be informed by the views of service users as to priorities. We shall also issue a template to help the NHS audit its premises for their accessibility for disabled people. A range of development work is also under way to assist the NHS in making fair access a reality.

I have listed just some of the wide range of action under way. As I have explained, much has already been done to improve our information and understanding about how the NHS treats its staff and about the experience of patients. Equal opportunities is integral to our programmes of modernisation. With equality indicators and the performance assessment framework, we shall be able to track progress more systematically than in the past.

I believe that it is right to concentrate efforts on seeing through that substantial programme of change. In response to the debates in the other place and in Committee we reconsidered the question of legislation as proposed in some of the amendments. I set out earlier why I do not believe that a piecemeal approach to the introduction of legislation is the right approach. A more fundamental approach would need to take into account more important considerations across Government.

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