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Baroness Carnegy of Lour: I too wish to speak to Amendment No. 105. Age Concern Scotland is also concerned. It probably will not be necessary to discuss the matter in the context of Part II if we can cover the matter now.

What the mover of the amendment and my noble friend said about the position of old people is critical. Some of the treatments will not give as much benefit to older people as to younger people because they do not have as long to live. Because of that, older people feel threatened and are extremely worried. It is a matter of great concern. It is important that it is plain in the Bill that age is not a factor. I understand that this is the National Year for Older People which makes it a funny time to do anything other than make certain that older people are included.

I am sorry that my noble friend Lord Howe was taken by surprise by the speed at which Question Time ended. The amendment tabled in his name related to resources that are to be taken into account when these matters are considered. That is a major issue. I am sure that the Minister will understand if he were to bring the matter into his comments on this amendment. The noble Baroness is quick on her feet but so is my noble friend. However, on that occasion he lost the race. I support in particular Amendment No. 105.

3.15 p.m.

Earl Howe: I am grateful to my noble friend for giving me the opportunity to speak to the amendment which I had not otherwise intended to do. The point my noble friend makes is extremely pertinent. The issue of resources is ever with us as we consider this part of the Bill. If the Committee will allow, I shall reserve my principal remarks to a later amendment where I believe that I can introduce them with somewhat more force than on this amendment.

Baroness Gardner of Parkes: I am somewhat concerned by Amendment No. 105. The principle is right but I am not sure that it should be on the face of the Bill. There will always be moments when a choice has to be made. For example, if there is one kidney, does one give it to the young woman or young man who may be bringing up a family or to the older person? One has to look at the clinical need. However, life expectancy must always be a slight factor. It must be difficult to choose to give a transplant to someone

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whose life would be extended by only one year when another person might live 50 years due to that same transplant.

I accept and support the principle of the amendment. There should be no cause for anxiety on the part of old people. But there will be certain resources--I do not refer only to financial resources although they are important--where difficult decisions may always have to be made by clinicians. Those decisions should be left to the clinician at that time.

Baroness Thomas of Walliswood: The noble Earl, Lord Howe, was not the only person caught on the hop by the rapid commencement of these proceedings.

High-tech care for elderly patients will always be a difficult issue. But there are other aspects of care of older people where the arguments do not sound so sensible. For example, when one is over 65 one is not automatically recalled for breast screening. Yet one is at greater risk of breast cancer when one is over 65 than at any other period in one's life.

Older people may become arthritic. However, if they go to the doctor's clinic they are quite likely to be told that it is just part of growing older and will not be offered treatment. But, if people can be kept mobile they are more likely to stay at home for longer and are less likely to go into extremely expensive nursing home care. The cost of quite serious interventions such as the special drug for Alzheimer's disease which is supposed to cost £1,000 a year may be compared with putting someone in a nursing home. That now costs a minimum of £350, and is more likely to be £450, a week. One can see the advantages of some treatments which may appear expensive but become more economic when comparing one budget with another. It is hoped that the joined-up writing between the healthcare services and social services will enable such cost comparisons to be made.

Lord Desai: I enter the debate because some important issues have been raised by the noble Baroness. It is interesting to compare the expected extra life years attained by treating a younger person or an older person. But, as the noble Baroness, Lady Thomas, said, if you do not treat that older person, what will be the ultimate cost? The older person will not conveniently die; he or she will cost quite a lot more when sick. There are delicate comparisons to be made.

If we are to have an age limit--I hope that we do not--it should be clearly and transparently stated. People should not be given the run-around with excuses that they are not being treated for some other reason. If one wants to make a rule about an age limit, then people will take out insurance, or something else. They should be told. Doctors should not hide behind specialisms or technicalities and administer a Treasury rule on medical grounds. That would be bad.

Lord Winston: Members of the Committee will forgive me for disagreeing with my noble friend Lord Desai--not for the first time! But one cannot make arbitrary age limits, especially in biology. Those have to be variable goal posts. They depend on many

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different factors. It would be fundamentally wrong in medicine to say that at a stated age someone was or was not fit for treatment.

Baroness O'Cathain: Does the noble Lord, Lord Winston, suggest that doctors should offer some excuse when not using a treatment because of the age of the person? That puts doctors into an invidious situation. They are sometimes rationing and are put into the position of having to tell fibs. I infer that situation from the noble Lord, Lord Desai. That is the issue.

Lord Winston: The noble Baroness, Lady Gardner, made clear that there must be a variation according to clinical circumstances. Doctors are inevitably in the unfortunate position of having sometimes to take such decision. It is to be hoped that they do so with wisdom and with a degree of collective responsibility rather than in isolation and in an authoritarian way.

Lord Clement-Jones: The debate has been extremely interesting. The Government have not been unconscious of the needs of older people. Indeed, they commissioned the national service framework for older people and there is in the offing a charter for the long term care of the elderly. In addition, they commissioned the Royal Commission, about which we will have a Statement later today. The key issue is whether such actions are sufficient to place on clinicians the duty to be conscious of the needs of older people.

The care of older people is a crucial issue. Indeed, my honourable friend in another place considered it to be so crucial that he recently put forward a Ten-Minute Rule Bill concerning discrimination and older people and outlined some extremely telling facts. The noble Lord, Lord Astor, mentioned some of them. For instance, women over 65 are not screened for breast cancer, despite evidence that they would benefit from early detection and treatment. Although the Government are conscious of the issue, their document Our Healthier Nation contained no targets for older people. It is easy to forget their needs, but, as we emphasised earlier in Committee, older people are key consumers in the NHS.

If the duty is not statutory, what is it to be? It must be a powerful duty to keep people on their toes. I am sure that the noble Lord, Lord Winston, is correct in saying that there must be flexibility in clinical behaviour, but the one thing we cannot have is discrimination.

Since tabling Amendment No. 105, I have been stunned by the number of people who have written to me or approached me telling me that it is a real problem because they have relatives who were not cared for in a proper fashion or who were ignored. We in this House have debated the standard of nursing of older people and some cases have been shocking. The standard may depend on the way in which boards are managed, but it also depends on attitudes towards older people. On the day on which we are to debate a Statement on the long-term care of the elderly, we must be careful before dismissing a statutory duty of this kind.

Baroness Gardner of Parkes: I wish to take up the point about breast cancer screening. The hospital of

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which I was chairman researched cases of breast cancer among elderly women and found the statistics misleading. As there is no universal screening, the women who attend for screening suspect that they have cause to do so. Therefore, the percentage appears to be higher among women above the age of 65, but when compared with the population as a whole it is not higher. We must not be side-tracked on that argument.

The general practice at which I am a patient recently sent all its patients, irrespective of age, for breast cancer screening. In a new project, it decided that that should be done. I understand that some practices are introducing a screening policy in a more general way, but it has always been the case that anyone who has any cause for anxiety can ask for breast screening at any time. That was the policy of the previous government and I am sure that this Government will continue it.

Baroness Hayman: Echoing the words of the noble Lord, Lord Clement-Jones, we have had a useful short debate on these important amendments dealing with issues of race and age in terms of the quality of care and the annual report of the commission for health improvement. We have also discussed the monitoring arrangement in NHS trusts and PCTs.

The noble Baroness, Lady Gardner of Parkes, referred to breast cancer screening and she is correct in saying that we should not give the wrong impressing. Any woman over 65 is entitled to have breast screening if she wishes. There is not at present a national programme of the screening of over 65s because the national screening committee advised that resources should be concentrated, in the first instance, on young women. However, we are considering extending the age limit in pilot schemes. It will not be a matter of taking an arbitrary age limit; the effectiveness of screening will be examined just as one would examine the effectiveness of a vaccination programme for younger people. The policy will in no sense suggest that facilities should be cut off at a certain age; it will in no sense suggest that it is not worth directing attention to the elderly.

Amendment No. 72 would extend the duty of quality to cover monitoring and improving the equity of treatment as well as the quality of care. Amendment No. 75 would introduce a requirement for NHS trusts and PCTs to include in their monitoring arrangements for quality,

    "monitoring by ethnic origin of individuals receiving health care".
Amendment No. 90 would require the commission's annual report to include material on its performance in respect of equal opportunities. Amendments Nos. 105 and 106 extend the principle of equal treatment, not on the basis of age, to the commission's exercise of its functions. In general, that follows our discussion earlier in Committee in the context of primary care trusts and the way in which we apply the important principles of equity of access to NHS services. That access should be fair and on the basis of clinical need. We made commitments to those ends in Our Healthier Nation Green Paper and The new NHS White Paper and through a range of other measures to improve fair access to services.

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In the foreword to A First Class Service, the Secretary of State for Health stated that fair and prompt access to modern and dependable treatment should be the goal. We have a strategy to improve quality across the board. Earlier in Committee when discussing the national institute for clinical excellence we spoke of reducing geographical variations which result from the disputes of evidence base and which can affect people whatever their age and ethnicity. However, if we are interested in equitable access to service we must tackle those issues as well as the issues of ethnicity and age. National service frameworks are a very important way of taking that forward because they aim to reduce unacceptable variations in care and treatment using the best evidence of clinical and cost effectiveness. They will be a key tool in tackling inequalities.

The purpose of the duty of quality is to ensure that all NHS provider organisations have a clear duty to put and keep in place arrangements to monitor and improve the quality of the healthcare they provide to all patients. The principles of clinical governance, which include care based on best available evidence, are applied to NHS organisations to all their patients. That in itself will have the effect of improving the equity of treatment on offer.

The explicit addition of "equity" to the definition of the duty of quality could create problems of definition. That concept is even more difficult to pin down and to assess than that of quality and could mean a range of different things; for example, equal access to treatment or fair treatment, taking account of both individual and collective need.

As regards Amendment No. 75, I am in full agreement that it is important that NHS trusts, primary care trusts and health authorities make effective use of the information they collect on the ethnic origin of the people receiving healthcare to help ensure that people from ethnic minorities are accessing the healthcare they need. However, I do not accept that an amendment to the duty of quality is the best way of taking that forward.

I hope that earlier in Committee I demonstrated the whole range of measures which we intend to take to reduce inequalities. The guidance we issued on health improvement programmes in October last year clearly sets out our expectations that we should identify and monitor targets and milestones for measurable improvements in health and healthcare and reducing inequalities. The guidance makes specific mention of mapping health inequalities and inequalities in access to services. Mapping of that kind will be informed by the type of information to which reference has already been made. The commission for health improvement will look at the quality of healthcare, and I stress again that that means the quality of healthcare for all people.

We debated earlier the needs of the elderly. I understand the reason for that; their needs have not been particularly well addressed in the past. We are trying to make progress in that area, and when my right honourable friend sent out the HAS 2000 report on dignity on the wards and care for the elderly he made clear his intention that it should be responded to by all parts of the NHS. Equally, the national service framework that we are

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setting out for service standards for older people will be an extremely important way of taking forward improvements in care for the elderly.

I referred earlier to screening, and we would certainly reject any crude, age-related cut-off point that did not allow people to have individual care and the care that they needed. But I suggest to the Committee that we run into danger when we look at age specific issues alone or issues related to ethnicity on their own. We discussed the Acheson Report, Inequalities in Health, earlier in Committee. It can be argued that poverty is one of the main inequalities, both in good health and in access to healthcare. These provisions, which deal with ethnicity and age, do not deal with poverty. They do not deal with access to services for people of different gender, and there have been some interesting issues raised, particularly in relation to coronary care, about differential access for men and women.

We run the risk of putting on the face of the Bill certain categories of people who might be disadvantaged but not others. The noble Lord, Lord Rix, is not well today and is therefore not with us, but I am sure that he would be saying that we should not neglect the needs of those with learning difficulties when we are looking at specific needs. I hope I can reassure the Committee that we recognise both the specific needs of older people--the NHS framework will be important in that respect--and the need for monitoring policies in terms of the access given to people of different ethnic origin. Again, we must go wider than that and understand what services are appropriate for specific ethnic groups. We must make sure not only that we have an equal playing field, for example, in terms of services for sickle cell disease but also that we have appropriate sickle cell services where the communities need them.

I urge the Committee to focus on our commitment to ensuring the duty of quality in the work of the commission. It must be devoted to ensuring that all patients have access to the services they need. That will encompass specific groups, without drawing a false distinction between them, and other patient groups that may be disadvantaged in the provision of healthcare.

3.30 p.m.

Baroness Thomas of Walliswood: We thank the Minister for her comprehensive response to this debate. I wish only to make the point that issues of age, poverty and race are often associated; they seem to hang together. But I do not feel the need to carry the discussion further.

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