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Baroness Crawley: My Lords, while I welcome the Minister's encouraging reply to the noble Baroness, Lady Thomas of Walliswood, and recognise the Government's good record on human rights and equality, is she aware of the disappointment felt by women's organisations throughout the country about the lack of action in relation to this convention? Can she assure us that the Government are seeking an early resolution to the problem?
Baroness Scotland of Asthal: My Lords, I certainly reassure my noble friend that the Government are aware of such disappointment. I assure her that the Government's commitment to equality and women's issues is as strong as it always has been. She rightly said that we have a proud record. We certainly do not seek to besmirch it by any tardiness. As I said, we will review the matter and there will be a full opportunity for extensive consultation on it. I am sure that my noble friend and many other colleagues will want to contribute to any such review.
Baroness Buscombe: My Lords, does the Minister agree that while actions speak louder than words, others will ask, "What do we actually achieve by signing the protocol?"? Is it not more sensible for us to concentrate on actively promoting our human rights agenda?
Baroness Scotland of Asthal: My Lords, that is a strong view, and the noble Baroness was right to say that even if we signed and ratified the protocol, the committee would be able to make recommendations that would not be binding on us. All of the conventions to which we are currently party are binding on us; that is also the case with our legislation. The noble Baroness rightly said that primary importance should be given to our Human Rights Act. That is not to detract from the potential importance of the protocol. That is why we said that we will review it and do so thoroughly.
Baroness Williams of Crosby: My Lords, does the Minister accept that this is not simply a case of establishing whether we have carried out a number of the legislative provisions that are required in relation to sexual and gender discrimination? Does she also recognise that the UK's full acceptance of CEDAW would be an example to a number of countries whose legislation is wholly unsatisfactory? In the light of that, will she assure the House that she will move as urgently as possible towards the full ratification of the protocol?
Baroness Scotland of Asthal: My Lords, I certainly accept that that is an encouragement to others, and I understand the symbolic nature that many sought to underscore. All of that is understood. However, she will know that this country is not simply interested in
symbolism; we are interested in action. We intend to undertake the review, look at the matter frankly and openly and then do something that will, I hope, make things better for the women of this country and encourage others to do the same.Asylum Seekers: Country of Origin Reports
3.30 p.m.
Earl Russell asked Her Majesty's Government:
- Whether they will consider setting up an independent unit to consider the safety of countries to which refugees may be returned.
Earl Russell: My Lords, I thank the Minister warmly for that reply. I believe that we all realise that the Home Office has a very wide range of responsibility. We respect that. But will the Minister remind the Home Office that it is not the Foreign Office?
Lord Rooker: My Lords, the Foreign Office is the Foreign Office. It works for the British Government and not for foreign governments. I cannot add to the Answer that I gave. The Home Office announced nearly two years ago that it would consider having independent documentation of the in-country reports. We are satisfied with the quality of the reports, but a research effort has been undertaken and we shall shortly publish the results.
Our own in-country reports are quoted by all western governments and, indeed, by the United Nations High Commissioner for Refugees. Therefore, I do not accept that they are defective. Nevertheless, in April 2000 we undertook to consider whether there was a role for an independent documentation office to produce those reports. They do not contain Home Office policy and they do not contain Foreign Office policy either.
Lord Renton: My Lords, with respect to the noble Earl, Lord Russell, is the noble Lord aware that people claiming to be refugees who are ordered to be returned are so ordered because it is felt that they are not refugees? Therefore, there is a contradiction in this matter.
Lord Rooker: My Lords, I do not believe that that is so. Some people found not to be refugees are not ordered to return because we have a policy of not returning people to certain countries. Therefore, it is not the case that every asylum seeker who fails to become a refugee is returned. It depends on the policy
regarding the country from which people come. It is well known that we do not return people to certain countries.
Lord Hardy of Wath: My Lords, is it not the case that a significant number of asylum seekers and those who organise asylum seekers come from member states of the Council of Europe? Bearing in mind that those member states all have administrations, laws and constitutions which are compatible with democracy and the practice of human rights, is it not reasonable to suggest that such refugees do not merit acceptance? Would it not be appropriate for our representatives in both the Council of Ministers and the Parliamentary Assembly in Strasbourg to pursue that matter more vigorously?
Lord Rooker: My Lords, I agree with my noble friend. Our country reports would make clear that it was acceptable to return people to countries that have rule of law and human rights legislation, but it would depend on the merits of the case. As I said, every case is judged on its individual merits. I believe that that is the safest way to operate. However, as my noble friend said, we must take into account the countries of the Council of Europe. It would be ludicrous if we were not able to return people to such countries; in that respect there would be a complete failure of the requirements relating to their membership of the Council of Europe.
Lord Dixon-Smith: My Lords, does the Minister agree that whether one is looking at an independent unit to consider the safety of countries or whether one is considering the reports from the Foreign Office, the matter that should really concern the House is the speed of government action and the firmness with which they act? The decision as to whether or not a country is safe is crucial, and, regrettably, the speed of action was too slow in the case of Zimbabwe.
Lord Rooker: My Lords, I do not accept that. We provide to asylum caseworkers country reports, published twice a year, together with bulletins. We also plan to publish the bulletins. Home Office staff also have access to the Foreign Office, to our high commissions, to embassies and to people on the ground. They have the best available information on which to make decisions in respect of asylum cases. On the evidence provided thus far, I simply do not accept that we were too slow in relation to Zimbabwe. We were right to make the decision when we did. It would be wrong for me to go into individual cases at present, but it is true that there is a serious problem in Zimbabwe. However, I do not accept that the decision was made too late.
Baroness Williams of Crosby: My Lords, I want to return to the matter raised by the noble Lord, Lord Dixon-Smith, because I believe that the Minister may wish to reconsider the assurance he has just given. It is the case that at the time when the Foreign Secretary was pressing for the suspension of Zimbabwe before
the Commonwealth heads of government, people who had close links with the opposition parties were still being returned to Zimbabwe. Can the Minister consider again whether a more rapid and widespread country assessment might be made, drawing on many of the extremely useful unofficial, as well as official, sources now available? As the Minister will appreciate, for the individual this can be a matter of life and death.
Lord Rooker: My Lords, indeed, and it is because there are unofficial sources that we cannot fully disclose from where we obtain the information. If we were to do so, it would cause those sources problems in the countries concerned. The country to which the noble Baroness referred is a particular case in point. To the best of my knowledge—I stand to be corrected—there is only one documented case of a person having been returned to his country and suffering a problem as a result. However, the opposition party removed that person to safety in Botswana. With all the acres of media coverage, we know of only one such case. We have yet to receive information regarding other such cases. The greatest pressure and publicity related to a person who was returned to South Africa, not Zimbabwe. The media constantly refer to Zimbabwe, whereas in that case the returnee went back to South Africa.
National Health Service Reform and Health Care Professions Bill
3.36 p.m.
The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt of Kings Heath): My Lords, I beg to move that this Bill be now read a second time. Earlier this month, we published our response to the Kennedy report into events at the Bristol Royal Infirmary. The response to those events marked a turning point for the National Health Service.
In today's world, people expect services to respond to their needs. Increasingly they want to make informed choices about how to be treated, where to be treated and by whom. The NHS Plan, which we published 18 months ago, set out our vision for the future of healthcare in this country, where patients are in the driving seat and able to make informed choices about their care, and the NHS is decentralised with a plurality of providers operating within a framework of clear national standards regulated independently.
The NHS needs two things: investment and reform. Today, investment in the NHS is growing faster than ever before: it is the fastest-growing health service of any major country in Europe; there are 10,000 more nurses than one year ago; last year was the first in 30 years when there were more, not fewer, beds in hospitals; the biggest hospital building programme in NHS history is now well under way; in the past year, 800 GP surgeries have been modernised; the NHS now has the world's best smoking cessation services;
prescribing of cholesterol-lowering drugs has risen by one-third; and waiting times for cancer and cardiac care are falling.With regard to reform, the NHS is today implementing the biggest programme of change in its 50-year history. Our 10-year reform programme is showing plenty of early promise, but we do not pretend that we have solved every problem. We have not. But, from talking to staff, I believe that there is an increasing recognition of the money and the changes coming through.
The Secretary of State for Health recently expanded on a number of key themes from the NHS Plan which will give patients greater choice over services. There will be a changed relationship between the NHS and the Government. A one million-strong service cannot and should not be run from Whitehall. In order for patient choice to thrive, it needs a different environment in which there is greater diversity and plurality in local services which have the freedom to innovate and respond to patient needs.
With our reforms we want to keep the National Health Service but change it to a values-based system in which different healthcare providers—in the public, private and voluntary sectors—provide comprehensive services to NHS patients within a common ethos: care free at the point of use, based on patient need and informed choice and not on ability to pay.
As Kennedy identified, it was a lack of clear standards and clear lines of accountability that underpinned the Bristol tragedy. In our first term we established a clear national framework within which local NHS services can operate. We have come far in four years. There are new national service standards for cancer, heart disease, mental health and care for older people. There is greater transparency over local service performance.
There is a new legal duty of quality and a new system of clinical governance to enshrine improvements throughout the NHS. There is the National Institute for Clinical Excellence (NICE) evaluating new treatments. For the first time the NHS has an independent inspectorate, the Commission for Health Improvement. With the NHS Modernisation Agency, there are now new systems for when things go wrong and more help to learn from what goes right. More focus than ever is being given to strengthening professional self-regulation.
Today, with that national framework in place, in our second term the centre of gravity is shifting decisively to the NHS front line. The task of managing the NHS is becoming one of overseeing a system, not an organisation. In future, the Department of Health should focus on outcomes and strategy and set local providers free to take care of the day-to-day management of inputs for themselves, informed and invigorated by strong patient and public involvement, with Ministers remaining accountable to Parliament for the overall performance of such a system.
That is the long-term strategy. To bring it about, a considerable degree of legislative change is required. The Bill enables day-to-day management of the health service to devolve to 28 new strategic health authorities in England. Those strategic health authorities will oversee the work of local NHS trusts and primary care trusts. Their chief executives will account both nationally and locally for the performance of those local health services. Franchises for running those strategic health authorities will be let, based on performance against an annual delivery agreement with the Department of Health.
The real power and resources in the NHS will move to the NHS front line. From April this year, locally-run primary care trusts, involving professionals and patients, will be up and running in all parts of the country. Within a few years they will control 75 per cent of the total NHS budget. They will be able to choose from which hospitals care is commissioned. The best hospitals are likely to be those where they too practise the philosophy of devolution and empowerment.
Clause 1 places a duty on the Secretary of State to set up strategic health authorities to cover the whole of England and provides for him to make regulations which contain requirements to consult on changes, such as names or boundaries. Clause 2 requires the Secretary of State to establish primary care trusts to cover the whole of England. Clause 3 enables the Secretary of State to delegate directly to primary care trusts the exercise of any functions conferred on him by health legislation; for example, the duty to provide hospital accommodation under Section 3 of the National Health Service Act 1977. Clause 4 amends primary care legislation to take account of the establishment of strategic health authorities and of the transfer of certain functions to primary care trusts. Clause 5 requires primary care trusts, rather than health authorities, to recognise local representative committees of family health service practitioners.
The same devolutionary principles will apply in Wales. The Bill enables the National Assembly to establish local health boards to exercise functions as it may direct. That arrangement will replace the current one of health authorities directing local health groups. Clause 22 gives effect to the National Assembly's commitment to ensure joint working in the development and implementation of local strategies for health and well-being by placing each local health board and local authority under a duty to formulate and implement a health and well-being strategy for the area. Clause 9 provides for local health boards to be funded directly by the National Assembly for Wales.
Clause 7 provides for the funding of strategic health authorities, mirroring the existing provision for the funding of special health authorities. Clause 8 provides for primary care trusts to be funded directly by the Secretary of State and allows performance payments, such as from the NHS performance fund, to be made direct to primary care trusts. Clause 10 amends the definitions of primary care trust expenditure, so that it
can be treated in the same way as health authority expenditure is currently, as regards non-cash-limited expenditure.For the first time, the NHS now has an independent inspectorate, the Commission for Health Improvement. CHI, as it is known, provides advice and information on clinical governance arrangements, conducts a rolling programme of local reviews focusing on the implementation of clinical governance and through the capacity for rapid investigation, helps the NHS identify and tackle serious or persistent clinical problems. It also conducts national reviews on the implementation of national service frameworks, on topics such as services for coronary heart disease, and examines the take-up of guidance issued by the National Institute for Clinical Excellence.
Through the Bill, CHI will have a new function of inspecting individual NHS trusts and other service providers offering NHS care against a set of agreed and published criteria. Where CHI finds evidence of unacceptably poor quality services, or of significant failings in the way that a body providing NHS services is being run, it will be able to recommend that special measures are taken. In future, CHI will also make an annual report to Parliament on its overall findings on the quality of services provided to NHS patients, as a mark of its independence.
Clause 11 amends Section 18 of the Health Act 1999 to clarify that the duty of NHS bodies to maintain arrangements for monitoring and improving the quality of healthcare provided should also include arrangements relating to the kind of environment in which patients receive healthcare services. Clause 12 extends CHI's remit to include carrying out reviews of any aspect of healthcare services. It requires CHI to publish a summary of each report it makes and provides that the Audit Commission must consult CHI on its value-for-money studies as part of better co-ordination of regulation of the NHS.
Clause 13 gives CHI the function of carrying out inspections of all bodies providing NHS services. It requires that CHI must report any discovery of healthcare of an unacceptably poor quality, or of significant failings in the way the body is being run, either to the Secretary of State or the National Assembly for Wales, whichever is appropriate. Such a report may recommend that special measures be taken.
Clause 14 amends CHI's constitution, giving it the right to appoint its own chief executive and providing that CHI must make an annual report about the quality of services to NHS patients to the Secretary of State and the National Assembly. The Secretary of State will lay this report before Parliament. It also enables CHI to set up an office for information on healthcare performance to collect and analyse data and carry out performance assessment.
Many of our reforms involve government acting on behalf of patients in order to influence how the NHS relates to the patients it is there to serve. They are about changing the culture of the NHS to put the needs of its patients first. But a service designed around the
needs of patients has to hand over more power directly to them. The Bill contains reforms to give patients a greater role and a stronger say in the NHS and in matters that affect their health. These provisions are the product of over 18 months of debate in Parliament, through public consultation, reaction to the Kennedy report and in the media.Patients forums will be set up in every NHS trust and primary care trust, with membership drawn from local patients, carers and representative organisations. Their main role will be to provide direct input from patients to NHS trusts and PCTs into how local NHS services are run and could be improved better to meet patient needs. Each patients forum will have a representative on the trust board.
An independent commission for patient and public involvement in health will provide support for patients forums, facilitate local co-ordination and co-operation between patients forums and promote the involvement of the public in decisions affecting their health. It will also report to the Government on how these new patient and public involvement mechanisms are working.
The independence of the system for patients and public involvement is critical to its success. During the Bill's passage in the other place, we have listened to suggestions about ways to make the system even more independent. We have strengthened the new commission's independence by removing the Secretary of State's power of veto over the appointment of its chief executive and staff. Patients forums' independence has been bolstered by changing their accounting arrangements so they will now receive their funding via the new independent commission rather than from their local NHS trust or PCT. The patients forums' role was also strengthened by giving them an explicit power to refer matters of concern to local authority overview and scrutiny committees.
Clause 15 requires the Secretary of State to establish a patients forum for each PCT and NHS trust in England and sets out its functions. Clause 16 gives the Secretary of State power to make regulations requiring NHS bodies, and others which own premises where family services are provided, to allow authorised members of patients forums to inspect those premises. Clause 17 requires patients forums to submit annual reports to the forum's trust, the Secretary of State, the new commission and the relevant overview and scrutiny committee of the local authority. Clause 18 enables the Secretary of State to make supplementary provision in relation to patient forums. Clause 19 establishes the new commission for patient and public involvement in health. Clause 20 provides for the abolition of community health councils.
Clause 21 relates specifically to prison health services. It makes provision for the NHS and the Prison Service to work more effectively together to fulfil their overlapping functions. It will enable them to pool their resources and to delegate their functions to one another. These arrangements parallel those set out in Section 31 of the Health Act 1999 to allow for closer working relationships between NHS bodies and local
authorities. Clause 21 also introduces an explicit duty of co-operation between the Prison Service and the NHS to secure and maintain the health of prisoners.Part 2 of the Bill is about the regulation of health care professionals, who may of course work in the NHS or elsewhere. A healthy system of self-regulation is essential for the kind of devolved NHS that I have described. As Professor Kennedy pointed out, it is also a necessity if patients are to feel confidence in the system.
For those reasons we said in the NHS Plan that we needed modernised and more accountable professional regulatory arrangements to offer better protection for patients. We also want faster and more transparent procedures and meaningful accountability. The regulatory bodies are already responding in constructive ways to government proposals, but more needs to be done to ensure that modernisation continues.
The Bill therefore takes forward a recommendation of the Kennedy report by introducing a new council for the regulation of healthcare professionals. The council will promote the interests of patients and other members of the public. Working with the regulators in a light-touch, consensus-building style as far as possible, it will build and manage a new framework for self-regulation. It will be independent of the Government. It will report directly to Parliament. It will consist of 10 representatives of patients, the public and healthcare providers and nine regulators; and it will oversee all the statutory regulated bodies.
Clause 23 provides for the establishment of the council. Clause 24 sets out its powers and duties. Clause 25 provides underpinning powers for the council and places certain duties on the regulatory bodies to ensure that the council can operate effectively. Clause 26 provides for the Secretary of State to set up a scheme for the council to investigate complaints about the regulatory bodies. Clause 27 provides that—in rare cases where the council considers it to be desirable for the protection of the public—it should be able to refer a regulator's final decision on a fitness to practise case to the High Court and its equivalents across the UK. We anticipate this power being used extremely sparingly.
The Bill deals with other aspects of professional self-regulation. Clauses 28 to 32 create consistency among the appeals procedures of all the regulatory bodies, while Clause 33 makes a small addition to our powers in respect of the reform of regulation of the pharmacy profession to bring them more into line with those for other professions.
Finally, Clauses 34 to 40 deal with miscellaneous provisions which underpin the rest of the Bill. Most notably, Clause 34 enables the Secretary of State to amend legislation relating to the health service in England and Wales by order if he thinks that such amendment will assist the consolidation of that legislation. The 1977 Act, itself a consolidation of previous legislation, has since been amended by some 57 further Acts. It is our intention to consolidate this legislation into a single new Act at the earliest suitable opportunity.
In conclusion, we envisage a fundamentally different kind of NHS; not a Whitehall-run structure but a values-based system. This Bill underpins that system—where government no longer run a nationalised industry but instead oversee a system of care; where greater diversity and devolution are underpinned by common standards and a common public service ethos; where there is greater diversity of provision and more freedoms for local services to improve care for patients; where treatment is free and provided according to need wherever it occurs; where there is a new common purpose shared across health sectors and a relentless focus on better health outcomes and less inequality; and where patients can make informed choices about their services and about their care.
This Bill may not be the last word on legislative change, but it delivers important legislative changes that are essential to underpin our strategy for the NHS. I commend the Bill to the House.
Moved, That the Bill be now read a second time.—(Lord Hunt of Kings Heath.)
3.58 p.m.
Earl Howe: My Lords, once again it falls to me to thank the Minister for introducing this Bill in his customarily clear and comprehensive way. That, I have to say, is about as far as I can go with expressions of gratitude. The Minister will, I hope, accept that on those occasions when I find myself in agreement with the Government, I have no difficulty in giving credit where it is due. When, as with this Bill, I find almost nothing to approve of in what the Government are doing, I have no hesitation in saying so in the plainest possible terms. I am afraid that the Minister will not find much comfort in what I am going to say about the proposals before us today.
When the Government were first elected in 1997, they set about a programme of reform of the NHS which consciously arrogated power back to the centre and away from individual doctors and managers. A command and control mentality and an overbearing ministerial style have been the hallmark of this Government's stewardship of the health service, to the extent that there is almost no manager, no doctor and no nurse who has not found their professional lives directly affected by target-setting directives and reporting requirements imposed by the Secretary of State.
The process of change initiated by the Health Act 1999 and continued in the Care Standards Act 2000 and the Health and Social Care Act 2001 has been sold to the public and the medical profession as implementing a grand vision of improved and more co-ordinated services for patients. As these changes, and the upheaval that goes with them, have been accepted and absorbed by NHS staff, we have at least had the comfort of ministerial assurances about the future: the importance of avoiding further wholesale upheaval; of respecting the wishes of local stakeholders; of preserving professional self-regulation; and of facilitating patient choice. This Bill
blows most of those assurances out of the water. It is a Bill with huge ramifications for the health service, the biggest reform for 25 years. At one and the same time it will impose seismic organisational change from top to bottom and provide a massive distraction from the pressing problems that the health service needs to solve if the key elements of the NHS Plan stand any chance of being delivered.The Minister has painted the Bill as a decentralising measure. I would be the first to cheer if I thought that that claim had real validity. But it is somewhat rich to make such a claim when the Bill does nothing whatever to reduce the ability of the Secretary of State to issue directions, instructions and targets to the NHS at local level. In fact the Bill contains 58 powers for the Secretary of State that are gained, retained or enhanced—58 ways, in other words, for him to issue orders. The devolution of budgets to PCTs would indeed be a good thing if PCTs could be assured of the freedom to spend the money in accordance with local priorities. But what do we see? The Secretary of State will have the power to set the budget of every PCT. He can set resource limits as well as cash limits. He can set performance rewards according to his own rules. He can hold money back if PCTs fail to perform to the targets of his choosing; and with the abolition of health authorities as currently configured, he will now be able to do all this not at one remove but directly. For good measure, strategic health authorities will be able to direct PCTs on any of their functions, whether or not those functions are delegated. We can call that decentralising if we want to be idiosyncratic, but the reality for the health service will be very different. Indeed, much of this entire Bill is direction-making writ large.
During our debates on the Health Act 1999, serious concerns were raised on all sides of the House about the dangers of any compulsory transition to PCTs. Amendments were carried—later reversed in another place—which would have prevented that happening. The noble Baroness, Lady Hayman, finally secured my acquiescence when she gave the following assurance:
- "It is important to say at the start that it is no part of the Government's agenda to impose primary care trusts on the service . . . We want measured change, progression to trust status, driven locally, based on local views. That is why the Secretary of State will be able to establish a trust only after local consultation".—[Official Report, 25/02/99; col. 1268.]
I do not suppose that the Minister is particularly concerned about that, but let me tell him that when noble Lords expressed their worries about enforced progression to trust status, they had in mind one thing above all: staff morale. It beats me how even this Government can have brought themselves to treat with such contempt the wishes and wisdom of thousands of general practitioners and NHS staff who are concerned above all else to ensure the performance of their prime duty—that of looking after patients.
I do not know whether the Minister has received, as I have, representations from doctors and managers, including the British Medical Association, about the
risks involved in this headlong rush for change. The recruitment of suitably qualified managers and clinical staff is already proving a very difficult task in many areas of the country. Many well qualified staff are leaving the health service.Those PCTs that already exist are new and largely untested bodies. In many cases, they are not adequately resourced to perform their current role. For them to take on all the functions listed in the NHS Plan—modernisation, commissioning, partnership with local authorities, health improvement plans, performance management, involvement with the public, and the rest—will be a very tall order indeed. For PCTs that have yet to be established, the task and the risks to patient care are truly mammoth. How much more will that be so if PCTs are saddled—as we suspect that they will be—with the outstanding deficits of health authorities? In a survey conducted by the National Primary Care Research and Development Centre and the King's Fund, three quarters of chief executives questioned said that the reorganisation would in their opinion delay the delivery of the national plan.
And what of the Government's protestations that they want to see a more patient-centred service? Once again, they have brought to Parliament their dog-eared proposal to abolish community health councils. Never have they stated in words of one syllable why they seek to do that.
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