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Lord Clement-Jones: I rise to support strongly the noble Earl, Lord Howe, on Amendment No. 148. The omission of the right of referral for disputed decisions in respect of the new bodies is serious and significant. I hesitate to rub further salt in the Minister's wounds about South Birmingham CHC, but that was a classic example of the importance of the rights of CHCs as currently constituted.
It is important for patients and their representatives to be able to dispute and to refer such disputes when there are arguments about the nature and structure of provision within the NHS. As I read it, there is nothing equivalent to that in the legislation. That would be deeply regrettable. It serves only to increase the mistrust of the provisions; that the aim is to make an easier life for NHS managers, Secretaries of State and Ministers in the Department of Health. However, that is not what we should be here to provide. We should be here to provide the possibility of robust public debate. That is what it is about. There should be the relevant and necessary powers to enable the bodies being set up under the Bill to engage in that. I look forward to hearing the Minister's comments.
Lord Filkin: I broadly agree with the objectives of what both noble Lords have argued. However, I suggest that they are already adequately covered, both in the Bill and in the regulations made under the Bill.
Therefore, the new clause is largely unnecessary. It duplicates the consultation provisions which are already in place or that we intend to put in place. For example, there are already specific duties of consultation in respect of primary care trusts, NHS trusts and care trusts, the details of which are set out in regulations. Clause 1 of the Bill gives the Secretary of State powers to make regulations containing requirements as to consultation which must be complied with before he makes an order under Section 8 of the National Health Service Act 1977 relating to strategic health authorities. Section 11 of the Health and Social Care Act, as amended, will require strategic health authorities to consult on services for which they are responsible.
My ministerial colleagues have made clear that there is to be a robust framework for referral by OSCs to the Secretary of State on matters of concern that are being consulted on and on the nature of the consultation to
ensure that those democratically-elected representatives of local communities can represent the views of their local communities to the national level. We are considering how best to provide for that within the framework of Section 7 of the Health and Social Care Act.We are sympathetic to the need to carry out proper and effective consultation and to ensure that disputed decisions are properly dealt with by democratically elected representatives of local people. However, this new clause overcomplicates and clutters the Bill with, we suggest, unnecessary detail.
We have made necessary provisions in the Bill and in the Health and Social Care Act—for example in Section 11—to ensure that the views, concerns and interests of patients and the public at large are fed into local decisions about the planning and development of the NHS. The complex set of arrangements set out in the new clause over-complicates what is already provided for in the Bill.
I turn to the specific matters. For example, with regard to patients forums, Clause 17, in relation to annual reports, already gives very clear powers for patients forums to carry their representations to the Secretary of State. In previous discussion we dealt with the right of OSCs to be consulted on any significant changes affecting the health service in the area. The reverse is the case with regard to the view that this is intended to make life easier for the Secretary of State or for health service professions. It is a belief that by articulating patient and public views one provides a more effective challenge to improve the service—one actually ensures that services are more likely to be changed. Therefore, the whole Bill is focused on strengthening public voices as one of the means of reforming the health service as well as being a right in its own respect. I therefore urge the noble Earl to withdraw the amendment.
Earl Howe: I found that reply very interesting. It revealed a number of points that I had not woken up to. I shall go away and study carefully what the Minister said. In essence, he is saying that this amendment is completely unnecessary because all the angles are already covered. I hope that that is right. I shall endeavour to satisfy myself that what the Minister said—I am sure in all good faith—is correct.
Perhaps I may ask the Minister, in so far as there are regulations still to come, when they are likely to be forthcoming. Does he have any idea when we are likely to see those regulations laid? For example, will it be in the next couple of months or a little later?
Lord Filkin: I cannot give a specific answer here and now, but I will give an indication of that matter at the next stage of the Bill.
Earl Howe: I am most grateful to the Minister. I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
[Amendment No. 149 not moved.]
Lord Clement-Jones moved Amendment No. 150:
- Before Clause 21, insert the following new clause—
The noble Lord said: We come on to pastures new with Clause 21. It deals with the joint working of the NHS and the prison health service.
Gross failings in the prison health service have been identified by a number of Members both of the other place and here, but notably by my noble friend Lord Avebury. He has discovered that, despite promises by Ministers to the Health Select Committee in the year 2000, there are still some 500 prisoners unable to access the secure psychiatric units that are needed. Yet these prisoners are currently in-patients on prison hospital wards. That is not something dreamt up by some estimate. It has been confirmed by Her Majesty's inspector of prisons. Indeed, it could actually be a gross underestimate.
The problem does not just reside in the area of mental health. This time last year in its report Prison Medicine: A Crisis Waiting to Break, the BMA had strong words to say about prison governors interfering in the clinical judgment of doctors by prohibiting the use of the most cost-effective medications in order to divert more resources into gaol security.
The then Chief Inspector of Prisons, Sir David Ramsbotham, said that the BMA was confirming horrendous examples of defective prison healthcare. I wonder what has really changed at all since that report. Indeed, I wonder what has changed at my local prison—Brixton prison—since 1999 when the governor threatened to turn away prisoners with health problems. He said that delivery of healthcare fell far short of the most basic acceptable standards. We need the continuity that complete merger between the prison health service and the health service could provide.
All except 24 of about 70,000 prisoners currently inside will come out. At present, we risk releasing them in a worse state of health than when they went in. According to the Office for National Statistics in a report published in 1998, 70 per cent of them are suffering from some form of personality disorder. In his 1996 report, Patient or Prisoner, Sir David Ramsbotham said that it was high time that the NHS assumed responsibility for healthcare. Regrettably, the 1999 Prison Service and NHS Executive joint report on the future organisation of prison health care put its trust, as does the Bill, in partnership arrangements.
Until the needs of prisoners are included in NHS estimates, provision will not be properly resourced. Prisons should be regarded as outstations of nominated NHS providers, which should be contracted to provide both services and staff. All informed commentators now agree that joint arrangements between the prison health service and
We on these Benches keep suggesting new avenues that in many cases take two years for the Government to adopt. I remind the Minister that integration between health and social care was firmly resisted during the passage of the Care Standards Act 2000 but finally came in the shape of care trusts under the Health and Social Care Act 2001. In 1999, during the passage of the Health Act 1999, we suggested that CHI should cover both the NHS and independent hospitals. That was finally accepted by the Secretary of State in response to the Kennedy report early this year.
Will our suggestion about complete integration of the prison health service and the NHS suffer a similar fate? Will we have to wait another year before the Government decide that such integration is sensible? I suggest that the Minister brings forward the blinding light and accepts that that may be a sensible way forward that would be of great benefit to those who are currently in prison. I beg to move.
Earl Howe: Like the noble Lord, Lord Clement-Jones, I welcome the opportunity to debate the Government's proposals for prison healthcare. I shall speak to Amendments Nos. 151, 153, 155, 157 and 158. Like the noble Lord, I have profound misgivings about the measures contained in the Bill and do not believe that they are anything like adequate to address the serious crisis that has overtaken prison doctors and their patients in the prison system.
Healthcare in prisons has been in a dire state for more than a decade. When he was chief inspector in 1991, Judge Stephen Tumim made strong criticisms of medical care in Wormwood Scrubs. Similar but more sweeping concern was repeatedly expressed by his successor, Sir David Ramsbotham, in connection with the Scrubs and many other prisons.
The prison environment presents perhaps the most extreme combination of adverse circumstances for health outcomes that one can dream up. As a population, prisoners are disproportionately afflicted with a range of serious health problems, the most prevalent and well recognised of which are mental illness, sexually transmitted diseases including HIV, and drug addiction.
In addition, the general physical health of prisoners is often poor. A sizeable proportion of offenders, especially young offenders, have experienced homelessness and have lived on the streets. Many are poorly educated. To add to that, living conditions in prison, which to say the least are not conducive to physical or mental health at the best of times, let alone when overcrowding is as bad as it is now, can often exaggerate a pre-existing condition.
In combination with the health problems of prisoners is a severe lack of healthcare resources in prison. Budgetary restrictions prevent doctors from prescribing the most effective medicines. There is a
The scale of mental health problems in prison is great. In 1996, a study showed that over 60 per cent of unconvicted male prisoners held on remand suffered from mental disorder. Some were in need of immediate treatment but were not receiving it. If ever we find ourselves trying to identify the causes of crime, in order to be tough on them, I shall defy anyone to come up with a better example than untreated mental illness or untreated drug dependency in prisons. The failure to deal properly with such conditions has a direct knock-on effect on the levels of criminal activity and creates little more than a revolving door in and out of prison for many offenders.
Against that background, it is no wonder that morale among prison doctors is generally at a low ebb. There is an acute shortage of prison GPs. Experienced prison doctors are leaving, and new doctors are deterred from entering. It is not just the frustration of working with too few resources that deters doctors, although that is a major part of the problem. The problem is even more deep-rooted than that. The noble Lord, Lord Clement-Jones, alluded to that. Doctors in prison find that their clinical judgment is second-guessed or interfered with by administrators, including prison governors. The BMA has reported a large increase in the number of inquiries and complaints from prison doctors who describe such situations.
Doctors in prisons have an ethical duty to provide standards of care in accordance with clinical need and on a par with those available to society at large. It is difficult for them to compromise those standards, even though most doctors recognise that there will inevitably be resource limitations in prisons that restrict their autonomy in one way or another. It is unacceptable for a professional clinical judgment to be overruled by management decisions that discount medical opinion and ignore the best interests of the patient.
Although much good can be done by the injection of further resources, as the Bill envisages, it is idle to suppose that doctors will be able to make headway in the existing crisis unless they are given unfettered clinical discretion to treat patients according to need and in the best possible way. I have grave doubts that a so-called partnership between the NHS and the Prison Service will be anything more than a cosmetic device that will leave prisoners almost as ill served as they are now. Joint working goes on at the moment and makes little impression.
In the final analysis, prison administrators are not doctors and do not understand medicine. Dr P J Keavney, chairman of the BMA Civil Service Committee, said:
However good governors may be in other ways, there is too much evidence that the sense of ownership that currently exists counts for nothing so far as concerns prison healthcare. The BMA cites one instance of a prison governor expressing indifference to the likelihood of a prisoner dying as a result of failure to transfer him to hospital. I do not say that that is typical but it is symptomatic of the wider problem.
It was again Sir David Ramsbotham who argued in an important paper published some six years ago for the full integration of prison healthcare services with the NHS. I agree with him that nothing short of a complete merger of the NHS with the prison medical service is capable of putting these matters right.
Yes, I admit that that would present difficulties. It would involve drawing up protocols that preserved the authority of governors in non-clinical matters and that bound doctors to observe and take account of the need to preserve security and prison discipline. However, that kind of protocol is not an impossibility; it is attainable. Simultaneously, a comprehensive health needs analysis of the Prison Service should be commissioned. I urge the Government to put such an analysis in train, whether or not this part of the Bill is amended.
I hope that the Minister will be able to respond constructively to the very important concerns that I and the noble Lord, Lord Clement-Jones, have raised.
"PRISONS
The Secretary of State shall by regulations determine that responsibility for health services in prisons shall be assumed by the National Health Service, and the Prison Act 1952 (c. 52) and the Prison Rules 1999 (S.I. 1999/728) shall be amended accordingly."
10 p.m.
"The Prison Service itself does not help matters by its insistence on an agenda for its governors which concentrates on process instead of clinical outcomes. The lack of understanding of clinical governance is a bar to the delivery of adequate healthcare within our penal institutions . . . In the end, a system focusing simply on 'process' to satisfy short-term political . . . concerns will fail to resolve the clinical needs of patients".
I fear that that is the answer to Ministers who argue—admittedly, with some logic but without a sense of the realities—that prison governors must retain a sense of ownership of the health and well-being of the prisoners in their care and that that can be preserved only if governors retain direct accountability for prison healthcare.
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