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Baroness Masham of Ilton: Before the Minister sits down, perhaps I may say how delighted I am to hear that his step-daughter is assistant governor at Wandsworth. I was very impressed with the staff we met there. I recommend that the Minister should go with her to see the healthcare centre for himself. It would make life so much easier for the staff and the prisoners if the prison had a new unit. It is having a new kitchen, but the health facilities should have come first.
Lord Filkin: I am happy to give that commitment in my private capacity.
10.30 p.m.
Lord Clement-Jones: I thank all those who have taken part in this important and interesting debate. In particular, I thank the Minister for his carefully considered reply, the noble Earl, Lord Howe, for his powerful speech and the noble Baronesses, Lady Masham and Lady Finlay, for their firsthand knowledge in this area, which has strongly informed the debate.
I am interested in the Minister's careful consideration of this matter. He mentioned that the option of complete transfer was considered in the document published in 1999. But the interesting point is that both of the previous HM chief inspectors came to the conclusion that transfer to the NHS was the best option. I am most interested in the fact that the Prison Service and the Department of Health have not agreed with that conclusion. Both Sir David Ramsbotham and Sir Stephen Tumim made it quite clear that, until that transfer took place, the health service in prisons would not be adequate.
Clearly, one must welcome the Minister's commitment to more resources, to the health improvement programmes in prisons, and to a number of other developments, such as the involvement of the National Clinical Assessment Authority. Of course, all those are very positive developments. However, this boils down to issues such as recruitment, clinical governance, and control. If we are not careful, and if health service provision in prisons continues to be a Prison Service responsibility, this will be a grave disincentive for the provision of quality medicine in prisons. That is my main worry. If this provision were brought into the mainstream, the quality might more easily be raised.
I suspect—although I do not know—that the reason for not giving the health service rather more responsibility in this area is to do with organisational tact. I thought it was slightly bizarre that this matter was seen as a two-way journey, as opposed to a single journey, under Clause 21. There are few circumstances in which community medicine would be provided in a prison. Although one can always be creative about these matters, I can see few people wishing to have their health services delivered in a prison. Perhaps that is just my misinterpretation of the Minister's comments.
It will become quite inevitable that we shall need a much greater transfer of responsibility to the health service. Of course that must take place within the discipline provided by the prison; that goes without saying. One would not hand over a prisoner to a general practitioner or an acute NHS hospital, lock, stock and barrel, just by transferring responsibility for their medical and health needs. That certainly does not follow from the integration that I am proposing.
The hour is late. This has been an extremely interesting debate. It is rare for us to have this kind of debate, because it crosses departments. None the less, it is extremely important that we keep worrying at this issue, because it is desperately important that we improve the healthcare in our prisons, as we have heard tonight. In the meantime, I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Clause 21 [Joint working with the prison service]:
[Amendments Nos. 151 to 153 not moved.]
Baroness Noakes moved Amendment No. 154:
- Page 27, line 24, leave out paragraph (a).
The noble Baroness said: I rise to move Amendment No. 154, and will also speak to Amendment No. 156. Amendment No. 154 deletes paragraph (a) of subsection (3) of Clause 21, and Amendment No. 156 is consequential in respect of paragraph (d). Paragraph (a) allows for arrangements to be prescribed for a fund to be set up. Both the NHS and the Prison Service can make contributions to such a fund, and the fund can pay the expenditure of the NHS and the Prison Service. That might seem straightforward, but I believe that it raises some important issues about accountability.
I turned to the Explanatory Notes to find out what these arrangements were all about. Paragraph 124 states that subsection (3)(a)
- "enables the creation of pooled budgets".
Rather more worryingly, the Explanatory Notes go on to say:
- "The resources contributed by each body will lose their identity as health or prison service money".
If those questions cannot be answered satisfactorily, the Committee might well conclude that the arrangement funds are dangerously irresponsible in terms of financial accountability. I beg to move.
Lord Filkin: Amendments Nos. 154 and 156 would remove the provisions for the establishment of pooled budgets between the Prison Service and NHS bodies. The noble Baroness has said why she thinks that would be appropriate. The amendments would undermine the fundamental aim of the clause, which is to promote improved opportunities for partnership working between the NHS and the Prison Service.
The provision for pooling of budgets allows for simplified and significantly more joined-up commissioning of health services for prisoners. It is an important aspect of the clause and a valuable tool for delivering the objectives about which I have spoken.
The point can best be made by illustrating how the partnership is working at the moment and how the pooling of resources can and does help. At present, 18 prisons in England are working with local NHS partners to develop new NHS-funded mental health teams to work in prisons. A further 25 such teams will be established during 2002-03 and a further wave by 2004.
The new NHS mental health teams are beginning to work in those prisons alongside existing staff employed by or contracted to the Prison Service to provide better care to inmates with serious mental health problems. The Bill will allow local services to put in place much closer partnership arrangements to get the best from the health services provided by the prison and its local NHS partners.
For example, in agreement with the prison, the local PCT could take responsibility for commissioning a single package of mental healthcare for prisoners. The Prison Service could delegate to the PCT the task of securing mental health services for inmates in that prison. The PCT could then commission services using a pooled budget comprising Prison Service funding currently spent on providing care for mentally ill prisoners and the resource the PCT is investing to develop the new NHS "in-reach" mental health teams.
Such arrangements could help to deliver a single, locally agreed and jointly owned package of care that was far better integrated and better value for money because of the PCT's healthcare commissioning expertise and leverage. It goes beyond what could be achieved through a system of contracts and payments between the individual agencies concerned.
The noble Baroness, Lady Noakes, raised some important but—and I do not wish to denigrate them—essentially technical points about how accountability chains and audit responsibilities will be handled. Under existing Section 31 provisions, each partnership needs to have a written agreement setting down the key framework issues for the partners to refer to. That includes the aims and outcomes of the partnership, the resources, the way in which the partnership will be managed, the eligibility criteria and assessment processes that are agreed and how disputes will be managed. A key feature will be the way in which the partnership is monitored, and that will be determined locally. We envisage that similar arrangements will apply to the new provisions.
Although this is no more than speculation—and we shall have further opportunity for clarification if necessary—it seems to me that there must be analogies between the outsourcing arrangements which I described made by prisons and PCTs. Although a prison may give its budget to a PCT, the prison will still be ultimately accountable for the effective use of those funds. Similarly, the PCT may be accountable for how it spends both its funds and the budget delegated to it by the Prison Service.
Those are important points and—to put the mind of the noble Baroness, Lady Noakes, at rest—I shall ensure beyond any doubt that there is no uncertainty or ambiguity about them. The fundamental point,
however, is that we believe that such pooled budget arrangements have the potential to make significant improvements in the quality of healthcare in prisons. We therefore believe that they are an important part of the Bill.
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