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Baroness Cumberlege: My Lords, I am reluctant to enter the debate, particularly as it concerns structure, because, in his reply to my noble friend Lord Peyton, I felt the Minister's finger on my collar. In previous times, when I was in government, we also reorganised. I hope that the Minister will remember our debates in Committee, when I sought strongly to get politicians out of meddling with the National Health Service. Although I had a lot of support from the Cross Benches and from the Labour Benches, I did not get much support from the Minister on that issue.

I want to speak about public health, because I remember that before the Minister and I were in this House, he was a very strong advocate of public health. He sought strongly to promulgate, disseminate and follow the findings of the report produced by Sir Donald Acheson, a former Chief Medical Officer.

However, the person who has made the most difference in public health throughout the ages is my noble friend Lord Waldegrave. My noble friend was the architect of a most coherent plan entitled, The Health of the Nation, which concentrated on five key

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areas; namely, coronary heart disease/strokes, cancer, mental health, HIV and AIDS, and accidents. Each of those areas had very specific targets—27 in all. The plan was concise, it was achievable, and it was targeted. When I became a junior Minister, it was my responsibility to implement the plan. It was one of the best parts of my job.

The plan was cited by the WHO—the World Health Organisation—to other nations as an example to follow. I remember attending conferences where the plan was extolled, which did not surprise me. It was so clear, well defined and strategic; it placed a huge emphasis on local involvement. That is my worry as regards the proposals now being put forward.

Having listened to my noble friend and the noble Lord, Lord Clement-Jones, there seems to me to be a great lack of clarity in the way that the structures have been established. We shall lose a great deal without clarity. Public health is one of the areas that are squeezed out when the pressure greatly increases. As we know, in the health service the immediate always pushes out the important. Therefore, above all others, this area needs to be most carefully defined.

We also need a good deal of involvement in the area. It can be described as a "nannying" area, because it can be quite irritating. Much of the process is very negative; for example, "Don't do this", or, "Don't do that". The skill is to make it fun—to inject some pizzazz into it and to ensure that people really want to go with the grain of it. The proposed new teams are most important, but I agree with my noble friend Lord Howe that a public health specialist should be involved. When I mentioned that possibility in Committee, the Minister responded by saying that he thought I was being too purist, and pointed out that perhaps I was ignoring the work of health visitors, nurses and others, who could take on that role. I understand that. Those people do have a part to play in the process. However, I believe that leadership in this area is most crucial. But it must be leadership that is very well respected by other health professionals, especially the medical profession.

We achieved a good deal through The Health of the Nation. Of the 27 targets, only three showed no improvement; namely, HIV/AIDS, teenage pregnancies, and obesity, which are still very challenging. I have to stress that, in two years, we did not have one case of measles that was not imported. It makes one sad to consider the current MMR debacle, because I thought that we had almost eliminated the disease. One of the engines for change was the health education authority, which has been abolished. When we reach Amendment No. 27, I hope that we shall be able to discuss its replacement.

Finally, I should like to address the issue of the directors of public health. In Committee, my noble friend Lord Howe asked about these specialists and their independence. Traditionally, directors of public health in this country have had a special responsibility over and above that of management. We have expected them to use their integrity and their professionalism to say how it really is in the health

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service. Those reports have been a touchstone, a marker in our social history. Their findings have made successive administrations feel both uncomfortable and embarrassed. However, such reports are hugely valuable because they are independent.

My noble friend mentioned the fact that the strategic health authorities will have performance management responsibilities in terms of public health. I should like to be clear in my own mind on how the Minister sees those people at the strategic level. Will they be medical managers, or will they be public health specialists? When one reads through their proposed duties, much of their work seems to be managerial. I believe that we need something beyond and above that level: we need people of much courage, who will be really passionate about their subject as they drive it forward. I hope that the Minister will pick up some of these points. The amendment before us nails down most clearly a duty on the SHAs and primary care trusts to improve the health of the nation, which is very important. I hope that the noble Lord will see merit in the amendment.

Baroness Masham of Ilton: My Lords, within the umbrella of public health there are many different subjects that are specialties of their own; for example, tuberculosis, HIV/AIDS, the different sexually-transmitted diseases, and the hepatitis diseases, all of which are on the increase. Healthy eating, smoking, education, alcohol and drug abuse, and vaccinations are other areas to consider. It is a huge umbrella. When there is change, there is insecurity. It takes about two years to bed down new health authorities. The Minister's meeting was most helpful, but we need to know that adequate funding and resourcing will be available, as well as co-operation between health and local authorities. I support the amendments.

Lord Peyton of Yeovil: My Lords, perhaps I may take this opportunity to thank the Minister for the way that he has succeeded in moving his department so quickly. I have now received a copy of his letter of 20th April, a very brief reading of which makes me almost tearful that I did not receive it earlier. However, this is a time—I hope—to be mildly useful and not, perhaps, a source of trouble to him before the end of this stage of the Bill.

As one of those people who has long attributed some of the problems and difficulties of the NHS to political meddling, it was a breath of fresh air to hear my noble friend Lady Cumberlege, who has experience of the health department, make exactly that point. I thank her warmly for doing so. There is one point that puzzles me. The amendment tabled in the name of my noble friend states:

"Each Strategic Health Authority shall have a duty to ... improve the health of members of the public within its area".

Similarly, Amendment No. 4, to which the noble Lord, Lord Clement-Jones, has attached his name, uses almost the same words with regard to primary care trusts. Perhaps the Minister—or, indeed, my noble

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friend—can say whether there is anything in the current duties of the SHAs, and those of the PCTs, that would exclude their seeking,

"to improve the health of members of the public within [their] area"?

Indeed, it seems to me that it follows almost from the name that such bodies would have no reason to exist unless it was their duty to do precisely that. I should be most grateful for some enlightenment.

Lord Turnberg: My Lords, I, too, was privileged to be present when my noble friend the Minister gave a briefing last week. However, I came away with a different impression from that gained by the noble Earl, Lord Howe. If one looks most carefully at what is currently lacking in the delivery of public health in its broadest terms, it is really concentrated at the primary care level. We have regional directors of public health and directors of public health at health authority level, but something is missing at the primary care level where much of the public's health needs to be addressed.

It seems to me that this proposal of a heavy investment of personnel with responsibilities for public health in primary care trusts is just what we need. Of course, they would need to work in networks and collaborate and co-operate across their "patch" and that is intended. It would be an impressive and worthwhile investment on the part of the Government. Those personnel would need to be monitored to make sure that they delivered. That would be done at strategic health authority level. As I say, the proposal would constitute a worthwhile involvement and investment on the part of the Government. We should support it.

4.30 p.m.

Baroness Pitkeathley: My Lords, there is much anxiety about the new system with regard to public health as has been evident in our debate. That is a natural anxiety. All of us who have an interest in this issue know that the way to bring about real improvements in the National Health Service is by improving the way we tackle public health; that is, by making people more aware of the effect of lifestyle on their health, enabling them to change their lifestyle if necessary and, above all, encouraging them to take more responsibility for their own health.

It must surely be clear that for such a range of public health functions to be effective they must be carried out as near to the patient and his or her family or carers as possible. It seems to me that only at primary care level can the needs of local populations, which will naturally vary, be understood and responded to. Only at that local level can needs be analysed and causes of ill health and health inequalities be responded to. Only at primary care level can leadership be exercised to ensure co-operation and co-ordination between services and to promote innovative solutions which are responsive to local needs. Of course, strategic health authorities will have an overseeing and a support role and that is right, but the main responsibility must lie with primary care trusts.

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Amendment No. 4 seems to me to be unnecessary as the responsibilities of primary care trusts in relation to public health are clearly set out. Many directors of public health are already in post and developing wide-ranging networks and relationships which will enable them to draw directly on the experience of patients and, indeed, of their whole populations. As chair of the New Opportunities Fund I pay tribute to some of those directors of public health in primary care trusts for the excellent support they have offered the New Opportunities Fund in getting some of our public health programmes off the ground. The knowledge they have of their local communities and their commitment to meeting their needs is truly impressive. The duties placed on them already are more than adequate. The best thing we can do now is to support them in carrying out those duties and to help them to deliver on the commitment the Government have shown to public health.

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