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Lord Campbell-Savours: I listened carefully to what the Minister said. Is the over-riding consideration that the Government simply do not want civil servants to be required to attend the Assembly, irrespective of the merits of this case? If it is, then we have to go back to the essential principle behind it. Is it right in principle
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Baroness Morgan of Drefelin: I thank noble Lords for giving me the opportunity to clarify the points that I am trying to make. The bottom line is that we are talking about the constitutional question of whether civil servants should be required to attend the Assembly. I was also putting forward the argument that because the health adviser advises the Assembly in spite of having a Civil Service position, the Assembly should not suffer. The role of the health adviser is to advise the Assembly, not just the Mayor. A Memorandum of Understanding between the health adviser and the Mayor clearly sets out the methods of communication and the level and speed of advice that is expected. There is a detailed process for working together. I hope I have answered the fundamental point and that the other points I have made reassure noble Lords that the role of the health adviser is positive for the Assembly as well as the Mayor.
Baroness Hanham: I am fascinated that my amendment has triggered this important debate because it will move us seamlessly on to the following amendments about why the health adviser has to be the regional director for health. I am much encouraged by the points that were made, and I shall certainly return to this matter at the next stage. It seems inconceivable that someone who is required to produce a strategy that will be put out to London should not, if necessary, be called in to the Assembly, if that is what Assembly Members need.
Baroness Morgan of Drefelin: This is an important point. The health adviser advises on the Mayor’s strategy—
Baroness Hanham: It is not making it any better. I am still attracted by my amendment. It will return at the next stage. I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
The Deputy Chairman of Committees: In calling Amendment No. 43, I should point out that if it is agreed to, I shall not be able to call Amendments Nos. 44 to 46 because of pre-emption.
Baroness Hanham moved Amendment No. 43:
The person who is the Health Adviser shall be appointed by the Mayor in accordance with the provisions of section 47 of this Act and be an employee of the Authority.
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(1) There shall also be one or more officers to be known as Deputy Health Advisers to the Greater London Authority (“Deputy Health Advisers”).
(2) Any of the Deputy Health Advisers may exercise functions of the Health Adviser at any time when he is authorised to do so by virtue of an authorisation given by the Health Adviser under subsection (5) of section 309A above.
(3) Any exercise of a function by a Deputy Health Adviser by virtue only of such an authorisation must be in accordance with the authorisation and any conditions imposed by the Health Adviser under that subsection.
(4) A Deputy Health Adviser shall also have such other functions as may be conferred or imposed on him by or under this Act.
The persons who are Deputy Health Advisers shall be appointed by the Mayor in accordance with section 67 of this Act and be employees of the Authority.”
The noble Baroness said: The motivation behind Amendments Nos. 43 and 45 is to explore further the appointment and status of the health adviser. We broadly welcome the new emphasis the Bill places on matters of public health and on tackling problems within the provision of the health service. I ought to declare my interest as chairman of an acute hospital trust in London. It is clear that, as a result of Part 4, the health adviser and, to a lesser extent, the deputies could have a great deal of influence on the health service for Londoners. As the Bill stands, the holder of the office will provide advice to the Greater London Authority on anything deemed by the health adviser to be a major public health issue and will also play a considerable role in the preparation of the health inequalities strategy. With this in mind, it is essential that we establish the Government’s vision for the health adviser and assess the level of accountability for that office.
Amendment No. 43 inserts new provisions into the Act making it clear that the health adviser and/or the deputies will be appointed by the Mayor and will be employees of the authority, which would enable them to be answerable to the authority. The purpose of Amendment No. 45, which is a probing amendment, is to assess whether it is appropriate that the health adviser is automatically the person who occupies the post of regional director of public health for London. We are not convinced that the health adviser should necessarily even be a civil servant from the department. There are plenty of people who work for the health service who would be capable of doing a job such as this. The aim of this amendment is essentially to investigate the potential accountability of the holder of an office with far-reaching influence over the people of London. We welcome the creation—are we all right?
The Deputy Chairman of Committees: I apologise, but my replacement has not turned up.
Baroness Hanham: We will welcome you to the end. I had better come to an end here. While welcoming the creation of a health adviser, we also question whether the Government have settled on the appropriate individual—the post holder, not the person—and method of selection. I have no criticism of the person, but it is a question of the office. I beg to move.
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Baroness Hamwee: I assume that the reference in new Section 309A should be to Section 67 not Section 47 of the Act. Section 47 is about the state of London debate, so it is unlikely.
Baroness Hanham: Yes, it should.
Baroness Hamwee: I assume the error was made by whoever typed up the written notes: “6” and “4” can look similar.
My other questions are to the Government. New Sections 309B and 309C require that the health adviser and the deputy health adviser are senior civil servants. I assume it is left as a matter of common sense that the health adviser who is appointed will be more senior in the Civil Service than the deputy health adviser, otherwise there could be a very strange position. It does not seem entirely likely.
I was intrigued by new Section 390A(5), which requires the health adviser to authorise the deputy health adviser. I accept that that can be general authorisation rather than specific authorisation, but is that the normal way of expressing that, or is there something particular in there? If it is particular, one might want to think further about it.
Lord Harris of Haringey: I have some sympathy with what I think the noble Baroness, Lady Hanham, is trying to do, but I am not sure whether her amendment succeeds in doing it. As I understand it, she wants to have a situation in which the health adviser might be the public health director, but might not be. My understanding of her amendment—again I may not understand it properly, or it may not be quite what was intended—is that essentially the health adviser will be an officer under Section 47 and an employee of the authority. That would preclude the possibility that the person is the public health director for London.
The amendment will not achieve the objective she wants—which is, as I understand it, that the Mayor will have a flexibility. He may appoint the public health director for London, who would be a civil servant, or some individual who would be a highly regarded expert in the field, who for these purposes would become an employee of the authority.
I should like to see whether my interpretation of the noble Baroness’s amendment is correct and to understand a little more. While there is an enormous value in the current arrangement, whereby the public health director for London acts as health adviser to the GLA, is there is any reason why that should be the arrangement for all time? Also, are there many other civil servants whose precise role and nature is defined so precisely, given that the roles of civil servants change quite frequently, and we have not had this post for many years in this form.
I am interested to know why the new clauses are drafted in such precise terms, saying that it must be this post or its successor’s, and whether the amendment would achieve the flexibility that the noble Baroness wants.
Baroness Hamwee: I missed what may have been the most important part of my note. I wanted to take the opportunity to put on record my appreciation of
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Baroness Hanham: I am not having a good day today. People are quietly picking holes in my amendments and how they are drafted. However, it is worth saying that the amendment requires exactly the interpretation that the noble Lord, Lord Harris, suggested. We do not see why it has to be the regional director; we believe that the Mayor should be able to have the choice either to have the regional director or someone else who is not within the Civil Service but who is in the health service, either as a director or deputy director. That should be optional—and if that is not clear in my amendment, that is what it should be.
Baroness Morgan of Drefelin: Amendment No. 43 provides for the health adviser to be an employee of the GLA, and to be appointed by the Mayor, rather than being the regional director of public health for London. I strongly resist this amendment. The regional director for public health, as the person with strategic responsibility for public health in London, is clearly the most appropriate person to be the health adviser to the Mayor and Assembly. She is uniquely placed to work across a range of organisations, ensuring that they all pull in the same direction to improve the health of all Londoners and reduce the shocking levels of health inequalities between them.
The Mayor, of course, has a crucial role to play, and is directly or indirectly responsible for many aspects of London life which influence Londoners’ health, from transport to public safety. Equally, other aspects of public health, such as improving the quality of health services delivered to Londoners, immunisation, and resilience planning in respect of health services, are clearly the responsibility of the NHS. It is therefore right that the health adviser, as London’s regional director of public health, remains accountable to the Department of Health and the strategic health authority, not to the Mayor.
7 pm
The current health adviser arrangement ensures that the Mayor and Assembly are provided with expert advice from the person responsible for public health in London and that there is a formal link between the GLA, the strategic health authority and the Department of Health. The GLA surely wants the most senior public health official in London advising it. The adviser, by definition, advises the Mayor and Assembly. She does not take decisions on their behalf. The current adviser has proved that she does not need to be accountable to the Mayor in order to provide advice on fulfilling his legal obligations with regard to health and health inequalities. These informal arrangements have been in place since 2000, and most people would agree that they work well.
Amendment No. 45 loosens the requirement that the health adviser is the regional director for public health by suggesting instead that the health adviser
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Baroness Hanham: I thank the Minister for that reply. I see that there may be some advantages in having this dual role for the regional director, but I am still not persuaded that that person has to be the adviser. Indeed, I can see some very good reasons why he might not need to be and for the Assembly to have even more independent advice. This amendment may not be perfect, but by the time we reach the next stage, it will be. I beg leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Baroness Andrews: I suggest that the Committee adjourns for five minutes for the Chairman to make alternative arrangements.
[The sitting was suspended from 7.02 to 7.07 pm.]
Baroness Hanham moved Amendment No. 44:
The noble Baroness said: The awesome number of amendments in this group is entirely due to the fact that an awesome number of health inequalities are mentioned in the Bill. My amendments would change the words “health inequalities” to “public health”. I shall expand on that a little.
The changes to Clause 22 are important. We broadly welcome the Mayor being required to provide a health strategy for London, but it needs to be of a different kind—or certainly wider than that envisaged by the clause. The Minister in the other place defined “health inequalities” as,
- “general health determinants”—[Official Report, Commons, Greater London Authority Bill Committee, 11/1/07; col. 119.]
General health determinants include housing, transport services, employment prospects, ease or difficulty of access to public services and lifestyle or behaviour aspects.
Although those are very important, it is not clear that they would also encompass the important organisational aspects of public health, such as the prevention and spread of infection, the protection of the public from epidemics such as avian flu, tuberculosis, HIV/AIDS, and other health problems of diabetes, obesity, and so on. The protection of the public from epidemics is an extremely important part of the role of public health bodies, and it is important to have policies that bring co-ordination from the health service and other public bodies in the face of disasters, whether they are London-wide or confined to a smaller area.
Serious infection was the basis of public health policy—that is where it all first started. It would seem a great mistake to jettison any of that, even by implication. Serious public health matters are currently managed
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I shall give the Committee a definition of public health. It is,
- “the science and art of preventing disease, prolonging life and promoting health through the organised efforts and informed choices of society, organisations, public and private, communities and individuals”.
It is the protection of those communities. I beg to move.
Baroness Gardner of Parkes: I shall speak about these amendments in general because there is a whole heap of them. I half support what my noble friend said, in so far as I was persuaded by the Minister’s remark that the right person is the regional director of public health for London. It was a well argued case, and I can see the sense in it. However, that case is for public health and supports my noble friend’s amendments.
I find the phrase “health inequality” very unsatisfactory. First, it is emotive, and, secondly, if I am being the devil’s advocate, when I read that one of the things the strategy must do is to,
I could say that that could be done by lowering the standard of those who are doing well down to the standard of those who are doing badly. To reduce the inequality is not necessarily to help the people at the bottom end to move up. I do not like the wording.
There are various other things. We have to be a bit careful because going back to GLC days, it was the policy of London regional government to take over the National Health Service, and I believe that the same principle follows with the GLA and that the Mayor would love to have the power to run the NHS in London. I have always bitterly opposed such a takeover because the National Health Service is such a huge concern already and to attempt to lump it in with regional government would be a disaster. The National Health Service is well run, but it is extremely complicated. My noble friend made the point that the Mayor should have a strategy. I agree with her definition of public health. The moment that
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This series of amendments goes a long way to help. One amendment deals with changing “reduction of health inequalities” to dealing with the “health of persons” in Greater London. That is what we are all concerned about—whereas the inequalities are very difficult to deal with. You could spend many years and vast amounts of money trying to decide what they were, whereas the director of public health already has a very clear image. On the other side of public health, when you are really considering something that is going to sweep in—some pandemic or epidemic that may hit London—there is a strong case for a strategy to deal with those situations. On the whole, these amendments are good and the Government should look again at the wording of this clause, as it is not satisfactory.
7.15 pm
Baroness Morgan of Drefelin: These amendments have triggered a fascinating and important debate. There are so many things that I should like to say in response, but time is getting on—
Baroness Hanham: We will have another opportunity.
Baroness Morgan of Drefelin: Good. This has prompted a debate about public health. We need to be clear that we are talking about aspects of public health that are a subset of the whole wide range of what public health encompasses, over which the Mayor has influence. We are talking about a subset of public health, which includes areas in which health determinants come under the influence of the Mayor.
The noble Baroness has been talking about public health in the widest possible sense. It is right that we should be looking at how the Mayor’s health inequality strategy dovetails with a London-wide effort, which plays into the role of the health adviser and why that adviser should be accountable to the strategic health authority and the Department of Health. The strategic health authority in London has responsibility for all the other aspects of health separate to those that we are talking about, which the Mayor has influence over. It is important that all of those are knitted together into a strategy that reaps real benefits for Londoners. That is the approach that is being built on here in the Bill.
After this Committee, we should discuss how the mechanics of that will work in reality. As we have heard, tribute has been paid to the health adviser and the system has worked well, and we have the opportunity outside the Committee to work through the issues that the noble Baroness has raised.
We believe strongly that the Bill’s focus on tackling health inequalities is justified, because broadening the remit of the strategy would dilute the focus on health
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