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Looking at what is coming up, 50 hospitals are in development and production for the NHS in this country, with another 30 queuing for development behind them. Their aggregate cost is said to be £53 billion, with front-end loading on their financing. That would imply a minimum of £3 billion a year that would need to be funded out of the existing NHS budget for the best part of the next 30 years. Will that money be replaced with like-for-like funding from the Treasury, and, if so, is that another hit for taxpayers’ pockets? Where will that money come from? Can an administrative burden be removed to cope with that? We do not seem to have a feel of where this is going in the long term. We deeply wish the noble Lord, Lord Darzi, to succeed in all his objectives, but all the factors that I have mentioned have a clinical impact because they will curtail the usefulness of what he can do, unless there is a financial structure within which he can operate.

Finally, we understand that at the moment PFI subjects do not appear anywhere on balance sheets as future liabilities. That is beginning to be a real problem because at present PFI costs are reaching the point where they have virtually repaid the capital cost of the equipment and facilities that they purchased and now have to go on as an enormous revenue outflow on behalf of the NHS for years to come. We ought to know the impact of that. It is time that we had a consolidated balance sheet and source and application accounts to show that.

I welcome the noble Lord, Lord Darzi, to his position, but I cannot imagine that he ever woke up one day and said, “My goodness me, I want to run the biggest business in Europe with all its financial issues”. He probably woke up and said, “It would be a lovely idea to reform the whole National Health Service”. We hope very much that he soon has the financial stability to enable him to do so.

3.30 pm

Baroness Massey of Darwen: My Lords, I am dazzled and somewhat overwhelmed by the previous speech. I was pleased to see in the gracious Speech an emphasis on aspirations to give children the best possible start in life and on improving conditions for vulnerable children and young people, including those in care. I was uncertain about which debate to speak in. I wanted to address youth justice issues, but I am convinced that my noble friends Lord Adonis and Lord Darzi will subscribe to the concept that children, with their needs, come first, beyond any system in which they may find themselves. Much of what I want to say will be applicable to all vulnerable young people. I look forward to working on the Children and Young Persons Bill, which I hope will get to grips with a number of issues that will make a real difference to the lives of young people.

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Many in your Lordships’ House have long been concerned for vulnerable young people; we have heard from some today. I declare an interest as the chair of the All-Party Group on Children, which has frequently expressed its concern for the education, health and well-being of vulnerable children and young people, who are too frequently not best served by public services. I also chair the National Treatment Agency for Substance Misuse, so I am very concerned about the impact of drugs and alcohol on offending behaviour.

My starting points for action on children and young people are the United Nations Convention on the Rights of the Child, which makes the welfare of the child paramount; the National Service Framework for Children, Young People and Maternity Services; and the Children Act 2004, building on Every Child Matters, which states that good outcomes for children include being healthy, staying safe, enjoying and achieving, making a positive contribution and achieving economic well-being. Those should be aspirations for all children, including damaged children and those who offend—frequently the same group of children.

I am aware that many good things have happened and that a health and social care strategy for young people in contact with the youth justice system is currently in preparation and will appear next year. Indeed, I was privileged to attend, earlier this week, a discussion day on that. At that seminar and from my reading and experience, several issues stand out as being in need of attention if we are to improve conditions for young people in the youth justice service, rehabilitate them and reduce offending. Very many organisations in the voluntary sector and the Children’s Commissioner have expressed the view that damaged children should not be damaged further. While there are undoubtedly dedicated professionals working with children, often structures and systems militate against them. The report of the noble Lord, Lord Carlile, is certainly worth revisiting.

I am aware of government action to lift children out of poverty, to increase the availability of child care, to introduce a national entitlement to free early years education, to raise standards in schools, to reduce teenage pregnancies and to reduce accidents involving children. All that is positive and to be commended, but challenges remain in both the short and the long terms. The intent of the noble Lord, Lord Darzi, to encourage healthcare that is fair, personalised, effective and safe must surely apply to all services, including those for young people who fall outside our mainstream systems. I find it encouraging that youth justice now comes under the brief of the Minister for Children, within the Department for Children, Schools and Families. Can the noble Lord, Lord Adonis, say how youth justice will be handled by the Children’s Minister? What links are being made to other sections of government, the voluntary sector and the Youth Justice Board?

The 2006 report from the Healthcare Commission and Her Majesty’s Chief Inspector of Probation points out:

In addition, one study indicated that over a third of young people in custody have a reading age of seven or less, 45.4 per cent have substance misuse problems, and between 40 and 49 per cent have been in local authority care, which was referred to by the noble Lord, Lord Ramsbotham. The costs of not dealing well with young people in the youth justice system cannot be ignored. Indeed, the cost of putting so many people into custody in the first place cannot be ignored. A place in a young offender institution costs around £50,000 a year and in 2005-06 more than 212,000 disposals were given in the youth justice system with 85,467 new entrants to the system. Every year, 8,000 young people pass through the system. In September 2007, there were 3,095 under-18 year-olds locked up. England has one of the highest levels of incarceration of young people in Europe. In 2006, 76 per cent of young people released from custody reoffended within 12 months. The system simply is not working, and that is a tragedy that must be addressed.

The standing conference on youth justice regrets the increase in the use of custody for children. Since 1992, custodial sentences have risen by nearly 90 per cent and the use of detention for children under the age of 15 has grown by 400 per cent, which is a shocking figure. The number of vulnerable children detained in youth offender institutions rose from 432 in 2002 to over 3,000 in 2004, and it continues to rise. There is a trend to increase the prosecution of young people, despite good evidence that prosecution tends to be of no use in preventing reoffending. The Youth Justice Board has expressed concern that the breach of ASBOs is impacting on child custody, and youth offending teams are concerned that they are rarely consulted about decisions on ASBOs.

We need to prevent young people from getting into trouble in the first place. That is a difficult challenge, which may be affected favourably by government action to do more for youth. We then need to assess the needs of young people who come into contact with youth justice and try to supply interventions that will help to rehabilitate them rather than encourage reoffending. It is a retrograde step to seek to provide more correctional institutions rather than to set out to improve health and education services for offenders outside institutions or inside them, if that is what it comes to. It is also sad and counterproductive that we are increasingly tending to demonise and criminalise young people when other corrective measures would be more effective and appropriate. A punitive approach labels children early as miscreants and may well encourage bad behaviour rather than treat it.

Let me now look at some of the areas that could be examined in order to tackle the problems with regard to young people’s health in the youth justice system. Some of the comments made by the noble Lord, Lord Darzi, about children in care are also relevant to the welfare of young offenders; we may want to explore that later. As the noble Earl, Lord Howe, said, this depends on culture and people, not just systems and

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structures. The Let’s Talk About It report, to which I referred, states that one of the most significant findings is a lack of strategic involvement in the healthcare of young offenders. There is no adequate engagement of healthcare professionals in 60 per cent of youth offending teams. The report recognises that that may be understandable, with changes in structures and competing agendas, but it is unsustainable, especially given that there is good practice in some areas of the country.

In numerous reports over the past few years we have heard of failures to work across specialisms, but within health services for young people in trouble there must be, across mental health problems, drug and alcohol problems and physical health needs, adequate assessment of need and co-ordinated monitoring of what is being provided. Every primary care trust must have a representative on the youth offending team. I realise that multiple PCTs may serve a YOT area, which is a complication, but it is not insurmountable. Services need to be responsive to the needs of 16 and 17 year-olds, particularly as that age group is responsible for the majority of crimes committed by young people and for the more serious crimes.

The joint inspection of youth offending teams in 2006-07 identified several areas that could be tackled—for example, case managers being untrained or unskilled in screening for physical health, poor communication between health professionals and case managers, and inadequate or non-existent service level agreements and protocols between YOTs and the various health providers. There was little evidence of systematic and formal evaluation of outcomes from interventions. One in six YOTs had no healthcare worker and a third of them had no mental health worker.

Various government departments have been good at identifying the needs of young people and other client groups. We have got better at listening to clients, including children and young people, although I have not come across much evidence of consulting young people in trouble with the law. My plea for today is that we exercise more caution in punishing young people and that we focus more on their welfare. If young people do get into trouble—and some of them get into horrendous trouble—we should purposefully assess why they are in trouble and what their needs are, and deal with those needs rather than making assumptions, labelling and stigmatising. I hope that the two Ministers here today will take that on board and influence colleagues in other departments as well as in their own on some of the issues that I have raised today.

I congratulate my noble friend Lord Darzi on his speech and look forward to my noble friend Lord Adonis responding to the debate—a gargantuan task. I look forward in particular to the new health and social care strategy for young people in contact with youth justice. I hope that it will dovetail with the Children and Young Persons Bill and that all this will benefit young lives on the ground.

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3.41 pm

Baroness Deech: My Lords, I join others in welcoming the opportunity that we have this afternoon to discuss health matters of such importance and to receive the assistance of the noble Lord, Lord Darzi, whose success your Lordships hope for.

It has been commented that there is little new in the legislative proposals made in the gracious Speech. In a non-pejorative sense, this is true of the Human Fertilisation and Embryology Bill, as the ethical and legal principles that it embodies have been of exceptional interest to this House and to the public for nearly 30 years, since the birth of the first IVF baby, Louise Brown—a miracle achieved by British doctors.

I declare my interest as the longest-serving chair of the Human Fertilisation and Embryology Authority—from 1994 to 2002. Noble Lords will understand if I go on to say that Britain is an acknowledged world leader in IVF, embryology and stem cell research. It is as advanced as the USA but more regulated, avoiding the excesses of freedom and restriction in the USA and in Europe. Progress in this country has been largely in tandem with public acceptability. Other countries have run into trouble: the US bans federally funded stem cell research while leaving basic IVF unregulated; Germany and Italy prohibit diagnoses and treatments that are taken for granted in the UK; and South Korea, an advanced nation, has suffered from fraud in its practices.

It stands to reason that the benefits of the existing law should be continued. It has the virtues of great flexibility of definition, discretion lodged in the regulator and a cascade of detailed decision-making down to the clinics, patients and scientists, all within an acceptable legal framework. This has been achieved since 1991 by the Human Fertilisation and Embryology Act. When I was chair of the authority under that Act, I was often accused of playing God, to which I would answer that it was not the chair or the members of the authority who were playing God. The Act represented, and still represents, a democratic compromise between strongly held views in society. The authority works to reconcile, to explain and to point to a way forward, and it is accountable to the public.

Our structure at the HFEA has been studied and emulated to a greater or lesser degree worldwide. It rests on the famous report authored by the noble Baroness, Lady Warnock, in 1984. The Warnock report remains the most constructive, pragmatic, ethical, deep and influential report of its kind in the world. It just goes to show how much you can achieve by putting a university philosopher in charge of building an element of government regulation—how much better than putting businesspeople in charge of university philosophy departments.

The Bill that will come before your Lordships transfers into primary legislation certain issues that so far have been left to the regulator: rules about pre-implantation genetic diagnosis, sex selection and animal-human hybrid embryos. The pre-legislative scrutiny committee on the Bill was able to come to conclusions on those issues, but it also tended to agree

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that the more that could be left to the regulator, the less likely the new law is to be short-lived and subject to legal challenge. Having heard evidence from ethicists, the committee rejected the notion of a national ethical body alongside the regulator.

The law already incorporates ethical principles that determine most matters and it is open to this House to consider the setting up of a parliamentary bioethical Select Committee. That would be difficult to achieve. How can one, in one committee, reconcile the opinions of those who would stop all embryo research and those who go along with the regulatory framework? There would certainly be fewer ethical concerns if IVF was generally available on the NHS and if there was no postcode lottery for the limited service that is available.

I must return to ethical questions. There are risks in the proposed new law that worry me. The risk is of dehumanisation. I am concerned to see that the Government still want to remove from the law that clause that states that the doctor proposing to give IVF treatment should consider the welfare of the future baby, including the need for a father. I find it extraordinary that it should at this moment be seriously considered that this House make a statement that, in welfare, there is no need for a father. This is a moment when we know from research in this country and abroad that a special contribution is made by fathers to the raising of their children, which is not replicated by the contribution made by mothers. We know that it is said that children lack male role models and that some of the violence and disorder in society is created by the lack of fathers.

There is a further risk. In reproduction in general, the role of men has been downplayed. In recent years, women have fought very hard to have their femininity and their wishes recognised in the field of reproduction. Every woman is a worthwhile person, whether or not she has children. She is regarded as in control of her body and has fought to be respected. But what about men? They are in danger in this field of being reduced to a sort of genetic contributor and nothing more. It would be deeply regrettable if the express reference to their role as parents were undermined or removed. Women have won the battle to be respected as parents and it is now, for once, time to worry about men as well.

There is another risk. I find it strange—I think that in 100 years it will be regarded as even more odd—that the law might provide that a birth certificate will show two women as the parents of the child. One understands that that comes from a desire not to discriminate, but at the same time we all respect the truth, and to have a birth certificate listing two women as parents is an odd way of pursuing the truth. The pre-legislative scrutiny committee was very anxious to ensure that donor-conceived children should be given every opportunity to discover the truth about their origins, but it believed that children need two parents, preferably including a father. The Bill will promote the truth about origins, so why should it also provide for birth certificates naming two parents of the same sex? The Bill will ensure non-discrimination between family units and persons,

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at the expense, it could be argued, of the welfare of the child. After all, British law still rightly discriminates against underage, polygamous and incestuous unions, so why should the family welfare of a child not be considered before the mother undergoes IVF?

Current government and judicial policy is that fathers have a vital role to play. We should not be afraid of being labelled politically incorrect in standing up for the welfare of the child, as we best understand it in current conditions, even though this House should be assured that the existing requirement to consider the welfare of the child, including the presence of a father, has not been, and will continue not to be, a barrier to treatment.

A sensible Bill would retain the HFEA, make reforms to the Human Tissue Authority and give broader discretion to the HFEA in future research involving hybrid embryos and genetic diagnosis. It would remove the excessive confidentiality provisions that block follow-up research on IVF children and would give the regulator greater powers over the charges and menu of treatments currently presented by private IVF work as well as greater enforcement powers. It should be minimalist, because what we already have is pretty good. Unfortunately, those who want to change abortion law and unsettle the consensus that has prevailed over the status of the embryo will look for opportunities to hijack the proposals.

This House should remember that ethical principles regarding human fertilisation have already been worked out. One such principle is the assurance of human dignity, worth and autonomy. Everyone is dignified, and everyone should have the right to consent to the use of their bodies and not to be treated as a bank of spare parts. The welfare of the potential child must be considered and safety must be given great weight in new treatments. All of us who remember the thalidomide situation so many years ago will understand the tremor of considering new and untested treatments, even in the light of the best possible scientific advice. Another ethical principle is respect for the status of the embryo. A new principle is that the saving of life is an acceptable use to which new advances in embryology may be put. However, let us not think that reaching ethical consensus is an easy matter. We are polarised.

I close on a more light-hearted note. Your Lordships will know that every religion has different views about the viability of foetuses and embryos and how deserving they are of protection. I am often asked what the Jewish view is of the viability of the foetus, to which I say, “It is not viable until it has graduated from medical school”. I look forward to further discussion of this important Bill and to improvements to the nation’s health.

3.53 pm

Baroness Cumberlege: My Lords, I congratulate the noble Lord, Lord Darzi, on his speech. I am delighted to see him here at the Dispatch Box. Before I address the issues in the Queen’s Speech, I shall mention his interim report, Our NHS, Our Future, to which he referred in his opening speech today. It is

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said that this report had to be hurried. None the less, it is very interesting, because it comes from a surgeon. The noble Lord’s skill is indisputable. He leads in his surgical field, and his reputation is international. The opening words of his report are:

Your Lordships must be sympathetic. After all, doctors and surgeons must be at the top of the popularity table and we politicians are, I fear, near the bottom.

The traditions of this land require every Minister to be answerable to Parliament, and I find myself strangely at one with the right honourable Prime Minister, who, through the Queen’s Speech, said:

The noble Lord, Lord Darzi, has for better or worse allowed himself to be appointed a Minister of the Crown, and therefore he is accountable to Parliament. In this House that is onerous—I know, I did the job for five years.

In your Lordships’ House the Minister is on his own, a solitary figure, whereas in another place there are cohorts—well, five—each with a portfolio of special interests. That luxury does not extend here. The Minister has to cover every aspect of health in every corner of England. I have no doubt that he can assimilate all the information very quickly while constantly checking on visits nationwide. Trying to manage a service that ultimately employs a staff of 1.3 million while attempting to meet the aspirations of the British public is taxing, in both senses of the word. That is especially true in an area that is so politically sensitive. Scarcely for a moment is the NHS out of the headlines. As a surgeon, the Minister may not wish to concern himself with the question so frequently asked within the service and outside: “Where has all the money gone?”. That is a harsh political question for the Government—a Government whom he has chosen to join.

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