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The National Health Service alone spends £17 billion a year on goods and services, and I have not included in that figure social care services, which is the great worry for us throughout the Bill; we are concerned that social care will be pushed down the pecking order. I do not know how much we spend on social care services in this country, including all those provided by the private sector, which will be covered by this Bill. It must be an enormous amount of money. How many people are employed by these sectors? Much is said about the millions working in the NHS, but we must add to that the figure for all those employed by care services, the resources that they use and the impact on the environment. The health and social care industry is truly massive; it is probably the biggest undertaking in this country.



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We must pay heed to future generations and not ruin their quality of life in order to satisfy our needs today. Indeed, failure to do so will increase the incidence of both physical and mental illness in the future.

[The Sitting was suspended for a Division in the House from 5.25 to5.35 pm.]

Baroness Tonge: I am delighted that we had a break just at that moment because I am sure that it has given the Minister a chance to find out exactly what the total cost is of health and social care services provided by both the state and the independent sector in this country, as well as the number of people employed in both undertakings. No doubt she will be ready with those figures for us by the end of the debate. I am beginning to sound like Boris Johnson, at least for a moment.

The Government’s sustainable development strategy, Securing the Future, launched only three years ago in 2005, called on new bodies, as they are created, to apply sustainable development duties. Recalling what the noble Lord, Lord Warner, said in the debate on the previous amendment—that this legislation merely implements a government manifesto promise—how can we possibly be denied this small but important alteration to the Bill in order to bring in the words “sustainable development”, which was also the subject of a government manifesto promise? I hope that the Minister will accept the point.

Perhaps the Government will respond by saying that the NHS has a carbon reduction strategy. We have certainly heard about that. But that programme addresses only carbon reduction, not sustainable development, which is a much broader concept. A sustainable development requirement would ensure that the health service used all its corporate powers and resources,

all these things are part of the health service—to benefit health and well-being by investing in local communities, the economy and the environment. Its carbon reduction strategy is much narrower in scope, addressing only one aspect of living within environmental limits. It does not and cannot include a full range of policy levers for carbon reduction, such as regulation, which the Department of Health determines. Indeed, the department needs to back the efforts of the NHS on carbon reduction by including sustainable development in its regulation. This is essential to ensure that the NHS meets the government target to reduce carbon dioxide emissions.

The NHS carbon management programme applies only to the health service, but here we are talking about the Care Quality Commission, which will be responsible for all social care services as well. So we cannot be told that the carbon reduction strategy makes our amendment unnecessary, because it covers only the NHS. Once again, I impress on the Committee our worry that social care services will miss out when the merger of the commissions takes place. The

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amendment is therefore essential for healthcare and social care to meet government targets and the Government’s own manifesto commitment on sustainable development. I thank the noble Lord, Lord Warner, for pointing that thought out to me. I beg to move.

Earl Howe: Whatever the Minister is willing to do or not to do about putting statutory objectives in the Bill, there is a strong case for the promotion of sustainable development to be one of the core purposes for which the commission is required to exercise its functions. Sustainable development is a goal that will endure, whatever Government may be in power.

The NHS alone is one of the largest employers in the world. It maintains a built estate of enormous size and is a vast consumer of energy. We need to think of such things as the management of waste, the use of energy and the use of transport. Buildings need to be designed in a way that will last and that will be conducive to the well-being of staff and patients. Procurement should be not just cost-effective but also environmentally friendly.

We are living at a time when climate change is never far from people’s everyday conversation. One of the effects of climate change may well be an increased tendency for us to experience extremes of weather, such as the dreadful floods that we saw last summer. The NHS needs to make contingency plans to cope with flood risk and to ensure that services are not disrupted by bad weather. The White Paper, Our Health, Our Care, Our Say, was clear about sustainability as part of future health policy; indeed, so important is the goal of sustainability within the NHS that I understand that there is now a sustainable development unit operating within the Department of Health.

Some public bodies, such as the National Assembly for Wales and the Greater London Authority, already have statutory duties in relation to sustainable development. In their document, Securing the Future, the Government undertook to apply sustainable development duties to new statutory bodies as they are created; the noble Baroness, Lady Tonge, mentioned that. Making sustainable development a part of what the CQC is about would encourage it to think sensibly about the use of its own resources, to recognise the need for having a good business case for any proposals that it looks at and to have measurable outcomes in any project that it oversees or undertakes.

I have read with interest the section on good corporate citizenship on the NHS website. It says:

So the department fully recognises the importance of being a good corporate citizen. I hope that the Minister will take the proposal away and look at it carefully.

Lord Lipsey: Ministers might be forgiven for starting to think that there was an umbilical cord running around every person in this Room, save for the Front Bench. To demonstrate that that is not true, I do not

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support the amendment and do not think that the Government should accept it. They will really stuff me if they announce when they reply that that they are accepting it, but I will take that risk. When I first saw the amendment, I thought, “Typical Liberal Democrats”—and then I saw that the noble Earl, Lord Howe, with whom I strongly agree on 99 per cent of matters, had put his name to it.

My concern is not about the idea that sustainable development is important, because of course it is. My concern is with the growing tendency in the modern world to elevate secondary objectives of organisations to the level of primary objectives, including by writing them into Bills. That is a terrible danger, often seen in the multiplication of targets for organisations. If you give an organisation one, two or three objectives, it can hope to fulfil them and be accountable for them. If you give it 20, 30 or 40, the task becomes unmanageable and the organisation may be diverted from its central tasks. Occam taught us,

forgive my French—which means, “Do not multiply beings without the necessity of doing so”. The same is true of objectives for regulators on the face of legislation.

5.45 pm

Baroness Barker: I am grateful to the noble Lord, Lord Lipsey, for his intervention. I would be horrified if people outside this Room got the impression that we were in agreement most of the time. I accept the thrust of what he said but, as this is a matter of singular importance, I disagree with him for this reason. In the corporate world, sustainability has reached levels of importance such that it is one of the primary objectives of most major companies. I was sad enough to have read my way through Tesco’s corporate social responsibility report, the bulk of which is about environmental matters and not about charitable giving and so on. Clearly in the private sector there is a massive financial incentive to develop sustainable policies and practices; in the public sector there is no such driver. That is why the noble Lord is wrong to take exception to the amendment. I believe that regulation and regulators in the public services play a role in driving forward an important agenda. It may not appear important to people in their day-to-day working lives, but it is a growing necessity.

Baroness Thornton: Amendment No. 24 would require the Care Quality Commission to perform its functions for the general purposes of encouraging the promotion of sustainable development. This would be in addition to the requirement in Clause 2 of the Bill for the commission to carry out its functions for the general purposes of encouraging improvements in healthcare, user-focused care and the efficient and effective use of resources.

I think that we all agree about the vital importance of delivering sustainable development. The Government are working hard and looking across the whole system for opportunities to push this important agenda forward using levers such as effective commissioning. In particular, we recognise the profound responsibility of the NHS

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because, as the noble Baroness said, it is such a large player in the public sector. Health and adult social care sectors spend more than £100 billion of public money—it is currently around £110 billion—and involve about 2.9 million people in the delivery of services.

Baroness Tonge: I am impressed.

Baroness Thornton: And I am impressed with the people behind me.

As such, through the forthcoming NHS carbon reduction strategy, to which the noble Baroness referred, we are determined to implement a system that helps to achieve our ambition of a significant reduction in carbon-related emissions. We expect to launch a consultation on this strategy in June 2008. But that will be a beginning and not an end. The noble Baroness is right: this is not the whole story.

The Care Quality Commission can of course play a role here. The good news is that the Health and Social Care Bill already allows us to give the Care Quality Commission an effective role in promoting and contributing to sustainable development across health and social care. The publication of comparative information is a significant incentive to improving services and I take this opportunity to put on record our intention to require the Care Quality Commission to publish information about the performance of NHS organisations and others in this vital area relating to how individual organisations are contributing to sustainable development.

Chapter 3 gives the Care Quality Commission responsibility for reviews and the publication of comparative information on the quality of care. Chapter 5 allows studies as to economy, efficiency and so on. Those functions already allow the commission to consider aspects of sustainable development. Moreover, the indicators used for the commission’s periodic reviews could, where appropriate for health and adult social care organisations, be used to promote energy efficiency and broader elements of the sustainable development agenda, such as reducing health inequalities and tackling obesity.

Our 2008-09 “vital signs” for PCT planning include, for the first time, an NHS carbon and energy efficiency indicator alongside those indicators for improving health and accessing effective care. Again, that is a start, not an end. We are committed to working up suitable indicators on sustainable development as one of the issues that the commission will consider in its periodic reviews. That approach may have greater impact than a general requirement such as is proposed in the amendment.

Baroness Tonge: I confess to being a little confused by that. All that we propose in our amendment is to include in the Bill two words from the Government’s own strategy. I think that the noble Baroness is saying that all these things are there, except those two words. Why is she so frightened to use those two words, which are the Government’s own phrase?



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Baroness Thornton: I am not frightened; I have been using them all the way through my explanation. If I may, I shall go on to explain why we do not want those words where the noble Baroness proposes to put them.

The risk with a more general purpose is that it is unclear what would be expected of the new commission and how it would balance that requirement with its primary role in assuring safety and quality of healthcare and adult social care services. We want action from the start. We do not want a long debate about sustainable development; we want the commission to have it embedded in what it is doing.

It would be unnecessary, for example, for the commission’s registration and enforcement functions in Chapter 2 to apply to sustainable development. Those functions and powers rightly apply where care service users are being exposed to unacceptable risks or poor-quality care. To illustrate that point, Members of the Committee would not expect the Care Quality Commission to close down a care provider on the basis of its carbon footprint or its poor energy efficiency record. On the other hand, there are perfectly plausible cases where the commission may quite rightly take enforcement action in response to an appalling care record against an otherwise energy efficient service.

I use that as an illustration of the problem with putting those words into the clause on the general functions of the commission. It is a question of how to build sustainability into the work at the relevant and appropriate moment. We are not convinced that it is most effective as a general purpose, so I ask the noble Baroness to withdraw the amendment.

Baroness Tonge: I thank the Minister for that reply, but the Committee is becoming a bit like that programme on Radio 4, “Points of View”. I do not know whether other Members of the Committee ever listen to it, but the producer of the programme always comes back and says that what he did was absolutely right and the listeners were absolutely wrong and should not have raised the issue. It is beginning to feel a bit like that.

To me, this seems to be the most innocuous phrase. The amendment would not “impose” sustainable development; it does not talk about taking to court or closing down any establishment that does not operate according to the government sustainable development strategy. It merely calls for the commission to promote sustainable development, which the Minister seems to have said in her reply that the Bill will do anyway. I still do not understand why we cannot use those words, but we will come back to this. We feel strongly about it—the noble Lord, Lord Lipsey, will know that Liberal Democrats feel very strongly indeed about the future of our planet—and we shall come back to it, but I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Lipsey moved Amendment No. 25:



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The noble Lord said: First, I confess that there is a touch of Gruyère cheese about this amendment. There is an obvious hole in it in that I suggest a separate sub-commission for social care but not for mental health. The sole reason for that is that I know nothing like enough about mental health to know whether that makes sense. However, there are many noble Lords in this Committee who can repair that disadvantage and, if the amendment is to proceed at a later stage, we can change it.

Secondly, I suggest in the amendment that only the social care sub-commission should consist solely of non-executive members of the commission. That does not matter now because, if I understood the Minister correctly, a commitment has been given that the commission will comprise solely of non-executive members, but it will need to come out at a later stage.

I make it clear that it remains my view—it is probably a majority view in the Committee—that this merger should not take place. I feel a sense of distress that my noble—and good—friend Lady Young, who is a superb person to do this, should nevertheless have to take on something that is fundamentally ill-conceived. Porting from yesterday’s Committee sitting, I say to her and to the Government that many of us feel that making the announcement today while this Committee was considering the issues involved in the Bill was an unwise provocation of the House.

Some noble Lords will have picked up the excellent article by Nigel Hawkes, the health and science editor of the Times. He is the Peter Riddell of that area of journalism, whose word is taken as gospel by those who follow such things. His article in the BMJ says:

Amen. Between now and possibly even beyond the passage of the Bill, those of us who feel this way have a challenge to find suggestions for delivering the advantages that the Government see in the Bill, including the cost savings, without the attendant dangers that some of us are so scared of. That is something on which I hope many noble Lords are actively deploying their minds.

I know this is a long introduction but there is not much more to go. The amendment has a different purpose and is intended to establish, if the merger goes ahead, how we can best mitigate the damage that I and others fear will be done by it. In particular, how can we protect the status and distinctive ethos of social care regulation, which, as the noble Baroness, Lady Tonge, said earlier, is our deepest concern? I believe that establishing sub-commissions of this kind would achieve that, while the overall board could have different kinds of objectives. Obviously, it would be

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somewhat dangerous for anyone in this Committee to devise detailed structures for the body—I am sure that the Minister will say that when she replies—but it would be enormously helpful if she would indicate that the Government have sympathy for the thinking behind the amendment. Will they actively ask the commission—it is delightful to have the chair designate beside me—to consider whether that kind of structure is not the way to carry things forward? That would at least alleviate some, if not all, of our fears about the merger. I beg to move.

6 pm

Baroness Meacher: I shall speak to Amendment No. 93 in this group which requires the Care Quality Commission to establish a sub-committee known as the mental health sub-committee. This sub-committee would be responsible for advising the commission about the exercise of the commission’s functions with respect to mental health services.

Why do we need to single out mental health in this way? First, patients detained under the Mental Health Act or the Mental Capacity Act who are subject to community treatment orders are likely to be less able to defend themselves than, perhaps, any other patients whose services will be the subject of regulation by the CQC. If you do not have your full mental capacities, you really are in a completely different situation from anyone else. I fully recognise that people with a range of disabilities and problems have their own vulnerabilities, but this is different.

Secondly, these patients are likely to be less able to understand whether or not services are being properly provided to them and, if not, to what extent. They may not even realise what is going on. Thirdly, these patients are not at liberty to change their service provider or opt out of the patient role. As I said previously in relation to another amendment, in a real sense they are prisoners in their environment in a quite different way from most other patients, although I recognise that some other patients may feel somewhat imprisoned.

If we take three examples the point can be readily illustrated. For example, how can a dementia patient who is not being adequately fed or cared for in a nursing home deal with that situation proactively? The same can be asked about an acutely ill psychotic patient on a locked ward who has an adverse reaction to medication and can hardly remain conscious; and about an acutely depressed service user under a community treatment order whose medication is so ineffective that they become suicidal. None of those people would be in a position to pursue concerns in a proactive way, as they would need to do with a normal regulatory regime.


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