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I hope that there will be particular expression of the ways in which we can provide support and encouragement for young offenders. My own experience from visits to our local YOIs at Deerbolt near Barnard Castle and Wetherby reinforces my awareness of how young offenders suffer from interrupted and occasional education, but also of the opportunities that those institutions could provide for skilled and inspirational teaching which could make a real difference to the future prospects of these individuals, as well as keeping them out of prison in the future. The emphasis in the Bill on 16-to-19 education could provide the basis for very significant improvements in this area, but that education needs to be appropriate to the young offenders

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themselves. The tragic story of the Barbed project at HMP Coldingley, where the graphic design studio sponsored by the Howard League for Penal Reform has now been closed, while not coming from a YOI experience, gives little confidence that there is enough flexibility in the prison estate and the prison system to fulfil educational and apprenticeship aims. When the Bill emerges, I look forward to seeing not just how those aims are expressed, but also how they are to be enforced and achieved.

I welcome the proposed child poverty Bill and the intention to enshrine in law the duty to eradicate child poverty by 2020. Like the noble Baroness, Lady Massey, I would like reassurance that this will include the commitment to halving child poverty by 2010. I welcome, too, the ways in which children will be helped by bringing forward rises in child benefit and child tax credits, as well as the beneficial effect of the cut in VAT on the lives of those in most need. However, we must be aware of the possible implications of the proposed welfare reform legislation: the answer to child poverty is to force people into work of whatever description. Some 57 per cent of poor households have someone at work within them, and that percentage is rising. For too many families, a move into work does not mean a move out of poverty. We need to beware of the impact of working antisocial hours on those on low incomes and on their families. Moving 300,000 lone parents into employment will not in itself reduce poverty.

I hope that the Government will take this opportunity to affirm their support for family life as part of the support for children and children in poverty, and that nothing in this package of legislation will be detrimental to that aim. It is significant that according to the National Centre for Social Research, workers contracted to work unsocial hours tend to be lower skilled and lower paid. Some 38 per cent of people with no qualifications work at the weekend compared with 15 per cent of those educated to degree level. In opening the debate the Minister spoke of the need for the talents of the whole population to be used in support of the country and our national economy. I hope that the Government will reaffirm that the talents expressed as a parent and the skills used in family life are among the talents that must not be wasted.

The Government are right to assert that work is an important part of our contribution to society and of our fulfilment of ourselves as individuals. That work needs to be sustainable and adequately paid if it is to fulfil the needs both of society and the individuals concerned, and if it is to bring families, and therefore children, out of poverty. In this respect, we must take care not to separate child poverty from all human poverty. I should like the Government to reaffirm their commitment to eradicating all poverty and social exclusion in our society.

We need fiscal changes in order to bring children out of poverty, and I welcome the moves towards them. We also need support for the strengthening of family relationships and in particular of the bond of marriage. The strength of the marriage relationship may at times be derided today, but from this Bench I remind noble Lords of our continued contention that

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the weakening of marriage has serious implications for the mutual belonging and care that is exercised within the community at large and which is crucial to both welfare reform and the eradication of child poverty—as well as to the whole way in which our society regards children, a point described so eloquently by the noble Baroness, Lady Walmsley. In this context, our support for marriage and for mature relationships in the upbringing of children is itself a response to the need to eradicate child poverty. I welcome the aim and I look forward to the introduction of fiscal measures to achieve it and to the support of family relationships in order to provide security and encouragement for all our growing children.

1.27 pm

Lord Warner: My Lords, it is a pleasure to have the opportunity to talk about the progress of the NHS under this Government and to say something about what continues to need close attention. I shall concentrate on the delivery of NHS change and improvement, but first let me declare my interests. I am the part-time chairman of the NHS London Provider Agency which focuses on improving performance in London’s NHS providers. I am also an adviser to the General Healthcare Group, Perot Systems and Byotrol, all of which have healthcare interests, so I am reasonably in touch with the current healthcare scene.

The Government are to be congratulated on their investment in the NHS to rectify what I regard as the gross underinvestment of the 1980s and the early 1990s. Alongside that investment they have introduced reform through foundation trusts, targets, choice, competition and political leadership to drive change. However, we need a continuing strategy of investment and reform. We know from the reports of the Healthcare Commission that access, mortality rates and care quality have all improved over the past 10 years. Only yesterday the commission published findings that show improvements in life expectancy at birth since the mid-1990s and a reduction in early deaths from cancers and coronary heart disease. The commission’s rankings of those trusts performing excellently have risen from 4 per cent to 26 per cent over the past three years. But overwhelmingly this improvement in excellence is shown in the foundation trusts rather than the non-foundation trusts.

I now come to the point that those who are listeners to the “Today” programme might call the John Humphrys’s “but” moment: the improvements have not been evenly spread. For example, about 40 per cent of trusts are still classified as “fair” and “weak” by the Healthcare Commission. Overwhelmingly, as I have said, these are trusts that have not obtained foundation trust status and, in some cases, have no prospect in the foreseeable future of doing so. Some of the extra largesse has not been used as well as it might have been and the productivity increases between 2000 and 2005 are somewhat unfortunate and disappointing.

The Government recognise, however, that further improvement is needed. They have announced, in difficult financial circumstances, a fair settlement for the NHS in 2009-10 and 2010-11 and are using sensibly

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the surplus that has been built up to help the NHS to continue to invest in good healthcare. As I understand the figures published by the Government, that allocation means that, on average, there will be a 5.5 per cent increase in both those years for primary care trusts. Even more significantly, my noble friend the Minister has provided a clear vision of the quality improvement for the future direction of the NHS to which, at least in principle, most people subscribe. The report he provided in London before becoming a Minister offers a real prospect for far-reaching improvement. However, we now need many parts of the NHS to raise their clinical and managerial game, particularly over the next two years before an almost inevitable reduction in all public sector allocations in order to reduce public borrowing. We have a window of opportunity for real change to continue over the next two years.

The proposed NHS constitution is a helpful framework document and has some important aspects in the way it balances rights and responsibilities. I like the emphasis on quality, accountability and choice, which are important drivers of NHS improvement. I am not opposed to giving the constitution some legal underpinning provided that it leads to driving improvement and does not wrap us up in red tape and, much more importantly, does not put the NHS in aspic and make it unable to respond speedily to medical advances and the inevitable increases in public expectations of our NHS. The only thing that is clear from the past 60 years is that medical advances have come thick and fast and that the public continue to expect the service to improve.

We will no doubt explore further the issues I have mentioned when we come to consider the new health Bill. However, the Bill will have not such a great impact over the next two to three years, and the remainder of my remarks relate to some of the areas where the Government and the NHS need to secure real change before the funding flows start to slow considerably.

It is explicit in my noble friend the Minister’s vision for the NHS that there will need to be a major reconfiguration of services, such as stroke and trauma, with many services being provided in different places from where they are now. This will, of course, take time. Quality indicators will make these changes inevitable. Changes of this kind require real clinical leadership and board and management commitment to change. It almost certainly means mergers of struggling trusts and, in some cases, an effective failure regime so that more competent organisations can take over those that fail. Not all of our geese are swans in the NHS. This will require political courage and many elected politicians across the parties will need to cease fantasising about the sustainability of some of the services in their local hospitals. It will require courage from doctors and politicians to stand up and describe the benefits of the changes that need to be made if we are to carry forward the next stage review.

Secondly, we will have to increase NHS investment in IT at the local level; it is no good the NHS continuing to moan locally about the national programme for IT. That programme, despite all the criticism, has delivered some major changes for the NHS. BT is to be congratulated on the work it has done in this country

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in putting in place a national spine; it is a major achievement of technology. Connecting for Health has brought enormous benefits for patients. Improvements in the transfer of imaging, in electronic prescribing, even in the much maligned choose-and-book system and in secure e-mails are among the advances that have already been delivered.

A great deal of focus has been placed on the failure to deliver as rapidly as most of us would want the electronic patient record. But this is not the time for the Government or the NHS to lose their nerve; we need to press on with getting it delivered. There will inevitably be technical glitches, but they can be overcome. We must understand that the NHS at the local level also has to raise its game on IT investment. It was never the case that the national programme would pay for the training of staff at local level and re-engineer all local systems. Parts of the NHS have failed to step up to the plate in the way they have invested in IT. We lag behind other countries at the trust level in what we invest in IT for a modern healthcare system.

There are two other areas in which resources can be freed up to benefit patient services and NHS development. The first area is in pathology services, where the Government and the NHS need to get behind the proposals of my noble friend Lord Carter of Coles, whose further report in this area is to be published shortly. When I was a Minister with some responsibility in this area I believed that the £2.5 billion or so that the NHS spends on pathology services had the capacity to deliver about a 20 per cent improvement in efficiency. Those kinds of sums would enable the NHS to adapt its pathology services to take advantage of the great advances in genomic medicine which are coming very fast.

The other area is a rather Cinderella area, not only of the NHS but of public services—I refer to the way in which we manage our buildings and land and our facilities management. This has been long-neglected, is very unfashionable and is something in which most politicians do not like to get involved, but the NHS footprint could be seriously reduced to free up assets for other social uses and to secure a capital return for the NHS. In addition, we need to look at what we are good at in the NHS. We are in the business of providing patient care, not managing buildings. Facilities management needs the kind of professionalisation that outsourcing by, for example, the Department for Work and Pensions has used so successfully over the past seven or eight years. There are some real gains to be made which could help with patient services in times of shortage.

I want to end, appropriately enough, with the end-of-life care strategy, on which the Government are to be congratulated. When we come to the health Bill I will want to look further at whether we can secure some stronger legal underpinning for health professionals to have regard to advanced decisions and to ensure that those decisions are incorporated in NHS medical records. We need a debate on that strategy before too long.

My last point concerns the issue of assisted dying, which has been in the media a great deal and will not go away. I do not want to start a debate on that today but the present legal position is untenable and, in the view of some of us, cruel. I should like to see the

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Government oversee a more robust way of establishing independently what public and medical opinion is in this area, in the way that Professor Mike Richards did so skilfully over the equally emotive issue of top-up fees. This is an area where the Government could help to improve the quality of the public debate.

1.40 pm

Baroness Cumberlege: My Lords, I congratulate the Minister on his opening speech and on his leadership in taking forward the review of the NHS. Its concentration on quality is already proving to be a strong motivating force within the NHS workforce.

I share many of the views and the aspirations of the noble Lord, Lord Warner, as well his concerns, but sadly I do not agree with his enthusiasm for the NHS constitution, on which I shall concentrate today. The constitution seeks to preserve the founding principles of the NHS. Sixty years ago my father joined the NHS and I remember his huge relief at its birth. Its values resonated with his own. His patients were grateful and respectful and they were ready to embrace the socialist ethic of 1948. His only problem was that remedies were very limited. The physician comforted while nature healed.

The NHS was ineffective, safe and cheap. Today it is effective, dangerous and very expensive. The population are not overly grateful, they are not deferential and they expect a miracle. A baby born through IVF is a near miracle. Surgery carried out by the noble Lord, Lord Darzi, is a near miracle—but he knows that his work will be outdated in a decade and we will have moved on to new technologies and innovations, a point also made by the noble Lord, Lord Warner.

One of this country’s leading scientists, in giving evidence to a working party that I chair, told us that by the next generation we will be able to find out the complete genome sequence of everyone, probably at birth. The information will tell us about the polygenic contributions to many diseases, such as diabetes, heart disease and susceptibility to tuberculosis. We will have identified the genes that cause autism and dyslexia. We will know about genetic variation associated with an individual’s ability as to whether they are good at maths, good at reading, good at writing or bad at them. It will be possible to have premarital genome sequencing of couples, with all sorts of predictions based on their genetic make-up. This is scary stuff and is in sharp contrast to 1948.

The year 1948 was a different world. Today the NHS is about the only vestige of pure socialism. Founded on the principle of,

the NHS is a vast co-operative. I do not believe that either socialism or the co-operative ethic resonate with people today. The part that might be remembered is,

The forgotten part is,

A co-operative is about balancing inputs with outputs, and both are exercises in unselfishness. With the “I want” society, I can understand why the Government

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are anxious to re-instil the underlying ethic of the NHS. My disappointment is that it has chosen legislation as its tool. With such a fast-changing world we need flexibility, inspiration and dynamic leadership. Legislation is none of those things. It is reductionist and rigid and it kills the spirit. A nurse going into a ward does not think, “I am here to give this patient his rights”; she goes in to give care.

In the NHS constitution almost every right and pledge has its caveat. For example:

“You have the right to access local NHS services. You will not be refused access on unreasonable grounds”.

What is unreasonable? Who is to judge? Certainly not the patient.

“You have the right to expect your local NHS to assess the health requirements of the local community and to put in place the services to meet those needs as considered necessary”.

Who is to judge what is necessary? Certainly not the public. This is in sharp contrast with the Medical Schools Council, which has taken on the Herculean task of defining the role of the doctor. With clarity it states that it is the patient and the patient’s interests that must define the role of the doctor.

The constitution uses the word “strive”, which it explains is a “pledge”:

“The NHS will strive”—

or pledge—

Why employ people if they are not going to make a difference to patients? That is a banality. I thought that the whole purpose of the NHS was to treat and care for patients. Again:

“The NHS will strive”—

or pledge—

Surely no employer, let alone the largest in this country involved in the business of health, sets out to ensure that its staff are unsafe and unwell. I use Pledge. It comes in an aerosol made by SC Johnson and omits a thin film of polish. These pledges are a thin film that tries to give a shine to this sad little document.

It seems that the Government are too frightened to declare their roots. More importantly, the constitution abandons the discipline required to make either the socialist or co-operative models work. Do the Government consider that these twin ethics are so outdated and so compromised that the NHS is based on unacceptable, and therefore unworkable, principles? If the Government want to hold to good principles, they cannot declare, as they do in paragraph 4.33 of their consultation document on the constitution, that:

“We have firmly ruled out linking access to NHS services to any sort of sanction for people not looking after their own health”.

I understand what a minefield this is. I also acknowledge that more and more doctors and nurses say, “In effect, you are wasting resources, or are untreatable, unless you get your weight down, change your diet, stop binge drinking and so on. Put your own health in order first”. There is no common sense and no courage

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within the constitution to absolve people from taking charge of their health. I would have more respect for it if it said, “We will give you a maximum of 10 minutes to tell you how to put your health right. Do it. Come back in six months”. At least we would have some honesty and some grip.

In the section on the principles that guide the NHS, we are told that the NHS aspires to train to the highest standards. Medical schools are now scared to fail pupils for fear of being sued. Those schools receive some of the brightest and best, but common sense says that not all the brightest and best will, regardless of commitment, make good doctors. Pass rates are now nearly 100 per cent. The Medical Schools Council understands this; in its document it states that doctors must have strong intellectual skills and must have the capacity to work out solutions from first principles. Here is rigour. Throughout its document, it uses the word “must”. If the Government are set on having a constitution, they must at least ensure that it says something. How about, “The NHS aspires to the highest standards. We carefully select the best for training and expect 75 per cent to qualify. All trainees must accept the school’s decision as final”. If you want the best, you have to cull the weakest.

I have taken a few examples from what I think is a weak and ineffectual document. Your Lordships may think that I am being too tough, but the trouble with socialism and co-operatives is that they become coupled with inefficiency and lack of commercial rigour and discipline. Perhaps, too, I have got it all wrong. To be fair, socialism and co-operatives get no mention in the constitution. Yet we all know that, deep down in people’s psyche, there is an innate desire for fairness in the NHS.

It would be arrogant to think that the NHS is solely a creature of government. Untold millions of hours are given by carers who put in so much more than they take out. Millions of hours are given by volunteers—directly, or indirectly via charities—for the nation’s health. Most doctors, nurses and people who work in the NHS are generous with their time and want their commitment encouraged. They understand,

They are givers and reluctant takers. Most want the failures out and the NHS to be the best.

The British have an inherent distrust of constitutions. Most recently, regarding the EU, we fought against a constitution. The Americans are rightly inspired by theirs, but the NHS constitution rates alongside the wishes of a seven year-old in Father Christmas’s grotto. It disgraces the word “constitution”. It has no grip, ambition to be edgy or 21st-century determination; it has nothing of distinction. Instead, it strives for somewhere just below average. Neither staff nor people should accept it. We deserve something better—much better.

1.53 pm

Lord Macdonald of Tradeston: My Lords, I welcome the opportunity to take part in this debate on the humble Address. I wish to draw your attention to two matters; one concerning education, the other cultural policy. I start by congratulating the Department for Innovation, Universities and Skills on the priority it is

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giving to skills and training and to increasing the number of apprenticeships available in these increasingly difficult times. I welcome the commitment in the Queen’s Speech to bring forward a Bill to reform education, training and apprenticeships. I also note the intention to continue to work closely with the devolved Administrations in the interests of all the people of the United Kingdom. I welcome that, too, since my first concern is informed by my role as Chancellor of Glasgow Caledonian University in Scotland. Our modern university, founded on the old colleges of technology, domestic science and nursing in Glasgow has a strong social mission. Glasgow Caledonian still works closely with no fewer than 26 further education colleges and a quarter of our students come to us from further education. In fact, the most deprived areas of Scotland supply one third of all our students. In the communities where the number of young people going into higher education has always been low, we have an initiative under way which Ministers might find of interest. Through our Caledonian Club, we sign up and mentor children from an early age as potential future students. They and their families are offered easy access to a friendly campus and culture and the hope is that this early inclusion will encourage the assumption that university education is a natural conclusion to their schooling whatever their background.


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