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Lord Malloch-Brown: My Lords, one of the conditions that Mr Tsvangirai has pressed for is that he has control of the economic team that he was assured under the agreement, and that therefore he has the right to select a central bank governor. It will be an early test of the credibility of the power-sharing that he be allowed to do so. I agree with the noble Lord that it is utterly implausible that we could put British taxpayers’ money into the hands of Gideon Gono.

Lord Avebury: My Lords, it was depressing that the Minister had to explain yet again to the participants at the AU meeting the actual meaning of sanctions. Did the participants understand that Mugabe himself is the main cause of the bankruptcy and universal starvation of the people of Zimbabwe? In any AU fallback plan that may become necessary as a result of the failure of the SADC initiative, will the first priority be to remove Mr Mugabe from office?

Lord Malloch-Brown: My Lords, when you are trying to make the current plan work, you do not want to undermine it by immediately discussing hypothetical alternatives should it fail. Again, our emphasis should be on making this work. The AU summiteers called for sanctions to be lifted because they believe that they interfere with humanitarian support to Zimbabwe. As the noble Lord observes, I explained to them again that the sanctions are targeted only at individuals and the corporate entities that are controlled by those individuals; they are not aimed against the people of Zimbabwe. Indeed, Britain is the second most generous humanitarian donor to that country, and I suspect that we will be putting in even more resources for humanitarian assistance by routes that we can control, due to the growing crisis.

The Earl of Sandwich: My Lords, there have been appalling assaults on Zimbabwean parliamentarians in the past. Does the Minister have any confidence that they will not continue?

Lord Malloch-Brown: My Lords, I have publicly said, as have my colleagues, that the release of political prisoners and the end of abductions and of political violence are the first test of the credibility of this agreement.

Lord Elton: My Lords, the Minister is clearly right to say that a humanitarian catastrophe on this scale means that political principle must be put second, but does he see a danger in the significant survival of Mugabe, albeit in a reduced state, setting a precedent for other outgoing, or should-be outgoing, new democratic Governments to reduce their own countries to penury to secure their own survival?

Lord Malloch-Brown: My Lords, we need to hope that Mr Mugabe is sui generis. Certainly, the mood of the summit was that there was no great enthusiasm for the agreement, just an acceptance that a pragmatic solution needed to be found in the interests of the people of the country. I very much hope that it will not lead to the precedent of the kind to which the noble Lord refers.

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The Duke of Montrose: My Lords, no doubt the Minister is aware that, under the Lancaster House agreement, we entered into a commitment to transfer funds to Zimbabwe in return for certain actions that we had to cut short because they were not being properly fulfilled. Is there any way in which the money that we now transfer to Zimbabwe could be seen to be completing our undertakings under the Lancaster House agreement so that that is never used against us?

Lord Malloch-Brown: My Lords, we feel that we met our commitments under the Lancaster House agreement. It is correct that some resources for land reform were not transferred because the Government of Zimbabwe at that time failed to give priority to land reform or to utilise the resources available to them. They are a Johnny-come-lately on this issue. It is important that the economic assistance that we very much hope we will be able to provide in the future to a new and effective Government in Zimbabwe will be less about paying an unmet debt under the Lancaster House agreement—a debt that we really do not accept there is—and more a demonstration of commitment from the people of Britain to the people of Zimbabwe to restore that beautiful country to the wealth and democratic opportunity that it has lost.

Sports Grounds Safety Authority Bill [HL]

First Reading

3.29 pm

A Bill to confer further powers on the Football Licensing Authority and to amend its name; and for connected purposes.

The Bill was introduced by Lord Faulkner of Worcester, read a first time and ordered to be printed.

Health Bill [HL]

Copy of Bill
Explanatory Notes

Second Reading

3.30 pm

Moved By Lord Darzi of Denham

The Parliamentary Under-Secretary of State, Department of Health (Lord Darzi of Denham): My Lords, the Bill contains important measures to increase the quality of NHS care, to raise the performance of NHS services and to improve public health. I welcome the opportunity to set out the purpose of the Bill and the policies behind it. I also look forward to the contributions of noble Lords and I am sure we will have a lively and informed debate. I know that the Bill will benefit from the careful and expert scrutiny it will be given in this House.

The key purpose of the Bill is to underpin the commitments set out in High Quality Care for All. My aim in that report was to set out a vision for an NHS sustainable in the 21st century—an NHS that gives

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people more information and choice, works effectively in partnership and has quality of care at its heart. I am proud that the next-stage review captured the views of around 60,000 people. This breadth of interest is a testament to our collective sense of pride in the National Health Service. The Bill will implement those measures in my report that require legislation. Just as importantly, it will help to embed the overarching theme of my review: that our approach to healthcare should be based on a drive to improve quality. From measures to improve performance and accountability to those that will improve quality of life and the personalisation of care, I believe that the Bill will help to foster a culture of quality in our health service for patients, the public and our staff, regardless of background and circumstance.

To set the context, it is worth reflecting briefly on the purpose of my report. There is a role for the Government in defining and communicating a vision of quality for the NHS, in setting priorities and ensuring clear rules to tackle unacceptable performance. However, it is only by freeing up clinicians, managers and service users that we can really drive up the quality of care. I intended my report to be an enabling report, setting out the national policies that will empower clinicians, patients and the public to drive the changes that are needed locally. In the same way, I believe that this will be an enabling Bill, one that empowers clinicians, patients and the public to improve health—a Bill built on strong local involvement and engagement.

I turn now to the specific provisions in the Bill. Part 1 sets out the framework for the new NHS Constitution. As noble Lords will be aware, the final constitution was published on 21st January, along with the handbook and other accompanying documents. It is this constitution to which the clauses refer. The Bill creates a new duty on all NHS bodies in England, as well as Monitor and the Care Quality Commission, to have regard to the constitution in their decisions and actions. The same duty applies to primary care services and providers of NHS services from other sectors. These bodies will all need to be able to demonstrate that they have given proper consideration to the constitution in their decisions and have very good reasons for any departure from it. The Bill also creates a new duty on the Secretary of State to review and republish the constitution every 10 years, to review the handbook to the constitution at least every three years, and to report on the impact of the constitution on patients, the public and staff.

The Government carefully considered a number of approaches to the constitution. Options ranged from setting out detailed provisions in primary legislation to no constitution at all. The risk of the former is a rigid legislative framework in which complex decisions about NHS care become the prerogative of the courts. The risk of the latter is a missed opportunity. The approach taken by the Government will empower patients, the public and staff without creating a “lawyers’ charter”. The constitution is separate from the Bill and sets out for the first time and in one place the rights to which we are entitled and the pledges which the NHS commits to deliver. It sets out the responsibilities which patients, the public and staff owe to each other to ensure the NHS operates fairly and effectively.

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The constitution also creates three new rights: to make choices about NHS care and the information to support those choices, to recommend vaccinations, and to expect local decisions on the funding of drugs and treatments to be made rationally following proper consideration of the evidence. I have been surprised at how much I have learnt from seeing these set out clearly in a single document. In an NHS where care is increasingly personalised, where the pace of change is rapid and where we draw on the expertise of organisations from small charities to large foundation trusts, I believe that there is a value in articulating these commitments in one place in securing the NHS for our future.

Clear, transparent information on quality has the potential to drive improvement. It enables clinical teams and managers to understand where and how to change what they do, empowers patients to make informed choices about their care, and increases accountability. Chapter 2 of Part 1 will place a new duty on all providers of NHS services to produce quality accounts, starting from April 2010. Building on close work with the NHS, quality accounts will include both nationally comparable and local data. They will provide information on safety, experience and outcomes in relation to clinical services, making this available to all, to inform how we develop our services to the highest standard. This is a tremendous opportunity to generate a cultural change in how the NHS understands and drives the quality of services to make a real difference to patient care.

The NHS of the 21st century will be one that puts people and their needs at the centre. My review showed clearly the importance that we place on care that is personal to us, and our desire to have greater control and choice over the services that we use. Drawing on our experience in social care, Chapter 3 of Part 1 legislates to enable the making of direct payments for health services. These are one means of offering people a personal health budget. We are working with the NHS, local authorities and other partners to design a pilot programme to test different approaches to personal health budgets. We want to understand the circumstances and conditions for which they are most effective and to ensure that we design appropriate safeguards.

I believe that the potential for personal health budgets, including direct payments, is significant. The opportunities they present are exciting. For instance, they could be a powerful tool to address inequalities in the health service. However, I also recognise that this is new territory. We need to weigh carefully the benefits of personalised health services against ensuring that the comprehensive NHS we all value so highly is not undermined. Regulations under the Bill will limit the use of direct payments to pilot schemes initially so that we can test our approach.

Chapter 4 of Part 1 gives the Secretary of State a power to make payments as prizes to promote innovation in relation to health services. I know from speaking to stakeholders that the NHS is recognised as a leader in the development of innovative techniques and technologies, but the adoption and spread of these new ideas is variable. Innovation prizes will

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reward those who have excelled and encourage others to do likewise, helping to foster a culture of innovation in the NHS.

Part 2 focuses on policies to improve the performance and accountability of NHS services. The majority of hospitals and trusts are performing well, providing high-quality services to patients and managing resources effectively. Where they are not, a series of local interventions is available to improve performance. However, in the rare cases where a challenged trust fails to turn itself around—despite commissioners, strategic health authorities and, in the case of foundation trusts, Monitor intervening—it is important to have clear processes to resolve that failure. The regime for unsustainable NHS providers, as set out in Chapter 1 of Part 2, is, in practice, the very last step for a provider which has been subject to previous actions aimed at recovery.

As a practising surgeon, I am aware that the reasons why providers or services may fail are complex. However, I am also acutely conscious that such failure has an unacceptable impact on the quality of care provided. In the rare circumstances where all else has failed, we need to ensure that there is a clear and transparent process to take these difficult decisions. The Bill provides for the appointment of a trust special administrator to take control of the provider, consult on the next steps and make recommendations to the Secretary of State on its future. These measures will protect patients and staff, and underpin the NHS performance framework and the NHS foundation trust regime.

Chapter 2 of Part 2 extends to strategic health authorities and other NHS and relevant health bodies powers for the Secretary of State to suspend public appointees. Currently, if a concern arises, the options are to allow an individual to continue in their role, to seek a resignation or to terminate the appointment. The new powers will allow time for a considered investigation, strengthening the way in which the healthcare system holds its leaders to account.

A personalised NHS goes hand in hand with a focus on the prevention of ill health, with individuals supported in making healthy choices. Part 3 of the Bill sets out measures to take forward the Government’s aim to reduce the incidence of illness and death caused by tobacco, and in particular to reduce the number of children and young people who take up smoking. As a result of government action, we now have the lowest smoking rates in England on record—one of our proudest achievements. However, smoking remains the main cause of preventable morbidity and premature death in this country, accounting for 87,000 deaths a year in England alone. It is the primary reason for the gap in healthy life expectancy between rich and poor.

The Bill makes provision for removing displays of tobacco products. It also provides powers for the Secretary of State to control the sale of tobacco products from vending machines, so that only people aged 18 or over can use them; or, ultimately, to prohibit such machines outright. I am aware that some noble Lords have expressed concerns about whether these measures are proportionate in current circumstances, and about the impact that they might have on small retailers. The Government also recognise that, despite

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the harm to health, some adults will choose to smoke. However, we have an important responsibility to enable and empower young people to make informed and healthy choices. The Government have consulted extensively on these proposals, and rigorously reviewed the evidence base.

Implementation of these proposals will be pragmatic and subject to further consultation. Measures on display will not come into force until 2011 for larger shops and 2013 for smaller businesses. This will allow smaller retailers time to adjust and refit their shops when old gantries would anyway need to be replaced. Restrictions on vending machines will come into force in 2011, and their effectiveness in reducing underage sales will be reviewed over at least two years to see whether a full ban would be necessary and proportionate. The proposals in the Health Bill form part of the Government’s new tobacco control strategy, which will be forthcoming this year. I know that there are a range of views, which I am sure we will debate fully.

Part 3 contains a number of other important measures, including new provisions to require PCTs to undertake assessments of pharmaceutical needs locally. We will reform the current control of entry system, replacing that test with new powers for primary care trusts to commission providers based on those local needs assessments. Along with new powers for PCTs to address poor performance and to provide local pharmaceutical services, the measures in the Bill will encourage pharmacies to strive consistently to provide the highest quality services. They will also enable PCTs to shape primary care services as a whole around the needs of their populations. Not only will these measures ensure community pharmacy services are brought within our world class commissioning programme, they will also help to secure pharmacy's place in the programme that I set out in High Quality Care for All.

Part 3 also extends the remit of local government ombudsmen to deal with complaints from those users of adult social care who arrange to pay for their own services. This is in direct response to the views of this House during the passage of the Health and Social Care Act 2008. I am delighted that we have been able to bring forward these measures at the first legislative opportunity.

Finally, Part 3 corrects a gap in the current legislation to enable Her Majesty’s Revenue and Customs to continue to share anonymised and aggregated information on GP and dentist pay within the UK health departments. This information is fundamental to the pay system for both professions and our proposal is to have the support of the relevant professional bodies.

The Health Bill includes a number of important measures to embed quality at the heart of the health service. It empowers clinical teams and managers to drive improvement in NHS care; it enables us to take more control over our own health and well-being; and it introduces measures to improve the performance and accountability of key NHS services. I look forward to further discussions as the Bill goes through the House, and to an informed, interesting and, above all, high-quality debate. I commend the Bill to the House.

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3.46 pm

Lord Naseby: My Lords, I believe in the National Health Service. I married into it, my family have worked in it, and I use it regularly. I also recognise the aspirations that the Minister voiced when he introduced the Bill and all the work that he has put in since he took up his current position. Nevertheless, since the Bill’s primary purpose—it is certainly the primary purpose of Part 1—and driving force is to create a new constitution, attached to which are “quality accounts” which by any yardstick are a huge new bureaucratic dimension, it is highly questionable whether it will be of any benefit to patients. I agree that Part 2 contains some useful provisions but question why those cannot be dealt with by regulation. Part 3, which has been flagged up as involving public health, seems to be driving only on the smoking front, ignoring totally the impact of obesity and alcohol on young people.

I shall deal first with the constitution. Ten years ago, the Government argued that they were ahead of other countries,

to many of the problems facing the health service, not least, at that time, MRSA. However, the Government were more interested in strategies and targets than results. The constitution attempts to set out the rights and responsibilities of our healthcare system, which has, as some would say, muddled through for the past 60 years. But there is a clear implied warning in the constitution: that those in our society who adhere to unhealthy habits, be it smoking, alcohol or obesity, may be refused NHS treatment. I think that that is morally outrageous and legally dubious, especially as it is all retrospective. It could never happen in the normal commercial world, where contracts are legally binding.

What is the reality of this so-called constitution? It is far from short: at 48 pages, it is longer than the constitution of the United States. It does not offer the certainties that an average person would expect. It is really just declaratory and not legally binding. What hope does it offer practically? Let us take the example of MRSA, on which we have the worst record in Europe. We have a legally binding hygiene code and advice and guidance from the Chief Medical Officer but that is being ignored and flouted. How will the constitution solve that or other problems?

The Minister mentioned the patient’s voice, but what do we find? Even the new Care Quality Commission has already had its wings clipped. There is great play about quality accounts—a meaningless concept which does not exist in normal commercial life. In any case we already have a whole raft of performance reviews, assessments and other forms of checking on performance. There is a terrible danger that it will be no more than box-ticking.

The basic structure is not stable even now. We have gone almost full circle, back to the structure as it was in 1997, when we had eight regional health authorities. The number of health authorities was increased to 28 under this Government, but now we are back to 10. In 1997 we had GP fund-holding, but then non-market-oriented primary care groups took over. We then had partially market-oriented primary care trusts. Now,

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we have practice-based commissioning—which sounds very similar to GP fund-holding. All that is against the background of the four systems that we now have in England, Wales Scotland, and Northern Ireland. I hope the Minister will give us a definition of what “Britain” is in relation to those four areas.

It is sad that the Swedes, in recent research done by Health Consumer Powerhouse, have found that our National Health Service rates 17th in the whole of Europe. We face no real increase in expenditure and capital projects being cut back. We also have the handicap of NICE. It is too slow, too cumbersome and not transparent. It duplicates the work of Scotland and uses the wrong models. It means that patients in our NHS get new products more slowly than anywhere else in Europe.

It is true that there are excellent reports as well, such as that of Mike Richards. That is good—but they are still not really acted on. I am sorry to complain to the Minister, but I wrote to him on 21 November with a particular case arising from Mike Richards, and I have not even had an acknowledgment. I will put that on the board again for the Minister.

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