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The whole pharmaceutical area, which is usually ignored by the Government, is now in a mess. The proportion of the NHS budget set aside for drugs is falling. The PPRS contract was broken. We have more counterfeit drugs in this country than we have had since the NHS was started. We have more and more online uncontrolled drugs. We have the National Health Service buying the cheapest it can possibly find, with little control over poor bioavailability. We have evidence of research going overseas. And there is now a real risk of shortages—I mean this seriously—because the blanket 5 per cent cut that the Government have demanded, allied to the fall in the price of sterling, has created an incentive to export medicines from this country.

I nearly forgot: mixed wards are back on the agenda. I have asked the Minister two Questions on that topic; both times he refuted the need for mixed wards to be removed, and now the Secretary of State announces, outside Parliament, that they are back on the agenda. They will be removed, he says. Perhaps in his wind-up the Minister will tell us what the new definition of “mixed wards” is.

Lastly, at the same time as the Bill is going through, health budgets are to be reorganised yet again. That means more delay and more upheaval.

I turn to Part 3 and the anti-smoking dimensions that allegedly come under public health. There is nothing on obesity, which affects some 60 per cent of our children, nor on alcohol abuse, which affects 10 per cent to 20 per cent of our children. The provision focuses solely on the 6 per cent of our children—which is still too many—who smoke. Against that background, it is surprising that you get bizarre occurrences such as that in the north-east, where there is a booklet now on how to use cannabis. It tells you about rolling cannabis and what the experiences of it are. On page 14 of this 20-page booklet, it finally mentions that cannabis is an illegal substance.

Why do I speak up as I do, as a non-smoker not owning any tobacco shares? Because tobacco, whether we like it or not, is a legitimate product. It is not the

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role of government in a democratic society to hound those who wish to enjoy tobacco and want to make a living selling it.

The issue is young people. The whole industry supports the reduction in the numbers of young people smoking. It is a product for adults and it may shorten people’s lives. But when one looks at the obituaries of those who went through the last war, they all seem to have been 90-plus. And if passive smoking were really as dangerous as it is described, most of us in this Chamber would have been long gone.

With 6 per cent of young people smoking—the figure is coming down and we congratulate everyone involved who provided education to make that happen—these proposals, if they were sensible, would be supported by all of us, I suspect. But they are not. The Minister mentions consultations. There are not as many as he suggests in terms of the proportion of people involved. Evidence from abroad is, sadly, distorted by the Government. The economic effect on small tobacconists’ shops is totally ignored. You can go into any small tobacconist’s shop, today or tomorrow, and you will see a huge sign saying that it is illegal to sell to under-18s—“No ID, no sale”. But we should remember that cigarettes make up 25 per cent of the turnover of a small tobacconist’s business.

What purpose is there in putting cigarettes under the counter, restricting consumer choice? You cannot even see the pack warnings if they are underneath the counter. The alterations will cost a couple of thousand, not the £500 that the Government indicate. Why do the Government not understand the real world? Putting those packs under the counter will simply result in a huge increase in illegal importation. Already 27 per cent of cigarettes are illegally imported, and it costs this country £3 billion to £4 billion in lost revenue. There is talk of blank packs, but the Government cannot infringe the intellectual property rights of legitimate products.

I shall be moving amendments in Committee, and I just hope that the Government will listen this time. My forecasts on the previous tobacco Bill were too modest. Those provisions have had a huge impact, not on a reduction in smoking but on a whole way of life with regard to the numbers of people employed and the enjoyment people have from a British pub. They have resulted in more smoking at home. Let us contrast that with what happens on the continent, where they have been a lot more sensible in allowing smoking rooms with air conditioning. Here, the existing legislation is not being enforced, with regard to proxy buying, for example, and support is not overwhelming for these proposals. The economic and social adverse effects are far greater than the tiny perceived gains.

3.57 pm

Baroness Tonge: My Lords, I have struggled for quite a while to find an opening line, which is always terribly important when you are speaking in this House. The best that I can come up with is that the Bill is paved with good intentions, as was the road to hell. The Bill is certainly full of good intentions, but I am not quite sure, because of its lack of detail and rather nebulous quality, just where it will lead us. I suspect that it will depend hugely on secondary legislation and

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regulations that will be published later. I must express my irritation and reservations on that count, because we have so little input into that part of the process.

Something is glaringly obvious in the constitution section. The Minister reminded me of it when he said that the future of the NHS depends on local involvement and engagement. Indeed it does, so why is there no mention of local authorities or local government, particularly social services provision, in the Bill? The constitution for the NHS is all very well, but I thought that we were heading towards joined-up care for patients. I thought that we wanted health and social care to be as one. Having a constitution just for the NHS, without any mention of what is probably for most people an even more important part of their care, is a very sad omission. I hope that we can address that during the Bill’s passage through this House.

I am also concerned about legality. The rather beautiful Handbook to the NHS Constitution says in its overview—it does not have a page number—that this,

Why then are the Government not afraid of legal action if certain rights are not fulfilled? For example, page 38 of the handbook talks about the right to be treated with dignity and respect, but I refer to the remarks of the noble Lord, Lord Naseby, about mixed-sex wards. If I go into hospital and find myself surrounded by male patients all behaving badly, as men always do, is that not abuse of my dignity and respect and could I not sue the health service for not having regard to it? I probably could and so I am quite worried. That is just one example, but the same probably applies to access to records and to the safety of our records. I have never understood why patients cannot hold their own records. Whether the health service has them or not, why cannot we be the owners of our own records? It is our body; they are our records. Why cannot we be responsible for them?

There is also the right to choose. I was extremely sad to see that, under the right to choose which service we would like, maternity services are not to be included. We have heard so much in recent years about the right to choose birth at home, birth on birthing stools, birth in water, birth in the air, birth wherever you can think of it; we have this right to choose how we wish to give birth to our babies, but apparently it is not to be included in the rights.

Another point on the constitution is that there is a missed opportunity under the obligations section. I have always felt that somehow in this country the NHS has allowed people to hand over their bodies and their health to the health service; it is no longer their responsibility because, whatever they do, the NHS will put it right. We could have had a stronger feel to the obligations. The handbook talks about taking responsibility for,

Yes, but perhaps there should also be warnings, not that the NHS will not treat you but that your treatment in the NHS may be delayed if you are too fat, if you

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are a heavy smoker or if you drink too much and have a hobnail liver. These things could have been pointed out under obligations.

Vaccination of children is great hobbyhorse of mine. In many countries, children are not allowed to go to state schools unless they have been vaccinated. I do not see why that could not have been in the section about patient obligations. We are losing our herd immunity in this country. That is very dangerous and very worrying and we should do something about it.

The idea behind quality accounts is wonderful. I know that in many trusts clinical teams already look at their work, evaluate their work and are prepared to report on the outcomes of their work. However, we must be distinct about this. I am not clear whether the clinical teams will produce the quality accounts, whether the trusts will publish them or whether the primary care trust as commissioners will publish them on what has been going on in its area. The handbook says that these accounts will be on display. Will we have a little display chart in every ambulance and every clinic saying, “Breast cancer for this team is nil per cent survival”? Of course, that is totally impossible, but it is a bit scary if we are going to have these things on display without any explanation for the patient.

I am worried that these accounts will be used as league tables or ultimately as targets and that people will try to choose because of the results. What about value added? We do that in school league tables. What about the clinical teams that operate on less healthy patients because they feel that they must, compared with the clinical teams that may choose the patients who will give them the best outcome? I am concerned about that.

I am also concerned that a new management line will be set up. Having worked in the health service for more than 30 years, I can see a director of quality looming on the horizon, with sub-directors, managers, managers’ PAs, teams and ladies with clipboards—in the last trust in which I worked, they were referred to as the “country casuals” and went round assessing, evaluating and counting; they were not very popular. It would be a waste of health service money if we were to set up another management line within each trust.

There is so little detail in the section on personal budgets that I can hardly comment. Will patients be able to top up? Will there be a list of approved services where they can purchase their care? I presume that we will have to await regulations for the detail, but where is the evaluation of the direct payments that have been made in social care in recent years? Who will evaluate any pilots? What say will this House and the other place have on the regulations on personal budgets, which are terribly important, as they represent a drift towards a totally new system of delivering healthcare in this country? It is important to do it slowly and carefully to see where we are going.

What a wonderful idea the innovation prizes are. I conjured up last night an image of a young Mr Darzi on the podium receiving his innovation prize, weeping with joy and lost for words. However, there is no detail. We must be very careful that the prizes go to the right people. I shall not enlarge on that, but we must be very careful.

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Last but not, I suspect, least in this debate is the contentious issue of tobacco. To declare an interest, I regard myself as a smoker. I smoked; I have not smoked for decades; but I know that if I had a cigarette, I would become a smoker again. Therefore, I welcome any attempt to prevent me from seeing the things, hearing about them, being tempted by them or being put in a place where others are smoking and I might feel the urge again. I welcome any initiative. I declare that interest because it is very important.

I regret that we do not have any comprehensive strategy for reducing the damage to heath caused by smoking. It seems that we have just put a few measures on advertising and display in a Bill. I have certainly received more briefings on this issue than on anything else in the Bill. It raises huge passions, as we have already seen. It is a missed opportunity.

My party and I support most of the measures in the Bill. The proposal on vending machines is pointless. I can well remember as a student trying to find late at night the vending machine that still had some Embassy tipped in it. They were the most revolting things, but if you are addicted to smoking, you will smoke anything in the end. Vending machines surely have to go. They should not be anywhere. I am a little concerned about the effect on small businesses if they are not allowed to display cigarettes. I agree that there must not be advertising displays, but if there were no cigarettes on display, would it not lead to a culture sous table, with one getting one’s cigarettes when the man has his back turned or when the policeman has gone out of the shop? I do not like the feel of that. It is not an adult way of dealing with the issue. However, I am sure that we shall spend a lot of time in Committee debating the purchase of tobacco.

To end on a contentious note, the missed opportunity here is in how we treat all drugs. Tobacco and alcohol are far more damaging than, for instance, cannabis, which has just been moved into class B. I cannot understand the thinking in this country—and the West generally—on drugs and how we should use and control them. It is a missed opportunity not to set up a royal commission on all drugs, including alcohol, tobacco and all currently illegal drugs, so that we can assess the harm that they do to individuals, the cost to the health service, the damage to society and, in the case of illegal drugs, the damage worldwide to other countries’ economies and crime rates.

This is an interesting Bill. The more one looks at it, the more interesting it gets. I am sure that it will get more interesting in Committee and I look forward to tonight’s debate.

4.11 pm

Baroness Emerton: My Lords, it gives me great pleasure to take part in the Second Reading of the Health Bill. Last year I had the pleasure of taking part in several of the working parties. I realise how much work has gone into the Bill and offer my congratulations to the Minister for the way that he has led this work and got us to the point where we have enabling legislation before us. At the same time, there will be areas, as has already been pointed out, that will be discussed fully

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and taken into account. I speak as a retired nurse and a former chairman of an NHS trust. Noble Lords will be familiar with my saying on every occasion that I rise to my feet that I am passionate about improving the delivery of care and reaching high-quality care, summed up in the review as an improved clinical outcome, improved safety for a patient and an improved patient experience. The Health Bill encapsulates the principles by which this can be achieved.

As the Minister said, there is evidence of excellent practice in the NHS, but I regret that there are still areas where poor practice is in evidence. It is essential that these areas are eradicated so that the public can feel assured that not only will clinical outcomes and safety be of the highest standard but patients will experience the highest quality of care and compassion at the most vulnerable times in their lives. We may feel that all is well with clinical outcomes and safety, but we know from various reports that all is not well in some circumstances. I was amazed in the last few weeks, when listening to the radio and reading the newspaper, by an edict about checking theatre instruments and swabs before completing an operation. I could name many former theatre superintendents who would turn in their graves if they had witnessed this edict. It is as though it were necessary to remind everyone in the operating theatre to check the number of instruments and swabs. This principle has been the bedrock of working in theatres. To have to be reminded of this again is surely to go full circle.

There is also the issue of trying to reintroduce protected meal times, when the ward is closed while the patients are prepared for their meal, supervised, assisted and given supplements if necessary. This is followed by a rest period, leading to good clinical outcomes and safety in preparation and serving, thus preventing infection and improving patients’ experience as they enjoy their meal.

We live in a world of constant change, and one can hear the cynics saying that this is yet more legislation that will cause further changes for an already overstretched staff. However, there are always patients or clients who require treatment and care, which need constant review and vigilance to ensure that appropriate high-quality care is delivered with compassion.

I support the principles of the introduction of the NHS Constitution, which sets out the rights and pledges and responsibilities of patients, members of the public and staff by law. However, there is a question over how effective this will be with just the phrase “duty to have regard to”. The Royal College of Nursing also supports the NHS Constitution concept but questions the fact that there is no statutory definition of duty to have regard to and no sanctions where there is no enforcement. I support the Royal College's view; all healthcare professionals are subject to a code of conduct set by the regulator, with sanctions. Would the Minister consider this point? I know that Her Majesty's Government do not wish to be prescriptive in legislation, but without such a definition the constitution may not be effective in its intent.

My second point relates to the bodies listed as having a duty to have regard to the constitution under Clause 2(2). I note there is no mention of

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education and training institutions. While I expect that subsection (3) covers these, I stress the importance of listing education and training institutions. The NHS Constitution is a foundation building block, and it is necessary that everyone is aware of it, especially when they begin as a student and all through their professional career development. I fervently believe in the correlation of theory to practice; there have been many instances in which a wide gap has emerged between the educational establishment and the practice area. I know that the Minister took account of this in his review and work is continuing on implementing changes, but inclusion of education and training institutions in subsection (2) would underline the importance of the part they play in ensuring that the NHS Constitution is understood and complied with.

Clause 3 relates to the review and revision of the NHS Constitution. Could representatives of the staff organisations and unions be included in the list of consultees? I am saddened that throughout the Bill there is an omission of the role of informal carers, of whom there are 5 to 6 million in the country. I am engaged as a formal carer at the moment. They play an important part and need mentioning.

The introduction of quality audits is a very welcome step forward. Much work has progressed in the past year to define methods of measurement, and their inclusion in this legislation emphasises the importance to everyone of measuring and recording delivery of care. I began this afternoon by emphasising my passion for improving the quality of care, and quality audits certainly represent a major step forward. However, while these audits go a long way to focusing attention on the quality of care, it could easily become a tick-box process without addressing the fundamental issue of the care and compassion required for patients. This is not easily measured and, therefore, not recorded, but it is very much part of the patient experience. It is fundamentally a matter of attitude and having respect for patients’ dignity and their often hidden anxieties at a most vulnerable time in their and their families’ lives. Addressing this issue is fundamental to high-quality care and requires sufficient resources in workforce supply, allowing time not only for tick-box recording but also for the compassion and support required. This is not easy to put into legislation but requires a culture change from the trust board members and the authority down to the front line of delivery of care, to ensure that there is a full understanding of the components of high-quality care. When good governance is in place, it usually indicates a high quality of care and great patient satisfaction. I hope that in some way this culture change can be achieved, in the interest of making quality audits more than a tick-box exercise.

I trust that the Minister will view these recommendations as a constructive and helpful way to carry out further consideration. I look forward to taking part in further stages of the Bill.

4.19 pm

Baroness Wall of New Barnet: My Lords, I must admit that I was tempted to set aside my speech after listening to the noble Baroness, Lady Tonge, and get into a dialogue with her about what, from my experience

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as chair of Barnet and Chase Farm Hospitals NHS Trust, I think really happens out there. However, I have prepared for this debate and worked very hard with people inside my own trust to make sure that I get the important points over. More importantly, my noble friend Lord Darzi is well equipped to respond to the points made.

In my NHS trust, we have already been looking at the quality agenda under the title Getting to grips with the 2009-10 Quality Agenda. Before I move on to what that looks like, I want to congratulate my noble friend on his first piece of legislation going through this House. I welcome the opportunity to contribute to the debate and to hear his thinking, particularly about Chapter 2 of Part 1, which deals with quality accounts, to which I will address myself today.

Last year, 2008, was a year of ideas, concepts, initiatives and proposals, particularly in London and specifically in the quality agenda. The challenge for provider trusts, PCTs and the NHS is to agree how we may turn these often embryonic concepts into an agreed framework to direct, monitor and achieve our shared objectives. The NHS Next Stage Review, High Quality Care For All, by my noble friend Lord Darzi, published in June 2008, contained a number of new concepts and definitions that set the scene for the 2009-10 quality agenda. The report gave a commitment to place a legal requirement on providers to publish information on the quality of their health services in a quality account. In doing so, they must ensure accountability to users of our services and support clinicians, commissioners and patients in driving forward improvements. We can only do that if everyone supports us. Quality accounts meet the clear and consistent message that we hear more and more often: people want to have more control over their health. Having information means being in control.

Quality has been defined in three components: patient safety, effectiveness of care and patient experience. Therefore, it may reasonably be proposed that the quality account should reflect those three components. Such a consistency of structure would contribute to another proposal that there should be a clear commitment to bring clarity to quality, a phrase often used in my own trust. Specifically, measured and published quality data should be accessible to a wider audience—to the stakeholders, including, most significantly, patients, potential patients and their carers.

In the Department of Health publication High Quality Care for All—Measuring for Quality Improvement: the Approach, principles for change are given to guide the implementation of the new quality initiatives by the Department of Health, SHAs, PCTs and trusts such as mine. Those quality initiatives are co-production, subsidiarity, clinical ownership and leadership and system alignment. While each of those principles is most apposite for the introduction of quality accounts, I wish to draw special attention to system alignment.

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