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On that point, we have to recognise that dignity is enormously important, particularly for elderly people, who have so much dignity stripped from them when they are in hospital. It is still not fully recognised within our hospitals how many elderly people detest being called by their Christian names by people who are young enough to be their grandsons and granddaughters. Those people may be important medical doctors or consultants, but this is not something that the older generation can accept easily. I should have thought that that would be an easy way to permit a patient to have dignity. I beg the Minister to take that on board, because it means a lot to elderly people who are in hospital.

To be told that we are no longer able to contemplate segregated wards, as we were quite recently, worries me a lot. Does that part of the constitution mean that we will be able to segregate, as we have been promised so many times? While we still have mixed wards, patients will have neither privacy nor dignity.

Finally, will the Minister say what Clause 17 on page 22 means? Am I correct in deducing that it relates to the suspension not of consultants and hospital doctors but to non-medics only? I have worried about suspension of hospital doctors for many years. I have a thick file of doctors who have been suspended unfairly. I once introduced a Bill about that. I take it that Clause 17 refers only to non-medics. Is the Minister confident that the present system of dealing with the suspension of hospital doctors is fair and acceptable to the medical groupings, given that the situation has been so sad and bad in the past?

6.36 pm

Baroness Golding: My Lords, because of my great age, I first came into the health service a long time ago, when it first started. I worked in many hospitals and clinics. I even gave up time to sit on a district health authority in order to do something about an aspect of the hospital that I was not happy with. I appreciate this large step forward in the history of the health service and congratulate my noble friend Lord Darzi on the very hard work that he has put into the proposals. I shall confine my remarks to the provisions on the prohibition of tobacco displays. In doing so, I declare an unsalaried interest as chairman of CitizenCard, a not-for-profit, proof-of-age card scheme. It is one of many.



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CitizenCard was founded in my former constituency of Newcastle-under-Lyme in the late 1990s following the Government’s decision to crack down on sales to children of alcohol and tobacco as well as gambling and other restricted products. A coalition of retailers and manufacturers launched this leading proof-of-age scheme with a generous endowment from British American Tobacco and now with funding from Camelot, Ladbrokes, Somerfield, the Association of Convenience Stores and the National Federation of Retail Newsagents—a good collection of hard-working and well-thought-of people. I am pleased to say that we expect soon to have issued more than 2 million cards, a large number of which will have been issued free of charge to young people through local authorities and schools. It is proof, if proof is needed, that traders and young people understand the age restriction laws that are in place and the need for an acceptable proof-of-age system to protect children and retailers alike.

Because of my chairmanship of the committee, I am aware more than most of the cost incurred and efforts made by the industry and retailers to keep within the law. Indeed, we spend many hours and much money spreading the word. We obey what the Government have told us to do. However, I know that the Bill will have a major impact on our courts. Retailers, such as corner shops which are already struggling to survive, will find it very hard to implement the provisions. The Government’s proposal to remove tobacco products from display—by covering the existing display gantry with a Venetian blind or curtain which will be raised or opened when a customer is being served, in an effort to hide these products from young people—is complete and utter nonsense. Such actions are bound to give more prominence to the selling of tobacco—fascinating to children as forbidden fruit—and cause stress and irritation to shopkeepers and customers alike, resulting in further encouragement of the illicit trade in tobacco, more small shops closing, and more jobs lost—a lot of jobs lost.

Do we never think of jobs when we think of health—other than jobs in the health service? When people lose their jobs, as we are discovering now, the stress puts them back into the health service; it does not take them out, as some of these proposals seem to suggest. Is that what we want? Do we want to bully adults into feeling guilty, giving as our excuse the protection of children? Or is it just an excuse to stop adults smoking, which, after all, is legal?

Why does the Bill not make it illegal for adults to buy tobacco for use by children? This would be really useful, and would protect the shopkeeper and the child. Why is it not in the Bill? Everybody would back it; that I do know. What will the Government do about the large black market in tobacco? That is where the children are getting their tobacco. They may tell you differently, but I have spent a lot of time in pubs, talking to young people every weekend in my former constituency, and I have heard things that the Bill does not take into account at all. There are things that can be done. They will be supported by the trade and by shops. They will be supported by tobacco manufacturers. However, putting even more pressure on shopkeepers is not one of them.



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I have never smoked. However, when I see what we have done to people, driving them out onto the streets to indulge in something that is legal, and from which my Government obtain a large amount of money, I am sorely tempted to join them, to show solidarity by doing something that I never thought I would want to do, namely take up smoking. You can pass as many laws as you like, but you have to take people with you. To shove things in their faces and down their throats, saying, “You cannot have this, you cannot have that”, is not the way forward. Do it gently. We have made progress in the health service over the years, gently, by introducing things step by step. Take it easy; people will come with you. Do not try to force them. Remember what happened with prohibition in America.

6.42 pm

Baroness Wilkins: My Lords, today the quality of contribution from what has been called the “mobile Bench” has reached new heights with the speech of the noble Baroness, Lady Campbell, which I regret that I have no hope of emulating.

The Minister and Government are to be warmly congratulated on their initiative in producing the first NHS Constitution. I welcome the single source of clear information about what citizens can expect from the NHS, and what the NHS should expect from its staff and from the people who use its services. The constitution has the potential to empower both patients and staff to drive improvements in the service. I look forward to it securing for the NHS an even firmer position as the UK's best loved public service, and one of the most significant achievements of any Government.

However, I support many organisations that have suggested that the constitution be given more backbone. Both RADAR and the National Council for Independent Living have argued for a more explicit statement in the constitution of Disability Discrimination Act rights, to ensure that the NHS is fully accessible to disabled people as equal citizens, with equal rights to use healthcare services. I welcome this proposal, which would send a clear signal to all healthcare providers that more of the same is not acceptable under the constitution.

Damning reports, such as Mencap’s Death by Indifference, have shown that people with learning difficulties and people with mental health problems have been denied equal access to healthcare. In its formal investigation into primary healthcare services, the Disability Rights Commission found that primary care trusts were failing to make “reasonable adjustments” to provide accessible services for disabled people, as required by the DDA. Reasonable adjustments include, for instance, the need for information to be made accessible. In 2004, the Guide Dogs for the Blind Association found that 95 per cent of visually impaired people never receive health advice, letters or prescriptions in the format that they need. The RNID has shown that one in four deaf or hard of hearing people has missed an NHS appointment because of poor communication. I ask the Minister to look again at the draft constitution and to make a clear statement of disabled people's rights under the DDA to ensure that all citizens have equal access to the NHS.



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I greatly welcome provisions in Chapter 3 to pilot direct payments in healthcare services. This is an immensely positive commitment from the Government. The National Centre for Independent Living has stated that direct payments,

in social care. There is no reason to suspect that the same cannot be achieved from the NHS—except that a much greater culture change will be required from the NHS than was needed from social care professions, because user independence is not one of its top values. Research on direct payment programmes in the social care sphere has identified ignorance and confusion among healthcare partners as factors impeding greater user independence. This challenge needs to be recognised and addressed from the outset if direct healthcare payments are to work effectively for service users.

The guidance for the pilot schemes makes it clear that direct payments will be given in accordance with a care plan only after an assessment of needs by the PCT, or by another organisation acting on its behalf. The problem is that PCTs have insufficient knowledge of specialist healthcare conditions. Does the Minister agree that it should be a requirement on PCTs to include specialist advice in creating care plans for people with specialist conditions and more complex cases? I declare an interest as someone who has been spinal cord injured for more than 40 years, with increasing pressure-sore problems. Two years ago, I had an inflamed bursa—where a pressure area tries to protect itself—that was misdiagnosed by my GP practice as an abscess. Fortunately, despite being urged by her colleagues to cut it out, which would have made my skin viability much worse, the GP decided to treat it conservatively, and I spent more than two months confined to bed on successive high doses of antibiotics before referring myself to my spinal unit, where it was immediately diagnosed correctly. I am now told that my PCT will be charged £500 for referring someone to the spinal unit, which will certainly deter it from doing so. Does the Minister agree that specialist input needs to be a requirement for developing a direct payment care plan if scarce NHS resources are not to be misused and wasted?

I welcome the provisions in the Bill to enable the involvement of voluntary sector organisations in providing assistance to people who will use direct payments in healthcare, and I declare an interest as an officer of HAFAD, my local user-led disability organisation, which provides direct payments support. The legal obligations on direct payment users to act as responsible employers mean that it is a false economy, and totally counterproductive, to expect people to manage them without adequate support. This is too often the case, and it is vital that access to support, advocacy and information be a requirement of the NHS pilots.

As the Bill progresses, I hope that the Government will clarify how the direct payment approaches in social care, welfare reform and now healthcare are being interconnected across departments, so that we do not just create new silos of funding and more bureaucracy and service duplication. Unified funding streams for public service support for disabled people will be one more step along the road to fulfilling the Government's aim of independent living for disabled

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people. A fully integrated system of individual budgets, underpinned by rights to choice and control spanning all public service support and specific enforceable entitlements, is the purpose of the Disabled Persons (Independent Living) Bill introduced by my noble friend Lord Ashley of Stoke, which will receive its Second Reading later this month. I hope the Government’s Health Bill and its provisions for rights, choice and control will succeed in taking one more step in its direction.

6.50 pm

The Earl of Liverpool: My Lords, I believe that there are some good aspirations and proposals in Parts 1 and 2 of the Bill to which I can give my cautious support. However, I have some concerns over quality accounts which, I believe, will involve the setting up of new management lines within each trust. I agree with other noble Lords that this could become just another box-filling exercise without any meaningful benefit. I agree with the noble Baroness, Lady Emerton, who was concerned that care and compassion does not appear to be included in the assessment exercise.

Before moving to Part 3, I should declare my interest as an occasional cigarette and cigar smoker and a member of the Lords and Commons Cigar and Pipe Smokers Club—unpaid. It may come, therefore, as no surprise when I say that Part 3 is the point at which I begin to despair. My noble friend Lady Knight made an excellent speech on this subject—indeed, it was a speech I wish I could have made—and I fear that there may be some repetition in what I say.

There comes a time when a line needs to be drawn in the sand beyond which the Government’s ever more encroaching nanny state should not be allowed to pass. That time is now. Of course we all know that smoking is not good for you and I agree that children under the age of 16 should not be encouraged to purchase tobacco products, but I am as certain as I can be that the proposals in the Bill are not the right way to achieve that. After all, have we not already opened children’s eyes far more to smoking by banning its use indoors in all public places? You now see far more adults smoking in the streets because of the ban—and where do children play? In the streets and in open spaces. Therefore to make it illegal to have so-called gantry displays of tobacco products in retail premises will have a negligible impact on children’s awareness of smoking.

What will this banning of displays do to help make us all good citizens? Absolutely nothing. It will simply encourage the trade in illegally imported products, as the noble Baroness, Lady Golding, said. This is already reducing the Government’s tax take by some £4 billion a year.

We should also consider the hard pressed businessmen who run corner shops and village shops. We already know that village pubs and post offices are under threat, with 34 pubs closing each week at the last count. Not only will the proposals in the Bill put further strain on these shopkeepers, who derive some 35 per cent of their turnover from the sale of tobacco products, but it will also put an even greater temptation in their way to sell illegally imported products on which they can achieve a far higher profit margin.



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There is also the question of health and safety at work. Shopkeepers will be forced to bury their heads under the counter or search behind some screen or Venetian blind, which they will have to open and shut like some Punch and Judy show, to obtain products which the purchaser quite legally wishes to buy. Not only will this undoubtedly lead to repetitive strain injuries and back problems, the burden of which will fall on the National Health Service, but it will also make these shopkeepers vulnerable targets to thieves and criminals, who will be tempted to shoplift or to have a go at the tills in shops. It will leave them much more vulnerable to this kind of attack and to pretend this is not the case is nonsense. Sadly, we all know that in a recession or depression the incidence of this kind of petty crime increases.

I hear siren voices on the government Front Bench saying that the Bill will not come into effect until, I think, 2013. Perhaps by then we shall be back in a benign period of economic growth, a hope devoutly to be wished. However, in reality, it does not matter when these regulations come into effect—the result will be the same.

I believe that the Government are guilty of schizophrenia on this issue. As has already been said, tobacco is a legal product. The Government receive around £10 billion per annum from the industry; it is a substantial contributor to the public coffers. Presumably the money is much needed in these straitened times when hundreds of billions of pounds are going out to shore up our financial institutions.

By enacting the legislation, the Government will guarantee for themselves reduced revenue and an increase in unlawful behaviour, be it through illegal imports or something worse. It will serve only to increase the interest of the young in tobacco products. Taking them off display and making shopkeepers furtively scrabble about under their counters will elevate cigarettes to a kind of banned substance and, as we all know, this will only increase certain people’s determination to get hold of some.

My advice to the Government is to remove Part 3 from the Bill. Sadly, I am sure that this will not happen, so I say to noble Lords of a like mind that we will have to gird ourselves up for the later stages of the Bill.

6.57 pm

Baroness Greengross: My Lords, I declare an interest as a member of the Equality and Human Rights Commission and a vice-president of Age Concern.

I share the widespread support for the NHS constitution. I believe that it provides the prospect of a quality standard that patients will be able to expect from the NHS and, most importantly, a degree of redress when that standard is not delivered. I have, however, chosen my words of welcome carefully and used the phrase “prospect” rather than “guarantee” of quality standard. I should like to draw the Minister’s attention to the many concerns shared by a number of organisations that what is proposed does not go far enough, particularly for older people, carers and those with multiple health problems.

The pledge to equal treatment for all patients is welcomed by older people, patients’ and carers’ groups

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and consumers generally. I echo the words of the noble Baroness, Lady Murphy, in welcoming the measures to improve in particular the situation of self-funders in purchasing care, and also the moving addresses by the noble Baronesses, Lady Campbell and Lady Wilkins, on direct payments. These provisions are overdue and necessary and I welcome them. However, I also echo the words of caution of the noble Baronesses, Lady Young and Lady Howarth, about direct payments, particularly when they are applied to vulnerable and frail people. We must be aware of the dangers of abuse, in particular financial abuse, by carers and relatives as well as by professionals. Unfortunately, that is not as rare as we would all wish.

For too long, older people, in particular, have suffered a great deal of discrimination in healthcare. I fear that the pledge in the Bill will become a meaningful reality only when it is taken together with provisions that I hope we shall see in the forthcoming Equality Bill, which will make such discrimination unlawful at last. It is wholly unacceptable in the 21st century for healthcare to be rationed or for access to services to be denied solely on age. Indeed, according to research carried out by Help the Aged, 77 per cent of members of the British Geriatrics Society would support the introduction of legislation against age discrimination in the NHS. If the professionals responsible for healthcare for older people believe that this longstanding sore in our healthcare policy is wrong then I suggest that we, as parliamentarians who have already agreed that discrimination is unacceptable in British society, have a duty to ensure that it is effectively addressed where it remains.

I hope that the newly announced dementia strategy, together with the Bill, will improve the situation of those suffering from that terrible disease. There are many examples that we can use as evidence of discrimination, when the disease is poorly diagnosed and treated and when the patient’s needs are often treated as social rather than making the NHS responsible for the services that are provided. If I fracture my hip, some of the pre-operative and post-operative treatment that I will need is social in character, but the NHS will take responsibility for providing it. In my view, that is discriminatory.

The principles in the constitution are a worthwhile attempt to crystallise overarching expectations of the NHS and NHS-funded providers. Those expectations must meet reality. I have already stressed the importance of a service for all based on clinical need and sound diagnosis and prognosis, irrespective of age. For older people, I would also quote two other aspects of NHS provision that are already problematic and must be addressed: foot care and dentistry. The former is a service that older people need more than the young, but its provision is patchy. Dentistry is an aspect of care that in recent years has proven difficult for the NHS to provide, not just for older people but for patients of all ages. I hope that the Government will be able to reassure me that what they are now proposing will indeed deliver the services needed by patients across the age range but particularly by older people, and that everyone will be made fully aware of their rights and of how to access effective redress if the medical care they need is not provided for them.



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I turn to quality accounts. In 2007 the Joint Committee on Human Rights, following its inquiry into the human rights of older people in healthcare, demanded nothing less than an entire change in culture to protect the human rights and dignity of older people in the NHS. The Bill could go some way to meeting those demands but only, as many noble Lords have mentioned, if “dignity” is included as a specific domain within quality accounts and if the needs of older people, rather than targets that fit into speciality or organisational boundaries, are at the heart of the reforms. The same principles apply to maternity care where quality of care, not necessarily waiting time or throughput, should be the focus of the service.

Lastly, I turn to the proposals for personal health budgets. There is widespread concern about aspects of those proposals, not least that there must be proper evaluation of the pilots before the concept is rolled out across the country. We must be sure that payments actually cover the costs of patients’ assessed needs and that the system will work for people who have multiple and complex needs. Many older people have a wide range of physical and mental health problems and they are worried that the proposed new scheme will not address all their needs. Carers are concerned that the proposals might add to the already significant burdens that they face, and people with a range of disabilities need to be reassured that their often individual requirements will be met. In all cases, once a thorough assessment has been made of a person’s needs, the funding of that assessment must be transportable if that person decides to move to a new area of the country, often to be with relatives in line with their human right to family life.

7.04 pm

Lord Stoddart of Swindon: My Lords, the National Health Service is a great service, but it is 60 years old. I have previously called for a royal commission on the service, but that has been refused. Perhaps with the constitution we have the next best thing, in what is a centralised health service. I hope the constitution works, although in parts it has a whiff of regimentation about it—probably the last thing you want in a health service.

My first comment about the constitution relates to page 13 of the handbook to the constitution, which says this:

“What this right means for patients ... NHS services are generally provided free of charge”.

That is the wrong message. They are not provided free of charge; they are paid for in advance. The cost to each person is quite high at £1,700 per annum, which means that a family of four pays on average £6,800 per annum for the NHS.

Lord Rea: That’s wrong.


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