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What is the UK’s role in this? First of all, we have to work with our neighbours in the EU, as well as the Commonwealth. If we cannot co-operate with our neighbours, we certainly cannot co-operate with others around the world. Secondly, we need political leadership for popular education to explain to our publics why sovereignty does not work anymore. I simply end by saying to my colleagues on the Conservative Benches as well as to the Government: we all need to explain to our publics how desperately we need stronger global and regional co-operation.

8.18 pm

Lord Howell of Guildford: My Lords, in the few minutes I have available to wind up for the Opposition, I will confine myself to saying that I almost 100 per cent agree with what the noble Baroness, Lady Howells of St Davids, had to say at the opening of this debate. The UN is falling short; the core of it does need reform; it is spectacularly out of step, as she says, and far-reaching transformation is needed. The irony is that successive Secretaries-General have called for reform to come again and again, when people have sincerely wanted reform, but it has not happened. Frankly, it is ridiculous that Japan, Germany, India and Brazil should not now be permanent members of the UN Security Council. Japan and Germany are the second and third largest funders of the United Nations, and Japan pays one-fifth of all peacekeeping operations of the UN. It is extraordinary that they are still excluded.

I agree very much agree with those who say—the noble Lord, Lord Hannay, is to the forefront in this—that reform needs to reflect the shift away from the old western and Atlantic hegemony. I agree with the noble

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Lord and I love his phrase “indispensable but ineffective”, which just about sums up the position. The same could be said of many other 20th-century institutions, in fact the whole architecture of the 20th century, which includes NATO, the IMF which has entirely the wrong weighting, the World Trade Organisation which is running out of steam, the nuclear proliferation or NPT regime which needs revising, and indeed the European Union.

We expect much too much of the United Nations. Our hopes become almost overweighed in favour of the belief that the United Nations, by talking and gathering together, can solve all the world’s problems. It cannot be done in that centralised way. We need new platforms and new networks in a totally transformed global situation. I was glad to hear the noble Lord, Lord Alderdice, in particular, say that the Commonwealth had a key part to play in this. When it comes to, as the noble Lord, Lord Judd, said, allowing the people of smaller and deprived nations to feel that they have a part to play, it is organisations such as the Commonwealth that are bound to give a supplementary role to what can be provided in the enormous and sometimes remote United Nations with its 181 members, or whatever the number is, where voices tend to be drowned in the higher babble of the whole organisation.

I simply end my few minutes by quoting Boutros Boutros Ghali, the former Secretary-General of the United Nations, who said in 1993:

“The globalization now taking place requires a profoundly renewed concept of the State. Between the isolated individual and the world there must be an intermediate element. This element is the State and national sovereignty. They respond to the needs of all human beings for identification. In a world both impersonal and fragmented such a need is greater than it has ever been in history”.

That Secretary-General put his finger on the fundamental need for a balance between the great UN forum, which has its part to play, and the needs of national identity and the nation states, which will be the most creative network of the 21st century. Boutros Boutros Ghali was one of the best Secretaries-General that the United Nations has had; of course, they refused him a second term.

8.22 pm

The Minister of State, Foreign and Commonwealth Office (Lord Malloch-Brown): My Lords, I, too, thank the noble Baroness, Lady Howells, for initiating this debate and reminding us of the UN’s glorious birth and the hopes which were vested in it at that time. When world leaders met in 1945 to lay down the charter of the United Nations, they did so on behalf of:

“We the peoples of the United Nations”.

Those were ambitious words for their time, when few of the peoples probably knew what was being done in their name, and they certainly could not foresee the changes that lay ahead of them and the role that the United Nations would play for better and sometimes for worse.

It is a measure of a historical story that I never tire of telling that those hardened battle-weary world leaders who gathered in San Francisco to confirm and sign

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the charter considered it such a precious document that when it was flown from San Francisco to the east coast, they attached a parachute to it in case it needed to be ejected from the plane, if there had been any risk of an accident.

The fact that the most world-weary group of statesmen, and sometimes women, that the 20th century saw, the allies who had prevailed in that most brutal and extended of wars, the Second World War, could have come together to form the United Nations and write that charter should give us pause, because the case is made frequently that somehow it was a naïve undertaking. We forget that these were men who had not just seen the horrors of the Holocaust and the brutality of a global war, but remembered very acutely and recently the failure of the League of Nations. They drew up this charter, not in a spirit of naïve hope that somehow humankind was to reform its character and that good would prevail over evil for ever after, but much more in a spirit of realism. This global world that we were embarking on was one where no country alone could exercise an imperial-like control over forces of law and order, or provide security or leadership to the world.

For President Roosevelt, and for President Truman who followed him, the United Nations was an exercise in collective security, where the burden of being the world’s policeman would be shared by the United States, the great victor of the Second World War, both with its allies in that war and more broadly with the rest of the world. This was, if you like, global order on the cheap. The United States did not expect that it would step up to the plate to replace the old colonial powers in some system of direct rule over large parts of the world. Rather, through the charter of the United Nations and the institutions created under it, it hoped that collective security would prevent another world war, that the promotion of economic and social development would liberate hundreds of millions—and, later, billions—from the condition of poverty to which they had been assigned, and that the promotion of the values for which the war was fought—the values of democracy and human rights—would be secured.

Many years later, when working for Kofi Annan, the previous Secretary-General, we thought of how we might renew this organisation. The Secretary-General commissioned vital reports, including that on the reform of the UN security arrangements, in which the noble Lord, Lord Hannay, participated. It seemed to the Secretary-General that he could do no better than reconfirm the three basic, original principles of the organisation; that it is should have three pillars. One was a peace and security pillar. The second was a development and humanitarian pillar. The third was a human rights and democracy pillar. We saw it as a three-legged stool. You could not have security without democracy and human rights, just as you could not have development without security, nor security without development and human rights. In other words, each of these goals and objectives was dependent not only on its own achievement but on the achievement of the other two as well.

I believe that this is an enormously important point about the UN. People tend to select the goal they prefer, be it human rights, development or security.

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Each, in a sense, calls forth an apparently very different vision of the world. The security one is about collective security. It is about how we defend our countries as the nature of warfare changes, as terrorism and asymmetrical conflict, with the targeting of civilians, breaks down the traditions of war between states and introduces new and often more deadly forms of conflict. It is about how we mutually deploy armed force to address these threats and how we protect the sovereignty of nations from overbearing neighbours or from attack from within.

The second goal, the goal of development, is one which calls forth, if you like, a more apparently liberal doctrine of how we emancipate and liberate people from poverty, inequality and from the marginalisation that comes from being born into a certain class, caste or race. This third goal, of human rights and democracy, often seems the most elusive, the most naive, of all. Yet over the years we have seen that on many occasions in the modern world security is provided by focusing on human rights and democracy.

Let us look at the UN’s role in achieving each of those goals. I say to my noble friend who introduced this Question that in some ways perhaps the UN has done a better job at living up to these original ambitions than she may fear. We have seen a sharp decrease in the number of people dying from violent conflict. The best analysis of that—carried out, for various reasons, in several institutions in Canada—suggests that UN peacekeeping has made a significant contribution to the decline in conflict both between and within countries. Similarly, with regard to development, we have seen hundreds of millions of people lifted out of poverty. In many cases, that is due to the bold actions of Governments and countries, but the contributing role of UN technical assistance has been critical. I refer to the role of organisations such as UNICEF or my old organisation, UNDP, in contributing advice and resources to help economic and social development. The UN has also played a role on the humanitarian side, where, for example, the World Food Programme and the UN High Commissioner for Refugees have made astonishing differences to the lives of millions of people.

I turn to the area of human rights and democracy. In some ways, the UN has been critical in promoting democracy. However, turning from the historic record to look to the future, and in response to those who have raised the issue of the Human Rights Council, I have to acknowledge that there is, as many speakers have said, a lot of unfinished business. In the case of the Human Rights Council, there has been reform but it has not been effective. I think that its membership became overexpanded. The reform did not create a chamber which was objective and which could rise above the national interests of those in it to provide a truly nation-blind, colour-blind and values-blind view of human rights. Instead, as we saw as recently as last week in the review of the Durban conference, a lot of terrible things have been said in that council. Nevertheless, we have introduced some reforms which, in some ways, have started to improve the quality of the UN’s work in human rights. We have introduced a mechanism called the universal periodic review, under which every member country must present and then defend its human rights record.

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Moving on from human rights, there has been an attempt to introduce new doctrines. My noble friend Lady Amos spoke about the doctrine of the responsibility to protect. That is a very important innovation; nevertheless, it is still fragile and, although acknowledged, it is not yet resolutely established. She properly raised the example of Sri Lanka, where the responsibility to protect is very much on display in that an awful lot of civilians’ lives have been put in danger by the violent internal conflict. However, to say that the UN has been inactive on this is unfair. It has not, if you like, waved at the doctrine because it is still a provocative one. Many countries see it as amounting to a foot in the door and they do not accept such interference in the internal affairs of member states. Therefore, the doctrine has to be pursued by other means, and the UN has been active in trying to secure humanitarian access. The Secretary-General, like our own Prime Minister, has repeatedly called for a ceasefire in Sri Lanka and for the protection of civilians.

I turn to the reform that has, perhaps, attracted most attention from noble Lords, including the noble Lord, Lord Hannay, and my noble friends Lord Judd and Lady Howells. I refer to the reform of the Security Council. In that regard, Britain is very clear indeed. We want to see the council enlarged, made more relevant to today’s world, made more representative and more authoritative as a result. We have pressed hard, most recently in partnership with France, to try to move this forward. The first round of a General Assembly-based debate on UN Security Council reform has just concluded and there will be discussions to follow. We feel strongly, as guardians, if you like, of the charter, which in some ways comes with our P5 membership, that rather than protecting and conserving that as just a privilege locked in history, we must renew this chamber by expanding its membership, by drawing in precisely those countries mentioned in the debate—Japan and the others whose names have been mentioned in this context—as members on some basis or other. Whether or not the membership will agree to an immediate expansion of permanent membership, or some intermediate solution, is a matter for the membership as a whole to conclude.

In finishing, let me just say to noble Lords that this Government are very committed to this. The question was raised by the noble Baroness, Lady Coussins, as to whether we should be doing more to press for the so-called “One” UN reforms. Let me say that a member of the panel that led to those recommendations was a certain G Brown Esquire, now Prime Minister of this country, so I do not think she need doubt the commitment of this Front Bench and of my colleagues in Government to achieving those reforms. In fact, a new administrator of UNDP took office this week and already she has had our Secretary of State for International Development in her office arguing the case for “One” UN reforms. The noble Baroness, Lady Coussins, need not be concerned. We are committed, because my right honourable friend the Prime Minister has recognised that, for a country such as Britain, our ability to exert influence in this modern world depends enormously on effective multilateralism and at the heart of that effective multilateralism lies that indispensable institution—to borrow at least half of the phrase of the noble Lord, Lord Hannay—the United Nations.

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Health Bill [HL]

Bill Main Page
Copy of the Bill
Explanatory Notes
11th Report from JCHR

Report (1st Day)(Continued)

8.37 pm

Clause 9 : Direct payments for health care

Amendment 23

Moved by Earl Howe

23: Clause 9, page 6, line 17, after “patient’s” insert “prior and informed”

Earl Howe: My Lords, I beg to move Amendment 23, which is designed to address a very straightforward issue, one raised with me by Diabetes UK. In Grand Committee, the noble Lord, Lord Darzi, spoke about personal health budgets and emphasised the Government’s intention that these should always be voluntary and that exactly the same principle applied to direct payments. The question I want to raise with him is whether the wording in the Bill provides a sufficient safeguard against abuse of the voluntary principle. New section 12A says,

which, at first blush, seems all right, but, if taken literally, the consent could be read as applying to the narrow issue of how the money in someone’s direct payment budget is applied and spent. It might not necessarily prevent a situation arising in which a patient does not really want a personal budget at all but, against his better judgment, he is persuaded or pressurised into accepting one. There is a difference between the right to refuse treatment and the right not to choose a personal budget of any kind. The Minister’s comments up to now have appeared to conflate the two. I have sympathy with the point made by Diabetes UK that the legislation should make it clear that personal health budgets of any kind—notional, third-party or direct payments—should remain voluntary, whether at the pilot stage or in the event that they are rolled out more widely. I am sure that the Minister will say that the wording in the Bill is adequate in this sense but, nevertheless, I would be glad if he would look at the matter again. I beg to move.

Baroness Barker: My Lords, I wish to speak to Amendments 25 and 31 in this group. As this is the first group of amendments on the subject of direct payments, perhaps I might reflect on the discussion in Committee. It would be accurate to say that we had an extensive debate—almost a full afternoon of one of our sittings in Grand Committee—during which the Minister was bowled question after question about direct payments, individual budgets, the principles underlying them, what the Government’s intentions are, the extent to which individual health budgets might be brought into play in respect of different patients and different conditions and the limitations of the proposed pilots.

I thank the noble Lord, Lord Darzi, for his letter of 18 March in which he restated, to a large extent, the answers that he gave in Committee. However, detail is lacking and that continues to be a source of considerable concern to many of us on this side of the House who

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are supportive of the principle of direct payments but have considerable concerns about how they might be introduced and about the potential detrimental effects which they might have on the National Health Service and particularly on the provision of services.

Since the Committee, the noble Baroness, Lady Campbell, has been kind enough to arrange a meeting for all Peers, attended by the noble Baroness, Lady Thornton, at which she and several people from the disability organisations with which she has long been associated and academics such as John Glasby from Birmingham University set out the experience of disabled people. They talked at considerable length about what they consider to be the potential benefits to service users of individual budgets. It seems to be my misfortune throughout this Bill to refer to the noble Baroness, Lady Campbell, when she is not in her place and I regret that I have to do so again. It would not be inaccurate to say that although there was considerable support for the potential for direct payments at that meeting, again, when Members of your Lordships’ House raised issues and asked questions, there were no answers. I find that deeply troubling.

That meeting gave rise to the tabling of Amendment 31, which, as noble Lords will see, bears a resemblance to an amendment tabled by the noble Baroness, Lady Greengross, in Committee in which she set out a list of conditions and services to which individual health budgets might apply. The purpose of both these amendments is to probe the Government’s intentions on the extent to which direct payments will be introduced in the NHS. It is of considerable interest and should give rise to a degree of concern that many of the organisations that have supported the principle of direct payments or individual health budgets have expressed their support on the understanding that they will be available to a small minority of patients who suffer from long-term conditions, and that there will be adequate advice and support for any person who has an individual budget. Neither of those two statements can be made with any certainty, given what is in the Bill and our discussions so far.

Amendment 31 refers to two particular conditions, both of which, in different ways, highlight some of the potential issues associated with individual health budgets. In Committee some noble Lords expressed the view that palliative care services, given their place in the National Health Service and the fact that they are largely supplied by independent organisations, principally charities, should be funded through direct payment. But the major providers of hospice care in the country have a very different view. By definition, palliative care—end-of-life care—is provided to individuals but it cannot be predicted when any particular individual will need it. At the moment part of the function of the NHS is to study populations and the incidence of conditions, and to make an assessment of the level of service needed to deal with them. That process runs right through to budgeting. There is an attempt at the heart of the NHS to address issues such as pooling of risk and equity of service. If palliative care came to be primarily funded by direct payments, the ability of providers to predict and provide a certain level of service would be extremely difficult. It might signal the end of the provision of palliative care within the

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NHS and I want to establish whether the Minister can envisage that as a consequence of the introduction of this policy.

At the meeting arranged by the noble Baroness, Lady Campbell, noble Lords who were interested in the subject discussed at considerable length the benefits of this service, and there are benefits. In Committee we discussed the fact that services can be more personalised and more effective for individual patients, and can contribute to greater health outcomes. At the meeting noble Lords—particularly the noble Baroness, Lady Cumberlege, who, I am sorry to see, is not here to take part in this debate, although she talked in Committee—saw that maternity services would be a good candidate for individual health budgets. Maternity services are required, usually, with about nine months’ anticipation of the need for them arising. They are planned on the basis of population studies. Thinking about the matter in greater detail, within the NHS there is at the moment a considerable move towards midwife-led units, on the basis that the majority of deliveries are uncomplicated and routine. However, there are always births that do not go according to plan and in which there is a sudden and urgent need for a woman to be referred to a consultant obstetrician.

The reason for suggesting that maternity services should be included in the pilots for individual health budgets is to test the point that I raised in Committee. To what extent has the Department of Health analysed the risk of turning some services, which may be elective, over to individual health budgets, and to what extent might they then jeopardise acute services because of the coexistence of the two? Amendment 25 suggests that it is the responsibility of the department to set out much more clearly than it has done to date those conditions and circumstances under which direct payment may, must or must not be made available. It is essential not only to the future of the policy but to the expectation that will be placed on it by NHS staff and, most particularly, by users. Both amendments signify a degree of frustration on my part that, having had detailed discussions about these matters over the last three months, we are no further forward in understanding just how radical this policy is intended to be and just what its potential implications are for NHS providers and patients.

The Parliamentary Under-Secretary of State, Department of Health, Lord Darzi of Denham: My Lords, this set of amendments deals with consent and the services and circumstances in which direct payments might be used. I turn first to Amendment 23, moved by the noble Earl, Lord Howe. It would require that a patient’s consent to receiving a direct payment is “prior and informed”. It is important to emphasise that personal health budgets, including direct payments, will be entirely voluntary. That is one of the core principles outlined in our policy document, Personal Health Budgets: First Steps. Of course, consent is enshrined in the very first sentence of this legislation for direct payments. No one should be forced to have direct payments if they do not want to, and I do not believe that anyone could be forced to accept such payment.

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