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Finally, the idea that devolving power to local authorities will deliver a plurality of outcomes is not always correct either. Local authorities are not neutral when commissioning services. They often have an aversion to selecting innovative approaches because they do not understand them. Many of their staff have only ever worked in the public sector. They do what they have always done, but change the wording on the forms to please the Government of the day. Look carefully and you will still see the same bodies under new clothes. Local authorities are often the least likely to choose an innovative approach to service delivery, so why are the Government looking to them alone? Could the Minister tell the House what criteria will be used to choose these authorities? How will he select the sheep from the goats? Or, like doctors, are they all as good as each other? Not in my experience.

I wish the Minister well in this time of opportunity. Partnership is a great thing and the present financial crisis is the time to embrace innovation. Never miss the opportunity presented by a good crisis. If you are to deliver, I would humbly suggest that you do not rely on structures or theories, but on people. Back the best people, be they in the business, public or social enterprise sectors, and, funnily enough, you will be fair to everyone.

4.59 pm

Baroness Wall of New Barnet: My Lords, through a very croaky voice-my voice box has just given up, forgive me-and after more than 30 previous speakers, I, too, welcome the noble Lord, Lord Hill, and congratulate him on his maiden speech. However, I particularly want to focus on the noble Earl, Lord Howe, and say how delighted I am that he has received the reward we all hoped he would receive by becoming a Minister on the Front Bench. It has been an absolute joy working with him over the six years that I have been here. So I say to him, "Well done", and look forward to working with him again in the future.

More importantly, I look forward to him coming to my hospital. I declare an interest as chair of Barnet and Chase Farm NHS Hospitals Trust, which is a two district general hospital trust serving the community in north London. On his appointment, the Secretary of State, Andrew Lansley, picked out my trust as the first one he should visit. From his interest, particularly in our A&E, and the questions he raised with us about the rest of the trust, it was obvious that he had gained a real insight into the services across our two hospitals. We greatly welcomed the opportunity to see him and to have his support.

Shaping the future of healthcare that is safe, of high quality and responsive is a vital component for any government reform in the NHS. In fact, it is enshrined in the NHS constitution that patients must receive the best care possible when they come into contact with our services. Patients, in consultation with their GPs-much of this has been referred to already today-have a choice about where they can

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receive their care or treatment, and we in Barnet and Chase Farm welcome that. I agree almost totally with the comments of my noble friend Lord Warner about the independent sector because the fact that people have the opportunity to use it makes our services better. I strongly believe that when a choice is offered, people will make sure that they are the ones who are chosen. We certainly do that in my hospital. The decisions patients make are the driving force behind my trust working hard to become the provider of choice, whatever the competition. If the Government are going to work on that principle, all I ask of the noble Earl is that we have a level playing field. That is very important.

We are committed to ensuring that every patient is treated with dignity, compassion and respect while receiving high-quality clinical care. Every time I follow the noble Baroness, Lady Knight, in a debate, I wish that I had said to her the last time, "Please come to my hospital" because the things she tells the House-which I am sure are true-are so heartbreaking. She will remember that we spoke in the House about the red trays. I shared with her our experience of the equipment we use in Barnet and Chase Farm which ensures that people who cannot feed themselves are drawn to the notice of everyone and receive support from either the nursing staff or volunteers; that because their red tray indicates, "I cannot do this by myself", someone goes along and helps them to do it. We now have red jokes which I am sure the noble Baroness, Lady Knight, will be delighted to know. Although we gave patients food, sometimes the water was too far away, and so we remedied that as well. I extend an invitation to the noble Baroness today and I shall make sure that I follow it up.

In my trust, we believe that greater ease of access to healthcare will improve patient outcomes. There is no mention in the gracious Speech of whether the coalition Government will continue with the four-hour A&E access target, from which our patients benefit and which they value. In my trust, in order to achieve the four-hour A&E target we had to go back to the drawing board and redesign the patient pathway so that patients are seen as quickly as possible but by the right clinician. This, too, is much better for patients and, thank goodness, the 12-hour trolley waits are a thing of the past-certainly in my trust. It is interesting that whenever patients talk to friends or relatives when they have come out of hospital, they comment on the quality of their treatment-about their operation being successful, we hope-mostly very favourably, but one thing they are quick to talk about, in the pub or wherever they go, is how long it took to be seen. No matter how good the quality of care was, if they were kept longer than they thought was appropriate, if it was longer than four hours-and four hours is not appropriate any more-they still remember that bit: "It was great but I had to wait". The focus of some kind of incentive for people to work on that is really important.

We in Barnet and Chase Farm regard the fact that we have achieved "green" on the "traffic-light" indicator for our access targets for so long-together with being "green" for just as long in our quality targets-as a

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key factor in patients choosing to come to our hospitals. Seeing those quality targets being met, they know that our hospitals are places where they will get both the treatment that they need and the performance that they are entitled to. Perhaps the noble Earl will tell us when responding that the value that patients place on this system is important also to the new Government. I put all the caveats around how we make sure that that happens.

One speaker today has talked about removing the Care Quality Commission. I would plead with the Government not to do that. It is a great improvement on the Healthcare Commission; it is much more proactive; and it makes our trust feel that we will be challenged and that we will be superb in the way we go about our work. Let us combine timely access with high-quality clinical care and sound financial management, which is equally important.

I make this plea for targets not because they are about being achieved at any cost-they are not-but because they are about treating patients well. People who benefit from really good access along with absolute professional care get seen more quickly. In my trust, the introduction of MRSA reduction targets-there has been much discussion of them today-has led to a reduction in MRSA bacteraemia cases every single year. The noble Baroness, Lady Knight, mentioned very high figures. Last year, we had 16 cases in our trust, which we thought was awful. This current year, we have had four cases, with no more than seven predicted by the end of the year. That is a result of the care that we make sure is given to patients. All the nightmare stories that one hears will happen again if people do not take care of their patients. This is another example of how appropriately set targets can provide better care and improved outcomes. It is good for patients. We again urge the coalition Government to hold us all to account in this way.

During this time of change, might I be so bold as to say that we must take care in making any decisions about changing or removing targets? They can and do benefit patients as long as we always have the patient and the quality of the service at the front of our minds, which is absolutely essential.

I conclude by sharing with your Lordships a case study made by the Department of Health on delivering same-sex accommodation, which was a flagship policy of the previous Labour Government. We hope that the new coalition Government will hold on to this policy and push all hospitals into delivering this environment which is so valued and appreciated by patients of both sexes. That is what dignity and care are about.

5.08 pm

Lord Addington: My Lords, coming in at number 35 in the batting order, I am surprised to discover that I have something to say which has not been covered already. That does not often happen in a debate such as this; you usually have to quote everybody in front of you.

I shall refer first to the education aspect of the debate. Before doing so, I welcome the noble Lord, Lord Hill, to the cross between Alice in Wonderland

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and Gormenghast which is how I have always regarded the House of Lords. He is welcome as a noble friend-something that I did not expect on 6 May to be saying. I hope that he will carry on in the same vein as that in which he started.

The coalition document refers to assessment for all pupils with special educational needs, which most people involved in the field have concluded is absolutely necessary. It will be important to make sure that we hit targets for improved literacy, for example. The previous Government, to give them their due, did throw resources at this problem and found out that we were not getting to the group of people with such things as dyslexia, which is a special interest of mine. Too many people were still not being identified or treated properly when they got through. The other hidden disabilities are as bad. What usually happens here, as the noble Lord will discover, is that the most extreme cases are dealt with first, provided that you have an articulate parent behind you. That is the absolute iron law. The organisations that do the work behind this are driven by those articulate parents. Dyslexic people from working class backgrounds, who often have dyslexic parents and dyslexic children, end up with people with dyslexia in prison. That would be roughly what I would say about it. We need to ensure that the assessment works and is given the time, place and energy and is made to cover all these conditions. The assessment may be a complicated one that takes several days or weeks, but it must be done in that way. If you miss this target, you will miss an opportunity. I shall come back to this at a later date-probably on a lot of later dates. I think noble Lords are nodding their heads in agreement. It is something that we must look at, and I encourage the noble Lord to engage fully with all the organisations out there. I hope that we can make a good fist of it. There is no right answer, but there may well be a better one in this field.

I turn to the link between culture and health. The noble Lord will not be surprised if I say that the linkage between sports and physical activity and health is absolutely obvious, but government has never really got hold of it. The idea is there, but we do not really correlate the two properly. The coalition document mentions helping sports clubs; something has been done, but not enough. I recommend the Bill that I brought forward on amateur sports clubs, and would like to take credit for all the drafting, but the CCPR would have my hide if I did. We do not give enough support to those taking sport outside school, in encouraging them to take it on after that.

I am worried by one of the other comments in the document that refers to school sports. One thing that we know about sporting activity is that it drops off at 16, 18 and 21. Those happen to be the dates at which people leave educational institutions. If you are fit as a flea at 15 and a fat slob at 22, the NHS ain't going to get a great deal of benefit. How do you encourage people? I asked the previous Government and the Government before that. The noble Earl, Lord Howe, and I have been noble friends and allies and noble opponents in this House. What is the best form of recruitment devised by all the sporting bodies supported by Sport England to keep people involved? I have had long and in-depth replies but I have never

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found out the best answer. How can we keep people engaged and active in sporting activity? People will then turn round and say that people can be healthy without playing a competitive sport. One in several thousand may have the motivation to do the 2.3 miles of jogging two to three times a week to keep their weight at the recommended level over a long period of time, but nobody else will. You need an incentive and a reason to get yourself involved; even if it is only to look good on the beach, you need a reason. It is easier to eat chips. The answer will not always be found in eating healthier food. You can get fat eating healthy food and watching TV. It might take slightly longer, but you can still do it. We need to give people an incentive to get involved. Will the Government ensure that the Department for Culture, Media and Sport and the Department of Health have regular meetings and discussions about how they can marry these two things together to ensure that there is some real interaction? I know that effort was put in before, but it seemed to disappear somewhere behind the Chinese walls. I do not doubt that many Ministers tried-they probably ended up wasting a great deal of time with my pushing to get this on-but please can they make a move through with a linkage that goes slightly further than Ministers saying occasionally, "Oh, we must do something". It happens that things fall away occasionally between Ministers who are supposed to meet each other.

If we are talking about protecting school playing fields in this document, please can somebody also address the fact that that battle might have been lost? It took 10 years for the previous Government to reverse their sell-off of school playing fields. Maybe they could have acted sooner, but they did not. They slowed it down, but did not reverse it. I think there was a great announcement, after about 10 years of asking this question, saying, "Finally, we've got two more than we had last year". Can we have a real addressing of the facilities available across the board for people to take on sport? Can we also look not just at school playing fields but at local authority and private playing fields? I asked that several times and it was never measured. Can we look at this in the round?

Finally, on the Department of Health, if we are encouraging people to play sport and take exercise, can the noble Earl, Lord Howe, tell me whether we are doing more about making better sport and exercise medicine available? That is because soft-tissue injuries which are not dealt with properly become chronic, leading to the person becoming less active-indeed, often, to them becoming disabled. It is an absolute fact that this happens. The process is slow; physiotherapy is slow to acquire. Instant treatment often solves problems overnight. Leaving them for several weeks means you have major problems requiring major involvement; I have case studies on that by the barrow load. I will not bore the House with those tonight, but unless something is done to bring these facets together, all the activity around the Olympics and other great sporting events will not achieve anything like it could. I would hope that, on my two questions, both noble Lords will go away and remember that they must talk to their colleagues and to the rest of the House to maintain pressure for this.



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5.17 pm

Lord Morris of Handsworth: My Lords, I, too, pay tribute to the gracious Speech and to those noble Lords who have delivered maiden speeches today-in particular, the noble Lord, Lord Hill, who delivered his from the Dispatch Box.

Unlike previous years, in order to explore the true intention of the Government's programme it is necessary to read not only the manifestos of the two parties in government but the important document The Coalition: Our Programme for Government. The Government, and indeed the gracious Speech, say that the legislative programme will be based on the principles of freedom, fairness and responsibility. Reflecting on what the coalition's programme commits to in respect of the National Health Service, I find it to be long on expectations but somewhat short on commitment to its users.

For example, as the noble Baroness, Lady Wall, who has just left her place, pointed out in her question, where is the commitment to guaranteeing maximum waiting times for hospital treatment-the commitment to a maximum wait for an urgent cancer treatment referral, or while in accident and emergency? In the context of the debate in your Lordships' House, these commitments might sound somewhat pedestrian, but if you are on the waiting list they are vital. Indeed, for some it could be a matter of life or death.

Today, though, I will examine the bigger picture, letting the notion of "freedom and fairness" pass. I want to focus on the principle of responsibility. Tucked away on page 25 of the coalition's programme for government is a paragraph on the NHS. It says:

"We will establish an independent NHS board to allocate resources and provide commissioning guidelines".

That statement raises questions and gives no real answers. The creation of an independent NHS board, as set out in that programme, challenges the very principle of political responsibility and political accountability. In essence, the coalition Government are proposing the creation of a superquango to run the National Health Service. What, then, of the promises over a number of years of "no more pointless reorganisations" of the NHS? What of the promise in the coalition programme to reduce the number and costs of quangos? In fact, the proposed NHS board will be the biggest, most expensive quango in the history of the NHS.

The coalition Government will argue that their proposed NHS board will prevent "political interference" but, to many, what has been loosely labelled as such is actually political accountability. Ministers will no doubt say that they want to devolve power, but there is a qualitative difference between devolving power and abdicating responsibility. Ministerial responsibility for the NHS cannot be outsourced or subcontracted to unelected quangos. Ultimately, it is the Government who must be held accountable for the funding and service decisions that shape, influence and affect the healthcare of the nation. Democratic accountability demands that Ministers, as we have seen today, come to the Dispatch Box to be questioned about their decisions on the running of the NHS.

The NHS is a public service that spends more than £100 billion of public money each year. It is an essential front-line public service that makes a difference to the

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quality of our lives, and we are all stakeholders in it. That is precisely why it is with Parliament that the buck must stop, not with some superquango that does not have to face the electorate or stand at the Dispatch Box.

The proposed NHS board raises a number of fundamental questions, and I hope that the Ministers will give us some answers. Will the board both commission and provide services? Who will own the assets of the NHS? Who will have responsibility for managing and monitoring those assets? How are taxpayers' interests to be protected and safeguarded? What will the relationship be between foundation trusts, primary care trusts and GP services?

If Ministers really want to improve our NHS and devolve decision-making, I am sure that the best way of doing that is to empower NHS professionals-our doctors, our nurses, our front-line healthcare workers. What the NHS does not need is the creation of a superquango that is unelected, unaccountable and unnecessary.

5.25 pm

Baroness Howarth of Breckland: My Lords, it is an absolute delight to see the noble Earl, Lord Howe, across the Chamber on the Front Bench. He and I have exchanged views for many years. Sometimes we have disagreed but he has always replied with grace. I also look forward to getting to know the new Minister. I hope he does half as well as the noble Earl; he will then do pretty well indeed.

It is in times of economic constraint that the services to the most vulnerable get lost. It is the most in need-the least vocal-who are diminished. I am sure that this Government will not want to lose sight of those who require our care. Recognising their commitment during the election, in the manifestos and in their speeches, I am particularly grateful for the concern already expressed. Before I move on, I specifically mention the ending of detention of children for immigration purposes. After many years' service in social care, I recognise that this is a complex issue, particularly since children must not be separated, as the right reverend Prelate said, from their families. The previous Government did much to end this practice. We now look to this Government to complete the task.

Unlike my noble friend Lord Sutherland, I welcome the commission to consider a sustainable long-term structure for the operation of social care. As chair of Livability, a charity providing services for severely disabled adults and young people, I recognise the challenge of delivering excellent opportunities to give individuals maximum choice and freedom with the balancing of cost. I hope the Minister will reassure me that looking for value will not lead to the lowest level of care and quality. People who need our services deserve the best that we can give. That is why the commission is so important in taking a broader look at all those in the social care system. I also hope that during this review the Government will look at simplifying some of the structures that we now have. The uncertainty and additional bureaucracy associated with assessment and care support planning under the personal budget programme-which has led to an industry of people set up to manage people's individual budgets, taking a top slice-is just one example of added complexity.



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Linking this commitment to improving public health and reducing health inequalities, I expect the Government to see the close link between health input through hospitals and medical facilities and practitioners, and the community care provided by those in social care in local authorities and voluntary organisations. For example, Little Hearts Matter is a small charity dealing with children who experience the most severe surgical interventions in heart conditions. I pay tribute to those specialist doctors who have given these children a life through brilliant intervention techniques. However, the children will spend most of their lives in the community, not in hospital, needing support services and follow-up care. I anticipate that the Government will see these interventions on a continuum, rather than as incidents, and support the whole, including the part played by the voluntary sector.

As noble Lords would expect, I now want to focus on children and children's care services. I am not speaking of education, important though I see it is, because many of your Lordships here will do so. However, I say to the Minister that without emotional stability and family support, children will fail to learn. Again, the two are interrelated. The previous Government said, "Education, education, education", and I said to them often on the Floor of this House, "Welfare, welfare, welfare, if children are to learn". As yet there seems to be no clear decision about the long-term plans for children's local authority services-children's trusts-but stabilising them is absolutely vital. They are working in a time of unprecedented pressure. Social workers need to know that they are as valued as teachers, nurses, economists and the rest. I did not hear mention of them in the introductory list of the noble Lord, Lord Hill, but perhaps he would like to learn more about their work. I would be delighted to inform him. Why is that? It is because we entrust them with the safeguarding of our children. We leave them with the most difficult decisions. They are damned if they remove children, damned if they don't and damned to hell if they get things wrong.


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