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On relations with Israel and the flotilla, which the noble Baroness, Lady Hussein-Ece, and several others rightly raised, we have underlined the need for full, credible, impartial and independent investigation into the MV "Mavi Marmara" incident. We have made it clear that we want to see a process that ensures full accountability and commands the confidence of the international community, including international participation. There is of course the UN panel of inquiry, which was set up to investigate the incident, beyond several other reports that have already come out. The UN inquiry fulfils these criteria, and we will be able to draw much better and sounder conclusions once it issues its report.

On the hard business side, on which we as a trading nation must always keep a firm eye, Turkey is a vital market for UK exporters. In recognising the amazing rates of growth that Turkey has recently achieved, the Prime Minister the other day set the UK the goal of doubling its trade with Turkey over the next five years. As the noble Lord, Lord Clement-Jones, and others said, companies such as Vodafone, Tesco and International Power are already well established there. UK Trade and Investment is redoubling its efforts to help even more firms to win business in Turkey. In my own department, the Foreign Office, we have been seeking both through our work with other departments and through our posts to promote that aim with the greatest possible vigour. We will continue to do so.

The Turkey that our Victorian forebears saw as the sick man of Europe and which then emerged out of the ruins of the Ottoman Empire as a new and vital force under Kemal Ataturk has been known well and respected by many of us. However, there is a new Turkey that we must now understand and respect even

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more, whose international stature and power are growing. It has been described as Europe's only so-called emerging economy, but we must think about questioning even that concept. Some would say, perhaps a little cynically, that if there is any emerging to do, it is just as much in western Europe-indeed, in our society-as it is in the Turkish economy.

The other day, Robert Zoellick, the extremely able chairman of the World Bank, observed that the very language of talking about the "third world" and "emerging powers" belonged to the previous age, and that we must now recognise that, with globalisation, all kinds of countries that were yesterday seen as being in the "developing country" category are now pace setters: highly dynamic growth economies in the new world setting. Dare I introduce into this debate the thought that our own 54-nation Commonwealth, of which we are a proud member and which used to be seen slightly as a useful talking shop, has now emerged with five, six or seven of the fastest-growing economies in the world and at the cutting edge of high technology? That is far removed from the concept of Britain and the West trying to place their template on the international order and supplying the capital and technology while others supplied the goods and commodities. That world has gone. We must understand that. Your Lordships, perhaps more than many legislatures and assemblies, understand that we are in this new world order.

Turkey matters intensely on the international stage. As the noble Baroness, Lady Symons, indicated, it is caught up in new patterns of trade flowing north-south as well as east-west: the new silk routes opening up between the GCC countries, the Arab world and the rising eastern powers. Suddenly, we must adjust to the fact that the Middle East, over which Turkey sits with its huge water sources, looks increasingly to the East rather than to the West in its trade patterns and relationships. All these matters are essential for our policy-making, because we must have access to these new partnerships and relationships in order to survive and prosper as a nation ourselves.

As a key NATO ally and a defence partner, especially in Afghanistan, Turkey is a crucial partner in building international security. Turkey is an immensely valuable partner in counterterrorism and fighting illegal migration, drug trafficking and organised crime. I have not said much about the sensitive area of migration, except possibly to observe that those who fear that the future closer involvement-and, we hope, Turkey's eventual membership of the European Union-would lead to a large shift of population from Turkey westwards may have it the wrong way around. The linking of this highly dynamic economy with our own might lead to flows of population and people seeking the ambience and encouragement of this high-growth economy. Perhaps that is a little fanciful, but these are the possibilities of the future. Furthermore, the size of the Turkish market and its startling rate of economic growth make Turkey without question a significant trading partner for the United Kingdom.

I have not answered every question, although I have tried. I think I have covered practically all the issues that have been raised in this fascinating debate. I have tried to set out a series of reasons, arguments and

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assessments as to why this Government attach such importance to our relationship with this great power, which has such a substantial, youthful and dynamic population. We have already taken decisive steps to inject a new dynamic into UK-Turkey relations. I encourage noble Lords-although perhaps I do not need to, because they already recognise the need-to embrace all that Turkey has to offer and to intensify engagement with Turkish counterparts in all fields of interest. This will serve to boost the prosperity and security of our own United Kingdom in the long term, which, after all, is one of our main concerns.

2.07 pm

Baroness Hussein-Ece: My Lords, I thank my noble friend the Minister for his comprehensive reply to this Motion. I also thank all noble Lords from across the House for an extremely interesting, positive and wide-ranging debate. There is so much expertise and knowledge in your Lordships' House. I have enjoyed listening to everyone's contribution, particularly that of the noble Baroness, Lady Symons, on the opposition Benches, reaffirming the commitment on her side of the House to the issue of the Motion that we are debating today.

I have also learnt things. It was interesting to hear my noble friend Lord Trimble talk of ambiguities and challenges. Of course there are challenges; no one denies that. Of course there must be ways, and hope, of resolving some of these difficulties in a positive way.

I also pay tribute to my noble friend Lord Sharkey for his amazing and insightful maiden speech. I look forward to many other contributions from him. It was timely that he was able to make his maiden speech in this debate.

I thank all other noble Lords for their contributions and everything that they have brought to this debate. I hope that it will carry on. It has been well informed, and I hope that it will take us forward positively in the coming months and years. Hopefully Turkey will see this as a sign that there is hope in the European Union and that it is not all negative.

I am particularly grateful to my noble friend Lord Selsdon for his hugely enjoyable and entertaining voyage around Turkey and the Mediterranean. With that, I beg leave to withdraw the Motion.

Motion withdrawn.

Violence Against Women


2.10 pm

Moved By Baroness Gould of Potternewton

Baroness Gould of Potternewton: My Lords, I am pleased to have the opportunity to introduce this debate on violence against women and girls. When I put the question into the ballot some months ago, I

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had little knowledge of the Government's intentions. The only reference in the coalition document related to examining ways of funding rape crisis centres from the victim surcharge. Not to take anything away from the invaluable work of rape crisis centres, but they cover only one aspect of an extremely wide and complex subject. I was surprised, having read a number of statements written by the Conservatives when in opposition. However, last November, the Government produced a policy document, Strategic Vision: Call to End Violence against Women and Girls. This answers some of the questions I would have raised, but certainly not all. Maybe we will hear more of the detail today and more will come when the action plan accompanying the strategy is issued in March; also, when we have the response to the Stern review into how rape complaints are handled by public authorities in England and Wales. I am pleased that the noble Baroness, Lady Stern, who is back from her holidays, is participating in the debate.

It has been fascinating to put the Labour Government's cross-government strategy alongside this Government's strategy paper. There are parallels in concept although perhaps not in detail in respect, for instance, of prevention, reduction of risk, provision of support when violence occurs, the importance of partnership working, ensuring that perpetrators are brought to justice and the importance of the training of front-line staff. I also welcome the reference to international work, following the work already started by my noble friend Lady Kinnock.

Before examining some of the details, I want to look at the breadth of the issue which any strategy has to respond to. Both of the strategies that were produced in 2009, and this Government's in 2010, use the definition determined by the UN Convention on the Elimination of All Forms of Discrimination Against Women that,

It is a pity that the Government have resorted to the inaccurate statement that it is the first time that a Government have agreed to work to a single criterion to eliminate violence against women and girls. The previous Government also adopted the wider criteria established at the 1995 UN Women's Conference in Beijing, which included violence resulting through the use of technology and through economic harm. This cohesive and co-ordinated approach ensures that violence against women encompasses but is not limited to, domestic abuse, including financial abuse, sexual violence, rape, exploitation including commercial exploitation, sexual harassment and bullying, pornography, stalking, trafficking, forced prostitution in adults, all child exploitation, female genital mutilation, forced marriages, and crimes said to be committed in the name of honour. There are many connections that can cut across all these forms of violence against women. Some seem to sustain it, while others indicate common impacts and consequences.

While I appreciate that there is to be a review relating to prostitution and a new strategy on human trafficking, their non-inclusion in the Government's

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strategy sends out a negative message that these issues are not forms of violence against women and girls as others are and means that policies will be less effective, such as those which overlap between trafficking, sexual exploitation or domestic violence. For instance, a young woman in prostitution may have a history of childhood abuse, a recent rape, or violent boyfriend or pimp to deal with. All those connections need to be made.

I have two other queries in respect of the strategy. While I appreciate the introduction of domestic violence orders, there is no reference to how, during the period that a ban is imposed on the perpetrator, the victim is going to be protected. I had hoped that the crucial review of the conviction rate for rape would have been reinstated, as in financial terms it will save only £441,000, which I have been told is the reason why it is being removed.

Many research studies continue to find alarming and unwavering levels of violence against women and girls in the UK, and I make no apology for repeating the figures since awareness is a crucial part of achieving change. Some 33 per cent of girls in an intimate partner relationship aged 13 to 17 have experienced some form of partner violence. Every year, a million women experience at least one incident of domestic abuse-nearly 20,000 cases a week, and 3.7 million women have been sexually assaulted at some point since the age of 16. There are 377 cases of forced marriage, many under the age of 16, and 12 so-called "honour" murders a year. In 2003, there were up to 4,000 women trafficked for sexual exploitation. Some 20 per cent of women say they have experienced stalking. Sixty-six thousand women have experienced FGM, and it is estimated by FORWARD, of which I am patron, that 24,000 girls are at risk every year.

Violence against women and girls will not be eliminated until the attitudes that excuse and normalise violence are challenged and transformed. For instance, 36 per cent of people believe that a woman is wholly or partly responsible for being sexually assaulted or raped if she is drunk and 26 per cent if she is wearing sexy clothes. One in five people think it would be acceptable in certain circumstances for a man to hit or slap a female partner. What I think is even more distressing is that one in two boys and one in three girls believe that in some circumstances it is all right to hit a woman or force her to have sex. It has to be made clear that the responsibility for any form of violence or abuse lies with the perpetrator.

Early intervention is a vital part of prevention, and has been key to both strategies, setting out which attitudes are acceptable and which are not. Schools and other institutions such as children's homes are important in challenging the formation of violence and in fostering positive attitudes towards respectful and equal relationships. Prevention of violence against women and girls needs to be deeply embedded across all aspects of the school curriculum, policy and practices, which prompts me to ask if the guidance produced by the Labour Government for teaching and non-teaching staff continues to be circulated and used, and when we will get confirmation that SRE and PSHE are to be included in the schools' curriculum. For while the coalition Government's commitment to teaching sexual

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consent in schools is welcome, this is not enough to create a safe school environment for girls and to tackle effectively attitudes that condone and normalise violence against women.

Equally, violence against women and girls must be a part of the work on sexualisation of children, child protection and parenting. Every day, all across the country, women and children are to be found in accident and emergency units, at doctors' surgeries, at sexual health clinics and drug and alcohol clinics bearing the impact of violence and abuse. The findings of the task force under Sir George Alberti, incorporating the focus groups undertaken by the Women's National Commission reinforced the importance of raising the profile of violence against women and girls, resulting in guidance being circulated to NHS staff. This was reinforced by the inclusion of violence against women and girls in the Operating Framework for the NHS in England 2010/11. Can the Minister assure the House that it will be a part of any new NHS operating framework?

Violence against women cuts across every aspect of public policy and every department of government and local government. There are links between violence against women and fear of crime, rape, assault or stalking, creating the fear of going out at night. Cuts in street lighting costs which are being proposed by some local authorities will only exacerbate that fear. Similarly, big sporting events are a target for increased trafficking and sexual violence, which requires the co-ordination of services both nationally and locally. Perhaps we could hear how that has been achieved. There is clearly value in the Government's cross-government committee on violence against women, but can the Minister indicate its role and membership, and how it will work with local government and the third sector, which will bear the brunt of implementation at a time when they are experiencing budget cuts?

As well as the long-term physical, psychological and social costs, violence against women also represents a significant cost to the economy-£40 billion per year. The direct cost of domestic violence in one year is £6 billion, the human and emotional costs being estimated at £17 billion and each case of rape is estimated to cost £76,000.

The Government are to allocate in total £28 million for specialist services over the next four years, of which £20 million will be funding for the Multi Agency Risk Assessment Conference, and both sexual violence and domestic violence independent advisers, as well as the National Domestic Violence Helpline. However, the Government strategy refers to initiatives such as MARACs and the IDVA as services, but they are not services as such. Will the Minister clarify that statement?

There is also a sustainable model of funding for rape crisis centres. However, no other women's services are included, particularly for the most vulnerable, and BME services are lacking in the policy almost entirely. It is also disappointing that there are no targets, milestones, measurements, monitoring and so forth in the document, but again, can we expect them to appear in the action plan?

Violence against women is not inevitable. In 2002, the World Health Organisation's ground-breaking research World Report on Violence and Health found that,

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That means that the prevention of violence against women requires identifying and challenging the root causes and drivers of violence against women, be it the unequal power relations between women and men, including gender inequality in social, cultural, economic and political spheres or the persistence of rigid gender stereotyping. Such interventions to address violence against women will be effective only if they are part of an embedded prevention strategy that challenges broader attitudes, practices and unequal power relations between women and men.

Leadership at all levels is needed to strongly challenge violence against women and to promote non-violent norms and respect for women. In addition to high-level political leadership, community mobilisation and leadership at a grass-roots level is important for transforming attitudes and driving social change at local level. I am proud to have been involved in my own local community in Brighton and Hove for some years now, where we have been doing that work. That means increasing the capacity of women's services, providing resources for women-only services and local communities to challenge violence against women at a local level and develop models of community-based prevention of violence against women.

Therefore, the prevention of violence against women needs to be located in policy frameworks that promote gender equality and tackle unequal power relations between women and men We must ensure that violence against women is included in the public sector equality duty objectives by public authorities under the Equality Act 2010, which I hope will be retained, and by regular public reporting on progress on key indicators of gender inequality-for example, the gender pay gap, gender division of paid and unpaid work, as well as women's representation in public decision-making.

To summarise, violence against women is one of the main causes and consequences of women's inequality. It represents a violation of women's rights, including the right to gender equality and non-discrimination, the right not to be treated in an inhuman and degrading way, the right to respect for private and family life, including the right to physical and psychological integrity, and the right to life. It will only be by providing adequate resources, support mechanisms and the necessary machinery that the vision that I am sure we all seek of a society where women and girls can lead lives free of the threat and reality of violence can be achieved. I beg to move.

2.24 pm

Lord Lester of Herne Hill: My Lords, it is a great pleasure to take part in this debate and I congratulate the noble Baroness, Lady Gould, on introducing a subject that unites the whole House. I am particularly pleased to take part in the debate because I do not see among the names of those who will speak any of the filibusteros who emulate Cato the Younger in deciding that the best way of obstructing the proceedings of the House is to talk on and on. This is a time-limited

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debate and, because on the whole women are more sensible than men, I expect that it will be as courteous as we have come to expect.

Among those who are speaking are the noble Baronesses, Lady Greengross and Lady Howe of Idlicote, both of whom took part in the historic debate that took part on 26 January 2007, when this House united in seeking to obtain civil protection against forced marriage. The noble and learned Baroness, Lady Scotland, was not able to be here for that, but she of course had played an important role in developing the work of the Forced Marriage Unit and its guidelines, and in her absence the noble Baroness, Lady Ashton of Upholland, stretched the limits of ministerial collective responsibility in encouraging me in a Private Member's Bill and eventually in persuading the Prime Minister Tony Blair to reverse himself and support the Bill, which became law.

I will deal with one matter that is raised in the Motion, which is about reform of the law, and suggest ways in which this country could use the Forced Marriage Act as a model for export within Europe and especially in the Indian subcontinent. The problems of domestic violence are of course not unique to any one country or religion, race or ethnic group. Because some of the aspects of domestic violence, such as the sexual grooming of young girls, children and so forth, have recently been linked with a particular section of the community, and because the right honourable Jack Straw has chosen to come out and say that this is a particular problem involving young Pakistani men, I want to emphasise that it is important not to indulge in ethnic or religious stereotypes. The problem of violence against women is an ancient problem that afflicts all societies, cultures and religions. You do not have to look to any one to stigmatise them. It is important that that should be said.

Forced marriage is only one example-a gross one-of domestic violence at its worst. Forced marriage is a crime. It is not labelled as such but it is a crime when it leads to murder, kidnapping, abduction and offences against the person of one kind and another. I agreed with the previous Government-I am sure the present Government agree as well-that criminal law is not the best way of tackling problems of domestic violence unless one can prove a case to a jury to a criminal standard of proof, which is very hard to do. In this House, we managed eventually to persuade the Government and the other House to deal with it through civil protection instead of relying entirely on the criminal law.

The advantage of civil protection and family law is that it does not involve any public dishonouring of families. It does not lead to victims being permanently separated from their families. It can be dealt with protectively and not punitively. It should diminish the problems by acting as a deterrent through contempt of court for those who violate the forced marriage protection orders. In this country, we have established a radical, new, innovative piece of legislation of which this House in particular should be proud.

I also think that the Forced Marriage Unit guidelines are now superb and I commend them to any noble Lords who have not seen them. They are detailed,

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practical, well directed and have grown out of the work that was done by the noble and learned Baroness, Lady Scotland. The problem is that these issues transcend national boundaries. They cannot be settled in any one country. They require co-operation across frontiers and mutual assistance by governments, judges and legislators.

At the moment within the Council of Europe-the 47 countries from Ireland in the west to Azerbaijan in the east-work is being done on a domestic violence convention. I am sure that the British Government are playing their part in that. My problem with the convention is that it emphasises criminal sanctions too much and does not sufficiently focus on the need for civil protection. I do not expect the Minister to respond to any of this today but I hope that those who are engaged in negotiating that convention will explain to our European partners the need for civil measures and not mainly a reliance on criminal ones. Within Europe we ought to be able to get not uniform but compatible civil protection measures in all 47 countries. That should be our aim under an umbrella convention.

That is one bit. The other is to do with places such as the Indian subcontinent. Many of those involved in the problems of forced marriage and honour crimes are, because of the history of migration to this country, connected with India, Pakistan and Bangladesh. It is really important that we work with those countries' governments and judges to get matching legislation so that if, for example, a young girl or boy is taken to one of those countries fraudulently in order to be given a partner that they must marry, there are measures in those countries that allow them to co-operate with the authorities in this country to get the victim protected and back to this country.

The noble and learned Baroness, Lady Butler-Sloss, managed to arrange a judicial protocol with the then Chief Justice of Pakistan, which you will find in a leaflet in the Foreign Office. Yet when I mentioned this to a Pakistani lawyer friend, she said that the trouble is that that initiative has never been put into legislation in Pakistan and has been treated as illegal. If that is the case, it is really important to persuade the Governments of Pakistan, India and Bangladesh and anyone else connected with the problem-but especially those countries because they are our good friends and neighbours in this area-to legislate, with legislation similar to ours. I am sure it can be done. It just requires some political will and initiative to do it. This ought to be, without being imperial, a major export. I hope that that part of reform will be taken seriously by this Government.

2.34 pm

Baroness Howe of Idlicote: My Lords, I add my thanks to the noble Baroness, Lady Gould, for the opportunity to debate this important subject. I congratulate my noble friend Lord Lester-he is and has been my noble friend on all subjects to do with equal opportunities for many years-on what he has achieved on forced marriage. It is a great achievement and I am proud to have played a small part in the original debate.

Your Lordships will have received excellent briefing and figures, put together with suggested priorities for

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action, from Amnesty International and the End Violence Against Women campaign. As they and the noble Baroness, Lady Gould, have said, one-in-three women around the world will have been so abused and in the UK alone, 3 million women a year will experience some form of violence. The direct economic cost of this each year to England and Wales alone is £6 billion with the human and emotional cost considerably higher, estimated to be no less than £17 billion, and quite apart from violence against women being seen as sexual discrimination and a legal violation of their fundamental human rights.

However, we live increasingly in a global world and it is a significant step forward that considerably more attention is being paid at the international level to promoting a legal requirement to end this abhorrent form of violence. The noble Lord, Lord Lester, has said that it is an example of where a bit more action should obviously take place. The role of new institutions such as UN Women-your Lordships discussed that on Monday-is one such example. All this will help and eventually this violence will not only become internationally illegal but also, more importantly, be increasingly seen as a totally unacceptable form of human behaviour-but, and it is a big but, we are a long way yet from achieving that goal.

We need also to be realistic, not least at a time when all countries face degrees of severe economic hardship. It would seem obvious, for example, that third world countries will take longer to achieve such a goal than developed countries. In parts of the world where conflict or environmental disasters have struck, progress will inevitably be limited or non-existent without much more external support. In environmental disaster areas, the example of Haiti is all too relevant. Hundreds of cases of rape and other forms of sexual violence have been reported in the camps during the past year, with organisations working on the ground believing that these are really only a fraction of the true number of women and girls who have experienced violence. Shamefully, it remains all too clear that in any conflict area it continues to be the unspoken but accepted view that the right to rape women and children is part of a "reward" for successful armies. That disgraceful situation needs a far higher international profile together with the determination to eliminate such behaviour.

Apart from our international role to promote the whole issue-I am sure other noble Lords will mention the importance of that-we surely have a duty to set a firm example here in the UK of what can be achieved. Yet there remains far too much domestic and other violence in the UK. The internet's existence may mean that the amount could be increasing. Your Lordships will recall recent court cases-they have been referred to already-of organised gangs of young men grooming very young women via the internet and I will not go further into that. However, the Government are certainly to be congratulated on having published two months ago their strategic vision, Call to end violence against women and girls. We all look forward to hearing their strategy and priorities for achieving this, due out I believe in March. I hope the Minister will be able to give us some hints about how this is all developing.

Like other noble Lords, I, too, have a wish list of issues that I hope will be included but above all I could

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not agree more with the noble Baroness, Lady Gould, that education of the rising generation must be a priority and the earlier it all begins the better. Some schools-they tend to be the equivalent of not private but voluntary schools-have succeeded with pupil mentoring of new recruits from nursery school upwards and firm stands have been taken against any forms of bullying. That needs to be spread much further. The noble Lord, Lord Northbourne, was here a moment ago but has disappeared. With him, I was hopeful that the previous Government's legislation for citizenship would enable genuine discussions about what parenthood involves to be gone through with the younger generation so that they have a much clearer view of their role in that respect. This should be a high priority now and in future in all schools.

We should not forget either the progress that has been made and when more is achieved things will improve further. Equal pay and more and wider job opportunities have not yet been totally achieved but there has been progress. A lot of this has helped to give women more confidence and money to leave abusive partners if that becomes necessary. More flexible work patterns will also help give more financial freedom as well as time with their children for both parents to develop satisfying, long-term relationships.

I end with two brief points about the need for us all to look carefully at the role of the media in all their forms-particularly, perhaps, the role that the internet plays. Knowing that the material we listen to and watch is not only viewed at home and at work on TV sets and computers but on machines that we all carry around in our pockets throughout the day and night, the first point is the extent to which all our broadcast media have become increasingly frightening and dramatic-even violent-in the drama and social issues that they cover. Noble Lords will certainly remember the recent bloodcurdling screams from "The Archers" but I am certainly thinking also of television soaps and much more, which we all see on television these days.

When I chaired the Broadcasting Standards Council, the watershed was still more or less observed but, again, with the 24-hour impact of the internet there is, in effect, no watershed these days and self-regulation by broadcasters reigns. It is almost as if the public appetite not only demands but, increasingly, is being fed frightening and aggressive material on an escalating scale. My concern is that this is unlikely to be soothing any potentially aggressive or violent behaviour. Those of us who do not believe that what we see and watch on television does not have an influence on us are an increasingly diminishing number. Anyhow, I hope that the Minister will take this back with her, think about it and, perhaps, have discussions with Ofcom about whether there is something more than we can be doing here.

My second point is more specific and will be briefer. It concerns the increasing need in this internet-dominated world to protect children from early contact with pornography and other forms of violence. I frequently raised this issue with the previous Government during the consideration of media legislation. All media equipment needs to have easily understood parental guidance on how to prevent children accessing this

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material. We must never forget that our children are always much more expert at these things then we are ever likely to be.

There is also, one feels, the need for more action at an international level. I really do not know and have not had the time to look up whether UNESCO or anybody else has, rather than just the ability to influence in this area, more specific responsibilities or powers. Internet service providers have some responsibility for checking that those wishing to access that kind of material are indeed adults, but should they have more responsibility? Perhaps someone could look at that. I know that some rules exist which should prevent the use of children in pornography and, to some extent, those are much more likely to be firm. Again, however, we all know that there is quite a lot of this stuff around even if it is more protected in certain ways.

It would be reassuring if the Minister could look at this whole area as part of the Government's strategy in looking at how to get rid of violence against women and children in the future.

2.44 pm

Baroness Massey of Darwen: My Lords, I thank my noble friend Lady Gould for introducing this debate. She also deserves thanks for all her work on behalf of women, in particular vulnerable and disadvantaged women. It is also good to see the noble Baroness, Lady Verma, responding. She, too, has long supported the principles of justice for women, whoever they are and whichever culture they belong to. My noble and learned friend Lady Scotland, especially in her previous role as Attorney-General, was also much concerned about issues relating to women.

It has been pointed out that women are physically weaker and often more economically disadvantaged. They often lack power, so others exert power over them. As has been said, violence against women takes many forms, be it rape, female genital mutilation, torture, forced marriage, beatings or other physical and psychological harm. On FGM, my noble friend Lady Rendell, who has involved herself with this outrage for many years, unfortunately cannot be here, but continues her efforts. I shall make a few introductory comments and then focus on women who are trafficked.

Some statistics have been given but they may be worth emphasising. Over 1 million women are victims of domestic abuse each year; over 300,000 women are sexually assaulted each year; and 60,000 women are raped each year. According to Women's Aid, 70 per cent of teenage mothers are in a violent relationship. All this has economic fallout. Violence against women costs the NHS about £1.2 billion a year for physical injuries, with an added £176 million for mental health care. Among women aged between 15 and 33, acts of violence cause more death and disabilities than cancer, malaria, traffic accidents or wars combined.

It is therefore gratifying that Theresa May has launched a plan to focus on violence against women. Like many others, I look forward to seeing the action plan. I understand that the Government's ambition is to have increased awareness of violence against women

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and girls. I am not sure how that will be measured but, like my noble friend Lady Gould, I would like to see education programmes in schools for girls and boys to counteract violence against women. There are financial implications in tackling violence against women, of course, but I hope that the Government will take into account the costs involved in not tackling it as well. I do not mean just the financial costs.

The trafficking of girls and women, in the UK but also elsewhere, is surely one of the most horrible of crimes against women. Again, the statistics are shocking. At any time, over 140,000 people are victims of trafficking. Of these, 84 per cent are trafficked for sexual exploitation and the majority of those are women. I want to ask the Minister again about the EU directive on human trafficking, an issue that has been raised before with the noble Lord, Lord De Mauley. This directive was voted in by the European Parliament by 643 votes to 10, with 14 abstentions, in December last year. I am aware that many British MEPs supported the directive. Just before Christmas, the noble Lord, Lord De Mauley, told a group of interested Peers that the Government would review their position once the directive was agreed. What is the current situation with regard to this directive and can those interested Peers be informed?

I go back to the impact of the trafficking of women and girls in Europe. A devastating report, Stolen Smiles, was published in 2006 by the London School of Hygiene and Tropical Medicine. I cannot go into all its details but they are chilling. Women were trafficked to 24 different countries, including 53 per cent to EU member states. Forty-two per cent of this group were between 21 and 25, the youngest being 15 and the oldest 45. Sixty per cent had been subject to some sort of violence before they were trafficked and 90 per cent had experienced sexual violence. Forty-four per cent had been tested for sexually transmitted infections, 17 per cent had had an induced abortion and 38 per cent reported having suicidal thoughts because of what happened to them.

Yet some victims of trafficking are prosecuted for crimes that they have been forced into doing. ECPAT UK, the umbrella organisation on trafficking, reports the case of three young Romanian women who had been trafficked for sexual exploitation. The trafficking was suspected by relevant agencies in Manchester but the women were prosecuted and spent time in prison on a charge of prostitution. This surely needs to be looked at. Perhaps the noble Lord, Lord Lester of Herne Hill, could employ his many talents in looking at that as well.

In 2008, the Association of Chief Police Officers, led by North Yorkshire Police's Chief Constable Grahame Maxwell, set up Project Acumen to try to better understand the nature and extent of the trafficking of foreign nationals for sexual exploitation. It concluded that the nature of trafficking makes it difficult to measure or estimate-it is a kind of covert issue. About 6,000 trafficking businesses and 30,000 women were involved in prostitution. There are large profits to be made and unreasonable control over victims is exercised, such as threats to families, debt, fear, shame and religious or cultural mechanisms. Trafficking is not smuggling; it is exploitation, and many of the

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victims are women. The exploitation is, of course, not just about sex. It may also be to do with employment practices.

A 2009 report by Eaves Housing for Women on trafficking and contemporary slavery in the UK points out that Governments of destination countries are often hesitant to address trafficking as a crime that violates vulnerable people because they see migration into those countries as always being desirable. It is not. The report also points out that the sexual abuse and rape of migrant domestic workers is common but underreported. The disclosure of such abuse is used as a threat by employers who know what impact this would have on the workers. Many would be unable to return to their families because of social and familial shame and stigma. What work is going on between the UK and countries from which people are trafficked to combat some of these problems?

A number of campaigns are under way in relation to violence against women. A number of dedicated individuals are involved in combating such violence. The UN Trust Fund is supporting programmes to support country-level efforts. I know that we shall all follow the progress of UN Women, which became operational this month. It has been referred to already and my noble friend Lady Prosser recently asked an Oral Question on the issue.

It is clear that violence against women is entrenched and that many women are locked out of economic and political engagement. This is not just about discrimination; it is about power and exploitation. I hope that this debate and all the issues that have been raised in it will be taken note of and that violence against women will return again and again to the agenda of this House.

2.52 pm

Baroness Hamwee: My Lords, I, too, thank the noble Baroness, Lady Gould, not just because she has given us the opportunity to discuss this wide-ranging subject but because of the importance of raising awareness of violence against women generally. I want to talk particularly about domestic violence and raising awareness of it.

For some years I was the chair of the board of Refuge, the domestic violence charity. In that capacity, I attended quite a number of events with different groups. On every one of those occasions, at which you can see people because you are standing at the front and facing the group, I was aware of at least one woman in the room who, with her expression and her body language, indicated that she was personally affected, although she would never say so. I often read the reaction as shock as she listened and as a sort of revelation-"This is not something that is happening only to me", and, importantly, "What is happening to me is not my fault". There is a need for awareness of the violence behind closed doors; it is private violence, but it is an issue for the whole of society.

My noble friend Lord Lester said that he welcomed this debate because women are civilised when we debate. Indeed we are; I do not take issue with him on that. I am not surprised that my noble friends Lord Lester and Lord Thomas are taking part in this debate. I wish that other male Members of this House were contributing as well-perhaps next time.

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The Motion refers to services. This point applies more widely than just to services dealing with violence, but I want to draw attention to telephone and internet services. It is often much easier, for many reasons, to seek help initially on the telephone. There may be practical reasons for that, although sometimes it takes an awful lot of organisation and care for a woman in a difficult situation to use a telephone. However, emotionally, as well, it is sometimes easier to express oneself when one is not face to face, because the human voice is such a powerful instrument.

I know of the demands that were placed on Refuge and those who worked for it, often in a voluntary capacity, in maintaining a helpline some years ago. A lot is owed to them and to the helpline sponsors. The establishment of the 24-hour national domestic violence free phone helpline, run in partnership between Women's Aid and Refuge, was not without its difficulties, but it was a good decision by the Government to support and fund it. Telephone helplines-in this case I have stressed 24-hour, national and free-and web-based services, to which the point also applies because increasingly people turn to the internet, are essentially not local. We are currently focusing very much on localised services, and I share in acknowledging the importance and effectiveness of services designed to meet the different needs of different communities. Sometimes those communities may be local, but helplines and internet services are not local services in the same way. They do not lend themselves in the same way to local organisation or, therefore, to local funding. I think that what I am saying is that not everything can be localised.

My third point is, in a way, more technical but it illustrates how society still needs to work towards recognising the extent-I think that I mean both the breadth and depth-of violence against women. I ask the Minister to take back the issue of introducing a criminal offence of liability for suicide, which would apply to cases in which the victim of cumulative abuse is ultimately driven to suicide. According to the British Crime Survey, 3 per cent of victims of domestic abuse in 2008-09 tried to kill themselves.

One woman who succeeded, in 2005, was Gurjit Dhaliwal, who suffered 25 years of abuse from her husband. It started, as so often it does, with controlling behaviour-"Don't go there, don't talk to that person"-and isolation from her family and it became physical when she was pregnant with her first child. Following a particularly brutal attack she hanged herself. She was found by her youngest son. Mr Dhaliwal was acquitted of manslaughter because the psychological harm that his wife had suffered did not fall within the definition of recognised psychiatric illness and therefore could not amount to grievous bodily harm. There is a distinction, and there was bound to be one, between psychological injury, which the court found in Mrs Dhaliwal's case, and psychiatric harm.

I know that the Government are aware of this issue. In 2009, for instance, ACPO, in a review for the Home Office on tackling the perpetrators of violence against women and girls, considered whether there should be a new homicide offence of liability for suicide and whether this should be created particularly with regard to relationship-based violence, including domestic abuse

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and, of course, so-called honour-based violence. The chief executive of Refuge, Sandra Horley, has discussed this with the Home Secretary. With two such eminent lawyers sitting in front of me, I am hesitant to bring this into the debate, but I am asking for serious consideration of the issue. I am certainly not seeking to provide a prescription at this point. I am conscious, too, that before the election my party argued that we had too much legislation and that too many criminal offences were created when there was already an offence on the statute book. This does not fall within that category.

I attended my first board meeting of Refuge on the day when I was asked if I would be prepared to become a Member of your Lordships' House. That was 20 years ago. In those 20 years we have seen huge advances in how the issue of domestic violence is dealt with, but we still have a long way to go.

3 pm

Baroness Greengross: My Lords, I shall look briefly at the situation in this country and then concentrate on older women and widows of all ages in many countries across the world. I add my congratulations to the noble Baroness, Lady Gould, who does so much to champion the cause of women at all times. It is a privilege to take part in this debate.

We know, as my noble friend Lady Howe clarified, that 3 million women experience violence every year in this country and that many more live with the legacy of abuse that they experienced in the past. We know that violence can also cause lasting psychological damage and that sexual offences bring the risk of HIV, other sexually transmitted diseases and forced pregnancies. Following that, I am sure the Minister is aware that it is estimated that violence against women costs this country £40 billion every year. From a purely economic perspective, let alone on any moral or societal grounds, the rising incidence of violence against women is totally unsustainable. I add my voice to the others here today that seek urgent action on all aspects of this important matter from the Government.

I turn to older women. Figures were produced by Help the Aged some time ago, in 2004, which showed that 20 per cent of elder abuse reported on its helpline was physical. Forty-four per cent of people calling the helpline reported more than one type of abuse occurring simultaneously. The vast majority-67 per cent-of people who reported violent abuse were women. The main recommendation following that report was that a comprehensive prevalence study was needed to establish the extent and impact of elder abuse throughout the UK. I could not find this report so I am not sure whether the prevalence study ever took place. I ask the Minister whether the Government have any plans to undertake a survey of this type or, if it has been done, to update the existing figures. This would help enormously, enabling us to eradicate a particularly disturbing form of violence.

I turn to the violence experienced by widows in particular. Of all the different categories of women affected by violence, this one is particularly vulnerable, but it is also notably ignored by Governments and the international community. Although there is very little

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research or data, we know through NGOs-in particular, I know through Widows for Peace through Democracy, to which I am most grateful for briefing me-that millions of widows of all ages, including wives of the missing and their daughters, suffer extreme forms of physical, sexual and psychological violence at the hands of both family members and the community at large. For example, in Africa, widows may be victims of harmful traditional practices, such as mourning and burial rites, including ritual cleansing by sex; forced widow inheritance, where a widow is forced to remarry with a husband's relative; and violence meted out in the context of inheritance and property disputes.

However, the worst violence to widows occurs in conflict and post-conflict environments. Widows and their daughters are often targeted for rape, sexual mutilation and forced prostitution since they have no man to protect them as they struggle to survive. In the Democratic Republic of Congo, Burundi and Sri Lanka, for example, this has been very noticeable. In Sri Lanka, more than 31,000 Tamil widows are aged under 30 and many of them are gang raped. In the DRC, hundreds of thousands of widows are rape victims, as they were in Rwanda during the genocide. In Nepal, many young widows of the conflict have been raped by their male relatives. In Kosovo, Bosnia, Iraq and Afghanistan, widows are still the poorest of the poor and routinely targeted for rape and forced prostitution. In many countries in Africa we know that widows are killed as witches, particularly in relation to the AIDS pandemic. In Afghanistan and Iraq, which I have mentioned, widows-increasing in number on a daily basis-experience violence, especially sexual violence, within and outside the family.

This issue is important because, as we know, these widows are the sole supporters of families and future generations, and they have an important role to play in development and peace-building. They need to be protected from violence so that they can care for and educate their children. We have already heard about the huge importance of education.

Lord Judd: The noble Baroness makes a profoundly important point. Would she agree that one of the grave implications of what she is talking about is that there is increasing evidence that violence against women is being used as a deliberate war weapon in conflict, as is rape? The trouble is that international law has not yet recognised this.

Baroness Greengross: I thank the noble Lord for that comment; I agree completely. I hope that the whole House will agree that this is an important issue which should be prioritised in our policies-for example in relation to our national action plans for the implementation of UNSCRs 1325 and 1890, which concern sexual violence against women in war. I agree completely. I hope the Minister can assure me that the Government will ensure that this issue is a priority that will not be overlooked.

3.08 pm

Lord Thomas of Gresford: My Lords, it was a sunny Sunday morning in the middle of the summer of 1971. I had spent the morning drafting seven divorce petitions. It was, I have to say, depressing and oppressive. At

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lunchtime I gave my wife a cuddle and said that I could not stand it any longer: I was not going to do this work any more-and I did not. As your Lordships will appreciate, that day is firmly fixed in my memory. I had had 10 years of it. As a solicitor you are very much closer to the client. As a young solicitor listening to women who had been attacked by their husbands or partners, I realised then what a terrible problem domestic violence was.

Later I was involved in many murder cases that involved domestic violence. The ones that stick out in my mind are those where women reacted to the abuse they had suffered over years. There was a lady who put a hammer through her husband's head when he was asleep, dragged his body into a back room and brought up her family for 20 years before the body was found. She received an absolute discharge. Another lady put a knife underneath a pillow on the sofa, took her husband out and got him really drunk and killed him when they got back. She was given a conditional discharge. I recall a third lady who, after years of abuse, reacted when her husband refused to come through for the dinner she had prepared for him. She picked up the bread knife, looked at it, put it down, picked up the carving knife and killed him. She was given a suspended sentence of imprisonment.

These cases occurred in the 1970s and 1980s and I take no credit for them, because I was prosecuting in each one, but they indicate that there were at that time humane judges who imposed humane sentences and were aware of the issues involved. Those sentences would be impossible in the climate of sentencing that has existed over the past 10 or 15 years. What lessons did I learn from this experience? There were some real psychopaths who enjoyed inflicting cruelty and pain. I remember that one man tied his wife to a chair and left her for three days in that position. But more often, faced with another sentient being, sometimes a dependant with needs and wants to be fulfilled and sometimes a person of superior intelligence and ability, many men are at a loss how to behave. Very often they have grown up without role models. As the noble Baroness, Lady Howe, pointed out, perhaps they take their models these days from violence that is portrayed in the media or, even worse, from pornography which is so freely available on the internet.

These are the last chapters in a matrimonial or other relationship but it is the first chapter that really counts. The Department of Health statistics show that 750,000 children witness domestic violence each year, and most of them do not share that experience with others. These are the closed doors to which my noble friend Lady Hamwee referred. In Wales we have a number of initiatives: the Children's Commissioner; MARAC, the Multi-agency risk assessment conferences, which started in Cardiff; and the current education policy of the Welsh coalition Government, which is well in advance of that in England. Personal and social education is a compulsory part of the education curriculum in Wales. The Welsh coalition Government put into effect explicitly the United Nations Convention on the Rights of the Child. Each school must agree a personal and social education policy which will include sex and relationship education and must be delivered by a senior member of staff.

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PSE and CWW-careers and the world of work-are mandatory components of the Welsh baccalaureate qualification, the WBQ. They are core studies. Learners are obliged to study four elements of PSE and undertake community participation. In Wales this is seen as an opportunity to explore social issues with young people just as they begin to form relationships with each other. The guidance given in a document entitled Personal and Social Education Framework for 7 to 19-year-olds inWales, published in 2008, states that learners should be given opportunities to develop a responsible attitude towards personal relationships; to understand the range of sexual attitudes, relationships and behaviours in society; to understand the importance of sexual health and the risks involved in sexual activity, including potential sexual exploitation; and to learn about the features of effective parenthood and the effect of loss and change in relationships.

Girls should be taught that domestic violence is never acceptable or justified, so that they will react if they are subjected to it. Boys must be taught what is acceptable behaviour, how to respect a partner and to learn about that give and take of a partnership which is the foundation of a stable home in which children can be taught values that will see them through their lives. Investment in education at this stage saves money in the long term on healthcare, lost days of work, criminal justice involvement, housing difficulties and other social problems. I cannot understand why the previous Government allowed the amendment that was introduced in the previous Session of Parliament to be dropped in the wash-up as it would have permitted similar compulsory education to be introduced in England.

Healthcare professionals have a great deal to say in this area. It is said that one-third of violence against women begins when they are pregnant. I do not know why that should be. Are they physically and emotionally vulnerable at that time? It is the policy in Wales that midwives should on a number of occasions-more than once-question a pregnant woman about any concerns that they may have at home in order to satisfy themselves that there is no background of domestic abuse which may harm the mother or the newly born child. That should be extended to other healthcare professionals such as nurses in accident and emergency departments who may have the opportunity to speak to the patient alone after an incident. Training takes place in some hospitals but there are sensitivities in involving health professionals in the detection and investigation of offences.

The Sheffield domestic abuse partnership case study is a new project that was set up in May 2010 because,

This project has grouped together a helpline, domestic violence advisers, outreach workers located in a hospital maternity wing, police domestic violence officers, social workers and youth offending service officers. I shall be very interested to read that study when it reports. It surely is the way ahead.

Specialist domestic violence courts have been successful but they are not rolled out across the whole of the country. Seventy-three per cent of domestic violence is

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repeat offending, with 27 per cent of victims attacked three or more times according to a progress report published in 2007-08. However, a woman will have been beaten many times before she involves the criminal justice system in the first place, which illustrates the strength of the points made by my noble friend Lord Lester. Home Office and academic studies establish that domestic violence accounts for between 16 per cent and 25 per cent of all recorded violent crime-up to a quarter of it results from domestic violence.

Specialist domestic violence courts have increased the number of convictions. However, the problem in these proceedings is keeping the victim on board as a witness. The courts provide specialist teams who are committed to cases being dealt with swiftly. This lessens the stress for a victim called to give evidence and decreases the opportunities for an abuser to stretch out the proceedings in the hope that the victim may be deterred from giving evidence or the chances that the defendant and victim may be reconciled by the time of trial with the victim retracting her statement. There is a disparity in the number of witnesses in domestic violence cases who retract their statements or refuse to attend court as compared with mainstream cases.

In a paper entitled Call to End Violence against Women and Girls, which has already been referred to, my honourable friend from another place, Lynne Featherstone, the Parliamentary Under-Secretary of State for Equalities and Criminal Information, said:

"We need to do, not simply talk about doing".

I commend her determination to make a real difference to women and girls who have suffered or are at risk of suffering violence, to ensure that they can achieve their full potential and live fulfilled lives.

3.19 pm

Baroness Stern: My Lords, I, too, thank the noble Baroness, Lady Gould, for initiating this debate and for encouraging me to participate at rather short notice. It will come as no surprise to noble Lords that I will concentrate my remarks on matters to do with rape.

Rape is of course mainly, although not exclusively, directed against women, and is one of the most serious, invasive and damaging aspects of violence against women. The work that I carried out for my review involved meeting a number of rape victims and listening to what they had to tell me. That made clear to me how damaging rape is and how long lasting its effects are. The report of my review was published last year. Therefore, I will look at some of the developments since then-most of them positive and welcome-as well as seek some guidance from the Minister on where she sees this work going.

Let me start by saying how welcome is the approach that the Government have taken in the document, Call to End Violence against Women and Girls, which agrees on the need for a broad response. Criminal justice is undoubtedly important, but equally important is prevention and support for the victims. I also welcome the way in which the Government have set the discussion in the document within the framework of international norms and standards on women's equality and the Government's obligations under those international

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instruments, which were listed comprehensively by the noble Baroness, Lady Gould. People who have suffered serious violence are entitled to support and help. That is not a favour or a charitable act but a right.

Moving to specific points, I think that one of the major issues surrounding discussion about rape is the question of outcomes in the criminal justice system. In that context, I shall first mention some steps that have been taken by the Ministry of Justice to ensure that the information in the public domain about how rape is dealt with is more useable and comparable than has been the case to date and is less likely to lead to misunderstandings and ill-informed argument. Alongside the announcement of their sensible decision not to proceed with providing anonymity to defendants in rape cases, the Government also published a report that pulled together research evidence. I was glad to have the opportunity-pre publication-to advise on the report. The report, Providing anonymity to those accused of rape: An assessment of evidence, gives for the first time a breakdown of the outcomes in rape cases that come to court.

I want to get those figures on the record, because the more widely known they are, the more likely it is that victims will feel, first, that it is worth reporting what has happened to them and, secondly, that it is worth staying with the process, even though it is lengthy and can be painful. The Ministry of Justice researchers carried out a one-off analysis that found that, of all the 2007 rape cases where the trial was completed by the end of 2008, 42 per cent of defendants were found not guilty and 58 per cent were convicted of an offence, of which 34 per cent were convicted of rape, 17 per cent of another sexual offence, 3 per cent of another violent offence, 3 per cent of another indictable offence, and 1 per cent of a summary-that is, a minor-offence. Thus, 54 per cent were convicted of rape or another sexual or violent offence. This is new information and it is important that we have been provided with it.

I also welcome the report's statement that,

This is particularly welcome because we shall at last be able to compare rape outcomes with those for other serious violent offences. I am very grateful to the research and statistical staff at the Ministry of Justice for the hard work that they have done in beginning to sort out the confusions over outcomes in cases of rape.

The research report also looked at evidence on false allegations and announced a welcome piece of work that will look at the extent and nature of false allegations. That work,

I particularly welcome the decision to undertake that piece of work. When I was carrying out my review, I found the matter of false allegations particularly concerning. Perverting the course of justice by making a false allegation of such a grave crime is serious-there

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is no doubt about that-but in some cases that I came across there was an anxiety about the surrounding circumstances, about the vulnerability of the accuser and about the level of culpability that suggested a more reflective approach might be appropriate. Noble Lords may have read about the case of the abused woman who retracted her report of rape under pressure and was jailed for making a false allegation, although she was subsequently released by the Lord Chief Justice. It is therefore much to be welcomed that the Director of Public Prosecutions announced in a recent statement that interested parties would be consulted about producing new guidance that in future the Crown Prosecution Service will consider before such cases are prosecuted.

I will move on quickly to the question of serious violence against street prostitutes. One of the most remarkable discoveries that I made in the course of the review was that much superb work is being done by a range of people to protect street prostitutes from violence and serious assault and to take the necessary steps to prosecute and bring to trial those who carry out such assaults. At the end of last year, I was privileged to attend a big meeting organised by the Metropolitan Police, at which specialist police from Liverpool, and the outstanding women who work as specialist independent sexual violence advisers with street prostitutes in Liverpool, were invited to share their experiences of the best way of convincing street prostitutes that it is worth reporting assaults and of helping them through the criminal justice process.

In that connection, I will mention a scheme called ugly mugs, which aims to collect intelligence on those likely to perpetrate violence against prostitutes and circulate the information to those likely to be harmed. After a pilot scheme, a plan for a national scheme has been put forward by the UK Network of Sex Work Projects, as there is evidence that such perpetrators tend to move from one city to another. Are the Government looking favourably at supporting the idea of a national scheme to take forward this valuable work?

Finally, I very much welcome the announcement by the Government of continued funding for sexual assault referral centres and independent sexual violence advisers. At the end of last November, I was happy to travel to Ipswich to cut the ribbon at the opening of the first sexual assault referral centre in Suffolk, which brings together the police, local authorities, health authorities and the voluntary sector in a co-ordinated effort to provide a complete service to rape victims of all ages. The opening of the centre was the outcome of years of hard work and a most heartening occasion. Therefore, I ask the Minister, whose commitment to this work is unswerving, to confirm that the Government are firmly behind the continued development of such centres to make them available as of right to every rape victim who wishes to attend one.

3.30 pm

Baroness Prosser: My Lords, I join others in thanking my noble friend Lady Gould for placing on the Order Paper this debate, in which I am particularly pleased to be able to participate.

There was a time when violence against women-and domestic violence in particular-was scarcely discussed. Domestic violence was part of life for many women,

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and nobody thought too much about it. It was either too shameful or simply a fact of life. Many of us will have heard of the ancient law that allowed a man to beat his wife with a stick as long as it was no thicker than his thumb. Happily, things have moved on and we now express our horror of, and opposition to, all kinds of violence against women and girls. Many individuals and organisations have worked tirelessly to persuade Governments of the need for a funded, strategic approach that will eventually eliminate this dreadful blot on our landscape.

Despite all the good work and expressed commitment, the violence continues. We have heard a number of statistics thus far, to which I will add a few: 1 million women every year experience at least one incident of domestic abuse-that is 20,000 women every week-and, on average, two women die every week at the hands of a violent partner. The problem starts young. We have already had statistics and information about the attitudes of teenagers. According to research conducted by the NSPCC, 43 per cent of teenage girls believe that it is acceptable for a boy to be aggressive towards his partner. It has already been said that education needs to play a much greater role.

What else can we do? I declare an interest as the deputy chair of the Equality and Human Rights Commission. In its triennial review laid before Parliament in 2010, the commission identified five major objectives, one of which was that society should aim to put an end to identity-based violence. The commission said that we should:

the information from the noble Baroness, Lady Stern, is of great interest in that regard. Thirdly, the commission said that we should,

It is also worth noting that, under the Equality Act 2006, the commission has a remit to use its powers to work towards the elimination of prejudice, hatred and hostility against equality groups.

Like others, I was pleased to see the previously mentioned report of Her Majesty's Government, Call to End Violence against Women and Girls, but I am concerned that the express commitment in the document will be rendered unworkable or undeliverable by other, separate government policies. For example, page 7 of the document states:

"The majority of services for victims of violence against women and girls are delivered at local level. We will support local areas to deliver the services that are right for their communities by stripping away unnecessary central government targets and initiatives ... Between now and 2013/14, we will also radically change the way these services are commissioned and delivered and encourage the involvement of local communities in deciding which local priorities should be funded".

First, how can local authorities expect to continue to deliver the required level of service, given the major cuts to local government funding? Secondly, I would be keen to know how a local debate on spending priorities-making choices, for example, between care for the frail and elderly versus money for domestic violence-would pan out. I could hazard a guess that domestic violence would not come off very well. Further,

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have the Government considered the possible impact on family life of forthcoming benefit cuts?

I am keen to make clear that I do not for one moment believe that domestic violence is confined to, or more prevalent in, households at the bottom of the financial ladder. It is correct to say that lack of money or uncertainty about whether the rent can be paid or whether the electricity meter can be fed places a huge strain on family life and can make a fragile situation collapse completely. Also, with no access to financial help, a woman cannot leave a violent family home.

I turn to the UK Government's international responsibilities, which have already been mentioned. We have signed up to CEDAW, which monitors the UN Convention on the Elimination of All Forms of Discrimination against Women. On Monday in this Chamber, I was assured of the Government's commitment to the UN office for work on gender-UN Women-but I was no clearer at the end of the Question and debate what that commitment means when translated into hard cash and practical support.

Women in many areas of the world look to countries such as the United Kingdom to come to their aid to help to save them from what can be appalling atrocities. Rape and mutilation are a daily occurrence in the Democratic Republic of Congo-a misnomer if ever there was one. There are so-called cultural practices that leave women with no rights to leave a violent partner or to reject forced marriages and female genital mutilation. If we are to consider ourselves as civilised and sympathetic to the plight of those women, words must be turned into action and must be backed up by the strategic allocation of appropriate resources. UN Resolution 1325 gives us the mechanism to deliver a better life for many women and girls who are currently suffering so badly, who feel abandoned and who are indeed victims of rape and violence as a weapon of war.

I am pleased to see from the previously mentioned government report that the role of champion has been created to ensure the coherence of the Government's violence against women work with UN Women. I shall be keen to hear how this work progresses.

3.37 pm

Baroness Walmsley: My Lords, I, too, thank the noble Baroness, Lady Gould, for introducing this debate. She has been an untiring campaigner on these issues, and long may she continue. It has been a very wide-ranging debate, and I hope to widen it even further with my small contribution. Earlier this week, I was very saddened to see on the front page of one of our national newspapers the face of a nine year-old girl. I think that Christina was her name. She was shot in Tucson, Arizona. She was born on a day of international violence, 9/11, and she died in a hail of bullets. The extremes of her life, the beginning and the end, were defined by violence.

That reminded me, if I needed any reminding, that, for many children, violence is a way of life. I want to concentrate on the early part of life in my contribution today. I believe that prevention is better than cure. We all know that it is more difficult and more expensive to

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put things right once they have gone wrong. I believe that violence occurs when people do not respect each other, do not know how to react and are unable to react sensibly to stress, so they resort to anger and violence.

There are many ways in which we can address those problems. I think that we must go right back to the very root of the problem. My noble kinsman mentioned the maternity unit, and that is not too early. As I have mentioned before in your Lordships' House-I hope that I will be excused for mentioning it again, because it is very important-research has shown that a major factor in the development of all violent tendencies lies in the structure of the developing infant brain. Early patterns are established, both psychologically and physiologically, which affect brain formation, the development of personality and consequent reaction to stimuli for the rest of the person's life. At birth, there are 100 billion neurones and 50 trillion synapses or connections between them, but by the age of three the number of synapses has increased twentyfold. Genes specify some of these connections, but others are the result of experience and are hard-wired by repeat experience. This is why the early experience of the baby is so vital and why early learned behaviour is so resistant to change.

The young brain is extremely vulnerable to trauma, in particular, to stress, which causes the brain to be awash with cortisol, the stress hormone. Cortisol gets in the way of synapses being properly established. That is why it matters and why we need to avoid stress in young babies. Problems will arise from many situations, for example, from violence against the mother or the child. The problem may be pre-natal alcohol or drug abuse. It may be postnatal depression or failure, for some reason, to bond with the mother, the father or any primary carer. A child who has experienced these sorts of stresses will often grow up unable to deal with stress or to establish healthy relationships and may be easily provoked to violence. It is not necessarily his fault.

That is why I welcome the fact that the Prime Minister has asked Graham Allen MP to produce a report about early intervention, which I believe will be published soon-next week, I think-and I pay tribute to him and those who have assisted him with his report. I also pay tribute to Iain Duncan Smith for realising the importance and value of early intervention. I look forward with eager anticipation to reading the report since I hope it will provide us with some of the ways forward to help deal with domestic and other violence at their roots, as well as with poverty, crime, ill health and lack of educational opportunity. I will judge the report, and I hope the Government will judge the report, on how early are the interventions it recommends and how rigorous the methodology used to select the interventions to fund. I hope the Government have put aside public money to invest in early intervention, since it will be a very good investment, but, of course, we must be sure that public money is being spent on the right things, so we must look very carefully at the report. I understand that there have been many submissions from experts emphasising the importance of the early years of life, and I wonder whether the Minister can tell me whether these submissions have

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been published because I would be very interested in reading them. If we as a Government have vision and if we are to be responsive to the mass of excellent research out there, we must tackle the roots of domestic violence with really early and proven interventions.

That is why, despite economic constraints, we must continue to invest in family support. Strong families produce well-balanced people with good emotional and mental health. Children learn to copy the behaviour of their parents, so we really need to put a full stop to physical violence against women and children in the home. A boy who is constantly being hit by his father and who watches his mother being hit by his father will think that is the normal thing to do, and when he grows up, he will probably decide to model that pattern and hit his partner, so we have to stop it at a very early stage.

However, there is a lot that can be done in schools, and I would like to tell your Lordships about two experiences I had before Christmas. They both relate to programmes with teenagers that I think also have an important place in our armoury against domestic violence. One was a visit to Winchmore School in north London where I saw young people exploring issues of domestic violence in their drama class. At lot has been said in this debate about the attitudes of teenagers, but I was impressed by the way the young people had identified the situations that might arise, analysed the issues and improvised little dramatised scenes to illustrate what happens. They had clearly picked up the fact that many violent offenders blame the woman for "provoking" them to violence, an excuse which the young people quite rightly did not accept at all.

The work also helped them to develop strategies for themselves and their fellow pupils to avoid violence and to respond appropriately to it when they came across it or experienced it themselves. The importance of being able to talk to their friends was very high up their list of things that can help. It is very important that we continue to have opportunities in schools for young people to explore these issues.

The other experience was chairing a seminar for the charity WOMANKIND about violence against women and girls. Two terrific groups of young people from schools many miles apart made a great impression on me. Noble Lords will not be surprised to learn, following the words of my noble kinsman Lord Thomas of Gresford, that one of them was from Wales, where they are ahead of us in many of these issues.

Both groups were acting as mentors or counsellors about violence and bullying in their own schools. They were girls and boys. Under the guidance of some very committed deputy head teachers, they told us how they worked. They made presentations to the rest of the school at assemblies, they worked through the school council to inform the rest of the school about the issues they had studied and learnt about and they made themselves available as a ready ear for troubled fellow pupils. Because of the guidance and support they had been given, they were able to direct pupils with problems to places where they could get further professional help if necessary. They claimed that their peers were now more likely to confide in them than in

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a teacher and that they had good training and support and knew what to do if serious matters arose. The whole school was more aware of the problems. Both groups claimed that bullying had decreased in the school, and-this is crucial-that the attitudes and respect of boys towards girls had very much improved. Such schemes have enormous value, and I hope they will continue to be funded. Many of them are funded by voluntary organisations.

Finally, may I put in a good word for the enormous value of high-quality personal, social, health and economic education in all schools at all levels, age-appropriate of course? All children need, and have a right to, such education to establish and maintain good relationships of all sorts throughout their lives and help them develop self-confidence and healthy attitudes to other people. We in this country are signatories to the UN Convention on the Rights of the Child. Articles 17, 24 and 29 oblige us to provide our children with such education. I hope that the forthcoming curriculum review will give PSHE the importance it deserves and I will continue to lobby Ministers for that.

3.47 pm

Baroness Finlay of Llandaff: My Lords, I am grateful to the House for allowing me to speak briefly in the gap in this important and powerful debate initiated by the noble Baroness, Lady Gould. I want to focus on healthcare and a concern as to whether the NHS reforms might inadvertently promote, rather than decrease, abuse blindness in healthcare. We know that one in four pregnant women is abused, that in just under a third of these cases abuse starts in pregnancy and in just over a third of those being abused, abuse worsens in pregnancy. We must recognise child abuse in the womb in policy, because the outcomes for these infants are worse, including an adverse effect on brain development, as the noble Baroness, Lady Walmsley described, an increase in risk of death in the first year of life, and underperformance throughout the rest of child development.

A study of midwives recently published showed that three-quarters in hospital practice and almost a half in the community had no training in domestic violence, and many had no child protection training. Even when trained, the training effect wears off, so abuse awareness needs to be part of clinical service contracts, with a requirement to ask the question and act on the response, and follow the Welsh example. In that study, although 12 per cent of community midwives encountered definite child abuse, only 2 per cent reported it, leaving a 10 per cent gap between identifying and acting on abuse.

Double vision requires simultaneously looking at the woman who is being abused and the child. The GP is in a unique position to ask about abuse; such questions are overwhelmingly acceptable to women, particularly those frightened of instigating any action themselves. Children in those households are 30 per cent to 60 per cent more likely to be abused, with poor performance and aggressive and disruptive behaviour.

Will the quality outcome framework that has changed general practice behaviour be looked at? Have the Government considered using QOF as a way of

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encouraging GPs prospectively and sensitively to ask about abuse and to signpost support? It has to be tackled at every opportunity.

3.50 pm

The Lord Bishop of Ripon and Leeds: My Lords, I, too, am grateful for the permission, and the nudge, to speak in the gap in this debate. I apologise to the House for not having been present for the opening speeches. Had I been able to be here I would have put my name down to speak in this crucial debate on the place of women in our society and on violence against them.

I want to make three cultural points. The first is to emphasise, as a number of noble Lords have come to do, the danger of secrecy in all this debate and the unwillingness of people to speak about violence against women-that is, those who are the direct victims of violence and those who know about that violence. There needs to be within our culture a much greater willingness to challenge violence against women than I detect at the moment.

Secondly, religious groups need to be encouraged to be quite clear about their opposition to violence against women and to their willingness to act where there is violence against women. I believe that the record of faiths in this area is not as good as it should be. I should like to encourage all of us, but particularly those with responsibilities within the faith communities of our country, to be still clearer about our opposition to all violence against women.

One way in which this can happen is through an increasing use of marriage preparation. A large number of young, and not so young, people come to marriage through the offices of the churches and other faith organisations. Our marriage preparation needs to make it still clearer that violence is completely wrong within a marriage relationship.

On the third of my cultural points, I support strongly what the noble Baroness, Lady Walmsley, said about the need to prevent violence in our homes from the earliest ages of children. I am among those, as many of your Lordships will be, who have signed documents and have been part of the various coalitions under the Children are Unbeatable! tag. The right reverend Prelate the Bishop of Gloucester is another who has signed and has been a part of that movement. I believe that we need to do more in law to stop any form of violence in our homes. I would hope that there might be support from the Minister in pursuing that.

This is a crucial area. I am pleased to have been given permission to contribute to it, and I look forward very much to the closing speeches and to a sense of direction and purpose in all that has been said today.

3.54 pm

Baroness Scotland of Asthal: My Lords, in replying, I declare an interest as patron of the Corporate Alliance Against Domestic Violence, chair of the All-Party Parliamentary Group on Domestic and Sexual Violence, and former chair of the Inter-Ministerial Group on Domestic Violence. I immediately congratulate very

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warmly my noble friend Baroness Gould on securing this debate and introducing it in such a comprehensive, fluent and informed manner, setting the tone and scope for this debate so that many noble Lords could fly under her wings and explore some vital issues. I also congratulate and thank all those who have participated in this debate so far, before the noble Baroness, Lady Verma, replies. Most of us are very old friends. We have been on this journey for a long time and it is good to see that we are all still here, although perhaps sad that we have not yet expunged violence against women.

As this debate has demonstrated, this is not an issue on which we have ever divided on party political lines. It is one that unites us in our determination to eradicate domestic violence and every other form of violence against women and young people. That was very much the tone in which we did battle together against this vicious crime during the last Labour Government. We did not hesitate to draw on the wisdom of many in this House, not least the noble Lord, Lord Lester, on forced marriage. We did that without repentance, although I would say to him very gently that he may have forgotten that the initial Bill was all about crime and our issue was that we thought it should be civil.

Lord Lester of Herne Hill: I am sorry to correct the noble and learned Baroness, but that is not quite right. The initial Bill was about harassment; it was never about crime.

Baroness Scotland of Asthal: My Lords, we will differ, but we will absolutely agree that we ended up in just the right place. I also agree with him that that legislation is more than fit for emulation, because it does what is prescribed on the tin. It is very effective, and delicately enables people to have their rights trenchantly supported but in a way that is sympathetic and effective. That is a demonstration of how well we have been able to work together. Noble Lords will remember that, when we first started to work on this issue in a very concentrated way in 2003 and 2004, we were met with some pretty stark statistics, some of which have been referred to already: one in four women, one in six men, 120 women and 20 men dying, and 89 per cent of repeat victimisation being of women.

The concerted effort that was made by all-those in the Government, those in local government, those in the third sector by individuals-enabled us, together in partnership, to make a strategic change. All of us remembered-and it has rightly been said in this debate-that this was not just a national but an international issue. As the World Health Organisation made clear, domestic violence was the greatest cause of morbidity in women and children globally. That had to be changed.

In the 13 years of Labour government, that determined action, together with all those who helped us, brought about some real progress. The instance of domestic violence has fallen by 64 per cent since 1997. There was, as the noble Baroness, Lady Stern, has already mentioned, a 54 per cent increase in the number of convictions for rape from 2000 to 2008. Our understanding of the economic cost of domestic violence to our country was stark. Professor Sylvia Walby, as many in this debate will remember, helped us greatly with her

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assessment in 2004 that the economic cost of domestic violence to our country was £23 billion: £3 billion of which was to public service, £2.7 billion to business, and £17 billion in pain, injury, loss and suffering. The models that we put together, as we have already been told, started in Wales. Cardiff was the launch pad of much of the good practice. However, we learnt that it has to be holistic. Everyone-all departments and entities-had to be involved.

As a result of that work, when Sylvia Walby went back to assess the cost of domestic violence at the end of 2009 we saw that we had together done something quite remarkable; we had reduced the cost of domestic violence by £7.5 billion. She used exactly the same model, so when it has been said in this debate that the UN identified that we can change violence against women, we know that that is right.

How did we do it? Many have already mentioned that in this debate: by introducing specialist services such as the specialist domestic violence courts. I absolutely understand that a number of courts are closing, but will the noble Baroness be kind enough to indicate whether any of the courts to close will be domestic violence courts? They have been pivotal in bringing about significant change, as had already been noted.

There were specialist domestic violence courts, specialist police officers, specialist prosecutors, the independent domestic violence advisers, the independent sexual violence advisers and, really importantly, the MARACs-the multi-agency risk assessment conferences-which enabled us to interdict the violence early, the point made by the noble Baroness, Lady Walmsley. Prevention is far better than cure. The point was emphasised so succinctly in the gap by the noble Baroness, Lady Finlay of Llandaff, who pinpointed the great work that we were able to do on health by helping professionals in the health service to identify and address it in vitro, and thereafter, really making a huge difference.

We know some of the things that we must do to intervene. We know that rape happens in marriage, and that those who are involved in violence against women often continue that violence outside the home and are a threat to others. The nexus between those two things is of great importance.

Having commended the Government for continuing their commitment to independent domestic violence, MARACs, the independent sexual violence advisers and the rape referral centres, I ask whether the noble Baroness has any assessment of the changes that will be made in local authority funding. Many of us believe that we are almost at a tipping point. We had the recipe and we were applying it. There was a lot of vigour and we were almost there. I share with the House and the noble Baroness, Lady Verma, who is passionately committed to this area and has been so not only from the moment she sat on the Front Benches opposite but for many years, the view that we may be at risk for some of the reasons touched on by the noble Baroness, Lady Prosser. I am hearing some very worrying issues.

The noble Baroness and the House will know that last year we saw a helpful decline in the number of people in many of the refuges. They were emptying. It was a downward trajectory. We are now told that that

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trajectory is going in the opposite direction. One refuge in particular was 100 per cent full and the only place in which a vulnerable woman and her children had to stay was in her car outside a police station, because there was no safer place for her to be. Just a year before, the refuge had had 60 per cent occupancy. It is a worrying indication.

I asked whether the Corporate Alliance Against Domestic Violence had any further information, and I have been told that right across the country, in the east and the west, it is hearing similar stories. Independent domestic violence advisers are being reduced. The noble Baroness will know that they have been key to prevention, risk assessment and change. In Portsmouth, I am given to understand that there were 10 independent domestic violence advisers, and it looks likely that they will be reduced to three. That pattern is happening all over the country. It has been suggested that the cause is that although local authorities were aware that there should be cuts, many of them had planned for cuts over the whole period of the Parliament, but the burden of frontloading those cuts means that they cannot do what they want to do. I commend the Government on their invitation to local authorities to consider very seriously indeed the consequences of those cuts. Can the noble Baroness say a little more about what she and her Government propose to do to ensure that the changes that we all worked so hard to implement remain in place, because every £1 spent on these services saves at least £6.

The noble Baroness was asked a further question by the noble Baroness, Lady Howe, and if I may I will ask her a little more. The noble Baroness, Lady Howe, discussed the effect of the internet on the sexual exploitation of our children. The noble Baroness will remember that it has been proposed that the Child Exploitation and Online Protection Centre, an organisation that has been praised by everyone, be subsumed into the Serious Organised Crime Agency. Will that in fact happen, bearing in mind that the move has been wholeheartedly condemned by so many, and is there likely to be a rethinking of the issue?

On trafficking, we would welcome a response from the Government on how they now propose to deal with the directive. The noble Baroness will remember that many on this side of the House fought very hard indeed to encourage the international community to work together on this, so it is a great sadness to us to see that the voice of Her Majesty's Government is not championing the issue right out in front.

We have had an extremely good debate. I look forward very much to the noble Baroness's answers to the numerous questions that she has been asked, and I should say that I agree with all of them.

4.08 pm

Baroness Verma: My Lords, I start by thanking the noble Baroness, Lady Gould of Potternewton, for initiating this important debate and all noble Lords for their valuable contributions. I welcome the fact that we have had a further opportunity to debate this important issue. The noble Baroness, Lady Gould, is a great champion of women and women's issues, and her never-ending energy in ensuring that their voices

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are heard is to be admired. I have enormous personal respect for the noble Baroness, whom I regard not just as a noble Baroness but as my friend.

It is unequivocally in the national interest to ensure that women and girls are able to achieve their potential and lead fulfilled lives. We will raise the position of women by promoting equal pay, ending discrimination in the workplace and tackling violence against women and girls both in this country and overseas. This is a key priority for our Government. Violence against women and girls cannot be accepted under any circumstances or for any reasons, yet we continue to see that, in the United Kingdom at least, one in four women will be the victim of domestic abuse and that every year, as has been said, more than 300,000 women are sexually assaulted and 60,000 raped. Internationally, findings in a number of developing countries suggest that violence against women and girls is significant and often endemic. Between 40 and 60 per cent of the women surveyed in Bangladesh, Ethiopia, Peru, Samoa, Thailand and Tanzania said that they had been abused by their immediate partners.

Our ambition is to end violence. We need to make a real difference to the lives of women and girls who have suffered or are suffering violence. We recognise that it is not a short-term task, and achieving this goal will prove difficult, with barriers and obstacles at every juncture, as we work towards a cultural shift.

The causes and consequences of violence against women and girls are, of course, extremely complex. For too long, work in this area has focused on the criminal justice response alone. This Government will continue to ensure that the police and courts have the tools that they need to bring offenders to justice and, more importantly, to ensure that victims have the support they need to rebuild their lives. However, this issue cannot be looked at in separate silos, but as a whole.

We are working across government to prevent and tackle violence against women and girls in the long term, and on 25 November last year we published our approach to how we will achieve this. For the first time, this approach includes our international efforts at bilateral and multilateral levels. To ensure that tackling violence against women and girls remains high on the international agenda, we have appointed Lynne Featherstone as the ministerial champion for tackling violence against women and girls overseas. The Home Office, the Foreign and Commonwealth Office and the Department for International Development are currently finalising plans to support the Minister in this important role.

We will also continue to promote the empowerment of women worldwide by supporting the newly formed agency UN Women, the implementation of the Convention on the Elimination of All Forms of Discrimination Against Women, and by placing gender equality and empowerment of women at the centre of international development-essential to the achievement of all millennium development goals.

It is extremely important that continued support for victims is available, particularly in an economic climate that requires us to spend less and yet work more effectively and efficiently. That is why we are

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determined to move away from the piecemeal funding arrangements of the previous Government. It is why we have allocated £28 million of stable Home Office funding for specialist services over the next four years. That will include the provision of funding and advice to local areas to support independent domestic violence adviser posts, independent sexual violence adviser posts and the role of the multi agency risk assessment conference co-ordinators.

The allocation includes direct support to voluntary and community sector organisations and I can confirm that the Home Office is currently inviting bids for the next financial year for funding totalling £5 million from services that support victims of domestic abuse and sexual assault. We will also continue to provide direct funding to the national helplines that provide support and advice to all victims of domestic violence, including men.

We are providing stable funding to those specialist services that have the greatest reach and we are working to ensure that our communications take the information about these services to all communities. Alongside that, we are developing a sustainable funding model to deliver new rape crisis centres across the country and we will provide existing centres with stable and long-term funding.

Women and girls in every area are being subject to abuse, and local authorities have an important role in ensuring that they are able to overcome the abuse. Despite the difficult economic climate, centrally we have sent out a clear message that violence against women and girls is unacceptable and it is a key priority for us to ensure that we have all our powers working to eliminate it. We will support local areas to deliver the services that their communities need by removing unnecessary targets, ensuring greater local accountability and raising awareness about abuse with front-line professionals.

The specific issue of funding for refuges is one that has been raised. I must be clear that the allocation of funds for domestic violence provision is a matter for local authorities to determine, based on local needs and priorities. However, throughout the spending review, we have been guided by a commitment to fairness, protecting the most vulnerable people in our society and, as far as possible, protecting front-line services.

We have secured investment of £6.5 billion for the Supporting People programme over the next four years. Local areas will continue to take decisions informed by local needs in commissioning housing-related support services for victims of domestic violence. The Government are also committed to finding a long-term solution to support women who come to this country on a spousal visa, find themselves a victim of domestic violence and have no recourse to public funds. We will continue to support these women while a more permanent solution is found. We are at the beginning of the work we want to do, at the beginning of a funding cycle in a difficult economic climate. While we will always keep our actions under review, this is our vision and approach for the coming years.

Law and the application and enforcement of the law are clearly part of what we do. I should like to highlight a number of key points in that area. From

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June 2011, we will pilot domestic violence protection orders for 12 months in West Mercia, Wiltshire and Manchester. The DVPOs will potentially provide an additional tool for the police in dealing with perpetrators of domestic violence to ensure that the victim has sufficient opportunity to consider her long-term options. We deferred the decision on the pilots so that we could understand their potential impact better and be sure that they would work before committing public funds. We will conduct a full evaluation before we make a decision on national implementation.

Section 9 of the Domestic Violence, Crime and Victims Act 2004 will bring into law a requirement on local areas to hold a multi-agency review following a case of adult domestic homicide. Domestic homicide reviews are an effective learning and prevention tool for local areas and we are working through the implications of this with our partners before implementing the power. We have committed to introducing this power in spring 2011.

Since the Forced Marriage (Civil Protection) Act 2007 came into force, we have issued 247 protection orders to protect vulnerable women and men. This is significant, but we know that much more needs to be done. We are committed to raising awareness of forced marriage not only for the individuals concerned but also so that their families and their communities understand that we will take action to prevent young people being forced into marriage against their will. We will also continue to support front-line professionals from schools, children and adult social care, housing, health and police by providing step-by-step advice.

Another issue of great concern is the lack of prosecutions for female genital mutilation. We have no reason to believe that the Crown Prosecution Service would not be prepared to prosecute if cases were referred to it and there was sufficient evidence to provide a realistic prospect of conviction. Anecdotally, the most likely barrier to prosecution is pressure from the family or wider community to stay silent. However, the Female Genital Mutilation Act 2003 provides a clear message that FGM is an unacceptable practice and illegal in England and Wales. The Act has also been a catalyst for outreach work and has helped to raise awareness of FGM. We will shortly launch new guidelines which will support front-line staff to tackle and prevent the practice, provide support to women and girls and encourage the referral of all suspected cases to the police for investigation.

Non-molestation and occupation orders can be made under Part IV of the Family Law Act 1996. Such orders are aimed at protecting women from violence or threatened violence, intimidation or harassment. An occupation order can specifically exclude a perpetrator from the family home or surrounding area. Such orders can provide vital protection for victims and their children. It is therefore important to note that the year-on-year rise in applications for non-molestation orders between 2007 and 2009 would appear to contradict suggestions that applicants may be deterred by the possible criminalisation of the respondent since Section 1 of the Domestic Violence, Crime and Victims Act was implemented in July 2007.

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The Sexual Offences Act 2003 was a complete overhaul of the legal framework for dealing with sexual offences and introduced a statutory definition of consent. We know that sexual violence and rape are underreported crimes and therefore neither prosecuted nor convicted as we would like them to be. There has been some progress. For example, during the four-year period from 2006-07 to 2009-10, the number of rape prosecutions by the CPS rose by 17 per cent from 3,264 to 3,819. But of course we need to do more, and the Government are determined to do more. Our response to the independent review of rape complaints by the noble Baroness, Lady Stern, will help set out our direction for this.

In October last year we implemented the Equality Act 2010. As part of the Act we are introducing a new public sector equality duty which requires public bodies to consider how their policies meet the needs of all those who use their services. Public bodies will be required to publish data on the impact of their work. This will include relevant data on how they are tackling violence against women and girls and will mean that the public are able to hold them to account.

I will now try to answer some of the questions put by noble Lords, and if I cannot do so I pledge to write to them. I understand fully the concerns of the noble Baroness, Lady Gould, about prostitution and trafficking being placed in separate strategies but I assure her that it in no way diminishes our determination to address those two particular issues. She is of course absolutely right: it will take a massive cultural shift, not just legislation, for us to be able to ensure that violence against women is on the decrease. We cannot change society and our community actions unless all the partners and actors play their roles within that shift, which we all want to happen.

The noble Baroness, as well as the noble Baroness, Lady Howe of Idlicote, asked about violence against women and girls being addressed in the teaching in schools. The Government will shortly be announcing a review into personal, social, health and economic education and sexual relationship education. The Department for Education's advisory group will feed into the review part of the coalition Government's commitment to the teaching of sexual consent and healthy relationships in the curriculum-an issue which I think the noble Baroness, Lady Walmsley, raised. Other noble Lords raised the issue of violence against women being addressed in the NHS operating framework. The Department of Health is currently considering the inclusion of violence against women and girls in that framework. Further details of the Government's approach in this area will be included in the violence against women and girls action plan in the spring.

I am grateful to the noble Baronesses, Lady Massey and Lady Gould, for raising the important issues surrounding trafficking. The Government are committed to working with others, including our European partners, to prevent human trafficking. Our work on trafficking will be taken forward in a separate strategy, as I have already said. In June 2010 the Government decided not to opt into the proposed EU directive on human trafficking, but also to review that position after implementation of the directive. Negotiations on the

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directive's text were agreed on 13 December, and the directive is scheduled for adoption early next year. If we later conclude that the directive would help us fight human trafficking, we will opt in. I reassure noble Lords that the UK has a very strong record in fighting trafficking and already complies in legislation and practice with most of what is required by the draft directive. The UK will continue to play an active role in helping to improve EU-wide efforts in combating human trafficking.

I turn to the concerns of the noble Baroness, Lady Walmsley, about the role of better communication in preventing violence against women and girls happening in the first place. This is at the heart of our Government's approach and we are taking steps to ensure that, through the curriculum and our cross-government communication strategy, all avenues are explored in ensuring that we do not fall short. We want to ensure that communications are available to all those who are at the forefront of identifying abuse. We are carefully considering the findings from the independent Munro review of child protection to focus on better supporting child-focused front-line practices. Further detail outlining how this will take place will be published in March. This Government have made a clear commitment to early intervention in the coalition's programme for government, which said that we would investigate a new approach to helping families with multiple problems where violence and abuse can be a risk factor.

The noble Baroness, Lady Howe of Idlicote, also talked about the sexualisation of children. It is essential that we take steps to challenge these messages, demonstrate that they are not acceptable and work to put positive models and messages in place. That is why the Government have asked Reg Bailey, chief executive of the Mothers' Union, to conduct an independent review into this issue. That will report in May 2011.

I am now going to try to read my scribbled notes; I apologise. The noble Baroness is right that this is not just going to be a United Kingdom problem-we also have to look at its implications internationally. We take that seriously, and, with our ministerial representative Lynne Featherstone, we hope that at UN Women the issues that we feel strongly about are focused and directed there.

My noble friend Lord Lester talked about forced marriages. It is a great privilege to have supported the noble Lord and the then Government when that Bill came to this House. I had the privilege of leading from the Conservative Benches. I come from a community where, unfortunately, this practice continues to blight and scar the lives of too many young boys and girls. It is a long and difficult journey to be able to ensure that we are making enough awareness available to those communities to make them see how much of a long-term impact such forced marriages have on young people. Wider than that, it frightens young people away from the prospect of marriage; they feel that they cannot approach their own immediate families to raise their own personal fears. Like the noble Lord, I intend to take every opportunity to endeavour to ensure that this issue is raised, not just in this country. Like the noble Lord, I take it as a personal mission to raise the issue in every country that I visit.

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The Government have committed to providing a full response to the review of the noble Baroness, Lady Stern, into how rape complaints are handled by public authorities in England and Wales. That will be published in the spring alongside the Government's violence against women action plan. The Government's response will highlight the importance of sexual assault referral centres and the role of rape crisis centres. The coalition Government's commitment to supporting those services is outlined in the strategic narrative on violence against women and girls that was published in the autumn. We have already awarded £2.2 million in 2010-11 to improving SARC provision. The Government will shortly announce further funding details for rape crisis centres and SARCs over the spending review period.

To touch on the "ugly mugs", the Government are currently funding a feasibility study into the development of a national ugly mug scheme. Such a scheme would help to co-ordinate the local schemes currently run by specialist voluntary sector projects. These allow people in prostitution to report information about incidents of violence that they have suffered or provide information about threatening or dangerous clients.

My noble friend Lady Hamwee raised the issue of the work of the Inter-Ministerial Group on Violence against Women and Girls, which is chaired by the Home Secretary. The Minister for Prisons is currently writing to the Home Secretary to clarify the position of the group and how it will take forward its work on recognising suicide as part of the abuse. I hope we will discuss this at our meeting in February.

The noble Baroness, Lady Greengross, talked about older women. I thank her for raising this serious but underreported issue. As someone whose business is in care, I understand completely the number of victims that go unreported simply because they do not know where to turn, because their immediate protectors are usually the very people who are carrying out the abuse. I will take that important message back to the department. We need to make sure that it is raised and that we are fully aware of it in our thinking and strategies. Widows are victims who often have the least voice or presence in society. They are often ostracised and abused, and their plights are often simply ignored. Again, it is something that we need to take back and think about more carefully.

I hope noble Lords will indulge me for one or two more minutes so that I can complete my responses. My noble friend Lord Thomas and the noble Baroness, Lady Finlay, talked about the training of health workers in dealing with violence against women and girls. The Department of Health is currently rolling out training to front-line health practitioners to identify the early signs of violence against women and girls. This is part of the Government's response to the Alberti review and the work of the Department of Health's task force on violence against women and girls. The Government are also exploring how health visitors might have a greater role in identifying the signs of domestic violence in the women they visit. Further details on the training of front-line workers to identify signs of violence in order to intervene early will be outlined in the Government's action plan in March.

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I agree very much with many of the things that the noble Baroness, Lady Prosser, said about there being substantial change, but there is still much to be done. In some communities where it is still acceptable as a norm to beat wives, sisters and daughters, that change is incredibly slow; and because those communities know the abuse will not be reported outside, the abuse will continue. There is a huge mountain to climb. There is no doubt about that.

The noble Baroness asked about our funding for UN Women. We are undergoing bilateral and multilateral reviews. Until those have concluded, which they should by the spring of this year, it is difficult to comment on funding. However, we are offering transitional support.

I have been passed a tart note telling me to say that I will write to all noble Lords whom I have not answered. I thank the noble Baroness for initiating this debate.

4.34 pm

Baroness Gould of Potternewton: My Lords, I thank everybody who has spoken in this debate, which has been very wide-ranging. One of the things that I always find fascinating about debates like this is how much you learn from other people. The expertise that there is around your Lordships' House has been offered today in this debate. It has shown the breadth of the subject that we are talking about, which makes it more difficult and complicated to solve. Certainly the solutions are in many ways very complex, but I do think these problems are solvable.

Many noble Lords mentioned the international situation. That is right and may be a subject for another debate, which I would very much appreciate, not least because I have been actively involved with both the UN and the Commonwealth Institute on the question of widows. I would like to have a debate on that subject.

The noble Baroness, Lady Hamwee, said that this was not just an issue for women. She is perfectly right: it is not just for women but for the whole of society. We have to raise awareness, talk about the issue as much as we can and work to find solutions. I look forward, as I am sure other noble Lords do, to working with the noble Baroness, Lady Verma, to make the strategy work so that we obtain a real solution to this very serious problem. In the mean time, I beg leave to withdraw the Motion.

Motion withdrawn.

NHS: Front-line and Specialised Services


4.35 pm

Asked By Lord Turnberg

Lord Turnberg: My Lords, I suspect that your Lordships may feel that we have had rather a surfeit of debates on the NHS of late, and we have not even seen

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the Bill yet. However, I am pleased to open this debate as it gives us an opportunity to reflect on what the Minister has said in his previous responses and to try to be constructive in preparing for the Bill.

I should express my interests again as someone who has spent most of his working life in the NHS as a physician and professor of medicine and then as president of the Royal College of Physicians and more recently as scientific adviser to the Association of Medical Research Charities. I am pleased that the noble Baroness, Lady Jolly, will make her maiden speech in this debate. I very much look forward to hearing what she has to say.

In our previous debates a large number of criticisms of the White Paper came up, ranging from the wide extent of the proposed changes and whether they were proportionate to the perceived problems of an NHS of which many noble Lords extol the virtues, to a sense that a damaging commercialisation was creeping in. I have to admit that the previous Government were not immune from reorganisation and re-reorganisation zeal but it is significant that it was only when there was a clear increase in funding and a remarkable rise in the number of nurses and doctors that we saw a real improvement in patient care. So while reorganisations may be necessary at times, it is money that talks. At a time when we will be seeing retrenchment in the service, we must ensure that we do not cut these front-line staff.

I imagine that the Minister is aware of the study carried out by Sir Brian Jarman a few years ago in which he showed that there was a strong negative correlation between the number of doctors in a hospital and the mortality rate in that hospital-the more doctors, the lower the death rate. In that light, are there to be any cuts in the number of trainee doctors in the near future?

I shall mention three specific topics that impinge on front-line services: the pathfinder consortia; integrated services; and research and teaching. The pathfinders should generate a lot of valuable information. Leaving aside the bias that is introduced by the fact that this is a group of self-selecting enthusiasts who may not represent the generality of somewhat disinterested GPs, the data they will produce should be extremely helpful in deciding which paths to go down and which to avoid. After all, that is what I understand by the term "pathfinder".

So my questions for the noble Earl are, first, will the Department of Health collect information that will help in the design and size of the generality of consortia when they are rolled out? Secondly, what sort of information will be used in this assessment? Will they be those easy to measure data such as waiting lists or waiting times which at best are relevant only to patients needing cold surgery, such as hip operations, but not relevant to the majority of patients you find in hospitals who are usually brought in as emergencies, such as those with heart attacks, strokes or collapses of various sorts? Or will they try to get information on outcomes that are more meaningful for patients, such as how well they were treated as individuals, how quickly they felt better and whether they got back to work, or whether smoking cessation measures have been more successful, how well alcohol reduction programmes

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are working and whether all these sorts of outcomes are better under the new arrangements? There is a very welcome emphasis on outcomes in the Government's strategy for cancer, published yesterday. I ask the noble Earl whether a similar approach is intended for the many non-cancer patients faced by the consortia. Many of these outcomes need long-term study, but how else are we going to know whether we are doing any good by these changes? Will the department gather the type of information that can let us know which pathfinders to follow and which to avoid?

I return to the issue of integrated care that everyone-the royal colleges, the BMA, and the King's Fund-see as the most effective way in which services should be designed and delivered. By integrated care, I mean integration not only across primary care and social services but right across the spectrum, from the community to the secondary care sector where so much of the costs are to be found. You have only to see an elderly patient lingering unnecessarily in an expensive and potentially dangerous hospital bed because of a lack of facilities in the community to recognise the importance of integration of care.

Problems are due not only to lack of facilities, but are equally likely to be due to poor communication between the two parts of what should be a seamless service. It is patients with complex, multiple diseases who form the majority and need seamless, joined-up, care across all three sectors. There are plenty of excellent guidelines to best practice for all these types of patients. The guidelines come from the royal colleges, specialist societies, medical research charities and a variety of other organisations. These guidelines are ripe for adoption by consortia for their contracts. One of the problems in the current NHS has been the slow take-up and implementation of good practice guidance. An obvious example is the national service framework for the care of stroke patients, published a decade ago and not yet fully implemented everywhere. What efforts will be made to encourage the spread of good practice, and how will that be incorporated into contracts by consortia? How will consortia use the expertise and knowledge of clinicians in secondary care and of front-line staff in the community sector? They should be working closely together. How will they overcome the potential barriers to this type of collaboration by the competitive environment and the "any willing provider" concept?

I want to say something about localism and its impact on research. In previous debates, the Minister was reassuringly clear about his commitment to research in the NHS, and the relative protection of the NHS research budget is of course very welcome. I congratulate the noble Earl and Dame Sally Davies on their efforts in achieving this. In this respect, what is to happen to OSCHR, the Office for Strategic Co-ordination of Health Research, the body set up to help co-ordinate research funding between the MRC and the NHS?

My main concern here is the role of GPs and the consortia in commissioning research and teaching. A recent survey by the Association of Medical Research Charities and Involve found that the vast majority of patients were happy to give consent for the use of their personal data for research, but that few GPs were interested in research, and that even the fairly

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straightforward business of seeking consent from patients was regarded by many as difficult and too time consuming. Therefore, if GPs are to have a key role in NHS research, it will be vital to give them some sort of incentive for their involvement. I should be very interested in hearing more from the noble Earl about how he thinks we might provide this stimulus.

Finally on research, I expect that the Minister will have seen the excellent recent report from the Academy of Medical Sciences, commissioned by his department, on the regulation of research. Is it his expectation that the Government will accept the recommendations in the report, particularly those relevant to streamlining regulation?

I hope I have been a little more constructive today and I look forward to the contributions of other noble Lords and, of course, to the response from the noble Earl.

4.45 pm

Lord Colwyn: My Lords, I congratulate the noble Lord, Lord Turnberg, on securing the debate and on his knowledgeable contribution. It was a privilege for me to work with him for a number of years at the Medical Protection Society.

I am delighted to be so far up the list this afternoon, although I am not sure if it is an advantage. I was given the number 2 slot in the last debate on health on 16 December and failed to excite the Minister with my questions. He has now kindly been in touch to tell me that there is a letter in my box. I am aware of the tremendous pressure that he must be under. I also failed to make an impression at Question Time earlier today and will make a comment on the regulation of herbal practitioners at the end of my few remarks, which will inevitably concern the dental aspects of front-line and specialised services.

NHS dentistry's place in the health reforms is unusual. As well as being subject to a change in commissioning arrangements, with responsibility for primary care dentistry being transferred from primary care trusts to the new national commissioning board, dentistry will undergo a parallel overhaul of the way it works, with completely new contractual arrangements being developed. This is a pivotal time for NHS dentistry, in which the mistakes of the previous Government's 2006 reforms can be rectified. It will be vital that our reforms engage the dental professionals who will deliver care under the new system, and I am pleased to say that the British Dental Association has offered its broad support to two important parts of the reforms. The decision to transfer responsibility for commissioning from PCTs to the new national commissioning board has been viewed positively by the profession. Given the problems and inconsistencies witnessed under PCT commissioning, that is unsurprising. Dentists have also been positive about the reforms to the dental contract that the coalition Government are undertaking. These reforms build on the work of Professor Jimmy Steele, whose critical report on the current system has produced a vision of a better system. Pilots will begin in April to develop this.

On the face of it, dentistry looks to have a bright future. The risks inherent in changing systems and commissioning arrangements simultaneously were

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highlighted by Labour's reforms in 2006, when the ability of PCTs to manage the introduction of the new dental contract was undermined by a reorganisation of primary care trusts that saw their number halved. The success of the coalition Government's reform of dentistry will depend on having the right people in place to manage change at an early stage of the reform process. It will also require a balance to be struck between central commissioning and engaging the local expertise of bodies such as local dental committees and figures such as consultants in dental public health.

Dental public health is an important issue in its own right, and ensuring that dental public health expertise inputs into new arrangements and is integral to the wider reform of public health will also influence the success of the reform of dental care. This House needs assurance that the Government plan to utilise those local dental experts in the new commissioning arrangements.

Another lesson we must learn from the 2006 reforms is the importance of properly testing elements of reform. Two major parts of those reforms, the revised patient charges and the system of units of dental activity by which dentists' work is measured, were not piloted in the lead-up to April 2006. As I said, pilots for the new reforms will commence in April. They will test different models that will include patient registration, quality and capitation. The models are intended to lead to a new dental contract that will facilitate a more preventive approach to dental care. The pilots must be given time, they must be properly evaluated and their lessons must be learnt in dialogue with the dental profession.

The Government will need to tread carefully as they pursue each of these reforms, ensuring that a co-ordinated approach to dentistry is taken across all departments within the Department of Health. They must manage the various strands of reform that will contribute to the creation of new arrangements for primary care dentistry in England. What guarantees will the Minister provide that the work on the three strands that will impact on the delivery of primary dental care-the new contract, public health and commissioning arrangements-will be joined up and co-ordinated?

I conclude with a question that I was unable to ask earlier today. Will my noble friend offer any encouragement to patients and to the practitioners who use herbal medicine and who regard regulation-as recommended in November 2000 by the Walton committee, of which I was a member, and the Pittilo independent report set up by the Department of Health-as vital to the practice and continuation of their profession?

4.50 pm

Baroness Sharp of Guildford: My Lords, I, too, thank the noble Lord, Lord Turnberg, for initiating this timely short debate, and I also look forward to the maiden speech of my noble friend Lady Jolly.

As most noble Lords will know, it is not usual for me to speak on National Health Service issues. I do not have the detailed knowledge that I have of the education system, but I retain an open mind about the proposed changes. I come from Surrey where we have

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not had a very happy experience with PCTs. Our PCT has had perennial financial problems of one sort or another. One area with which I have some concern is the future of community hospitals. The decisions they have made have been bad and incredibly vacillating, and have taken far too long. By contrast I have had good experience with my GP practice, and most of my friends are also extremely happy with their GPs. My own practice is very innovative and go-ahead, and I am pleased at the thought that it will have more power.

Of the reforms, I welcome very much the greater local accountability. We on the Liberal Democrat Benches have long argued for bringing together the responsibilities for health and social care, and a greater role for local authorities. The creation of the health and well-being boards will bring together, within the NHS, both the social care and the related children's care and public health services. That is a very important step in helping to provide us with joined-up health services. I also welcome the focus on patients and their needs. I hope that it will not just be rhetoric. In most cases, patients defer to decisions made by their own GPs or by the consultants they see, but there is a danger that the whole system may be too dominated by professionals and the mentality that professionals know best what to do. It is, therefore, extremely important that we retain within the various boards lay membership at all levels-in the GP consortia and all the way up to the NHS commissioning board.

Lastly, I welcome the establishment of HealthWatch. I was quite involved at one point with our local community health council and I regretted very much its replacement 10 years back by what struck me as a relatively toothless link committee. I hope that HealthWatch, together with local scrutiny committees, will mean that there is a genuine watchdog for the patient in terms of quality and accountability.

I have five questions for the Minister. First, precisely what is the role and what will be the powers of the NHS commissioning board? Secondly, where within the system does NICE now fit? I am grateful for reassurances from the Minister at a meeting the other day that NICE will not be abolished, but indeed would be strengthened. However, it would be useful if those reassurances were on the record and he could tell the House how it will fit into the greater scheme of things. Thirdly, I do not understand the trail of accountability in the new system. Who will set the budget for the GP consortia and who will oversee their expenditures? What happens if they overspend? Who holds them to account? With the strategic health authorities now going, who will oversee hospital expenditures and hold them to account if they overspend? While I welcome the bringing together of local public health services with the community and children's health services, will there be enough resources to meet needs given the cuts in local authority funding? Already instances of bed-blocking are reappearing. My noble friend John Shipley raised the issue of bed-blocking in Newcastle with the Minister the other day and there are other instances. As a school governor I have experience of children's and adolescent mental health services and the lack of facilities to provide educational psychologists when they are needed to back up special educational needs provision in schools. Time and again,

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the NHS has failed to deliver on its responsibilities. How are we to get really effective linking-up between health and local government services?

Finally, the health and well-being boards will bring together public health and social care services, but one of the traditional problems of the NHS has been the divide between primary and secondary care. What incentives are there within the system to improve that relationship? In particular, there is the relationship between GP care and specialist care. Can the Minister tell us a little more about proposals there? I look forward to hearing the answers that the Minister will give us on those issues.

4.55 pm

Baroness Masham of Ilton: My Lords, I thank the noble Lord, Lord Turnberg, for introducing this important debate. It is important because there are so many concerned people who fear, with the spending cuts, that some of their vital specialised services, which are lifelines, may be severed. I hope that the noble Earl can allay some of those fears.

I must declare an interest, as I am president and founder of the Spinal Injuries Association. There is hardly anything more catastrophic than breaking one's neck and finding that you are paralysed from that point down. It is bad enough breaking one's back, but in all cases there can be complications, and specialised treatment is vital, otherwise complications occur, leading to human suffering and unnecessary costs for the NHS.

With this huge reorganisation, perhaps there is a chance to improve some front-line services and the specialised services. The White Paper states that patients should be central to the NHS. Are those just words, or will there be action? Will the Government listen to patients, patients' groups, and their doctors? There should be shared decision-making-nothing about me without me.

We were once the leading country in the world in the treatment of spinal cord injured patients. All of us with an interest in the subject would like that specialty to be returned to its former glory. Doctors, nurses and physiotherapists would come to our national centre from all over the world to train. We are concerned that, already, some expert consultants have retired, and more are to go. Therefore, I ask the Minister a few questions, which perhaps he can answer by letter.

Are there plans to reinstate spinal cord injury medicine as a speciality or subspecialty? The specialty status was lost in 1995 as a result of the alignment with European regulations. That has resulted in considerable loss of appeal and skills. Are there plans to create a national register, a database, for spinal cord patients? Do the Government know whether current trainees will be able to continue the same services offered by retiring consultants in spinal cord injuries? Is there adequate capacity to meet the readmission needs of spinal cord injured patients to spinal cord injury centres? I do not think so.

Are your Lordships aware that there are more than 9,000 new cases of tuberculosis in the United Kingdom every year? In the UK, the number of deaths from TB

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is 1.5 times higher than the number of deaths from HIV/AIDS. London has the highest TB rate of any major capital city in western Europe. Prevention is vital. I consider it a front-line service. The Find & Treat team, which runs the mobile x-ray unit, focuses on screening groups in London with social risk factors, especially the homeless with TB. Homelessness is a risk factor for multidrug-resistant tuberculosis. That underlines the importance of ensuring that complex cases are detected early and supported to successfully complete treatment.

The emergence of extensively drug-resistant tuberculosis threatens to make the disease untreatable. The Find & Treat team is excellent, and I hope funding can be found so that it can continue its valuable work.

Childhood cancer and leukaemia are rare conditions that require complex and highly skilled diagnostic and treatment services to achieve the best outcomes. Without specialised, centralised cancer care and excellent front-line local paediatric services, there is a risk that not all children with curable diseases will be cured. These services must be safeguarded, built on and improved.

5 pm

The Lord Bishop of Gloucester: My Lords, I speak as until recently the chair of the Church of England's Hospital Chaplaincies Council, and, as it happens, the husband of a specialist in palliative medicine and the father of a fairly newly qualified hospital doctor. I believe passionately in the National Health Service and want to see its future secure.

I share some of the concerns expressed recently by primary care trusts about what might be endangered by their demise and by my own church's response to the Government's proposals through its mission and public affairs council, and I hope these concerns are among the issues that the Minister will want to address. There is time to do little more than list them.

First, there is in the proposals a risk of losing local intelligence and grip on performance in the management of poorly performing doctors and practices. Secondly, there is a lack of clarity about future commissioning arrangements for learning disability services, mental services and services for other vulnerable groups. Thirdly, the White Paper does not consider what additional GP training might be needed to make effective patient-centred services a reality. In the absence of training and monitoring, it would be all too easy to see the provision of patient-centred services being reduced to a box-ticking exercise. Fourthly, the proposals do not make it clear which services are considered to be front-line services and which are ancillary or administrative. In seeking to cut administrative costs, both commissioners and providers may find themselves under pressure with regard to allied health professionals and chaplaincy services, yet holistic care is essential for good health outcomes; the expertise of allied health professionals and chaplains ought not to be minimised in delivering such care. Fifthly, and perhaps more fundamentally, there is a question about the ability of local authorities to take on new responsibilities in the face of 20 per cent cuts in their own budgets. Linked with this is the complexity of what is proposed, with GP consortia responsible for commissioning healthcare, local authorities

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receiving an enhanced role in relation to public health and health and well-being boards also having a part to play. The fact that GP consortia and local authorities are not coterminous will make the commissioning process more difficult.

Alongside these worries, I make two other points very briefly. The first is that for the new arrangements to work, there needs to be rising morale in the health service. That cannot happen while there is a culture that is dismissive of the achievements of recent years. It may well be right, for instance, for PCTs to disappear, but their work does not need to be criticised or rubbished. Unlike the experience of the noble Baroness, Lady Sharp, in Surrey, in Gloucestershire where I live and work, the PCT has brought about transformation in infrastructure with new buildings, in finance with historical debts resolved, in health outcomes, for instance in the reduction of teenage pregnancies, and in engagement with clinicians and communities. We need to affirm and honour those who work in the NHS, or else the quality of the health service could trickle through our fingers as morale dips at the same time as difficulty climbs.

Finally, we need more honesty and realism. Changes are almost bound to damage front-line and specialised services. We have to save money. We have to make choices. We need to accept that not everything can be delivered. If we can start being honest about that, there can be genuine debate about priorities and proper consideration of what can and cannot be achieved. Instead, and this contributes to the collapse of morale, we keep up a pretence that cuts need not damage services and we expect those who work in the NHS to deliver the impossible, but they cannot.

5.05 pm

Lord Winston: My Lords, back in November, when I had just come back from cycling around Beijing and seeing at first hand the health service in China, I spoke later that day in a similar debate when the noble Earl, Lord Howe, admonished me for being somewhat acerbic in my comments about the health service. I hope that he has forgiven me, because I think a combination of my jet lag, my passion for the health service-like his passion for the health service, which I greatly respect-and the anxiety that one sometimes feels when speaking from these Benches, and for me the unusual taste of being very briefly on the Front Bench, resulted in my being rather stronger in my remarks than perhaps I should have been. I would, however, like to ask him some questions about the third issue that the noble Lord, Lord Turnberg, has produced in his debate, and I congratulate him on introducing it. May I also say what a pleasure it is to see that the noble Baroness, Lady Jolly, has put her name down to make her maiden speech in this debate? We look forward to hearing her in just a moment.

Noble Lords must forgive me if I concentrate on hospital medicine, but that is the area I know best. I remember many years ago, from my experience in the United States-when I was a visiting professor in Baltimore and Boston, and later in Texas-that the Americans were very surprised at the massive surgical experience that we could gain in the health service in this country because of the way in which the service

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was run. We could centralise many specialised services and do very advanced work that was both innovative and useful for research. One issue is that, while this has been more difficult since the introduction of the internal market, there have been at least some attempts to get back to doing exactly that.

Many aspects are really important for centralisation. First of all, that kind of centralisation is best for some patients with particular needs if they can travel to a service. That often means that they are going to get the best medicine. It is a question not of patient choice but of making sure that they get the best treatment from the most qualified people. Secondly, that kind of centralisation is ideal as a pull for teaching. It is also excellent-indeed, some people would say essential-for training people to make sure that we get the best surgeons. It is a problem that the noble Earl, Lord Howe, is very conscious of, given the changes that have happened as a result not of the NHS but of European pressures, which have made things more difficult.

Centralisation is also important for innovation. The key issue is how these expected changes in the health service will affect our excellence in research. What I really want is reassurance from the noble Earl that the sorts of things that were developed in the health service hitherto will not be difficult to achieve under the current proposals in the White Paper. For example, it seems impossible to imagine that in vitro fertilisation could develop as a research procedure in the structure as proposed. Certainly, during my time at Hammersmith, I saw by-pass surgery, transplant surgery and the cancer smear test being developed, and many other examples of innovative surgery and medicine. Many of the great institutions, such as Great Ormond Street, Hammersmith, and some in Liverpool, Manchester and elsewhere have been made great and international because they have been able to function in a way that it is difficult to see will continue under the structure in this White Paper. I want to make certain that the Minister agrees-I know he does-that the jewel in our crown is the National Health Service. A very special aspect of that, which is internationally recognised, is the unique nature of academic medicine in this country. I would like him to tell us how academic medicine will be protected and will flourish in the structure of the White Paper.

5.09 pm

Baroness Jolly: My Lords, I start by thanking noble Lords kindly for the warm welcome that I have found since my introduction on Tuesday-from Members opposite as well as from my own Benches. Advice about my speech was to keep it simple, but most of all to keep it short. I extend these thanks to members of staff who have been exceptionally helpful in all manner of ways. I must say that I am not without trepidation. My introduction by comparison was easy, as once in my robes I was but an actor. Today, I feel somewhat naked without them, particularly in such eminent company.

I live in Cornwall in a community of some six or seven houses overlooking Bodmin Moor. We have little choice in our services. We use them where we can find them and so rely on them all to be excellent, as the noble Lord, Lord Winston, said. Disappointment is

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rare. My sponsors, my noble friends Lord Tyler and Lord Teverson, have both left their mark on Cornwall, and I am delighted that today another friend of Cornwall was introduced-my noble friend Lord Marks of Henley-on-Thames. The bottom left-hand corner may be far away, but in this place it will not be forgotten.

I trained as a control engineer, taught maths for 15 years, and spent time living and working in the Gulf. On coming home, I joined an NHS trust board. Some years later, a couple of NHS reorganisations found me chairing a Cornish PCT and managing a budget of £120 million. Recently, I have been working for Macmillan Cancer Support, a charity dedicated to providing excellent services to those whose lives are affected by cancer, as well as for a campaigning organisation on issues as varied as fuel poverty and survivorship. It was difficult delivering services in such a rural environment, especially ensuring that services are linked as seamlessly as possible with our social services. Not a year went by when we did not have to find savings to be passed on to services.

In the past, my family has had brief engagements with the NHS, but it was not until last November when my father had a heart attack that I saw the NHS in action for real, for one of mine. One evening, he went to bed feeling unwell. We called NHS Direct. It called an ambulance, which was with us in 15 minutes. After a half-hour dash he was admitted directly to the South West Cardiothoracic Centre in Plymouth. His ECG had been e-mailed ahead by the ambulance crew and he was met by a team called in on a Saturday night. Led by Dr Haywood, his team was professional, caring and candid. The ward really resembled the bridge from the starship "Enterprise", but it was here too that I heard talk of patient dignity and advocacy. My father mattered, as did my mother-a lady who will be 90 on her next birthday.

Cornwall still has a network of community hospitals that allows patients to be treated nearer their homes, relieves beds in the pressured acute units and prepares patients to return home. In time, at my local community hospital in Launceston, I saw at first hand social services working with the ward team, the physio and occupational therapists. The patient came first and together they got my Dad home. Sadly, the NHS was no match finally for age and frailty. He died one month ago today. We saw the NHS at its finest, from the highest of high-tech medicine to the best of nursing care, working seamlessly across four NHS organisations and social services.

In the PCT our decisions involved executive directors, non-executive directors and, most importantly, health professionals. We were committed to a comprehensive service that is available to all, free at the point of use and based on need and not on the ability to pay. We took into consideration local issues-rurality, sparcity, atypical demographics and huge population increases in the summer. We did not run or commission services in the same way in Cornwall as they are here in the capital.

In conclusion, the points made by the noble Lord, Lord Turnberg, are well made. I would add that in reframing the NHS, I trust that the noble Earl will give

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every care and consideration to service delivery and, more importantly, to appropriate and adequate funding for far-flung remote rural areas, such as Cornwall.

5.15 pm

Baroness Finlay of Llandaff: My Lords, I am delighted to follow the noble Baroness, Lady Jolly. I welcome her and congratulate her on having made a superb short maiden speech in the time available. She has shown a deep affection and critical praise of the NHS. She brings to us experience from engineering and maths, and the critical thinking from that, as well as extensive personal, administrative and provision experience in the NHS and the voluntary sector. I am sure the Liberal Democrats celebrate her being on their Benches, and we must celebrate her addition to this House.

I speak as a clinician in the NHS, and declare all those interests in so doing. The Government have inherited much from the previous Government. They have inherited the problem of the PFI burden, with high interest rates that will increase the burden on hospitals. This will not go away during reorganisation. They have also inherited, as the noble Baroness, Lady Jolly, has illustrated, very high levels of satisfaction with the NHS as we know it. In 2009, indeed, 64 per cent of the population declared themselves to be satisfied or very satisfied. Even among Conservative voters, the figure was 61 per cent.

The public out there fear the loss of the NHS. They fear the escalating costs that they see in US healthcare. A major concern is the concept of "any willing provider" and its effect on primary and secondary care. The competition engendered by this concept seems to work against collaboration. In private-provider competition there seem to be three main problems. The first one, identified in the US, is fraud. The biggest department in the FBI is that which investigates fraud in healthcare, yet we have US providers advising us. I find that worrying. The second problem concerns the role of Monitor. Will Monitor promote competition? The US system and others show that health outcomes are better where collaboration is higher. I ask the Minister why collaboration between primary and secondary care is not the key marker rather than a pre-requirement to competition. The third problem relates to European law. Current law on services of general intent allow subsidiarity for publicly provided healthcare, but if it is privately provided it will become subject to general interest regulations. If the reorganisation fails, can the service effectively be renationalised?

I turn briefly to financial failure. Current legislation allows for a failing foundation trust to be brought back into public administration, but that will be repealed. What will happen if a GP consortium runs out of money? Will the patients be left with less or no care? I understand that there is to be a central levy to allow for failure. I ask the Minister how it was calculated, and whether the Government are confident that it will be enough to continue care provision, particularly if faced with multiple failures at the end of the financial year. If a GP consortium fails, will it be taken over by the private sector, as is happening with hospitals?

The NHS is there for patients. The phrase "nothing about me without me" is both clever and wholly appropriate, referring to clear simple terms of informed

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consent, but when transposed to choices in healthcare provider it can become distorted rhetoric. The choices that people have to make relate to decisions across all parts of care: whether to remain at home when ill; whether to have a gastrostomy, as swallowing fails in neurological disease; or whether to try physiotherapy to defer joint replacement surgery. There are decisions about immunisation versus infection risks and about how to manage psychotic disease relapse.

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