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We all know that autism is a complex disability, and many professionals will not have sufficient understanding of the needs of that group, nor of what services are necessary to meet those needs. As such, they need guidance, training and, of course, robust data. The Department of Health is currently conducting a review of the social care data that it asks local authorities to collect. For the first time, it is considering including data on autism. That is essential to ensure that local areas have adequate data on the needs of the people with autism, so that they can plan to serve them effectively. What progress is being made on that review of social care data and including autism in those data?

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To conclude, let me say a few words about three key areas: guidance, training and data. On the question of guidance, NICE's proposals to develop two quality standards on autism, along with the NICE guidelines on autism, if followed and implemented fully, will help the commissioning consortia to commission the right services for people with autism. That is certainly most welcome.

As for training, the document Fulfilling and Rewarding Lives, the strategy for adults with autism in England, commits the health department, working with the General Medical Council and the Postgraduate Medical Education Training Board, to ensure that autism is part of the core training for doctors. That, too, is welcome, but becomes even more urgent as GPs take on a more strategic commissioning role, if the Bill goes through as it is.

Finally, data collection and planning for people with autism is currently very poor. Only 20 per cent of joint strategic needs assessments even mention autism, let alone ensuring that services are planned through the process. We must do much better than that. One of the biggest problems that health and well-being boards and GP commissioning consortia will have will be assessing need, to obtain robust data and ensure that they are available. It is therefore crucial that data collected by those bodies must be broken down by multiple disabilities such as a child with autism, epilepsy and depression. That, in turn, needs to be supported by the NHS outcome frameworks to incentivise that and ensure that it works.

I have posed a number of questions to the Minister, and I have no doubt that he will want to discuss those with officials. I am quite happy for him to write to me later and, probably, to put a letter in the Library.

People with autism often do not have a voice. We can be that voice. We can make sure that the Government listen, understand and respond to their needs in this massive shake-up of the National Health Service. I am encouraged in this Chamber to believe that we will not let down people with autism; we will be the voice of those who do not have a voice of their own.

8.43 pm

Baroness Tyler of Enfield: My Lords, it is perhaps inevitable that NHS reform is a subject which generates a great deal of heat but, at times, it seems, precious little light. The NHS is a precious institution; it is one that binds us together; one to which most of us have a very strong emotional attachment. Perhaps like close family members, it is something that we feel that we know well and love but have seen warts and all.

I support many of the principles behind the Bill-increased patient involvement and choice, and integration between health and social care-and welcome many of the changes that the Government have made to the Bill as a result of the Future Forum's work, particularly the strengthened role of the health and well-being boards. The challenges that the NHS faces are immense. I do not need to rehearse them; many noble Lords referred to them, as did the Minister in his most eloquent opening speech. However, I want to draw attention particularly to the challenge of the scale of the health inequalities in this country, which are so often linked to public health issues.

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The challenges are daunting and I have no doubt that reform is needed. I have never been one of those who thought that the NHS could simply stand still and deal with these challenges, particularly at a time when it is being asked to find £20 billion of efficiency savings. We need a fundamental change in the way that healthcare is delivered to people. I am not really talking about structures here-it is more about how those really big slugs of expenditure are used and how the decisions get taken, although of course structures influence those decisions.

At present, foundation trusts have a financial incentive to maximise their activity while GP referrals to hospital consultants do not have any impact on their own budgets. These sorts of arrangements can run counter to the efficient use of the totality of the NHS resource, particularly in chronic care cases. We need to move to a world in which community, primary and secondary care providers have a shared interest and incentive in optimising the most effective use of NHS money for the whole population. For me, in essence, this will be the key test of the success of these reforms.

Inevitably, much of the debate has focused on what I call the architecture of the NHS. This will always be complicated, given the NHS's scale and complexity, and often feels quite incomprehensible to people not involved in the subject on a daily basis-and I include myself in those numbers. I fully understand that something as huge as the NHS needs a proper management and governance structure, but I fear that much of the political debate will feel a long way removed from the reality of people's everyday lives. Arguments about cherry-picking, marketisation and commissioner/provider splits are important, but they often seem to have very little relevance if your main concern is that you cannot get an appointment with your GP-or, indeed, get on to the GP's books-are waiting for a hospital referral or for an operation or are worried about the long-term care of a family member leaving hospital who is unable to look after themselves.

What really matters to most people is the quality, timeliness, responsiveness and personalised nature of the care and that it is delivered in a way that treats them with dignity and respect, is compassionate and has human warmth. People do not want to feel as if they are going through an impersonal, one-size-fits-all sausage-machine type of health system. A lot of that has to do with culture and attitudes, workforce training and standards of clinical leadership-often things that you cannot legislate for.

I do not take a doctrinaire stance on matters of structure, but the structures must contain the right incentives to ensure not only efficiency and value for money but equitable access and outcomes. I am comfortable with a mixed economy of providers-indeed, we have had that for a number of years now in the NHS-provided that there is indeed a level playing field. We heard about this earlier in the debate.

One point that perhaps has not been made in the debate is whether there is a level playing field for charities, others in the voluntary sector and NHS providers. At the moment, in a number of respects, including on issues like how VAT is treated, there is not a level playing field. I know that many charities

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feel at a distinct disadvantage. The voluntary sector makes a hugely valuable contribution to health outcomes, particularly for vulnerable groups and those with some of the most complex needs. I call upon the Minister to outline his plans for ensuring that the playing field that he talked about really is level for the voluntary sector.

I will judge the success of these reforms, and whether all the time and energy expended on them has been well placed, on whether they improve outcomes for the whole population, particularly the most needy and vulnerable, who all too often have been short-changed in the past. Noble Lords will be familiar with the statistics on health inequalities, but they are stark and bear repetition. In London, where I live, men's life expectancy ranges from 71 years in one ward in Haringey to 88 years in one ward in Kensington and Chelsea-a difference of 17 years. This underlines the absolutely critical need to put more focus on public health interventions. I welcome the establishment of Public Health England and the fact that public health functions at a local level will now sit with local authorities. However, as the Bill progresses, I hope it will be possible to strengthen still further the provisions relating to health inequalities.

Mental health is an area where I still have considerable concerns. I pay tribute to the eloquent remarks of the noble Baroness, Lady Hollins. Too often, NHS services and structures are designed around physical healthcare needs, with mental health then squeezed in as an afterthought. For example, the NHS 18-week waiting time never applied to mental health. The Bill presents an opportunity to put mental health on an equal footing with physical health, but there are worrying signs that history may repeat itself. In a world without targets the system hinges on properly designed outcome indicators, yet proper mental health outcomes have yet to be developed. Tariffs are also key to the system but mental health tariffs are still not up and running. Without those tariffs in place, I fear that commissioners will struggle to allocate appropriate budgets to mental health and will be working in what you might call a different currency from that of the physical health world, which will make integration harder.

There were other things that I should like to have said, including on children's mental health, but I do not have time to do that. I shall finish by going back to where all of this started-the central underlying principle of "No decision about me without me". A strong evidence base is building up which shows that outcomes improve where patients are actively involved in decisions about their care and treatment, not least because they are far more likely to stick to their treatment regime. However, the latest data from the national patient survey show that a large number of patients still do not feel that they are involved in those decisions. Indeed, the figures have barely improved since 2002. Research also shows that patients care more about being able to exercise choice in the type of treatment than about being able to choose between providers-that is, which hospital or GP to use. We know that patient involvement is strongly linked to health inequalities. Therefore, I ask the Minister to clarify the Government's intention in this area, so that increased patient involvement is indeed a key outcome of these reforms.

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I look forward to the detailed scrutiny of the Bill in Committee to strengthen and improve it further. That is where we should now proceed without delay.

8.52 pm

Baroness Gould of Potternewton: My Lords, I, too, want to raise the question of public health, but I want to talk much more about the structures and whether it is possible, with the structures that we have, to meet the Government's commitment to focus on public health. I hope these are not just fine words and that there is a real commitment to public health. I agreed with the Minister when he said this morning that public health had received little coverage to date. For me, it is absolutely key. To quote a senior physician: "Healthcare is vital to all of us some of the time, but public health is vital to us all of the time". That is something that we should bear in mind constantly.

I support the decision that public health should return to its origins in local government for many of the reasons that other noble Lords have indicated. The local authority is best placed to influence the factors that have the biggest impact on a person's health. I genuinely want the new structure to succeed, which is why I want to raise some of my concerns about the present position. I am concerned about the fragmentation of the services, for instance the proposed split of sexual health services when integration is essential. That applies to many other services, too. I am concerned about the lack of clarity in lines of accountability and access between Public Health England, commissioning groups, the NHS, the health and well-being boards and the directors of public health. I am concerned about the lack of a definition of what constitutes public health, how it will relate to all the other key functions of local government and, not least, the inadequacy of the designated funding. It might be ring-fenced but, without a definition of what it covers, ring-fencing is meaningless. We have the concepts but not the detail, and it is the detail that we should look for in Committee.

Public Health England, an executive agency within the Department of Health and under the direct control of the Secretary of State, will oversee the operation of the public health system and manage national issues such as flu pandemics, as well as incorporating the Health Protection Agency and the National Treatment Agency for Substance Misuse. That for me raises a serious question about the independence of the staff of those two bodies, for without independence it seems impossible that they are going to be able to carry out their job in surveillance and monitoring. We really have to look seriously at whether that is the right position.

Crucial to public health are the directors of public health. They are appointed by the local authority, but in contrast to the protection afforded to other key local authority staff they have no significant protection of tenure. A local authority may terminate the appointment of the director of public health only after consultation with the Secretary of State. I would like to know what the role of the Secretary of State is. Can he overturn the decision of the local authority?

Also diminishing the role of the DPH is the lack of provisions guaranteeing the necessary resources, staffing and status to allow him or her to carry out their

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important responsibilities. To be effective, they have to be senior officers who, I believe, report directly to the chief executive of the council. The Government reject the argument that DPHs and other public health officials have to be registered with an appropriate statutory body, ignoring expert advice such as that from the Royal College of Physicians, which says:

"An expert and influential Director of Public Health will be essential if a more localised system of public health is to be effective".

The Faculty of Public Health regards statutory registration as essential to ensuring the quality of the senior public health workforce and to protecting the public, as did the Future Forum and the House of Lords Select Committee on HIV and Aids. As a consequence of the Government's proposal for a voluntary system, an employer can appoint untrained and unqualified applicants to vital positions, including that of director of public health. An example of what might happen is that a voluntary registered public health specialist is on call when an emergency happens, requiring an instant decision that could be one of life or death. Surely that person must have the required expertise to take that decision and not be in a position where they might put people's lives at risk.

Key to the scrutiny of commissioning decisions as well as to the voice of the people are the health and well-being boards, which have been mentioned. At this stage, I have only one question for the Minister. Does he believe that the Bill gives these boards sufficient power to ensure that service delivery matches local needs and to take on the responsibility for producing the joint strategic needs assessment, ensuring that this is taken into account in developing commissioning plans? "Having regard", as the Bill says, does not necessarily mean acceptance or implementation.

A further point relating to the localisation of public health is the question of the national tariff. An amendment moved by the Health Minister, Simon Burns, makes it clear that unlike services commissioned by the CCGs, national tariffs will not apply to local authority or public health services. This is a particular problem for sexual health. The return to a system of block contracts will threaten the open access nature of all sexual health services and potentially restrict those able to attend services according to age or place of residence.

The London Specialised Commissioning Group has shown that commissioning on a broader basis provides efficiencies, economies of scale and uniform standards of treatment, so providing the best service for the patient and bringing it in line with the Government's stated aim of the future being patient-centred. I ask the Minister quite sincerely to examine this proposal. It is essential that there is flexibility in the tariff system.

No one would argue that the NHS does not need reform, or that there is no place for conditions in commissioning, or that the focus should not be beyond the patient, but I see no case for this distortion of the NHS on which this Bill is allegedly based. There is no democratic mandate, and no consensus for these dramatic changes, and I find it very difficult to understand how the Government can ignore the volume of concern that has been expressed about this Bill from all quarters of the health service and the public.

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I must also ask the Minister about the ethics of the Government starting such a major reorganisation before the legislation is complete. It seems to be an attempt to override the parliamentary process. Both concepts of "national" and "service" are being dismantled. Those ideals are clearly of less importance than the unevidenced rationale to break up the NHS and provide incentives for the private sector. It may be that we can hear a little more in the Minister's reply about the question of competition, which we did not hear about this morning.

I ask the Government to genuinely listen, to put the NHS first and to give it the stability it needs, rather than just continuing with the dangerous limbo in which the NHS is at present. I shall support the amendments of my noble friend Lord Rea and the noble Lord, Lord Owen. There is so much to rethink. There are so many questions to answer and so many things to put right in the Bill. Supporting both or either of the amendments gives us the opportunity to do that, and I hope that we will have that opportunity.

9 pm

Lord Walton of Detchant: My Lords, as it is 66 years since I graduated in medicine, I can say with total confidence that I am the only Member of your Lordships' House who was practising medicine before the NHS came in. I can remember, as a paediatric houseman in 1945-46, seeing children admitted with perforated appendices because two penn'orth of castor oil was cheaper than the doctor. Thank goodness that after the health service came in-and I am one of its most fervent supporters-that kind of experience became something of the past.

In 1996 I was invited by the British Medical Association to give a lecture to celebrate the 50th anniversary of the passage of the NHS Act, which I was very pleased to do. I said that in those 50 years I had lived through eight reorganisations of the NHS. In the 15 years since I gave that lecture there have been nine major and minor reorganisations. No Government have ever been willing to let the people in the NHS get on with it without producing some kind of modification.

Looking back over those years, I recall that in 1974 I was dean of a medical school when Lord Joseph, as he became-he was then Sir Keith Joseph-as Secretary of State, introduced a massive reorganisation of the NHS. It was a painful experience. It was based totally on a detailed report by McKinsey management consultants that the Government at the time swallowed whole, and they created district health authorities, area health authorities and regional health authorities. The reorganisation introduced consensus management and the result was that the whole decision-making process in the NHS congealed. The reorganisation took two years to implement. It took another two years to show that it was disastrous, and another three years to get rid of it. I just want to be quite clear about the reasons why I look upon this Bill, enshrined in two enormous volumes and 300 pages, with a certain healthy scepticism-as I have done over a number of other reorganisations. Do any of your Lordships remember, much more recently, the primary care-led NHS? That was an arrangement that foundered without trace.

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The Bill in its original form was, in my opinion, potentially dangerous and totally unacceptable. I have to say that the Future Forum under the leadership of Steve Field has produced significant improvements, but the Bill remains full of potential hazards. I know that my noble friend Lord Owen has done his best to produce an amendment that he believes would allow the possibility of making the Bill much more acceptable. I have reservations. I have not yet decided which way I shall vote, although one reason for not voting for his amendment is that I am now in my 90th year, and the delay that it would cause might make it uncertain that I would be able to contribute to the later stages. However, that is another issue that we will look at in a moment. I am going to confine myself and not talk now about the responsibilities of the Secretary of State or about competition. I am going to keep my powder dry on such issues until Committee.

Today I want to mention four things that give me particular concern. The first is commissioning. I believe that there has been a vast improvement in the standard of general practice in the UK since the introduction years ago of vocational training. I have an excellent general practitioner-he was one of my former students-and I have discussed with him this issue. He is the very first to admit that whereas he and his GP colleagues can fulfil a major role through these new commissioning groups, they do not have the expertise or knowledge to be able to fulfil the responsibilities of commissioning highly specialised services. That will fall to the national Commissioning Board.

Recently I have served on two all-party group inquiries looking at facilities across the UK for patients with neuromuscular disease and for patients with Parkinsonism. They demonstrated a remarkable unevenness of standards of diagnostic services and of care in these specialties in different parts of the country. When these major deficiencies were drawn to the attention of the chief executives of the strategic health authorities they were so shocked that they took action to correct the problem.

I do not believe that the national Commissioning Board, as a single entity, could-however experienced, however distinguished-look after national commissioning across the entire country. It is inevitable, and I believe that David Nicholson agrees with this, that there must be not a regional-that is not an attractive word nowadays-but a sub-national component, with these individuals commissioning throughout the country, and they must be located, I hope, in relation to the so-called clinical senates which are going to be introduced. We are living in an era when genomic medicine is developing a whole series of new treatments and orphan drugs are emerging for patients with rare diseases. Some time ago it was unthought of that these diseases would be amenable to treatment. Therefore a sub-national commissioning responsibility is absolutely crucial to help to advise the national Commissioning Board on its responsibilities.

I turn now to education and training. There is nothing in the Bill at all about the crucial relationship with the universities for the undergraduate training of doctors, dentists and other healthcare professionals. That must come in. Equally, the Bill takes no real account of the fact that, ever since the NHS began, it

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is the statutory responsibility of the National Health Service to provide postgraduate training for doctors, nurses and dentists in specialties. That is the financial and organisational responsibility of the NHS.

There was an astonishing suggestion in the original White Paper that they were going to replace the postgraduate deans with local skills networks. This was utterly staggering and took no account of the fact that the postgraduate deans play a major role not only in appointing young doctors to their foundation posts and specialist registrar posts, but in providing the postgraduate training that is so essential for the future. Perhaps I may ask the Minister in what way these deans, with the abolition of strategic health authorities, will have the ability to make certain that foundation trusts and commissioning groups will provide the facilities that are essential for the education of these individuals. This must be in the Bill but it is not there at the moment. It is crucial that that is recognised.

Also-and I speak as a former president of the General Medical Council-under the Medical Acts the GMC has the statutory responsibility to oversee and provide high standards of medical education and to co-ordinate all phases of medical education in collaboration with the medical royal colleges and so on. The Bill is silent on that issue.

The noble Lord, Lord Willis, made an excellent speech, and so did the noble Baroness, Lady Warwick, about research. One must recognise that although there are three sentences in the Bill about the responsibility of the NHS for research, they are not enough. Today's discovery in basic medical science brings tomorrow's practical development in patient care. Years ago I chaired an inquiry into research in the NHS, which led to the Culyer report and led, eventually, to the establishment of the National Institute for Health Research. The Government of the day said that 1.5 per cent of the national health budget would be spent on research. It has never got up to more than 0.9 per cent, but nevertheless could the Minister confirm that the work being done by NIHR under the inspired leadership of Dr Sally Davies and others will be protected? Will it be made clear to commissioning groups and independent foundations trusts that they have a responsibility for research? I echo entirely what the noble Lord, Lord Willis, said about the crucial importance of accepting the report of the Academy of Medical Sciences, so expertly chaired by Sir Michael Rawlins, which will make the organisation of clinical trials, which have become so incredibly complex, very much easier. It is important that this be enshrined in the Bill.

There is so much more that I could say, but the Bill at the moment is shot full of deficiencies, ambiguities and other defects. It is incumbent on this House, with its expertise and the experience of its Members, to see this Bill through a long and detailed Committee stage to amend it and make it acceptable, in the interests of the long-suffering healthcare professionals and, above all, our patients and the British public.

9.11 pm

Baroness Royall of Blaisdon: My Lords, what a pleasure to follow the noble Lord Walton of Detchant, with his wise words, his healthy scepticism, his wealth

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of experience and his staggering link with history. It is a real pleasure to be here with somebody who was here at the birth of the NHS. I find it difficult to match his mental dexterity in my 57th year, I have to say.

It may seem odd that I am speaking from the Back Benches when we have such a stellar cast on our Front Bench, but like everybody else in this Chamber, I feel passionately about the NHS and care deeply about it. For me, this is not about politics; it is about passion and principles. My resolve to speak about this Bill has been strengthened by the hundreds of letters, briefings and e-mails that we have all received from so many people up and down this country. We have a remarkable health service; we should celebrate its success. It is absolutely not broken and it is the envy of the world. That is not to say that it cannot be better; of course it can be better. But it is a fine service.

Before I begin, I must comment on the flurry of letters that have been written by the noble Earl and the Secretary of State. In the case of my noble friend Lady Jay and the noble Lord, Lord Owen, they were received far later than they should have been received, and I understand that one noble Lord among us did not receive his letter until the press had received it. I would say in passing that if that had happened under my Government we would have been slaughtered in this House by all sides, and rightly so.

I am in favour of reform, as is my party, as we clearly demonstrated when we were in government. I well understand the budgetary demands and technological advances, the increased need for health and social care and citizens' aspirations for a better health service. All these things mean that the health service cannot stand still, but it cannot be right that, while the NHS and its brilliant, dedicated staff are grappling with the huge changes that result from the Nicholson challenges, the Government are imposing a massive, destabilising, top-down reorganisation for which they have no mandate. For any reform to succeed, it has to be owned by those who work in the service, and it is clear that there are very few people working in the health service who support the profound changes being introduced by this Bill. My first question to the Minister, for whom I have the highest personal and professional regard, is to ask where the evidence is that the spending of billions of pounds on this reorganisation will work and why the Government have to do it now. Clearly the Government are following a political timetable, and I believe that this Bill is ideologically driven. It was certainly interesting to listen to the noble Baroness, Lady Jolly, when she admitted that the proposals had driven a coach and horses through the coalition agreement. Services are being cut, waiting lists are going up, nurses and doctors are tearing their hair out all over the country because they are having to make cuts and cut certain services, and they know that they cannot make any further cuts without affecting patient care. The noble Lord, Lord Clement-Jones, said that it looked as if the cuts were being made rather than resources being redeployed, and I believe that to be the case. So why are the Government now inflicting this Bill upon the health service?

My major concern, however, is about the principles which underpin this Bill, especially that relating to competition. As my noble friend Lord Darzi pointed

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out, free market idolatry is dangerous, and this Bill as it stands makes a free competitive market the linchpin of our NHS. That cannot be right, and it offends against the founding principles of the NHS, which have been much quoted today. Like so many noble Lords, while I am happy to be a consumer in relation to electricity and telecoms, I want to be a patient when I am ill. When my loved ones are ill I want them to receive quality care. Choice is empowering, but when my loved ones need emergency treatment, I want the ambulance to take them to the appropriate centre of excellence, where there is no question of financial transactions. Any step along the road to an American free market in health and social care is a dangerous step, a step too far, and this Bill is, I believe, a step too far.

This morning the right reverend Prelate the Bishop of Bristol mentioned his concern that some health organisations, in order to succeed in the tendering processes, might use unqualified staff, which would be cheaper. That is a real fear, and that is just one reason why I wholeheartedly agree with the noble Baroness, Lady Masham of Ilton, that Clauses 225 and 226 on regulatory bodies must be mandatory.

I want a National Health Service in which all citizens, no matter where they live, no matter what their age or income, have access to quality care, free at the point of delivery. As my noble friend Lord Darzi said, quality must be our collective purpose and common endeavour. But it must be quality for all. There are many elements in this Bill which I fear will lead to a fragmented competitive market rather than a comprehensive public service which reduces health inequalities. Despite the duty of the Secretary of State to have regard to reducing inequalities, I believe that that is too weak. Things like the removal of the patient cap will move the NHS towards a two-tier healthcare system in which private patients could jump the queue. That would exacerbate the health inequalities in our country and I also fear a post code lottery.

We were told today by the IFS that 400,000 children will fall into poverty by 2015. That will entrench the health inequalities in our society. Surely now is the time to do everything possible to ensure that in health and social care, at the very least, we are doing everything possible to minimise health inequalities.

One of the small parts of the Bill on which I will be working relates to the abolition of public bodies. The Government have of course abolished various public bodies to which the citizens of this country are very much committed, such as the Youth Justice Board and the coronial office. They have a very strong policy on public bodies and on getting rid of quangos. In spite of that, with this Bill, they are creating the biggest quango in the world and they are creating hundreds of public bodies. I would just quote a couple of comments from the noble Lord, Lord Taylor of Holbeach, in the Public Bodies Bill debate. He said:

"The landscape for public bodies needs radical reform to increase transparency and accountability".-[Official Report, 14/10/10; col. 622.]

He also said:

"The quango state has in the past suited both government and politicians. It has never suited the British public, who expect clarity and, as taxpayers, insist, rightly, that Ministers ensure that

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every pound the Government spend is spent efficiently and effectively".-[Official Report, 9/11/10; col. 64.]

I do wonder what is happening with this Bill and the various quangos that are being created.

I also wish to raise conflict of interest among GPs. I do not know whether noble Lords are aware, but quite recently it was reported that GPs at a health centre in York had written to patients saying that the NHS will no longer fund minor operations and instead they offered to carry out the procedures for a fee. This is an unprecedented step in the health service. They advised patients that for a number of minor surgical procedures, such as ingrowing toenails, mole removal and chopping out of warts and cysts, they would have to go private. This GP practice is also part of HBG Ltd, which is wholly owned by the practice. So the people who are offering private healthcare are the GPs in question. That cannot be right, and I ask the Minister to look into similar cases and for his assurance that this will not be allowed in future.

The noble Lord, Lord Willis, made a superb speech about research and development. I very much hope that the Government will take on board absolutely everything he said as I believe it is very necessary for a modern health service.

My final point is about prostate cancer, which is very dear to my heart. The Prostate Cancer Charity provided me with an excellent briefing, which I seem to have lost, in which it mentioned various things. The noble Baroness, Lady Williams, mentioned it this morning and some dreadful things that are happening in America. The Prostate Cancer Charity is concerned about the cost of reforms, the savings that are required and the fact that these might threaten clinical nurse specialist posts. I am very worried about things such as late diagnosis and will seek reassurance from the Minister that the Bill is not going to affect referral and diagnosis of conditions such as prostate cancer. My husband died because of his late referral in respect of prostate cancer and I would not want that to happen to any other man or loved one in this country. I should also add that it is common knowledge that, once he had been diagnosed, my husband received the best possible care in this country.

The NHS was established by a Labour Government in place of fear. The Conservatives voted against it at that time. This Bill has established a new climate of fear among staff and patients as it seeks to transform our National Health Service, which provides quality care, into a free market. I will be supporting my noble friend Lord Rea, but should his amendment fall, I will certainly support the amendment of the noble Lord, Lord Owen, which will not delay but will enhance the scrutiny of this very, very important Bill.

9.23 pm

Lord Monks: My Lords, I rise to make a point about good management, which I hope will be accepted as a truism throughout the House. It is a solid management principle that when you are doing something complicated and difficult, and certainly when you are doing it for the first time, you are likely to make mistakes. Excellence comes through practice, repetition and continuous

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improvement. It applies to surgeons, and administrators, and it should guide us through the management of the NHS.

The NHS is much improved in many respects in recent years. However, as the noble Lord, Lord Walton, made plain, it has for too long been in a state of constant change-almost death by review. The present systems were only just bedding in when this Bill was swung on the nation without inclusion in the manifestos or explicit mention at the election. Indeed, a major spasm of reorganisation is already under way, despite the fact that the Bill has not cleared this House. We have pre-emptive, premature implementation, and I am sure I am not the only one who rather thinks that this House is being taken for granted. So now it is upheaval time again: enormous costs, new systems, new contracts, new turf battles, new everything. A bonanza for the consultants, the lawyers and the logo-designers; but a nightmare for those who are going to be managing the NHS, wrestling at the same time with financial pressures, staff uncertainties and morale problems. For me, this is British public administration at its worst, lurching from review to review. The Government could have tackled the problems in the NHS in a consensual and incremental way and stopped short of volcanic change. However, pejoratively, they have rejected an approach of this kind as piecemeal and have gone instead for the big bang.

The central ideology of this big bang is that the Secretary of State is shrinking his role while expanding the role of the market. This is a profound challenge to the ethos of the NHS. It was not set up with competition as its guiding star; indeed, I doubt whether it will be any good at competing with private providers. These, I guess, will have a field day-hoovering up the profitable treatments while leaving the chronic, the difficult and the expensive for the NHS, mired as it will be in administrative and cost-cutting mayhem.

I am not surprised that the Conservative Party has embarked on this drive towards private health. It has always contained some powerful forces that do not like the NHS and yearn for the American way. However, I am surprised that the Liberal Democrats-with honourable exceptions-have so far followed the same path. As my noble friend Lady Thornton said at the start of the debate, the Liberal Party played a significant and honourable role in the formation of the welfare state through the efforts of people like Lloyd George, Keynes and Beveridge. I like to think that these titans might be spinning in their graves at their successors' current pursuit of this Bill. I hope the noble Lords on the Benches opposite-indeed, all the noble Lords on the Benches opposite-will reflect on what they are doing before it is finally too late.

9.26 pm

Lord Harris of Haringey: My Lords, at this two-thirds point in this debate, I make no apology for focusing my remarks on Part 5 of the Bill, and the quality of the voice for patients that it offers. This Bill is likely to damage irreparably the National Health Service, creating a service that is less accountable and more fragmented; that is increasingly provided by for-profit organisations; and where the relationship of trust between doctors and their patients is undermined. Under such

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circumstances, an effective structure is essential to support patients in navigating their way through the new arrangements, to ensure that their needs and concerns-both individually and collectively-are not neglected in the brave new world of private suppliers feeding on the remnants of public provision. It is essential to guarantee that, with the democratic deficit that will now open up in health provision in this country, the impact of the changes is catalogued and drawn to the attention of those charged with regulating the new system, of Parliament and ultimately of the public who are paying for it.

I declare a former interest as someone who-for 12 years-was director of the Association of Community Health Councils, then the statutory body representing the interests of the public and the users of the NHS. The Government are now bringing forward another round of proposals to fill the void left by Community Health Councils when they were abolished in 2003. They were succeeded by patient and public involvement forums, which lasted four years before they were replaced by local involvement networks. Again, with a life of four years, LINks are to go, to be replaced by HealthWatch. The sequence of change in consumer organisations is a poor recommendation of the previous Government. I am shocked to see that the current Government are moving forward in a similar vein.

Of course, the Government's objectives are laudable: "No decision about me without me" is as resonant as previous rhetoric about putting the patient at the heart of the NHS or the mantras about patient empowerment 10 to 15 years ago. Some of your Lordships will even remember John Major's Patient's Charter-that daughter of the Citizen's Charter and that cousin of the Cones Hotline. How does the high-sounding rhetoric match up to the reality of this Bill? How far are patients going to be involved in decisions about managing their own care and treatment? It is simply not clear whether these are adequately safeguarded in the Bill. A duty to promote involvement or a duty to promote choice is not a sufficient guarantee. Who will hold clinical commissioning groups or the NHS Commissioning Board to account for the extent to which they have promoted that involvement or choice? Where will patients go for redress if they find that their family doctor will not refer them for treatment or investigation but insists on managing that treatment or conducting that investigation within the practice, thereby keeping the resource that would otherwise go with that patient? What will be the process for ensuring that key commissioning decisions are in line with the preferences of those affected by them and that those decisions reflect the expertise that patients have in their own conditions and the experience that patients collectively have of their local services?

Presumably we will be told that this is where HealthWatch will come in, but what will HealthWatch mean in practice? The first problem is that it is unclear how local healthwatch groups will be constituted. If individuals are simply going to be self-selected, their views, though valuable, will not necessarily be representative of all service users, and there is a risk that because of that they will not be treated by commissioning groups as having legitimacy. Members of local healthwatch groups need to have their own

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local accountability and must have the resources to engage with the wider community to be able to assess and represent their views.

Resources will also be necessary to enable local healthwatch groups to provide advice, support and advocacy. This will be an important and potentially substantial role in the brave new world of the NHS that this Bill creates: a world where patients will no longer be clear whether their GPs are acting in their interests or to bolster their practice's coffers; a world where decisions about what is to be commissioned will be taken with no clear system of public accountability; and a world where for-profit providers will increasingly squeeze out those that are not-for-profit and where profitable treatments will be cherry-picked.

A strong system of patient advocacy and support will be needed, but will it be provided? This will depend on the decisions of hundreds of local councils. The money provided by the Department of Health will not be ring-fenced, and there will be no mandating of local authorities about the nature and quality of HealthWatch services that should be supported. All this is in the name of localism, that same localism that has seen the budgets of LINks drop dramatically this year, in some instances by more than 50 per cent, despite, as the Minister told a number of us last night, the Department of Health saying that it has increased the resources available. The resources went up, but the resources available for local healthwatch went down. It is a localism that means that the Minister can offer us no assurances that those advocacy services that he promises us will be adequate. In future spending rounds who will argue with the Treasury for the moneys for HealthWatch? Will it be the Department of Health, which will have no say in whether the services expected are being delivered, or DCLG, which will have no interest in those services, or will the current commitment be allowed to wither on the vine as no department fights its corner?

Is it even appropriate that local healthwatch groups should be resourced via local authorities which themselves will have responsibilities for social care provision? Is there not a potential or perceived conflict of interest here? How comfortable will a local healthwatch group be in criticising its paymasters about the quality of that provision?

Finally, there is the relationship with national HealthWatch. A national structure is essential for the views and concerns of local healthwatch groups to be captured and articulated at national level, but that national structure must grow from and be a creature of the local groups, not sit above them as a mere sub-committee of a regulator, moreover a regulator to which requests for action and even criticism may need to be directed by that structure.

The new NHS will need a strong and independent user voice. The Government keep citing the proposals on HealthWatch as evidence not only that such a voice will exist but that the patient will indeed be central to the myriad new structures that they are proposing.

Yet the danger is that what we are being offered is no more than a fig-leaf whose own legitimacy will be flimsy, a fig-leaf whose resources will be plundered as local government itself faces a future with rapidly

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dwindling money, a fig-leaf whose independence is compromised by its relationship with a paymaster whose provision it is supposed to be monitoring, and, above all, a fig-leaf protecting the nakedness and insufficiency of the protestations that no decisions about the patient will be taken without him or her. My Lords, it is just not good enough.

9.35 pm

Lord Cotter: My Lords, today we have had the chance to debate just about the most important subject for the people of this country that could be facing us-health.

I pay tribute at this stage to those who work in the health service and who put their heart and soul into caring for us and our families. I also thank the many people in the health service who have sent us information about their concerns with and practical experiences of the health service, as well as their concerns about the treatment that they will receive in the future. It is easy to dismiss such information as lobbying. I do not see it as that; I think that we can make a judgment about what is and is not relevant. However, it has been very important for this debate to have received so much information from our own parts of the country, as well as nationally, about how people feel and about their concerns with what we are now addressing. We are also at a time when morale among staff in the health service is extremely low. That is the message that I get from them. Many people are waiting for the results of this Bill with some trepidation.

Regardless of going into the detail of the proposals, I wonder whether such detailed changes are right at this time-perhaps at any time-when we are so short of the money that is required to implement the measures. I liken it to throwing all the balls in the air and hoping that they will land the right way. I do not want to be too negative or at this late hour to repeat too much of what has already been said. However, there are worries about competition. Is it really the case that providers can be fined a considerable figure if they are not seen to be competing enough? How is that to be assessed? Competition in what way?

One of the big commitments of the coalition Government is to reduce red tape and bureaucracy in this country. That is good but, with all the myriad bodies that are being created to implement the Bill, are we sure that we are not adding more bureaucracy rather than having less? It has been suggested that the number of quangos will increase from 163 to more than 500. Is that so? If it is, is not the complexity, bureaucracy and red tape that that could create a matter of concern? It is of course necessary to have regulation but we need to be careful that it is the right sort of regulation.

The role of the Secretary of State has been raised more than once, having been put into question or, at least, been questioned. I am sure that the Minister will be able to provide an assurance in this area, because this is seen as a crucial point to be addressed.

Another point that has arisen in the debate today and has also been in evidence for a while, and on which we need clarification, is the situation regarding

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untrained health workers or healthcare assistants. Will they be covered by a voluntary register or, better still, have a binding code of conduct? This will give reassurance and perhaps raise the standards that we expect to receive from the health service.

For the 15 years or so that I have been in Parliament, I have been aware of the need for all Bills to have strong impact assessments. I remember in about 1998 or 1999 thinking that quite a lot of Bills which were not adequately supported by impact assessments were going through Parliament and, over time, that has been proved to be so. However, I have seen it expressed that the impact assessment associated with this Bill is perhaps not sufficient to cover all the different changes that will take place. I would be interested to hear from the Minister whether that is so.

It is late at night, but I would like to turn to a personal point. I hope that we can all consider the health service in respect of the alternative health sector. I have gained very much from being treated by Chinese medicine, acupuncture and herbal treatments, as have a number of members of my family. I know that acupuncture has been discussed quite a lot but not so many years ago it was dismissed out of hand as some sort of quaint treatment, which has not proved to be the case. Recently, I opened the World Congress of Chinese Medicine in London, and I was asked to speak as I have an interest in the subject. I stayed for a good part of the day and it was absolutely clear how much scientific work has been done to assess and to show that there are clear improvements to be had from acupuncture.

I have also gained very much from herbal treatments. My experience with alternative medicine is that you get a quick diagnosis and treatment on the same day. The experience of my friends and family is that the assessment is often very good and getting treatment right away is, of course, so vital and can result in improvement in people's health much quicker than perhaps happens in the health service. I do not want to be too critical but when you go to a GP, they can be a bit puzzled about your condition and eventually they say after a month of trying this and that, "I will send you to a consultant". But time elapses and my experience with the alternative medicine sector, particularly with Chinese medicine, is that it is very good in that respect. I throw this point out to the Minister to see whether we can formalise it for the future.

I have repeated some of the points that have been made during the debate, which has clearly indicated that there is much work to be done to address fears and concerns and, if necessary, to make corrections to the Bill. We have a big job and a big responsibility ahead of us to ensure that we in this House check the legislation and ensure that the NHS is safe in our hands.

9.43 pm

Baroness Hughes of Stretford: My Lords, the noble Baroness, Lady Tyler, among other noble Lords, referred to the fact that the Bill and the debate have, perhaps necessarily, been predominantly about structures, pathways and commissioning boards, which are all very important, but I want to focus on people and specifically on

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children and young people. I believe that whatever is left of the Bill, after this process of scrutiny and its passage through the Houses, it is vital that we take the opportunity, in so far as we can, to improve prospects for children and young people. I say that for several reasons.

First, despite there being many dedicated health professionals, the health system has often not worked well for children and young people. I know from when I was Minister for Children that the NHS, certainly at its top levels, has been very resistant to including indicators for the improvement of outcomes for children. Sir Ian Kennedy in his report last year said that many professionals feel that services for children and young people have traditionally had a low priority in the health service and that fewer resources have been allocated by the NHS nationally, regionally and locally to children's health services. The system does not always respond well to children whose needs are complex and who require good integration between health and other services. That is the case particularly in respect of disabled and looked-after children. In addition, meeting children's and young persons' needs often requires joint commissioning of all services for children-health alongside social care, education, statutory and voluntary organisations, and those speaking for and working with families.

Secondly, we have to consider that current social and economic events will have an adverse impact on children's health, and we can expect their health needs to rise. With rising unemployment, we can expect a rise in child poverty and mental illness among parents. The IFS report published today states that families are suffering an "unprecedented collapse" in living standards. Welfare benefit changes will reduce the incomes of the poorest families, affecting their nutrition and well-being. We are seeing key services such as Sure Start centres and parenting support being lost. All this, as we know from the past, will have an adverse effect on children's health. In addition, the Bill threatens to disrupt existing child protection mechanisms and the relationships between organisations working together to safeguard children.

Thirdly, the Government stress their aim to put patients and public views at the centre of commissioning, yet there are very few mechanisms for children and young people to influence the commissioning and delivery of health services. Research by the National Children's Bureau published recently shows that existing structures for patient consultation, the local involvement networks, are struggling to register children's voices. Any new mechanisms to involve local people in determining health needs must include children and young people from the outset.

Above all, the Bill makes no specific reference to children and young people and, perhaps more importantly, nor has discourse from the government Benches. That commentary has not signalled the need for the reforms to work better for children. I want many changes to be made to the Bill to ensure that the system works better for children and young people. I shall restrict my comments to the Minister to five issues. Although I relate those issues to children and young people, they arise from endemic flaws in the Bill and will therefore have an impact on other groups of patients.

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First, how do the Government propose to ensure that children and young persons' health is given high priority in commissioning? Will the Minister consider amending Clause 20 so that the Secretary of State's mandate to the NHS Commissioning Board must include priorities for children's health and for reducing health inequalities between children? There is also a need to focus on reducing health inequalities at the local level. Will the Minister also consider placing a duty on the health and well-being boards and the clinical commissioning groups to reduce health inequalities particularly among children?

Secondly, the proposals for commissioning, as I have mentioned, have serious implications for the co-ordination of health and social care responses to child protection. The Government's current proposals split responsibility across three bodies: the NHS Commissioning Board for primary care, the clinical commissioning groups for acute mental health and maternity care, and the health and well-being boards for early years. Where will the clinical lead and the accountability for child protection lie? How will the Secretary of State ensure that every local area has robust and transparent arrangements for child protection?

Thirdly, the Government's proposals significantly increase the complexity and bureaucracy of the health system, as my noble friends Lord Hutton and Lady Armstrong of Hill Top have pointed out, with many more organisations responsible for different aspects of commissioning and monitoring. Different services will be commissioned at different levels-the NHS Commissioning Board, clinical commissioning groups, larger consortia of commissioners and local authorities. Children at risk, looked-after children, disabled children and those with complex needs will require packages of services drawn from all these levels and from social care and education. Will the Minister set out how these services will be integrated locally? What role will the health and well-being boards play in establishing a local framework for integration? The Bill, even after amendment in the other place, seems to imply that this is an optional part of the remit for the health and well-being boards and of the scope of the joint health and well-being strategy. The remit for integration seems to be optional. Will the Minister agree to amend Clauses 192 and 197 so that this is rectified?

Certain groups of children, for example looked-after children, care leavers and Gypsy, Roma and Traveller children in particular, are often particularly vulnerable to health problems and are also more likely to move across local authority boundaries. Will the Minister say specifically how he will ensure that the needs of these children and young people do not fall between the cracks of what I believe will be a more fragmented system, with a greater lack of coterminosity, as my noble friend Lady Royall has pointed out, than before?

How will the Minister ensure that the voices of children and young people are given strong recognition and clear ways to express themselves within the system? The Government talk much about giving patients and the public greater influence over decisions about healthcare, but there is no mention of children and young people. Local healthwatch organisations and HealthWatch England must be required to have specific and dedicated child-friendly ways in which the views

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of children and young people can be elicited and acted on. Will the Minister amend the Bill so that this is an explicit requirement on local and national healthwatch organisations?

I look forward to the Minister's reply and to pursuing these issues further in Committee.

9.52 pm

Lord Ramsbotham: My Lords, like other noble Lords I have received an incredible number of e-mails and letters about the Bill. I suspect, too, that like many other noble Lords, as I listened to the reasoned case for the Bill put forward this morning by the Minister with his customary skill and courtesy, I could be forgiven for wondering what all the fuss was about. However, when like my noble friend Lady O'Loan I thought through the list of those who had written to me, I reflected that the vast majority are either patients or practitioners. What they have to say confirms the concern of the noble Baroness, Lady Williams of Crosby, that the Government have not yet made the case for the Bill with the public, and in particular with the two groups of people whose best interests are, they claim, paramount in the provision of health and social care.

Many noble Lords have rightly concentrated on concerns about competition and the position of the Secretary of State. However, like my noble friends Lord Walton and Lord Kakkar, I do not believe that these should be hived off to a Select Committee, mirroring committee practice in the other place. Far better that in order to do justice to the concerns that have been voiced to us and to exploit the undisputed expertise that has been deployed already, and will I am sure continue to be so, all aspects of the Bill should be debated in detail on the Floor of the House, however long that takes.

Rather than repeat what others have said, I intend to concentrate on three what may seem more prosaic matters in the time available. All have common NHS involvement in announced policies of other ministries about whose achievement I am now uncertain in the context of the Bill.

Noble Lords will not be surprised that having, as Chief Inspector of Prisons, proposed in 1996 that the NHS should be made responsible for prison healthcare, I should start with that. At the same time, I expressed the view that prison healthcare was a public health issue because almost all prisoners will be released and the state of their mental and physical health at that time is a matter of public interest. Furthermore, imprisonment provides an opportunity for the identification and initial treatment of mental and physical health problems that can be continued in the community in the form of aftercare.

I am very glad that the NHS has been responsible for the provision of prison healthcare since 2004, and that there is now a director of offender health in the Department of Health who has a seat on the board of NOMS in the Ministry of Justice. I am also glad to see in Clause 12, which requires the commissioning board,

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in new paragraph (c),

However, I do not think that that definition is precise enough, and I shall be tabling amendments to flesh it out to include responsibility for those in immigration detention, secure children's homes and police custody.

I include the police in connection with the provision of another aspect of offender healthcare that I shall seek to flesh out: the diversion from prison of those with mental health problems. Psychiatric morbidity is a huge problem in our prisons; the Office for National Statistics proves that. In addition to the 500 prisoners per year who qualify for sectioning under the Mental Health Act, 70 per cent suffer from a least one personality disorder. Under the previous Government, the noble Lord, Lord Bradley, wrote a report making practical recommendations for diversion, but implementation is still in the early stages. As diversion begins at police stations, it is important that there is adequate health care provision to make it possible. I assume that that will be a matter for both commissioning and health and well-being boards.

Not all offenders are sentenced to expensive imprisonment. At the heart of the Government's proposals for reducing prison numbers are improved community sentences conducted by the probation service as credible alternatives. There is absolutely no reason why such sentences should not include the same identification and treatment of mental and physical health problems as in prison, but, at present, locally delivered probation lacks the healthcare provision that exists in local authority youth offender teams. I shall therefore be tabling amendments to rectify that, in line with Clause 191(2)(g), which states that health and well-being boards must consist of,

I move on to education. I have lost count of the number of times that I have raised the issue of communication skills, or the lack of them, which is the scourge of the 21st century, on the Floor of this House. In the current Education Bill, which has just completed its passage through Grand Committee, I tabled amendments calling for the communication abilities of all children to be assessed before they begin primary school, to enable them to engage with their teachers. I proposed the same in a number of education, welfare and justice Bills under the previous Government. They were followed by announced intentions to do something, but nothing has happened, except in Northern Ireland, where the NHS now assesses every child at the age of two. Similar provision in England and Wales is dogged by the fact that because speech and language therapists belong to the NHS and are funded by individual primary care trusts, no other ministry will fund their provision. The end result is that the future of countless young people in this country is being unnecessarily blighted, and I shall be tabling amendments to ensure that such provision is debated in detail.

Finally, I raise a mental health issue connected with the Armed Forces covenant and the treatment of serving and retired service men and women, as well as provision in the community, which touches on many

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issues to do with regulation. I will not bore the House with details of the problems over the treatment of post-traumatic stress disorder caused by the narrowness of NICE guidelines, which preclude the loose use of alternative therapies, but I believe that it is confusing for Clause 225 to provide for both the professional standards authority for health and social care and the proposed health and social care council each to run voluntary registers for unregulated health professionals, such as psychotherapists and councillors. I shall be tabling amendments accordingly.

There is a great deal of work to be done on the Bill. I sympathise with the Minister on his impending workload, but he starts with one overwhelming advantage; he enjoys the respect and trust of the whole House.

10 pm

Baroness Massey of Darwen: My Lords, I rise humbly after so many excellent speeches and after so much expertise has been expressed. I shall raise some issues about public health and then speak about my concerns on child health in this Bill, following my noble friend Lady Hughes. I agree with her about the lack of discourse about children's health generally and the importance of integrating systems to deal with children.

On public health, I declare an interest as chair of the National Treatment Agency for Substance Misuse, the NTA, an organisation that will become part of Public Health England. I pay tribute to the Minister for his consideration, sympathy and astuteness regarding negotiations about arm's-length bodies. He has an unenviable task and I admire him for his work on it.

There are issues around the future of public health in relation not only to drugs but to alcohol, HIV, sexual health and other services. I am proud that the NTA has contributed to the improvement of drug services. The number of people in treatment has more than doubled in 10 years, waiting times are now very short and the use of opiates and crack has gone down, as research has recently shown. Service users have been significantly involved in the development of services. It has been shown that for every £1 spent on treatment for drug use, at least £7 is ultimately saved.

The Minister spoke, many hours ago now, about the importance of outcomes in health. Here we have an example of positive outcomes that could be built on in relation to public health. The improvements that we have seen are due to a strong focus on drugs as a problem for crime and health and to the appropriate ring-fenced funding over the past 10 years. Structures are in place, collaboration between agencies is notable and I like to think that the assistance of clients into recovery will continue to improve. They will not do so, though, without attention to many of the issues raised here today, including just now by the noble Lord, Lord Ramsbotham, who will be a very busy person with all those amendments.

My concerns are around the role of clinical commissioning groups and how they will engage with health and well-being boards; about the integration of health and social care for areas like drugs, alcohol and sexual health, where there is potential for fragmentation; and about the accountability of the NHS Commissioning Board for effective integrated care. I hope that the Minister will address some of these issues.

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I begin my concerns about child health with the concerns of many children's organisations that the Bill must deliver for children and young people and that child health must be given the priority it deserves. I declare another interest as chair of the All-Party Parliamentary Group for Children. Sir Ian Kennedy's report last year has already been mentioned by my noble friend Lady Hughes. Children comprise 22 per cent of the population, and children are often helpless in the face of the actions of others-for example, in passive smoking. A report today raises the potential problem of the increase in relative child poverty, which, according to the report, will affect about one-quarter of all young people. I worry about the interaction between poverty and health, and I worry about the invisibility of children in health services.

We know that Graham Allen, in his recent report on early intervention, expressed the view that early intervention in social and intellectual development is vital if children are to develop positively. The same is true of health interventions. There is a great deal of evidence to show that encouraging good physical and mental health at an early age is vital to future well-being.

I shall quickly make three basic points. First, the voice of the child must be heard. Children must have a say in decisions about local services and care, as recommended by the NHS Future Forum. HealthWatch England and local HealthWatch must be instrumental in this. Secondly, local services for children must be integrated and must talk to each other. We have already seen the disastrous effects of the lack of such integration. The clinical commissioning groups, whose boundaries do not align with local authorities, must set out how effective partnerships will be developed to promote child well-being. Thirdly, surely young people with complex needs may well fall through the gaps between services as they move into adulthood. Universal services, specialist services and services for parents, families and children must connect with each other to ensure that there is a clear pathway for individuals throughout life.

Coalitions of organisations concerned for the welfare of children agree that the Bill must be amended. For example, in Clause 20, as my noble friend mentioned, priorities for improving child health services should be included in the mandate to the NHS Commissioning Board. In Clause 192, health and well-being boards must, rather than may, encourage integrated planning and delivery across health and social care services. In Clause 190, the joint health and well-being strategy must, rather than may, include a statement on how health and social care services could be better integrated with health-related services. Local HealthWatch organisations must promote the involvement of children and young people. There must be clear accountability for promoting the health and well-being of looked-after children and care leavers within new structures. Clause 162 would abolish the private patient cap, meaning that hospitals could treat any number of private patients. This could be detrimental to NHS patients and disadvantageous to low-income families and children.

Plans for involving the voluntary sector and communities must be clarified. We are all indebted to the voluntary sector for all its sterling work with children and other aspects of community life. The

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Royal College of Paediatrics and Child Health recommends that Clause 191 on the membership of health and well-being boards should designate professionals who are responsible for safeguarding. It also recommends that, in Clause 23, proposed new Section 14V should be amended to include maltreatment, not just the prevention, diagnosis and treatment of illness.

We shall of course return to these issues. However, I plead with the Government to take child health very seriously. Early intervention and preventive strategies are not only humane and contribute to lifelong well-being, they have economic advantages that should surely be a consideration.

10.08 pm

Viscount Eccles: My Lords, it is a great pleasure to follow the noble Baroness, Lady Massey. My interests are somewhat different. I declare that for many years I have worked with the Hospital for Tropical Diseases. I first got involved in helping to move the hospital from St Pancras. We created a small fundraising group to raise 50 per cent of the cost of the move. What convinced me that we should support the move was asking the chief nurse what she thought. She said, "I'm fed up with humping bottles of oxygen around the hospital when everybody else seems to get it delivered in a pipe". That was an example of necessary modernisation and the front line knowing what it needed.

I shall make only one more comment about the Hospital for Tropical Diseases. In its clinical faculty there is an expert on leprosy. Your Lordships might not think that it is necessary for the National Health Service to know a great deal about leprosy. However, there are some lepers in this country. That speciality is very important and, in the context of such a large organisation, it is always possible that it could be forgotten. That should not happen. I should declare that I am chairman of a small charitable trust, the Hospital for Tropical Diseases Foundation. That hospital is 200 years old. Arguably the start of the Health Service goes back about 90 years. In 1918, the Cavendish lectures were delivered and the theme was:

"The best means for preserving health and curing disease should be available for every citizen by right, not by favour".

The speaker went on to say:

"I venture to think that this will be an article of faith for every political party".

That was in 1918. It would be wonderful if we could agree that there is no dispute or disagreement about the themes of that speaker 90 years ago. There followed a 25-year gap between that, not unconnected with the financial difficulties of the 1920s, and Beveridge. As your Lordships will remember, Beveridge connected want, disease, ignorance, squalor and idleness directly to health. His report was rapidly accepted by the coalition Government of the day.

In 1944 there was the White Paper-it is remarkable that this was happening in the middle of the Second World War-in which it was generally assumed that there would be around 30 area integrated health authorities. However, that was not the decision of the post-war Government. They opted for something more centralised. We should leave it to history to judge

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whether it would have been better to follow the prescription of the 1944 White Paper or whether what was decided was better. We should live with the decision and not refight those battles.

The progress in medicine in this country since then has been driven mostly by international western research and development. It is important to remember how open the exchange of information is in the western world on these matters. It has also been driven by brilliant engineering. If we think of what it was like to go to the dentist when we were young and think of it now, the development by engineers of drills over that period has been quite amazing. This progress, from research and development and from engineering, will continue, and everybody expects that it will continue. The question that then arises is how significant are the detailed statutory arrangements that we make in order to back up, control and perhaps regulate this progress. Are these statutory arrangements more than enabling mechanisms, or are they possibly disabling mechanisms? Will not the progress continue, whatever the statutes say? I think that it will.

Whatever any Government thought about statutory arrangements, if they went into an election having made what the public considered to be serious mistakes about the Health Service, they would pay the penalty. I am not sure that we should spend too much time in the face of legitimate democratic expectations worrying about the constitution committees and thoughts on the role of the Secretary of State. I feel sure that these matters can be satisfactorily resolved in Committee and on Report.

Secondly, in some of the representations that we have all received, particularly those from expert bodies, the opportunities for progress, which has already taken place, are seen to outweigh politics, either internal to the NHS or external. However, for others it is not so. Some people seem to oppose change, perhaps any change. My conclusion is that in total the representations tell us that this is a serious Bill that needs serious debate and scrutiny without delay. Many serious matters need debate-for example, reducing inequalities, the balance between general practice and the many other services, the balance of resources between prevention and cure, anti-competitive behaviour, and many other matters. Nevertheless, what the Bill needs now is scrutiny and improvement, and I look forward to Committee.

10.16 pm

Lord MacKenzie of Culkein: My Lords, I will try to concentrate on some of the issues that are of concern to me about healthcare and the Bill. First, I should make it clear that my interest in healthcare derives from my being, until nine years or so ago, on the register of general nurses. However, despite being too old to be still registered, it is a truism to say that once a nurse, always a nurse.

I have spent most of my working lifetime defending the health service. I am not going to stand here tonight and pretend that all is perfect, when clearly that could not be the case. There is room for improvement and that can and should be made. That means that sometimes reorganisation might be necessary. Structures cannot be preserved in aspic for ever. However, the NHS has

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rarely had long periods without organisational change. How often have we heard the cry that the National Health Service needs stability rather than this constant cycle of change that brings ever more cost, usually more bureaucracy, lots of redundancy for senior skilled staff and much more unsettlement for employees?

I have seen more reports and reorganisations than I care to remember. I begin with the Salmon report on nursing. I am not going to read the others that I have on my list. The noble Lord, Lord Walton of Detchant, has already dealt with some of them, and he beautifully demolished the 1974 reorganisation of the National Health Service, which, I recall, was accompanied by the dreaded Grey Book. I will resist listing the reorganisations.

We have also had quite a lot of change in the past few years, and some of that has been good. Despite what has been said about productivity in the National Health Service in recent years, I contend, for example, that the ending of two-year waiting lists, the ending of patients lying for hours and sometimes days on trolleys, the cancer targets, the cardiac targets, the stroke targets and the new buildings have led to better patient experience and outcomes. There are now signs that we are starting to go backwards, certainly at least in terms of waiting times.

Like many, I might have been prepared to give the Bill a fairer wind had it not been for the promises before the election that were largely replicated in the coalition agreement to the effect that there were to be no more wasteful top-down reorganisations. It is not a case of a Government coming to power and looking at the books, which is the usual excuse. One might be forgiven for suspecting that this is a deliberate ploy to tell the electorate one thing while planning to do precisely the opposite.

Of course the Secretary of State in the health department should not be micromanaging the National Health Service. As I see it, this Bill will allow Governments to wash their hands and absolve themselves of any responsibility from any inconvenient questions or issues on healthcare and to blame some of the new quangos the Bill will set up. The powerful speech of the noble Lord, Lord Owen, gave a perfect example here. What if there was to be a pandemic? I would hate to be the Secretary of State who tried to say, "It is nothing to do with us-it is a matter for the chairman of a quango".

It is not unusual for change to be resisted but leadership is about taking the public with one. In the case of this Bill it is also about taking employees and importantly the many professions with one as well. It is all too easy and too convenient to suggest that persons who fail to agree are motivated merely by self-interest. I do not include the noble Earl the Minister in this-I have never heard him say a disparaging word about health staff in all the time I have known him in this House-but some spokespersons for the party opposite should be more careful than to resort to the lazy argument that, for example, the 4,000-plus public health specialists were either politically motivated or too idle to read and understand the round robin before signing it. That is not the way to influence debate and it is not the way to make friends. It is crass and insulting.

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I want to deal with one or two aspects of the delivery of hospital care. I had the unenviable experience fairly recently of observing that at pretty close hand. As a result of a catastrophic error during laparoscopic surgery, I spent almost six months in four hospitals rather than the one night which had been anticipated. As a former deliverer of care, I was on the receiving end and a rather fascinated observer. The specialist surgical team who, I guess, saved my life once the original error was recognised were superb, as were the colleagues who carried out the follow-up surgery some three months later. They were pretty special to be able to make any restorative surgery at all.

I felt safe when I was in intensive care and high dependency. The staffing levels were great, the skill mix was right and the medical, nursing and physiotherapy staff could not be faulted. However, as I later moved from ward to ward and hospital to hospital I took rather a different view. I am not going to join the noble Lord, Lord Waddington, in his general criticisms of nursing staff. I know that nursing has moved on and the patient profile is vastly different, and very many skills and interventions are different because of the advances in medicines and surgery. However, some of the skill sets are the same as when I was nursing, particularly the issue of essential care. Somewhere along the line this has been lost and the status of what we used to call basic nursing is, I fear, no longer there. I am not sure whether this is due to nurse education, the nature of the structures in which nursing care is now delivered or whether it is a cultural matter, but it is one of the issues that needs to be addressed and it is not anything to do with overseas nursing staff, which was being suggested by the noble Lord, Lord Waddington.

Overstretch is a particular problem but one of the real problems is skill mix. Far too often the ratio of registered nurse to healthcare support worker is not right. Healthcare assistants are often left to carry out procedures for which they are not properly prepared or mentored. I support what the noble Baroness, Lady Emerton, said about mandated staffing levels and ratios. Ward sisters and charge nurses are understandably and clearly not doing the same job as when I was nursing. There are some really good exceptions but there is not enough evidence, in my view, of clinical leadership. It is right that the ward sister has a wider role than just getting sleeves rolled up on the ward, but there needs to be a better balance. It is not a return to the matron that we need-it is a return to the authority and to the clinical leadership of the sister or charge nurse. Patients deserve competent and compassionate care.

I was out of the country when the chief executive of the Royal College of Nursing said some nurses were not up to the mark, so I missed most of that debate. Like Peter Carter, my job was to defend nurses and nursing and I have no doubt that if I had said the same things I would have been roundly criticised by some of my members, and I suspect that Dr Carter was as well. However, we have to be honest. If we are concerned about the nursing profession and about patients, we have to admit that not all nurses are up to the mark. I am intrigued by the plans of the Heart of England NHS Foundation Trust to trial quite a different mix of

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university education and hands-on training. I wish that trial well, because it has the possibility to meet some of the issues about which I am concerned.

My old union, the Confederation of Health Service Employees, always argued for a qualified service. Many people would think that that was a bit optimistic and pie in the sky, but we supported Project 2000 and the drive to university education, rather than just nurse training. But we always wanted support workers, whatever their job titles, to be trained and regulated; that was not at the time supported by other nurses' organisations because there was a fear that we were trying to replicate the enrolled nurse. That was not so, but there is now a widespread recognition that the public will be and must be better protected by regulation. The present training of healthcare assistants is variable in quantity and quality, yet nursing tasks are routinely delegated. I realise that there are many job titles and many different roles carried out by support workers, but there is a solid case for regulation, and it must be mandatory regulation rather than voluntary.

I shall touch on one other area in which I think that the Bill is deficient-in the commissioning for persons with less common conditions. I refer, for example, to patients with neurological conditions such as motor neurone disease. My closest friend lived with, and subsequently died from, motor neurone disease, and I have seen that ghastly condition at close quarters. Most GPs will perhaps see one case in a working lifetime, and most nurses will never see it. I never saw one in practice, although I have nursed other distressing neurological conditions such as Huntingdon's syndrome. The concern is that CCGs covering a small population and working in isolation are less likely to be able to deliver the service for patients in this category. I am advised that effective commissioning will need a population size of a quarter of a million for many neurological conditions, and much more like half a million for motor neurone disease. In the latter case, for example, a half a million population would have about 30 people suffering from motor neurone disease. How is it planned that people with less common conditions can have access to the healthcare required? Will the CCGs have a duty to work together to commission those groups? How will that be reflected in the Bill and how will the commissioning board enforce commissioning for those services if CCGs fail to work together? Will there be an advisory group for neurological conditions within the commissioning board?

We have a problem already with some of the CCGs. There are going to be no PCTs, as the coalition agreement said, to act as champions for people with residual services or less common conditions. I am told that in one area of the country there are now seven CCGs but presently one PCT. The charity Parkinson's UK has already agreed with one of the CCGs that there is a need for a specialist nurse; so far, so good, but instead of working together the CCG concerned has already told Parkinson's UK that it is up to it to convince the other CCGs of the need for a specialist nurse. So much for collaboration. I hope that the Minister can tell us that this is not going to be the pattern that many of us fear.

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It is difficult for me to wish this Bill a fair wind as it stands; there is going to have to be major change as it proceeds through this place, and I look forward to much of that.

10.28 pm

Baroness Barker: My Lords, I have never been the 73rd speaker in a debate in your Lordships' House before, but that is because I have never spoken about reform of the House of Lords or hunting. I have watched people who have spoken at spot number 73, and at this time of night it is not about great oratory; it is about making four or five key points that point up major issues of the Bill. That is what I am going to do.

Several hours ago, the noble Earl, Lord Howe, set out his eloquent introduction to the reasoning behind the Bill. He talked, as did the noble Baroness, Lady Thornton, about the antecedents to the Bill-not many of the Bills debated in this House during the time of the Labour Government, as she said. One of the key antecedents to this Bill was the Wanless report of 2004, a piece of work remarkable for its depth and detail. In essence it said three things. The first was that whatever the level of resources we give to the NHS, we will never ever be able to meet demand fully. It went on to say that the long-term viability of an NHS that is free at the point of need depends on two things in particular: the extent to which the public are engaged in protecting their own health and the extent to which clinicians are involved in decision-making and innovation.

The Wanless report informed much of the work of the noble Lord, Lord Darzi-the work on the NHS constitution, for example. That, in turn, has formed some of the building blocks of this legislation. In so far as it does, I welcome some of it. Like other noble Lords who have spoken from these Benches, I welcome some of the things in the Bill. Health and well-being boards and the integration of public health and local government are long overdue. Just as Derek Wanless said all those years ago, there are very many determinants of health, the answers to which lie outwith the scope of the NHS, and they always will. That is an important achievement which is in this Bill as the result of work by some of my Liberal Democrat colleagues.

However, there are a number of issues on which I and my colleagues, notwithstanding the work of some of my colleagues down the other end, remain to be convinced. Much has already been said on the Secretary of State's duties and accountability. There is a key question which I think every person in the land wishes to be able to answer. Who is ultimately responsible for my local health service, and if it is poor, who is responsible for sorting it out? Some people may be forgiven for thinking that at the moment there is an easy answer to that question. Very often there is not an answer at all, and very often if there is an answer, the answer is "the Secretary of State". That, I am afraid, is not an acceptable way to go forward for much of our health service.

I listened very carefully to the comments of the noble Lord, Lord Owen, and I agree with him: it is inconceivable that in extremis the Secretary of State could not take emergency and urgent powers to order the NHS to cope with something such as a pandemic. The truth is that most of the time the NHS is not

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working in extremis-it is working on day-to-day health. The issue identified by my noble friend Lord Marks in the Bill is the duty of the Secretary of State to promote autonomy. Those two things are incompatible. We need to assess the duty of the Secretary of State, as the noble Earl, Lord Howe, said this morning, as part of a long chain of responsibility, from the NHS Commissioning Board, through Monitor, to clinical commissioning groups.

I want to ask the Minister a key question. In what circumstances will departmental Ministers be obliged to answer detailed questions in Parliament on the performance of NHS commissioners and providers, and what will be the nature of any direct lines of accountability between Parliament, the NHS Commissioning Board and Monitor? The accountability of the NHS Commissioning Board is a matter of great concern to me. The idea of an independent board was one which surfaced as Conservative policy in, I think, 2007. It was very much favoured by a number of the health think tanks at the time and then disappeared without trace until it re-emerged after the election. Now it is in this Bill, but there are a great many questions of detail which still need to be answered. Its accountability to the public, given that it has extensive powers, needs to come under much greater scrutiny than is currently planned. I should like to know whether the Commissioning Board will be subject to the same standards of accountability as clinical commissioning groups. The Commissioning Board will also be responsible for holding commissioning groups to account for their performance. It will do so with reference to quality outcomes, commissioning guidance and the commissioning outcomes framework. Can the Government say how the board itself will be held to account for the quality of its own commissioning? By whom will it be held to account?

There has been an awful lot of talk today about competition. Much of it, I think, has been slightly off the mark. I think it is now true that any qualifying provider will be limited to those areas where there is a national or local tariff, ensuring that competition is based on quality, not on price. I am sorry that a number of noble Lords are not present. I would say to the noble Baroness, Lady Jay of Paddington, who quoted the example in Surrey, and to the noble Baroness, Lady Royall, that the examples they gave of services being tendered out are happening under the current legislation and are being done on price alone. That is unacceptable. In the course of our deliberations on this Bill, I think we should go back and take out some of the stuff that was introduced by previous Labour Ministers which favoured private sector providers. That was absolutely unacceptable. If we have to have competition, I want to see it on quality of outcomes. However, I say to noble Lords that it is not the issue of competition law but the issue of procurement law that we really need to scrutinise in great detail. That is a very technical matter that I do not propose to go into at this time of night. For those of us who have worked in social care, we know that it is the effects of procurement law that can have the more far-reaching consequences.

The reason for having this Bill is to deal with very significant challenges to the health service, one of which is dementia. I am not going to remind noble

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Lords of the scale of the problem of dementia. In 30 years' time 1.5 million families will be dealing with it. It is therefore important that, throughout this Bill, carers in particular have a far greater role in the design and commissioning of services than now. I will wish to see that strengthened.

By all means, we should debate the private patient income cap. We did so in this House in November 2009, at the instigation of a noble Baroness on the Cross Benches. The NHS has raised money from private patients since approximately 1948. The issue that is more important than the cap is the requirement on trusts to show how and precisely why they have chosen to accept private patients and how it will benefit their NHS patients. It can-we know that it is possible to develop a lot of research through private income, which ultimately has a benefit for NHS patients.

I want to finish on the question of the two amendments before us. The amendment tabled by the noble Lord, Lord Rea, is clear in its motivation, its intention and its effect. I do not think the arguments for it were particularly strong and I say to those Members on the Labour Benches who have been critical of the NHS for anticipating this legislation that I do not recall PCTs hanging around in 2006 for the passage of that legislation. In 2008, the Government went ahead with appointing the chair and the chief executive of the CQC before this House had finished debating the legislation on setting up that body.

To the noble Lord, Lord Owen, I simply say that I want to defend the NHS and am as passionate about that as any of the other speakers today. This Bill deserves the most detailed scrutiny that this House can give it. The scope and detail of today's debate have shown the standard of scrutiny that it may receive. I genuinely do not see how a Select Committee of 14 people could bring the range of experience and wisdom to this Bill that I think it needs. I care about the NHS. If we have no other reason to be in this House, it is to defend the NHS. It is our duty to do that-without filibustering or playing games, but through several months of very, very hard and detailed work. My colleagues have already done much to make this Bill better. At the moment, I could not support it-there is much more work to be done. I, for one, ask for the opportunity to do my job.

10.40 pm

Lord Whitty: My Lords, I come to this from a slightly different angle. Unlike many noble Lords who have spoken, I am not an expert in the NHS. I have always had a very good experience as a patient, but I have none of the expertise that has been demonstrated here today. I do, however, have considerable experience of other regulated markets and of consumer representation in those markets, and I would like to focus on the proposals in that area in this Bill.

The Government's objective is pretty radical. They want to move the NHS from what they see as a bureaucratic state provider to a system that is run by combining internal and external market regulation. They want to see, quite rightly, some market that does not actually have a cash nexus between the provider and the ultimate consumer. I am afraid that no precedent

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exists for doing this in the way the Government intend. It is very important that the way in which we are moving is seen as pretty radical. This is not a marginal change; it is not straightforward continuity on some of the changes made by the Labour Government; it is not even the latest instalment on the list of the noble Lord, Lord Walton, of top-down structural reorganisations over the past 50 years.

I accept that this is not privatisation in the normal sense, but it is a change that is almost as revolutionary as privatisation was in some of the other public services. When we vote tomorrow, and later on in the various stages of this Bill if we get there, Members of this House should be under no illusion: if the Bill goes ahead, we will change the nature of the NHS and the way in which it is understood by the vast majority of the public. There may be arguments for it, and we will come to that, but this is an entirely new model of delivery and a new model of regulation based on unproven premises that potentially put in jeopardy many of the achievements of our healthcare service, which, as the noble Baroness, Lady Williams, pointed out today, is reckoned by many authorities to be one of the most cost-effective in the world.

The rationale of cost saving is by no means clear. The noble Lord, Lord Cotter, recently cast aspersions on the quality of the impact assessment, with which I would not disagree, but in one regard it is commendably frank. On the potential benefits, it says on page 13 that,

In other words, there is no proven cost saving. One has to get to about page 45 to see where the real cost saving envisaged by the Government is; they identify National Health Service pensions and terms and conditions as being excessive and suggest that moving away from NHS workforce conditions to private providers will therefore provide savings. However, the commissioning proposition itself does not have an identified cost benefit.

Nevertheless, assuming that the Government get through tomorrow and that we will deal with this Bill, there are some fairly central problems about how they actually implement it. Let us take the commissioning propositions first. The ostensible reasons for changing the whole basis of procurement are twofold. They want greater clinician involvement in procurement-I do not disagree with that-and they want greater devolution of decision-making. I agree with that as well. However, greater clinician influence does not mean that the whole process is handed over to clinicians. Greater devolution should not mean huge fragmentation.

It is not yet clear to me why it was decided that GP-based commissioning was to be the preferred choice. It is not clear, from the propositions in this Bill, how we will ensure that choice in this matter-and choice is a big word in the Government's proposition-is the patient's choice and not the choice of the commissioners themselves, or of the commissioning agency or those

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whom they employ. It is already clear-and the poll today underlines this-that the majority of GPs do not want this move. In a few cases, GP practices and other clinicians could probably set up an administrative procurement process, but in most cases it will divert them from their central role as clinicians and in practice they will employ others-private commercial companies -to do it, and it is not clear who regulates them.

The whole process is intended to be patient-centred, but since the creation of the NHS, patients have always been confident that when dealing with their GP or any specialist they get advice based on their clinical condition and there is no contamination of that advice by the possibility of financial gain by the person who is giving it. Unfortunately these propositions raise that doubt-I put it no higher-particularly when GP practices may provide some of the services that they commission or they are associated with companies that may have some role in providing those services.

What is the exact relationship between the local commissioning CCGs and what has been termed the biggest quango of them all, the national NHS Commissioning Board, in this new system? Clearly some of the concerns that I and others have will be covered by regulations, guidelines and injunctions from that board. Are we not in danger of replacing one top-down system with another?

There was an alternative. There are bits of the Bill that I agree with, particularly the provisions on public health that bring the local authority structure and the health service structure more closely together. Why was it not possible to use those structures, where NHS structures are roughly coterminous with local authority structures, as the basis for commissioning rather than fragmenting below that level and running the risk of having suboptimal provision of procurement?

On regulation itself and the regulator Monitor, Monitor will have a range of responsibilities, some of which are contradictory. It sets prices, ensures continuity of service, provides a failure regime, licenses providers jointly with the CQC and, crucially, has the job of promoting integration while at the same time having to come down on anticompetitive behaviour. I am not sure that joint licensing with another regulator is workable. In other areas where an economic regulator does licensing or franchising, there is a clear demarcation between different regulators or, alternatively, it is all in one regulator. I cite water on the one hand and energy on the other. There are other complications because the national commissioning board would also be a quasi-regulator, and there is also the role of NICE in this operation.

Following the pause, we have a slight change in the role of Monitor in this area. It was suggested that it was a dilution in response to pressure from the Lib Dems, but a move from promoting competition, which suggests nurturing new providers, to preventing anticompetitive behaviour, which is a much more draconian potential intervention in preventing certain behaviour, is not a dilution. In the context of the health service, it is not clear what anticompetitive behaviour is because, as noble Lords have said, it is clear that collaboration, specialisation, agreement between providers-the kind of things that in general competition

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law would be regarded as anticompetitive behaviour-are not relevant. In fact, not only are they not relevant; they are a huge advantage in treating many conditions and many patients in the health service.

Therefore, what do the Government mean by anticompetitive behaviour in this area? Even if, as the noble Baroness, Lady Barker, has just said, competition is primarily on quality, which I appreciate, it is still unclear what anticompetitive behaviour would be in this context. What would be regarded as cartels in other markets are clearly collaboration, collusion and the delivery of integrated services in the health service. Even more fundamentally, competition and choice require surplus. Is the price-fixing that Monitor will be required to engage in fixing a price at a level that ensures surplus? If so, what is the cost-effectiveness and value for money of that?

My final point relates to consumer representation. HealthWatch is a good new concept. However, consumer representation has to be independent not only of the provider and the Government but of the regulator as well. The location of HealthWatch in the CCG is not independence. It is not clear that it will have its own resources or staffing, and it is regarded in the proposed legislation as a sub-committee of the regulator. That is not appropriate, independent consumer representation for the patients of the NHS.

The Government are in a bit of difficulty on this Bill. They may be in difficulty tomorrow, and they will certainly be in difficulty as we go into Committee. However, I hope that in considering the Bill, some of the central issues relating to the nature of the regulation and consumer involvement in the health service will be addressed when some of the questions that I and others have raised are answered.

10.50 pm

Baroness Meacher: My Lords, I shall address only three issues-I am sorry; I am losing my voice. The starting point for any reform has to be to define the problem. The Government have defined excessive bureaucracy as the key. Having, in my view, identified the wrong problem, it is not surprising that the Bill comes up with what I would regard as the wrong solution-wholesale organisational change. The real reasons for the financial pressures on the NHS are twofold in my view: first, the failure of the system under all political parties over the decades to lead to the necessary closure of hospitals in the interests of patients; and, secondly, the failure of commissioners over the years to identify the need for much smaller acute hospitals-a wholesale shift from acute hospital beds to community services.

Will the new structures make it more likely that the essential closures will occur in the future in contrast with the past? The King's Fund is concerned that there should not be too much centralisation of power. I am sure that that is right for many decisions but, in the case of service closures, surely only the NHS Commissioning Board will have the clout and the independence from local campaigning groups to judge the evidence objectively and to make unpopular decisions, when necessary. Of course, local campaigns are legitimate and important but difficult decisions are quite another matter. The Minister puts his confidence in local

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authorities, health bodies and consultative groups to undertake a needs analysis and take responsibility for closures. My heart sinks.

The noble Baroness, Lady Williams, has strongly supported the continuation of the Secretary of State's powers. With respect to most decisions I support the noble Baroness wholeheartedly. However, when closures or reconfigurations have to be made in the interests of patients and the long-term health of the NHS, then in my view if the case has been made out-the evidence is there-and is supported by the NHS Commissioning Board, the Secretary of State should only need to satisfy himself or herself that the proper procedures have been followed. At this stage, I have no confidence at all that the new system will be any better than the old in this all-important respect unless we manage to make a key amendment during the passage of the Bill. I know that there is some discussion and thought about the precise role of the Secretary of State. I think that we have to have evidence-based decision-making, and it is very difficult for politicians, whatever their colour.

I now want to turn to the need for the wholesale closure of acute beds and investment in intensive community services for patients with long-term conditions, terminally ill people and those with dementia. We know that hospitals are the worst possible place for these patients, yet vast numbers enter hospital for a procedure that requires perhaps only four, five or six days in hospital but they never get out. Why? It is because there are no intensive community care services to enable them to do so. What will the Bill contribute to this problem? In my view, nothing.

The transformation happened in mental health about 30 years ago, with the wholesale closure of big asylums and their replacement with small in-patient units and a complex array of community care services. There was shock and panic at the time but it was the right policy. Now, with modern surgical techniques, day surgery and very short hospital stays, the time is right for a similar revolution in acute medicine. Indeed, I remember the noble Baroness, Lady Bottomley, saying exactly that when she was Secretary of State all those years ago. It has not happened.

Today, then, elderly, terminally ill people and those with long-term conditions remain in hospital, deteriorating, becoming more demented, underfed and even starved of water on occasions. Soon, discharge from hospital becomes impossible. The average length of stay of these particular groups before they finally die a miserable death in a hospital bed is about two years. All this could be resolved with good commissioning and leadership from the top.

In East London, our commissioners-no credit to me at all-took this step, de-commissioning just one ward and investing in intensive community care. We call it a virtual ward. The savings are £2 million a year; the ward costs £3 million a year to run; the community costs are under £1 million; and 623 patients have been through the virtual ward in just six months, with an average stay in the virtual ward of 10 to 15 days before returning to normal community care. Early feedback suggests that patients are very happy. No legislation was required to do that and it needs to be replicated across the country, as it can be.

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My third point concerns the threat of privatisation of NHS services and even hospitals. The Minister assured me yesterday that the capital assets of a hospital would not be sold to private profit-making companies. This is of immense importance. Once a hospital is sold it will be almost impossible to get it back into public ownership. The irreversibility of some of these developments is one of my big concerns about the Bill.

We know that the profit motive is entirely unsuited to the health service. The Economist calculated that the market-driven US healthcare system in 2009 generated between $250 and $325 billion of charges for unnecessary care. The UK cannot afford such waste. Also, what of the patients put through unpleasant procedures to provide profits for others but no gain and perhaps risk to themselves? That is why I feel so passionately about this issue.

I agree that competition is healthy but can the Minister give an assurance on the Floor of the House that profit-making organisations will not be permitted, as he said yesterday, to take over the capital assets of hospitals. This at least would enable future Governments to reverse the planned privatisation of services. I hope that the Minister may even go further. Trusts and other not-for-profit organisations can provide healthy competition. Can the Minister give the House some assurance that such organisations would be regarded as preferred providers when compared with profit-making companies, bearing in mind the experience in the US, Germany and elsewhere?

This is an unnecessary, costly and-I hate to say-potentially dangerous piece of legislation. I hope that the Minister can allay some of my fears tomorrow.

10.57 pm

Viscount Bridgeman: My Lords, I declare an interest as a former chairman of the Hospital of St John and St Elizabeth, in St John's Wood. That hospital is unusual in that it is an independent hospital that has within its charity, and on the same premises, St John's Hospice which is wholly National Health Service, contracted to seven primary care trusts north of the Thames. Anyone who works in that environment has the experience of the excellent relations between the private and the public sectors. We receive considerable help and have very good relationships with the adjacent teaching hospitals of St. Mary's Hospital, the Royal Free Hospital and UCH. Fortunately, the conflict between private and public sectors is no longer a burning issue and it certainly does not form a major part of the current Bill, so in the short time available, I intend to speak to other aspects.

The Minister has articulated, with admirable clarity, the basic reasons why major reform of the National Health Service is now needed. He rightly went back to the origins in 1946. The understandable expectation of Ministers at that time was that the health of the nation would be brought up to an acceptable level and that in these broad, sunlit uplands, the role of the National Health Service would be one essentially of care and maintenance.

However, as my noble friend has said, there have been three developments, which were understandably, in the uncertain times just after the war, not then fully

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appreciated: namely, the rising expectation of patients, the fact that life expectancy has now increased so markedly-a tribute to the huge success of the NHS-and last, but unfortunately not least, the massive progress of new technology and its exponentially rising costs. We have been given a homely example by my noble friend Lord Eccles, who is not in his place, of the progress in the dental drill. Add to this the present economic situation and it is clear, for that reason alone, that doing nothing is not an option, a sentiment echoed by several noble Lords from all sides of the House.

In his impressive speech, my noble friend also paid tribute to the origins of the reforms initiated by the previous Administration, although the noble Baroness, Lady Thornton, appeared slightly reluctant to accept quite as much of the credit as my noble friend was offering.

At this late hour, I want to touch on only one aspect of the Bill's proposals: the creation of the CCGs. A point made by a GP for whom I have a very high regard is that there are more bad GPs and more bad GP practices than is generally supposed. Some GPs are on their own out of choice; others are on their own because they cannot get on with their partners in the practice-which in itself begs a question. So often, these sole or very small practices are underresourced both in personnel and funding. This is where the CCGs will be in a position to provide the resources which enable the weaker-performing practices in a group to be brought up to an acceptable standard. I remind your Lordships that it will be obligatory under the Bill for every general practice in England to join a CCG.

The PCTs, which the CCGs will replace, have been far too small in many cases and have spent far too much time competing with each other. The CCGs will be larger and better resourced. Not only will they be charged with commissioning services not provided directly by GPs but they will also have access to clinical networks advising on single areas of care such as cancer-that possibly addresses a point raised by the noble Lord, Lord MacKenzie, who, too, is not in place; perhaps my noble friend the Minister can confirm it-and to the new clinical senates in each area of the country which will provide multiprofessional advice on local commissioning plans. There is also HealthWatch, a powerful new watchdog set up to fight for patients' rights and referred to by the noble Lord, Lord Whitty. I also welcome the inclusion of a nurse-usually, I imagine, from a practice-and a consultant specialist on CCG boards, a recommendation of the independent review forum. All these bodies will be hosted by the NHS Commissioning Board.

I have listed these groups in some detail because I suggest to your Lordships that, with all these interlocking bodies, the possibility of cherry picking or of cosy deals where there is a potential conflict of interest will hopefully be eliminated when it comes to commissioning, for this has been a concern running through so much of the correspondence that many of us will have received.

I am sure that I speak for many when I say how I have once again been reminded in this huge amount of correspondence just how much the NHS is loved and respected, and just how much gratitude it inspires. It is

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only natural for many people who owe it so much to feel that any substantial change must be for the worse. The public as a whole are unaware of how much the service must change. I hope that my noble friend the Minister, who has done such an admirable job in setting out his stall today, will with some urgency address the need to communicate continuously with the public to get over the message of what the Bill sets out to achieve. And achieve I am sure it will in marking a seminal stage in the further development and improvement of what has been referred to more than once today as our greatest national treasure.

Perhaps I may refer to the amendment proposed by the noble Lord, Lord Owen. Today's debate has once again seen your Lordships' House at its best. It has been conducted conscientiously, courteously and constructively, which I am confident will be carried through to Committee. I hope that those noble Lords who are uncertain as to whether they should support the amendment of the noble Lord, Lord Owen, will feel reassured that the Bill will receive proper scrutiny-which includes addressing the constitutional issues-wholly on the Floor of this House and will therefore not support his amendment. I myself will not be supporting it.

11.04 pm

Baroness Smith of Basildon: My Lords, clearly, in a debate of this length, there will be some repetition on various issues. There is an old saying "everything has been said but not yet by everyone". But having listened to most of the speeches in the Chamber or on the monitors today, I know that is not true of this debate. The length and complexity of the Bill makes it a little like an onion-every time you peel another layer, new issues and potential consequences become evident, as we have heard from so many of the expert contributions today. I do not want to raise issues that have been raised already, but what has struck me during this debate is that many noble Lords who are not supporting either of the amendments before us today have still referred to their serious concerns about the Bill and said that your Lordships' House should seek to make significant amendments in Committee. That should warn the Government how deep the concerns are about the Bill.

I can think of few Bills that have caused so much controversy and concern in Parliament and in the country as a whole. I was told before I came back into the Chamber this evening that in just 36 hours, 100,000 people have signed a petition collected by 38 Degrees in support of the amendment of the noble Lords, Lord Owen and Lord Hennessy. That is a hugely significant number.

I am not an expert but I listen to the experts and even after the Government had their extraordinary pause after the Committee stage in the other House and made amendments, they failed to satisfy or give confidence to the very people who have responsibility for implementing the Government's changes. Today, the Royal College of General Practitioners in a poll of around 1,900 of its members announced that only 4 per cent agreed with the reforms and 70 per cent said that they were against the Government's reforms as they stand at present in the Bill. More alarming

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for the Government, nearly 30 per cent were more opposed to the Bill after the reforms than they were before.

The Royal College of Nursing said that the Bill would have a serious and detrimental impact. The BMA has called on Peers to reject or substantially amend the Bill and 400 public health workers wrote to all Peers last week opposing the Bill as it stands. Some 60 medical professionals, including hospital consultants and the General Secretary of the Royal College of Midwives, say that it needs suspension or significant amendment. The noble Baroness, Lady Hollins, as a past president of the Royal College of Psychiatrists, spoke earlier about its serious concerns.

This is extraordinary. Those speaking about the Bill are professionals-people whom we trust with our care. They have no reason to oppose the Bill other than their professionalism. If the Government cannot give confidence to the professionals, how can we then expect the professionals to give confidence to the public?

I have two main areas of concern. The first is the level and degree of change. This is a huge structural change for which there is no mandate. Also, any change of this significance has to be evidence-based. I have not seen the evidence that tells me that we need legislation to effect this degree of structural change in order to move towards more clinical involvement in commissioning. Even the Secretary of State, Andrew Lansley, said that 90 per cent of the Bill could be achieved without the legislation making such substantial structural change. If we see this also against the backdrop of financial pressures in the health service, stresses in the system and increased waiting times, that adds to the complexity of having to drive and push through change at a difficult time. With such significant change, there has to be support and confidence from those who are expected to implement the new system. There is evidence that the Government do not have that. I have no doubt that even if the Bill becomes law-and I hope we will see significant changes-staff at all levels in the NHS will do their best to make it work. But that is too much for us to ask of them and I do not believe that that is how this House wants to proceed.

My main medical concern is the fragmentation of the system, which will make collaboration and integration of services-between health and social care in particular-more difficult. If your Lordships' House is concerned about a postcode lottery now, imagine how it will be when all GP practices are responsible for commissioning. We have seen the pressures the health service is under. Your Lordships may have read reports of the letter from the Haxby and Wigginton Health Centre in York last week. Having set up its own company, HBG Ltd, to undertake minor private operations, it has now written to patients waiting for such minor surgical procedures with a price list, given that these procedures are no longer available on the NHS. You can have a skin tag removed for £56.30, a sebaceous cyst removed for £214.01 or a benign lesion, including a mole, removed for £243.

Unfortunately, it does not take too much imagination to imagine the impact that that could have on patients if replicated across the country, especially in times of

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financial constraint. How many other GPs will set up their own minor surgical units to undertake private work or seek out partnerships with private providers?

With all those changes, the Bill is also a genuinely missed opportunity to tackle some of the most difficult and entrenched problems in the health service. With such substantial legislation, we need to ask: what are the greatest problems facing the National Health Service; and does the Bill address them in a way that adequately deals with the problems?

To take one example, most experts are agreed that the spiralling costs of providing quality and appropriate health and social care for an ageing population is one of the greatest challenges. So many older people are admitted to acute care. Whatever the ultimate reason, it is often as a result of inadequate integration between health and social care which could have improved their quality of life and helped them to stay safely in their own homes for longer. That challenge must be met. It is a structural problem, a health problem and a cost problem.

Imagine an 82 year-old, Mrs Brown, who is quite frail but otherwise fairly healthy. She just needs a little extra care, support and attention in her own home. She may have a minor medical problem. It does not require hospitalisation, but it cannot be met by social care alone: it is a medical need. Currently, her medical care is free, and her social care will usually be charged, but it is basic social care in her own home that is most likely to keep her out of an acute hospital. For Mrs Brown's quality of life and to reduce the pressure on acute care in the health service, we all know that it would be so much better to provide for all her needs at home as long as possible.

Despite the best intentions behind the Bill, with the health and well-being boards, the way that it fragments services will make that even harder to deliver, as the noble Baroness, Lady Wheeler, outlined earlier.

A well kept secret, although not among my friends and family, is that I am not a great fan of the Guardian newspaper, especially after it recommended to its readers that they vote Liberal Democrat at the previous election-but every sinner has an opportunity to repent. I commend to your Lordships tomorrow's Guardian editorial. It advises Labour and Cross-Bench Peers to vote against Second Reading but then advises all Members to vote for the Motion proposed by the noble Lords, Lord Owen and Lord Hennessy. I will not indulge your Lordships' House by reading the entire editorial, although I recommend it, but it states, as a message to Liberal Democrats:

"The descendants of a liberal party which helped to found the NHS now must decide whether they are prepared to risk a row to defend it. Capitulation here could carry a higher price than raising student fees".

I regard that as essential reading for all Liberal Democrats in your Lordships' House and another place.

On the evidence so far, I have grave doubts about the Government's willingness to accept changes that may be brought forward by your Lordships' House by effective scrutiny. For that reason, I feel that I have to vote for the amendment of the noble Lord, Lord Rea, but I shall also vote enthusiastically for the amendment

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of the noble Lords, Lord Owen and Lord Hennessy, because I have no doubt that the only way that this Bill can be made fit for purpose, or be improved to serve the best interests of the population of this country and the NHS, is by effective, detailed scrutiny. It will be hard work, but the penalty to pay if we do not undertake that scrutiny is that we lose the NHS, which we value so much.

11.14 pm

Lord Adebowale: My Lords, I shall speak briefly at this late hour but first I declare some interests. I am the chief executive of Turning Point, a social enterprise that provides health and social care services to probably over 140,000 people in 250 locations. I am a member of the National Quality Board and the NHS Future Forum, about which I will speak in a minute. I also took part in the Commission on 2020 Public Services review and am an honorary president of the Community Practitioners and Health Visitors Association. Just in case noble Lords are wondering whether I get any sleep, I am also a non-executive director of a small IT company that provides services to the NHS. The most important thing for me, though, is that my mother was a nurse in the NHS for 30 years, and that the NHS actually saved my life. The NHS runs in my bloodstream -literally.

I shall make some remarks about my experience of being part of the listening exercise and on the Future Forum. I have been listening hard, so hard that my ears still ring, not just to the experts such as the RCGP, the BMA and the RCN, whose leaders I have taken the trouble to trouble about their opinions of the Bill, which have often been convoluted or misrepresented in some of the press-the best way is to talk to them directly-but also to ordinary people, my neighbours, GPs and people who have sent me e-mails by the hundred about the Bill.

While I have every admiration for Professor Field and his herding of the cats that were the members of the forum, I have greater admiration for the Minister in his attempt to persuade the BMA, the RGCP and the RCN that the Bill is a good thing. I can speak only from what I hear, and the leaders of those organisations are not in favour of the Bill; that is what they have told me face to face. As has been said, one has to respect the voice of such well respected and experienced professionals. I have heard that the leaders of these organisations may not represent their membership in their expressions of concern about the Bill. I do not agree; certainly, from the number of e-mails that I have received, I think we have a problem, which cannot simply be put to one side by saying that people's fears are imagined.

However, having said that, I have said publicly that the Future Forum exercise was flawed. It is always a good idea to listen, but it is better to listen at the start of the process rather than at the end. Still, it is better to listen than not to listen at all, which is why I took part. Indeed, some changes have been made to the Bill that I welcome, as have many Peers. The strengthening of the health and well-being boards, the greater emphasis on the JSNA, the rhetoric in the Bill about integration and the role of Monitor are all welcome, but they are not enough in themselves. I shall explain why.

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There are issues around Monitor and related issues around competition, such as the definition of competition, what Monitor does and how it does it. Frankly, competition has been rife in the NHS for as long as I can remember; it is part of what the NHS is and does. That is not really the issue; the issue is who benefits from that competition and how it is managed. Not enough has been said about the need for collaboration. Anyone who knows anything about systems in which there are limited resources knows that competition can actually waste resources. What you need to do-rather boringly, some people think-is emphasise collaboration. That is what is necessary, particularly with regard to organisations like mine, which is a not for profit company competing with the public and private sectors.

I note the point made by the noble Baroness, Lady Barker, about quality. I agree that one could argue that the elements in the Bill that reflect the Government's intent to emphasise quality, not just cost, are welcome. As is always the case, though, quality is hard to define when cost is the imperative and budgets are tight. The Bill does not say much about the balance of judgment between quality and cost in these decisions, so I am still concerned about that. I will be getting up at 6 o'clock tomorrow morning to explain to a load of social enterprises why and how to survive in the world of competition described in part of the Bill.

Let me rush to some kind of conclusion. My major concern is whether the Bill will reduce health inequalities. This is something that was not mentioned in the Minister's introduction, yet it is central to the Bill. Inequality is not just immoral but very expensive. The core purpose of any change to the NHS must be to reduce health inequalities, yet it is not mentioned. It was mentioned by the noble Baroness, Lady Armstrong, and others. As the co-chair of the APPG on complex needs and chief executive of an organisation that focuses on complex needs, I want to tell the House that it is not a question of the things that have a tariff, the things that have a market or the things that happen in hospitals. It is the things that do not have a tariff, the things that do not happen in hospitals and the things that we do not discuss that dictate the future. We do not discuss complex needs and they will dictate the future and the cost to the NHS. They need to be discussed.

We have not discussed the inverse care law. If the Bill does not show how it will reverse the inverse care law, it will fail-and fail in several ways, not just in relation to cost.

We talk about commissioning but I rarely see commissioning. Even in the course of this debate people have used the term in several different ways. The noble Lord, Lord Whitty, referred to procurement. I think he meant commissioning. Others talked about purchasing. I have a problem in that commissioning is hardly defined, yet we know that commissioning defined is services delivered. I should like the Bill to say much more about what commissioning is, what is expected of commissioners and how they will be held accountable. It is certainly not good enough that the clinical commissioning groups will have to pay due regard. There has to be a plague on the houses of both health and well-being boards and clinical commissioning groups so that they deliver a joined-up vision of services in an

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area-one that respects a definition of commissioning as the means by which you understand the needs of an individual and/or a community such that you can build a platform for procurement. Note that it is not the same thing as procurement.

Such a definition might go some way towards driving what the Minister referred to when he mentioned HealthWatch and ensuring that communities have a say in what gets commissioned on their behalf. I am very concerned that we are loading a lot on to HealthWatch at a time when we are reducing its resources and, indeed, making the mistake of making those resources susceptible to the very people whom HealthWatch will be criticising. This was pointed out by the noble Lord, Lord Harris.

I end by asking the Minister to respond specifically to the following points in his summary, as well as the points that have already been made by me and other Peers. First, there is the overall responsibility of the Secretary of State for universal healthcare. Forgive me; I am an unsophisticated politician but it seems to me that the NHS is a political construct. Many people who have spoken to me do not really care whether the Secretary of State says that he is responsible or not; he will be. We have a duty to ensure that that responsibility is made clear. Who is in charge? It will be the Secretary of State. Secondly, there should be a responsibility on community commissioning groups not just to pay due regard. We should ensure that there is a duty on them to show how they have engaged the JSNA and the health and well-being board in their commissioning decisions. Thirdly, commissioning should be defined and structured in such a way as to ensure community engagement. That is the only way that you will engage people at the sharp end of the inverse care law. Finally, commissioning should be held to account for the quality of its engagement with health and social care in the community in any given area. I look forward to the Minister's response and to further debate in Committee. I have not decided what to do about amendments but that is, frankly, the least of our worries.

11.24 pm

Lord Morris of Handsworth: My Lords, like many in this debate I am also a long-term user of the National Health Service, as are my family and friends. As I move towards my advancing years, I recognise that I am likely to become more dependent on the NHS, as are my family members. We have much to be thankful for in its dedicated service and the people who provide that service. It is accepted that our publicly owned, publicly funded and publicly accounted National Health Service is admired throughout the world. It is universal and comprehensive and of course free at the point of use. It is dedicated to making a difference, not a profit. It is designed to ensure freedom from fear for every man, woman and child in our country, regardless of gender, race, religion, sexuality, class or income. I believe in the NHS. I value what it does. We all do.

Actually, I thought David Cameron did too. I recall his words at the Tory party conference in 2006. They are worth repeating. Back then, David Cameron declared proudly:

"Tony Blair explained his priorities in three words: education, education, education. I can do mine in three letters: NHS".

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He also said:

"For me, it is not a question of saying the NHS is safe in my hands. Of course it will be".

He went on to promise no more pointless, disruptive reorganisation. He promised that change would be driven by the wishes and needs of the NHS professionals and patients. Well, Prime Minister, far from ending pointless disruption, this Bill as it stands will bring about the biggest and most costly and pointless reorganisation in the entire history of the NHS. As far as I understand it from all the professionals and patients, this Bill's changes are being driven and forced through against the advice of and without the support of virtually every professional health body and patient group in the country.

Based on that 2006 conference speech, the Prime Minister would be voting against the Bill that he is pushing through in 2011. Not only is this Bill a cocktail of untested proposals which are considered reforms, but they are proposals without any electoral mandate. As we have heard time and again today in this debate, neither the Conservative nor Liberal Democrat manifestos contained these proposals. There was no mention of them in the coalition agreement. This Bill and its radical proposals have come entirely out of the blue-in every sense, judging by the political philosophy that seems to underpin them.

I said that the NHS was designed to ensure freedom from fear, but fear has dominated much of what has been said in this debate. We have been inundated with letters and e-mails condemning these proposals. Ordinary men and women are expressing their fears and concerns about the future for themselves and their families, as publicly as they have the means to do so. We fear most that the NHS could be dismantled through lack of any real co-ordination, any real commitment and the consultation that never really happened. No one in our country voted for this Bill and I trust that not many in your Lordships' House will do so either.

11.30 pm

Lord Crisp: My Lords, there is a great deal that is good in the Bill, but I am going to speak only about the areas that I think are problematic. I was chief executive of the NHS and Permanent Secretary at the Department of Health for five years, and I know as well as everyone else in your Lordships' Chamber that the NHS has improved but that it needs continued and continuing improvement. Every Friday for more than five years I went out and about visiting hospitals and surgeries, and saw the good and the bad. The good was wonderful. There was more of that but there were also some bad and shocking things.

My biggest impression is that the Bill is a wasted opportunity-I follow the noble Baroness, Lady Smith, in this. In part, that is because despite all this upheaval the Bill does not focus on the major issues that the NHS is facing; in part, it is because of the poor process; and in part, it is because the Bill does some unnecessary things. On the process, I entirely exempt the noble Earl, Lord Howe, and, like others, I congratulate him on the way that he has brought so many people to meet us in your Lordships' House and explain and discuss the detail.

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However, there is also the big issue of trust that the noble Baroness, Lady Williams, and the noble Lord, Lord Owen, have raised and which the Government must address. The underlying issue here is that the NHS is a social contract with the country's citizens. I suspect that people, whatever their politics, fear that changes will be made in that implicit social contract and that-the NHS constitution notwithstanding-we will move towards a set of commercial contracts that treat us not as citizens but as customers. We have expectations that the Government will secure our health and healthcare, and that doctors and nurses in the NHS will always do their best for us. That goes much further than the small print of contracts. I echo the point made by my noble friend Lord Adebowale that the things that are not in the tariff are as important for many patients as the things that will be in the tariff and the contracts. This is therefore about solidarity and trust, and people see this as being put at risk-rightly or wrongly-both in the role of the Secretary of State and in some of the aspects of competition. I shall come back to that.

The Bill is a wasted opportunity because there are two basic problems with it and with the process that got us here. The only unifying themes in the Bill are structural; they are not about services or the issues that the NHS has to face up to about securing cost or securing improved quality. A number of noble Lords have also spoken about how the largest number of patients and the greatest cost for the NHS are people with long-term conditions-often multiple long-term conditions-who need a different sort of health service from the one we have. We are still too hospital and doctor-focused. We need to be more community-focused and much more people-focused. That is about major service change.

Belatedly, issues of integration have been brought into the Bill, but if they were really at the heart of the legislation the Bill would be about providing health and social care in a much more integrated way and we would be clear about how strategic change will happen. It is not at all clear that local groups can do this and, frankly, the levers of markets and GPs being in charge are not enough to achieve the changes we need. This is compounded by the problems of changes and the compromises that have been made so far in the passage of the Bill, which will add bureaucracy and inertia. We are retrofitting changes to an already complex and untested Bill. All this is made worse by a failure to communicate.

I move on to specific points. On the issue of the Secretary of State, as a former chief executive and Permanent Secretary, I recognise the importance of separation between the various roles. The noble Baroness, Lady Bottomley, talked about her perception of that. Perhaps I may say that as a former chief executive, being rung at this time of night, and indeed an hour later, pretty regularly by more than one Secretary of State, I should quite like there to be that separation for my successors. I know that people will say that the words that have been changed only confirm what has happened and that it will be okay when the failure regime is in place-and that therefore there will be a mechanism for dealing with failing trusts-but frankly this is risky; this is untried regulation.

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We only need to think of the banks-we did not get the regulation right there. This is also an issue of trust and expectation, and it is unnecessary if we understand what the Constitution Committee said. If the Government are prepared to be at all flexible, we can get this right relatively easily. There is no huge set of issues that need to change. I also ask the question asked by the noble Lord, Lord Williamson: why was it necessary to make that change?

I am very much in favour of local decision-making, and, as a number of noble Lords have said, over the years we have seen more devolution to primary care groups, to primary care trusts and to many others. These have been successful in some cases and not in others. GPs in the lead and clinical roles are obviously fundamental, but there are risks here, which have not been talked about very much yet, of conflicts of interest and damage to the reputation of doctors. I know that the noble Baroness, Lady Royall, mentioned one particular case where it is already being suggested that doctors are acting in their own interest.

Let me be clear; I am not being critical of GPs in saying this, and I recognise that some people believe that the code of medical ethics will mean that doctors will always put patients first. However, we only have to look at other countries to know of many examples where that has not happened, and while it may happen this year the question may be whether it will happen in 10 or 15 years' time. This could damage the reputation of doctors, and it does not have to happen. This is about perception, reality and trust. That is what needs to be tackled, and we need better arrangements for handling this. Again, I believe we can find them during the scrutiny process, but the Government need to address this and make it clear.

The noble Lord, Lord Darzi, talked about what in his experience worked best with a coalition of patients, clinicians and managers-not just GPs. I do not see this yet in the Bill. There is not enough focus on patient power, for all the reasons that the noble Baroness, Lady Masham, raised. It is not only doctors who understand health; patients do, albeit in a different way, but they need the space and greater power and influence, not as consumers but as citizens and participants in their own care. If the Government were being really radical, they would have given them more say in this Bill.

I could also go on about social services, and while I welcome the public health and other provisions there needs to be more scope for sharing budgets and for aligning action between the NHS, local government and other local actors. One result of these sorts of concerns is that the Bill has added bureaucracy and complexity. Starting without a clear service focus and integration is leading to even greater complication.

Let me touch on competition. In my experience in the NHS, the introduction of competition clearly worked, providing patients with choice and introducing ISTCs. I can show noble Lords the graphs that showed the results change, often because of the threat of competition. We saw competition as one of the other tools the Government have to make change happen.

Something that has not been mentioned very much is that new entrants are fantastically important. This week I have seen people from mental health services

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who have some really good ideas about changing mental health services. We need to get new entrants in, and to encourage new entrants from the voluntary sector and other areas and not just the private sector. Something else I have not heard said is that just as the public sector is diverse, so is the private sector. Some people are very much driven by the same passion that you see in the NHS, and we should not forget that.

Nevertheless, there are outstanding questions about competition. Will competition law stop mergers? Can the Minister tell us what the limits of markets are? My noble friend Lord Adebowale made a real point about collaboration. Competition can be a tool, but it is really not the only one.

I have other concerns about the commissioning of primary care, patient confidentiality, some aspects of professional regulation and education and much more-but let me be pragmatic. I know from my experience how difficult it is to make change, and how much foundation trusts and choice were opposed. I also know that the NHS wants clarity, and we must give it to it. As always, my former colleagues will get the best deal for patients within whatever political framework they are given. That is what they do. We have the chance to improve the framework. The Bill can be improved, but we need enough time to do so. Perhaps most importantly we need to make sure we maintain the trust and faith of the public, maintain the improvement and maintain the NHS as a social contract and not a commercial one.

11.39 pm

Baroness Whitaker: My Lords, it is always a pleasure to follow the noble Lord, Lord Crisp, after his broad sweep. I want to focus on two much narrower areas, which do not seem well served by this Bill. The first is mental health, and I declare an interest as a former member of the Tavistock and Portman NHS Trust. It is fair to say that mental health has always been underfunded, considering its importance to our general health, so eloquently described by the noble Baroness, Lady Hollins, and its importance to our well-being and the economy. Old people in particular seem to be rather left out of the reckoning. I believe that the National Service Framework for Mental Health applies only to people below 65. This is odd when you think where dementia strikes most.

Professor Lewis Wolpert, in his illuminating book, You're Looking Very Well, says that fewer than 10 per cent of older people with clinical depression are referred to specialist mental health services. Some 40 per cent of those in care homes have been reported to be depressed. Indeed, more than 2 million older people over 65 have symptoms of depression; but according to Age Concern the vast majority are denied help. Would independent provision of these unpopular specialisms have any traction on this huge lack of capacity? How can this Bill prevent such ageism?

I am also aware of long waits for basic assessment; even when people have attempted suicide, three months is not uncommon. Waiting lists for this significant area of health are not being kept low, as David Cameron promised. How does the Bill improve this dangerous delay?

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To focus down to the Tavistock's own part of London, wholesale reorganisation of treatment capacity, perhaps more properly called elimination, is already having an adverse effect on patient care; some in-patients have been transferred far away from their families, while some small and valued local centres, like the Camden Psychotherapy Unit, have fallen foul of changes in council tendering criteria and suddenly have no funding. The CPU treats 90 patients a year, many of them vulnerable and socially deprived. They will lose their local service. These are not people who can always easily travel, and clinical excellence has lost out to larger, apparently more commercially attractive providers. I think that the Bill allows centres to close without public consultation, so will this problem become more widespread? What assurances have we that there will be the wish or the capacity to commission mental health services to the extent necessary?

The second area of concern to me is speech therapy, another field of supreme importance to our ability to go about our lives. I speak as a patron of the British Stammering Association and, indeed, as a long-term practitioner of stammering. But there are, of course, very much more severe communication problems than stammering, as a consequence of stroke, cancer, brain injury, learning difficulties and hearing impairment, which effectively impede relationships, proper education and employability.

I am grateful to the Communication Trust for the following disturbing figures. My noble friend Lady Wilkins had some more. Over 1 million children have speech, language or communication needs not caused by external factors such as language neglect or having English as an additional language-that is two or three in the average class. Over a quarter of all statemented children at primary level have specific language impairment needs as their primary need. It is the most common disability in childhood. Communication difficulties are common in young offenders, looked-after children and those who have conduct disorders and other behavioural difficulties. Alleviating the communication problems has a dramatic effect. The noble Lord, Lord Ramsbotham, referred to this. It really matters to intervene early if these children are to be given anything like a fair chance in life. GPs do not tend to refer early enough in the case of stammering, which is a very intractable disability, and they do not always know enough to realise what needs to be done. Only 9 per cent of childhood referrals come from GPs. Other health workers tend to refer earlier, and more effectively. Commissioning is at present complex and fragmented, so there is a very good case for speech, language and communication needs to come within public health. Can the Minister tell me whether this is the case? Does he recognise the importance of integrated commissioning for speech, language and communication services, not just within the health sector, but also between health and education commissioners, to which my noble friend Lady Wilkins also drew attention?

There are risks in the proposal to split responsibility for the commissioning of children's public health services, with the NHS Commissioning Board responsible from the mother's pregnancy to five years, and local authorities for five to 19 year-olds. So what role will the health

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and well-being boards play in ensuring effective and co-ordinated commissioning of children's services, and can the Minister confirm whether the boards will be encouraged to consider pooled budgets and joint commissioning arrangements for speech therapy services for children?

11.46 pm

The Earl of Clancarty: My Lords, I rise, as others are doing, who do not usually speak in a health debate, to register my own concern about this Bill, with its potential far-reaching significance. If I have interests to declare, it is that my wife is a health journalist and my brother a surgeon who, like many, is devoted to the NHS as a public service.

Despite its faults, since its inception the NHS has been over decades a public service without equal. In my case, as someone with a chronic condition-asthma-I have benefited from the way it has been managed, indeed the way that the NHS still is able to handle long-term conditions. But I have also seen the NHS at its best in acute situations, such as when my own daughter was born nearly two months premature. Undoubtedly, her life was saved by the NHS.

The question I would then ask is: would these have been managed as well, and for free, under private care? I do not believe that they would, but more authoritative support for that belief lies in the huge number of briefings that we in this Chamber have all received from the healthcare experts themselves: from doctors, consultants, nurses, patients, academics, institutions, organisations, hundreds of people-indeed the tip of an iceberg of opinion, the overwhelming majority of whom are highly critical of this Bill, and critical in much the same vein, which is that the move towards greater commercialisation, a road that this Government are already proceeding down before this Bill is even passed, will be a huge disaster for the NHS.

This is an important question, because the main threat to the NHS lies in the introduction of the free competitive market, and indeed the noble Baroness, Lady Jay, has already given us today the example of Assura Medical being the preferred bidder for Surrey community health services over an award-winning social enterprise.

I believe that if an entity such as the NHS changes radically its internal workings, then the message and meaning of that entity must also change. This is why I share the fear many have that the NHS will simply become a kitemark, because what was previously the key aspect of that entity-healthcare that was universal, comprehensive and free-will simply not be compatible with the NHS's new construction.

In the first instance, though, and what should be greatly disturbing to the public, is the discrepancy between on the one hand what the experts think and say, and on the other what the Government say they are doing and what they say the experts feel about this Bill.

If the term "privatisation of the NHS" had been used by any party in its manifesto, we all know that no voter would have gone near it. Andrew Lansley denied last week at the Conservative Party annual conference that that is what the Government are doing when he said,

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Yet in the-perhaps to his credit-more transparent words of the Minister at the Independent Healthcare Forum on 7 September, previously mentioned in this debate by the noble Lord, Lord Clinton-Davis, not only did he say that there will be,

but that-

To me, that is as clear a signal of an intent to privatise the NHS as one could possibly give, whether such intent is acknowledged or not. It does not take a healthcare expert to understand, even with checks in place, but with a marked reduction in accountability for the Government, as this Bill would effect, that our National Health Service would become an industry where the public NHS is only one provider among a host of private ones; and one that may very likely eventually be squeezed out altogether.

This sense is supported by what the healthcare experts say. Organisations including the Royal College of General Practitioners, the BMA, the Royal College of Nursing, the Royal College of Midwives and many others directly contradicted David Cameron's statement on 7 September at Commons Question Time of healthcare organisations' support for the reforms.

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