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The problem in recent weeks is that the Government have had the louder voice-what Andrew Lansley and David Cameron say gets coverage in the media. The healthcare experts, by and large, have not had that coverage. However, it is right that we should give a voice in this Chamber to these views. They are not being given enough of one, and, to be blunt, I know as a non-healthcare expert, whose views I would rather pay attention to.

For example, there can be no more damning indictment of this Bill than the letter published in the Daily Telegraph on 4 October from over 400 top healthcare professionals that stated:

"The Bill ... ushers in a ... degree of marketisation and commercialisation that will fragment patient care; aggravate risks to individual patient safety; erode medical ethics and trust within the health system; widen health inequalities; waste much money on attempts to regulate and manage competition; and undermine the ability of the health system to respond effectively and efficiently to communicable disease outbreaks and other public health emergencies".

Dr Peter Carter, chief executive of the Royal College of Nursing, says:

"This fragmentation risks ... preventing health providers from collaborating in the interests of patients. We must avoid a situation where existing NHS providers are left with expensive areas of care while private providers are able to 'cherry pick' the services which can be delivered easily".

But of course that is exactly what will happen with a level playing field, and the head start, the necessary head start, that the public NHS as a provider has always had-which is also, perhaps I may remind your Lordships, our head start, as the NHS belongs to us not private individuals-will be lost, and that services such as acute care, which I understand private providers do not like, will suffer.

Yesterday, the Royal College of General Practitioners published a survey saying that more than 70 per cent of respondents strongly agree, or agree, with proposals by some organisations and clinicians that this Bill be

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withdrawn. Seventy per cent said they did not wish to be on the board of a clinical commissioning group and a mere 4 per cent thought the reforms would lead to better care. It is also expected that a significant number of GPs who do not have the expertise, inclination or time will employ private companies to do the work, creating distance and adding to the financial drain. This-despite what the Government would clearly like the public and us to believe-is the true picture of medical professional opinion. How many more, then, do we need?

A major reason why we find ourselves in this situation now is that the movement towards privatisation did not of course start with the present Government but has been proceeding by degrees over a long period of time; largely, it has to be said, unremarked upon by the public. In an article for the London Review of Books published on 22 September, James Meek says:

"The more closely one looks at what has happened over the last 25 years, the more clearly one can perceive a consistent programme for commercialising the NHS that is independent of party political platforms: a purposeful leviathan of ideas that powers on steadily beneath the surface bickering of the political cycle, never changing course".

One contemporary challenge of the National Health Service is how a degree of patient choice can be accommodated within it without greater competition being understood as its necessary corollary. I say "degree" because I wonder how much patient choice as an ideal has in fact been overplayed. Yes, it is right that you should have the option of seeing a different doctor if you have a bad relationship with the one you have been seeing; yes, you should be able to have a second opinion; and yes, you should be able to visit a different hospital if you had a bad experience at the first. By and large, however, I believe that what a patient wants is appropriate care and the guidance to achieve that-something that can only happen, surely, in an NHS based on mutual trust and co-operation rather than competition. Indeed, the Coalition of Medical Specialty Societies says,

"For the overwhelming majority of our patients, having access to high quality and suitable care is more important than choice".

Generally speaking, people do not want to travel across the country. A new article published in the Lancetby Alyson Pollock and others finds no evidence that patient choice saves lives. It noted that, given a multiple choice, patients choose the hospitals nearest to them.

When we had to rush our daughter to hospital with suspected meningitis a month after her early birth and just 48 hours after she had been allowed home, there was no choice involved. It was an instant snap judgment uninformed by outcomes, specialism or recommendations. We simply drove her to the nearest hospital, knowing instinctively that with acute care, time can be the most important factor in survival rate. However, if, through competition, the local hospital's A&E department has been shut or the whole hospital closed, there is going to be no choice anyway.

To acknowledge the long-term creeping movement toward privatisation could make those who support a public NHS highly pessimistic, but because this is the biggest leap yet towards full-scale privatisation, we are nevertheless at a crossroads where this trend could still

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be stopped in its tracks and even reversed, where we still have a chance to say "enough is enough". This is why I support first and foremost the amendment tabled by the noble Lord, Lord Rea. This is the NHS privatisation Bill. The public understand it as such and we should call it by that name and reject it.

11.56 pm

Lord Lucas:My Lords,the Royal College of General Practitioners should know better than to publish phooey surveys like that; they are supposed to understand what evidence-based medicine is. The same applies to polling: a random collection of self-selected GPs answering a poll online does not produce valid answers. But I will be just as rude about the Department of Health, which employed one poll to produce a similar low-quality piece of work and then trumpeted its results. We really ought to insist that a group of professionals who propose to believe in evidence-based medicine apply the same standards to their politics as they apply to their medicine.

There seems to be widespread acceptance that commissioning groups in one form or another are a good idea. I certainly share that view: I want my GP to have a real influence on the provision of care in the area where I live. I want my concerns and the concerns of his other patients to be reflected in the way that the NHS evolves locally. It seems to me that the structural changes we are looking at in this Bill largely flow from that change. If we are going to have real decision-taking at that sort of level, we have to push a good deal of power down from the Secretary of State.

I also accept what I think many other people agree with-that patient choice is important; that being able to choose between different remedies, different hospitals and different styles of doing things is important. I had a long view of hospitals in the course of my late wife's illness; it is astonishing, as the noble Lord, Lord Crisp, said, how variable care is. St George's Hospital had a wonderful ward for kidney patients; it had one of the worst wards I have ever encountered a few paces away. To be able to choose, to be able not just to suffer what is thrown at you but to have a voice in it, seems to be a very important part of the way that I would like my NHS to be.

If one is to have choice then-as the noble Lord, Lord Darzi, and others have pointed out-competition flows from that. You cannot have choice between two alternatives without those alternatives being in some way in competition with each other.

I think that the basics of this Bill flow from things that fundamentally we seem to agree with all around this House. I was very persuaded by the speeches of the noble Lords, Lord Warner and Lord Darzi, in that regard. There is a lot of common ground and I do not think that we should be too put off by the layer of political manure which the opposition Front Bench is attempting to spread on this. As the noble Lord, Lord Darzi, said, to believe in the NHS is to believe in the reform of the NHS-words which could well apply to this House in similar form-and I think that that is the basic understanding that we should approach this Bill with.



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A lot of reservations have been expressed about detailed elements of this Bill, and listening to those who have expertise in those various areas, I am sure that I will take a close interest in them as we go through. There seems to be a lot of worthwhile discussion ahead. It is not clear to me, for instance, how integrated provision for people with complex needs is proposed to be dealt with under the structures that we have in the Bill. I have similar interests in how freedom of information will be dealt with in a health service with a much greater variety of providers, and I am keen to make sure that the structures encourage what one might call commissioning a community-getting the real community very much more involved in providing healthcare, looking after the elderly and looking after its own. That seems to me to be an expression of localism and community care that we ought to encourage and that ought to be possible once you get commissioning down to much more local entities than we have at the moment.

I do not know what the answer is to the question posed by the noble Lord, Lord Owen, about the Secretary of State's responsibility. He made a serious and thoughtful speech, as have others in this House, and I shall listen to the debates on that subject with great interest, but I do not see the argument for a separate committee to examine it. It seems to me to be a question which is deeply embedded in many aspects of this Bill, and I cannot see how we can separate discussion of it. I have been very impressed by the speeches that I have listened to today. I think that we have the expertise and understanding in this House to do justice to the questions that he raises. So I shall not be supporting his amendment or, indeed, that of the noble Lord, Lord Rea.

12.02 am

The Earl of Listowel:My Lords, I shall try to follow the contributions of the noble Baroness, Lady Hughes of Stretford, and the noble Baroness, Lady Massey of Darwen, who is chair of the All-Party Parliamentary Group on Children, in my remarks on children. Before I do so, I join other noble Lords in thanking the organisers of the helpful briefing meetings: the noble Baroness, Lady Thornton, and the Minister. I was most grateful for the opportunity to speak with the Minister last week and raise one of my concerns about the Bill with him.

I shall also refer briefly to the eloquent and powerful speech by my noble friend Lady Hollins, in which she raised concerns about how far we have to go in winning the hearts and minds of those in practice on the ground in the NHS. She also talked about the way that mental health in adults is so often overlooked and services for them are underdeveloped. I know that the Minister was very concerned when he recognised that 40 per cent of adults who smoke have a mental disorder and that there is a strong association between mental ill health and such pernicious self-harming behaviour. In a conversation following her speech, I checked with the noble Baroness that the aetiology-the roots-of much adult mental ill health begin in childhood. Personality disorders and depression are very often associated with difficulties in the earliest parts of childhood.



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That reminds me of the utmost importance of effective early intervention with children and families and, most of all, of ensuring that parents are supported in building strong, consistent relationships with their children. Parents need support to be able to love their child. If they demonstrate their love for each other, the child will learn in later life to make those strong bonds. Also important, for example, are good perinatal care; good midwifery, with midwives engaging early with parents; and good health visitors.

I should declare an interest as a trustee of the Michael Sieff Foundation, a children's welfare organisation.

There is much that I can welcome in Her Majesty's Government's approach to the Bill. I should like to address the following: the importance of recruiting and retaining the best staff in the NHS; ensuring that the Bill helps to bring about effective early intervention with children and families and does not hinder it; and, finally, the need to pay particular attention to children with complex needs, as well as their families, and I include children looked after by local authorities.

I share the concern expressed by many of your Lordships today that the new commissioning arrangements hold the serious risk of leading to fragmentation of provision. We need to be very careful to avoid that.

I can say to the Minister that I have been immensely heartened by the approach that he and his colleagues have been taking to health visitors, teachers, social workers and others who are at the sharp end of caring for children. I admired and welcomed the section in the first Queen's Speech by this Government in which they called for more autonomy to be given to teachers, doctors and other professionals. I respect the principle enshrined in the Bill of empowering clinicians to manage their own work. I know therefore that the Minister will listen very carefully to the call from my noble friend Lord Walton of Detchant for careful consideration to be given to the future of the training and recruitment of doctors. I take that further. Today, we have heard concerns about unregistered carers. We need to ensure, through careful recruitment and good development and training, that people working in the NHS are of the very highest calibre. I hope that the Minister will allow the House to assist him in his work on this area, ensuring that the Bill provides what is needed.

The Government's White Paper on education and excellence in teaching and Professor Eileen Munro's final report on safeguarding children both recognised that the best outcome for our children can be achieved only by attracting and supporting the best candidates in social work and teaching. It is the sine qua non of success in these sectors and it seems to me to be equally applicable to health. I believe that this should go without saying, yet when one thinks of the plight of health visitors, the pressure on midwives, and the many health trusts in which staff consistently report poor support and morale, it needs to be said. It needs to be said when one thinks of the shortages of child and adolescent psychiatrists and the urgent need for more child mental health professionals. I look forward to working with the Minister and colleagues to ensure that the Bill delivers the best possible framework in which NHS staff can operate. I listened with care to the noble Lord, Lord MacKenzie of Culkein, on the

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issue of nurses. Unless we nurture our doctors and nurses, especially in this very difficult time, they will not be able to nurture the children, families and others in their care. One cannot be warm or show kindness if one does not feel valued and supported oneself.

I should now like to consider the importance of ensuring that the Bill promotes effective early intervention with children and families and does not hinder it. There are 11.8 million children in England, of whom about 65,000 are currently looked after by local authorities. I pay tribute to the vision of the Minister's colleague in the other place, the right honourable Iain Duncan Smith, in his work in promoting the cause of effective early intervention with families, his establishment of the Centre for Social Justice, his long work on and commitment to understanding the needs of vulnerable families, his bipartisan approach, and his close partnership with Graham Allen MP, the Labour Member for Nottingham North.

The coalition Government have commissioned important reports from Dame Clare Tickell, Dr Eileen Munro, Graham Allen MP and Frank Field MP, among others, and have instituted the family law review. Breaking the cycle of deprivation by effective early intervention is, as I understand it, a cause at the core of this Government's endeavours and I look forward to working with the Minister and colleagues to ensure that this Bill meets the Government's own high ambitions in this area.

I have been reminded that the Kennedy report highlighted the relative neglect of services to children and families in the NHS. The Nicholson challenge poses the risk that these vital services may be further undercut if they continue in this state of relative neglect. For the sake of the future of these children and the future productivity of this nation, who will pay for the care of all the elderly who are accruing now and will accrue in the future? We must ensure that the culture within the NHS changes. We must prioritise children and families more. I hope the Minister will be prepared to further strengthen the position of children and families in this Bill, in particular by including them in the mandate of the NHS commission.

My third theme is the need for a seamless inter-agency service for children with complex needs. Children must not fall down the cracks between services.

I will stop at this point. I reiterate that we need to put into practice the theme of early intervention. It is key. So much work has been done on it and we can use that in this Bill to make a real difference to children and families-a real difference to the future of this country.

12.11 am

Lord Collins of Highbury: My Lords, I am very aware that my contribution has been eagerly awaited by all noble Lords who are still here. As the 85th speaker, and the last tonight, I suspect that it is not its content but its end that is desired most. Therefore, I promise not to go on too long.

After reading hundreds of e-mails from both users and providers of the NHS, and having listened carefully to the debate so far, I remain of the view that was ably expressed by my noble friend Lady Thornton this

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morning when she said that in making these top-down changes to our NHS, this coalition Government have no mandate, no evidence and no support. Like many in this House, I do not want a health service that stands still. I was, and remain, a keen supporter of the health policies of the last Labour Government which, as my noble friend Lord Warner reminded us, were identified in our manifestos in 2001 and 2005, and on which we won.

The change agenda then was to deliver the best outcomes for the patient and best value for taxpayers. I fear that the changes proposed in this Bill, despite what the Minister states, will not improve care for the patient and will be extremely costly to taxpayers. The worthy aims expressed by the Minister are not the issue. As we have heard many times throughout this debate, the aims can be achieved without a major high-risk, high-cost reorganisation of the NHS.

My fear-I think that this is shared by many-is that ideology drives the promoters of the Bill. It is an ideology that sees a competitive free market as the way to deliver healthcare efficiently. As the noble Lord, Lord Owen, said, this is not a model supported by the British public. I do not often find myself agreeing with the noble Lord, but I thought that he was spot on when he explained why the NHS had so much support from the British public: it is because, in the distribution of resources, it is fair.

For me, modernisation of the health service was, and is, about addressing unacceptable variation in standards; inequality; lack of integration-vertically and horizontally; the fixation with acute care rather than better primary care; and more investment in prevention and public health.

My real concern is that I do not see this Bill as being helpful in addressing these key issues. In fact, I see a Bill that will cause fragmentation rather than integration. It is in this context that I wish to raise three specific issues, which I hope to address further in the event that my noble friend's amendment is not carried tomorrow.

First, on public health, while I accept and agree that the transfer of public health functions to local authorities creates the potential for better alignment with other responsibilities and other issues-we have heard mention in the debate of housing, environment and education-that will not happen unless directors of public health are in a position to shape policy in these areas. I along with many others fear that the Government's response to the NHS Future Forum offers no further clarity over the role, status and work of directors of public health.

Secondly, on HIV and the role of prevention and treatment, the House of Lords Select Committee report on HIV in the UK, chaired by the noble Lord, Lord Fowler, identified that more than a quarter of those infected have not been diagnosed and are unaware of their condition. This affects the individual concerned and spreads the disease further. Better testing must be a priority. The committee proposed routine testing for all new patients at GP surgeries and general medical admissions beginning in areas where the prevalence of HIV is highest. It also proposed the legalisation and regulation of home testing.



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Spending on prevention is seriously inadequate. HIV is entirely preventable, but the latest figures show that the Government spent only £2.9 million on national prevention programmes, compared with £762 million on treatment. My concern with the Bill is the disconnect in planning between prevention and treatment, plus the strong probability that public health budgets will be severely limited, leading to even further underfunded prevention campaigns. There needs to be better investment in evidence-based HIV prevention work to prevent the treatment bill rising even further.

I turn finally to diabetes. The noble Earl the Minister knows that, last week in the debate on non-communicable diseases, I "came out" as a type 2 diabetic. My condition has been caused, as I am repeatedly reminded in the media and even by some noble Lords in the House, by my bad lifestyle as a former smoker and a person who eats too much-that is fair enough. However, as a result of NHS provision, I am now very much aware that diabetes is a complex and lifelong condition.

My regular testing and treatment, comprising GP surgery, podiatry clinic, retinal screening, specialist eye clinic and dietician, is a perfect example of a pathway of services where primary, secondary and community healthcare and social care are integrated around my needs. My early diagnosis and this integrated pathway of care will keep me free of the worst and most costly consequences of this disease.

Although the amended Bill requires the NHS Commissioning Board and clinical commissioning groups to promote integration, Diabetes UK, which has given me excellent support, proposes that to strengthen this vital duty the NHS Commissioning Board and clinical commissioning groups must report annually on how they are fulfilling their duty to promote integration.

The Government have stated that they are committed to the principle of "no decision about me without me" and there is substantial evidence about the benefits of patient involvement on health outcomes, something that I know only too well.

Diabetes UK believes that the Bill should be further improved by defining the involvement of individual patients and their carers in decisions relating to their own care and treatment. In addition, collective patient, patient organisation and carer expertise must be central to commissioning decisions and service design through the introduction of an overarching principle of co-design in the commissioning of care pathways.

It is essential that this collective experience and knowledge is used in the design and commissioning decisions to gain the benefit of the experiences of a wide range of patients, not simply a small number of individuals. The Secretary of State for Health has said that,

yet it is not clear from the Bill that that is the case. The Bill has been amended with a duty laid on Monitor to exercise its function to enable services to be provided in an integrated way. However, the balance still appears to be in favour of competition over integration.

One big concern for me is that the need to demonstrate that competition requirements have not been infringed will drive elements of the diabetes care pathway to be

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opened to competition and will be fragmented. It will not be the joined-up treatment and understanding of the podiatrist knowing what the dietician is advising. It will break the trust between elements of the pathway over time. I understand from Diabetes UK that there are discussions currently about the possibility of integrated pathways being commissioned rather than individual parts of the pathway. But it is suggested that this could

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happen only if the whole pathway was subject to competition. Diabetes UK believes that this is impracticable and so do I, and I urge the noble Earl in his reply to outline clearly how integrated pathways will be commissioned.

Debate adjourned until tomorrow.

House adjourned at 12.23 am.


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