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House of Lords

Tuesday, 25 October 2011.

2.30 pm

Prayers-read by the Lord Bishop of Ripon and Leeds.

Youth Services


2.37 pm

Asked By Baroness Royall of Blaisdon

The Parliamentary Under-Secretary of State for Schools (Lord Hill of Oareford): My Lords, the Government will set out their plans for an overall youth strategy later in the year. English Councils can draw on their revenue support grant and the early intervention grant to fund youth services. Central government is also meeting capital costs of £141 million for 63 myplace youth centres in disadvantaged areas, funding provision of national importance for vulnerable young people by 18 voluntary organisations and piloting national citizen service for 16 year-olds.

Baroness Royall of Blaisdon: My Lords, I am grateful to the Minister for that Answer. It all sounds very good when it comes from the Minister's lips but it would not feel like that to the 1,000 young people I met this morning at a very excellent Choose Youth rally. They are concerned that they are being unfairly treated when their services are disproportionately cut. If he looks at the figures, the Minister will agree with me that youth services up and down the country are being disproportionately cut. Does he agree that support for young people is a cost-effective way to change people's lives and that if they are missing out we are missing out as a society?

Lord Hill of Oareford: I agree with the noble Baroness, Lady Royall, about the importance of supporting young people. I know that she is carrying out a review to look at ways to make it easier for them to get more engaged from a democratic point of view. That is extremely important. It is the case that we have had to take difficult decisions on funding. As I have said to the House on many previous occasions, it is also the case that when we were faced with a decision last year on where to prioritise our public spending we took the view that, given the need to make hard choices and the overall situation that we faced, the more sensible place to put it was in pre-16 funding as all the evidence shows that how children do before 16 is the strongest determinant of how they do after 16.

Baroness Walmsley: My Lords, 28 local authorities have not declared what their youth services plans are, as they are required to do by law. What can the

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Government do to protect youth services in those areas as local authorities have a statutory duty to provide positive experiences for young people?

Lord Hill of Oareford: My noble friend is absolutely right about the statutory duty that local authorities are under. Under that same legislation-I think it is the 1996 Act-the department is able to chase up local authorities to see what they are doing. Ultimately, there is a power to intervene if the Secretary of State thinks that local authorities are failing to fulfil those duties in the long term. Across the country a varied picture is emerging of how local authorities are responding to the funding challenge that they face through the early intervention grant. As we have debated many times before in other contexts, we think that local authorities are best placed to exercise that judgment. However, at a difficult time, we are seeing across the piece a growing focus on providing support for disadvantaged young people particularly.

Lord Laming: My Lords, how will the Secretary of State make a judgment on whether the provision by each local authority is adequate to meet the needs of its young people?

Lord Hill of Oareford: I fear that I am not going to be able to give a precise answer to the noble Lord. As is often the case, these judgments need to be made on a case-by-case basis, but those powers do exist in that legislation. I know that this is something that my honourable friend Mr Loughton, who is the responsible Minister, is aware of.

Baroness McIntosh of Hudnall: My Lords, the Minister will no doubt not be aware that I, along with colleagues, spent some part of this morning listening to evidence provided by voluntary service groups which are offering services to at-risk young women in Leeds, the north-east and elsewhere. No doubt he will be aware that these voluntary sector services are coming under enormous pressure at the moment because their core funding is, on the whole, being removed. Will he acknowledge the enormous contribution the voluntary sector makes in the area of youth services and tell the House in what way he thinks their current funding crisis can be helped?

Lord Hill of Oareford: I am grateful to the noble Baroness for giving me the opportunity to say how much we welcome the role played by the voluntary sector. It is extremely important, as she says, and we would be keen to extend that role. That is one of the areas that I know my honourable friend Mr Loughton is looking at in bringing forward proposals later in the year-probably at the end of November-and launching his "positive for youth" strategy, which will look at involving that sector. I know he is working with the voluntary sector on that plan. More generally, on the noble Baroness's point about the funding situation, there is not a lot that I can say. I do not hide the fact that we face a difficult financial situation. We have had to make difficult choices and have pushed those choices down to local authorities where we think they can most sensibly be made. Beyond that, so far as the money is concerned, there is little extra I can add.

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Lord Roberts of Llandudno: My Lords, with youth unemployment having touched more than a million, what provision do the Government have in mind to help 16 to 18 year-olds who find themselves penniless and jobless at the present time?

Lord Hill of Oareford: The Government are seeking to address that important issue in a range of ways. One is through the raising of the participation age, where we are building on the measures taken by the previous Government; another is by increasing the number of apprenticeships offered to the 16 to 18 year-old group; and another is through the record funding going into education and training for 16 to 18 year-olds. We can work on this in a range of ways. It is not just my department that is involved. Across government a range of departments needs to be active in this area, and that is something we are taking extremely seriously.

The Lord Bishop of Ripon and Leeds: My Lords, in view of the meetings taking place, not least the one this morning, will the Minister tell us what contribution he envisages young people themselves making in the development of "positive for youth" over the coming years?

Lord Hill of Oareford: The involvement of young people is extremely important and relates to one of the points made by the noble Baroness, Lady Royall of Blaisdon. I know that my honourable friend is extremely keen to make sure that young people are fully involved in the development of this policy. In part it is through becoming more engaged in parliamentary-type activities and in part it is helping my honourable friend to shape his own thinking. In part it is through national citizen service, which is where young people themselves can acquire the skills to set up sustainable projects in their own areas. There is a whole range of ways, and it is an extremely important point.

Scotland: Director General for External Affairs


2.45 pm

Asked ByLord Forsyth of Drumlean

Lord Wallace of Saltaire: My Lords, the Cabinet Office's Senior Leadership Committee, chaired by the Cabinet Secretary, approved the appointment of a director-general of strategy and external affairs in the Scottish Government and that the post would be advertised at a starting salary of between £115,000 and £125,000 per annum. The figure of £200,000

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appears nowhere in the particulars of the post, although I saw it floated in the Scottish edition of the Daily Telegraph.

Lord Forsyth of Drumlean: My Lords, I am most grateful for that Answer, but if the Cabinet Secretary believes that it is okay to spend public money on recruiting officials to work on reserved matters such as the constitution, is it okay for the nationalist Administration to use officials to work out policy on, for example, withdrawal from NATO or removing nuclear weapons from Scottish soil? Will my noble friend consider amending the Scotland Bill to put officials, Ministers and Members of the Scottish Parliament in exactly the same position as members in local government, whereby they will be liable to surcharge where they incur illegal expenditure?

Lord Wallace of Saltaire: As a former Secretary of State for Scotland, the noble Lord is treading on slightly sensitive ground by comparing the Scottish Government to an English local authority. There is no statutory basis in the Scotland Act for such surcharges, but I think I hear the shape of an amendment that might be tabled to the current Scotland Bill when it reaches Committee.

Baroness Liddell of Coatdyke: My Lords, does the Minister agree that the creation of jobs such as this leads to tremendous uncertainty that is added to by the coyness of the First Minister in revealing the date for the proposed referendum on separation? That uncertainty affects Scottish businesses and other businesses that may be seeking to invest. However, it also affects Scottish families who are worried about their pensions, social security payments and jobs. Would this money not be much better spent trying to find jobs for the one in four young Scotsmen who are out of work?

Lord Wallace of Saltaire: My Lords, that is an extremely good political intervention that I trust will appear in the Scottish press tomorrow. The devolved Administrations work best when they work constructively with the Westminster Government. That is how government should operate. Different Governments need to work constructively together. I know that there are those who know the Scottish First Minister better than I do and think that he is a very provocative populist who likes provoking the Westminster Government. That is clearly part of what is going on.

Lord Maclennan of Rogart: While acknowledging that the origin of this post was with the Cabinet Secretary, since it was announced it appears that surreptitious steps have been taken by the Permanent Secretary in the Scotland Office to go much beyond the role of the Scottish Parliament and the Scottish Executive. Will my noble friend agree to accept the advice given by the leaders of the three major parties in Parliament that Sir Gus O'Donnell should now institute an inquiry into the conduct of this role and, in particular, examine whether the purpose, as set out on the Scottish Government website, to develop Scotland's

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constitutional framework, is being stretched beyond its original purpose into the dismantling of the United Kingdom's constitution?

Lord Wallace of Saltaire: My Lords, again, the Scottish First Minister is highly skilled at stretching issues to the absolute outer limits of what is acceptable. This is clearly being played in Scottish politics in that way. We discussed the question of the senior civil servant in the Scottish Executive last time. I simply stress that at the end of the day the Scottish Executive are responsible to the Scottish Parliament, and through it to Scottish voters. Scottish voters want to be concerned about what is happening in the management of health, education and the Scottish economy when they look at the Scottish Government, and may not take kindly to a Scottish Government who spend too much of their time on extraneous issues.

Lord Hamilton of Epsom: My Lords, did not all the machinations by the SNP make those undertakings that we were given by the Labour Government pretty hollow, when they introduced Scottish devolution, which they said would strengthen the union?

Lord Wallace of Saltaire: My Lords, no political system remains entirely stable for ever. There is a dynamic and a dynamism in which I have to say my own sense was that we were a very overcentralised union, both in England and as far as the other nations were concerned. We are better off with effective devolved Administrations, but it is quite clear that the current SNP Administration want to stir the pot very vigorously.

Lord Foulkes of Cumnock: My Lords, as one of the people who strongly advocated devolution, I agree with the Minister-we are better off with it. However, unfortunately, among a lot of United Kingdom Ministers and civil servants there is an imperfect understanding of what is meant by devolution. The Minister himself spoke about Governments talking to Governments. With respect, a devolved Government are subsidiary to the United Kingdom Government. We have devolved power; we have not ceded power to them. I wonder if it would not be wise, now that we are getting rid of Sir Gus O'Donnell, to ask Jeremy Heywood to have a new look at this, to see how we can ensure that the Scottish Government do what they are set up to do. As my noble friend Lady Liddell said, look after the interests of the people of Scotland in the devolved areas, and leave it to us to deal with the reserved areas.

Lord Wallace of Saltaire: My Lords, I have already said that. I have to say, devolved Administrations do need to look at constitutional arrangements. They also need to look at some aspects of external affairs. For example, two years ago I read a report proposing that the Government of Jersey should establish an external affairs unit to deal with the very considerable relations they have with the European Union. Clearly, the question that the noble Lord, Lord Forsyth, mentioned -the suggestion from the SNP that Scotland should leave NATO-would require Scottish independence first. Suggestions that that is something for which civil

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servants might already prepare would clearly be well outside the bounds of the envelope which the First Minister for Scotland loves to stretch so much.

Companion to the Standing Orders


2.53 pm

Asked By Lord Williams of Elvel

The Chancellor of the Duchy of Lancaster (Lord Strathclyde): My Lords, as Leader of the House I have a particular responsibility to advise the House on procedure and order. However the Companion makes clear that because the House is self-regulating, the preservation of order and the maintenance of the rules of debate are the responsibility of the House itself, of all the Members who are present. It is open to any Member to draw the House's attention to breaches of order at any time.

Lord Williams of Elvel: My Lords, I am grateful to the noble Lord the Leader of the House for that response. I am sure that he is absolutely right, but is he aware that during the passage of the Armed Forces Bill, at Report, the usual channels managed to stitch up a deal apparently in order to avoid Divisions at Report of that Bill, and postpone them to Third Reading? The deal transgressed not only the letter but the spirit of the Companion. Will he give us an assurance that that sort of deal will never happen again?

Lord Strathclyde: My Lords, I am well aware of the situation that arose on Report of the Armed Forces Bill. The reason why an agreement took place was so as to allow the Health and Social Care Bill Second Reading to be postponed from Tuesday 4 October to Tuesday 11 October. I think the whole House would have approved of that decision. These decisions were made by the usual channels, as I made clear, so as to help the House as a whole. I do not think there was any detriment in taking that decision.

Lord Stoddart of Swindon: I speak as one who took part in the discussion about this. Was not the real reason for the decision on the Armed Forces Bill to accommodate the Conservative Party conference and the ability of Members of this House to attend that conference? Am I right in thinking that the same problem is going to arise next year, when this House will be recalled during the Tory Party conference? Will the noble Lord the Leader of the House look at the position for next year to ensure that the House's business takes preference over that of the Conservative Party?

Lord Strathclyde: My Lords, I can assure the noble Lord from personal observation that there were very few Members of the House of Lords-of all parties-

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present at the Conservative Party conference. They were far more likely to be attending to their duties in your Lordships' House. It is true that the Chief Whip has announced that the House will sit next year during the week of the Conservative Party conference, but this is in large part due to representations that have been made to me and others from all parts of the House that they would rather come back earlier in October than sit in September, as we did this year.

Lord Geddes: Will my noble friend confirm that there is no such person in this House as "the noble Minister"? There is "the noble Lord the Minister and "the Minister" but there is no such person as "the noble Minister".

Lord Strathclyde: My Lords, I can confirm that my noble friend is entirely correct.

Lord Brooke of Alverthorpe: My Lords, if there is an agreement between the usual channels to breach the Companion, should we not have an arrangement whereby the agreement of the House is sought?

Lord Strathclyde: My Lords, it is an intriguing idea. I have very recently proposed in a paper to the Procedure Committee that, in tightening up the rules at Third Reading, we should think of mechanisms whereby the House itself agrees to them so as to give those decisions greater power.

Lord Alderdice: My Lords, does my noble friend accept that, if over a period of time the usual channels find it difficult to reach agreement or to carry the support of all Members of the House, a time may come when it is necessary to look at the establishment of a business committee for the House to take into account not only the Government and the Opposition but the Cross-Benchers, the Bishops and others within your Lordships' House?

Lord Strathclyde: My Lords, it is true that there have been some difficulties in reaching usual channels agreement over the past 12 months, but there are some signs that that period of difficulty is coming to an end. My understanding from the government Chief Whip is that relations at the moment are extremely good. I think it is too hasty to say that we should throw away a system that has served the interests of the House and of the different political parties extremely well over a long period.

Lord Grenfell: My Lords, on the eve of the memorial service for the late Lord Ampthill, who passionately championed respect for the provisions of the Companion, I find the Question of my noble friend Lord Williams particularly apt. Does the Minister agree that those minded to abolish this House have a very special duty to ensure from now onwards that any lack of respect for the rules in a new Chamber is not excused by its elected Members on the grounds that they were not respected by the House that they have replaced?

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Lord Strathclyde: My Lords, if a successor House were to be created, it would of course be up to that House to decide on its rules, how to manage its affairs, how to co-ordinate itself and, indeed, how to regulate itself. My role as Leader of this House is to make sure that the Companion is stuck to and that everyone is aware of the rules. However, as I said in reply to the original Question from the noble Lord, Lord Williams of Elvel, it is up to every Member of the House to play a part in that.

Lord Cormack: My Lords, does my noble friend accept that an elected House would consist of Members who would actually want to go to the party conference, and is that not an added reason for keeping things as they are?

Lord Strathclyde: My noble friend has very cleverly introduced yet another subject. Of course, it would be entirely up to them whether they went to the Conservative Party conference.

Baroness Royall of Blaisdon: My Lords, the whole House will understand that some of the difficulties that have arisen in usual channels and throughout the House as a whole have emanated from the fact that we have too much legislation and too much badly drafted legislation. We all agree-I am sure that the noble Lord will agree-that what we need is more pre-legislative scrutiny. At the moment we have five Bills in pre-legislative scrutiny. Does this mean that we will only have five Bills in the next Queen's Speech?

Lord Strathclyde: The noble Baroness the Leader of the Opposition reiterates an old saw. I can assure her that we have not been any more ambitious in this session than her party was in the first Session of the previous Government. There are a good number of Bills in pre-legislative Committee at the moment-the noble Baroness said there were five, I thought there might have been six-I am sure that there will be more, and equally sure that there will be more than five Bills when we get to the Queen's Speech.

Government: Commercial Lobbying of Ministers


3.01 pm

Asked By Lord Low of Dalston

Lord Wallace of Saltaire: My Lords, the Ministerial Code sets out the ways of working for Ministers. On taking office, the Prime Minister committed to the quarterly publication of Minister's meetings with external organisations and the hospitality received. He also strengthened the code in relation to former Ministers to include a two-year ban on lobbying Government

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and a requirement for former Ministers, for two years after leaving office, to obtain the advice of the independent Advisory Committee On Business Appointments about any job or appointment they wish to take up, and to abide by the committee's advice, which is made public.

Lord Low of Dalston: My Lords, following the Prime Minister's request to him to investigate the former Defence Secretary's conduct in relation to the Ministerial Code, the Cabinet Secretary wrote in his report that more allegations had arisen,

If the Government do not intend to set up an inquiry, how do they propose to go about getting those answers, which I am sure both Parliament and the country will be anxious to hear?

Lord Wallace of Saltaire: My Lords, there has been an inquiry on the Werrity affair, and I was not aware that we needed a further inquiry on it. The Government are committed to as much transparency as possible, not only in ministerial meetings-I assure the noble Lord that it relates to people as far down the food chain as me, in terms of what is required about my diary being published-but in the funding that is provided for various activities.

Baroness Williams of Crosby: My Lords, I fully welcome the steps taken by the Prime Minister. Will my noble friend agree that a further move toward a register of lobbyists would be extremely useful in controlling what has become a very fast-moving interest group in the field of politics? Will he also agree that this would make an inquiry of the kind requested by the noble Lord, Lord Low, very much more straightforward?

Lord Wallace of Saltaire: My Lords, the coalition Government are committed to introducing a statutory register of lobbyists, and will publish proposals in the form of a consultation document next month.

Lord Dykes: My Lords, to what extent in the last 12 months has the senior corporate chairmen's group visited No. 10? Will the Minister assess its influence in those regular visits and say how many have occurred?

Lord Wallace of Saltaire: My Lords, I do not have details on that, so I will have to write to the noble Lord about it.

Lord Hunt of Kings Heath: My Lords, can we return to the question asked by the noble Lord, Lord Low, who identified that there are still matters in the Cabinet Secretary's report that need to be answered? That is why a further inquiry is required. Will the noble Lord say why the Government will not institute such an inquiry?

Lord Wallace of Saltaire: My Lords, the Minister about whose conduct that inquiry was held has now resigned. The Government will look again at the report and see whether there are matters that need further investigation. Perhaps I may remind the noble Lord

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that when a statutory register of lobbyists was proposed by the Public Affairs Select Committee in 2009, the previous Government declined to accept that report and said that they preferred a voluntary register. However, to their credit, the Labour Government in their manifesto for the last election supported a statutory register.

Baroness Whitaker: When the Minister responds to the noble Lord, Lord Dykes, about the senior corporate chairmen's group, will he include information about what representations it made to the Prime Minister about the corruption Bill?

Lord Wallace of Saltaire: As regards the Bribery Bill, we will do our best to provide whatever information is available. I say to noble Lords that lobbying is a huge industry. My notes say that professional lobbying is a £2 billion industry that has a huge presence in Parliament. The Hansard Society estimates that some MPs are approached by lobbyists more than 100 times per week. I suspect that Members of this House may feel that non-commercial lobbies, too, are sometimes fairly pressing. We have had a large number of messages and letters in the past week, not only on the NHS-some of them might be considered self-interested-but on Amendment 80 to the Education Bill.

Lord Hunt of Kings Heath: My Lords, I am sure that the noble Lord will wish to be put right in relation to the point that he has just made. We did go for a voluntary register as a first base, but we were always prepared to legislate if necessary. It is actions undertaken on his Government's watch that have made a regulatory system needed under statute.

Lord Wallace of Saltaire: My Lords, I look forward very much to the comments that the noble Lord and others in his party will make on the consultation document when it is published next month. Having looked at this, I say that defining a commercial lobby is not entirely easy at the edges. That is one reason why the consultation document has been delayed. I have in my notes the phrase, "If it looks like lobbying and sounds like lobbying, we think it is lobbying"-but I suspect that we need a rather clearer definition than that.

Baroness Symons of Vernham Dean: My Lords, I apologise if I misunderstood what the noble Lord said a moment or two ago. He seemed to imply, in answer to an earlier supplementary question, that if a Minister resigns the Government will somehow escape scrutiny for what happened on their watch. He said: "But the Minister has now resigned". The point made was that the Cabinet Secretary has said that since the first investigation further matters have arisen. The question we put to the Minister is: how will this now be investigated? Surely he cannot be suggesting that the former Minister will escape scrutiny.

Lord Wallace of Saltaire: If there are further matters to be investigated, I assure the noble Baroness that they will be. Some of these matters are not simply of the behaviour of one Minister; they concern standards of conduct in public life.

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Public Services Reform (Scotland) Act 2010 (Consequential Modifications of Enactments) Order 2011

Motion to Approve

3.07 pm

Moved By Lord Wallace of Tankerness

Motion agreed.

Health and Social Care Bill

Main Bill page
19th Report Delegated Powers Committee

Committee (1st Day)

3.08 pm

Amendment 1

Moved by Baroness Thornton

1: Before Clause 1, insert the following new Clause-

"Principles of the Health Service in England

(1) Any person or body performing functions or exercising powers under this Act in relation to the Health Service in England must have regard to the principles and values outlined in the NHS Constitution.

(2) Any person or body performing functions or exercising powers under this Act in relation to the Health Service in England, or providing services as part of the Health Service in England, must provide quality, equity, integration and accountability, not the market.

(3) The primacy of patient care shall not be compromised by any structural or financial re-organisation of the Health Service in England.

(4) There must be transparency and openness wherever taxpayers' money is being spent, and all accountable individuals and bodies should abide by the Nolan principles.

(5) "The Nolan principles" means the seven general principles of public life set out in the First Report of the Committee on Standards in Public Life (Cm 2850).

(6) Schedule (Principles of the Health Service in England) has effect."

The Lord Speaker (Baroness D'Souza): My Lords, I point out to the Committee that in line 8 of the amendment, there is a misprint. "Must provide quality" should be read as "must promote quality".

Baroness Thornton: My Lords, I thank the Lord Speaker for making that correction and assure the Committee that the correct word is "promote", not "provide". In the context of the Bill, as noble Lords will be aware, the difference between promote and provide is a subject on which we will have many debates in the days to come. I apologise to the Committee for not having read my own amendment more carefully when it was published.

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To noble Lords who are familiar with this kind of amendment, I apologise in advance. There may be some who are not; we have many new Peers with us today. Perhaps I may explain what we are doing here. The Liberal Democrats will be more familiar with this procedure because from time to time they placed this kind of amendment before the House, aiming to set a framework for the Bill in question or to give further definition of a Bill. Indeed, from time to time, they succeeded in persuading the House to support them. I know the House appreciates a good precedent. I believe that the last time there was an amendment before Clause 1 was in the Apprenticeships, Skills, Children and Learning Bill in 2009, when the Liberal Democrats and the Conservatives both put amendments down before Clause 1. Forgive me, I am not absolutely certain if either or both of them succeeded. I have a feeling that the noble Baroness, Lady Sharp, may have succeeded on that occasion.

The aim of this amendment is to set out some principles and a framework for the Bill to follow. In doing so, we have sought the widest possible genesis for this amendment, and I will explain this to the Committee in a moment. This first amendment kicks off Committee stage and concerns the principles that ought to underpin the health service in England. The amendment stresses the rights and pledges, values and principles, as outlined in the NHS constitution produced by Labour when in government. The amendment also places protection and promotion of patient care above structural or financial reorganisation. It calls for transparency and openness in decision-making, especially those decisions on funding, to ground proper accountability at the heart of our National Health Service. It seeks to set a framework around which the debate on the rest of the Bill can follow. I tabled this amendment partly because while the Government say they agree with all of these matters, at present the Bill still fails to reassure people that it delivers them. The confusion and lack of trust will be the substantive matter in many of the almost 400 amendments that have already been put down on this Bill.

At their spring conference, the Liberal Democrats made it clear that they wished to set beyond doubt that the Bill will not establish the NHS as a utility-style market based on the now outdated model that is currently failing in energy. How right the Liberal Democrats were. I share the doubts of the noble Baroness, Lady Williams, that the changes in the Bill achieve that. The need for a defining set of principles arises out of the failure of the Government to provide any reasonable explanation of what this Bill is for and what their strategy for the NHS actually is. The Government keep telling us that it has to be a different NHS so I am seeking some definition on what we can agree about and to place those principles at the front of the Bill.

We like to think of this amendment as a perfect cross-party marriage in its crafting. We have something old, something new, something borrowed and something blue. The old is the NHS constitution; although not very old, it was devised and brought about by the Labour Government and put through the House by my noble friend Lord Darzi, and we are proud of it. This is in subsection (1) of this amendment and is reflected in Amendment 52 to the schedules that list

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the principles of the NHS constitution, particularly with relation to patient care. I have borrowed the words of subsection (2) from the resolution that was passed at the Liberal Democrat spring conference, with the very slight addition of "integration and accountability", which I am sure would have been there had they thought of them. I did wonder about the last three words-"not the market"-but I think everyone knows what that means. It does not mean that the NHS should not be engaged with the market, nor that there is not a place for the planned use of private and other providers within the NHS. It is there because the first Bill included a clear commitment to use competition as the main means of reforming the NHS and I think we still need to be clear that this is not the case. These Benches and the Liberal Democrats are in some agreement about this matter-at least I hope we are-and I think we should say so at the beginning of this Bill. Subsection (3) is blue, coming as it does from the coalition agreement. We will stop top-down reorganisations that get in the way of patient care. These words echo those of the Prime Minister when he said, "no top-down reorganisation". The new, in subsection (4), is the most recent player in this Bill: the Future Forum, which has quite rightly brought the probity of the Nolan principles into this Bill.

It seems to me that only with clarity around the principles will the Government have any chance of taking the 1 million-plus staff of the NHS with them. Given the British Medical Association survey released yesterday, and GPs' survey a week or so ago, the words of the Royal College of Nursing and many others, the Government have some way to go in persuading the staff to wholeheartedly support these changes. So I suggest that this statement of principles will help the Government in this task. It will also help the passage of this Bill. I hope that the Minister and the Committee will feel the same.

3.15 pm

Baroness Williams of Crosby: My Lords, may I briefly address the proposal put forward by the noble Baroness, Lady Thornton? She has made a considerable contribution to the discussion in this House about the health services; not least by organising an impressive series of seminars that were attended by many Members of this House, from all parties and also from the Cross Benches. We are extremely grateful for this.

I am moved very little by the preamble, in the sense that the central issue behind it, which I fully share-that is to say, the clear responsibility of the Secretary of State for a comprehensive health service free at time of need-is primarily, in fact, already embodied in the debate we are about to have on the first group of amendments after the amendments on education and training. The way that this has been addressed by the noble Baroness, Lady Thornton, herself but also by other members of this House, not least the noble and learned Lord, Lord Mackay of Clashfern, provides the basis for a very satisfactory, detailed and careful consideration of what the role of the Secretary of the State is.

We know that there are still fears about ambiguity. On this I agree with what the noble Baroness, Lady Thornton, has indicated. These fears have been very

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strongly outlined: first, by the Future Forum which said in its report that it had concerns about the accountability of the Secretary of State and, secondly, in the brilliant and concise report of the Constitution Committee, an all-party committee of this House. The committee pointed to its concerns about whether the responsibility and accountability of the Secretary of State emerged sufficiently clearly, and it gave a very impressive argument to the effect that some doubts remain about the position.

Since that time, of course, there have been concerns-rightly so-about some of the knock-on effects of removing accountability of a clear kind from the Secretary of State. All through this Bill, there are situations where the Secretary of State might be or might not be involved. I shall give two examples. The first is about the possibility of conflict between Monitor and the NHS Commissioning Board and how that is to be resolved, where one might suppose that the Secretary of State would be the ultimate decider. The second is on the question of what happens if there is a major emergency in the country of a health nature and whether the public would not, in fact, expect the Secretary of State to be the ultimate source of accountability.

My feeling is that it is better to address these issues very clearly as each one comes up, and to set out in detail, therefore, what the precise responsibilities of the Secretary of State are. Certainly, if one wants simply to assert-which many of us obviously fully understand-a concern and a liking for the NHS, the Secretary of State's responsibility was reiterated and reaffirmed some time ago after intervention by my right honourable friend in another place, Mr Nicholas Clegg, and others.

This is not an issue for which we should hold up the whole of the Committee proceedings but, in assessing once again the commitment of many of this House to the NHS, it is certainly not objectionable. For the reasons I have given, however, it is perhaps not wise to detain ourselves on this issue at the moment.

I would add two other problems. The wording of the preamble before Clause 1 is mostly fine, but frankly I am a bit worried about subsection (3). One thing we must not do is, as it were, encompass the NHS in a form of unchangeability when all of us know that major changes have to be made within its structure. Therefore, subsection (3) could be a rigidification of the situation. Having said that, however, I believe that we should now move on from this issue to look at the most clear, legally expressed considerations of what should be the clear and accountable responsibilities of the Secretary of State.

Lord Hennessy of Nympsfield: My Lords, having suggested during the Second Reading debate that your Lordships might consider the value of a preamble to the Bill which captures the ethos and purpose of the National Health Service, I was grateful to the noble Earl, Lord Howe, in his letter of 20 October to noble Lords, for describing it as "an interesting idea". The Minister went on to say that,

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I note and accept that preambles have fallen into disuse, but I continue to see the value of capturing the NHS ethos and purposes firmly right at the top of the legislation, which is why I welcome the proposed amendment in the name of the noble Baroness, Lady Thornton, as a surrogate for a preamble.

I am especially pleased by the NHS constitution occupying a prime position in the amendment's attempt to capture the principles of the health service in England. The first two principles expressed in the NHS constitution must continue to suffuse the whole enterprise and its legislative underpinnings. The first principle declares:

"The NHS provides a comprehensive service, available to allirrespective of gender, race, disability, age, sexual orientation, religion or belief. It has a duty to each and every individual that it serves and must respect their human rights. At the same time, it has a wider social duty to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population".

Principle 2 explains quite briefly that:

"Access to NHS services is based on clinical need, not an individual's ability to pay.NHS services are free of charge, except in limited circumstances sanctioned by Parliament".

Faith in those principles runs deep in our country, powerfully and, very largely I think, consensually. They deserve to be emblazoned at the top of this Bill through a clear reference to the NHS constitution. In fact, apart from the words "not the market", the amendment before us could, I suggest, represent a common bonding for our deliberations, however fiercely contested will be many of the clauses to come, just as the sustenance of a comprehensive National Health Service free at the point of delivery is one of, or perhaps the most, tenacious common bondings of our people and our country.

Baroness Murphy: My Lords, one cannot help but be moved by the commitment of the noble Lord, Lord Hennessy. In view of the public discussion that has gone on outside this Chamber, we all welcome a recommitment to the principles of the NHS constitution. But I have a number of really serious concerns about the amendment as it stands. For a start, remembering back to the 2009 Act, the whole point about the NHS constitution is that it was not just a set of airy-fairy principles, it concerned how those principles were to be put into effect. To extract these crucial principles, which along with the noble Lord, Lord Hennessy, I wholly support, and put them separately at the beginning of the Bill is to confuse the issue and, I think, to leave us open to further legal challenges over what the NHS is about. The NHS constitution stands; that it must stand is reiterated in the Bill, and therefore we should not seek to water it down in any way.

The second part of the amendment again does not quite reflect what we have tried to do, as we discussed the development of this Bill, to ensure that the NHS is about improving quality. It is not about accepting quality, equity, integration and accountability as is; it is about continuous change leading to improvement. Again, I think that that is not reflected in subsection (2), which is very confused, and I really do not understand the phrase at the end, "not the market". What does that mean, and how does it relate to the,

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The third subsection, about the primacy of patient care, is crucial. We want to see the primacy of patient care throughout the Bill. Again, however, as it stands, the amendment would rule out structural and financial reorganisations, for example to improve the formula for allocation of resources to local clinical commissioning groups. It would rule out the decisions that we want local groups of commissioners to make regarding reconfiguration. It would stultify the development of an improved health service. I really think that that is confusing.

As for the Nolan principles, I think that all of us would say that they are crucial. But they are in the Bill as it is, as they were in every NHS Act recently. Standards in public life are something that everybody who is in public service must be committed to, and they are in employees' terms and conditions of service. These are desirable things, and I am very sympathetic to the desire to make a comprehensive statement of the commitment of all sides of this House to a universal and comprehensive NHS. However, this amendment is not it.

Baroness Jolly: My Lords, I do not intend to take an awful lot of your time with my comments. I agree with many comments made by my noble friend Lady Williams, and I share the anxieties expressed by the noble Baroness, Lady Murphy. To a certain extent I am bemused, because we have a perfectly good NHS constitution. It has been said that it is only three years old and indeed it is. It was a result of the work of the Labour Peer the noble Lord, Lord Darzi, and involved a huge cross-party effort. This is to be commended. This amendment does not match it in breadth or scope.

We are now in Committee and it is not sensible of us to prolong the debate. We have many, many days yet to go and we really need to move on and get on with the Bill. However, I want to finish by thanking the noble Baroness, Lady Thornton, for her compliments about our conference motions and the way in which our policy is made following votes by our members at conference. The second subsection of this amendment came from a motion to our conference last spring. We wanted the NHS to work for patients and not providers and as a result of this and the Future Forum deliberations, this was acknowledged. Furthermore the Monitor duties were changed to reflect this so that they now are about the promotion and protection of patient care. I really feel that we need to move on and get on with the Bill.

Baroness Donaghy: My Lords, I support this amendment for three reasons. I will be brief, bearing in mind the comments made by the noble Baroness, Lady Williams.

First, in a Question in the House today, the noble Lord, Lord Low of Dalston, asked for an inquiry into the nature and extent of commercial lobbying of Ministers. If it is considered bad now, I have a great fear that it will be an even bigger problem when we get to the commercialisation of the National Health Service. As a former member of the Committee on Standards in Public Life and a former acting chair, I regard it as a reassurance to have reference to the Nolan principles in this amendment. More importantly, I think that it will be a reassurance for the members of staff who work in the health service.

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I want to draw the Committee's attention to two of the most important parts of the principles: openness and accountability. We have already seen-certainly in my experience as a non-executive director of a foundation trust until a couple of years ago-phrases such as "commercial confidentiality" creeping into discussions about how we conduct our health service. How much more will that phrase creep in when the kind of proposals in this Bill become an Act?

Currently, research and knowledge are shared by the medical profession, both nationally and internationally. If you are involved in any way in higher education and medical research, you will see how important that is for the advancement of medicine generally. Unless we embed these principles in the amendment, I fear that they will be under threat and the efforts of our medical profession will be compromised.

3.30 pm

Lord Rea: My Lords, I have spent most of my professional life working in the National Health Service. I have also worked in and observed other healthcare systems and have come to value the NHS all the more not only for its universality but for the high quality of its coverage. I admire it also for its economy of working. We spend considerably less on health per head of population than most other countries at a similar stage of economic development.

By and large, the NHS has conformed to the principles laid down in the amendment. Of course, it is far from perfect. Its bureaucracy, as the noble Baroness, Lady Williams, said, is sometimes inflexible. For example, the treatment of whistleblowers is often inappropriate. Internal criticism should be heard and acted upon and not suppressed, but this Bill is not necessary in order to correct that. The amendment is an important reminder to government at both national and local level of what the NHS stands for. Any action by government or individual staff should be taken with these principles firmly in mind.

Baroness Morgan of Drefelin: My Lords, there is nothing like suggesting to a House of Lords Committee that we move on to encourage one to stand up and contribute.

The noble Baroness, Lady Thornton, mentioned the debate that took place at the start of the Committee stage of the Apprenticeships, Skills, Children and Learning Bill, now an Act, in 2009. I remember sitting behind the Dispatch Box next to my then noble friend Lord Young listening to the noble Lord, Lord Hunt of Wirral, make a very convincing case for the Opposition on the need to set out a clear definition of apprenticeships and the importance of a well thought through, principled preamble. I remember listening to my noble friend take the Committee through a detailed and well argued explanation of how all those issues were carefully covered throughout the very long Bill. However, both Her Majesty's Opposition and the Liberal Democrats were united in saying that they needed to be stated clearly at the start of the Bill. They won the day and there that statement is in the apprenticeships Act.

When I saw the amendment of the noble Baroness, Lady Thornton, it made me think about all the important legislation of the past, and it led me to the Children

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Act 1989, which I am sure the Government are still very proud of. An important aspect of that Act is the principle of paramountcy, whereby the interests of the child are paramount in any decisions taken about their health and welfare.

Listening to debates on this Bill, I have felt genuine concern about how we resolve issues around conflict of interest. The relationship between a health professional -a doctor, nurse or physiotherapist, but principally a doctor-and their patient is based on an extremely high level of trust and is one of the cornerstones of our NHS, and I was wondering how the importance of that trust and that relationship could be incorporated in some principles. Have the Minister or the noble Baroness, Lady Thornton, thought about whether it would be appropriate to have a principle under which the needs and interests of the patient should be paramount when decisions are made about them? Obviously, there are a lot of ways of thinking about that from a legal perspective, but it is something that we need to be very concerned about. How is the conflict of interest to be carefully managed where a GP refers a patient to a service that they own and profit from? How can patients-whether as individuals or a population-be absolutely sure of the decisions being made about them, at every level throughout the system, including commissioning? It is very important that we think about the principles underpinning the health service. This is a very important debate.

The Earl of Listowel: My Lords, I am most grateful to the noble Baroness for this debate on the primacy of patient care. It is very important. All noble Lords may well agree that this is fundamental, so I hope they will forgive me if I raise one concern with the Minister, which has been raised by people who practise in the NHS. The constant changes to the National Health Service over many years, particularly in England, have undermined, to some degree, our efforts to deliver the best to our patients. It is something I am familiar with from speaking to child mental health professionals in the past. They have complained that constant change undermines their ability to make relationships with other professionals work effectively around the child. Also, they get to know a commissioner who then changes. It is a different area, but social workers have also raised with me the issue of local authority changes. I remember speaking to a local authority social worker on a Friday evening who was despairing at yet another structural change to social service provision within the local authority.

In its briefing to Members of your Lordships' House on the Bill, the Nuffield Foundation also expressed concern at the constant changes to the NHS and the short horizons. One Secretary of State may make changes but then a new Government arrive and there is another upheaval. I recognise what the noble Baroness, Lady Williams, says: flexibility and changes are needed, but my sense from speaking to the professionals and expert think tanks is that there has been too much change over a continual period. This was reinforced in the briefing that the presidents of the royal colleges gave to Members of your Lordships' House this week, in which the president of the Royal College of General Practitioners finished with a very powerful plea: "Please,

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give us some stability; please stop changing the NHS". She particularly alluded to the experience in Scotland. If I remember correctly, she said that for about the same investment Scotland has better productivity. She lays this at the door of the fact that over several years there has been some stability within the health service there. I take this opportunity to ask the Minister whether, in future, he will keep in mind the need to allow important changes to bed down. Perhaps we could build a bit more of a consensus on what needs to be done, recruit and retain the best professionals on the ground and allow them to evolve the best practices. Then we will see better outcomes for our patients, with a similar input.

Lord Mawhinney: My Lords, the noble Lord, Lord Hennessey, started by reminding us that preambles have somewhat gone out of fashion. Personally, that does not bother me one way or the other: if there is value in a preamble, we ought to get serious about that value, whether or not it is a common occurrence. However, I want very gently to take issue with the noble Baronesses, Lady Williams and Lady Jolly. I do not think we should be rushing on; this amendment requires serious consideration, not least because it is headed:

"Principles of the Health Service in England".

I have been in this place, at both ends, for long enough to know that if we nod this preamble through so that we can get on to the meat of the Bill, for 10 or 20 days in Committee, or whatever it takes, noble Members will keep reverting to the fact that we have already established the principles in the preamble and that will determine how we should proceed. That is not helpful, certainly not if we have nodded this through as a "God, motherhood and apple pie" type of procedure.

I was struck by the introductory comments of the noble Baroness, Lady Thornton. I liked her phrase "borrowed and blue"-that was very imaginative. Whether it was meant to detract or distract from the substance of the words we will never know, because she did not spend much time talking about the substance of the words. However, I put it to her: how can you have a principle when the person who is moving it says, "I am a bit worried about the words 'not the market' but, hey, we all know what it means"? The truth is that we do not know what it means and I hope that the noble Baroness, Lady Williams, will not take it amiss if I say that if this is borrowed from a motion to a Lib Dem conference, we are probably even less likely to understand what it means. We cannot have a principle when nobody knows what its words are actually saying, including the noble Baroness who moved them.

Proposed new subsection (3) talks about:

"The primacy of patient care".

I am an extremely privileged individual: I have served in this building for 32 years, as a Health Minister for a few of those years. No matter who is in government and who is in opposition, I have never heard anybody promote a proposal on the health service that is not predicated on the words "the primacy of patient care". It is one of those phrases that we all use to reassure

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everybody, particularly those who do not agree with us, that actually, deep down, we are all right when it comes to the NHS. I have done it; I see others in this Chamber who have done it in my hearing, and I say to the noble Baroness, Lady Thornton, that I do not know what it means as a principle. It has to have some meat attached to it to have any substance, which it does not.

Since I have taken issue with the noble Baroness, Lady Williams, let me now agree with her comment about the reference to structure. I can hear us nodding this through and then saying, when we get into the meat of the Bill, "Of course, we have already dealt with the principle that the structure must not be changed, so we cannot have this particular amendment and we cannot pursue this particular idea. Let us move on". Therefore, I have serious reservations about this; not the principle of a preamble, but the substance of what it is we are being asked to accept and the lack of clarity in the amendment. My concern is that this lack of clarity will then be used, unhelpfully, to shape our detailed consideration of the Bill when we get to the principles and the meat-to which I look forward.

3.45 pm

Baroness Finlay of Llandaff: My Lords, it has been said that if you do not know where you have come from, you do not know where you are going. It is important for us to remember what we are talking about: a nationalised healthcare provision that arose originally because there were people who could access no healthcare. We have a situation in this country that is the envy of the world: if you are seriously ill, by and large you will get treated well and, most of the time, to standards of international excellence irrespective of who you are, your financial means, your social standing or anything. That does not apply in other parts of the world.

Those of us who have spent any time in the US will have seen what happens to some people who are not covered. I will never forget a young black man I saw with a terrible cardiac condition. All the money had run out and he was dying in a hospital because there was no further treatment. I was a medical student then and it made me resolve never to practise privately, which I never have, and to do all I could to further the principles of the NHS.

I suggest that there is much merit in considering a preamble, as the noble Lord, Lord Mawhinney, has just outlined. This brief debate has shown that the wording of this preamble is not right-I am sure that the noble Baroness, Lady Thornton, will not be moving it today-but that there would be merit in taking it away and coming back to it at a later stage. Perhaps I am wrong and she intends to move it; I did not have that discussion with her beforehand. However, I suggest that there is much here to commend.

We have a country that is very worried about its NHS, which is much beloved because it is the universal insurance policy that everyone needs if things go terribly wrong and they lose their health. The NHS Constitution was universally welcomed because it set out simple principles. There is much merit in enshrining that at the front of the Bill partly because, as it is

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written now, it concurs with the NHS and the direction of travel, accepting lots of change, that we want to see. There is anxiety that this could be amended in future.

We have had scandals about bad patient care. We have heard about bad staff attitudes, things not being done properly and personal interest overriding the interests of the patient population. There is much to be said for looking at putting in the Bill the vocational role of patient care and the duty to the health of the nation for those who are well to prevent ill health where we can, maximise the potential of those who are ill and restore them as much as possible to quality living. In the delivery of that, everyone, wherever they are coming from, whether they are a state sector employee or a private commercial venture, should adhere to the Nolan principles. That very essence of how we care for each other in our society sets the moral tone for the whole of our society. The Nolan principles are, if you like, the minimum that we should require across the board.

There is the question of transparency and openness. Questions have already been raised during this debate about potential conflicts of interest for those commissioning who may also be providing. There is a need for transparency about financial transactions and other personal career interests that might be there-about family members working in different parts of the service, about where people's thinking might be biased and distorted, and about where there may be a wish to cover up one thing or another for different motives but where transparency would serve the greater good better. Linked to that, of course, is openness.

There is much merit in stating up-front on the Bill where we want to go. Where the NHS has come from, starting before its foundation and then as it evolved, has served us better than the alternatives. We want to drive up care and we want to change. Much can be changed and made more efficient. Nobody is advocating fossilising the services we have, but the principles about what we are trying to do need to be in the Bill.

Lord Mackay of Clashfern: My Lords, in 1946, the then Government promoted the National Health Service. They did so in the National Health Service Act 1946. Section 1 of that Act states:

"It shall be the duty of the Minister of Health (hereafter in this Act referred to as 'the Minister') to promote the establishment in England and Wales of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness, and for that purpose to provide or secure the effective provision of services in accordance with the following provisions of this Act".

Section 1(2) states:

"The services so provided shall be free of charge, except where any provision of this Act expressly provides for the making and recovery of charges".

These are plain, clear, concise words which completely incorporate the fundamental principles of the National Health Service, as they have done since 1946. What is more, these provisions are enforceable at law, as the decision quoted by the Constitution Committee shows. They are enforceable in law, clearly, easily, without difficulty.

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The previous Labour Administration had many skilled Ministers in the Department of Health to my certain knowledge and I pay my warmest tribute to them. One of them was the noble Lord, Lord Darzi, and during his watch in this House the National Health Service constitution was promoted. As some of my noble friends have said, that was agreed by all parties. The noble Lord, on behalf of the Government, declined to put that in a statute. I questioned that, because if we are dealing with the constitution of the service, one would think that it should go into the statute that is the fundamental part of setting up the service.

The Act of Parliament incorporated a duty such as referred to in the first part of this amendment, to have regard to the constitution. Everyone in the health service had to have regard to the constitution. The Government declined to put that into legislation. When I asked the noble Lord, Lord Darzi, why that was, he explained that he did not wish the constitution of the NHS to become a plaything for lawyers.

Noble Lords will understand that that reason was not particularly attractive to me. On the other hand, the sense of what he was saying certainly was, and I accept that it was wise and is still wise. The obligation to have regard to the constitution is fundamental and remains. However, I do not believe that it is possible for us to provide a simpler, clearer and more effective preamble to the National Health Service Act at any time than that which was thought of by the founding fathers of the National Health Service in 1946.

I should point out that this is not strictly a preamble at all; it is a first clause in the Bill. However appropriate some of these sentiments may have been for a resolution at a party conference, they are not suitable for an Act of Parliament, in my respectful submission, because the provisions in an Act of Parliament should be enforceable. When we have such a clear constitution of the NHS and such a fine example in what was provided by the founding fathers, which is enforceable, I respectfully suggest that it is unwise to muddy the waters now. I embrace all the sentiments expressed in this draft amendment and hope that we will have them in mind as we go through our later deliberations. All the sentiments are very acceptable, with the exception of the one about the market, which I find a little difficult. However, I will not elaborate on that now.

I am extremely grateful to the noble Baroness, Lady Thornton, and the noble Lords, Lord Hennessy and Lord Owen, for discussing this matter with me yesterday. I greatly profited from that discussion. It took me back to the beginning of 1946 when I was a second-year student at university. I remember that one of the difficulties envisaged in the founding of the health service was the fact that family doctors-GPs-did not wish to be employed by the Government. Therefore, the constitution provided that the Secretary of State had to provide the service-he did that from time to time at the beginning in hospitals and so on-or secure the provision of the service. "Secure the provision" was, of course, the one operative for GPs. That has served us well. As far as I am concerned, the proposed constitution, however one appreciates the principles that it expresses, is neither as clear or precise nor as

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readily enforceable as what we have. I respectfully suggest to the noble Baroness that she might wish to consider that aspect.

Lord Peston: My Lords, I, too, support my noble friend Lady Thornton. I suffer from the disadvantage that it seems to me the amendments are totally clear and it is perfectly obvious what they are saying. I totally agree with them for one specific reason which noble Lords opposite will find extremely disagreeable; namely, that I believe that this Bill paves the way for the end of the National Health Service as it was founded and as we know it and have experienced it. The whole purpose of our deliberations in Committee is to try to save the National Health Service. I am not optimistic that we can do it, because the Government do not seem to be in listening mode on this Bill.

The noble Lord, Lord Hennessy, puts his finger on the main question here, which is the ethos of the National Health Service. If someone does not understand the difference between a market ethos and, if you like, a public service ethos, they ought not to be taking part in these debates, as the two are completely different. The purpose of a market ethos is to make money and perhaps then do good as a result. I refer to the famous Adam Smith quotation regarding the baker and the butcher and why they provide their services. However, that is not the nature of the health service. Noble Lords opposite cannot wriggle out of that.

Noble Lords may also find it disagreeable that the only reason I am alive today and addressing them is because I have had marvellous service from the NHS over the past few years in my time of need. That service was as good as any that one could pay for. I, of course, paid for it though my taxes, but you cannot buy a better service. That is the fundamental point, and noble Lords opposite cannot wriggle out. If they support the Bill and do not like these amendments, they are paving the way for the end of the service as we know it.

4 pm

That is a completely different question from: "Is the health service as efficient as it could be?". Anybody who knows much about it knows that it is not. I was writing articles 30 or 40 years ago saying that those of us who were devoted to the public sector must also be devoted to efficiency in the public sector. That is still my view. To take an obvious example, there is vast overprescribing in the NHS. One reason for that is that, in many cases, when a patient goes to see a doctor, the doctor feels unable to say, "There's nothing I can do to help you". It happens that I am lucky with my neurological problems: I have to see my consultant regularly because he wants to make sure I am still alive, but other than that, when I see him, he says, "Of course, there is nothing I can do for your condition", and then we talk a bit about the world in general and then he says, "See you again in three months".

In the case of prescribing, the patient wants something done and will not be told that there is nothing to be done to help him, but the poor old GP does the best he can, so he writes another prescription. If noble Lords have ever had to clear up after an elderly relative who

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has died, they will have discovered in the medicine cabinet loads of prescribed medicines that were never taken, never used. As my noble friend Lord Rea said, I am not suggesting for one moment that the health service is perfect, but this Bill is not the way to remedy that kind of deficiency. So I have two hopes: first, that my noble friend divides the House on this issue, because it is so fundamental that we really ought to hear the voices as to who goes one way and who goes the other. I also hope that enough noble Lords vote for this amendment so that we can start as best we can to rescue the health service that we love.

Lord Ribeiro: My Lords, I am grateful to my noble friend Lord Mawhinney for referring to the words, "motherhood and apple pie", because when I first saw this amendment, that is the way it looked. When one reads proposed subsections (1), (2)-or parts of it- (4), (5) and (6), they seem pretty innocuous. However, in proposed subsection (2), we are talking about high principles, which none of us would disagree with-principles which crop up time and again throughout the Bill. Quality-something that the noble Lord, Lord Darzi, referred to in a speech a few weeks ago -equity, integration, accountability are all points that we will address in the coming weeks, and are fundamental aspects of this Bill. However, the phrase "not the market" is not a principle-it is a mechanism for delivering what one wants.

The noble Lord, Lord Peston, said that any form of market would turn the NHS into a privatised industry. May I remind him that during the time of the previous Administration, we had independent sector treatment centres? What were they if not an example of a market-driven industry? They were introduced-

Lord Peston: I was not a Minister in that Government, so I do not have to defend them.

Lord Ribeiro: At least the noble Lord recognises that it was something that happened, and that it was a market. It was deliberately introduced by the previous Government. Were it not for the fact that NHS consultants were excluded from working in that area, it achieved the objective it was designed to do, which was to reduce waiting list numbers. However, it was a market, so if we were to accept proposed subsection (2), we would effectively say that we must call an end to all forms of privatised healthcare provision that currently exist in the NHS. I think that noble Lords would agree that this would not be acceptable.

Proposed subsection (3) talks about restructuring and reorganisation. The noble Baroness, Lady Williams, addressed this very effectively when she said that we do not want to encapsulate the NHS in aspic, creating rigidity rather than flexibility. The previous time the House debated the health service, I made reference to the decision that had been made on Chase Farm. It had taken 17 years for it to be made. If we were to accept proposed new subsection (3), effectively every constituent of Chase Farm would have a very good legal reason to challenge why that reorganisation had taken place. While I am fully supportive of the idea in Amendment 52 of having the NHS constitution clearly

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laid out-we all agree with, understand and support it-I am not in agreement that the five principles as set out in Amendment 1 should be accepted in their present form. If it came to a vote, I would certainly oppose the amendment.

Lord Bichard: I have some sympathy with the suggestion that we should set out at the beginning of the Bill the values and principles on which the service is based. My difficulty is that I fear the amendment is not appropriate or adequate in its current form. Therefore, I will be unable to support it for reasons that other noble Lords have given, and for two others in particular.

First-and others may find this provocative-the NHS is still not driven often enough by the primacy of patient care. It is not, therefore, enough to say that the primacy of patient care will not be compromised by structural or financial reorganisations. We should surely be much more positively committed to the need to redesign services around patients, and I thought that that was one of the major purposes of the Bill. It is difficult to believe that in a modern world we can be content that people should stay in accident and emergency departments for four hours and longer. That is a question not just of resources but the way in which we design the service and the primacy we give to the patient. We cannot be comfortable that that is happening enough. I agree that we should not have more structural reorganisation, but that in itself is not enough. We should positively redesign our services.

The second reason why it is difficult to agree with this particular amendment is that if we are going to have a clear statement of values and principles, they should be clearly directed at the commissioning agent itself-the service-not to contractual providers. They should be built into contracts and specifications, and the service should ensure that these are taken seriously. I am afraid that the amendment seems to be muddled in that respect, and we cannot expect people performing functions to behave in a way that the commissioning agent is not specifying and requiring. Therefore, the values should be directed primarily at the commissioning agent.

I regret that I cannot support the amendment; I would like to see a clear statement of values early in the Bill, but this is not it.

Baroness Barker: My Lords, when I looked at the amendment that the noble Lord, Lord Hunt of Kings Heath, had put his name to, I was immediately taken back to the debates on the Mental Health Bill that many Members of the House worked on. I am sorry that the noble Lord is not in his place. I mention a phrase of his in that debate. I have some form as regards proposing that there be principles at the head of a Bill, just as he has a lot of form in resisting them. He and several of his colleagues spent a considerable amount of time resisting all attempts to have principles inserted into that Bill. When we were discussing that issue in 2007, the noble Lord, Lord Hunt, in reply to my noble friend Lord Carlile, said that,

That for me is the problem with the amendment.

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Various Members of the Committee have talked about the NHS Constitution. I am afraid that the consequence of selecting some parts of it may be that the noble Baroness, Lady Thornton, is unintentionally placing other parts of the NHS Constitution at a lower legal status. I want to defend the members of my party at their conference in Sheffield. When they voted on a resolution, they were not voting for legislation. They were passing some words in the form of a resolution. This section has been taken from a far bigger resolution. They were expressing their views, which were then taken forward into the Future Forum work. I would not condemn them for doing that. But I do not think that those words are now adequate to achieve what is intended.

A number of noble Lords have talked about openness and accountability, and the importance of the Nolan principles. Those are important. As we continue through this Committee stage, I want to look in great detail at how those principles are applied to the NHS Commissioning Board, and to clinical commissioning groups, because it is how those principles work in practice that is important.

For a number of reasons I cannot support this amendment. But I would think it unfair to characterise anybody who does not support it as resiling from these or any other principles. We do support many of them. We will return to many of them during further stages of this Bill, and I hope that we will make sure that some of them are passed into the legislation, but not this amendment in this form.

Lord Owen: My Lords, I support the proposed new clause. It is not perfect, but that is not the issue. What we are really debating is whether we want, at the start of this legislation, something that talks about the principles and values of the National Health Service. It will not be easy to find the right words. The noble and learned Lord, Lord Mackay of Clashfern, drew attention to some very fine words in the original NHS Act, and they might well find their place. It is not a preamble, but it has the spirit of a preamble behind it. It is very necessary.

Let me explain one thing. People know that I was a doctor, a medical scientist, and also a Minister of Health. But it is not so well known that I was for 15 years on the board of Abbott Laboratories-one of the largest healthcare companies in the world-and there will be many occasions in Committee when I will be dealing with conflicts of loyalties because I am still a shareholder. I just wish to state that.

It is also important to realise that I am not opposed to the market. Indeed, at very early stages in 1985, I was the advocate of the internal market. I must say I am ashamed of that advocacy now. So often the work that was done on an internal market is used to justify the external market that is the basic fundamental underpinning of this Bill, which I am afraid will become an Act.

Ten years old is a very impressionable age. My father, in 1948, said to our family that this was a day of freedom for him. He had voted Labour in 1945. He had been a general practitioner through the 1930s in the Welsh valleys, and he had never got used to charging

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patients. This was the day when he no longer had to charge patients. But he always said with a rueful smile that there were a few exceptions. One was the Gypsy encampment, which considered that a consultation had taken place only if silver had crossed the palm.

We all know there is a market and there always has been. People have talked about the independence of general practitioners, which has been fiercely fought for. But the interesting thing about this National Health Service legislation is that it was not only a Labour Government achievement. When I was on the Labour Benches I used to proudly claim it as a Labour achievement. Then when I worked with the Liberals and the alliance, I used to claim it was Beveridge. The truth of the matter is that if there are two outstanding people who can claim paternity to the spirit and values and principles of the NHS, they are Beveridge and Bevan.

There is a great wish in this country, wherever people are situated in the political colour frame, to keep some of these values in whatever happens to this NHS. I happen to agree with the noble Lord who spoke that this is a disastrous Bill. It will unutterably change the principles of the National Health Service, and I shall reflect that argument. I have not done so to date because I have tried to see a mechanism whereby the Bill can be discussed. Others will, with perfectly genuine motives, consider it an achievement and the right direction for the NHS, but I think that we ought to be able to agree on the values. I hope that, whatever happens to this amendment in a vote, we will not lose the basic spirit of trying to find a form of words that will underpin these principles and values. They are very important.

4.15 pm

I want to stress another thing. People forget the market value of having a substantial National Health Service, and I think that it is being fragmented with wilful disregard. I cannot understand how the Treasury has accepted the disbandment of the procurement policies of the National Health Service, which have ensured far more value for money in the British National Health Service than in any other national health service of whatever form or dimension around the world. Fifteen years in an American healthcare company and being married to an American, who is also a British citizen, make me very well aware of the deficiencies and problems of the healthcare system in the United States, and I do not want to see it come here. We will therefore have to look at some of the strengths of the National Health Service.

I have lost any hope of convincing the government or Liberal Democrat Benches about the substance of the Bill. It is going to go through. That is unfortunate but that is the reality. However, I hope that we will be able to focus on some of the issues relating to a market, where great damage is being done. How do you challenge a massive American healthcare company if you are a disaggregated part of the structure-a single foundation hospital or a single commissioning group? Do you seriously think that a major healthcare company, whether it is in Switzerland, Germany, the United States or even here in the UK, is going to listen to us? Are we seriously going to dismantle this structure?

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When I was Minister of Health, I was also the sponsoring Minister for the industry. This Government, like the Government beforehand, are very keen to build on the biomedical companies in this country, as well as the two large pharmaceutical companies, GlaxoSmithKline and AstraZeneca, and quite rightly so. They are important, modern, scientific industries, and we have something to contribute to the world in these areas. However, part of the reason we have been able to build up these industries is that the direction of healthcare policy has been able to understand, work with and partnership the industry. Only a few days ago, an extraordinary announcement was made about the malarial vaccine being developed by GSK in partnership with the Bill and Melinda Gates Foundation, amply financially supported by Buffett and his millions. I ask the Committee to consider carefully that, within the values and principles of a health service which is predominantly free, there are also great strengths in the purchasing power of a whole country. I hope that we will do that.

Apart from the good sport in quoting the Liberal Democrat conference in relation to subsection (2) of the proposed new clause-we are not all innocents here-I think that all the issues in the clause are important. I should be only too happy to see it amended, because none of these things can be considered on first go to contain all the right elements. However, underlying it is a principle: are we trying to maintain some of the principles and values of the health service that we have had since 1948 or are we hell-bent on destroying it and replacing it with market principles at each and every turn?

This is not an internal market. It is an external market. If we do not, in this House, start to dismantle some aspects of it and see some merits in the structure of the health service as it currently is-economic merits, benefits of having the strength to use your market power as a large purchaser-then, in my view, we will not only destroy the National Health Service, but we will make health care in this country a great deal more expensive than it currently is. You have only to look at the percentage of GDP which the United States spends on overall healthcare and the return it gets, and then compare that with this country, to realise that we have a jewel which we are in great danger of throwing away.

The Earl of Listowel: Is the noble Lord aware of the report commissioned by the Government and published last year, led by Sir Philip Green, which looked at improving government efficiency? He argued very strongly for improved procurement practices and, in particular, for using the collective strength of all government departments together to improve procurement, perhaps appointing two or three very senior civil servants to procure this. Does the noble Lord recall that, and does that not support what he has been saying?

Lord Phillips of Sudbury: My Lords, I shall not detain you long. I cannot resist-given that the noble Lord, Lord Owen, was in reminiscing mood-recollecting that my Welsh father was personally appointed by Aneurin Bevan to be responsible for the inauguration of the health service in what was then the county of

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West Suffolk. My infancy was taken up with traipsing around hospitals and surgeries in his wake. I am as totally committed to the National Health Service as any man or woman on earth. Indeed, one of my daughters was admitted last night as an emergency patient to an NHS hospital.

Perhaps I may echo the words of the noble and learned Lord, Lord Mackay of Clashfern, because I think that he spoke from great experience and with great wisdom. I am sorry that that flies in the face of what the noble Baroness, Lady Thornton, said, in what was one of the most radical charm offensives towards these Benches in the history of charm offensives. However, as others have said, the notion of incorporating resolutions of party political conferences into legislation is a short road to legislative anarchy. I want to make two points in relation to that.

First, I absolutely concede that an upfront statement of principles makes legislation more comprehensible and more friendly to the layperson. I do not deny that for a second, and that very much draws me to such a statement. But then one comes to the hard, unaccommodating realities of construing statutes. We already have here a Bill of 445 pages, with at least that number of pages to come in secondary legislation, with-as I counted the other night-DHS documentation in support of the Bill in excess of 1,000 pages. I put it to the noble Baroness that principles, however well drafted, may give even more room for manoeuvre and obfuscation to my profession. There is room enough already in this Bill.

If noble Lords do not know what I am talking about, I offer an example. There is no reference in the amendment as drafted to an absolutely fundamental principle of this Bill, which is the subject of an amendment in the name of the noble Baroness, Lady Finlay, the noble Lord, Lord Kakkar, and myself-namely equality of clinical treatment and care for NHS patients with private patients. That is but one example of an omission in the present statement of principles. I am sure that many Lords in other parts of the House could say, "What about this?" or "What about that?". We could argue until the cows come home. All the while, as the noble and learned Lord, Lord Mackay of Clashfern, reminded us, we have that historic, catholic and satisfactory statement in the 1946 Act of what it is all about. Therefore, I add my voice, with a degree of reluctance, to the voices of those who feel that the amendment, although good in intention, might not achieve its purpose but sow inadvertent mischief.

Lord Newton of Braintree: My Lords, I begin a very brief set of remarks by apologising to the House, and especially to my noble friend Lady Williams and to the noble Lord, Lord Hennessy, for not having been here at the beginning of the debate. The reason is perhaps apposite and might help to calm down the noble Lord, Lord Peston; I was at an NHS clinic in Braintree at lunchtime.

On the basis of this debate and looking at the amendment, I am with my noble friend Lord Mawhinney and a number of other noble Lords who have no objection to a preamble or general statement of principle. I will come back to that in a minute. However, if we need one, this amendment is not it, as the noble Lord,

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Lord Bichard, said. There is a case for the Government looking at a possible preamble or broad statement of principle, partly because, in my judgment at least, the views that the noble Lords, Lord Peston and Lord Owen, expressed-which would lead me, if I believed that they were true, to refuse to support the Bill-have raised fears and concerns among a significant number of members of the public. If we can reassure them by a preamble or statement of principle at a proper time, we should do it.

My noble and learned friend Lord Mackay of Clashfern did us a service by going back to the founding statement in the 1946 Act. I say to the Labour Front Bench that it may need a bit of tweaking-I have not studied it in the way that my noble and learned friend has-but going back to the statement of principles on which the NHS was founded would give people that reassurance. For me as a Conservative, and no doubt for the Liberal Democrats as well, it would do a real service by assuring people that we are not about destroying the NHS but about making it better and more fully equipped to fulfil its initial objectives. I hope that my noble friend will look at what my noble and learned friend suggested.

Lord Alderdice: My Lords, I agree considerably with the suggestion of the noble Baroness, Lady Thornton, that some of us might have a sense of déjà vu about the setting down of a list of principles pre-Clause 1. She is right that it is what opposition parties tend to do-and the response, as the noble Baroness, Lady Morgan, pointed out, is that Governments tend to resist them. Her Government were no different from how I suspect the Minister will be in this respect. However, I hope that when Liberal Democrats and Conservatives in the past put down such amendments, they were a little more careful about the wording.

As a number of noble Lords who are susceptible to the notion of a statement of principles pointed out, the statements before us are not very well put. The first states that the health service,

I have no doubt that if this had come forward as a government proposal rather than an opposition amendment, the Opposition's place would have been to say, "Only having regard to the principles and values? What about all the other aspects of the NHS constitution? Will they not be set aside now that we have a subsequent piece of legislation?". Legally, that would be a perfectly legitimate point. The second one identifies a number of principles-quality, equity, integration and accountability -and then speaks of the market, which is not a principle at all. It is a mechanism, as my noble friend Lord Ribeiro rightly said. Indeed, the noble Baroness then pointed out that actually a little care was lacking in the setting down of the original words.

4.30 pm

If a statement of principles is needed, and there may well be a case for it, we have to be very careful about what we set down. If it is the case, and it may very well be, that the noble Baroness has set this down, as one often does in Committee, not in order to press things to a vote but to press the Minister for a response

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which may then issue forth to something further on Report, I would not want to press my comments any further because that is a completely legitimate thing to do. However, if one was to seriously consider that some of these words came from a political notion or speeches at anybody's party conference and that does not necessarily make them appropriate for a piece of justiciable legislation, that is of course a wholly different matter.

The noble Lord, Lord Owen, who never speaks more passionately than when he speaks about the health service, has rightly drawn our attention to important matters of concern when it comes to dealing with commercial requirements, as is inevitably the case in the National Health Service. As he quite rightly says, and with an interest which he has announced, the pharmaceutical companies are not National Health Service companies, they are commercial companies. It is true that no matter what you do there is going to have to be an interaction and an engagement. He raises the question of how could a single clinical commissioning group hold to account a major multinational pharmaceutical organisation, and he is absolutely right. That is not where it would be done. It is for the national NHS Commissioning Board to set down tariffs, and if it sets down tariffs at an appropriate level that gives a modest return but no big cut to any of these international healthcare organisations, I think you will find that they will not be half so interested in engaging for business as some noble Lords fear.

I understand that there are always a lot of fears around when we talk about our health system and healthcare. We are here to try to consider it as dispassionately and as reflectively as possible. I encourage your Lordships, whenever we look at any change to the National Health Service, not to jump to the conclusion that the only other model is the healthcare system in the United States of America, nor that we have nothing to learn from any other healthcare systems anywhere else in the world. Some noble Lords have mentioned their adverse experiences in the United States. Indeed, I have had those experiences too. On the contrary, my experiences in the French healthcare system are extremely positive and sometimes rather better than my experiences in the National Health Service within which I worked, as do many members of my family. We need to be careful that we do not shut out light from other quarters where it is genuinely light and we do not get panicked by suggestions that the only alternative is the United States healthcare system that neither we here nor many people in the United States, including the President of the United States, think is a particularly good system at all.

We are in Committee, and if this amendment has been put forward in the spirit of Committee-not as something to vote upon but to press the Minister on-I think many of us will have some sympathy with that and perhaps something more suitable will come back at a later stage. However, one must agree that it is not suitable to go into the Bill, certainly in this form.

The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): My Lords, I begin by thanking the noble Baroness for introducing these

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first two amendments in our Committee proceedings. I confess that I approach them with a feeling of some nostalgia: a debate about overarching principles has been a feature of our Committee proceedings on a number of health Bills over the past several years, and I therefore understand entirely why the noble Baroness and other noble Lords opposite should have approached this particular Bill with a similar thought in mind.

Amendments 1 and 52, tabled in the names of the noble Lords, Lord Hunt and Lord Beecham, and the noble Baronesses, Lady Thornton and Lady Wheeler, seek to set out the key principles of the NHS. I am grateful to the noble Baroness, Lady Thornton, for explaining them so clearly. As regards their broad intent, I am sure she will be pleased to hear that the Government support most of these principles very warmly.

However, despite having confessed to a feeling of nostalgia on the Opposition's general approach, unfortunately I have to let them down gently by saying that the amendments as they stand will not do. I suggest to the Committee that the various principles listed can be categorised into two groups: the unimpeachable and the unworkable. Unfortunately, even the unimpeachable parts are completely superfluous in legal terms. As we are in the business of creating statute-which, the noble Lords will understand, needs to be devoid of unnecessary verbiage-that does actually matter.

Let me start with what might be termed unimpeachable but unnecessary. I hope that I do not need to say again what I have already said on a number of occasions-that the Government strongly support the NHS Constitution. All organisations, including private bodies, already have a legal duty to have regard to the constitution when performing NHS functions or providing NHS services. Included in these principles is that:

"NHS services must reflect the needs and preferences of patients, their families and their carers".

This enshrines the principle that the NHS is there for patients. Under the Health Act 2009, the Government cannot change the principles in the constitution except through regulations.

We have already made provision in the Bill for the NHS Commissioning Board and clinical commissioning groups to have regard to the NHS Constitution. Commissioners, therefore, are covered by the Bill. NHS providers, including foundation trusts, are already subject to this duty under the 2009 Act. We are not changing this. I am sure that it is unwitting on the part of the noble Baroness, but this subsection set out in Amendment 1 would actually do something undesirable; which is to restrict the group of people who must have regard to the constitution. At the moment, the duty applies not only to NHS bodies, and others performing statutory functions under the Act, but also to those providing services to the NHS under contract, including private providers. The amendment would appear to have the effect of removing these people from the constitution's sphere of application. I cannot believe that the noble Lords opposite want this; and I certainly do not.

The amendment is also restrictive-again, no doubt, unwittingly-in referring just to the principles and values contained in the NHS Constitution. My noble friend Lord Alderdice was right to point out that it

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fails to refer to the rights and responsibilities laid out in the constitution, which many might say should not be seen as being of lesser importance. The amendment sends out conflicting, and therefore confusing, signals about the constitution.

Subsection (4) states that:

"There must be transparency and openness wherever taxpayers' money is being spent, and all accountable individuals and bodies should abide by the Nolan principles".

We do, of course, agree that transparency, openness and accountability must be general principles applicable to the NHS. This is why, under the new system, every NHS organisation will have its duties transparently conferred by Parliament, with the Secretary of State retaining ultimate accountability for the NHS. It is why we are providing for the boards of foundation trusts and clinical commissioning groups to meet in public, and it is why we have said that all NHS contracts will be published. As we will discuss over the coming weeks, I genuinely believe that this Bill will provide a far greater degree of transparency than current legislation about what the Government require of the NHS, and what is delivered in return. It is, I suggest, unnecessary to augment these tangible provisions with a generalised statement of principle-and unwise as well, because expressed as an absolute duty, it does not make allowance for those things which should certainly not be open to transparency and openness, such as patient confidentiality.

While I fully welcome the due regard paid by noble Lords to the noble Lord, Lord Nolan's fine seven principles of public life, the suggestion that these must be set out as principles of the NHS for all bodies to abide by is unnecessary because there is already an expectation that all public bodies, including those of the NHS, should abide by the Nolan principles. My noble and learned friend Lord Mackay was right to remind us of something else. To put the Nolan principles into statute would, I am afraid, represent a fast route to a lawyers' charter, something that the previous Government wanted to avoid when they set up the NHS Constitution. We have already made specific pledges that NHS bodies must abide by the Nolan principles. The Government said in the July document, Developing the NHS Commissioning Board:

"Subject to the passage of the Bill, the Board will be required to have a Chair and at least five non-executive members. Their key purpose will be to ensure effective governance, consistent with Nolan Principles, to hold the Board's executives to account, and to contribute to the success of the Board's key external relationships".

In our response to the Future Forum, we said that:

"The authorisation process for clinical commissioning groups will ensure that they have robust governance requirements consistent with Nolan principles and are accountable and transparent. This will not be a one-off test: the NHS Commissioning Board will hold commissioning groups to account for this on an ongoing basis".

It is not necessary to enshrine the Nolan principles in statute. They already have force and will continue to do so.

Subsection (2) of the new clause says that NHS services should,

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which roughly paraphrases some of the principles in the constitution. It also overlaps or duplicates some of the general duties we have set out in the Bill, such as those relating to quality and integration. However, it adds the words "not the market" which is not a phrase that one might describe as being of luminous clarity. "The market" is a phrase which could mean all sorts of things. I take it that the noble Baroness does not mean that the NHS should never purchase anything at all from a private body or organisation in the marketplace or benefit from improvements in quality which derive from such providers. If she means the market for healthcare provision, as I think she does, that too would bring to a complete halt the process begun in earnest by the last Government which has led to patient choice in elective services. I know that the noble Baroness is not against patient choice, so it would be a pity if an amendment were to put that policy in doubt. The Government are absolutely clear, however, that an American-type free market in health services should not and will not happen in this country. I would simply point to the amendments made in another place which put this beyond doubt. The Bill now explicitly provides that Monitor's role is to protect the interests of patients and the public, not to promote competition as if it were an end in itself. It also contains a range of safeguards against the use of price competition or any policy that might favour a particular sector of providers.

The market has a part to play in the NHS. It can enhance choice and drive up quality. As the noble Lord, Lord Darzi, said at Second Reading:

"The right competition for the right reasons can drive us to achieve more, work harder, strive higher, and stretch our hands and reach for excellence. It can spark creativity and light the fire of innovation".-[Official Report, 11/10/11; col. 1492.]

Subsection (3) in the amendment refers to the primacy of patient care. We can all agree with the sentiment that underlies this: patients come first. I take the point made by the noble Earl, Lord Listowel, that change has been unsettling for NHS staff in the past. However, as worded, the amendment may have the effect of creating a presumption against any reconfiguration of NHS services, for the simple reason that all reconfiguration brings with it a certain element of inconvenience for patients, however temporary. If the NHS were prevented by concerns over whether it had complied with this duty from reorganising itself financially, it would not be able to extend the scope of the tariff, for example, in response to the creation of a new integrated pathway of care. Improved outcomes for patients were at the heart of our NHS White Paper and at the heart of this Bill: greater choice and patient involvement, continuous improvements in quality, reduced inequalities, and better integration around the needs of individuals are the objectives set out in the Bill with force and clarity. We cannot have a provision that acts as a block on all future change.

4.45 pm

There was much debate at Second Reading about the need for reorganisation and change. Many noble Lords spoke persuasively about the challenges facing the NHS and the need for services to modernise. I will not repeat those points here. As with competition, I

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doubt if anyone would argue that restructuring is an end in itself, yet restructuring is sometimes necessary to put in place a sustainable framework that creates the right incentives and opportunities for NHS services to improve. That is what I believe the Bill does and to quote again the noble Lord, Lord Darzi, at Second Reading:

"To believe in the NHS is to believe in its reform".-[Official Report, 11/10/11; col. 1492.]

I am inclined to give the benefit of the doubt to the Benches opposite by accepting that they have tabled these amendments in good faith. However, as I have explained, they cannot be supported as they stand, not least because their practical effect would be to bring the NHS to a halt. Having said that, we have been clear from the introduction of this Bill-indeed the publication of the White Paper-that we are open to new ideas and improvements as to how the Bill can better meet the vision set for it. That is why we made changes last year following the public engagement and why we had the Future Forum exercise earlier this year.

Amendment 1 is a case of clear common ground in its intent. There are a good number of issues contained in the amendment. I have outlined how I feel the Bill already addresses many of them. However, issues as important as this are always worthy of exploring further to see if improvements can be made. We have been doing so and I undertake that we will continue to do so in the light of this amendment.

I hope what I have said gives reassurance to the Benches opposite that in terms of intent we are on their side. Nevertheless, I hope in the light of the quite serious flaws in the drafting the noble Baroness will think again and withdraw Amendment 1.

Baroness Thornton: My Lords, I thank all noble Lords who have taken part in this debate. It is a very useful start to the Committee stage and consideration of this Bill. I want to say to noble Lords who began their remarks by suggesting that somehow or other this was not an appropriate amendment to put down that this is the Committee stage. It is entirely appropriate to look at a preamble and principles that should inform the rest of the Bill. I want to thank noble Lords for all their remarks-particularly the noble Lord, Lord Hennessey, my noble friend Lady Donaghy, my noble friend Lord Rea and the noble Baroness, Lady Morgan, for their very wise words.

The noble Baroness, Lady Jolly, said the constitution is a good constitution. If that is so, why should it not be in the Bill? Indeed, at 80 minutes into this discussion, the noble Baroness also said that we might be wasting the time of the House; that it was not sensible to prolong the debate. I think the debate has shown the noble Baroness, Lady Jolly, that it was a discussion worth having. I hope that when the Liberal Democrats do not feel comfortable about things we propose from these Benches they will not suggest we are prolonging the debate.

The noble Earl, Lord Listowel, made very important points about the principles of trust and the principles that should underpin this Bill. I take comfort from the

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questions the noble Earl raised. I thank the noble Lord, Lord Mawhinney, for his good sense until he reached his conclusion, of course. There is nothing wrong with repeating good things in a Bill. In fact this House spends a lot of its time putting things into Bills that are repetition of what has gone before.

The noble Baroness, Lady Finlay, made a very wise speech. She said our NHS is the envy of the world and that is indeed true. She also made a very good point about the importance of the statement of principles and what it might achieve. We think that this is a good statement of principles, drawing on a variety of sources, and I shall probably test the opinion of the House on it. However, if we fail on this occasion, I should be very happy to work with the noble Baroness and any other noble Lord to find another form of words which we might bring back at a later stage of the Bill-indeed, the noble and learned Lord, Lord Mackay, might have given us the drafting.

The noble Lord, Lord Ribeiro, said that it was motherhood and apple pie. There is a mixture of messages here, but I actually think that motherhood and apple pie are really rather good. The noble Lord spoke about entering the market. As I made clear in my opening remarks, the part of the amendment which refers to the market addresses the priorities and principles that should be used to underpin the future of the NHS. If those priorities and principles are applied clearly, they are not the market in those terms.

I took some comfort from the remarks of the noble Baroness, Lady Barker, because she knows that we have been round this course on many occasions. The noble Lord, Lord Owen, prayed in aid Bevan and Beveridge, and I thank him for his support. To the noble Lord, Lord Phillips of Sudbury, I say that it is clear my charm offensive is not going to work on his Benches, which I regret. However, if he wishes to raise the issue of the number of pages in this legislation and its supporting documentation, he probably needs to address those remarks to the Minister and not to me.

The noble Lord, Lord Alderdice, misunderstood the point about the constitution. I do not know which light he thinks the amendment seeks to shut off, because we think that it provides us with a broad base of principles.

The Minister provided his usual forensic interpretation of the amendment. I had a great sense of déjà-vu, because all the arguments that he used against it were exactly those that I had heard my noble friends use against having a statement of principles or preamble in a Bill when they were Ministers.

Earl Howe: The difference was that in the 2009 Act I gave way to those arguments.

Baroness Thornton: The noble Earl set up, and then knocked down, a series of Aunt Sallies about the market, about how the amendment would halt change, and about how it was too big, too small and too detailed. It is actually rather small. I understand the Minister's position on this. We have a long way to go on this Bill and this is just the beginning of it. We do not see why passing the amendment will inhibit further debate or discussion on the Bill in its entirety. In fact,

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I know this House too well not to know that nothing will inhibit noble Lords from discussing the Bill in the detail that it merits.

Earl Howe: Is the noble Baroness saying that the NHS Constitution needs to change by virtue of her amendments?

Baroness Thornton: No, that is not what the amendment says.

Earl Howe: It is, my Lords, because Amendment 52 does not repeat the NHS Constitution. Ninety per cent of the principles are missing from it and we therefore move into a new world. The previous Government laid down very clear procedures as to what to do when a Government wished to change the principles of the NHS. That involves public consultation and so on. Does the noble Baroness wish to bypass all that?

Baroness Thornton: My Lords, this is Parliament. We can take a decision. It is not about changing the NHS Constitution. We are seeking to put some of the principles of the constitution in the Bill. We think that that is a perfectly proper thing to do. I beg to test the opinion of the House.

4.54 pm

Division on Amendment 1

Contents 212; Not-Contents 244.

Amendment 1 disagreed.

Division No. 1


Adams of Craigielea, B.
Adonis, L.
Ahmed, L.
Alton of Liverpool, L.
Anderson of Swansea, L.
Andrews, B.
Armstrong of Hill Top, B.
Bach, L.
Bakewell, B.
Bannside, L.
Barnett, L.
Bassam of Brighton, L. [Teller]
Beecham, L.
Berkeley, L.
Best, L.
Billingham, B.
Bilston, L.
Borrie, L.
Boyd of Duncansby, L.
Bradley, L.
Brookman, L.
Brooks of Tremorfa, L.
Browne of Belmont, L.
Browne of Ladyton, L.
Cameron of Dillington, L.
Campbell of Surbiton, B.
Campbell-Savours, L.
Carter of Coles, L.
Chandos, V.
Chester, Bp.
Christopher, L.
Clancarty, E.
Clark of Windermere, L.
Clarke of Hampstead, L.
Clinton-Davis, L.
Cobbold, L.
Collins of Highbury, L.
Colville of Culross, V.
Condon, L.
Corston, B.
Coussins, B.
Cox, B.
Crawley, B.
Davies of Coity, L.
Davies of Oldham, L.
Davies of Stamford, L.
Desai, L.
Donaghy, B.
Drake, B.
Dubs, L.
Elder, L.
Elystan-Morgan, L.
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Finlay of Llandaff, B.
Ford, B.

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Foster of Bishop Auckland, L.
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Listowel, E.
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Mallalieu, B.
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Martin of Springburn, L.
Massey of Darwen, B.
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Noon, L.
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Ramsay of Cartvale, B.
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Ripon and Leeds, Bp.
Robertson of Port Ellen, L.
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Rosser, L.
Rowlands, L.
Royall of Blaisdon, B.
Scotland of Asthal, B.
Sherlock, B.
Simon, V.
Smith of Basildon, B.
Smith of Finsbury, L.
Smith of Gilmorehill, B.
Snape, L.
Soley, L.
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Stevenson of Balmacara, L.
Stoddart of Swindon, L.
Stone of Blackheath, L.
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Taylor of Bolton, B.
Temple-Morris, L.
Thornton, B.
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Touhig, L.
Triesman, L.
Tunnicliffe, L. [Teller]
Turnberg, L.
Turner of Camden, B.
Wall of New Barnet, B.
Walpole, L.
Warwick of Undercliffe, B.
Watson of Invergowrie, L.
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Wheeler, B.
Whitaker, B.
Wigley, L.
Wilkins, B.
Williams of Baglan, L.
Williams of Elvel, L.
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Wood of Anfield, L.
Woolmer of Leeds, L.
Worthington, B.
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Young of Hornsey, B.
Young of Norwood Green, L.

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Addington, L.
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Armstrong of Ilminster, L.
Arran, E.
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Benjamin, B.
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Boothroyd, B.
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Bridgeman, V.
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5.07 pm

Clause 1 : Secretary of State's duty to promote comprehensive health service

Lord Patel: My Lords, I shall just say something while I wait for my noble friend Lord Walton. My name is to Amendment 2, and I have no doubt that when my noble friend returns-I am glad to see that he has.

Amendment 2

Moved by Lord Walton of Detchant

2: Clause 1, page 2, line 1, at end insert-

"(c) in the provision of education and training of the health care workforce"

Lord Walton of Detchant: My Lords, I was locked out. As the spirit of reminiscence is in the air, I greatly enjoyed listening to the many impassioned speeches

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on the first amendment. I look back, as a fervent supporter of the NHS, upon the days when, as a medical student in 1944 and an officer in the British Medical Students Association, I confronted the then Minister for Health, Mr Willink, lobbying against the Act because I was pressed by the BMA. Subsequently, as I said at Second Reading, I learnt as a houseman what the horrors of the pre-NHS medical process were in the UK.

Clause 1 of the Bill, which inserts new Clause 1(1) in the National Health Service Act 2006, is very similar to what we learnt in the 1946 Act, which was so closely quoted by the noble and learned Lord, Lord Mackay of Clashfern. I am tabling this amendment with my noble friend Lord Patel because the wording in the Bill at the moment says:

"The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement ... in the physical and mental health of the people of England, and ... in the prevention, diagnosis and treatment of illness".

Those objectives cannot be achieved without improving the provision of education and training for the healthcare workforce-hence the reason for tabling this amendment with my noble friend Lord Patel. The other amendments grouped with ours come to a similar conclusion. The wording is different and so is the emphasis, but they all have the same objective: putting a requirement for the NHS to provide education and training for its workers into the Bill.

When the NHS began, it was recognised that a partnership needed to be established with the universities and the other higher education organisations that trained doctors, dentists and other healthcare professionals. In the original contracts of doctors working in the National Health Service, it was fully recognised that academic clinicians employed by the universities would devote part of their time to teaching and research, but would give clinical services to the NHS for about half their time. In return, it was also accepted as an article of faith from the beginning of the National Health Service that consultants working in the NHS would be required to undertake teaching, for instance of medical students.

The financial responsibility for training undergraduate doctors and dentists was that of the universities, but from the inception of the NHS it was made absolutely clear that postgraduate training of its specialists, dentists and, later, nurses was the financial responsibility of the National Health Service. That has always been the case. To that end, the NHS paid for and established postgraduate deanships in every region of the country. Those postgraduate deans continue, and supervise the training of specialist surgeons, physicians, dentists and more recently, to an extent, the postgraduate and continuing education of other healthcare professionals. Our purpose in tabling this amendment is to make certain that this responsibility is acknowledged in the Bill.

It is clear that government Amendment 43 reaches much the same kind of objective, but responsibility for training and education is so crucial that it should be highlighted in Clause 1. It is absolutely essential. Having said that, there are many uncertainties about which the Bill is lamentably silent. For instance, in what sense is postgraduate training of the NHS workforce

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enshrined in mechanisms in partnership with the universities? What will be the future of postgraduate deans? We understand that they are to be retained, but who will employ them? The NHS will be required to fund them, but where will they be placed? If they are housed in the so-called clinical senates, how many senates will there be, where will they be located and what will their responsibilities be in the provision of postgraduate education and training? Will their responsibilities take full account of the statutory responsibilities of the regulatory authorities, such as the General Medical Council, the General Dental Council, the Nursing and Midwifery Council and so on? Will that be enshrined in statute?

Even more crucially, if certain NHS organisations are to be taken over by any willing provider-I am not saying that this will come about-what mechanism will be introduced in the Bill to require that those NHS bodies will still provide the facilities for education and training of the workforce? That is absolutely crucial. An exactly similar requirement is needed to make certain that commissioning bodies and the national Commissioning Board have a responsibility to maintain the high quality of education and training that has been such a feature of our NHS, in collaboration with universities and other higher education bodies, ever since the NHS was established. These issues are not included in the Bill and require to be included. I beg to move.

5.15 pm

Lord Patel: My Lords, my name is added to this amendment along with that of the noble Lord, Lord Walton of Detchant. He has alluded to the need to include this amendment in the Bill. I consider that not only do we need it but that it is not strong enough. We may have to consider making it stronger. I say this because it is important to indicate on the face of the Bill that the Secretary of State has the responsibility to promote and secure a high-level of education in the whole of the workforce that delivers healthcare. I use the example of medical education and training but that applies equally to the training of nurses and other health professionals who are also regulated.

The current system of medical education and training-a model that is copied by many other countries and is widely respected-has evolved over many years. It is not something that was planned overnight and then executed. It has delivered well trained doctors who have improved healthcare. The system is complex and its essential relationships with different organisations and responsibilities are well documented. Only about 18 months ago, legislation was introduced which further changed the regulatory mechanisms for the training of doctors and nurses by making the General Medical Council the sole regulator of doctors' training from entry to medical school to the day they retire, including postgraduate training, continuing professional development and revalidation. If we tinker with this, we run the risk of fragmenting it and making it inconsistent.

As my noble friend has already mentioned, under the GMC we have postgraduate deans, the royal colleges, the deaneries, undergraduate deaneries and the local hospitals where doctors are trained. These work together

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in a complex relationship to deliver high-quality medical education and training. The Department of Health has issued a consultation document, Liberating the NHS: Developing the Healthcare Workforce. Some of its proposals have caused a great deal of concern. If those proposals are implemented we run the risk of damaging what has been built up over many years. Adopting a localised approach to education, training and workforce planning to meet the short-term needs of employers will destroy the national training for a national workforce that has been developed over a long time.

There are many other concerns; for instance, the lack of clarity over the role of Health Education England. How will it hold education providers and commissioners to account? There are serious concerns about the continuing role of postgraduate deans, a very important group of people in the delivery and quality assurance of medical education and training. Uncertainties about the role of postgraduate deans are already leading to concerns about managing the recruitment of doctors into training in 2012. There is a lack of information about what part local skills networks will play and about the risk of serious damage occurring to workforce planning, and a lack of clarity about their governance and accountability. The training of doctors also includes training in research methodologies, as the noble Lord, Lord Walton, mentioned. Development of academic doctors is crucial. We already have a problem with recruitment to academic medicine. Therefore, training in research methodologies, postgraduate research and higher degrees in research is crucial. None of these is included in the Bill. They are not included because, we are told, there will be a second Bill. It might even be called the social care and health Bill as opposed to the Health and Social Care Bill. However, we are waiting for the responses from Future Forum, which is considering this. Then we will have the Government's response, despite the fact that they have indicated that all the proposals in Liberating the NHS: Developing the Healthcare Workforce will need to be implemented by April 2012-the time is rather short. Perhaps the Minister will indicate when we are likely to see this Bill related to education and training. If there is not a satisfactory answer, we may have to consider putting a framework for medical education and training in this Bill.

Baroness Finlay of Llandaff: My Lords, I have two amendments in this group, but noble Lords who have looked at them will have noticed that they are almost identical. One of them has inverted commas in it. At this point, I ask the Committee to discount Amendment 8B because the inverted commas do not mean a great deal. However, I would like to take a moment out to pay tribute to those in the Public Bill Office, where this drafting error occurred, and I know exactly why. They have had unending patience, have been infinitely polite to everybody who has gone up there and have provided impartial advice when under enormous pressure. So if this is the only mistake they have made with my amendments, they have done amazingly well.

I would now like to quote from the report from Future Forum by Steve Field. In it he pointed out:

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"The professional development of all staff providing NHS funded services is critical to the delivery of safe, high-quality care but is not being taken seriously enough".

I am glad to see that the Government have also decided to put down an amendment providing that we should state on the face of this Bill the importance of education and training.

Amendment 8A is almost exactly the same as Amendment 6 except that it adds the words, "a nationally co-ordinated system". The reason is that currently, the standards are set by deaneries, the royal colleges, the universities and the regulators. At the other end from the high-profile degrees and specialist competencies from the royal colleges, there are qualifications such as the NVQs, which have been used for training healthcare assistants. There has recently been much debate about the standard of healthcare assistants, but I think there is a foundation there that could be built on to raise standards across the board. However, it needs to be nationally co-ordinated rather than have lots of odd little bits of training in one particular area, because otherwise when staff transfer, the organisation of management of another area believes that they are adequately trained, when actually there is no national benchmark for that competency. That is why I put in the words "nationally co-ordinated".

I turn to the amendment put down by the Government. I hope that the Minister will explain how those deaneries and those national co-ordinating bodies that set standards will link in. Will the national Commissioning Board and the clinical commissioning groups have to consider education and training in everything that they do? If they do, the deaneries will have a national planning function in conjunction with the royal colleges and specialist societies which set specific competency standards. I also wonder whether this government amendment, which talks about the health service in England, takes consideration of the NHS in Wales and Northern Ireland. If it does, how would that happen and, if it does not, what arrangements have been made with the devolved Administrations?

I should also ask whether the Secretary of State has a comprehensive duty. Will the national Commissioning Board and clinical commissioning groups have a duty to include education and training when deciding contracts and making commissioning decisions? If they do not do build in education and training right across the piece, will an appeal go to the Secretary of State?

In proposed new subsection (1) of the Government's amendment, there is mention of,

Given the nature of the health service as we see it developing, am I right to understand that that would include all private providers, all voluntary sector providers and all public health and health protection arrangements? Am I right that any provider which does not then provide education and training would need to prove why they were exempt from providing it, if they have a contract for a specific service?

We heard earlier about the independent treatment centres and the sense that they had milked off some healthcare services but had not undertaken training and education. We hear now about specialist trainees in some of the disciplines. Orthopaedics is a clear

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example whereby a lot of shoulder and knee surgery is not being done in their training environment, so the trainees are not adequately exposed to the range of operations. Indeed, an orthopaedic surgeon contacted me about how she was crowded out in theatre by trainees desperate to watch her carry out a shoulder operation simply because they had not seen that operation done-whereas previously they had broader experience.

If the clinical care of patients is contracted out to private sector or voluntary sector providers, the clinical experience associated with providing that care, if it is high quality, will provide a fantastic education and training opportunity. If we are truly developing a healthcare workforce that will be comprehensive for the needs of the nation, it does not matter who owns the building or the service where that patient is being treated. If that is really high quality, there is much to be learnt. In all the years when I have asked patients if they minded students, postgraduates or whoever being present, there have been only two occasions when patients have said that they would prefer them not to be there-and they were for very understandable reasons. Everyone understands the need to educate and train, and the majority of patients understand that if the person looking after them is also teaching they are being held to account by the group that they are teaching.

Those are some of my questions to the Minister when he comes to speak to his amendment. I ask the noble Baroness, Lady Thornton, and the noble Lord, Lord Hunt of Kings Heath, whether they see the use of the word "comprehensive" as a duty on the national Commissioning Board and clinical commissioning groups, and whether, when they talk about delivering NHS services, they are intending that private providers and public health are included.

My final point is: whichever of these amendments is agreed-and I have a sneaking suspicion that mine will not be top of the polls; but that is the way it tumbles-the different providers, whoever they are, need to contribute to the cost of education and training. I suggest that when determining a tariff, those who do not contribute to education and training on a particular part that they are providing should not receive the full tariff because they will be ducking out of part of the ongoing responsibility to secure the nation's health.

5.30 pm

Lord Turnberg: In speaking to these amendments, I am conscious that we are hamstrung by the fact that we have an education and training regulation or Bill to follow. So there is much to come. However, education is so important and so much an integral part of every aspect of the NHS that we must have some recognition of that in this Bill. It is just not possible to imagine a health service run by an uneducated workforce. I am obviously in support of all these amendments, and I am delighted that the Government have got their own helpful amendment in there, but there is much that remains to be clarified. I hope that noble Lords will forgive me if I go over some of these just a little. I should state my own interests of having spent most of my working life deeply involved in undergraduate and postgraduate medical education.

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It is vitally important for the Secretary of State to take on responsibility for education and training in the NHS. It is how that responsibility is fulfilled that I want to focus on, by examining where the potential risks lie in this Bill to the system that we currently have in place and, indeed, where we might take advantage of the Bill to look for improvements in the way that we operate now. I will concentrate on medical education as the system I know best.

At the moment, GPs and hospital specialists are trained using a range of curriculums designed and delivered by the medical royal colleges. The colleges assess the trainees and set their exams, and all of this has to be approved by the General Medical Council. The GMC is the competent body set up under EU law that has to ensure that the training programmes reach the minimum standards set by the EU. It has to be said that in the UK we are way above those minimum standards. All of that is relatively straight-forward. But most of the actual delivery of all this training has to take place locally, at GP practices and hospitals. It is here that we have to be very careful as the NHS moves into its new mode of working.

At this level, the royal colleges have oversight of training through their own regional adviser network, while the postgraduate deans and their teams make sure that the conditions for training are right and that the trainees go through the programmes supervised by local programme directors. They are available in every major discipline and speciality. So there is a complex network for direct oversight of postgraduate education which currently works reasonably well.

However, it is the deans who carry the heavy responsibility of the budget for salaries for all of the trainees. They pay their salaries and they can, theoretically, withdraw funding for trainees if trusts fail to provide the right conditions for training. So the postgraduate deans are absolutely critical and yet their role is threatened as the strategic health authorities which now employ them seem to be disappearing. The deans have enormous power, and budgetary responsibility, but where will they go, and who will appoint and employ them now? I believe that it makes a lot of sense to think about them being employed somehow by the proposed new Health Education England when that is set up, but meanwhile it will be critically important not to lose them. Uncertainty about their future is not a good recipe for them to function effectively. They need some certainty now.

Leaving the deans aside for the moment, it is clear that the current system is dependent on close-working collaboration between them and the royal colleges, the GMC and, at the local level, the consultants and GPs doing the training. All this is going on in an NHS busily providing services for patients at the same time. This is the second threat to education, because it is increasingly evident that the service pressures on consultants and GPs are limiting their capacity to provide the teaching. They are increasingly feeling that the time available to teach is being eroded as service pressures build up. This is not a new phenomenon, but one that is more obvious now. The fear is that this will get worse unless-this is the key-we place a duty on the commissioners of the service for them to fund the extra sessions that consultants need to teach their trainees. One alternative might be for the postgraduate

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deans to have a budget for these sessions, but I suspect that this would not meet with much favour. I personally am not moved by it. It is a responsibility that we have to place on the commissioners.

Finally, I want to mention the public health doctors and their training in the brave new world. They are in some disarray, as I understand it from the public health doctors themselves. The directors of public health are to be transferred to the employment of local authorities. That makes some sense, at least on the face of it. But there may well be difficulties. They may find that the local authority terms and conditions are significantly different from the NHS terms. That may affect recruitment and retention. I have a fear of a return to the days of the medical officer of health, who was in the local authority, rather a rather sad figure remote from the medical community at large. However, rather more important is the training and education of public health doctors. It is quite unclear where the local authorities sit in relation to meeting the needs of those trainees in what is a vital medical discipline. It may be that all of this has been thought through. If so, it would be helpful to hear about it. The public health community certainly needs to know.

Meanwhile, I think that a better solution all round would be for the public health doctors to be employed by Public Health England and for them to be seconded to the local authorities. That might be more satisfactory all round, and it would give some security to the education and training of this key professional group.

I have not spoken about nursing education, not because it is not important-it clearly is-but because we are coming to it later in the Bill, and at least some aspects of nurse training and education will come in later clauses. I am sure that we will return to that. For the moment, I want to support this group of amendments, including that of the Government. But it seems entirely possible, I fear, that there will be further amendments at a later stage to try to tease out some of the issues I have been discussing.

Lord Ribeiro: My Lords, I thank the noble Lords, Lord Walton of Detchant and Lord Patel, for introducing this amendment. It highlights not only the importance of education and training in advance of the report that we will receive later in the autumn from the Future Forum group, but the fact that the Government have responded with an amendment of their own. That identifies the importance of bringing it on to the face of the Bill, so much so that it is right at the very beginning of Part 1. It is one of six duties that the Secretary of State now has to perform. That is very important.

It is quite understandable in a Chamber such as this one, full of doctors, that we tend to overemphasise the importance of medical education. As the noble Lord, Lord Turnberg, rightly said, nursing will be discussed later. However, it is not just about nursing. My wife is a physiotherapist-there are physiotherapists, radiographers and other healthcare workers as well. That is why the Government's amendment talks about education and training without qualifying exactly which areas we are discussing. It is important that we bear that in mind.

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The noble Baroness, Lady Finlay, I think, referred earlier to the independent sector treatment centres and the lack of training in that area. I must declare an interest as a past president of the Royal College of Surgeons. I had countless negotiations with the Department of Health to put into place a requirement for independent sector treatment centres to be able to train. The big issue was that all the surgeons and the ISTCs were overseas doctors. No UK doctors were allowed to train. We asked for a way in which we could introduce NHS consultants into what was effectively spare elective capacity. I fundamentally believe that we must separate emergency and elective surgery to produce the best-quality care for patients.

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