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House of Lords

Wednesday, 2 November 2011.

3 pm

Prayers-read by the Lord Bishop of Bath and Wells.

Police: Station Closures


3.07 pm

Asked By Lord Hunt of Kings Heath

The Minister of State, Home Office (Lord Henley): My Lords, this information is not collected centrally. Decisions about resources are, rightly, matters for chief constables to take locally with their police authorities. What is important is how visible and available the police are. We want to see police officers on the streets, preventing and cutting crime, rather than behind their desks. Modern policing reaches people through many means, not just through police stations.

Lord Hunt of Kings Heath: My Lords, I am most grateful to the noble Lord for that illuminating Answer. Could it be that the Government do not collect this information centrally because the information is too embarrassing to them? Can the Minister confirm that the recent Sunday Times survey that showed 350 public counters due for closure in the next few months is accurate? Can he also confirm that his ministerial colleague in the Home Office, Lynne Featherstone, has been running a campaign in her constituency against police cuts and the closure of public counters? Does he agree that this is somewhat hypocritical, and does it not show that she knows that these cuts are going to have an impact on the police's ability to fight crime?

Lord Henley: My Lords, I am aware of the research in the Sunday Times to which the noble Lord refers. I am not sure it was conducted on the most scientific basis and therefore we will not take much notice of it. I am also aware of what my honourable friend Ms Featherstone had to say about issues in her own constituency. I understand her views were purely about her own constituency, and she is a very good constituency MP. I can assure the House that, like all government Ministers, she is fully committed to what the Government and the Home Office are doing to make the necessary savings-savings forced on us by the profligate manner in which the party opposite behaved when they were last in government.

Baroness Doocey: My Lords, I declare an interest as a member of the Metropolitan Police Authority. Does the Minister agree that the economic situation and

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budget cuts may force the new police commissioners to choose between maintaining police numbers and selling police properties?

Lord Henley: My Lords, I thank my noble friend for that question, and I am aware that she is a member of the Metropolitan Police Authority. The question is about police contact, and the important thing to remember is that police contact is not just about stations; as I made clear in my original Answer, it is about police stations and all other means by which we can achieve that police contact. Police stations are not necessarily always the best means of doing that.

Lord Harris of Haringey: My Lords, I, too, declare an interest as a member of the Metropolitan Police Authority. Given that contact is the key issue, how does the Home Office view the decisions by the Mayor of London and his deputy for policing to cut by nearly a half the number of sergeants responsible for safer neighbourhoods and liaising closely with local communities? Is that not a significant reduction in contact with the community?

Lord Henley: The noble Lord is a member of that police authority and will no doubt put those questions to the mayor in due course. The important point is that those decisions are made by the appropriate authority. It is not for us to micromanage these things; it is for us to make the appropriate resources available to the police. We accept that the cuts that we are having to make, which were forced on us by the previous Government, are difficult. However, they are challenging but manageable, and all police authorities will manage to achieve them.

Baroness Chalker of Wallasey: My Lords, will my noble friend the Minister encourage chief constables to use those early-retired persons who are prepared to volunteer their services both to man desks in police stations and to carry out other non-police but essential back-up tasks? This is working extremely well in a number of areas of the Metropolitan force, and I believe that it should be widely extended across the country.

Lord Henley: My noble friend makes a very good point indeed and I will certainly take it on board. It is quite right that we should make use of the expertise that we have to make sure that policemen who are still available for front-line duties can do them and are not wasted behind the doors of the police station doing bureaucratic jobs.

Baroness Smith of Basildon: My Lords, perhaps I can help the Minister, who said that he does not know how many police stations have closed. In my county of Essex, seven police stations have closed, but, worse than that, we now have no more 24-hour police stations, and most police stations are open only between noon and 6 pm. Given that the Chief Inspector of Constabulary said that a 12 per cent cut in police budgets was the most that could be saved, how can the Government justify a 20 per cent cut in Essex? What impact will this have, and why did they not listen to the chief inspector?

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Lord Henley: My Lords, that is obviously a matter for the authorities in Essex. We accept that things will be difficult, as I have made clear in all the supplementary answers that I have offered to the House. The noble Baroness will be aware of the most recent report from HMIC, Adapting to Austerity, which was published in July this year and which sets out a summary of forces' workforce plans for the spending review period. The number working in front-line roles is expected to fall by just 2 per cent on average, but it must be for each force to decide how to do that itself.

Lord Brooke of Sutton Mandeville: Since the Official Opposition are leading with their chin, does my noble friend recall that under the doctrine of collective responsibility Labour Ministers were seen on the picket lines and at the protests against the closure of hospitals in their constituencies?

Lord Henley: My Lords, it is not unusual for the Opposition to lead with their chin, so perhaps I ought to remind them of what one of their own former police spokesmen said only too recently. Vernon Coaker, the former shadow Police Minister, said:

"Ideally, you want the station to remain in the town but if that's not possible and they don't have the money then we have to look at alternatives ... A lot of areas do operate without a station but they all have a presence".

Lord Taylor of Blackburn: My Lords, what would the Minister's reaction be to the recommendation, if it was made, that the police station at Penrith close?

Lord Henley: My Lords, I am not aware of such a suggestion, but, if it was made, obviously I would want to discuss it with the chief constable of the authority I happen to live in. However, it would be for him and not for me or for any other Home Office Minister to decide what was appropriate for Cumbria policing and policing in Penrith.

Baroness Farrington of Ribbleton: My Lords, would the Minister care to comment on the Government's priorities for the police service in this country, given that they are introducing, at great public expense, an untried and unpiloted new system that replaces police authorities instead of using that money in the way the overwhelming majority of the public want it to be used: on the police service in their locality, including police stations?

Lord Henley: I will not rehearse the debates that we had at some considerable length on the police Bill when it recently went through this House. This House and another place, Parliament as a whole, decided in favour of police commissioners, which we feel is the right way forward and is what we will do. It will create much greater local accountability. If the noble Baroness looks at what we have at the moment in the form of police authorities and what we will have in the future with police and crime commissioners, she will, in due course, recognise that that will be a great improvement.

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EU: Economy


3.15 pm

Asked By Lord Dykes

The Commercial Secretary to the Treasury (Lord Sassoon): My Lords, the Government support the euro area's commitment to ensure financial stability of the euro area. A comprehensive and sustainable solution is urgently needed and is in the UK's interest. This can be achieved only by the euro area working closely together. The Government also recognise the urgent need to boost growth across the EU and are pushing completion of the single market, promotion of trade, reduction in regulation and greater innovation.

Lord Dykes: My Lords, I thank the Minister and the whole Government for having shown steady and firm solidarity with our eurozone partner countries and for their strenuous efforts to solve current financial and economic problems. Does he agree that such a firm stance must be maintained to stop deep market panic despite the monumental shock of the Greek referendum decision?

Lord Sassoon: I am grateful to my noble friend for recognising the constructive role which the UK Government have played in pushing forward the many strands of important discussion in the EU at the moment. I indeed agree that the agreement signed last week has to be delivered by all member states, including Greece. We will be working hard to play our part to that end.

Lord Liddle: Does the Minister agree that, in this very grave moment of crisis for Europe and for Greece, we should be urging the Greeks to recognise that, for all the inevitability of hard and painful times that lie ahead for them, it is the eurozone that is forgiving half their debts, rescuing their banks and providing the financial support to keep their economy afloat? Should the British Government not hold out a hand of friendship to Greece, for whose democracy we have a proud historical record of support, and not indulge in arrogant lecturing by a Government whose economic policies are leading to depression in this country?

Lord Sassoon: My Lords, we hold out a hand of friendship to all our EU partners and to many other countries, but it is for Greece to make its own decisions. I am not going to lecture the Greeks, but it is clear that all parties to the deal last week have to deliver on their commitments.

Lord Higgins: My Lords, is it not high time that the usual channels got together and arranged for a debate in this House on the crisis in the eurozone, since we

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have had no opportunity other than on Statements and Questions to pursue the matter so far? In particular, should we not have some views expressed on the contingency plans which need to be made should a country leave the eurozone?

Lord Sassoon: My Lords, without wishing to encourage a huge rush of additional speakers, we already have a decent number of very interested and expert noble Lords down for a debate on Europe tomorrow. Indeed, this House is taking the matter very seriously.

Lord Reid of Cardowan: My Lords, is it not obvious to all but the most blinkered zealot that, whether the Greeks default or not, in the medium to long term the only prospect of survival for the eurozone-even that is not guaranteed-is with such a centralisation of political and fiscal ancillary powers that we would effectively have created qualitatively two different European structures? Will the Government enlighten us on what contingency planning they are making for the day that will inevitably come when that decision or those decisions have to be made?

Lord Sassoon: My Lords, I do not accept the very simplistic idea that we are headed for a two-speed Europe. There is already a variable geometry in Europe in other areas apart from the euro, such as justice and home affairs, where there are different arrangements for certain member states. The critical lesson out of all this is that the UK must stick to its own fiscal deficit reduction policies because it is those which are giving us the benefit of 10-year interest rates today at 2.2 per cent, whereas countries such as Italy, which had interest rates very similar to ours before the financial crisis, have interest rates not at 2.2 per cent but at 6.2 per cent. So we must stick to keeping our own house in order.

Lord Pearson of Rannoch: My Lords, further to the question put by the Minister's noble friend Lord Higgins, have the Government given any thought to the cost of returning first Greece and in due course the other crippled economies of the eurozone to their national currencies and, if necessary, supporting that transition with some variation of the Marshall plan? Have they thought about that concept, compared with continuing to throw unknown trillions at a project which cannot be saved?

Lord Sassoon: My Lords, the first thing to understand is that the UK is not part of the stability mechanism that the eurozone is putting in place, and we will not contribute to specific bailouts. On the other hand, the eurozone takes about 40 per cent of our exports and it continues to be the principal interest of the UK Government to make sure that the eurozone and the whole of the EU prosper and grow, to the benefit of our own economy.

Lord Grocott: Could the Minister spell out the difference between a variable geometry Europe and a two-speed Europe?

Lord Sassoon: My Lords, I think that I have already done so. The two-speed Europe that people seek to paint is one between the eurozone and the rest, but

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thanks to the work of the Prime Minister at the 23 October Council, the very important principle was accepted that those matters which relate to all EU members and the whole of the EU, such as the single market, will of course continue to be the province of the EU 27. That is the critical acceptance which has been made by the Council and the Commission at the prompting of the Prime Minister.

NHS: Private Healthcare


3.22 pm

Asked By Lord Collins of Highbury

The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): My Lords, the Department of Health does not permit organisations, including general practitioner practices, to use the NHS logo to promote their non-NHS services, including private healthcare services.

Lord Collins of Highbury: I thank the noble Earl for his response, but of course most of us in the Chamber have read in the newspapers recently about the case of a GP practice writing to its patients. I believe that what happened there goes straight to the heart of general practice; that is, the relationship between the doctor and the patient. It is a relationship that I fear the Government show no sign of understanding. Will he give an assurance that the proposed form of commissioning in the health Bill will not result in the nightmare possibility of the doctor changing from the person who decides the best medical treatment for the patient to the person who decides what can be afforded?

Earl Howe: My Lords, I can give that broad assurance, but the noble Lord will know that it is already within the GMC code that doctors have to consider the totality of the resources available to them and take account of the needs of all their patients. With that qualification, of course our reforms are designed to ensure that the highest-quality care is delivered to every patient according to his or her needs.

Lord Walton of Detchant: My Lords, is the noble Earl aware that in the 1980s, when I was president of the General Medical Council, it was unethical for doctors to advertise and those who did could be disciplined? However, I and a number of other members of the council were summoned before the Office of Fair Trading and were accused of restraint of trade. After a lengthy hearing, it was agreed that GPs should be allowed to advertise, but that consultants should not in order to preserve the gatekeeper function of a GP for access to special services. Has the situation changed?

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Earl Howe: My Lords, the issue of advertisements is slightly different from the issue surrounding logos, in particular the NHS logo. What I can tell the noble Lord is that where independent providers have their own logo and wish to use it, they can within the specifications outlined in the NHS guidelines. In cases where organisations are providing both NHS and private services, and those could include a general practitioner, then the information relating to the private services must not carry the NHS brand or logo type, and information relating to the private services must be kept separate from the NHS ones.

Baroness Gardner of Parkes: I have been a national health dentist. Surely the national health logo could be in the premises without necessarily being on the advertisement. It is important that practitioners should be clear on these matters. Patients want to know what services are available, whether they are national health or private and what the choices are, and it would be a deficiency on the part of a national health practitioner not to at least have information available. How can you differentiate so that it is not claimed that the NHS logo has been involved when you are basically a national health practice?

Earl Howe: My Lords, other than for GPs, dentists and pharmacists, where use of the logo is voluntary-although it is very widely used-providers of NHS services are required to display the NHS logo as a sign of their commitment to the NHS patients that they treat. That is fine as far as it goes. However, where private services are also being delivered from the same premises, there are clear rules laid down that the NHS logo must be nowhere near any information about those services and that patients have to be absolutely clear what service they are receiving, whether it is NHS or private.

Lord Harris of Haringey: On the basis of that answer, does the noble Earl accept that it is inappropriate for an NHS general practitioner, during an NHS consultation with a patient, to offer their own private, non-evidence-based services instead of an NHS service -in other words, to offer their own private services in the context of an NHS consultation? I speak from personal experience.

Earl Howe: My Lords, except in limited circumstances, which must be set out in their contract, primary medical service contractors-GPs, in other words-cannot directly or indirectly seek or accept from any of their patients a payment or other remuneration for any treatment. The prohibition not only relates to treatment provided under the primary medical services contract but extends to any treatment that may be provided to the patient.

Baroness Jolly: My Lords, we all agree that the NHS logo must be one of the most trusted brands in the UK. It is currently outside diagnostic and treatment centres which are privately run, so can the noble Earl tell the House whether the Government will issue guidance to any qualified private providers about the use of the logo?

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Earl Howe: The rules as regards any qualified private providers will remain exactly as they are now. There must be absolute clarity as to when services are being provided by the NHS and when they are not.

Baroness Thornton: My Lords, perhaps I may press the Minister, following on from the question of the noble Baroness, Lady Jolly. I looked at the NHS brand guidelines website and it is most specific about the colours, size, margins, borders and even communication principles. It is silent, however, about who cannot use the NHS logo. It has a list of organisations which can use it but is silent about who cannot. Given that we may be heading towards a world with a multiplicity of providers, will the Minister undertake to look at the NHS brand guidelines with a view to making it clear under what circumstances the brand may or may not be used?

Earl Howe: I will, of course, look at that point. However, the NHS logo is considered to be the cornerstone of the NHS brand identity. The letters NHS and the logo type are trademarks managed by the branding team at the Department of Health on behalf of the Secretary of State for Health, who technically holds the trademark. They are extremely well recognised and trusted, and use of them is very carefully controlled indeed.

Baroness Finlay of Llandaff: Are the Government satisfied that the general practitioners in the focus of this Question were not subject to double payment-first, paid under the terms of their GMS contract for general medical services to patients on their list, and, secondly, then receiving private payments for giving the service that had already been paid for under the GMS contract?

Earl Howe: My Lords, I have already indicated that there must be a clear separation between NHS services provided by a general practitioner and its private services-or indeed services for which it is entitled to charge that fall outside its contract. The rule is that patients should be left in no doubt about which service they receive.

Energy: Carbon Capture and Storage


3.30 pm

Asked By Lord Ezra

The Parliamentary Under-Secretary of State, Department of Energy and Climate Change (Lord Marland): My Lords, the prospects for carbon capture and storage in the UK are good. We have six other applicants in the European new entrants' reserve 300 competition. Through FEED, we have developed substantial practical guidance on the delivery of CCS projects. We will launch a streamlined selection process for future CCS projects

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as soon as possible and expand on our plans in the next eight weeks. I can confirm that the £1 billion remains available for this.

Lord Ezra: My Lords, while it is regrettable that the Longannet project has been withdrawn, it is satisfactory to note that these other projects are coming forward and, in particular, that the Government will speed up the selection process. Would the Minister agree that a successful demonstration of carbon capture and storage on a commercial scale could not only reduce carbon emissions but also lead to the creation of many new jobs and substantial overseas earnings?

Lord Marland: My Lords, it is difficult to disagree with any single word that the noble Lord, Lord Ezra, said. He is obviously a leading expert in the field. It is gratifying to hear him make a statement like this and be so supportive of the Government's plans.

Lord Lawson of Blaby: My Lords, is it not clear that the withdrawal of the Longannet proposal demonstrates what most people who have studied this know, that carbon capture and storage is a lovely idea but is both technologically improbable and economically prohibitive? Is it not about time, when there is great financial and public spending stringency, that the Government stopped throwing money at this lost cause?

Lord Marland: My noble friend Lord Lawson makes several good points. The reality is that that is why, having been the negotiating Minister for the project, I decided to call a stop to it. I felt that the financing for this particular project was going off the dial. We have been given an envelope with which to invest, one that is more than generous for the prospect. It is part of the coalition agreement and there is support from all sides of the House that we press on with this groundbreaking technology. Britain is famous for groundbreaking technology and we should-and will-continue to invest in that.

Lord Winston: My Lords, I declare an interest as a member of the Engineering and Physical Sciences Research Council. Does the Minister agree that it is likely that there will be a considerable use of fossil fuels, particularly coal, in many parts of the world and there is clearly a commercial advantage in Britain being first? Would he remind the House how much money we spend on research in this area through the research councils? Does he feel that that is sufficient money in view of the importance of this area?

Lord Marland: I can only talk about what the Government have spent in FEED, which is their investigative, exploratory work on this. To date, we have spent more than £60 million-quite a significant figure. As I said earlier, we have committed £1 billion to the project. We will learn even more as we go into the next project and I hope that we will be successful.

Lord Teverson: My Lords, I very much welcome the renewed commitment of the Government and my noble friend to carbon capture and storage in future.

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Will the Government look at fossil fuels other than coal? How do they see co-operation with other nations, for instance China, in developing this technology to our mutual benefit?

Lord Marland: I am grateful to the noble Lord, Lord Teverson, for his very good points. The reality is that if we all had our time again we would start on gas, which is going to be fundamental to the future of our energy supply. I am at one with the noble Lord, Lord Lawson, on this, for a change. I very much hope that in the next competition we will have a lot of applicants for a gas project and that we can become world leaders in its carbon capture and storage.

Lord Broers: My Lords, does the Minister agree with me that of course all these low-carbon energy approaches are risky and expensive? This is further evidence that for CCS this is particularly the case. We have had our two large projects stopped; it could be incredibly expensive and feasibility is far from demonstrated. Does not that teach us that we had better get on with nuclear power in a more aggressive way and expand our nuclear capability?

Lord Marland: I am delighted to say that on 31 October EDF put its 30,000-page document in for planning for the first new nuclear power station to be launched for 27 years. I can only totally agree with the noble Lord.

Baroness Worthington: My Lords, I am very grateful for the Minister's comments about gas. It is certainly true that if we could be back in time we should have had a much broader approach to the competition. How does the Minister intend to communicate to the Treasury the lessons learnt from this negotiation? This is an important technology and cannot be done on the cheap. We must provide sufficient funds to get this technology out and proven, so that we can become a world leader in it.

Lord Marland: I am very grateful for the support of the noble Baroness, Lady Worthington. I can confirm that the Treasury has agreed to £1 billion of support for this, in addition, one hopes, to European money for which we are applying. In my own view, that is a very significant figure in these current times to support this project.

Baroness Smith of Basildon: My Lords, the Minister indicated in his Answer that European funding may be available for CCS. Given the collapse of Longannet, will the UK still be able to meet the timescale for that funding, and can that funding be used for capital support for carbon capture and storage projects in this country?

Lord Marland: I can confirm to the noble Baroness that that is the case. I would not say that Longannet has collapsed; we have merely said that we are not going to proceed with it. But I can confirm that that is the case.

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Health and Social Care Bill


3.37 pm

Lord Kennedy of Southwark: My Lords, I beg leave to present a petition from Lewisham SOS NHS.

The petition prays that the House will recognise the clear present and future danger of the Health and Social Care Bill 2011 to the health and well-being of people and that the Bill be withdrawn from further consideration forthwith.

Petition presented.

Procedure of the House Committee

Membership Motion

3.37 pm

Moved By The Chairman of Committees

Motion agreed.

Rehabilitation of Offenders (Amendment) Bill [HL]

Bill Main Page


3.38 pm

Report received.

Health and Social Care Bill

Main Bill page

Committee (2nd Day)

3.38 pm

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

Debate on Amendment 3 resumed.

The Lord Speaker (Baroness D'Souza): My Lords, I would like to remind the Committee that if either Amendment 3 or Amendment 4 is agreed to, I cannot call Amendment 5 by reason of pre-emption. I call the noble Baroness, Lady Williams of Crosby.

Baroness Williams of Crosby: I apologise for the slight delay in rising to my feet-my understanding was that the Minister was proposing to start the debate by making a statement. I apologise for delaying the House. Let me say right away that I do not resile in any way from the amendment which the noble Baronesses, Lady Jay and Lady Thornton, the noble Lord, Lord Patel, and I have put down. We believe that it is important to have an absolutely solid basis by which the whole of the House and the public can understand exactly the accountabilities and responsibilities of the Secretary of State. It is therefore of great importance

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that this House, in this crucial Committee sitting, is able to reach a clear understanding of what those responsibilities and accountabilities are.

I very much hope that that will be possible as there are still legal questions about the particular meaning of both the amendment put forward by the noble and learned Lord, Lord Mackay of Clashfern, and the amendment put forward in the names of the noble Baroness, Lady Jay, myself and others. There are still difficulties and differences of opinion between legal voices about exactly what the forethought of those amendments is and just how clearly they lay out the responsibilities and accountability of the Secretary of State. Some Members of this House will recognise that one difficulty is that the Secretary of State is extremely anxious to avoid any further micromanagement of the health services because he believes that it would reduce professional discretion. I think that many of us sympathise with that argument.

The difficulty is that many of us also believe that the Secretary of State should have clear accountability for the very large sums involved in financing the NHS at present. We also have regard to the fact that there are certain crucial responsibilities revolving around things such as national emergencies for which we believe the public would expect the Secretary of State to be the person responsible. So on constitutional grounds, and on grounds of financial accountability and clear responsibility in certain areas of national concern, we are anxious to see that the Secretary of State retains those responsibilities. However, the possibility of drafting legislation which comprises both the issue of having no micromanagement and the issue of the crucial ultimate responsibilities of the Secretary of State has proved somewhat elusive. In that situation, I hope very much that the Government will consider pressing ahead with trying to draft acceptable legislation for Report stage, when I hope there can be broad agreement about what the responsibilities are. I cannot answer for my noble friend the Minister, of course, but I hope that he will give consideration to that request.

Perhaps I may quickly add three other considerations. The first, which I have mentioned already, is the area of legal ambiguity. I think that all Members of this House will have heard clashes of opinion about the precise meaning of the amendment before us. I regret that, and I hope the legal profession will forgive me for saying that when there is more than one lawyer in a room there is very often more than one opinion. That is exactly the situation in which we find ourselves. Secondly, many of us feel-I would certainly speak for myself and my party, and this point was raised by the noble Baroness, Lady Jay-that it is absolutely critical to look at Clauses 4 and 10 together with Clause 1, rather than trying to take them separately. They are intimately interrelated. Many of us recognise that to make a change in Clause 1 without taking on board the implications of Clauses 4 and 10 would leave us in a world of deep twilight uncertainty.

The third issue is perhaps a bigger one; perhaps it constitutes a vision that I profoundly hold. I think we all recognise that the NHS is deeply cherished in this country. It is something to which people cling, as they find themselves facing financial hardship, as one of

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the few certainties and areas of trust that they can rely on. However, we also know without any doubt of the essential need for change in the NHS-my noble friend the Minister and others have made this absolutely clear-if we are to be able to finance an aging population, and not least, although we often neglect this, the very welcome survival of far more people with chronic sicknesses than used to be the case even 20 years ago, all of which lays heavy responsibilities on the health service. Because of that, I for one feel strongly that the greatest prize that this House could give to the future of health services in this country would be to reach a broad political consensus on the issue, so that the NHS and other health services, as they go forward, find that they are based on a solid rock of acceptance and consensus that will carry us through many of the ups and downs that we are bound to face in the next few years.

3.45 pm

Therefore, I ask the Minister of State whether he will consider asking those of us who have put down amendments-I am one of them-to withdraw them in light of the need for further discussion. That would allow us to bring forward, I hope, a very broadly agreed proposal at Report stage in this House, when we have also considered the issues around the autonomy clause.

Finally, I add one more thing, for which I hope I will be forgiven. I know that those who have been in the House for a long time are fully aware of this, but it may be helpful for those relatively new Peers who are not fully aware of it. If an issue is brought up in Committee and then voted on and voted down, it cannot come back again on Report or at any other stage of the proceedings on the Bill. That would be disastrous. It would mean that if any vote were carried, we could not then go back to trying to get broader and stronger agreement on Report. It would simply mean that the whole issue disappeared. This is far too important an issue to be allowed to disappear. Therefore, I plead with those who I fully understand passionately support my amendment or that of the noble and learned Lord, Lord Mackay of Clashfern, to allow their passions to be put to one side, temporarily at least, while we contemplate the absolute necessity of debating this more fully, trying to draw a consensus from it and accepting that we can go back to these matters on Report, when a vote would be appropriate, right and timely.

Lord Mackay of Clashfern: My Lords, in response to the obvious concern over the Secretary of State's responsibilities, as narrated in the Bill, I attempted to find, from a completely impartial point of view, a solution that would commend itself to everyone. In due course, I came up with an amendment, which your Lordships have seen. My first action was to send a copy of it to the noble Lord, Lord Owen, and others, including the noble Baroness, Lady Thornton. I hope that demonstrated that there was nothing partisan or anything of that sort about it. In trying to put the amendment together, I looked very closely at what the Constitution Committee had said. I think the

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noble Baroness, Lady Jay, and I demonstrated last time that we had considered these matters in some detail.

I also considered all that had been said about concerns on this matter in the Second Reading speeches, of which there were quite a few. I have endeavoured to meet these concerns in the amendment. As I say, I hoped that the House would find it acceptable but a number of questions have been raised and, as the noble Baroness said, lawyers are apt to disagree on these matters. On the other hand, lawyers are usually reasonably able to reach agreement when they set their minds to it. Therefore, I have no intention of moving my amendment today so there can be no question of its acceptance or otherwise today. An amendment to it has been proposed by my noble friend Lord Greaves. He told me that his idea was to find out what the meaning of "ultimate" was. Maybe I should briefly deal with that now. "Ultimare" is the Latin verb from which it comes, which means to come to the end-not always a comfortable position. The definition in the Oxford English Dictionary is:

"Lying beyond all others; forming the final aim or object".

That is the sort of idea that I had-that it is the final responsibility of the Secretary of State; in other words, in ordinary language, "The buck stops here". That was my object in using that phraseology.

During my researches in the Oxford English Dictionary I noticed that Dr Johnson said in 1758 that to be idle is the ultimate purpose of the busy. As I say, I have no intention of moving my amendment today. I hope that we can reach agreement on this matter in informal discussions outside the Chamber. A large number of important practical issues remain to be considered in subsequent Committee days. This sort of question, which is primarily rather theoretical but very important from the point of view of people's attitude to the National Health Service, should be determined. However, it would be more conveniently determined in discussions between ourselves outside the Chamber. Certainly, I would be willing to participate in those discussions if the amendments before us today are not proceeded with.

The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): My Lords, before we move further forward with our debate, I hope that noble Lords will find it helpful if I make a very brief intervention. I am aware that a number of noble Lords wish to speak and I have no wish to prevent that. The Committee must, of course, proceed as it sees fit. However, I felt it might be useful to those intending to speak if I indicated now rather than later what the Government's preferred course is in relation to this group of amendments. Some noble Lords will be aware that the Government regard the amendment tabled in the name of my noble and learned friend Lord Mackay and the noble Lord, Lord Kakkar, as having particular merit in the context of this debate. Notwithstanding that, and having spoken to a number of noble Lords during the past few days, including my noble and learned friend, it is my view that the best course for this Committee would be for none of the amendments in this group to be moved today, and instead for us to use the time between now and Report

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to reflect further on these matters in a spirit of co-operation. I shall, of course, say more when I wind up the debate but it may assist the Committee to know that that is the position that I shall be taking.

Baroness Thornton: In the spirit of co-operation across the House it might be useful if I outline the position of these Benches, too. During the past few days I have said to anybody who would listen to me that this is the position in which I thought we probably ought to end up. Those who have been sitting with me on the Long Table can bear testament to that. The reason I added my name to the amendment of the noble Baroness, Lady Williams, is because I feel strongly that that is the right way forward. I am very pleased to hear that the noble Baroness has not resiled from her position on that. I have talked to several lawyers and consider that the amendment in the name of the noble and learned Lord, Lord Mackay, may address political issues but does not fully address the legal issues concerning the responsibility of the Secretary of State.

I have what I can assure noble Lords is a sparkling 10-minute speech, but I do not intend to make it now. However, I may save it for a later occasion. I think this is a good solution if other noble Lords agree with it. I look for an assurance from the Minister about how the discussions on this matter should proceed. We have a record on this Bill of cross-House discussions involving all the people with an interest and expertise in matters relating to it. In that spirit, I wish these amendments to be withdrawn so that not only our lawyers but our medical experts, and, indeed, the Constitution Committee, can be persuaded to have another go at this issue. Towards Christmas we may find a solution that suits us all. If not, I may instead have to make my 12-minute sparkling speech on Report. I hope that the House will feel that this is a good way forward.

Lord Laming: My Lords, it is clear that around the whole House it is felt that the constitutional position of the Secretary of State is of immense importance. The House must give careful thought to that issue in order that we get it right, because the National Health Service is important to every citizen, as we heard earlier during our consideration of a Question. What the health service stands for, how it carries out its responsibilities and where responsibility and accountability rests are of great importance.

The House is indebted to all those Members who have put their names to the amendments. They are thoughtful amendments that represent the best interests and work of this House. It is a great credit to those who have put their names to the amendments that they are happy to consider withdrawing them today, because it is important that the House should not take precipitous action, that we accept the thoughtful response from the Minister and that we give plenty of time and opportunity to try to resolve this. There is actually a shared commitment around the House, and I therefore have every confidence that the House will reach agreement. I very much hope that noble Lords who have tabled these amendments will accept this opportunity to meet with the noble Earl and resolve this matter before the next stage of the Bill.

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Baroness Jolly: My Lords, I am hugely grateful for the position where we now find ourselves. I am in total agreement with the previous speakers that we need to move this issue on, take back Clauses 1 and 4, use the same sort of language, and bring the matter back on Report. I should like to put on record how I am totally in awe of the work of my noble friend Lady Williams in this regard. We have also been hugely helped by the clear thinking of the noble Lord, Lord Marks of Henley-on-Thames.

While I am thanking people, I should also like to say how much I welcomed the approach of the noble and learned Lord, Lord Mackay of Clashfern. We should recognise the amount of work he put into his amendment. It was useful to take a fresh approach to what was becoming a thorny problem and bring to the House new language to look at, because, for reasons that we have already rehearsed, we were not too happy with the proposals. One of the matters that I should like the Minister to take back with him-here I borrow some language from the noble Lord, Lord Hennessy, which I think he used at Second Reading-is consideration of whether we can maintain the DNA of the Bill when producing the new work that will come before us on Report.

From these Benches, I repeat that we need a reworked clause with completely unambiguous language that will reflect the duties of the Secretary of State for the 21st century and the new NHS that we are trying to forge.

Baroness Andrews: My Lords, I think I can add the support of these Benches to the extraordinary way in which this matter has been resolved. It is a great tribute to my noble friend Lady Thornton, who has led so many of the debates across this House, during which many aspirations have been drawn out, problems identified and voices collected. The Minister responded clearly to what the noble Baroness, Lady Williams, expressed so well: the peculiar trust and confidence that is held in the National Health Service in this country and how careful we must be in our processes to honour that expectation and trust, so that clarity on the legal responsibilities and the future of the NHS is absolutely secure.

Lord Mawhinney: My Lords, I would not presume to speak for my noble colleagues on these Benches, but it seems to me right that someone who would be openly classified as a supporter of this Government should rise to say thank you to my noble friend for his statement, which finds support not only on the Benches opposite or on the Lib Dem Benches but, I presume, on these Benches also. I say that as someone who has actively taken part in the proceedings thus far.

My personal view is that this House owes a debt to the Minister. I would guess that it was not necessarily the case that all of his colleagues immediately jumped to the same conclusion as him, but he jumped to it having listened to the debate last week. We should express our appreciation not only for the fact that he jumped to that conclusion but for the tone that he has set in delivering it. If that tone prevails during the rest of Committee we will all be the better for it and, much

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more importantly, the country and the National Health Service will be the better for it.

I have one substantive comment to make to my noble friend. None of us will want to question in any way the professional expertise of the legal profession. I am sure that it is to the benefit of the House that legal minds apply themselves to trying to find a way forward that would be broadly acceptable. I say gently to my noble friend that this is also about medicine and the delivery of medical care and, if he would permit me to use a not very fashionable word, it must also be seen in a political context. Those are aspects of the deliberations which I hope that he will bear in mind, and not simply adhere to the consensus legal opinion, no matter how good or persuasive it may be, before that is tested in both the medical and the political world.

Baroness Jay of Paddington: My Lords, as one who has been involved peripherally in the discussions over the past few days with the Minister, I follow the noble Lord, Lord Mawhinney, in paying tribute to the Minister for his great patience and courtesy in the number of times and the way in which he has sought to talk to everyone involved in this.

Further to the question of my noble friend Lady Thornton and the noble Baroness, Lady Williams, in exactly what form would the Minister see further discussions taking place? Several Members of the House have referred to the possibility of the Constitution Committee-which, as the House knows, I have the privilege of chairing-taking this up again. There have already been informal discussions in private sessions of the committee about ways in which we might take this forward. It would be helpful if we could have some indication of how the Minister sees that happening and how it may develop. I very much take on board the points made all around the House about the way in which the Bill as a whole, not simply this clause, has been discussed and how helpful that has been.

Baroness Tonge: My Lords, I am sorry to create just a small ripple in the sea of calm and tranquillity that represents this Chamber this afternoon, but I follow on from what the noble Baroness just said and ask: is there no procedure that we could adopt which would bring the decision of the House on this matter of the duty of the Secretary of State to provide health services back before Report? Report will not be for two months, perhaps, by which time we will have been discussing all the other issues in the health service in a sort of vacuum. How can we discuss all the things that we want a health service to do if we do not know whether the Secretary of State is going to have a duty to provide them? It seems rather odd that we are putting the cart before the horse, or whatever the correct analogy is. This is an important matter. I feel very strongly that we should know as soon as possible whether the Secretary of State will have a duty to provide health services in this country. If we do not have that reassurance, we will have not a National Health Service but a national health shambles.

Lord Newton of Braintree: My Lords, I say gently to the noble Baroness that I had understood that the whole purpose of the proposal made this afternoon by

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the noble Baroness, Lady Williams, was to give us a chance to look at all the practical issues in the Bill before returning to this umbrella of principles. I can see that one could argue it either way. I have no more right to speak on behalf of my Benches than my noble friend but I share his views entirely and, indeed, I expressed them last week. What is being proposed must be the right way to proceed. It has consensus support around the Committee and I think that we should get on with it and let the Minister explain how he will conduct the discussions. Let us just leave it there.

Lord Warner: My Lords, perhaps I may intervene briefly not in any way to damage this positive outbreak of peace but to make a practical suggestion. Much of the Constitution Committee's report turned on the judgment of the noble and learned Lord, Lord Woolf, in the Coughlan case.

Baroness Jay of Paddington: My Lords, I must intervene on that point. That is only the secondary point of the report.

Lord Warner: Perhaps I may be allowed to deal with it, whether it is the first or secondary point-I do not have the report with me. The point that I wish to make is that we have the noble and learned Lord available to us in this House. If we are to have some arrangement to consider how we go forward on this, I think that it would be sensible to discuss the matter with him because he has sat on cases where the role of the Secretary of State has been a key factor in the courts.

Lord Greaves: My Lords, I discovered at the end of last week that it is possible to table an amendment as part of a group if the debate on that group has been adjourned and the first item in the group has not been put to the House. I did not know that that was possible until I asked. We can all do something new every day in your Lordships' House. Therefore, I put forward a small amendment to question the use of the word "ultimate" in relation to the Secretary of State's powers. My noble and learned friend Lord Mackay very kindly responded to that before I had a chance to speak to it.

I picked up this issue following comments made last week by the noble Lord, Lord Harris of Haringey, concerning "ultimate". I went home, looked at dictionaries and did my own research, as did my noble and learned friend. I looked in the most recent and biggest dictionary that I could find, which was the Shorter Oxford English Dictionary. I also looked online, as one does nowadays, and spent a happy time looking at what online dictionaries say. If I can gently tease the noble Baroness, Lady Thornton, it is a much better exercise than looking at Twitter, if I may say so.

Noble Lords: Oh!

Lord Greaves: My Lords, I am not going to reveal all my researches and enlighten the Committee on the meaning of "ultimate", except to say-

Baroness Thornton: Perhaps I may say to the noble Lord that I very happily follow him.

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Lord Greaves: If the noble Baroness wishes, I shall put lots of information about the word "ultimate" on the Labour Lords' Twitter account. It might enlighten people more than some of the stuff that has appeared. I say all that gently and in a teasing way. I am now quite convinced that there are difficulties with this word and I merely promise the Committee that, if it reappears on Report, I shall be probing it again.

I thought that my noble friend Lady Williams of Crosby made a wonderful speech this afternoon. If we can get this right, it will do two things. First, it takes out the really difficult sting of part of this Bill. There are other issues in the Bill-I understand that, and we will debate them-but this particular issue threatened to wreck the Committee stage by setting it off on an entirely wrong note. If we can get this right it will help us in the next 12 sittings to have a proper Committee stage and not just political arguments.

The second point is that the wording, which was in the amendment tabled by my noble friend Lady Williams, from the present legislation has lasted for well over half a century-more than 60 years in fact. If it needs updating-50 or 60 years after the health service was founded-we need to find wording that will last another half a century as the basis for a publicly funded, publicly provided, available-to-everybody health service.

Lord Marks of Henley-on-Thames: These amendments have presented your Lordships' House with a very difficult task. I join others in paying tribute to my noble friend the Minister, my noble and learned friend Lord Mackay, and to the noble Baronesses, Lady Thornton, Lady Williams and Lady Jay, for the wisdom they have shown in proposing to withdraw their amendments today.

I shall take just a moment or two of your Lordships' time, if I may, to say why I think these amendments present the Committee with such a difficult task. The point was made by the noble Baroness, Lady Jay, in her speech last week. The central feature of this part of the Bill is to transfer, by Clause 10, the duty under Section 3 of the 2006 Act to provide the specific services carried out by the NHS from the Secretary of State to the commissioning groups. The challenge that we now have to meet is to achieve a balance between ensuring a decentralised structure and retaining a truly National Health Service for which the Secretary of State has ultimate responsibility. Given that transfer of provision, what the Secretary of State has to do-and all he can do-is to exercise his functions specifically accorded to him by the Bill. He has to exercise them in such a way to ensure that services are provided, however Clause 1(2) is ultimately worded, and to fulfil his duty under Clause 1 to promote a comprehensive service. That is why the crucial task of this Committee is to look at those functions and ensure that his functions and powers are up to the task and meet that balance.

A further point that I see as being of considerable importance is the proposed duties to provide autonomy by the Secretary of State under Clause 4 and on the board under the new Section 13F introduced by Clause 20. The problem is that the autonomy provisions in the Bill threaten to undermine the Secretary of State's primary duty to secure the provision of services. We have to deal with what is at best tension and at worst

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inherent conflict between the Secretary of State's overall responsibility, however expressed, and the duties to promote autonomy. That conflict must be expressed when we come to it, whatever we do about Clause 1(2).

I have some confidence that your Lordships' House and the department will be able to achieve consensus and I remind your Lordships that not only have we heard from Labour, Liberal Democrat and Cross-Bench Peers in favour of amending the Bill as presently drafted, we have also heard from my noble and learned friend Lord Mackay and from the noble Lords, Lord Newton and Lord Mawhinney, both former health Ministers, who yield to no one in their commitment to and understanding of the NHS. There remains much to be done but I suggest that there is reason for optimism that we might achieve a resolution of all these issues that is effective in helping to secure the future of the health service.

4.15 pm

The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): My Lords, this has been an excellent debate. It has proved one thing in my mind: an issue of this importance for the Bill-the overarching duty of the Secretary of State for the NHS-has benefited enormously from having a Committee of the Whole House to consider it. Without unnecessarily detaining the Committee, I hope it will be helpful if I say something on the record about each amendment.

I begin with Amendment 3, tabled by my noble friend Lady Williams, the noble Lord, Lord Patel, and the noble Baroness, Lady Thornton, and Amendment 5, tabled by the noble Baroness, Lady Thornton, and the noble Lord, Lord Hunt. Both amendments would have the effect of restoring the Secretary of State's current duty to provide services in Section 1 of the National Health Service Act. There has been extensive discussion of this both today and at Second Reading, so I shall not recap all the arguments. The core argument is that the duty to provide no longer reflects the practical reality of how NHS services are delivered or our proposals for the Secretary of State's functions in the new system.

Before I explain further, I should make clear that we are now discussing the Secretary of State's relationship with NHS services rather than his duties in relation to public health, where his direct responsibilities for provision remain firmly in place. In that context, I refer noble Lords to Clause 8 of the Bill. While I understand that many people are attached to wording that dates back to the founding Act of 1946, it is now more than 20 years since the Secretary of State had any direct responsibility for the provision of services. Only a tiny minority of NHS services-those still provided by PCTs -are carried out under the Secretary of State's delegated function of providing services. In future, all NHS services will be provided by NHS trusts or foundation trusts, both of which have their own self-standing powers to provide services and do not rely on the Secretary of State's duty to provide under Section 1(2), or by independent providers. The Secretary of State will have no powers to provide NHS services. That is the reality.

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I am grateful to the noble Lord, Lord Warner, and to my noble friends Lord Newton and Lady Cumberlege for their persuasive arguments articulating the need to reflect this reality in legislation. As my noble and learned friend Lord Mackay helpfully explained, the Secretary of State has never had an unqualified duty to provide services; he has had a duty to provide or secure the provision of services. In recent years he has relied on the latter part of that duty to fulfil his functions, while the former part has ceased to have any practical relevance. I hope that that answers the question posed by the noble Baroness, Lady Jay.

There is another reason why it would be wrong to reinstate the duty on the Secretary of State to provide. Under the legal framework of the Bill, the Secretary of State no longer possesses powers to direct others to provide services. Therefore, unless we were to re-impose a system of regulations or directions by which the Secretary of State could delegate his duty to provide and control its exercise, which would risk replicating the micromanagement of the status quo, it is hard to see how this legal obligation to provide services could be fulfilled. For obvious reasons, it would be undesirable to create a situation in which the Secretary of State provided services himself. Also, in practice he would lack the capacity to do so, for example in terms of staff and facilities.

Instead, the duty we propose in the Bill is a more accurate reflection of what Ministers do. In line with policy that has evolved over two decades, the Secretary of State will not provide services or directly manage providers; nor will he have the powers to do these things. Instead, providers will be regulated independently. Rather than intervening in day-to-day decisions by local providers, the Secretary of State will have powers to hold to account the regulators, Monitor and CQC, for the way that they are performing their functions, and powers to hold the NHS Commissioning Board to account for the way that services are commissioned. In other words, the Secretary of State-

Baroness Scotland of Asthal: My Lords, I hesitate to intervene on the noble Earl, who knows I hold him in the highest possible esteem, but I think he is now treading on some contentious legal issues. Bearing in mind the wonderful consensus that we have now reached, I would just ask him to consider whether, at this stage, some of those issues are really helpful because the noble Earl will know that the Secretary of State does, by his servants, agents or otherwise, provide services and, indeed, there have been times when there has been a pandemic when the Secretary of State has had to make such provision. These are contentious issues which I am sure could intrigue us for many hours, but since we have happily come to the conclusion that we have had a surfeit of such happiness and wish to go forward, I gently say to the noble Earl that this might be a moment when we could swiftly do that.

Lord Lester of Herne Hill: My Lords, I would not have intervened otherwise, but I respectfully disagree with what the noble and learned Baroness, Lady Scotland, has just said. I am finding it very helpful to listen carefully for this reason: it seems to me that the Secretary of State must have a duty to secure the provision,

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as has been said by the Minister, for the purposes of giving effect to our international treaties, including those on human rights. Therefore, what he is saying at the moment is very important to me in trying to see how one can get wording that will include that as well.

Earl Howe: I am grateful to my noble friend. I apologise to the Committee. I had thought that it would be helpful if I commented on each amendment for the sake of the record so that, going forward, the Government's view of each amendment would be clear.

Baroness Thornton: The reason I did not make my 12-minute speech was that we are now going to go into a period of consideration. I respectfully say to the Minister that we could start the whole debate all over again if he continues telling us what the Government do or do not believe on this because that is presupposing, and possibly pre-empting, the discussions that we are about to have. The noble Lord may find it useful, but we have had a lot of this discussion. We have now, I thought, agreed to move into discussions outside the Chamber.

Earl Howe: I shall, of course, be guided by the Committee. If it is the wish of the Committee that I do not explain the Government's view, then I will not do so. With apologies to those noble Lords whose questions I am not going to answer now-

Lord Harris of Haringey: I appreciate that the noble Earl is moving to a position of not addressing those questions, but it is important that he tells the Committee whether the Government have a fixed mind on these matters or whether they are going to approach with an open mind the discussions that we, in an outbreak of consensus, have agreed should happen and try to build on that consensus. If the views are closed, it raises some very difficult issues for the Committee.

Earl Howe: No, my Lords, there are no closed views. That is the reason why I suggested earlier that it was time to reflect and engage in discussions in the spirit of co-operation. I would not have said that if I had had a closed mind to them. There would not have been any point in the discussions. I simply wished to do noble Lords the courtesy of answering their questions and addressing the points that they had made. If noble Lords would rather that I did not do that, then we can make life easier for ourselves. I will certainly write to noble Lords if they would like to inform me afterwards that they wish to receive a letter. If they do not, I will not write. It is entirely up to them. I do not wish to make work for myself unnecessarily.

I have said that I believe the balance of advantage for this Committee lies in our agreeing collectively not to amend the Bill at this stage and I am pleased that there seems to be consensus around that view. I believe instead that it would be profitable for me to engage with noble Lords in all parts of the House, both personally and with the help of my officials, between now and Report to try to reach consensus on these important matters. I would just say to my noble friend Lord Marks that that includes the issues that he has helpfully raised this afternoon. I believe that he is right

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to associate Clause 4 in particular with the matters that we have been considering. Those discussions can be carried out in an informal way with interested Peers or in individual meetings in the House or my department. There is a place for either type of discussion. My concern is only that it is an inclusive process involving Peers from all sides of the House, and that will include listening to the views of the Constitution Committee should it choose to continue its valuable role.

With that, I hope that no noble Lord will feel cheated by the brevity of my contribution and I shall sit down.

Baroness Williams of Crosby: I am happy to withdraw my amendment given the statement made by the Minister. I also join the many people in this House who have said how much we appreciate his almost unending patience with us and his willingness to listen and engage in extremely informed and very intelligent debate. It gives me pleasure on this occasion to withdraw the amendment.

Amendment 3 withdrawn.

Amendments 4 moved.

Amendments 4A (to Amendment 4) not moved.

Amendments 5 and 6 moved.

Amendment 7

Moved by Lord Beecham

7: Clause 1, page 2, line 7, at end insert-

"( ) For the purposes of this Act "the health service in England" is defined as those services provided under section 3 of this Act."

Lord Beecham: My Lords, I rise to move this amendment in my name and those of my noble friends Lady Thornton and Lord Hunt of Kings Heath. As we make steady progress through this Bill, your Lordships will encounter many amendments more elegantly drafted than this one, I have to admit. Given the evident affection in which lawyers are held in your Lordships' House, I trust that this member of the junior branch of the profession will be forgiven for the drafting of this amendment, especially as I was not responsible for it-

Baroness Thornton: You are.

Lord Beecham: But I did subscribe to it. There is a sort of collective responsibility on these Benches, too.

This is a probing amendment-it could hardly be anything else in the circumstances-that tries to deal with what actually constitutes the health service. Of course, this phrase runs through the Bill but there is not within the Bill a definition of what constitutes the health service, let alone "a comprehensive health service"-the words used in Clause 1, which we will be returning to on Report. The amendment seeks to add to Clause 1(3) and the intention is to reflect Section 3 of the 2006 Health Act, which laid out clearly, to a reasonable extent at any rate, the scope of the Secretary of State's duties. The Secretary of State was obliged to,

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broadly six categories of service, amplified in Schedule 1 to the Act by more detailed requirements around medical inspection for pupils at schools and issues of that kind.

It clearly is impossible to lay down in legislation everything that might be brought within the purview of the Secretary of State or indeed any other body for the purposes of defining precisely what a national health service should be and what would constitute a comprehensive health service. Clause 10 in any event transfers some of those responsibilities to commissioning groups, as the noble Lord, Lord Marks, has pointed out, but it is not entirely clear from the clause, to put it mildly, what functions will be included in their responsibilities.

4.30 pm

The implicit suggestion in the amendment is therefore that at some point it would be helpful to have in the Bill not an exhaustive list, because that would be impossible, given the changes in medical needs and indeed in medical treatments, but an indication of which areas of responsibility for health should be prescribed as areas in which decisions must be made and policies and services delivered by whomever the Bill ultimately vests those responsibilities.

The need for that, subject of course to the further discussions and debates that will ensue upon the Bill, is enhanced by the possibility-I put it no higher than that-that at the end of the day we might have not so much a single national health service but a series of services that are connected, if you will, and for which ultimately there will be responsibility at some level as yet to be determined, rather than a simple broad national agenda.

In any event, it would clearly be wrong to make a provision that would restrict the service to any particular list of functions laid down at this time. It would need to be possible to extend that list to meet changes in circumstance, and that would clearly be a necessary condition of any move to create a more visible account of what the service should be about. We on this side of your Lordships' House are certainly looking to see the National Health Service as a comprehensive national service that is comprehensive in the sense of being accessible to all citizens but not necessarily providing every conceivable medical treatment for every conceivable medical condition.

Lord Newton of Braintree: Will the noble Lord explain what he actually wants, because I am now thoroughly confused? First, he seeks the reincarnation of a section of the 2006 Act, which, if I remember rightly, was a consolidation Act-in other words, merely a record of what had already happened in history. He then goes on to say that he does not want to ossify-although he did not use that word-the service; he wants flexibility but accepts that it is not possible at any one time to define everything that the service provides. I simply do not know what he is saying.

Lord Beecham: My Lords, I am saying that the Bill should lay down at this stage a range of services that will be part of a national health service but that that

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should not be limited by reference to a particular moment. There will have to be flexibility, but the Bill should clearly indicate, as the 2006 Act did, areas that, taken together, constitute a national health service. It is a simple enough proposition. The content would have to be debated as we go forward, but this is a probing amendment that is designed to ventilate the issue in the hope that some consideration might be given in the course of proceedings on the Bill to the changes that are required.

Ultimately, some decisions will have to be taken about what services are to be provided, not least about the services in Clause 1(3) that must be provided free of charge. People are entitled to know what services they will get free of charge at any given time. As I have said, at some point these matters should be elaborated. There is also an issue about how public health services are to be regarded in the light of the Bill's current proposals; for example, in relation to the role of Monitor, competition issues and the like.

Amendment 7 seeks to establish a method of taking this discussion forward so that all of us may be clearer about what we are entitled to expect of a National Health Service and, for the purposes particularly of new Section 1(3) of the National Health Service Act 2006, what services would be provided free of charge. I hope that we can look at that matter and perhaps return to it on Report. In that light, I beg to move.

The Earl of Listowel: I thank the noble Lord, Lord Beecham, for moving this amendment and for giving us an opportunity to discuss a definition of the services of the National Health Service. Perhaps the Committee will forgive me if I make now the arguments that I had hoped to make in the later debate on mental and physical health in the health service, for which I am unable to be present. Those arguments are also pertinent to this amendment.

I seek reassurance from the Minister that the new arrangements for the health service will have a specific duty to focus on support of the relationship between the parent and the child, or whoever is acting in loco parentis for that parent, particularly during the early years and in adolescence. Professionals say that adult mental health hinges on the relationships between the primary carers and the child in early life and in adolescence.

The Government's White Paper highlighted that mental health is important to public health. It follows that in the future we have to be even more careful to ensure, without being overly intrusive, that the relationships between parents and children in the earliest years and in adolescence are as supportive as possible. The health service should have an important role in that. For instance, there is tremendous pressure to generate more early years nursery places. In a recession, we want parents to work and to help build capacity. Nurseries need to be cheap, yet we know that high-quality early years intervention is crucial to better outcomes for children. We also know that the people who work in those settings are often underpaid and not properly supported, and that there can be a high turnover of staff. In driving people, for understandable reasons, to use nursery provision more, there is a danger that the relationship between the parent and the child could be undermined.

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The evidence indicates that high-quality early years education produces better outcomes in school for children. Professor Jay Belsky at the University of London investigated this issue. Exposure to poor-quality early years education and nursery care over a number of years can have serious, although small, deleterious effects. But if a lot of children go through these experiences, the overall impact can be significant. It is very hard to measure-this is probably why it does not get prioritised enough-what difference it makes if there is not sufficient support for relationships between parents and children in the earliest years and in adolescence. It is easy to measure cognitive performance in schools, whereas the relationship between parent and child in the earliest years and adolescence is hard to measure. However, qualitatively I am very clear, after consulting with colleagues in the mental health profession, that it is hugely important to get that support right.

I know that the Department of Health works closely with early years services to try to offer such support, but there are still shortcomings. For instance, there is not sufficient support in adult mental health services for adults as parents in children's centres, and more work could be done. An old chestnut is that, if a parent is presenting with mental health issues, thought is not always given to the fact that the parent has children who will have needs. If a parent is mentally ill, what are the mental health needs of the children? Again, if a child presents with mental health problems, a proper assessment needs to be made to look at whether perhaps the best input is to support the parents. That may help the child to get better.

Noble Lords will be pleased to know that I will not say much more. A few years ago I remember working with a young man who was just coming out of adolescence. His father was an alcoholic and he had experienced domestic violence in his home. I was seeing him and working with him once a week for six months. The issues he had were that he was experiencing growing paranoia, he was fearful and distrustful of the staff, he was mercurial and unpredictable in his behaviours and he had a difficult relationship with women. If there had been better support for that family, perhaps the nascent problems we saw at the time could have been nipped in the bud and he would not have had those difficulties.

I am sorry if I am not explaining myself sufficiently clearly, but I would be grateful if the Minister could reassure the Committee that in any of the new arrangements there will be a particular focus on getting in early to support families, both parents and those acting in the role of parents, in their relationships with their children to make sure that those relationships are strong. Children will then have a good basis from which to grow and enter adulthood. I hope that that will be a priority in the new arrangements.

Earl Howe: My Lords, Amendment 7, tabled by the noble Lords, Lord Beecham and Lord Hunt, and the noble Baroness, Lady Thornton, seeks to set out a new definition of the health service in England as,

of the 2006 Act. While I know that the noble Lord has the best interests of the NHS at heart, I fear that this

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amendment might achieve the opposite of what he intends because its effect would be to narrow the definition of the health service.

Section 3 of the NHS Act 2006, as amended, will set out the services that clinical commissioning groups will be required to commission, including, for example, maternity services, hospital accommodation and, in answer to the noble Earl, Lord Listowel,

Defining the health service as meaning only those services set out in this section would limit the application of the provisions of the Act, excluding other vital parts of the health service that are not defined in Section 3. For example, that definition would exclude primary care and specialised services, which would be commissioned by the NHS Commissioning Board, and public health services, which would be provided or commissioned by the Secretary of State or local authorities. Clause 1(1) of the current Bill retains the Secretary of State's duty to promote a,

This clearly sets out what the health service must do. Any attempt to define it more precisely might have the perverse effect of leading to an NHS which delivered fewer services.

I can assure the noble Lord that services commissioned by clinical commissioning groups will be covered by the wording of the unamended clause, and thus these services will be covered by the Secretary of State's duty to promote the comprehensive health service. As part of the health service, those services must remain free of charge. Clinical commissioning groups will be responsible for commissioning the services listed in Section 3 of the 2006 Act such as hospital services and maternity services. They must arrange those services, although as with primary care trusts at present, Section 3 will permit them discretion to determine precisely what services are necessary to meet the reasonable requirements of their local population. The Commissioning Board will issue commissioning guidelines and monitor the commissioning activity of CCGs with a view to ensuring that no essential services go uncommissioned in any given locality.

4.45 pm

I say again to the noble Earl, Lord Listowel, that we will consider mental health issues in a later amendment tabled by the noble Baroness, Lady Hollins, and I will be happy to cover the issues around the parent/child relationship then. However, I agree very strongly with the point the noble Earl made about the importance of the parent/child relationship. In a nutshell, our reforms are aimed at empowering patients, including their families and carers, and the Bill provides a strong footing for that relationship to be strengthened.

I can assure the noble Lord, Lord Beecham, that this is not the Secretary of State washing his hands of the NHS. The Secretary of State will retain-at the risk of reopening the previous debate-ultimate accountability for promoting the comprehensive health service. The

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Bill gives the Secretary of State extensive powers of oversight and stewardship of the NHS. His powers include the power to prescribe, in the standing rules regulations under proposed new Section 6E of the 2006 Act, inserted by Clause 17, that CCGs must commission specified services.

I think the noble Lord suggested that the 2006 Act was clearer about what the health service was and that this Bill makes it less clear. The Bill does not reduce the clarity of the 2006 Act in terms of a description of the services which must be provided as part of the health service. Section 3 and Schedule 1 remain in place so far as the services covered are concerned; it is simply the identity of the body responsible for arranging them which will change.

The noble Lord asked what was wrong with an illustrative list. There is already an illustrative list in Section 3 of the NHS Act 2006 which, as I have said, sets out the services the CCGs will be required to provide. However, attempts to define that list more precisely will inevitably lead to the problems that I have outlined. I hope that reassures the noble Lord that the existing definition is satisfactory and that he will withdraw his amendment.

The Earl of Listowel: I thank the Minister for providing me with the strong assurance that to him and his colleagues the strengthening of the parent/child relationship is absolutely crucial in what they are doing. There is strong agreement with that point and I thank him for that. I will look forward to reading with interest in Hansard the later discussion on mental health.

The Minister mentioned the availability of essential services. To highlight the current concerns, an effective and well respected foster care charity operating in all the nations of the United Kingdom had to create its own child and adolescent mental health services in Wales because there was so little available in that nation. On children's homes, it has been recognised for a long while that often our most vulnerable children are placed in children's homes with staff who are poorly equipped to meet their needs. There have been important steps forward in improving that situation but, crucial to that, is ensuring that those staff get the mental health support they need. That is becoming more widely available over time, but it is still piecemeal. We need to ensure that those kinds of situations do not continue into the future.

I am grateful for the Minister's assurances about the Government's priorities in this area and, as I say, I look forward to reading the debate in Hansard.

Lord Beecham: My Lords, I am grateful to the noble Earl, Lord Listowel, for once again bringing his expertise on this issue. He is perhaps the leading proponent in your Lordships' House of the concerns around children's health and other matters relating to children, and his contribution today certainly falls in line with our experience of his many contributions in that area of policy.

I am also grateful to the Minister for his reply. I did not, and the amendment does not, suggest that we should have an exhaustive, finite list of responsibilities

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or functions which comprise the National Health Service. That would clearly be inappropriate. I thought I had made that clear but perhaps failed to do so. The noble Lord rightly pointed out that, under Clauses 10 and 11, responsibilities are effectively transferred from the Secretary of State to clinical commissioning groups. Had this amendment been taken forward, it would have identified for those groups the services which they should carry out. Of course, the transfer imposes the duty to arrange for the provision of services to the extent that each commissioning group considers necessary. That provision raises the question of the extent to which there is still a commonly accepted view of a National Health Service. That is an open question that we will no doubt return to in different forms as we go forward, but in the circumstances I beg leave to withdraw the amendment.

Amendment 7 withdrawn.

Amendments 8 to 8A not moved.

Amendment 8B had been withdrawn from the Marshalled List.

Clause 1 agreed.

Clause 2 : The Secretary of State's duty as to improvement in quality of service

Amendment 9

Moved by Baroness Thornton

9: Clause 2, page 2, line 12, after "service" insert "by providing services or making arrangements for others to provide services"

Baroness Thornton: My Lords, I will also speak to Amendments 10 and 14. The purpose of these amendments is to strengthen the responsibilities of the Secretary of State for improving quality by changing the requirement to act with a view to reducing inequalities to providing services or making arrangements for others to provide services that ensure an improvement in quality. Furthermore, in the light of Clause 1 removing the Secretary of State's role in providing services-although we still have that matter to resolve-it probes the extent to which the Secretary of State might be able to effect an improvement in the quality of services.

In general, we would welcome and support an explicit duty being placed on the Secretary of State to improve quality-of course we would. The grouping of these amendments has two components. First, it makes the point that quality and inequality affect communities as well as individuals, so planning must be on a geographically defined basis. Secondly, there are amendments designed to make the Secretary of State more directly rather than indirectly accountable-that goes back to the Clause 1 argument again. Amendments 9 and 10 tighten up the Secretary of State's duties. As amended, the provision would state that the Secretary of State must exercise the functions of the Secretary of State in relation to the health service by providing services or making arrangements for others to provide services to secure continuous improvement in the quality of services provided. This mirrors the changes that we have argued for in relation

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to Clause 1, to make the Secretary of State more directly responsible rather having responsibility at one stage removed.

As I am sure the noble Baroness, Lady Finlay, will explain to the House, the amendments in her name are also important. This is the first time-but certainly not the last-that the idea is introduced of responsibility for an area-based population. The amendments acknowledge that quality and inequality affect communities as well as individuals. We support this idea of area-based responsibility and will later seek clarification on how basing some commissioning on GPs can be reconciled with the need to plan for geographical populations. Indeed, Amendment 14 is on the same theme, making the Secretary of State directly responsible and going back to that formulation of provision as opposed to being one step removed. As amended, the provision would say that in discharging the duty under subsection (1) of the proposed new Section 1A of the 2006 Act, the Secretary of State must either provide services that ensure, or make arrangements to ensure continuous improvement in the outcomes that are achieved. Actually, the amendment is defective because the word "must" has to be left in.

Lord Mawhinney: I am extremely grateful to the noble Baroness, but she skated over what an area-based population is. Presumably, if the Secretary of State has responsibility for individuals he has responsibility for a lot of individuals who happen to live cheek by jowl to each other. I am sure that it would be helpful to the Committee-and it would certainly be helpful to me-if she told us what an area-based population is or might be.

Baroness Thornton: The amendments that open the debate are in the name of the noble Baroness, Lady Finlay, so I suspect that she will also take the opportunity to explain that to the Committee. However, I think that we will have several debates as we move through the Bill that are about the concerns that some of us have if the commissioning of services is based on GP lists and not on a population in an area. What this probing amendment seeks to do is to help to open up that discussion about how you make sure that there are not people in an area who may not be on a GP list and who fall through the cracks in terms of health provision in that area.

This series of amendments seeks to do two things. One is to raise the point about equality and inequality as it affects communities as well as individuals. For example, the provision of family planning services in an area affects an area as well as the individuals who make use of the services, and you would indeed plan those services. That may not be a good example because of course that is public health, but I think that the Minister will see that you have to look at how you plan services in terms of not only the individuals but the needs of an area.

Lord Newton of Braintree: I am sorry to interrupt, and this may be another question for the noble Baroness, Lady Finlay, but what is a primary care trust if it is not concerned with the population of the area as that primary care trust is defined? This all seems to me like gobbledegook.

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Baroness Thornton: My Lords, it is about the people in the area-but of course primary care trusts are going to be abolished by this Bill.

Lord Newton of Braintree: The noble Baroness said that this was the first time that we had had area-based planning, but a primary care trust is an area-based entity, planning for the population of an area.

Baroness Thornton: I think that the noble Lord misheard me. I said that it was the first time that we had discussed this in the process of this Bill. I beg to move.

Baroness Finlay of Llandaff: My Lords, I shall speak especially to Amendments 10A, 10B and 11A, and address my remarks principally to Amendment 10A, whose aim is to avoid fragmentation and inequity through a loss of contiguous, coterminous and comprehensive area-based structures for healthcare resource allocation planning, commissioning and service co-ordination. The amendment would ensure that the sensible changes that were just agreed today over GP contracts for this year are carried forward into GP consortia arrangements. The Secretary of State, Andrew Lansley, himself discussed issues around area-based practice at the congress for the Royal College of General Practitioners last month, and had a fairly extensive and open discussion with the GPs there on this topic.

I move to the Bill as it stands. I hope that with some of the background discussions that have been happening, my amendment will not just be dismissed and will be quite seriously considered, because it might solve a problem.

In the Bill, the new commissioning consortia's duty-

Lord Mawhinney: I am sorry, I may be the only person in the Committee who is thick enough not to understand what is going on, but I have to say that I do not. I asked the noble Baroness, Lady Thornton, to define something that she said she was in favour of, which was area-based entities, but she palmed that off on to the noble Baroness, Lady Finlay. I would be grateful if she would define what an area is. Is it a county, a city, a town or a village? Is it the north-east or the south-west? Who in the context of this Bill does she see as having responsibility for defining the area and addressing the issue in the area?

5 pm

Baroness Finlay of Llandaff: I would be grateful if the noble Lord would bear with me for a couple of minutes while I go through a few paragraphs and try to explain how this clause poses some problems, because I agree that it is pretty complicated.

The new commissioning consortias' duty in the Bill is to arrange for health services provision that applies to those enrolled patients registered with them. This contrasts with primary care trusts, and the other structures that will be disbanded when the new structures come in, because the population of the consortia will be drawn from the patient lists of member general practices rather than from residents living within a defined

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geographical area. That means that as clinical commissioning groups they will have the freedom to choose who they take on to their registers, regardless of where they live. As a consequence, the population for which a clinical commissioning group is responsible may not include all individuals and families living in the local area, so may not represent an area-based population. However, it may have some people whose primary residence is a long way away but who decide to register with a GP because that is where they work and where they are during the week.

It has been suggested that individuals and families who are not enrolled within a local commissioning group's general practitioners may not be covered and would therefore need to be covered by a small number of more centralised clinical commissioning groups, which will effectively mop up those individuals and families who lack membership within a local clinical commissioning group. I would therefore be grateful if the Minister could confirm the arrangements for those patients, such as people who are homeless, and who may for whatever reason not be on a particular general practitioner's list. Can he also explain to the Committee how these patients will be allocated to receive primary medical care services since that allocation duty currently falls to primary care trusts, which will not be there in the future? The services will be designated from the commissioning board, which is at quite some distance from patients who do not have a GP and from individual GPs.

The combination of removing geographical responsibility for the provision of healthcare, together with the removal of practice boundaries, creates a number of risks: an inability to plan for local services; a risk of worsening health inequalities and social segregation; and fragmentation between social care and healthcare-the former being based on local authority boundaries and the latter then being based on a potentially England-wide catchment area, depending on who registered with a GP. Allocating resources based on the GP-registered list rather than any geographical population will mean that there would not be coterminosity with public health-or, importantly, with local authority services, which are responsible for much social care and for the safeguarding of children and vulnerable adults. A lot of those responsibilities for safeguarding held by a local authority relate to the geographical area of a local authority.

With GPs potentially competing for patients across the whole country there could be fragmentation, especially if someone registers near their place of work as when they are ill they are likely either to be at home or to return home, which may be many miles away. They may need services at home, particularly medical and nursing care, if the condition is sufficiently serious to require them. Yet the GP with whom they are registered for primary medical services would then be at a distance that would make home visiting impossible.

In April of this year the Health Select Committee emphasised the importance of aligning care to geographical boundaries, making this point:

"Aligning geographic boundaries between local NHS commissioning bodies and social care authorities has often been found to promote efficient working between the two agencies. There will in the first instance be more local NHS commissioning

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bodies than social care authorities; the Committee therefore encourages NHS commissioning bodies to form groups which reflect local social care boundaries for the purpose of promoting close working across the institutional boundary. History suggests that some such groups will find the opportunities created by co-terminosity encourage more extensive integration of their activities".

To paraphrase that, I hope that my amendment is in line with the recommendation of the Health Select Committee.

The local authority will take over many functions of current PCTs, especially over safeguarding, as I said. This is important, particularly for children who are unable to transfer their own care. Different children from the same family who are at particular risk and on an at-risk register will potentially be registered in different places by abusive parents who deliberately want to ensure that they limit, or almost exclude themselves from, surveillance. I am sure I do not need to remind the House that the tragedy of Baby P was an example of a parent who avoided surveillance and, tragically, avoided it far too effectively.

The other difficulty is that there are families who have very complex lifestyles, with different members registered at different distances, particularly if they are mobile families. This will make it very hard to obtain an overall picture of the health, education and safeguarding services if these are not coterminous. Where local authority, education authority and health provision are coterminous, there is a much better chance of a good transfer of important data on the welfare of these children who are at risk.

Public health is a major and very welcome focus of the Government. This amendment is also necessary to ensure that the NHS will adequately address those issues of health improvement such as smoking cessation, screening for disease, immunisation and so on, where treating people as a population rather than a collection of separate individuals is more effective. Public health can achieve optimal population health outcomes only if there are area-based organisational structures and frameworks in the health system. That becomes particularly important in more rural areas, as it ensures optimising efficiency, accountability and effectively integrated care.

The amendment also supports the Secretary of State's responsibility for issues of health protection, such as the control of an epidemic of infectious disease. Such an epidemic cannot be dealt with just by treating individuals. It requires an area-based approach, using vaccinations, population monitoring and so on to ensure disease containment. Additionally, without coterminous working of health and local authority, planning of capacity becomes harder.

General practice can certainly do much to improve its quality of service in some areas, particularly access to primary care through extended hours, out-of-hours coverage of the population and decreasing the dangers that are encountered with the lone-worker GP who does not have contact with other colleagues. General practice could go towards federated models of practice; that is not incompatible with the spirit of this amendment. However, all these improvements need geographical areas to function properly and drive up quality of care.

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Epidemiological research has been a strength of the UK, building on registers of a precisely defined denominator of patients, categorised by age, sex and so on, and known to be living in a particular environment. Weakening it by multiple registration will break the link of geography with health and may impede the aim of driving up quality. It will certainly impede our ability to carry out effective quality-based research on improving health in the future.

Another area that I want to address briefly is that of the medical examiners in relation to coronial jurisdictions. Their work depends on them being geographically area-based and seeing the death certificates of all the general practitioners within that area as they come through. There is a concern that if there is wide fragmentation it may be more difficult to pick up trends that should not be there.

Amendments 10B and 11A seek to delete "or" and insert "and" to make subsection (1) of proposed new Section 1A of the 2006 Act refer to the prevention, diagnosis and treatment of illness, and then go on to public health. I suggest that these amendments are logical as they would ensure that the Secretary of State has a duty to improve all three of those aspects in relation to illness. The measure also emphasises the importance of public health in conjunction with the prevention, diagnosis and treatment of illness. I stress that "illness" includes both mental and physical illness.

Lord Walton of Detchant: My Lords, my noble friend has, as always, been extraordinarily persuasive in her detailed argument in support of her Amendment 10A. I apologise to her and to the Committee for not having discussed it in detail with her beforehand. The intention underlying the amendment is in every way admirable. Amendment 10B, to which she spoke more briefly, deserves a great deal of attention and would greatly improve Clause 2 of the Bill. My only concern with her remarks about area-based populations relates to the definition that would be attached to the clause. New Section 1A(1), as inserted by Clause 2, is defective in my opinion in that it refers to,

The provision of services in the National Health Service does not relate simply to the treatment and improvement of the health of individuals. As the term "public health" implies, it deals also with the improvement of the health of communities. After all, public health doctors were called community physicians until quite recently. In many ways I would have preferred to see the clause include, after the word "individuals", "and/or communities" to make that position entirely clear. I warmly support the principles underlying my noble friend's amendment but the wording requires a little attention as throughout my professional career I have been very familiar with the hazards that arise in attempting to draft and redraft documents in committees, large and small. I do believe that this matter needs to be given attention by the Minister.

Lord Warner: My Lords, I am not altogether sure whether I rise to support these amendments or not. I promise the noble Lord, Lord Mawhinney, that the phrase "area-based populations" will not pass my lips

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after this utterance. There is a question which it is apposite that I raise with the Minister under this group of amendments as it has puzzled me for some time. Under the present arrangements, we have a public body called a primary care trust which can cope with a set of circumstances in which people are thrown off a GP's list, have not got onto a GP's list or have a lifestyle which means that they are disinclined to join a GP's list. There is a mixed bag of people. This group of people live in a particular area, however that is defined. It is an area for which, somewhere in the country, a primary care trust is responsible. In the world of clinical group commissioning which is based on practice lists, I am not altogether clear how this group of people are safeguarded.

I am sure that the brilliant minds of the officials in the Department of Health have thought of this and have a cunning plan that, no doubt, the noble Earl will divulge to us. However, it is an issue that has caused concern, and I do not feel equipped to answer that concern because I am not clear as to how the Government will cope with that group of people.

5.15 pm

Baroness Williams of Crosby: My Lords, perhaps I may ask a couple of questions in this short debate and thank the noble Baroness, Lady Finlay, for her comprehensive presentation. This is a difficult area of the Bill. First, what happens with someone whose main residence is in one place but who is actually very dependent on out-of-hours care because of the nature of their job. There must be literally hundreds of thousands of commuters for whom the natural place they would like to go, due to the recollection of personal data and all the rest of it, would be the clinical commissioning group in their home area, but because they spend a great deal of time at work a long way away they will in fact depend on out-of-time services. I am troubled by the low quality of some of those services in comparison to what we might call mainstream NHS care.

The second question is perhaps easily answered. Can the Minister say something about the relationship of both new structures to NHS Direct? I am not clear as to whose responsibility NHS Direct will be. Will it continue as a kind of separate freewheeling service or be linked to a clinical commissioning group; and, if so, at which end of the spectrum would it be linked?

Baroness Murphy: My Lords, I am particularly concerned about the area-based issue because, like many people, I have been banging on for years about the importance of coterminosity between health and social services. However, my experience over the years has been that that has not made much difference to the co-ordination of care between health and social care.

I want to raise a point about the new arrangements. I understand that we are trying to move away from the old RAWP funding formulation, which has always been deeply unsatisfactory and open to political manipulation, to the funding of real groups of patient populations on a risk-assessment base. To achieve that, there is no doubt in my mind that you must have real people on real lists, whether or not that clinical commissioning group has a responsibility to provide for a population

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within the group. You must be able to work towards a funding solution for those clinical commissioning groups that reflects real need and moves away from the old area-based populations.

I think that that may be the response I would give the noble Baroness, Lady Finlay. I did not really understand the brief amendments in this group that were not specifically related to this question so I address my issues to that.

The Lord Bishop of Chester: My Lords, I completely support the amendment in the name of the noble Baroness, Lady Finlay, but wonder whether what she wants could be achieved-it might be a small step in the right direction in relation to legislation generally-by simply removing from the Bill the words "provided to individuals". The term "individuals" has a jarring effect. "Provided to people" might sound a bit better, but "individuals" has a slightly impersonal feel, especially as we are concerned as a Committee and as a House about the "national" character of the National Health Service. References to individuals jar in that regard as well. Simply requiring improvement in the provision of services might achieve what the noble Baroness seeks in her amendment.

Baroness Cumberlege: My Lords, I should like to ask a few questions about Amendment 10A. I thank the noble Baroness, Lady Finlay, for her introduction, but we do not yet have a precise definition of what she means by area-based populations. All sorts of different services have different catchment areas. At the beginning, the noble Baroness cited family planning services. She said that she felt that perhaps it was a bad example, and I think it probably is because there are so many different services that require different boundaries. I am for coterminosity as far as we can get it, because when I was a regional chairman, I saw that where you had coterminosity between the health service and local government, you could achieve a great deal. That worked well, but when one examined it carefully, it was not so much about the boundaries; it was about the relationships built between different people. That was what made the services work extremely well.

With regard to GP practices, GPs usually want people within their area, especially if they will have to do home visits. I have been in the situation-I am sure that many noble Lords have-where I had an emergency in London but my GP is 52 miles away. That can be coped with; you can still manage that, although it is quite awkward in some respects. My anxiety about allocating patients to different GPs-being neat and tidy and trying to get all the boundaries sorted-is that I do not know what it does for choice. Perhaps the noble Baroness will say something about that. What happens when people want to choose a different GP who is out of their area, which is what we want to do locally but are unable to because the boundaries have been so clearly fixed, I have to say, by the GPs themselves?

Lord Rea: My Lords, the noble Baroness, Lady Finlay, has somewhat stolen my thunder because I had meant to say almost exactly what she said, but I was

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going to mention it when we got to the part of the Bill describing the clinical commissioning groups. Schedule 2, which relates to clinical commissioning groups, states:

"A clinical commissioning group must have a constitution ... The constitution must specify",

the name, the members and the area of the group. That is there. I would like the noble Earl to describe how that area is to be measured and whether it is to be coterminous with existing boundaries, particularly local authority boundaries, for the very reason given by the noble Baroness, Lady Finlay.

Baroness Tonge: My Lords, most of the points I wanted to raise have already been raised so I will not repeat them. I congratulate the noble Baroness, Lady Finlay, on her comprehensive overview of her amendments. What concerns me most is those patients who fall through the net of the new general practice commissioning groups. If it is not area-based and there is not a primary care trust responsible for allocating those patients, where will people who do not speak English very well, asylum-seekers, the homeless, mentioned by the noble Baroness, and Travellers go? What about those patients whom I remember well, whom most GP practices did not want on their lists at all and who were rotated around general practices in order that they got medical treatment? What will happen to all those patients? There are many of them and some of them have severe disabilities and some are severely mentally ill. They fall into all sorts of groups. I am extremely concerned that without an area base or a responsibility on a PCT or a commissioning group to deal with patients in a particular geographical area, those patients will suffer hugely.

I want to make one final point. The other service that will suffer hugely is our accident and emergency departments, because if those people do not have GPs, that is where they will go. I was a casualty officer in central London for a whole year, once upon a time, and I virtually ran a general practice there then for patients who were unattached to general practices. That problem will increase, and I hope that the Minister will address that in his comments.

Baroness Finlay of Llandaff: My Lords, it may help the Committee if I explain how the GP contract is being renegotiated; I hope that I get this right. Instead of a GP contract covering a rigidly defined area, as now, there will be an outer ring as well. If patients move a bit further away but stay within that outer ring area, instead of being forced to change their GP, they will be able to remain with their current GP. Therefore, I think that the problem of choice, to which the noble Baroness, Lady Cumberlege, alluded, should in large part be solved by the negotiations that the Government have just had with GPs. There is of course a difficulty in defining any area but to date the areas have been defined by GPs, and they will still have to define the outer area or outer ring to which it is practical for them travel to carry out home visits and so on.

As I understand it, a decision has not yet been taken on what will happen with people who, like most of your Lordships, are classified as temporary residents. Many of us live a long way from here and, if we need to see a GP, we register as a temporary resident with

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one somewhere in Westminster. I am not sure how those arrangements will work in the future but they have served us reasonably well until now. The danger in relation to allocation relates precisely to those patients to whom the noble Baroness, Lady Tonge, referred-those who have been thrown off GP lists or cannot get themselves signed on to a GP list for whatever reason but still have healthcare needs. If those needs are not met, that will impact on the very social fabric of our society. I hope that I have clarified some of the points.

Baroness Hussein-Ece: I should like to ask a couple of questions to clarify where the debate is going. As my noble friend Lady Tonge said, for a number of years some groups have found it almost impossible to get a GP. It is almost a case of GPs selecting the people they want on their lists; it is an unwritten code. That is why asylum-seeking families, refugee families and others with very high needs will always find it difficult to get a GP, and I want to ask the noble Baroness, Lady Finlay, how her amendment will assist that.

Equally, as has already been mentioned, areas of high need have in my experience always been in inner cities, where it has been difficult for some people to register with a GP. We know that attendance at A&E departments has become extremely high in some areas-almost unsustainably so-and I want to ask how the amendment will address that too.

There are also families who are placed by local authorities in temporary accommodation in other areas. Currently, a local authority is responsible for such a family-for example, social services or family support may be involved with the children. However, if that family is placed in another borough way out of the catchment area, I am not sure who their GP will be. Perhaps the Minister can respond to that as well and say how that would work with a local authority having responsibility for a family placed well outside the area. Would that family still be able to get support by going on to a GP list in the new area? Would that connection be made? Over the years we have worked very hard to make sure that social care, healthcare and local authorities all work together in partnership. Perhaps we could have an explanation of how it is going to work when families with very high needs are spread around.

Lord Newton of Braintree: My Lords, your Lordships will have realised by now that I am basically a simple-minded soul. I am struggling to discover what this issue is but it seems to come down to one specific point: do clinical commissioning groups have the same responsibilities as primary care trusts for planning services for all the people that they think live in their area? That is the core question. Do they have an area base-I dare to risk upsetting my noble friend-for their activities? I understand that it has been decreed that no practice can be part of two clinical commissioning groups; they cannot overlap and have to be distinct and separate. In a sense they are the same as primary care trusts. Do they have a responsibility to plan and provide services for all the people known to be in that area? The rest of this is all peripheral. I require services from the NHS both in London and at home in Essex, and I normally get them. But people in Westminster,

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where my flat is, know perfectly well that there are lots of second homes in Westminster, and presumably the health authorities and primary care trusts know that as well and plan on that basis. It is a simple question: does somebody have a responsibility to plan and provide services for all the people in their area? Yes or no?

Noble Lords: No.

5.30 pm

Earl Howe: Yes, my Lords. I hope that I can reassure noble Lords on their very valid concerns on this topic. Perhaps I can say a few general words first of all about quality. The Government's ambition in modernising the NHS is to create a health service that delivers outcomes as good as any in the world. We all know that at its best the NHS is world-class, but we also know that there are important areas where the quality and outcomes of care could and should be improved. If we are to safeguard the quality of services and drive improvement, we must take positive action. We are addressing the structural weaknesses in the system and seeking to embed the principle of quality throughout. This is why the Bill creates a legal duty for the Secretary of State and for the NHS Commissioning Board and clinical commissioning groups to be guided by the need to improve quality in all that they do.

In doing this we are building on the work of the previous Government under the noble Lord, Lord Darzi, and in particular we are using the definition of quality that he introduced-care that is effective, safe and delivers a good experience for patients. By positioning the quality duty in the context of a duty in Clause 3-to bear in mind the need to reduce inequalities within the population in designing services, particularly the most vulnerable members of society-we intend that these reforms will deliver the vision of high-quality care for all, as he so ably articulated.

Amendments 9, 10 and 14 place a duty on the Secretary of State to provide or secure the provision of services that in their turn should secure continuous quality improvement. We have already debated at great length Clause 1 and the duty to provide, and I shall not rehearse that discussion again, but I should like to be clear that it is the role of commissioners to drive quality improvements and the role of the Secretary of State to seek to improve quality by exercising his functions. He will do this, for example, through the mandate that he sets for the board, or the outcomes framework which he will issue and to which the board must have regard when it exercises its duty in relation to quality.

The amendments also place a duty on the Secretary of State to secure continuous improvement in the quality of services. Similar amendments were debated at some length in another place. It was clear throughout those debates that there is extensive and wide-ranging support for the principle that the health service should strive to provide the best possible service to patients. I thank the noble Baroness, Lady Thornton, for indicating her support for that principle. I am sure that we share it. As drafted, the Secretary of State, and in practice the Department of Health, is required to seek to achieve continuous improvement even if external factors

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mean that in particular cases such improvement may not be delivered. In our view, the clause as drafted should do what is necessary to deliver improvement in the quality of services while not imposing unreasonable or unrealistic burdens on the Secretary of State and the NHS. We believe that this duty, taken alongside those placing the same duty on the board and clinical commissioning groups, and the expectations that the Secretary of State will set through the outcomes framework, already ensures that the principle of securing continuous improvement in service quality is embedded throughout the health service and the wider care system. I hope that I have reassured the noble Baroness, Lady Thornton, of the Government's commitment to the continuous improvement of quality within the health service, and that she will not press her amendments.

I turn to Amendments 10A, 10B and 11A, tabled by the noble Baroness, Lady Finlay. They seek to strengthen the duty by inserting "and" in place of "or" where the clause lists the areas that the duty to secure quality improvement applies to. The noble Baroness expressed concern previously about the wording. I assure her that "or" is the appropriate word and that we are not allowing the Secretary of State to neglect certain aspects of healthcare when exercising their duty. There is no risk that the courts could misinterpret the unamended clause as meaning that the Secretary of State has to exercise his functions with a view to securing continuous improvement in the quality of services in only some rather than all areas that the Bill specifies.

The duty refers to quality in respect of services provided to individuals. In many cases, particular services provided to an individual will relate to one or more of the matters referred to in new subsection (1)(a) and (b), but not to all of them. For example, the service may be to prevent or diagnose illness but not to treat. Another service might be to treat but not to diagnose. The use of "or" makes it clear that the duty applies to the quality of all services, whatever the purpose for which they are provided. Although I am certain that it is not the noble Baroness's intention, the use of "and" would inaccurately suggest that the duty could apply only to the provision of services that prevent or treat illness.

Amendment 10A seeks to extend the duty to improve the quality of services from those provided to individuals to those provided at a population level. Of course it is just as important for public health services to improve as it is for any other sort of health service, but new Section 1A already recognises that with its explicit reference to public health services in subsection (1)(b), which refers to the,

The wording is echoed in Clauses 8 and 9, which set out the new public health duties of the Secretary of State and of local authorities.

Clauses 8 and 9 provide examples of steps that may be taken under those duties and that might therefore be subject to the duty of quality in new Section 1A. They include providing information and advice, for example, as well as preventing or treating illness. This means that new Section 1A already applies to a wide range of public health services. Any public health activity that involves the provision of a service to

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individuals-albeit that the general purpose is to improve or protect health at a population level-such as vaccination or smoking cessation, would be covered by the duty in the clause as drafted. Of course, improving the health of populations cannot be achieved without improving the health of individuals. I make it clear that some steps may be taken to improve or protect public health under Clauses 8 and 9. These extend beyond services provided to individuals.

I turn to questions that were raised. The noble Baronesses, Lady Thornton and Lady Finlay, spoke about the importance of commissioning for an area-based population. We completely agree with the general sentiment. That is why CCGs, contrary to the perception of some noble Lords, will commission for all unregistered patients within their geographic area, as well as for those on their registered lists and others to be defined in regulations. I refer noble Lords to Clause 10(3), which is on page 6. It is also why we are establishing health and well-being boards to agree a holistic strategy for their area. That is Clause 190.

We amended the Bill in another place to clarify that clinical commissioning groups have responsibility not only for patients registered with the GP practices that comprise their membership, but for those usually resident in the clinical commissioning group's area who are not registered with any GP practice. We must also ensure, when we exercise the power to set out other persons for whom a CCG has responsibility, to provide through regulations that a CCG has responsibility for ensuring that everyone in its area can access urgent and emergency care. I turn to my noble friend Lady Tonge, who asked me about that issue.

Baroness Tonge: Will the Minister clarify the phrase "clinical commissioning group area"? I thought that it was not going to be defined. I obviously got the wrong end of the stick. GPs are free to have patients on their lists from wherever; therefore, what does he mean by their "area"?

Earl Howe: My Lords, I will address that question in a moment, if I may. The noble Lord, Lord Warner, asked how clinical commissioning groups will deal with the non-registered population in practice. Individual clinical commissioning groups will have responsibility for ensuring that patients resident in their area who are not registered with a GP have the same access to the care for which the clinical commissioning group has commissioning responsibility as a patient registered with a GP. Individual clinical commissioning groups will need to ensure that they have sufficient geographical focus to be able to commission emergency care services for anyone who needs them when in their area. The National Health Service Commissioning Board will be responsible for establishing a comprehensive system of clinical commissioning groups covering the whole of England, and the board will be responsible for commissioning primary medical care for the unregistered patient population. I think that my noble friend Lady Tonge is confusing two issues.

Lord Warner: Can I just be absolutely clear that I have understood the noble Earl? Is he saying that a clinical commissioning group with a defined geographical

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area for which it is responsible also has a responsibility to find out about the needs of all those who are not registered with a GP, including homeless people, asylum seekers, rough sleepers and you name it? Is he saying that the group has a responsibility to find out how many of those people are in its area and that it must commission services for them?

Earl Howe: Let me be clear: each clinical commissioning group will have a specific geographic area and will have responsibilities linked to it. This addresses the question asked by the noble Lord, Lord Rea, as well. Unregistered patients of any shape or kind are one example. Clinical commissioning groups will be informed by the work done in the health and well-being boards, whose job it will be to define the health needs of an area and what they believe the priorities are for commissioning in that area, and to produce a joint health and well-being strategy that addresses those priorities. The interaction between the health and well-being board and the clinical commissioning group should ensure that the marginalised groups of people to whom the noble Lord refers will be catered for.

Lord Walton of Detchant: The noble Earl has been extraordinarily helpful in his comments. However, in new Section 1A, entitled Duty as to improvement in quality of services, subsection (1) states:

However, it reads as if (a) and (b) were qualifying clauses, qualifying the services provided to individuals. As I read it, it does not make it clear that the quality of services provided to communities would be embraced by this even though it refers to public health. That is my concern, and I would be grateful if the noble Earl could in due course consult as to whether I am totally mistaken in that view.

5.45 pm

Earl Howe: I will cover that point in a second. I should perhaps clarify that the area covered by an individual clinical commissioning group will be agreed with the NHS Commissioning Board and, as I will explain in a minute, that area should not without good reason cross local authority boundaries. That is a different issue from the issue raised by the noble Lord, Lord Rea, of GP practice boundaries, and we need to distinguish the two in our minds.

The right reverend Prelate asked why we could not remove the words "provided to individuals". The duty on the Secretary of State to act,

is worded to refer to the "services provided to individuals". This is because the NHS treats patients on an individual basis. Overall improvement in the quality of the treatment service will improve the health of the population as a whole, but we must not forget that there is a separate, complementary duty to improve the health of the population as a whole using public health mechanisms. Improvement is necessary in both prevention and

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treatment, and the Bill sets out separate duties in relation to other population-based activity; for example, population-based public health research.

In answer to the noble Baroness, Lady Finlay, the Government accepted the NHS Future Forum's recommendation that the boundaries of local clinical commissioning groups should not normally cross those of local authorities, and this is now reflected in the proposed authorisation framework for CCGs, subject to the agreement of the process with the NHS Commissioning Board. However, we do not believe it would be in patients' interests to make this an absolute rule. One of the key roles for clinical commissioning groups will be to manage relationships with local hospital providers and in some areas patient flows into acute hospitals do not match local authority boundaries. The proposed authorisation framework makes clear that CCG areas may cross local authority boundaries only where, for reasons like these, it is demonstrably in the interests of patients.

In answer to my noble friend Lady Cumberlege, whose comments I very much welcomed, all relevant clinical commissioning groups will be required to appoint a representative to the health and well-being board if part or all of their area falls within or coincides with the local authority area. That will provide a vehicle for NHS and local authority commissioners to work together on the health and well-being of the population. There is nothing to prevent health and well-being boards from inviting other clinical commissioning groups that have large numbers of registered patients within the local authority area to attend and be represented. I hope that goes some way towards addressing the concerns that the noble Baroness raised. She expressed a general fear about lack of coterminosity between local authorities and CCGs, leading to fragmentation. As I have said, there is going to be a presumption against CCGs crossing local authority boundaries, but there is an important point in this connection in Clause 20, which will impose a duty on the board in new Section 13M in relation to promoting integration; in particular, new Section 13M(3) will impose a duty on the board to,

where this would assist with integration of health and social care.

The noble Baroness also referred to GP practice boundaries. She will know that the previous Government, as well as the present Government, were keen to ask patients about the choice of GP practice. It is our aim, which we expressed in the White Paper, to give every patient a clear right to register with any GP practice they want from an open list without being restricted by where they live. Many, if not most, patients are quite content with their local GP practice, but a significant minority have problems registering with a GP practice of their choice or with securing access to the high quality and range of care services that they deserve.

I can inform the Committee that agreement was reached with the BMA today. NHS employers have been discussing our proposals with the General Practitioners Committee of the BMA as part of the annual GP contract negotiations, and the agreement

2 Nov 2011 : Column 1270

that we have reached with that committee is that from April 2012 GP practices will agree with their primary care trust an outer practice boundary whereby they will retain, where clinically appropriate, existing patients who have moved house in the outer boundary area.

There will also be a choice pilot in two or three cities, or possibly parts of cities, whereby patients will be able to visit a practice either as a non-registered out of area patient, for which the practice will receive a fee, or as a registered out of area patient. Practices will join the pilot on a voluntary basis. I think that that represents a very satisfactory way forward. We can look at which model works, if either of them does, and see what the problems are with each.

The noble Baroness asked about the risk of cherry picking patients. We do not see that as a danger. Under their contracts, GPs have a measure of discretion in accepting applications to join their patient lists. However, they can refuse to register a patient only on reasonable and non-discriminatory grounds. They cannot turn patients away simply on the grounds of their medical condition, or for that matter on the grounds of their race, gender, social class, age, religion, sexual orientation, appearance or disability. In future, we want to make it easier for people to choose the best GP practice for themselves and their families. The pilot arrangements that we have agreed will be invaluable to understanding more fully the issues of GP choice.

I hope I have covered most of the points that have been raised. I hope that my answer to the question posed by the noble Lord, Lord Warner, satisfied him, but I just reiterate that CCGs' responsibility for planning for homeless people and all the groups that he mentioned is a core part of the CCGs' functions.

Lord Newton of Braintree: My Lords, I take it that the answer to my question is that CCGs do have a duty to plan for everyone in their area. However, along the way, the Minister indicated that some of the information that will enable them to do this will come from health and well-being boards and their assessment of the needs of the population. The fact is that the health and well-being boards do not cover the same areas. They might cover the area of a number of CCGs, but they do not relate to the specific area of any specific CCG. The question is therefore: do the health and well-being boards have a duty to translate their information into the areas covered by CCGs?

Earl Howe: I am grateful to my noble friend. The point I was seeking to make was that health and well-being boards will be in a very good position to assess and have a sense of the unregistered and, if I can express it this way, the more dispossessed elements of society. I think CCGs will find that an invaluable source of information in planning the commissioning of services.

My noble friend asked me a yes or no question: are CCGs just like PCTs? In terms of population responsibility, the responsibilities are very similar. CCGs are responsible for patients on the registered lists of their constituent practices as well as having specific area-based responsibilities, as I pointed out, linked to their unique geographic coverage. It is possible for

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individuals within that area to be registered with a GP practice which is a member of a different CCG. They would therefore be the responsibility of that other CCG. So that is a slight complication. However, it is important to remember the critical role of health and well-being boards in planning in a holistic way across an area covering not just the NHS but public health, social care and other services.

Lord Newton of Braintree: I am sorry to press the Minister further. I want to ask one further question and then I will shut up-I promise. Health and well-being boards, and possibly CCGs, will cover widely differing kinds of area: urban populations where there may be many more homes and people, asylum seekers and the like; conurbations of one kind or another; and a rural periphery. Let us make this oversimple. Do the CCGs in the conurbations know what their situation is in respect of homelessness, asylum seekers and all the other things that the noble Lord, Lord Warner, talked about?

Earl Howe: My Lords, there are perhaps several issues bound up in my noble friend's question. It is entirely possible that a CCG will cover two local authority areas. In that event, it will have a clear duty to work in partnership with both local authorities to improve health and well-being and to secure more integrated services. Do health and well-being boards need to translate their assessments for each clinical commissioning group area? The CCG will need to use the joint strategy of the health and well-being board to inform its commissioning plan according to the needs of its local population. It is in its interests to ensure that the information is translatable.

I would be happy to write to my noble friend because there is a clear narrative here, although I may not be expressing it entirely clearly. Obviously, there will be instances where boundaries do not coincide. As I have said, we are aiming for that not to happen but it will in some cases and it has to be dealt with in terms of the duties that we set out.

Lord Warner: I will not torture or tweak the Minister any further but I will ask him to make a sensible response on this issue after today's Committee sitting. It would be extremely helpful if he could take two or three areas-perhaps an urban area and an urban/rural area-and show us where there is a health and well-being board and where there are pathfinder groups of CCGs, and how this would work in practice. I think that we would find this much easier to understand if there was a diagram.

Earl Howe: I absolutely agree with the noble Lord. It is all very well me trying to describe in words what the duties will lead to but a graphic depiction of how this might work is a very good idea, which I would be happy to follow through.

Baroness Tonge: I am sorry to torture the Minister further. He seems to be saying that clinical commissioning groups are PCTs by another name, with the exception of public health services and community services. That is the impression I get. Can he tell us how much it will cost to transfer the bureaucracy of the PCTs to the bureaucracy of the clinical commissioning groups?

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Earl Howe: There is a hypothesis in my noble friend's question that I do not necessarily accept but I would be happy to write to her with the figures.

Baroness Hussein-Ece: I am sorry to press the Minister on the point I made about homeless families who are placed in different boroughs or areas by their local authority. Under the present system, the GP practice where the family was originally based would wash its hands of that family and say, "You are no longer in my area". Is the Minister saying that wherever a family has been placed, they would still be able to retain the services of the GP where it originated from or would they have to register with a practice close to the temporary accommodation in which they may have been placed. Such placements can last for many years. Will the family have to seek a GP close to where they have been placed or could they still use the GP services from whence they came?

Earl Howe: It would depend how far the family had moved away from the GP practice. What I was trying to say was that the agreement we have reached with the BMA comprises two elements. One is that the outer boundary of a GP practice is going to be flexed in a sensible and pragmatic way so that if you move a few streets away from where you were previously living, you can still be treated in the same GP practice. The other element of the agreement is the pilots that we are looking at. They are only pilots and we will set them up in order to experiment and learn lessons from how they work. It is impossible for me to give my noble friend a generalised statement at the moment because it will depend on the circumstances. At present, the rules will remain roughly as they are other than the flexed boundary rule that I have mentioned.

6 pm

Baroness Finlay of Llandaff: My Lords, I thank the Minister most sincerely. Apart from anything else, he has explained the BMA agreement far better than I did in my attempted few sentences. I hope that that has provided some reassurance to the House.

I am grateful to him for explaining the problem with the wording in Amendments 10B and 11A, and I accept that he has assured us of the totality of the Secretary of State's duties overall in relation to the two proposed subsections. I thank him for explaining, in relation to the other amendment in this group, that the mandate set by the Secretary of State is one to which the Commissioning Board must have regard. That was precisely why I was concerned about also having "areas" because the Commissioning Board will be contracting with GPs themselves for their clinical services, which is separate from the role of the clinical commissioning group. So I have a little nagging doubt and that is why I put this right at the front of the Bill. I am sure we are going to return to the word "area" as we work our way through the Bill.

For the moment, however, I am grateful for the noble Earl's explanations. I also thank all noble Lords who have contributed to the debate, particularly the noble Lord, Lord Warner, for what I think was a flash of brightness in the fog when he asked for a diagram that will set this out geographically for us. That will be most helpful.

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Baroness Thornton: My Lords, this has been a very worthwhile discussion. As I said at the outset, there are two issues here. I am grateful to the noble Earl for reassuring us about the issues to do with quality, which he has done very satisfactorily indeed. I should give the noble Baroness, Lady Finlay, a vote of thanks. I knew that she would explain the issues about area-based clinical commissioning groups much more clearly than I. Moreover, the noble Lord, Lord Newton, put his finger on it when he asked whether the clinical commissioning groups will be structured on the basis of clearly defined geographical areas contiguous with each other and inclusive of the entire population. I think the noble Earl said "yes" to that question.

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