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Clause 14 transfers responsibility for a number of public health activities from the Secretary of State, including the transfer to clinical commissioning groups of the Secretary of State's responsibility for the supply of wheelchairs. This issue has not come up; noble Lords seem to be relatively content. I hope that, if they are concerned, they will make contact in time.

Clause 19 allows the Secretary of State to delegate by arrangement his public health functions to the NHS Commissioning Board, clinical commissioning groups or local authorities. Where the Secretary of State enters arrangements under new Section 7A, the function will remain that of the Secretary of State, but it will be exercised by the body that is under and subject to those arrangements. When a local authority, the Commissioning Board or a clinical commissioning group exercises the Secretary of State's public health functions, it will be liable for its own acts or omissions. However, the Secretary of State will remain responsible for the function in the sense that he will be accountable to Parliament and will have to check that continued delegation is appropriate and that the function is being exercised appropriately.

The noble Baroness, Lady Finlay, spoke about "and" and "or". I assure her that the provision is expressed in a non-excluding way. I know that "chair and table and desk" appears to mean that you have everything, but if you put in "or" it makes it easier: if you have a chair and table, you are not ruled out if you do not have a desk as well. I hope that the noble Baroness is reassured. When I sought explanation about when to use "and" and "or", it was explained that having "or" makes a provision more inclusive than having "and". Therefore, the noble Baroness can be reassured that we are not going down the line of wanting treatment with no diagnosis. I cannot imagine that the medical profession would agree to that even if we were to propose it.

Baroness Finlay of Llandaff: I am grateful for the reassurance that the noble Baroness does not see any way of uncoupling diagnosis from treatment. I am not terribly comfortable with the furniture analogy. Pieces of furniture are not as complex and integrated as human bodies.

Baroness Northover: I have a feeling that carpenters might disagree. Nevertheless, I take on board what the noble Baroness says, and I hope that I have reassured her.



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Where was I? I think that I have covered the points spelled out by various noble Lords on research and evidence. Research and evidence would rightly run right the way through these arrangements, and I would have expected noble Lords to flag this up. It is absolutely crucial that evidence underpins the work that is done. I heard what was said about nudging, and so on. The Select Committee itself said that it welcomed the exploration of new ways of doing things, provided that they do not dislodge other ways of assessing things. It is extremely important that, in all these areas, you assess what the impact of something is. I hope that noble Lords will be reassured. We will come on to this in a minute.

Lord Warner: I suggest the noble Baroness reads the report of the inquiry chaired by the noble Baroness, Lady Neuberger, which makes it very clear that the scientific evidence to back up nudge as a way forward is extremely weak.

Baroness Northover: I hear what the noble Lord says. To judge so quickly something which has only exploded on to the agenda relatively recently does not seem to me to be terribly scientific. As a former social scientist, I do not think that that is giving quite enough time to assess it. However, the Government absolutely hear what the noble Lord says. We need a range of ways of exploring things. If people suggest ways of probing and investigating areas, then all those areas need to be assessed properly, and given due time to take effect.

I was about to come on to the point that, in this Bill-noble Lords have flagged this up-there is provision for continuing to measure children even though that public health responsibility has gone over to local authorities. It underpins our understanding of the extent to which we have obesity among children. It is extremely important that it is carried forward, and I think that that bears out the Government's commitment to continued research.

I have covered patient records. The noble Lord, Lord Turnberg, asked about child services. I know that my noble friend will be coming back into full view in a minute, and will address some of these areas, so maybe that is best covered then. We are extremely concerned to make sure that, across all areas, these matters are properly co-ordinated.

I have addressed the point raised about the separate annual reports. The Secretary of State is reporting generally, across all these areas. I hope that I have not missed out any key areas. There was a question from the noble Lord, Lord Turnberg, about Public Health England. It will indeed be able to receive research funding from the majority of sources from which the HPA is currently receiving research income. This was a key point that was flagged up by noble Lords last night, and it has been confirmed. Research is clearly vital for the specialist expertise required in Public Health England.

I appreciate noble Lords' probing on all these important areas, but I hope that at this stage the noble Lord will be happy to withdraw the amendment.



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2.15 pm

Lord Beecham: My Lords, I am grateful to the Minister for her reply, although I shall resist the temptation to follow her into the realm of rearranging the furniture or even the deckchairs on the NHS "Titanic". She rather missed the point of Amendment 69ZA, which adds to the provision in the Bill that will require each local authority to,

the duty to take such steps as are appropriate to tackle the problems of health inequalities. That is the point that the amendment seeks to enshrine in the Bill. It is a duty that will lie on the Secretary of State for national purposes, but not for local purposes.

Baroness Northover: I am sorry that the noble Lord feels that I did not adequately deal with that. The point I made is that moving public health to local authorities will join up a lot of the other factors-housing, the environment and so on-for which they have responsibilities. As the Marmot review highlighted, that should help to address some of those areas.

It is also worth bearing in mind that the Equality Act introduced by the previous Government is relevant across all these areas and in terms of the groups with protected characteristics. Many of those who suffer from particularly bad health would be covered by that.

Lord Beecham: My Lords, it is surely clearer to have in one place the responsibility for reducing health inequalities. The amendment simply adds to the Bill:

That is the right place to have it when one is delegating that responsibility. The noble Baroness referred to the ring-fenced grant, which will, of course, apply to the public health function but, as she has just said, the public health function is not confined to what might be described as health expenditure. This duty to reduce health inequalities as part of local government's new responsibilities should be embodied in statute, to ensure it in the consideration of the rest of local authorities' functions and budgets.

I noted the remarks of the noble Baroness, Lady Williams, who is not in her place. She seemed to think that the Government have given independence to public health bodies. I hope she is right in her inference, but I am not so sure. We will return to this matter when we discuss Public Health England and other aspects of the Bill, including the role of public health specialists and directors of public health within local government. There are amendments that reinforce the independence of such postholders which are necessary additions to the Bill. I accept that the Government's aspirations may be in line with that, but it seems to me that the Bill does not go far enough in providing them.

I want to return briefly to my amendment, which I do not think the Minister referred to, which is based on the recommendations of the Select Committee report on the public health impact of budget changes for the national level of public health, which affects Public Health England and the local authorities. I refer to the observations of the Select Committee:



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"The Department of Health must also make clear how the actual level of funding for public health will relate to the historic baseline. We seek reassurance from the Department that, in setting the public health budget, it will take account of objective measures of need. This must apply in respect of both the national budget and allocations to local authorities".

The next paragraph says:

"Although the Department of Health states that, in the current reduction of NHS management and administration costs, frontline public health services are being protected, we have heard evidence to the contrary. Furthermore, the Department has failed to give a convincing account of its distinction between frontline and non-frontline spending in public health services. Unless it can do so, the suspicion will remain that it is an arbitrary distinction and that public health services are suffering, and will suffer, in consequence of the cuts that are being made".

In relation to the health premium, which as yet we have barely explored, the committee said:

"We are concerned about the proposed introduction of the Health Premium. We believe there is a significant risk that, by targeting resources away from the areas with the most significant continuing problems, it will undermine their ability to intervene effectively and thereby further widen health inequalities. Although many witnesses welcomed the proposed ring-fencing of public health budgets ... and the Committee understands the short-term attractions of this approach, it does not believe it represents a desirable long term development".

After further analysis, the committee said that,

Baroness Northover: I am sorry that the noble Lord thought I did not cover the first point. I did not make myself clear. With regard to the total figure for the health premium, which I mentioned briefly-and the Department of Health will be publishing something shortly-there is consultation on that. There is always controversy over how best to do that. I recognise what the Health Select Committee says about not wanting to have an inadvertent removal of money from where it is most needed to an area that might need it less, which appears to have done better and so on. These things are clearly very complex, as the noble Lord will know, and there is consultation on how best that should be taken forward so that it is most effective and does not have that unintended consequence.

Lord Beecham: Of course there is consultation going on. It has been going on for an inordinate amount of time and we need to see the outcome of that-as indeed does local government-during the passage of this Bill, I hope. These are critically important matters which at the moment remain opaque, to put it mildly. Of course there will be a report in due course, but the financial aspects of that report must be consistent with the thrust of the policy, and on that we are clearly not in a position to make a judgment. This is a matter to which we will clearly have to return, possibly in conjunction with the Bill, possibly separately. If local authorities are to undertake these increased responsibilities, there will have to be a satisfactory system to make possible the operation of the machinery that the Bill is creating.



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Having said that, I acknowledge that these are all probing amendments. I hope that the Government will look at some of them with a view to possibly adopting them in future. On that basis, I beg leave to withdraw the amendment.

Amendment 60B withdrawn.

Amendment 61 not moved.

Amendment 62

Tabled by Lord Warner

62: Clause 8, page 4, line 26, at end insert "using the best scientific and other evidence available and without regard to special interests"

Lord Warner: My Lords, I do not wish to prolong this debate. I was very grateful for all the support that I got around the House for some of the ideas in these amendments. I wish to give notice to the Minister that I remain unconvinced by what has been said so far-that the Secretary of State's duty will be exercised in a way that guarantees he takes account of independent scientific evidence. We will return to that later in this debate, but in the mean time I will not move my amendment.

Amendment 62 not moved.

Amendments 62A to 65 not moved.

2.24 pm

Sitting suspended.

2.55 pm

Amendment 65A

Moved by Lord Sharkey

65A: Clause 8, page 4, line 37, at end insert "in particular, public information and advice campaigns, especially those aimed at improving the levels of early diagnosis of serious conditions"

Lord Sharkey: My Lords, each of the four amendments in my name is a probing amendment. All the amendments refer to one particular aspect of NHS activity: public health information and advice campaigns. The Department of Health has a long and distinguished history in deciding which issues need such campaigns, and actually running, funding and monitoring the campaigns. In this area there is a very large body of experience and expertise that resides in the Department of Health. Many of these public health campaigns have been very successful. Thousands and thousands of lives have been saved as a direct outcome, and these campaigns are an established and key part of the public health armoury.

The most obvious part of many public health information and advice campaigns is often the mass media component, but there is always much more to it than that. In June 2004, the Health Development Agency noted that these campaigns typically also involve the mobilising and supporting of local agencies and

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professionals who have direct contact with the campaign target, bringing together partnerships of public, private, professional and voluntary organisations, and encouraging local and national policy changes so as to create a supportive environment in which people are more able or willing to change their behaviour. Devising and managing these campaigns is a demanding and difficult job. The Department of Health has been doing this job very well for decades. Importantly, it has been doing this job centrally. This is not just a reflection of the current NHS architecture. For the public health and information campaigns to work efficiently, simple direction and control is a necessary requirement.

The Department of Health is running a national obesity campaign and a national dementia campaign. In January there will also be a national campaign aimed at raising awareness of the symptoms of bowel cancer. Each of these campaigns builds upon a solid foundation of knowledge and experience of the issues, and of what it takes to run a successful campaign-knowledge and experience held, not exclusively, but very largely, in the Department of Health. Each of these campaigns can reasonably expected to be directly responsible for saving thousands of lives, and for improving the efficiency of the NHS.

The success of the original and groundbreaking HIV/AIDS campaigns in the 1980s, under the direction of my noble friend Lord Fowler, is well known. That success continues. Recently, regional pilots of dementia and bowel cancer campaigns have shown, for bowel cancer, a 48 per cent increase in the number of people visiting their GP with symptoms, and for dementia, 63 per cent of people aware of the campaign said that they would visit their GP if they saw any possible symptoms. There is a long-standing and proven ability of public health information and advice campaigns to generate early awareness and early action, both things absolutely critical for dealing effectively with some of the more serious medical conditions.

Success rates in cancer treatment are a prime example of this. We know that England's cancer survival rates are currently poorer than those of many comparable countries. I know that we are part of the International Cancer Benchmarking Partnership to try to understand why this is, but without waiting for a definitive answer, it is quite clear that early diagnosis is an absolutely critical factor. In Improving Outcomes: A Strategy forCancer, published in January of this year, the Department of Health notes that improving public awareness of the signs and symptoms of cancer and encouraging people to visit their GP when they have these symptoms, is a key ambition. That is why the Department of Health last year provided £9 million to support cancer awareness campaigns. It is a crucial feature of these campaigns, and most others, that they are very largely given priority, direction and funding centrally by the Department of Health.

My concern, and the point of my amendments, is that in the new architecture of the NHS, this central direction and funding will disappear, either suddenly, or more likely, gradually, as current and planned campaigns reach the end of their lives. I entirely accept that the Government understand the merit of public health information and advice campaigns and

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would want them to continue. I am much less certain, however, that they will continue in any effective form if responsibility for them is diffused throughout the system and central control and funding vanishes. It is not of course that I think that there will be local objections in principle to public health information and advice campaigns, but in hard-pressed localities there may well be a temptation to assign lower priorities and less funding to them. Even if the local need for such campaigns is acknowledged and acted on, making sure that the campaigns are properly devised, properly run and properly integrated will present difficulties without clear central oversight.

3 pm

The first three amendments are aimed at making explicit the Secretary of State's central responsibility for public health information and advice campaigns, and explicitly require him to consider the desirability of such campaigns when he draws up the mandate. The final amendment requires the board to include public health information and advice campaigns in its duty to promote education. These are all probing amendments, which are looking, essentially, for two things. First, they seek an assurance that large-scale public health information and advice campaigns will continue to exist and will be an important part of the public health armoury. Secondly, they seek an explanation of how in future public health information and advice campaigns will be originated, how they will be driven and how they will be controlled, funded and assessed. I beg to move.

Baroness Gould of Potternewton: My Lords, I support these amendments, which are so relevant to recent proposals in the Select Committee report on HIV/AIDS. The Bill calls for the Secretary of State to take steps to promote public health in England from disease or dangers to health. Without a doubt the most effective way of achieving that aim is through the provision of public information, advice and awareness-raising campaigns, first, in respect of prevention and, secondly, in respect of early treatment and care.

That proposal would mean the promotion of early testing as well as testing for the estimated 22,000 people who have HIV but do not know that they are infected and who, as a consequence, are likely to transmit the disease further. It would also ensure the availability of testing. At the moment the venues for testing are fairly restricted but the Government are considering proposals by the HPA and NICE to widen the range of settings where testing might take place, particularly in areas of high prevalence. We await the Government's decision on those reports. The need to raise awareness of early testing is crucial to prevent onward transmission of the disease. There is no better example than the evidence obtained from antenatal clinics which have had campaigns and have given information to pregnant women about mother-to-child transmission and where the number of such cases is now extremely low. That advice should be taken by the Government.

I raise these points specifically because the Government's response to the Select Committee on the need for awareness-raising campaigns did not give the assurances that we might have hoped for. While

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there are campaigns currently targeted at those most at risk of HIV-we hope that they will continue, but we are not certain that that will be the case-it was very short-sighted that there was no guarantee of the inclusion of HIV on any national sexual health campaigns, if in fact there are to be any. This amendment would be helpful in making that happen. There was a complete rejection of campaigns directed at the general public. Those were not considered to be necessary, yet we know that there is a growing diversification of HIV into other communities. For those people, early diagnosis is essential.

There was, however, a welcome for a web-based campaign run by the National AIDS Trust, which is specifically designed to get prevention and awareness messages to the general public. In a sense, therefore, we have a little contradiction in the need, and the process does go round in a circle. Lack of awareness by the public is one reason why the stigma of HIV persists and why there are so many mistaken beliefs about HIV. It is often the fear of that stigma that deters people who might be at risk from going for HIV testing or even STI testing. Effective awareness-raising campaigns would overcome some of those difficulties and are essential if we are to promote early testing and reduce the levels of HIV, which are growing each year, and thus reduce the levels of transmission.

It seems to me that not to have those campaigns is not only poor health practice but economically short-sighted. The HPA suggests that, if we had prevented the estimated 3,800 or so HIV infections acquired in the UK in 2010, we would have saved over £35 million annually, or £1.2 billion over a lifetime of cost. Treatment is very expensive. That seems to me an enormous amount of money when compared to the cost of running effective and regular public awareness-raising campaigns. Surely common sense tells us that the campaigns should continue.

Baroness Masham of Ilton: My Lords, these amendments relating to campaigns are very important. My question is: who will be carrying them out? I would like to highlight the problems of late diagnosis of HIV/AIDS, tuberculosis, hepatitis B and C, and meningitis.

Many people are living with HIV/AIDS who do not know that they are infected. There needs to be sensitive targeting of campaigns. If diagnosis is late, the condition is much more difficult and expensive to treat, as has been said. There are often co-infections of HIV/AIDS and tuberculosis. Late diagnosis in TB is very dangerous. Along with the growing problem of drug-resistant TB, there is extensively drug-resistant tuberculosis, which is very dangerous and much more expensive to treat and takes much longer.

I would like to mention the effective and important work of the group Find & Treat, which goes out to find homeless and other people who are difficult to find, who may have TB, and test them. The group now wants to test for co-infections, which would be much more effective and less expensive in the long run. This type of infection is on the increase. There is a fear that, unless local authorities and the National Health Service

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work together, there may be fragmentation, and these people, who should be treated early, may fall through the net. Find & Treat needs all the support that it can get to carry on this very important work.

Hepatitis B is very infectious, but there is now a vaccination, which is good. However, there is no vaccination for hepatitis C. Both types of hepatitis have been found to be a huge problem in prisons. There is a problem of liver disease with hepatitis C. Early diagnosis is important for all infections. In the case of meningitis, there have been far too many tragedies because of late diagnosis. The public-and doctors-need to be reminded continually how important this issue is by means of campaigns and guidelines. My GP always waits for guidelines from the Department of Health.

Baroness Randerson: My Lords, I speak in support of these amendments tabled by my noble friend. I strongly welcome the provisions in this Bill that ensure that the NHS and local governments work together on public health. I believe that these provisions are long overdue. However, as my noble friend said, we need to ensure that central responsibility and control is retained to be able to have high-profile, national public health campaigns.

I am the co-chair of the All-Party Parliamentary Group on Hepatology and I participate today from that perspective. I wish to speak especially about hepatitis C. In the summer, the group produced a report emphasising the points that I am making about the importance of national public health campaigns. The current proposals will affect those suffering from this disease and will improve the response at a local level. However, they will also ensure that we need a national response. Hepatitis C is a preventable and curable cancer-causing, blood-borne virus. The main groups affected are intravenous drug users, or those who have been, and certain ethnic groups from south Asia who were also badly affected because, very tragically, they were immunised in childhood during mass immunisation campaigns using dirty needles.

As has been said, a stigma is attached to hepatitis C, as it is to HIV/AIDS. As a result of that stigma, it has largely been ignored by government ever since it was first identified in the late 1980s. Deaths from the disease are rising; mortality has risen by between 39 and 45 per cent since 2005 and the number estimated to be affected is between 250,000 and 466,000. I say "estimated" because the majority of those affected are undiagnosed. That is the key point in relation to public health campaigns.

The picture in Britain is not the same as the picture in most of the rest of Europe. Elsewhere deaths from the disease are falling because there have been high-profile public campaigns and strategies to deal with the disease. As a result, diagnosis has been very much earlier. I said that the majority of people suffering from the disease are undiagnosed, but why is that? They are undiagnosed because it is a tricky disease. It remains asymptomatic for 10, 20 or even 30 years, and by the time the symptoms occur it may be too late for a cure. It is certainly very possible that any attempts at treatment are very complex and expensive. That outcome can be

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a result of the stigma, but it can also be a result of ignorance because we have had no big public health campaigns. There is ignorance on the part of clinicians and the public. Delayed diagnosis costs not just lives but a great deal of money. There is a range of clinically effective and cost-effective treatments for the disease that can cure and that are recommended by NICE, and more and better treatments, due to go to NICE in the near future, are in the pipeline.

That is the background. As I see it, that is how the Bill will help, but it needs to be improved in order to help even more. The local government NHS LINk will enable local public health campaigns to focus on local needs. Given the list of at-risk groups that I have described, it is obvious that an area with a high population of those from south Asia, for example, will be enabled to target their health messages appropriately. An area that is aware that it has a particular problem with drug use will do the same. Of course, many people will be affected by the disease who do not live in those target areas, and they need to be screened and treated in the same way, so local campaigns need to supplement and bolster national information campaigns, not replace them.

We have already heard from my noble friend reference to the dementia campaign that is currently being run, and there has been reference to the AIDS campaign. I would say very strongly to the Minister that we need a hepatitis C campaign of similar impact. Without the proposals in these amendments, I believe that there might not be sufficient obligation on the Government to co-ordinate these campaigns. I very much look forward to Minister's response on this issue.

My final point is that successful national and local campaigns will inevitably have a knock-on effect on commissioning services. More patients will be diagnosed, and that will mean more needing treatment. In the long term, of course, there will be a fall-off in the demand for treatment because of higher public awareness and, one hopes, very much safer behaviour as a result. That fall-off will take years, however, and it is essential that GP services, hospitals services and, for example, drug and alcohol action teams all have the increased capacity brought into line at the same time as such campaigns take place. It is therefore even more important that there is the central control and direction to which I referred. That is just one example; other noble Lords have given similar examples, and I urge the Minister to give this serious consideration.

3.15 pm

Lord Davies of Stamford: My Lords, there is no provision on the Order Paper for debates on Clauses 8 or 9 to stand part. Rather than risk taking up the time of the House by necessarily opening such a debate, I wanted to make a few general remarks under the heading of this group of amendments because it touches on Clauses 8 and 9.

All of us in this Committee are very concerned about public health. It is a priority for anybody in public life and really must be. Some telling points have been made both this morning and this afternoon, and I particularly retain the remarks about the importance of addressing the threat of obesity, which we know

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causes an awful lot of medical conditions, and the very important issue of tobacco smoking. We have made tremendous progress in public health by bringing down smoking. The results are already clear in the reduction of the incidence of some of the cancers. It is also important to address the threat of sexually transmitted diseases, and some very good and sensible things have been said about AIDS and hepatitis B and C. To that list I would add chlamydia, which does not normally have fatal consequences but has very sad consequences for infertility. It is far too widespread at the present time.

There are a number of other areas about which we should all be concerned. One that concerns me is the introduction into this country of tropical diseases by airline passengers and the great importance of making sure that clinicians are properly trained to identify the symptoms as rapidly as possible and to deal with them. The facilities are there to quarantine where necessary people who have highly infectious tropical diseases.

Another public health risk that we ought to be aware of is the danger of strains of bacteria emerging that are immune to antibiotics, very largely as a result of the excessive and irresponsible prescribing of antibiotics-sometimes quite disgracefully as a placebo-and a lack of discipline on the part of patients in completing a course of antibiotics. That is a serious issue that has not been addressed by any public campaign, as far as I know.

All of us are concerned about the danger of a viral epidemic in the form of some new strain of flu or something of that kind. We are very much aware of it because the media talk about it a lot. That has not gone away; we must not get complacent about that. I am glad that in the area of the protection of public health, the Government have made it clear that, unlike in the area of the provision of clinical treatment, the Secretary of State has a clear responsibility stated explicitly and unambiguously in the Bill.

However, the Government have missed an opportunity to simplify and rationalise the bureaucratic structures and lines of accountability. That would have been very desirable. What is emerging here is an extremely complex structure of responsibility. The Secretary of State uniquely has responsibility for taking necessary measures for the protection of public health but shares that responsibility with local authorities in the area of improvements to public health. The Bill makes it clear that the Secretary of State "may" and local authorities "must" take measures in this area, so there is the prospect of a highly undesirable situation in which the Secretary of State takes such action but that duplicates what local authorities are doing. I do not think we have heard in the course of the debate exactly how the Minister envisages the relationship between Public Health England, the Secretary of State and local authorities with their new medical officers developing. I almost called them "medical officers for health" because I think this is a revival of that old concept, and they did a wonderful job in their time. However, I believe that they are going to be called "directors of public health" and are to be established under Clause 9 by all local authorities.



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We need to understand what the relationship between these bodies is going to be. The noble Baroness, Lady Northover, said earlier that the Health Protection Agency is to be abolished. That is what it states in the Bill, but I understand that actually it is going to be subsumed more or less in toto into Public Health England. We need some transparency on that. I would like to know how many people are going to be involved in the agency because these bodies can be extremely expensive. We want to make sure that we are getting proper value for public money.

I am particularly concerned about the suggestion in Clause 19 that the Secretary of State may devolve on to clinical commissioning groups or the National Commissioning Board his responsibilities in the public health area. So there we have another bureaucracy that has the potential to become involved without being clearly defined. There is a frightening element in that clause which provides that any liabilities arising as a result of the involvement of the National Commissioning Board or clinical commissioning groups in the public health area will accrue to those bodies and to no one else; in other words, not to the Secretary of State. The Secretary of State is not delegating his authority; he is not using the National Commissioning Board or clinical commissioning groups as his agent under his direction, which would be an appropriate thing for him to do; but rather he is abandoning his responsibility to this completely different set of bodies whose main job is in the area of diagnosis and treatment. Again, that is a very confusing picture.

The proliferation of bodies and lack of clarity about bureaucratic responsibilities should be a matter of concern to us all for at least three reasons. The first is that it makes it very difficult for the general public. I find it difficult to understand exactly what the hierarchy of responsibility is. Human beings never give of their best unless their responsibilities are clearly defined and demarcated so that they can be held responsible for those areas for which they really are responsible. They are simply hopeless if other people might be equally responsible. We have not talked about the health and well-being boards. What have they got to do with public health? It is quite unclear to me, but presumably they have some role in this area. It is very confusing and I think that that is very undesirable.

The second reason is the matter of cost. Anybody who has dealt with the NHS as a Member of Parliament, as a business or in any other context knows that one of the great troubles with the NHS is that whenever a decision needs to be taken, there are around 26 people in the room from at least 12 different departments and agencies. That is extremely bad from the point of view of clear decision-making. It means that all decisions take a long time and the costs go up indefinitely. It seems that we have a formula in the area of public health for the replication or even the aggravation of that problem.

The third reason why we should have clarity of responsibility in this area is because people do not perform if they can simply get out of any kind of sense of responsibility by saying that it is someone

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else's fault. We are providing endless opportunities for excuses to be made and for people to avoid their responsibilities. I would be very relieved if the Minister could reassure me that these fears are groundless and give clear reasons why that is so.

Baroness Hollins: My Lords, I shall speak briefly about the importance of information in an early diagnosis. I have two areas to focus on. First, people with learning disabilities often get a late diagnosis and suffer terribly because of it, with an earlier death as a consequence for many. Often that is because of a lack of accessible information. I speak as the executive chair of a social enterprise, called Beyond Words, which designs pictorial information to try to bring health and social care information to people who cannot read. Any public health information campaigns need to remember that not everybody can read information easily; it has to be designed to be inclusive.

Secondly, I have a question about how the accessibility of information about the bureaucratic structures of the NHS will help with early diagnosis. This is to do with the current "choose and book" system. Something that has happened to a close relative of mind in the past few weeks made me realise that I do not know how the Bill is addressing the whole issue of better choice for patients. I will briefly tell noble Lords the story. It is about somebody who needs an early diagnosis for what seems like a serious, rare, long-term condition and who has been referred through the choose and book system to four different hospitals to see four different specialists in different areas, where those specialists cannot easily communicate with each other because their hospital systems do not speak to each other. The person concerned chose the hospitals that offered the earliest appointments, which is what most people do and what choose and book offers you. You take the first appointment because you are worried, but the hospital consultant is unable to refer to a consultant in the same hospital with whom they would be able to consult. The patient has to go back to the GP and back through the choose and book system. It is not working.

There is something about information and early diagnosis here as well. I could not see where, apart from under information, I could raise this issue. I look forward to hearing a response from the Minister.

Baroness Northover: My Lords, Amendments 65A, 71ZA, 97A and 133A seek to raise the priority within the Bill of public health information advice designed to encourage the early diagnosis of serious conditions. Improving early diagnosis is an important objective across the whole health system, which includes the new public health system. I am very grateful to noble Lords for raising such a significant issue.

I completely agree with my noble friend Lord Sharkey as to the important role of information advice campaigns. I hope that I can reassure him that the changes to public health will not see the end of such campaigns. Where such campaigns work, we want to see more of them. We know how important early diagnosis is in treating cancer, for example. Thus, people coming forward for bowel cancer screening can be diagnosed at a stage where the disease is totally curable.



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The noble Baronesses, Lady Masham and Lady Gould, emphasised other areas in which treatment is more effective earlier but also where there is a risk of infection, such as HIV, TB, hepatitis and meningitis. The noble Lord, Lord Davies, flagged up other STDs, among other issues. We are well aware of the importance of these areas. This is also where local authorities' involvement in public health should assist rather than detract. The noble Baroness, Lady Gould, rightly flagged up this issue in relation to HIV/AIDS. No doubt we will return specifically to the points that she has raised when we debate HIV/AIDS on 1 December, World AIDS day, a debate to which I am responding. I look forward very much to our discussions then.

We will no doubt come back later to wider discussions of Public Heath England and the directors of public health, to which the noble Lord, Lord Davies, referred. Perhaps his notions can be revisited then when attached to the appropriate amendments.

As I outlined in the debate on the previous group of amendments, Clause 8 sets out the Secretary of State's new duty to take steps to protect public health. It illustrates this duty with a list of steps that would be appropriate for the Secretary of State to take. That list includes the provision of information and advice. Amendment 65A would amplify that to specify that this could include information in campaigns around early diagnosis. I should explain that the list in Clause 8 is neither prescriptive nor exhaustive. The amendment would not therefore either require or give the Secretary of State a new power to do anything that the clause does not already accommodate.

Similarly, Amendment 71ZA would have the equivalent effect on a list of steps that local authorities may take under their new duty to improve public health. As we have already said, local authorities' new responsibility will include behavioural and lifestyle campaigns to prevent serious illness and they will be funded accordingly. The Department of Health is also working with stakeholders from the NHS, local government and voluntary and community sectors to finalise the operational design of the new public health system. We expect to publish proposals shortly and they will set out how we expect to promote early diagnosis through the system.

Of course, the NHS will continue to play an important part in public health, a point emphasised by the noble Baroness, Lady Finlay, earlier. The Bill allows the Secretary of State to mandate or agree particular services that will be the responsibility of the NHS Commissioning Board. Amendment 97A seeks to ensure that he will consider early diagnosis campaigns when he does so. I hope that the noble Lord, Lord Sharkey, will be reassured that this is something which we are already considering. I can also reassure noble Lords that the objective of Amendment 133A is already met by the clause as drafted. Where the Commissioning Board is engaged in early diagnosis campaigns, then the duty to promote the integration of services would automatically apply to those campaigns just as they would to any other health, or health-related, services.

I emphasise that we especially expect advice and information to continue to play a major role in early diagnosis and local authorities will be able to contribute

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to that. Meanwhile, Public Health England, too, will be able to manage and support effective national campaigns. We will be publishing further detail shortly on how the different levels of the system will work.

In short, I believe that we are in total agreement with noble Lords about the principles underlying their amendments and with what noble Lords have said in the debate. We share their desire for improvement in this area. We all know what huge potential early diagnosis offers and the vital importance in this of public health campaigns. The Bill as drafted offers all the necessary support for that ambition. I therefore hope that the noble Lord will accept that and withdraw his amendment.

Lord Beecham: My Lords, as we are in Committee, I can repair my omission in failing to anticipate the Minister's response to what has been a very good debate. I congratulate the noble Lord, Lord Sharkey, on tabling these amendments. I take issue with him slightly over one matter he mentioned: the relative performance of this country in terms of cancer survival rates. Recent reports make clear that they have improved substantially and are now beginning to outstrip those of other comparable health services. However, that does not detract at all from the thrust of the amendments.

The Minister referred to bowel cancer screening. That is but one example of the importance of early diagnosis, and public information can certainly assist in that context. As some of your Lordships may recall, I have some personal experience of this because my wife died of colon cancer last year. Her symptom was constipation, which is not a predominant symptom. Relatively speaking it is a less frequent symptom, but even now it is not something that some of the literature and material produced by cancer charities refers to. That is an illustration of the need for clear information to be given. There has been a very successful campaign about stroke, which was temporarily halted and then resumed. There is clearly a role for that kind of campaign. I should have thought that the Government could accede to the request for these duties and responsibilities to be included in the Bill.

Although I certainly strongly support the amendments, there are perhaps two riders that I might add. The first is that information, which of course can be in many forms, is not of itself necessarily enough. For example, information in labelling on food does not convey very much to people. This is an example of nudging not being enough. In some cases what is needed, apart from information, is action, and I hope that, as part of their public health agenda, the Government will take a rather firmer line in making requirements of the food industry and others concerning what goes into the nation's diet.

The other rider relates to the efficacy of some kinds of campaigning. This does need to be measured. Some campaigns-noble Lords have referred to them-have been extremely effective; others, less so. The rather dramatic advertising about HIV and AIDS in the early days was not thought to have been particularly effective. It seems to me that in the interests of effectiveness and efficiency-that is, in terms of the expenditure involved-we need to evaluate what sort of campaigning and publicity works.



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With all those qualifications, such as they are, I strongly support the noble Lord's amendments. I hope that the Government will take another look at whether sending a very clear signal by having these kinds of amendments made to the Bill would assist what we all agree across the House is a prime responsibility and a prime opportunity for the Government to advance the public health agenda.

Baroness Northover: My Lords, my apologies if I leapt up far too soon. I caught the noble Lord's colleague's eye and it looked as though no one would be speaking from that side of the Chamber. However, I am incredibly glad to hear what is in fact cross-party support for this kind of campaign. The noble Lord is absolutely right: the part that charities play and have played in many of these campaigns is absolutely critical, not the least of which is Cancer Research UK and its various campaigns. Therefore, I thank the noble Lord for his contribution.

Lord Sharkey: I thank all noble Lords who have spoken to the amendments and I thank the Minister for her response. I should also like to register the propensity of all Governments to make sudden cuts to public information campaigns. Last year, the Government announced a freeze on their £540 million annual publicity budget. On 29 May this year, they announced a partial thaw, with expenditure of £44 million on four campaigns in England. This followed the publication of a Department of Health report called Changing Behaviour, Improving Outcomes, which found that, for example, after the cessation of campaigns, calls to the Change4Life information line fell by 90 per cent, calls to the FRANK drugs line fell by 22 per cent and visits to the NHS Smokefree website fell by 50 per cent.

All that illustrates my continuing concern that it is too easy to cut public health information campaigns and that it might be even easier in devolved organisations. Therefore, notwithstanding the Minister's helpful response, I continue to believe that we need safeguards against such cuts written into the Bill. I look forward to discussing this again on Report. I beg leave to withdraw the amendment.

Amendment 65A withdrawn.

Amendment 66

Moved by Baroness Finlay of Llandaff

66: Clause 8, page 4, line 38, at end insert-

"( ) providing services for the prevention and treatment of harmful drinking and alcohol dependence."

Baroness Finlay of Llandaff: My Lords, I hope the Committee will agree that it would be more convenient to discuss the spirit of this amendment when we come to the later group of amendments that focus on issues around alcohol-the group beginning with Amendment 71 -and that the other amendment in this group, Amendment 74B, warrants a short debate in its own right. I beg to move.



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Baroness Thornton: My Lords, I thank the noble Baroness. This small amount of grouping and degrouping was partly to do with having everybody present and correct for a good debate on alcohol and its dependency.

However, Amendment 74B in my name and that of my noble friend Lord Beecham raises an important issue. I was heartened to hear the Minister say that there is a list in Clause 8 that was not exclusive, because this amendment is about a list that is not exclusive that we want to put in the Bill.

I start by marking the fact that today is national COPD day. It is appropriate that when discussing public health, we should mark the fact that millions of our fellow citizens have chronic obstructive pulmonary disease, and many of them have it as a result of their lifestyle choices that they made possibly when they were very much younger. It is very appropriate that in this debate about public health, what leads people into chronic conditions should be part of it. I also mention the fact that today-not unrelated to this-the British Medical Association issued its call for a ban on smoking in cars and an extension of tobacco regulation, which also merits some consideration.

Amendment 74B places in the Bill a by-no-means-exclusive list of matters that are important for the improvement of public health. We are trying to tease out whether and how a comprehensive approach to public health, which takes account of all pertinent matters, becomes possible in the framework that the Government are outlining for the promotion of public health. For example, the list includes issues such as employment or the lack of it, poor quality housing and its effects on health, air and water quality, and so on. They all concern the improvement of public health.

One of the reasons behind the amendment, and its place in the Bill, is that it also concerns the disbursement of grants and loans in Clause 9(4). As has already been said, we are also exploring what the Secretary of State and local authorities might, and could be expected to spend their funding on. I return to the question raised by my noble friend Lord Beecham about the public health premium. If we apply the proposed list in the amendment to my home town of Bradford, where there are very high indices of deprivation, how will the areas with the most severe and serious deprivation qualify for a public health premium when they are starting from such a very low base? I am sure that there is an answer to that question but I would like to have it on the record.

Evidence was given by the Association of Directors of Public Health to the Health Select Committee when precisely that point was raised. I hope that if the Government cannot answer my question now, they will be able to address it when they respond to that excellent report.

3.45 pm

Baroness Gould of Potternewton: My Lords, it is interesting that there is not a universally accepted definition of public health. There are, however, broad domains of public health, be they health improvement, health protection or health services. The Faculty of Public Health defines public health as:



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That is a very broad definition. It could almost include every range of local government services. It seems to me that there is a need for some guidance on what aspects should be included in the ring-fenced budget. We have previously been told that there will be no breakdown of the budget within that ring-fencing, which makes it even more important that some guidelines are laid down. The frequent reply from the Minister has been that we leave it to each local authority to determine what public health is. But while I appreciate that there will be a variation in needs between different authorities in different areas, some guidance and priorities might be useful to them.

I am delighted that my noble friend has highlighted sexual health as being important because there is a great deal of concern that sexual health will not be a favoured issue for many local authorities. Furthermore, as regards HIV for instance, there is no understanding that there is all too often a relationship between the required long-term care and other aspects of local government services. There is also concern that, unless it is highlighted, there will be a lack of understanding by local authorities of the divide within the commissioning arrangements for HIV and contraceptive services between the National Commissioning Board's responsibilities and their own-for prevention and testing in the case of HIV and for the establishment of clinics for special cases in the case of contraception. Guidance would give local authorities greater clarity of their roles and responsibilities and the fact that they are a key player in this process of integration. I am sorry to refer again to the response to the Select Committee report on HIV and AIDS, but it is so topical. The Government identify that integration where possible-whatever that means-will be by the NHS Commissioning Board, clinical commissioning groups and health and well-being boards. That will apply to all health services so there is no need to have a special duty applying to the integration of specific services, such as sexual health and HIV. However, I think that is a misjudgment. Having some identification priorities would give guidance as to which areas require special duties.

At Second Reading, the Minister referred to the Advisory Committee on Resource Allocation, which is an independent expert committee that has been asked to advise on a public health formula to inform the distribution of the public health grant across local authorities, saying that it intends to publish further detail later this year. So I appreciate that we are not going to get the detail for which I would have asked on the distribution of that grant. If we could get some detail, that would be very helpful, but perhaps I may remind the Minister that there is only two months left this year and I hope that we will get that response before the end of it. The calculation of spend on public health, including sexual health services, must be based on robust and accurate data, so can the Minister identify how that can be achieved without a specific definition of what it should include? I appreciate that the Minister has so far always rejected the idea of

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coming up with a definition and he certainly might not agree with the list that is before him. Nevertheless, I would be grateful if he could rethink this. There needs to be some principle laid down to make sure that local authorities understand what public health actually means.

Baroness Northover: My Lords, Amendment 66 would add alcohol services to the list of examples that the Secretary of State may take under his new duty to protect health and Amendment 74B would add a number of steps, including one on alcohol, to the equivalent list of steps for local authorities to take up under their new duty. I appreciate the decision by the noble Baroness, Lady Finlay, to regroup and we will discuss her amendments a little later. However, the noble Baroness, Lady Thornton, followed by the noble Baroness, Lady Gould, decided that the group should stay in place.

Adding to the Bill's list of steps that may be taken may highlight an issue but would not materially alter the situation. The noble Baroness, Lady Thornton, with her governmental background, is clearly extremely familiar with the function served by these indicative lists. I appreciate her indication that she is probing on this. Obviously it is extremely important in these different areas.

I also note the definition of public health that the noble Baroness, Lady Gould, quoted. I scribbled down the part about the science and art of promoting health and well-being through the organised efforts of society. That illustrates that this is an evolving and moving area. We hope that it will evolve and move because public health has now been put with local authorities. By joining up all the different areas we wish to join up, we hope that the field of public health will move along. Therefore, it is not appropriate to put in the Bill such a definition, which is set at a particular time, because of the evolution that I hope will expand in a way that the noble Baroness-who clearly is not satisfied-will be happy with.

Baroness Gould of Potternewton: We are talking about a ring-fenced budget; we are not talking about a general local government budget. Therefore, there must be some guidance on what should go into that budget. I do not mind whether it is a definition in the Bill or guidance, but something must be done to make sure that we know what is in the ring-fenced budget.

Baroness Northover: The noble Baroness is absolutely right. This is not simply philosophy. Therefore, regulations will provide that guidance. In the mean time, I say that this is an issue on which we have spent considerable time working. She is probably aware of the July 2011 update to the public health White Paper. If she is not, I suggest that she looks at it. Paragraph A.10 on page 27 contains a list of the areas in which we expect local authorities to engage. I am sure that the noble Baroness, Lady Thornton, will be pleased that the list starts with tobacco control. The noble Baroness, Lady Finlay, may note that the second item is alcohol and drug-misuse services. Other issues that noble Lords have mentioned are also listed, such as obesity and community nutrition initiatives. The list is long.



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Baroness Thornton: The Minister is giving a list-and there are at least two further lists in Clauses 8 and 9. I cannot see why my list should not be in there, too.

Baroness Northover: I can see the temptation. The list in the Bill is indicative. These lists are always subject to much debate about what goes in and what stays out. I fully understand why the noble Baroness wishes to add her list. However, we would resist adding to the list in the Bill, which is, as she knows, indicative. We appreciate people's contributions to what needs to be covered in these areas. I point out to her that the list-no doubt we will spend many hours debating the regulations-includes all sorts of things, such as mental health services and dental public health services. I will not read out the whole list. If noble Lords think that something is on it that should not be there, or that other things that are not on it should be, I am sure that we will consider those points as we debate the regulations.

I noted a response to the noble Baroness, Lady Hollins, but I think that I may be referring to a previous debate. She is absolutely right to emphasise that we have to make sure that everything we do is patient-centred. All the changes must focus on that. It is a challenge for everybody. Perhaps people have tried to do it before. No doubt we will have problems trying to do it ourselves, now and in the future, but that has to be the focus. Therefore, we have to remember the diversity of the patients that we are talking about. I am sorry; that answer belonged in an earlier debate.

I know that we will return later to debate alcohol. I hope that noble Lords will not press the amendments in this group.

Baroness Finlay of Llandaff: I beg leave to withdraw the amendment.

Amendment 66 withdrawn.

Amendment 66A not moved.

Amendment 67

Moved by Lord Rooker

67: Clause 8, page 4, line 38, at end insert-

"( ) The Secretary of State shall appoint a Chief Environmental Health Officer for England.

( ) The Chief Environmental Health Officer for England shall give advice to and report to the Chief Medical Officer for England on all such aspects of environmental and public health as are relevant to the public health functions referred to in this section and the duties referred to in section 2B of this Act.

( ) The Secretary of State shall report to Parliament annually on the work of the Chief Environmental Health Officer for England."

Lord Rooker: My Lords, this is a brief probing amendment that is mirrored by my noble friend's Amendment 75A, which is identical. I originally thought that I had tabled this as a new clause and it had appeared as an amendment. I would like to take the opportunity, by the way, to apologise to the House for

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being missing when a couple of the amendments that are in my name were moved by other noble Lords. My absence was unavoidable.

The reason for the amendment is straightforward: it is to test the views on the creation of a chief environmental health officer for England. Historically, of course, there has been a chief environmental health officer position since the days before 1974, when I was elected to the other place. It was abolished, I think, on 1 April 1974 during the massive reorganisation that year. That was the last time local authorities had the lead responsibility for public health services. Each local authority had a medical officer of health in those days-in Birmingham, in fact, we called them the chief medical officer of health.

Today, England has a Chief Medical Officer of health, but not a chief environmental health officer. The amendment, and my noble friend's new clause, proposes that the Secretary of State should appoint a chief environmental health officer for England. In Wales, there is a chief environmental health officer in post. In Scotland and Northern Ireland, there are arrangements that are similar to that. Indeed, there are things happening in the devolveds that are streets ahead of what is happening in England. I have to say that my experience is that Westminster, in the centre, is completely unaware of it all, mainly because, regretfully, there is not a degree of communication. The respect agenda is not actually being played out in practice. Nevertheless, these things are happening elsewhere and there is a good case for making similar arrangements in England. This would recognise the role played by environmental health in promoting health and well-being and the importance of assuring environmental health input into policy-making at the highest level. That is part of the key issue: to get it involved at the highest level.

There are some other amendments, for a further debate, that relate to the complications-again, unique in England-of two-tier local government. This issue does not arise in Wales, Scotland and Northern Ireland. There is a complete mishmash in England. The way in which we inherited the current two-tier local government structure was not planned. That actually highlights some of the difficulties with environmental health, which cannot be done and is not done at county level, of course, although I will save that point for other amendments.

England currently lacks this input into policy-making at the highest level. The appointment of a chief environmental health officer would assist in that area. I am very guided in this by the Chartered Institute of Environmental Health. It has made some very positive remarks about the Bill and given some input into this part of the Bill, in no way to whinge or criticise but rather to strengthen the Bill.

It is envisaged that the chief environmental health officer will focus on a preventive approach to achieving good health outcomes, and in particular on the wider determinants of good health and well-being. The postholder will be able to review the relevant data and advise the Department of Health, Public Health England, NICE and the Chief Medical Officer. It is envisaged as part of the package of proposals and amendments

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that the chartered institute has proposed that the chief environmental health officer answers to the Chief Medical Officer to have that input into preventive strategies and the wider determinants of health, in the widest sense that the public understand it, and to oversee the development of good practice within local authorities and their partner organisations.

4 pm

There is a real impact on local government because of the way in which the Bill moves aspects of what I will call the NHS into local government. It is crucial that people in local government, particularly environmental health officers, working as they are in a multitude of areas of activity for local government, feel that there is a head of profession to develop good practice, provide leadership at the very top and have input into policy and policy-making at the very highest level. An annual report to Parliament by the chief environmental health officer for England would not go amiss.

This is a probing amendment to test whether the Government have thought about this. It would be interesting to know what discussions they have had with local government. It would be very interesting indeed if the Minister could explain and show the House the benefit of any discussions the Government have had with Wales, Scotland and Northern Ireland about ideas of difference. Devolution means that things will be different. I make it absolutely clear that I am not arguing for things to be the same, but there are benefits that you can learn from discussion, and I am not clear that there have been such discussions. At the moment, England will be the loser, in particular because of the mishmash of two-tier local government, without the central leadership that a chief environmental health officer could provide. I beg to move.

Baroness Finlay of Llandaff: My Lords, I hope that the Government will be able to give some assurance that environmental health will be recognised in the new public health services that will be established. I became acutely aware of the importance and contribution of environmental health when I chaired the House of Lords Science and Technology Select Committee inquiry into allergy. Environmental health officers were most helpful on issues around climate change, air quality, diesel particles and the hyperallergenic effect of high levels of diesel in making pollen more allergenic.

When I chaired the inquiry into carbon monoxide poisoning, I had a great deal of help from the Chartered Institute of Environmental Health on gas safety and gas regulation. It brought its engineering and architectural expertise to inform that inquiry. It is important to be aware that although these professionals are called environmental health officers, they come from a broad range of backgrounds and bring in engineering, architecture and what you might broadly call environmental physics to inform the health debate. They are complementary to but not duplicated by the provisions in standard public health medicine.

Lord Greaves:I echo everything that the noble Baroness, Lady Finlay, has just said. The noble Lord, Lord Rooker, has raised some extremely important issues and hit some serious problems at the heart of

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the Bill. I am not sure that his solution is the right one, but it needs discussion. I am sorry that the noble Baroness, Lady Gould, in not in her place because she made the important point that the meaning of the phrase "public health" has evolved over the years. The core Public Health Act 1936 was about the role of local authorities in relation to public health and what we now call environmental health.

In the 1974 local government reorganisation, public health functions were split. Half went to the health service, the other half remained with local government, and the phrases "environmental health" and "environmental health officers" were largely invented at that time to distinguish the new environmental health service from what had previously been public health. Of course, in two-tier authorities environmental health is a function of the lower-tier authority.

The noble Lord, Lord Rooker, made a very important point. We have some amendments coming up, probably in a few hours' time, when we will discuss this, so I will not say a great deal more about that now except to make the basic point that it is very important indeed that environmental health functions, which already rest with unitary authorities but in county and district areas will rest with district authorities, are properly integrated with the rest of the public health function.

As the noble Baroness, Lady Finlay, said, the things that environmental health officers and departments do are astonishingly varied. If a problem is clearly a public health or environmental health problem, they will find the expertise, go out and get expert advice if it does not exist within that authority, and tackle it. It is a very important function indeed. However, at the national level, environmental health, as defined in the Local Government Act 1974, rests with the Department for Communities and Local Government, not with the Department of Health. It probably ought to rest with the DCLG because it is very clearly a local government function, but again, at the national level, the Government need to take action to integrate it into the new, very important public health functions of the Secretary of State.

Lord Whitty: My Lords, as my noble friend Lord Rooker has said, I have an amendment in this group that is precisely the same as his, except that it was directed at a different point. My noble friend has made a strong case for this particular dimension of addressing environmental health issues, but there is also the wider issue of the lacuna in the Bill, as has been touched on. There is one major shift that the White Paper, the post-pause White Paper and now the Bill are driving for: the shift of public health, including environmental health, to local authorities. However, the Bill itself reflects very little of that. The noble Baroness, Lady Thornton, in response to the group of amendments before last, referred to the fact that work was being done on it and said that she hoped this would see the light of day fairly soon.

The establishment of Public Health England as part of the department-cum-executive agency is hardly reflected in this Bill at all. The issues that relate to the respective role of the local authorities, to which my noble friend Lord Greaves has referred, are not reflected

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in this Bill at all. We have a major shift, going back to pre-1974, that makes public health the responsibility of local authorities. We have a recent history in which all the expertise in environmental health departments has been seriously squeezed because the requirements are mostly non-statutory. EHOs have been diverted on to other issues. We are coming into a further famine of local authority funding. The local authorities will be receiving this new public health responsibility at a time when their total resources are being squeezed and restricted and other priorities are impinging.

Before this Bill completes its course, we need greater clarity on how public health and environmental health responsibilities are to be carried out; what the structure of them is going to be; what the co-ordination among local authorities, and from the centre to the local authorities, is going to be; what the exact role of Public Health England is going to be; and, frankly, at least some broad indication of how that is being resourced.

Lord Greaves: The noble Lord raised the question of funding. Does he agree that this will perhaps be exacerbated in two-tier areas because the ring-fenced public health funding will go to the top-tier authorities, whereas the environmental health functions will remain with the lower-tier authorities-which indeed are extremely squeezed on their funding because this is what we call "other services", which are not regarded as a priority-and finding a way of getting some of that funding down to the lower-tier environmental health authorities is a question that needs to be looked at?

Lord Northbourne: My Lords, perhaps I may intervene now to ask the Minister to say, when he is winding up, what happens if the local authority does not do what it is supposed to do? It is not impossible. In fact, there is a great variety, as we sit here today, in the performance of local authorities. They are managed by elected members, who want to please their electorates, so there are all sorts of arguments for thinking that not every local authority is going to be very enthusiastic about these additional objectives.

Lord Whitty: My Lords, I will leave that question for the Minister, because it clearly raises wider issues. I totally agree with the noble Lord, Lord Greaves, that one of the most acute effects of all this will be at the district level, where the funds are less protected, and where there is already some difficulty and some serious variability in performance and resourcing.

Given the Government's support for the establishment of a chief environmental health officer at the centre to help co-ordinate all these issues and-if you like-to punch the weight of environmental health in the other range of priorities which the Department of Health has to pursue, I would ask the Minister this. Will the assessment of public health and the ongoing process she described in trying to defend the Bill from not spelling this out in great detail, lists or no lists, be available to us before we complete the consideration of this Bill, the exact timescale of which looks ever lengthier? Nevertheless, before we reach final conclusions

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on this, we need to have greater clarity on the direction in which the Government are going on public health, and, I would argue, on environmental health in particular.

I shall mention one other issue that relates to this. The abolition of the HPA also has significant implications in this area. I intend to come back to this at a later stage, but some of the functions of what are currently statutory authorities are going to go to Public Health England, as I understand it, and there is some confusion there as to how that will be carried out, what authority those roles will have and what their local manifestations will be. Under the new structure we will have health protection units around the country. So that is just one more complication here. By Report we ought to have some greater clarity in the strategy of the Government. I ask the Minister to give us an indication of that.

Lord Rea: My Lords, I had not intended to intervene on this amendment, but just from memory, I can think of several areas where the presence of an environmental health officer at the centre would perhaps have speeded things up. The noble Baroness, Lady Finlay, alluded to air quality, but there are other examples as well. I am old enough to remember the smog of 1951 and the enormous benefit of the Clean Air Act which followed a few years later. I was also in your Lordships' House when lead-free petrol was debated, and when that became law nationally. There is also the question of food safety-the noble Lord, Lord Rooker, will know all about this-particularly the BSE epidemic, when it became necessary to ban animal-sourced feed for ruminant animals. Again, that required national legislation. Local environmental health officers, who do a fantastically important job, would not have been able to deal with these things on a local basis.

4.15 pm

Lord Beecham: My Lords, in my youth-your Lordships might think it a rather sad youth-I was, at age 25, opposition spokesman on Newcastle City Council on a pre-Seebohm health committee, which had two remarkably effective and powerful chief officers. One was the medical officer of health, and the other was the chief public health officer. That was the designation of what I suspect we would now call environmental health officers. They were a very powerful combination and very influential within the council. But the point is that they were working together, which is precisely what my noble friend's amendment seeks to achieve at national level. In later debates we will undoubtedly discuss the role at local level. It is absolutely right to identify this as a core function.

The noble Lord, Lord Rea, referred to one aspect of the role of such officers in environmental issues affecting public health. Perhaps I may revert for a moment to the previous debate and my noble friend Lady Thornton's proposal to list some matters for inclusion as public health issues in the scope of the duties of local authorities and the Government. Several of those-including nutrition, air and water quality, adequate housing standards, fuel poverty, and possibly even occupational health-will fall within the domain precisely of this kind of appointment. It therefore seems to me that working alongside the chief medical officer of health, or reporting to him-a position of

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the kind covered by my noble friend's amendment- would be entirely appropriate and effective. That binary combination or approach would ensure that, across the range of public health issues, there would be the best leadership and the best advice would be available to Ministers at national level and, similarly, at the local level. If it were to be matched, as I hope it would be, that advice would be available to local authorities.

The noble Lord, Lord Northbourne, referred to variations in the practice of local authorities in terms of the resources they devote to this topic. That was undoubtedly true in the past and will no doubt be true in the future, but it is also true at present. The practice of primary care trusts in terms of the way that they allocate budgets is by no means uniform, although I am not necessarily suggesting that it should be. But that is precisely one of the difficulties that I suspect we will encounter when the Government are forced to determine how much is currently being spent, how much perhaps should be spent and how much is to be allocated through any formula-based system under the ring-fencing scheme to be pronounced.

Individual authorities will have different ways of applying core funding, but that does not represent a substantive change from what we have now. Indeed, I would hope that, given greater public accountability, we will have a better outcome than we have had in the existing pattern. I warmly endorse my noble friend's amendment.

Baroness Northover: My Lords, I thank the noble Lord, Lord Rooker, for giving me the opportunity to highlight the outstanding work that environmental health officers carry out in district councils as well as in the private and voluntary sectors. The Chartered Institute of Environmental Health, to which he referred, also does an excellent job in presenting the issues nationally and in liaising with central government. They will all continue to play a crucial and developing role in public health.

The noble Lord has long been a doughty fighter on environmental issues. I remember my astonishment when, as a Minister, he granted an amendment which I had tabled that he had been refused permission to grant. I therefore feel very mean in suggesting that I will not be reciprocating today. However, when the noble Baroness, Lady Finlay, raised her points, I was rather glad that, when acting on the Energy Bill in relation to the point for which she fought on preventing carbon monoxide poisoning, I was at least able to grant something there, although I know that that was more limited than what is being sought now.

I should stress that environmental health officers, along with other local authority staff, will be very much inside the group of professionals and practitioners in local government who will form part of the wider public health workforce. Consequently, we expect many opportunities for them in the future to contribute to and to shape local plans and priorities. Surely that will help transform this area, because public health, as I indicated, needs to be defined widely. In its new location it will change in order to have the effects that we wish to see. The noble Lords, Lord Beecham and Lord Rea, are right to urge working together, especially given the history of these officers.



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At the national level, the Chief Medical Officer will have a central role in providing impartial and objective advice on public health to the Secretary of State for Health and to the Government as a whole. She will be the leading advocate for public health within, across and beyond the Government, advocating the design of policies that improve health and well-being. We are clear that this role includes advising on environmental health issues as well, and that the Chief Medical Officer will in turn continue to be able to seek such advice on environmental health and other issues whenever necessary just as she can do now. The Government believe that, as valuable as environmental health expertise is, this makes the post of chief environmental health officer unnecessary.

The noble Lord is of course right to urge discussion across devolved areas in all fields, as we can learn from each other. He might be reassured that the Chief Medical Officers of the various Administrations meet regularly, and that Public Health England, like the Health Protection Agency, will in some ways have a remit that extends beyond England and thus offer the chance to learn from the experience of others. We remain confident that Ministers will receive high-quality advice from the CMO on environmental health. I stress that we also need to look internationally and draw on research and experience very widely in this field. We can learn a lot from that.

The noble Lord's amendment calls for the Secretary of State to,

We agree on the need for transparency and believe that the Secretary of State's accountability for public health at the national level is a major strength of the new system. This is why Clause 50 of this Bill requires the Secretary of State to publish an annual report to Parliament on the working of the comprehensive health service as a whole, which will include his and local authorities' new public health functions.

The noble Lord, Lord Whitty, asked what the Government are going to do about ring-fencing the budget. Some of the issues that he raised were discussed in the first grouping on public health. I do not know whether he was in his place at the time. If he was not, he should be reassured that his noble friend Lord Warner intends to flag up some of the concerns that he raised in a later grouping, and we have various other groupings in which his concerns will no doubt be flagged up. I point out in relation to our discussion on the previous group that we will be using regulations to set out what essential services local authorities have to provide. Noble Lords can also see what is in the White Paper.

I want to clarify what will be covered in regulations so that if I was not clear in the last grouping, I can be clear now. Essential services that we think need to be delivered consistently across the country-for example, dealing with local emergencies-will be included in regulations. We will use publications like the updated White Paper, which I quoted earlier, to set expectations about the totality of services to be covered by the public health ring-fence. I hope that that provides clarification.



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My noble friend Lord Greaves talked about the co-operation between different councils-county councils, district councils and so on. District councils have local insight and expertise. In many cases they will have the lead on key services affecting health and well-being, such as housing and environmental health. Health and well-being boards will play a big part in local health improvement activity and must find themselves able to involve local councils so that they work most effectively.

The noble Lord, Lord Northbourne-sorry to startle the noble Lord-wondered what would happen if local authorities do not carry out their duties. The Secretary of State does not have a conventional performance management role with local government-I am sure that those in local government will be pleased to know. However, he does have the power to intervene and ensure that particular services are provided if a local authority fails to do so. Local authorities will also have to account for their use of their ring-fenced grants, and the power exists to recoup money if the conditions attached to the grant are not met. I hope that that reassures the noble Lord.

In summary, it is very clear that environmental health is and will continue to be a very important component of the public health system, which will be led locally by directors of public health. I hope that the noble Lord is prepared to withdraw his amendment.

Lord Rooker: My Lords, I am grateful to the Minister for her reply, and particularly for reminding me about the favour that I did her. It proves that Ministers can make policy at the Dispatch Box. I accepted her amendment against advice; I used the excuse that there would have been a government defeat if I had not. She cannot use that tonight because I shall not press the amendment anyway, but I am very grateful that she remembered that.

I do not want to make a long speech. The Minister said that the work of environmental health officers is absolutely fundamental. They are the unsung heroes of policing a system in this country for our citizens on a whole range of issues, whether food, air quality or other matters. The public are aware of them only when things go wrong. I am reluctant to go down this route, but I declare an interest of chairing the board of the Food Standards Agency, which is a government department, and that is why I do not speak on it in this House. Environmental officers are unsung heroes and they deserve our support. They provide a 24/7 operation and they go into areas where, by and large, police officers would go in only pairs. Late at night they visit takeaway enterprises and so on. They do an enormous amount of work.

I also hear what the Minister said in answer to the point about discussion between the four Governments in the UK. If the only link between the four UK Governments on the respect agenda is between the four Chief Medical Officers, we are in dead trouble. Although that is important, it is more important that Ministers in the four Governments who have similar responsibilities talk to each other. Devolution means that things will be done differently-we are not looking

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for a one-size-fits-all situation-but it is crucial that there is co-operation, consultation and information. Major changes take place without any contact whatever with other Governments and it is the same in this area. There is no doubt that that causes problems. I am sure that we will turn in more detail to the issues relating to local government in regard to other amendments and we may or may not come back to this on Report. In the mean time, I beg leave to withdraw the amendment.

Amendment 67 withdrawn.

Amendments 67A and 68 not moved.

Clause 8 agreed.

4.30 pm

Clause 9 : Duties as to improvement of public health

Amendment 68A not moved.

Amendment 68AA

Moved by Lord Northbourne

68AA: Clause 9, page 5, line 13, after first "the" insert "physical and mental"

Lord Northbourne: My Lords, since I set down these amendments a good deal of water has passed under the bridge. Fortunately, that will enable me to be briefer than I otherwise would have been. The first and most important thing that happened was the excellent debate on Amendment 11 in the name of the noble Baroness, Lady Hollins. I do not wish to reopen that debate this evening but I want to draw attention to two rather more fundamental matters in addition to what was mentioned in that debate.

The main one is what we mean by health. Do we believe, and do the Government believe, that health means simply freedom from illness or disability, physical or mental? Or do we believe that health can and should mean more than that? I dare say the noble Lord, Lord Layard, if he were in his place-he certainly spoke on Amendment 11-might have supported me in suggesting that health relates both to physical and mental well-being and that we should be doing much more to promote mental well-being, a subject on which the noble Lord, Lord Layard, has written an excellent book. I quote in this context the Childcare Act 2006, which defines well-being on page 1:

"In this Act 'well-being', in relation to children, means their well-being so far as relating to-

(a) physical and mental health and emotional well-being;"-

emotional well-being is an important one-

"(b) protection from harm and neglect;

(c) education, training and recreation;

(d) the contribution made by them to society;

(e) social and economic well-being".

The important thing is physical, mental and emotional health and also such things as self-confidence and self-esteem. I should like to ask the Government to define what they mean by "health" in the Bill. I should

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also like to ask the Government to place more emphasis in this Bill on prevention-on services and policies to prevent a lack of health rather than focusing mainly, as the Bill does at the moment, on trying to repair the damage when things have gone wrong.

I am not sure whether technically I should withdraw those two amendments or whether I should do so at the end. I will now go on to Amendments 71ZAA, 72A and 97ZA. These amendments are intended to probe the Government's intentions on two further issues which I consider to be very important. The first is my concern about whether the Bill will effectively and adequately address the health needs of children. That concern is also raised by the noble Lord, Lord Ramsbotham, who unfortunately is not in his place, in an amendment which I support, Will it provide the services that children need? In that context, why does the Long Title of the Bill specifically refers to "adult social care services" but makes no mention of children's care services?

My second concern relates to the role of parents in securing the physical and mental health of their children. I doubt whether this Bill shows enough concern for the role of parents, especially in the very early years, in promoting good mental and physical health for their children. The Bill's emphasis seems to be more on clinical interventions to treat ill-health rather than on preventing it in the first place. Only last week, the NSPCC published new research showing that more than 20 per cent of babies born today have mothers who are either dependent on drugs or alcohol or who are subject to domestic violence. How will the Bill address that problem? Too many mothers and fathers today cannot give their children the care and education they need because they themselves have never experienced a happy, supportive home life. Today, we as a society have done very little to help those parents to help their children. How will the Bill help in that situation?

Recent research shows that the majority of a child's brain development takes place in the last months of pregnancy and in the first two years after birth. This is the time when nearly all children spend most of their time in the care of a parent. Children are learning from their environment every hour of every day. The lessons they learn are often hard to dislodge. What they learn in those years is crucially important if they are going to progress smoothly and confidently into nursery school, reception class, primary and secondary school and on to a healthy adult life. Yet, as far as I can see, the Bill makes little or no mention of the preparation of parents for their important role in developing the physical, mental and emotional health of their child. Parental responsibility in that context ought to be deeply embedded in the Bill because healthy children grow up to be healthy adults who themselves are more likely to have healthy families. Research shows that, from the financial point of view, early intervention is extremely cost-effective. In the context of the Bill, what is the Government's policy on preventing ill health? On that note, I should like to withdraw the amendment.

The Deputy Chairman of Committees (Lord Brougham and Vaux): The noble Lord cannot withdraw the amendment until he has moved it. The Question is whether Amendment 68AA shall be agreed to.



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Lord Northbourne: I beg the Committee's pardon. I was trying to withdraw the amendment before having moved it. I beg to move.

Baroness Williams of Crosby: My Lords, I am not quite sure whether the amendment is before us or not, but I shall make a brief assumption that it is and then I will allow the noble Lord to decide whether to sustain or withdraw it.

As we all know, the noble Lord has made a very distinguished contribution to the whole issue of the status and well-being of children and it is fair that we should recognise that. In particular, he has gone to a great effort to underpin the importance of early education and such things as the Sure Start programme. I want to add two points. The first is that, as a former Secretary of State for education, I remember working very hard to try to persuade my colleagues in the educational world that there should be an emphasis on education in parenting.

It is perfectly true that the early stages of a child's life are vital, but as the noble Lord, Lord Northbourne, has pointed out, research shows that the link between what a child becomes and its parental inheritance is very close indeed. One of the more disturbing pieces of recent research shows the close link between an abused child and an abuser. Many young people who are abusive parents are in fact the children of abusive parents. Tragically, this dreadful tradition can move on from generation to generation. I simply want to make the point that it is not just a case of Sure Start for the child, it is also a case of proper education and training for the parents.

I have often felt that we should try to link sex education with parental education to bring out above all the extraordinary responsibility that a human child is because it takes so long to grow up compared with the young of most other species. A human child is dependent for many years, and I believe that we should put more emphasis on that than we do. However, it is not fair to make the Department of Health the sole responsible power for addressing this difficult subject. It requires a degree of working between departments, including education and other departments. I simply want to put on the record before the Minister replies the importance of securing co-operation between the Department of Health and the Department for Education, and for that matter social care on this particular set of issues.

My last point is quite straightforward. One of the aspects of training children in parenthood is to allow them to see what it is like to care for a young child. Some teenagers at school will not necessarily have younger siblings. Long ago when I was the prisons Minister-I should have talked about this when the noble Lord, Lord Ramsbotham, was in his place-I introduced a group of offenders, all young boys, to the task of helping in the care and support of children with Down's syndrome. That relationship had an amazing effect on both parties. The young offenders suddenly realised that they were responsible for someone much younger than themselves who was dependent on them, while the Down's syndrome children suddenly had older brothers who were devoted to them and to

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whom they could address their huge capacity for affection. There is a lot of room for bringing young people together with children and teaching them something more than we know now about what it is to be a parent and the huge responsibilities involved in that role.

Baroness Thornton: I should just say how pleased I am that the noble Lord, Lord Northbourne, has brought his great experience and commitment to the children and the family into this debate. I urge him to remain in his place for the debate that we are going to have very soon on children.

Earl Howe: My Lords, as the noble Lord, Lord Northbourne, mentioned, the two amendments in this group, Amendments 68AA and 69AA, are essentially dealing with the same matter on which we had considerable debate on an earlier day. Both seek to make an explicit reference in the provisions of the Bill to improving the physical and mental health of the population. I can well understand that the noble Lord with his extensive knowledge and experience of child health in particular should have tabled these amendments. The other amendments to which he spoke are in a later group. I shall respond briefly to those, but I hope that he will forgive me if I do not do so at length, because I think that there will be other noble Lords when we get to that group who will want to expand even more fully on the issue of children's health.

I shall not dwell again, if the noble Lord will forgive me, on issues raised in the course of the earlier debate, on 2 November, but I reassure him that all references to illness throughout the Bill relate to both physical and mental illness. Illness is defined in the 2006 Act to include mental illness. Equally, it is not for nothing that we have chosen the name health and well-being board to refer to the mechanism at local authority level to define the health needs and priorities of a local area and set a health and well-being strategy to guide commissioners. That sense of well-being is to be at the forefront of commissioners' minds. The Bill does not provide an explicit definition of health, but I assure the noble Lord that it recognises that well-being means more than the absence of illness and needs to be addressed separately. The approach in the NHS Act and other legislation is that health is simply given its ordinary definition and is not redefined.

The noble Lord, not for the first time, spoke compellingly about the importance of parents in supporting both the health and well-being of children. I could not agree with him more. The whole spirit of the measures set out in this Bill is to give more control and empowerment to patients. For children, that includes their parents. As such, I ask the noble Lord not to despair by reason of the lack of words in the Bill on this topic, as the intent is most certainly there. It is not for nothing, either, that the Bill places duties on the Secretary of State and other bodies in the Bill to exercise their functions with a view to securing continuous improvement in the quality of services. The agenda set by the noble Lord, Lord Darzi, in the last Government runs through this Bill like a thread, and it is our ambition for clinical commissioning groups that the prevention agenda should be centre stage for them, as

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it already is for practice-based commissioning groups, which are looking at what we call the QIPP agenda-quality, innovation, productivity and prevention-as a way of driving efficiency and better quality care into primary medical services. I am sure that all noble Lords' ambition is that the NHS should not just be a national treatment service; it should be a national health and well-being service in the fullest sense.

On the public front, I am sure that the noble Lord will have noticed that in Clause 8 new Section 2A is inserted into the 2006 Act. I draw his attention to subsection (2)(d) in that new section, which refers explicitly to prevention in the area of public health.

We will come to the other amendments spoken to by the noble Lord when we come to a later group, but I will just comment very briefly on them at this point.

As regards Amendment 71ZAA, our general approach is not to specify particular services in the Bill. It already allows the Secretary of State or local authorities to take steps to improve the health of the people of England or the people in the local authority's area. Once again, it is a case of making that general provision. Bear in mind that if we specify one group of people, it carries the implication that we are excluding others, which of course we do not want to do.

The same point applies with Amendment 97ZA. Strictly speaking, Amendment 99A is unnecessary. The mandate is clearly relevant to other government priorities. There are already established mechanisms for ensuring that policy is consistent across government and therefore we would fully expect the Department for Education to provide input on any relevant parts of the mandate. I hope that the noble Lord will be reassured by my brief comments on this matter. His comments are well taken; equally in the light of what I have said, I hope that he will feel able to withdraw the amendment.

4.45 pm

Baroness Hollins: My Lords, I might add that Amendments 68A and 69A refer back to Clause 1 and the Secretary of State's duty to promote a comprehensive health service,

"designed to secure improvement ... in the physical and mental health of the people of England".

Of course, I support the amendments and note that their purpose is different from the purpose of my own extensively debated and supported amendments, which sought to ensure improvement in the quality of services for people with illness. I specify both mental and physical illness. Rather than speaking about mental health, I actually speak about illness. Instead of detaining the House now, perhaps I could speak to the Minister at a later date.

Earl Howe: My Lords, I should be happy to speak to the noble Baroness on this topic. I have been reflecting on it since our debate some days ago. I do not suggest that the amendments tabled by the noble Lord, Lord Northbourne, are designed to do exactly the same as those of the noble Baroness, however they draw our attention to a similar definitional issue.



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Lord Northbourne: I am most grateful to the noble Earl for giving so many excellent assurances on the questions that I asked him. I apologise profoundly to the noble Baroness, Lady Williams, for nearly cutting her out of the debate. For some reason I was confused about the procedures. I beg leave to withdraw the amendment.

Amendment 68AA withdrawn.

Amendments 68B to 70 not moved.

Amendment 71

Moved by Baroness Finlay of Llandaff

71: Clause 9, page 5, line 17, leave out "may" and insert "must"

Baroness Finlay of Llandaff: My Lords, I am grateful to the House for being so accommodating in moving the amendments slightly so that we can discuss alcohol now. The reason for this group of amendments is because of the ever increasing problem and toll on our society from alcohol misuse. These amendments are designed to ensure that alcohol misuse is a national priority for the Secretary of State and a priority for local authorities and clinical commissioning groups. Amendments 328, 329 and 331 ensure that local organisations have levers in their responsibility to promote integration; and that health and well-being boards and health and well-being strategies take into account alcohol misuse and are devised with appropriate expertise in alcohol misuse.

Turning to the individual amendments, we passed over Amendment 66 briefly for convenience, but it links to Amendment 71, which changes the duty on the Secretary of State from "may" to "must" because of the danger to health that alcohol poses. Alcohol is a major and growing public health concern. Alcohol misuse affects 4 per cent of the population and more than 10 million people drink above the recommended limits. The prevalence of liver disease, to which alcohol is the major contributor, is growing and is set to overtake stroke and coronary heart disease as a cause of death in the next 10 to 15 years. This is set out in the Department of Health's document on developing a national liver strategy, published last year.

Last year, more than 1 million hospital admissions were due to alcohol misuse. This represents a doubling in the number of admissions over eight years and the rise is becoming exponential. The estimated cost of alcohol-related harm to the NHS in England is £2.7 billion based on 2006-07 prices. However, the overall cost to the nation from all aspects of alcohol abuse is £20 billion. The Exchequer gets back only £13 billion from tax on alcohol, so there is a £7 billion gap. We just cannot leave that unaddressed. Amendment 72 would insert a new subsection to state that one of the steps that local authorities and the Secretary of State might take to improve public health is,



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In Clause 9, local authorities will take new responsibilities for public health. As PCTs and strategic health authorities are abolished and their responsibilities are transferred to clinical commissioning groups and the Commissioning Board, there is a need to make sure that nothing falls through any gaps. Local authorities' new public health responsibilities will be supported through their ring-fenced budget of £4 billion, which we have already heard about. However, at present they are unaware of how much funding they will actually receive, and there is a real danger that, with a squeeze on local government's finance, the budget may be used to fill other gaps within the increasing number of responsibilities that local authorities will be taking over.

The Bill does not specifically state that local authorities will have responsibility for alcohol services, but those of us who have put our names to these amendments are keen to see that in the Bill. It has to become a statutory responsibility, given that the problem is evergrowing. The Department of Health's consultation on commissioning and funding routes for public health stated that the commissioning of treatment, harm reduction and prevention services for alcohol and drugs will be the responsibility of these local authorities.

The public health outcomes framework includes outcomes on the rate of hospital admissions per 100,000 for alcohol-related harm, and the NHS outcomes framework includes a measure of the mortality rate among the under-75 age group from liver disease, based on a set of conditions where alcohol contributes to 50 to 60 per cent of liver disease overall in the country.

The voluntary sector providers of alcohol services risk a disinvestment in their services if they are not given sufficient priority. They find that their services are already often marginalised and stigmatised because they are dealing with a marginalised and stigmatised group. Some alcohol services that are currently funded by the National Treatment Agency for Substance Misuse will be integrated into Public Health England, and the future of its funding is unclear.

Alcohol services have tended to be a Cinderella in public health, with smoking and illegal drug misuse tending to be prioritised over alcohol. I completely welcome the emphasis on smoking cessation and tackling illegal drug misuse but I regret that alcohol has slipped past and the problem has escalated in the process.

To put this into perspective, on average £136 is spent on dependent drinkers, compared with more than £1,300 on dependent drug users. Yet we know that the social toll on the health, particularly of children in families where there is a problem drinker, can be as great as the toll where drug abuse is going on. The cost of smoking has been estimated to be £2.7 billion a year, which is the same as the cost to the NHS of alcohol. The problem is no smaller than smoking.

The wording in Amendment 202 is designed to ensure that clinical commissioning groups have a duty to make reducing alcohol-related harm a priority. General practitioners have a crucial role to play in identifying, assessing and referring people with alcohol use disorders. General practitioners have tended to under-identify alcohol misuse and, unfortunately, GPs

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identify only about one in 67 males and one in 82 females who are hazardous and harmful drinkers. Detection in general practice is currently woefully inadequate. Less than one-third of GPs use an alcohol-screening questionnaire.

The Government have indicated that 15 per cent of QOF funding will be assigned to public health and primary prevention indicators from 2013. All the proposed public health indicators are focused on smoking, and the indicator for screening for alcohol misuse has to date been rejected. There is strong evidence that brief intervention and advice in primary care can lead to one in eight people reducing their drinking to sensible levels, so it becomes a very cost-effective and clinically effective intervention. That has been demonstrated in 22 randomised control trials, so there is a very high level of evidence for this clinical intervention.

Amendments 238 and 239 are designed to ensure that the joint health and well-being strategies takes into account the drinking levels in the local population and, in preparing those strategies, that the people who have experience in alcohol services are involved. The joint strategic needs assessment must include an examination of levels of hazardous, harmful and dependent alcohol use in the population and must widen the scope of the local authority with its partner clinical commissioning groups in preparing the health and well-being strategy to include alcohol service representatives.

These joint needs assessments will be very important in underpinning the overall direction taken with funding and commissioning services. That is why Amendment 331 requires health and well-being boards to include expertise in alcohol and drug services in the preparation of reports and strategies on the health and well-being boards. It is worth noting that the criminal injury compensation from alcohol-related injury alone is substantial and is a cost that we are handing on to the next generation. There is also a cost to the private sector from alcohol abuse, which comes completely outside any health costs, such as when premises are damaged, sometimes very severely and set on fire in alcohol-fuelled criminal activity.

Overall, integration is essential. If we are going to spend £400 million per annum on dealing with alcohol-fuelled injury that results in hospital admissions and violent woundings, one must remember that that is only the cost of those that have been recorded by the police. The actual cost just from injuries and woundings is possibly twice that. With an overall cost of £21 billion to the public purse from alcohol abuse, I suggest that this cannot be ignored in the Bill. I beg to move.

5 pm

Baroness Hollins: My Lords, as my noble friend Lady Finlay has eloquently explained, alcohol misuse is one of the major public health challenges that we face in the UK. It causes wide harm to individuals and places a significant burden on the National Health Service. Even more widely, it has a devastating effect on families, on communities and within wider society, and it is vital that the reforms to the NHS are effective in helping to address this challenge. This is an important

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debate in an uncertain time for alcohol services. I understand that local authorities are set to commission alcohol services out of their ring-fenced £4 billion budget, but there is no guarantee how much of that will go to alcohol services. Furthermore, public health is a wide-ranging area and there are concerns that alcohol services may have to compete with wider public health initiatives.

I hope that the Government will use this important opportunity to show how alcohol services will be prioritised in the reforms. I know that one particular opportunity lies in the Government's alcohol strategy which is expected in the near future. I would welcome a commitment from the Government that this strategy will make clear how alcohol services will be made a priority in local authority delivery and in primary and secondary NHS care. At the same time primary care and the new clinical commissioning groups will need to continue to play a key role in screening and treating people with alcohol misuse problems, and it is vital that they are incentivised to do so.

The quality and outcomes framework is a vital primary care lever to ensure that GPs prioritise specific conditions. At present there is one very limited QOF indicator on alcohol to provide lifestyle advice to patients with hypertension. The Government have indicated that 15 per cent of the QOF funding will be assigned to public health and primary prevention indictors from 2013. However, at present all of the proposed public health indicators are focused on smoking, and the indicator on screening for alcohol misuse has, regrettably, been rejected.

What is clear is that integration of services will be the key to ensuring that people with alcohol misuse problems are not lost in the system and that the various agencies involved in care work together. The amendments in this group make the important case that people who understand alcohol misuse and alcohol services should be involved in health and well-being boards and in producing health and well-being strategies. Health and well-being boards seem to present significant opportunities ahead, but only if alcohol is made a clear local priority.

Lord Wigley: My Lords, I rise with some trepidation as this Bill applies to England only, although there are some consequential effects on Wales. As I was speaking in Grand Committee on the Welfare Reform Bill upstairs a moment ago on initiatives in Wales which should be copied in England, I hope that initiatives in this area will be copied by the National Assembly for Wales and I very much hope that the spirit of the amendments, some of which I have my name alongside, can be taken on board by the Government, even if the wording is not perfect.

I welcome the address made by the noble Baroness, Lady Finlay, in opening this debate and pay tribute to the work that she has undertaken in this context, which is recognised all round. I come from a generation in Wales where we used to have to smuggle ourselves out to the pubs because of the general ban on alcohol that used to exist. In previous generations, understandably and rightly, there had been a clamping down on alcohol use in Wales. My parents' generation referred to whisky,

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for example, as medicine and very rarely used it. In fact, the pledge was a general feature of society there. My generation was responsible for a movement in another direction. The pendulum swung and is still swinging in that direction and it is time to start it swinging back.

I have no doubt at all that alcohol is one of the greatest problems that we have in our society today. I say that not as a teetotaller although I restrict myself two months of the year to not touching the stuff because it is so important that we have self-discipline as well as discipline that may come from the statute book. But in terms of violence, the break-up of families, poor performance at work-one remembers David Lloyd George's initiatives in the First World War to try and clamp down on alcohol because of the effect on the war effort-criminality, injuries and the pressure on accident and emergency departments in hospitals, and the social disruption that arises from it, we can see the effect all around. The effect seems to be hitting people younger and younger. Children at the ages of 11, 12 and 13 are showing the effects of alcohol. That cannot be acceptable.

I realise that in an area of social responsibility such as this it is sometimes difficult to legislate. However, there must be pressure to turn the tide in another direction. Amendment 202 refers to establishing a duty to reduce alcohol harm. Amendment 328 covers the assessment of alcohol damage in local communities. Amendment 329 would provide appropriate places for representatives of alcohol services. These modest steps, taken together, would add up to a message that would come across. I implore the Minister, even if he cannot accept the amendments, to accept the thrust of the argument that lies behind them, because we have to do something about this great scourge of our society today.

Lord Brooke of Alverthorpe: My Lords, I hope that the noble Earl will accept these amendments. In many respects they are very modest. I have grave doubts about the extent to which we will be able to influence the course of events in this arena with the changes that we have before us. I am grateful to him for responding in his long letter of 20 October to all of us who raised a variety of questions at Second Reading. He endeavoured to address some of the topics that I had raised on alcohol, labelling, licensing and so on. However, I still believe that ultimately the major issues on alcohol policy will need to be addressed at the centre.

One can do nothing about the cost of alcohol at local level. It must be done centrally. That is being addressed-but inadequately. The marketing of alcohol is something over which local authorities and well-being boards will have no control whatever. The drinks industry is increasingly marketing on the internet and targeting youngsters, particularly in the social networking sphere. I heard recently that one-third of young girls aged 13 to 16 surveyed in Essex are suffering blackouts from excessive drinking. If they continue to drink like that, they will not be ill immediately-they will have good fun and games-but within 10 years, when they get to their late 20s, they will have real problems. What will health and well-being boards be able to do about

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that? I have been pestering the noble Earl on the labelling issue for quite some time. Nothing can be done about that at local level.

There is one issue that we could have done something about at local level, but we missed our chance. The noble Lord, Lord Clement-Jones, will recall that when we debated the Police and Social Responsibility Bill, we addressed the freedom that people now have to issue licences on a much more liberal basis than used to be the case-we now have a proliferation of off-licences everywhere-but were unable to effect any changes that would have given local authorities greater powers to limit the way in which licences are granted locally. Again, nothing can be done by health and well-being boards.

These are major topics and I wonder how much power there will be to change the course of events. These issues all link to related topics such as obesity and diabetes. It is important that we do not delude ourselves into believing that there will be massive changes without a strong drive from the centre. The nudge-nudge approach will not work with the big drinks industry. Neither, as the noble Baroness, Lady Williams, mentioned this morning, will it work in the context of food, with salt, fats and sugar. These are real problems for people and very little change will be effected at local level; it must all be done centrally.

I come back to the amendments before us. They are very modest and I see no reason why they cannot be accepted. In particular, I will look at the endeavour to achieve change at GP level. Many GPs have been very innovative. Initiatives have been offered to them to effect changes and a number of them have taken up the cudgels and worked adventurously to identify the problems at local level in their communities. Many more have not been doing anything like what should have been done. The Government have declined to accept the screening possibility that was mentioned. Again, I hope that they will be prepared to review their position on that.

Overall, I urge the Government not to reject the modest changes here, but to accept the amendments.

Lord Turnberg: My Lords, I should like to speak to the amendments in the name of the noble Baroness, Lady Finlay of Llandaff, and others. I do not think that it is necessary for me to reiterate the dangers of excessive alcohol consumption. The damage done by alcohol is obvious to anyone who visits an A&E department on a Friday or Saturday evening-and indeed, now, almost every evening during the week. It is the cause of more than 1 million admissions a year to hospitals-that is, admissions to hospital beds, not to the A&E department. Liver disease is spiralling out of control. All of this has been described very eloquently by the noble Baronesses, Lady Finlay of Llandaff and Lady Hollins, and other noble Lords.

I want to concentrate on the sort of things that we might be doing-in addition to the things suggested, very modestly, in these amendments-with regard to two aspects, prevention and treatment. It is pretty obvious that the system of voluntary pledges with the alcohol industry does not work. It has not yet worked, and does not look like it ever will. The drinks industry

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is not in the business of reducing alcohol consumption. We cannot suggest that it is. We have tried the voluntary pledges system, and it is obviously not having an impact.

I agree entirely with my noble friend Lord Brooke of Alverthorpe that we need a national strategy. We cannot rely on local authorities alone. In any national strategy, I fear that we have to focus on the price of alcohol. Our history has shown that every time the price of alcohol goes up, the incidence of liver disease and death from liver death goes down. It is the most effective measure. The Government have suggested that we should look at the minimal unit price, which is the price based on VAT and duty, as the minimal level. That is a pretty pathetic level and it does not work. I am reliably informed by Sir Ian Gilmore, who is a guru on the effects on alcohol, that this price measure affects no more than one in 4,000 drinks that are on sale. You have only to go to the supermarket. It is still possible, for example, to get three litres of 7.5 per cent cider-which is the drink of choice of many-for £2.99, and if you are lucky you can get a two-for-one offer, too. Price is critical. It is clear that the Department of Health is not responsible for pricing, duty and so on, but it must put pressure on for a rise in the price. It is not very popular with journalists, and it is even less popular with politicians. Nevertheless, it is an important measure.

I shall talk about treatment. There is no doubt that the best results from treatment come where there is an integrated team approach to patients suffering from the effects of severe alcohol ingestion. That is a team which combines specialist nurses, specialist doctors, primary care doctors and their team in an integrated way. A good example of that service is the one run by Dr Kieran Moriarty in Bolton. It is a very good system. Unfortunately, there are too few of those sorts of arrangements available. We need many more. They work, because you can actually do something with them. You prevent further damage from alcohol by aborting the effects of alcohol very early on. It works.

There is a lot that is needed, and a lot that can be done. We certainly cannot rely on the drinks industry to put up the price. We have to do something nationally. We have to enhance the alcohol services. I hope we can see some action here. I support these amendments as a first step.

5.15 pm

Baroness Masham of Ilton: My Lords, providing services for the prevention and treatment of harmful drinking and alcohol dependence is essential. Alcoholism ruins many lives. There is a very worrying rise in liver disease, especially among young women, caused by a combination of hepatitis C, which we have discussed today, and dangerous levels of drinking. It is causing great pressure on hospitals' liver disease wards.

Those in young offender institutions and prisons have often been involved in domestic violence, drink-driving, fights and violent crime due to too much alcohol. For years, prisons have had money for drug-abuse rehabilitation, but very little for alcohol misuse, although the problem has been bigger. As a result of the problems

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alcohol contributes to crime, I hope that the Government will try to promote alcohol-misuse rehabilitation in prisons. It should not be left out.

Huge pressure is put on the staff of A&E departments, especially on Friday and Saturday nights, by alcohol abuse. One young doctor who works in an A&E department here in London told me the other day that he was concerned that it took so much longer to attend to patients who were drunk that he felt that some other patients were being put at risk. Alcohol abuse can cause all sorts of problems. It should have concerted effort spent on it. Many voluntary organisations help with alcohol-abuse rehabilitation, but the private centres are very expensive and are not available to most people. There is also the problem of coaddiction to drugs and alcohol which has affected many young lives.

Lord MacKenzie of Culkein: I have put my name to Amendment 202 which deals with general practitioners. I do not intend to detain the Committee because the points I was going to make have already been eloquently made by the noble Baroness, Lady Finlay of Llandaff, and others. I want to reiterate the point about general practitioners not identifying alcohol misuse. For the life of me, I cannot understand why there is no quality assessment framework indicator for screening for alcohol and why that is not part of the programme. There is evidence that screening works, as the noble Lord, Lord Brooke of Alverthorpe, said. It is clinically cost-effective. There is an urgent need to prioritise the issue of alcohol abuse, and this amendment gives us that opportunity. I hope that the Minister will be able to say something positive about that this evening.

Lord Northbourne: I rise to support the amendment moved by the noble Baroness, Lady Finlay. One thing that has so far not been mentioned is that it is important to think about the alternatives to alcohol and to regular alcohol use. I used to spend a certain amount of time with very disadvantaged young people, and a great deal of their problem was boredom, inferiority complexes and no belief that there was any real future for them, so let us also think about all sorts of other things that they might be doing.

Lord Rea: My Lords, as a former GP, I echo the words of my noble friend Lord MacKenzie. Screening for alcoholism should be added to the QAF measures in view of all the reasons that have been eloquently adumbrated by other people. I want to raise a fairly basic problem which is the cost of alcohol services. At the moment, a lot of these are funded as outreach programmes by PCTs, and those are going to be transferred to local authorities. They will have to be paid for out of the index-linked £4 billion-odd that is going to be given to local authorities for this purpose. Perhaps the Minister could say whether the actual cost of running these alcohol services is being taken into account when considering how that £4 billion is going to be calculated. There are also plenty of other services being transferred to local authorities.

Baroness Thornton: My Lords, I rise to comment on these excellent amendments, and to support my noble friend Lord Beecham who has his name against

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Amendment 71. Amendment 71 is one of those very small amendments that changes "may" to "must" but it is actually at the heart of this discussion. What we are talking about here is how national campaigns will be linked to local action, and how they will be funded.

I start by reminding the Committee of some of the key components of this Government's health policy on the harmful use of alcohol: banning the sale of alcohol below cost price; reviewing alcohol taxation and pricing to ensure that it tackles binge drinking without unfairly penalising responsible drinkers, pubs and important local industries; overhauling the Licensing Act; local authorities having more powers to remove licences and refuse grants that are causing problems; allowing councils and police to shut down establishments; doubling the fines for underage alcohol sales; and local councils being able to charge more for late-night licences.

My noble friend Lord Brooke put his finger on it, as did my noble friend Lord Turnberg, when he expressed scepticism as to the efficacy of these when you link them to the responsibility deal pledges on labelling. As part of the public health responsibility deal agreed with the Government in March 2011, UK alcohol beverage companies have pledged-that is an interesting word to use in this context-to implement a health labelling scheme to better inform consumers about responsible drinking. This pledge is in line with the industry's response to the Department of Health's consultation in May 2010 on options for improving information on the labels of alcoholic drinks to support consumers in making healthier choices in the UK. I do not think this is going to work.

Will the Government be reviewing their national campaign on alcohol and the misuse of alcohol in the light of this Bill? We have a national policy and a campaign, presumably run and directed by the Secretary of State for Health through the public health agency within the department. We have to look at what will actually happen on the ground and indeed address the dangers or risks that are posed by this Bill. A key question is the distinction between primary prevention and secondary prevention, which is complex in relation to the prevention of alcohol misuse. It is a concern when interventions cannot be clearly delineated as primary and secondary prevention. It seems that the reforms being proposed here will make that worse, not better.

Multiple commissions across one therapy, such as alcohol misuse, may cause uncertainty over who is responsible for funding services considered for both primary and secondary prevention. The worst case scenario is that neither the directors of public health nor the GP consortia commission secondary prevention services because the directors of public health are focused on primary prevention, awareness and information, the GPs are focused on treating the physical complications and harms relating to alcohol, and the hospitals are mopping up the people who turn up needing treatment for alcohol abuse.

If we are to tackle the fact that the number of hospital admissions was over a million in the last year, and that it is estimated to cost the NHS £2.7 billion a year-almost twice the equivalent figure for 2001,

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with the costs to society being even greater-there has to be co-ordination between national and local, and some direction about how these programmes will be carried through at local level. On these Benches we are therefore very sympathetic to what we see as a series of rather modest and focused amendments. We hope that the Minister will be able to look upon them with some sympathy.

Baroness Northover: My Lords, Amendments 71, 71A, 72, 74A, 202, 328, 329 and 331, make alternations to local authorities' new duty for public health. In introducing this group, the noble Baroness, Lady Finlay, has made a very powerful case, as one would expect from somebody who has campaigned for a very long time in this area. Clearly, the harm caused by alcohol is unacceptably high, and everyone has to play a role in reducing its harmful use. She is absolutely right in her campaign on this. As she says, 1.1 million hospital admissions were alcohol-related, out of a total of 14 million admissions, at a cost of £2.7 billion. It is of course extremely striking that 13 per cent of 11 to 15 year-olds reported drinking in the last week. I am acutely aware of the particular vulnerabilities of children and young people in this regard. The British Crime Survey suggests that alcohol is linked to half of all violent crime, so you can see the significance of what we are talking about here.

Can I assure the noble Baroness, Lady Masham, that indeed, we are very acutely aware of how many prisoners have alcohol problems, as well as drug and mental health problems? As a Whip in the Ministry of Justice, I can assure the noble Baroness that we regard this as extremely important and that we are seeking to tackle it.

Local directors of public health in local authorities will have a key role in tackling alcohol harm. Can I assure the noble Baroness, Lady Finlay, that this will need to be addressed at every level of the health service and public health? That is why it receives such prominence in the paper that I referred to earlier. Again, I refer to the fact that public health, itself in the past very much a Cinderella service, is now at the front and centre of these changes. We hope that the involvement in local authorities will help to change this.

There are a number of steps that need to be taken; I would like to flag up some that the Government are taking at the moment. The noble Baroness, Lady Thornton, made reference to a number of these, and we are fully aware that this is a range of things, and that neither this Government nor the previous one, in all the range of things that we have undertaken so far, have made a dent in this problem. We recognise that this problem is driven by economic and social change, and it needs to be addressed in that regard, and understood very fully. In terms of relevant things which are happening, local directors of public health and local authorities will have a key role in tackling alcohol harm. We know that engaging with those drinking above the lower risk guidelines early on, and providing advice or referral for treatment for those who need it, does work, and that that is helpful.

While the health services have made improvements, much more needs to be done to identify consistently

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early signs of drinking above the lower risk guidelines, and to offer advice whenever and wherever the opportunity arises. I know how difficult this is with teenage children.

The coalition's programme for Government, to which the noble Baroness, Lady Thornton, referred, committed to a ban on the sale of alcohol below cost. It also committed to review alcohol taxation and pricing to ensure that it tackles binge drinking. The Treasury published its review of taxation on 30 November 2010 and set out changes to duty on beer.

I hope that the noble Lord, Lord Turnberg, will be reassured that we will bring together the Government's approach in an alcohol strategy, which is to be published towards the end of this year. We are reforming the Licensing Act via the Police Reform and Social Responsibility Act to enable local communities to ensure responsible retailing of alcohol. Also mentioned was the consultation on the public health outcomes framework.

5.30 pm

Lord Turnberg: In the review that the Government are undertaking, will they take note of the publication on alcohol by the Academy of Medical Sciences, produced by Sir Michael Marmot two or three years ago? It recommended a whole series of things to do. Unfortunately, the Government of the day sexed it down and we were not able to move much further with it. I hope that this Government will take it into account.

Baroness Northover: I note what the noble Lord has said in regard to his Government. I would be astonished if those working on this strategy were not bearing that in mind, but I will check. I can assure the noble Lord that, in the unlikely event that they are not, I will bring the review to their attention so that they can factor it in.

The noble Lord, Lord Rea, asked whether the current spending on alcohol is included in local authorities' funding for public health. I can assure him that that is the case and that what is being spent by PCTs on commissioning alcohol services will be reflected in the resources transferred to local authorities.

Amendments 66 and 72 would add,

to the list of steps that the Secretary of State and local authorities may take under new Sections 2A and 2B. However, the Bill already gives the Secretary of State and local authorities the ability to take appropriate steps to address harmful drinking. The new public health responsibilities in this Bill give local authorities a ring-fenced grant to ensure that local authorities have the resources to deliver their public health responsibilities, including alcohol misuse services. Obviously, there was discussion of that ring-fence grant previously. I think it is a move forward that, instead of public health being part of the overall NHS and subject to being raided, there will be a ring-fenced grant.

Clinical commissioning groups are already under a duty-under Section 3 of the NHS Act, as amended

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by Clause 10, and under new Section 3A-to commission services as they consider appropriate as part of the health service or to secure improvement in the physical and mental health of their population. Given the scale of the problem, it would be astonishing if that was not part of how they see their responsibility.

I can further reassure your Lordships' House that the importance of services which reduce alcohol-related harm will not be overlooked. The Secretary of State will set the strategic direction of the NHS through the mandate to the NHS Commissioning Board. This should be the route for highlighting priorities for the health service and I have no doubt that debates in Parliament, such as this, and in the wider sphere will help to influence that.

Amendments 328 and 329 would require joint strategic needs assessments to include an assessment of alcoholism in the local population and the involvement of representatives from alcohol services in the preparation of the joint health and well-being strategy. While we fully support the principle that the joint strategic needs assessments need to be comprehensive, we do not feel that it is necessary to include this amendment in the Bill. The scope of this assessment will naturally include the needs related to harm from alcohol. However, we have retained the power for the Secretary of State to issue guidance on the preparation of the joint strategic needs assessment. We will ensure that it covers the need to consider alcoholism, which I hope will reassure noble Lords.

Amendment 329 would require local authorities and clinical commissioning groups to,

in the preparation of the joint health and well-being strategy. While there is no representative of alcohol services in the local area on the health and well-being board, it would still be able to involve experts as appropriate or invite them to be members of the board. On Amendment 331, which would require health and well-being boards to include,

the same point applies: they could be a member of the board or their advice could be sought. The legislation sets out a minimum membership for these boards-

Baroness Thornton: I am slightly disturbed that so far the Minister has given us lots of coulds and maybes and "there is no reason why they should not". Given the scale of this problem, I think that the Government need to look carefully at what goes on the face of this Bill and what is put in regulations about the problem of alcohol abuse.

Baroness Northover: I think that that point comes through loud and clear from this debate. I note what the noble Baroness said about what goes into the Bill or in regulation. She will know, from her experience of government, that generally speaking you do not put this sort of thing into the Bill. However, I take on board very much what she said about regulation, and I will take that back to the department.

The noble Baroness rightly focused on the joint strategic needs assessment and analysis of the current and future health and social care needs of an area. This would include the health and social care needs

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that are alcohol-harm related. Health and well-being boards would be able to involve people as necessary. As I said, noble Lords have made a very strong case for tackling alcohol abuse, which is very much economically and socially driven by the changes that underlie why this has come about. I have no doubt whatever that this issue will continue to dominate our debates, whether over regulation or over the Secretary of State's mandate. This is a difficult area to tackle, as we know and as the previous Government knew, and it is best tackled as a cross-party attempt.

If only putting such matters into the Bill was a panacea. However, I am sure that the noble Baroness recognises that that is not the case. We realise that a range of measures must be taken, and I can assure the noble Baroness, Lady Thornton, that we constantly review the effectiveness of what we do. If we did not, I am sure that noble Lords would ensure that we did. I hope, therefore, that the noble Baroness will agree to withdraw her amendment.

The Archbishop of York: As the Minister resumes her seat, I would ask: if the matter is so serious, what is the problem with changing the word from "may" to "must"? What difficulty does that bring? Seeing the seriousness of the matter, why do the Government continue to say, "We will watch this", "We will do this", or "There will be a review of this"? This is a very simple amendment. I would have thought that they could, for once, admit and accept that the amendment be inserted, instead of postponing for some future thing. What is the real problem? I have not heard an answer to why "may" must remain and "must" must not be inserted.

Baroness Finlay of Llandaff: I am extremely grateful to the most reverend Primate for that very eloquent and sensible interjection at this stage. I know that, in responding, the Minister has tried to be reassuring, but I note that she said that the scale of the problem is such that it would be astonishing if it was not addressed.

The Minister also said that it would not be a panacea to put it into the Bill, and there I disagree because it is not a panacea putting things in legislation. We have to protect the children growing up in this country who are abused through alcohol-related harm. They are bereaved by the deaths of their parents through alcohol. They are becoming the next victims of excessive misuse of alcohol. To do that, we have to put things into the Bill. We have seatbelt legislation, which has dramatically decreased the number of children who die in road accidents. We have legislation about smoking in public places, which has dramatically decreased smoking. In Wales, we are actively looking at smoking in confined places and at legislation on domestic abuse, precisely because of the alcohol-fuelled domestic abuse problem that is escalating, as my noble friend Lord Wigley said earlier.

I am most grateful to all noble Lords who have contributed to the debate. The call for something in relation to general practitioners has been overwhelming from several noble Lords. I remind the House that secondary care is being evermore squeezed-squeezed until the pips squeak-and is taking a hit for the

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failure of alcohol-misuse control in our communities. That is where massive expenditure is incurred. It all seems to come together and it seems as though that is the final sump. The financial hit alone deprives other patients with other conditions from being looked after properly.

I shall not divide the Committee on this today, but I say to the Government that the failure of the Ministry of Justice to bring in pilots to control excessive drinking and drunkenness in our city centres, through allowing sentencing schemes for magistrates, has strengthened my resolve. Unless we get something in the Bill, all the strategies and persuasion in the world will not turn around this ever-increasing toll-the graph goes up and up. At this stage, I shall withdraw the amendment but I shall certainly return to it on Report. I hope that the Minister and the Bill team will engage in some constructive discussions as it would be much better for everyone to reach a compromise on this rather than to have to divide the House.

Amendment 71 withdrawn.

Amendments 71ZA to 72 not moved.

5.45 pm

Amendment 72A

Moved by Lord Ramsbotham

72A: Clause 9, page 5, line 23, at end insert-

"( ) providing services to improve communication skills in children and adults;"

Lord Ramsbotham: My Lords, I was hoping to speak in support of my noble friend Lord Northbourne, who introduced a whole cluster of amendments which had at their heart not just parenting but the development of our children. I do not want to bore the House but my interest in this subject goes back to an occasion when I visited a young offender institution in Scotland. When I was walking round with the governor of the prison he said to me that if he had to get rid of all his staff, the last one out of the gate would be his speech and language therapist. I asked why and he said, "Because none of the children can communicate, either with each other or with us, and unless they can communicate there is absolutely nothing that we can do with them, or for them, and that includes their education, their discipline, their healthcare and indeed their general well-being". Therefore this group of amendments-Amendments 72A, 81A, 200A, 201ZA, 327B, 327C, 329A, 331C, 333B and 91A-is all to do with getting speech and language communication needs for our children, which is the most common disability shared by children and adults in this country, put properly into the context of the Bill.

I think it is recognised that communication skills are the key life skill and the single most important factor in determining a child's life chances. They are the means by which people form relationships and make choices and by which people access education, employment and society in general. Over the past few years-ever since I first became aware of this problem-I

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have been worried that nobody seems to be grasping the fact that every child's communication ability must be assessed properly and as early as possible in life so that they can be given the best possible chance.

Following that experience in the young offender institution I was responsible for a two-year pilot with speech and language therapists in two young offender institutions. This pilot proved conclusively that if an assessment had been carried out much earlier those offenders may well have not ended up in the institution and that a very large number of them would not have been excluded or evicted from education because they would have been able to engage with their teachers. I have therefore been trying to interject in various education and justice Bills over the past six years the need for such an assessment to be built in to the education of this country. It is interesting that Northern Ireland has listened-now every child there is assessed for their communication skills at the age of two. That might be very early but, on the other hand, it also identifies potential problems. The amelioration of those problems can then begin early enough for the children to be able to engage in education.

Unfortunately, although that need has been accepted in education and justice Bills, nothing has happened because neither the education nor the justice department is responsible for funding those who have to make the assessment. Indeed, in 2005, when this pilot scheme came to an end, the Minister-Mr Paul Goggins-was invited to examine the funding of the possible provision of assessment. He could not work it out because neither the Ministry of Justice nor the Department for Education was willing to fund. When it came down to it, we found that individual speech and language assessors were the responsibility of individual primary care trusts around the country. Some of them decided that the assessors were essential and some of them did not and, therefore, it became a postcode lottery.

If we accept that communication difficulties severely limit an individual's participation in education, in the world of work and in their family and community life then it stands to reason that unidentified speech and language problems can pose a secondary challenge, as they lead to diminished social skills, poor educational outcomes, anti-social behaviour, unemployment and mental health problems. In other words, all the factors that arise from a failure to assess communication skills and to enable people to communicate as well as possible can become a public health issue. I believe that it should be regarded as such, which is why these amendments mention the need for those who are responsible to have an integrated approach in order to ensure that all the relevant healthcare professionals liaise with each other and make certain that every child is given the proper start in life to enable them to engage with all the things that follow. This will require liaison with education and other authorities. I am not going to list all the various things that speech and language therapists can do, but one of the problems at the moment is that the assessment in many places is left, for example, to district nurses who have been trained by speech and language therapists. That is fine, except that we are told that the funding for speech and

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language therapists is to be cut and therefore it may be that their ability to train those who carry out these assessments will be inhibited.


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