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5.30 pm

Baroness Wall of New Barnet: My Lords, I, too, support the amendment. I want to focus particularly on integration in terms of what is provided by an acute hospital, compared with what is provided in the community. The noble Earl will know how many times I have spoken about how important and welcome it is that-as my noble friend Lady Pitkeathley said-the Bill includes social care and the patient pathway. However, the patient pathway does not and will not happen for the very reasons that this amendment identifies. It does not happen because of the integration described in the patient pathway, all parts of which patients are attached to, and all parts of which the providers of care try to work to. It will not happen unless the commissioners ensure two things. First, the tariff must make it happen. A tariff must be developed which says that this should be done somewhere else and we must say what the tariff measurement will be. Secondly, they must account for it. We know that while very often commissioners-certainly in the clusters that I am involved with in north-central London-try hard to prevent patients from going to hospital and to prevent repeat visits to hospital, in reality it does not work.

I am very supportive of this part of this Bill, and very keen on the integrated elements, not just with the local authorities-as has been said-but also within the health provision itself, because it is not happening now. These amendments address just that. Can we please hear from the Minister that he understands that the only way for people to be treated nearer to home is by addressing what the tariff is and how we measure it, as well as through accountability of both of the Commissioning Board and Monitor to ensure that this happens? Even in well intentioned trusts, it does not happen because there is nothing in place to make it happen.

Lord Sutherland of Houndwood: My Lords, I support the amendment for three reasons. First, were it to be implemented, the effectiveness of the care provided would be magnified and significantly improved for every individual involved. Secondly, there would be better value for money. Whether we like it or not, the two professions fight with each other over budget: that is the reality. Unless they are pushed towards talking to each other seriously-which this amendment does-that will continue, and we will have the consequence of expensive hospital care militating against the provision of adequate home care. Thirdly, human beings are individuals. Over time especially, they have a number of ailments that need to be seen together, and they need to be treated as individuals. An individual does not break up into bits, going to one institution for part of his or her care and to a second institution for another part. There is a real difficulty here. Previous research shows very clearly that trying to put a dividing line between health and social care does not work.

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We hear statements implying that it is going to be really quite difficult. This is not rocket science. It must be based on two professions coming together. This is being done in Scotland at the moment, and they have found ways to move ahead. I understand that there are pilots going on in England at the moment sponsored by the department, and I look forward with great interest to seeing what comes out of these. However, there is a lacuna in the Bill regarding how health and social care integrate. As long as this is so, the amendment would push things forward significantly.

Lord Turnberg: My Lords, we have heard that integrated care means different things to different people. As far these amendments are concerned-including the one to which my name is attached-the focus is on the integration of hospital care, NHS care and social care. Almost since its inception, the biggest problem for the NHS has been the division between health and social services; the division between funding-which of course drives everything-and management.

Acute services have always been the focus of most NHS funding. One might expect me to say, as a former acute care physician, that that is entirely appropriate. However, it has always been clear that this division, with different funding streams, has led to dreadful miscommunication between two sets of staff working under quite different systems, who fail to talk to each other in anything like a timely manner.

The end result is well rehearsed. Patients who would have been much better cared for at home-or in a nursing home if one were available and if someone could have made a proper assessment-finish up in an acute hospital which is poorly designed to provide the sort of care that they really need. On the other side, patients-usually elderly-are admitted to hospital for entirely appropriate reasons, but linger there well after their acute need has been sorted out. Clearly, if we had common funding of health and social services, we could see people employed across this divide. That is what we need: people with a foot in both camps. I take the point made by the noble Lord, Lord Mawhinney, that it takes two to tango-it takes both the heath service and local authorities, and they do not tango terribly well. While we do not have common funding, however, at least we can work towards it. Here we have an opportunity to emphasise the duty that should be placed on the NHS, for one, to ensure integration at this level. This is of such importance for patients that we should emphasise it at the least in this relatively minor way here.

Lord Newton of Braintree: My Lords, I support-with some trepidation-what my noble friend Lord Mawhinney has said, and I pick up the point about it taking two to tango. I yield to nobody in my support for integrated services. I heard what the noble Baroness, Lady Young-a person with whom I go back a long way-said about diabetes, and I do not disagree with it. I do not disagree with what the noble Baroness, Lady Pitkeathley-with whom I go back even further I think-said, presumably arising from her experience as part of Age Concern. The question is whether this amendment does it, or whether in fact it contains things which will make it more difficult. As the noble

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Lord, Lord Turnberg, said, it takes two to tango. As I read it, every responsibility here is laid on health service bodies, not local authority or social service bodies. If we are to go down this sort of path, we need to lay equal obligations on both.

However, the issue goes beyond that. It should be recognised that one of the most difficult or most needy areas in this field is mental health, which I know something about even though I no longer have a direct interest. With mental health there is a need for co-operation not just between the various statutory authorities-indeed, many mental health trusts are partnership trusts with the local social services department and have made significant progress, as was true of the one with which I was involved until January-but with voluntary organisations. Where are they covered in all this? I had a difficult case in a mental health trust that I chaired 10 or 15 years ago. Nobody in any statutory service, whether local authority or health, had known that the patient in question was undergoing anger management courses paid for privately, and that caused problems. Last weekend, I was talking to someone in Braintree who is interested in the Rethink Mental Illness charity and is trying to build up the local Rethink art therapy classes, for which he thinks he has acquired a building. That, too, ought to be integrated with the services provided by the mainstream.

I do not believe that this amendment, however valuable it is and however worthy its objective, will achieve that objective without a great deal more sophistication. Personally I would rather leave it to the Minister and his department to issue guidance and apply pressure in rather different ways to produce the integration that we all want. At any rate, I look forward to what the Minister has to say. He may draw more encouragement than usual from some of my remarks and I might even vote with him if it comes to that.

Lord Warner: Before the noble Lord sits down, perhaps I may ask him and his noble friend behind him whether they have seen Amendment 161A, which would introduce a new clause on standards of adult social care.

Baroness Northover: My Lords, perhaps I may remind noble Lords that we are at Report stage. According to my note, only the mover of an amendment or the Lord in charge of the Bill can interrupt with short questions.

Lord Warner: I am the mover of the amendment and I was interrupting with a short question to the noble Lords, who seem to be unaware of a part of the Bill which addresses their concern. Before I was interrupted, I was going to ask them whether they had seen Amendment 161A, which says that the duty would enable the Secretary of State to address the issue of reducing,

and give him powers to produce regulations to deal with that. Therefore, we will be coming to an amendment which, if agreed, will enable their concerns to be addressed.

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Lord Newton of Braintree: Perhaps I may respond to the noble Lord from a sedentary position. I was aware of that but, to be honest, I think that we need a coherent single approach.

Baroness Armstrong of Hill Top: My Lords, this debate has been very interesting. I agree with the last comment of the noble Lord, Lord Newton: we need an integrated approach. I support the amendment but I do so with deep frustration. The truth is that the Bill is inadequate and contradictory, and it starts from the wrong place. What everybody wants from the Bill is an answer to the question, "How do we reform the National Health Service now to deal with the starkest view that is facing us in terms of increased numbers of people with long-term conditions?". The past success of the health service is now keeping many more people alive and many of them will have long-term conditions for much longer. That is the single thing with which the National Health Service is going to have to deal with much more skill and integration than ever before, but the Bill makes it very difficult to do that. The noble Lords, Lord Mawhinney and Lord Newton, have made that point for us, so I shall not go on with it. We need a Bill which understands where the National Health Service needs to go and what we need to do to reform our services so that patients get the very best outcome in the most cost-effective way, given what is and will be going on in our economy for a long time to come. However, this chaotic Bill will not do that.

5.45 pm

Baroness Jolly: My Lords, I shall not repeat the many arguments that have been eloquently put this afternoon but it is just worth reflecting, as several noble Lords have already done, that integration is not new. Pooled budgets are not new. Torbay has tried to look at integration as a whole-system approach. My noble friend Lord Newton spoke about mental health integration, which occurs for some conditions in some areas. Therefore, integration is not new. The evidence that it is hugely beneficial is legion. That fact is evidence-based. Not only is integrated working better for people but it makes them better quicker and more effectively. However, integration is not universal. When I read through the Bill, I, like the noble Baroness, Lady Pitkeathley, was delighted to see that there was a duty on both the board and clinical commissioning groups to promote integration. That is good news but in a sense we are trying to use legislation to change culture. That is what it is all about. We have spoken about cultural change, and we have to put together two organisations that are not well used to working together. They jolly well should be but they are not. Therefore, we welcome what is in the Bill, although clearly more needs to be done.

I am quite surprised that the areas highlighted in the amendment would not form part of a regular reporting system, which is what is being called for. We would expect the board to take a lead on the mandate and the business plan. I should have thought that the board, the clinical commissioning groups and the Secretary of State would be expected to report on the status and progress of integration across the whole system. I should be very interested to

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hear from the Minister how this is expected to happen. Will he indicate how the reporting would function on an annual basis and whether the mandate and annual plan would be used in the way suggested in the amendment?

Lord Owen: My Lords, I rise to speak because I am a little troubled. It looks as though the Minister will object to this amendment. Of course, we are speaking in advance of knowing what he is going to do but I should like to give two or three reasons why I very much hope that he accepts the amendment.

First, using the term "social care" in the Bill means that expectations will rise. Those expectations have not been fulfilled and, to be honest, they could not have been. Nevertheless, it was a good idea to try to point to the fact that this was about more than NHS care or healthcare. We all know-it has been said many times in our debates-that there is no way that we can look at the narrow definition of the health service; it has to be broader.

The other powerful argument which I thought the noble Baroness was going to make is that this is a cultural change, and that needs to be re-emphasised at every stage as part of an educative process. Let us take the national Commissioning Board. This is a new body and the person who has been appointed to chair it is an academic lawyer-a person of great distinction. I am not objecting to the fact that it may be somebody with not very long experience of the health service. Nevertheless, a lot of hopes are vested in that Commissioning Board and to draw attention to it in a more declaratory way in this Bill is very important. It needs to know and see in clear terms in the Bill that this is part of its remit. I take great notice of what has been said about the reluctance of local authorities to respond to this. Were we having a debate involving local authority services, I would raise that, too. For a very long time I have believed that in the 1948 Act a great mistake was made in not pooling together local authority health services and welfare and social services in a comprehensive package. As everybody knows, there was a very deep debate inside the then Labour Government between Herbert Morrison and Aneurin Bevan.

There is also another debate about decentralisation and centralisation. That has been with us all these years. In the very early 1960s I wrote a book about a unified health service. When I was a Minister, there was a great deal of animosity within the medical profession at the thought of working closely with local authorities. It is amazing how that has changed. There is now a readiness in the medical profession in particular-nurses have always done it-to work across these things. I shall make no more points, but I hope that the Minister will accept this amendment. With all the reservations that have been put down, nobody should believe that this legislation will have a very big impact on social care anyhow, but pointing it in the right direction at this moment would be helpful.

Baroness Hollins: The amendments have particular relevance to mental health and learning disability services. In speaking in this debate, I declare an interest

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as a past president of the Royal College of Psychiatrists. I shall focus my comments on commissioning integrated care.

I remember that in the early 1980s, when I was newly a consultant, we had jointly commissioned services. They worked effectively and provided a very accessible way of developing integrated services. I shall talk briefly about the work that the Royal College of Psychiatrists has already done to support integrated commissioning since the Bill was first mooted. The joint commissioning panel on mental health was launched in April 2011. It is led by the Royal College of Psychiatrists and the Royal College of General Practitioners. It is a collaboration of 15 other leading organisations, service users and carers with an interest in mental health, learning disabilities and well-being across health and social care. It draws on expertise from across the statutory, voluntary and private sectors.

It has already produced guides on primary mental health care and liaison mental health services, which is relevant to the comments of my noble friend Lady Young about integrated care for people with diabetes. My interest here is integrating mental health care into the diabetes pathway. The panel is working on both commissioning guidance: on what is needed; and on practical commissioning tools-how to do it. The practical how-to-do-it tools have been developed with strategic health authorities, thus providing important support to the emerging and new NHS structures. They will be ready in 2013.

The joint commissioning panel on mental health is an example of an existing strong and practical partnership, which brings together the whole mental health sector with government to develop and implement integrated high-quality care and interventions. Incidentally, it is hard to understand why professional organisations leading this work were excluded from the Prime Minister's recent summit on implementation, given this real focus on that issue. Mental health can so easily be forgotten along with other complex services when physicians, surgeons and politicians are debating health rather than mental and physical health. I am interested to know the Minister's views on whether this cultural change needs to be in legislation. Some of the experience gained in jointly commissioning mental health services provides very good learning for services traditionally seen as providing stand-alone health episodes-good learning that could be used to develop integrated services in other areas of healthcare.

The Earl of Listowel: In rising briefly in support of the amendments, I pay tribute to the Government for their contribution in this area already. This is a personal view, but in my experience the best professionals will find a way through against all odds and against the system to work together in partnership to improve outcomes. What the Government have been doing with the social work workforce in terms of raising the threshold of entry to social work, the additional support for newly qualified social workers and the review by Professor Eileen Munro on child and family social workers is a welcome part to this. I hear again and again from people on the front line that an obstacle to integration is continual structural change. When disciplines have stability and can grow together they can learn to

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work in partnership effectively. Finally, I welcome the building of capacity in the social work workforce, which will assist with the question of better integrated working.

Baroness Howarth of Breckland: My Lords, I want to speak briefly, not having spoken earlier. In answer to a Question from the noble Lord, Lord Walton, earlier in the day, the Minister talked about his great belief in the integration of services. Indeed, he talked about health and social care services in relation to people with neurological diseases. I have no doubt that the Minister and, I am sure, the Government have a great belief in integration. The problem is that it is in the "too difficult" box. Whenever we hear discussions about how we will make a start on the problem, there are real questions about how, about when, about the costs, about which particular authority, and so on. We had a demonstration earlier of the way in which different parts of the organisation-the health service and the local authority-can be set against each other in terms of the working together that they need to do.

I declare an interest as I am involved in a number of charities that have a health focus-a large number of very good partnerships of health and social care working together. I shall describe one briefly simply because I think it is helpful to have an example. It is a brain injury unit in Suffolk where the health services and a voluntary organisation with social care work in a pioneering way to ensure that people can return to the community instead of being hospitalised or unable to communicate with their families in any way. That kind of work is going on and I know that there are other pilots up and down the country looking at how financial services can be brought together.

I come back to a point that I was making at the beginning, which is that the too-difficult box means that there is a need to find a place to start. I do not know whether the Minister believes that this amendment, with Amendment 161A-it is important to look at them together as they give a balance of health and social care-sees them as the way of making a start. If not, I ask him the very pointed question: when will the Government start? Why is this called the Health and Social Care Bill because, as was said previously, expectations were raised enormously in those who receive social care services? In what way will the Government take the whole plan forward? I know that they have promised a Green Paper, a White Paper and to take things forward, but if we do not have a clear picture, the amendment itself will not help. It alone cannot bring about what people have been discussing, which is the culture change.

Those of us who have been involved in these services for 50 years and more-many who have already spoken can, unfortunately, claim that-have lived with these differences. They have had a profound effect on people's lives, as the noble Lord, Lord Sutherland, said. We have experienced them personally because we have had families going through the services, and we have seen them professionally with patient clients. The other thing I rather worry about is the medicalisation of everybody in this because people who want social care do not necessarily want medicalised social care; they want medical care when they need it.

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I am really asking the Minister, so I can think about whether I support these amendments: what is the alternative to ensure absolutely that the Government move forward in a proper programme that brings integration in health and social care to the benefit of every individual patient who needs that sort of care?

6 pm

Baroness Masham of Ilton: My Lords, I would like to ask the movers of the amendment a question just for my own concern. Health is free at the point of delivery so there should be no problem with integration between primary and secondary care. However, this is not the case in social care as there is means testing. How does this affect integration?

Baroness Thornton: My Lords, I am not going to attempt to answer the noble Baroness's question. I shall leave that for my noble friend Lord Warner or the noble Lord, Lord Patel. The noble Lord, Lord Patel, and my noble friends Lord Warner, Lady Pitkeathley and Lord Turnberg made a very good job of introducing these amendments, stressing the importance of joint commissioning, the work of the Health Select Committee in the Commons and its recommendations, and indeed the vital nature of tariff reform. This is a modest but very important amendment that strengthens the Bill.

Every time we meet on Report on this Bill we are in a different world. The world we are in today is not the same one we were in 10 days ago. As we speak, the Royal College of Physicians has decided by a majority of 80 per cent to ballot its members about how they feel about the Health and Social Care Bill. By my counting that leaves only two royal colleges which have not consulted their membership so far. We all know what the results of the consultations have been, but still we plough on with this Bill.

The remarks of the noble Lords, Lord Mawhinney and Lord Newton, and the noble Baroness, Lady Jolly, together underline the defects of this Bill. Why are we having a debate about integration at this point in the passage of this Bill? It occurred to me that perhaps those debates should have been had before we had the Bill. However, because you cannot achieve everything does not mean that you should not try to achieve something. That is what these amendments do and that is why we on these Benches are very keen to support them. It seems to me that through all the many definitions of integration that we have discussed in this House, the one that is going to have the most effect on budget and finance is in these amendments here before us today. I hope the Minister will accept these amendments because they will improve this Bill.

Earl Howe: My Lords, integration has been a consistent theme throughout our debates on the Bill and the noble Lord, Lord Warner has made a number of highly informed speeches on this topic, as indeed have many in your Lordships' House. The noble Lord, Lord Warner, made a powerful case for taking action for further integration. There is no disagreement between us on this. It is why the Government have already

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taken a number of steps to do precisely what he is asking and I name a selection only. We have put duties on commissioners to promote integration. We are creating health and well-being boards, bringing together health and social care commissioners and their representatives-one of the main manifestations of joined-up thinking in this Bill. We are strengthening the duties in relation to pooled budgets. We are placing specific duties on Monitor to support integration and tabling an amendment prior to Report giving Monitor express power to do that. We are working with the Future Forum, the King's Fund and the Nuffield Trust in a whole range of non-legislative measures. This is not as the noble Baroness, Lady Howarth, put it, something the Government have put into the "too difficult" box. We are determined that we need to tackle this. I hope no one in your Lordships' House is left in any doubt about our commitment in this area.

There are numerous examples of the non-legislative things we are already doing. We agreed with the Future Forum's recommendations that the board should produce commissioning guidance for CCGs that focuses on how to meet the needs of different groups of people who may have multiple problems such as the frail elderly. By April 2012 the department will put in place new metrics that bring together existing data on patients' experiences at the interface between services. We are working with the NHS Institute for Innovation and Improvement to identify and spread examples of good practice in local measurement and improvement of pathways of care. Through the NHS operating framework for 2012-13 we are asking all PCTs to work with their local authority partners to look at how integration can be better achieved. I have a whole string of other examples.

As I have said, the commitment of the Government in this area should not be doubted. I was very pleased to see the King's Fund and the Nuffield Trust in their report to the Future Forum recognising that,

this Bill,

That is exactly right. While there is clearly work to be done to make this a reality, the Bill will, for the first time, create duties for NHS bodies to promote and encourage the commissioning and provision of integrated services. It is a difficult concept to define. While the noble Lord, Lord Warner, is to be congratulated on the attempt he has made in his amendment, my fear is that the amendment will not actually take us very far. The precise term "integration" is used only in headings in the Bill and the concept of integration is applied in a number of different contexts so a fixed definition of this kind may not be appropriate in every case. It may be too narrow in some cases-some noble Lords have alluded to that point. It is also a somewhat circular definition, referring as it does to integration meaning the delivery of integrated care. That serves to illustrate the real difficulties with this approach.

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I am not convinced that it is necessary to try to describe what integration means. Integration is a broad concept. It could encompass a range of measures. As the recent King's Fund and Nuffield Trust report noted,

Yes that is right and the duty on the board in new Section 13M is absolutely consistent with that approach.

We were very grateful to the Future Forum for its recent work on integrated care. We welcome its recommendation that the entire health and social care system should share a clear and common understanding of the value of integration as a means of putting patients at the centre of their care. However, it was also clear that rather than being an end in itself, integration is,

That is surely right. There must be the scope for integration to be adaptable to the needs of local communities and individual patients. The noble Lord's definition holds,

as the objective in itself when improving outcomes and reducing inequalities should be the ultimate objectives.

Very recently, I was advised of a paper produced by the World Health Organization in 2008, Integrated Health Services - What and Why? It starts off by stating that integrated health services mean different things to different people. It lists a whole variety of interpretations of what integrated healthcare means and says that it is in essence very difficult to boil these things down to a definition that is going to please everybody. It also casts doubt-I do not want to make too much of it-on the empirical base for claiming that integration is the answer in every set of circumstances. In making that point, I do not want to imply that the Government are anything other than fully committed to integration, because we certainly are, but the paper's conclusion is:

"'Integration' is used by different people to mean different things. Combined with the fact that this is an issue which arouses strong feelings, there is clearly much scope for misunderstanding and fruitless polarization".

For the World Health Organization to come to that conclusion tells a story. In drafting the various duties and powers in relation to integration, we have consciously avoided a fixed definition to allow for a measure of flexibility and innovative thinking. We have focused on the purpose-the "why" rather than the "how".

I recently met front-line staff when I visited the NHS on the Isle of Wight to look at how they were delivering an efficient, integrated, urgent care service. I made a point of asking them whether they thought that a definition of integration in the Bill would be helpful. I received a resounding no in response. They felt that something like that would stifle their ability to apply fresh thinking and to come up with inventive solutions of their own as to how best to provide integrated care. We are clear that we should not put clinicians, who know the needs of their patients best, in a straitjacket by defining integration in the Bill.

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Clearly, it will be important that the board and CCGs are held to account for delivering against these duties. They are already required to set out in their annual reports how they have exercised their functions, including how they have met the various duties placed on them.

Amendment 38C also makes particular reference to the board and Monitor developing tariffs that will support integration. On that point, I reassure the noble Lord that the duties on the board and Monitor to promote integration would apply in relation to their functions in relation to the tariff. The clauses on the tariff allow a high degree of flexibility for the board to adopt different approaches to tariffs, including "bundles" of services or pathways, and we are committed to extending these. They also allow scope for local flexibility in how the rules are applied where necessary. The noble Baroness, Lady Wall, provided considerable insight into what is needed here. Perhaps it would be helpful if I gave an example of a pathway tariff.

In 2012-13, we are introducing a "year of care" tariff for funding cystic fibrosis services, developed with the support of the Cystic Fibrosis Trust. This includes all the care for cystic fibrosis patients for a whole year. The price is broken down into different "bands", depending on the complexity of the patient. The tariff will cover the care undertaken by specialist centres and local hospitals, but it will be paid only to the specialist centre thereby promoting better joint working between specialist centres and local hospitals. We are confident that the board, with support from Monitor, will continue to develop and increase the scope of bundled service tariffs where it is clear that tariff design of that kind is appropriate and will deliver benefits to the patient.

6.15 pm

Under the proposed system, Monitor and the board will have to agree elements of the tariff with each other at all stages. The methodology would be subject to consultation and capable of independent review to ensure transparency and fairness. In addition, under Clause 119, the board and Monitor are specifically required, in developing standard specifications of services for the purposes of the national tariff, to have regard to whether this could have an adverse impact on the provision of services.

I hope that that provides sufficient reassurance to the noble Lord, Lord Warner, that the emphasis on integration is there, but that he will accept that trying to pin down in words what it should look like may be counterproductive. This is not an argument about the Government's commitment to integration or what we are doing on the ground to achieve it; it is an argument about a specific mechanism designed to achieve it. I think that it is a mechanism that is ill-advised. I hope that the noble Lord will agree to withdraw his amendment.

Lord Winston: I have a short question for the Minister because I feel that it is an important issue. Perhaps I may very briefly tell him about something that I learnt of last week. A friend of mine went to a very famous ENT hospital after a month with a fractured nose-

Noble Lords: Order!

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Baroness Northover:My Lords, the Minister has sat down, so it is for the mover of the amendment to respond.

Lord Winston: I am sure that the Minister will want to answer my question because it is not aggressive or political; it is really to find out how this Bill will work. When somebody goes to casualty after a month with a broken nose and complains, "Look, my main problem is the pain in my sinuses which I have had for a long time", and is told by the doctor when they had already waited six hours, "I'm afraid the sinuses are a different department. You'll have to make another appointment", that is a problem with integration. How does the Minister think we might accomplish better integration with this Bill?

Earl Howe: It is a very interesting question from the noble Lord. When I visited Oldham a few weeks ago, I saw for myself how they were getting around that problem in the context of musculoskeletal services. Instead of patients being shunted from pillar to post, they had a system whereby the patient could move seamlessly and immediately from one specialist to another. They did not have to be referred; they could ring up the centre and ask to see a particular person. That is the kind of integrated model that we need to see rolled out more generally in other services. I recognise the issue that the noble Lord raises, but it is one that we are seeing inventive solutions arising to address. I hope that the work being done will do that.

Lord Warner: My Lords, there have been some extremely powerful speeches of support for this amendment for which I am extremely grateful. I am grateful in particular to my co-signatories and I noted the powerful speeches of the noble Lords, Lord Owen and Lord Sutherland, and the noble Baroness, Lady Young. They have made the case for an amendment of this kind to the Bill.

I was disappointed by the Minister's response. That was not just because I got only a B- for my definition-I expected to have my homework marked by officials in the Department of Health and was not expecting to get a high score-but because I think that the definition meets the needs that we have. I find it very difficult to see how the Minister can stand up and say, "Well, we're going hold people to account; we're going to monitor their performance", if we do not have a definition against which we are going to monitor their performance.

The definition proposed by the amendment moves us away from a preoccupation with integration as organisation and process change to delivery of services to the individual. I do not see how the Minister can say, "We're concerned about outcomes for individuals", if we do not integrate delivery. You are highly unlikely, I would say as a jobbing ex-public sector manager, to get good outcomes if you have not orchestrated the delivery of the services to the individual that meets their needs.

Earl Howe: I would not want the noble Lord to believe that I was dismissive of the point that he has just made. I recognise that it is important that we

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somehow give the meaning of integration a clearer explanation, whether that is through the guidance issued by the board or, indeed, the Explanatory Notes to the Bill. I am just wary of putting something in the Bill. That is all.

Lord Warner: I guess I am more of a risk taker than the noble Earl and I believe that we could put a definition of this kind in the Bill. It would cause no confusion-indeed, it would remove it-in the minds of many people working day in, day out in the NHS. As to those who have asked, "What is the purpose of some of the other changes?", the noble Lord, Lord Owen, powerfully made the point that we need to give strong signals to these new players in the game. We want them to start off knowing that they will be held to account in their annual reports for monitoring their progress on integration. We want that: it is deliberate. We want them to know that Parliament put that in the Bill for a purpose. I am not satisfied with the Government's response and I beg leave to test the opinion of the House.

6.21 pm

Division on Amendment 38C

Contents 206; Not-Contents 227.

Amendment 38C disagreed.

Division No. 2


Adams of Craigielea, B.
Adebowale, L.
Adonis, L.
Afshar, B.
Ahmed, L.
Alton of Liverpool, L.
Anderson of Swansea, L.
Andrews, B.
Armstrong of Hill Top, B.
Bach, L.
Bakewell, B.
Barnett, L.
Bassam of Brighton, L. [Teller]
Beecham, L.
Berkeley, L.
Bhattacharyya, L.
Bilston, L.
Blackstone, B.
Blood, B.
Boateng, L.
Boothroyd, B.
Borrie, L.
Bragg, L.
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27 Feb 2012 : Column 1095

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Aberdare, L.
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Anelay of St Johns, B. [Teller]
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Benjamin, B.
Berridge, B.

27 Feb 2012 : Column 1096

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6.33 pm

Clause 20 : Functions of Special Health Authorities

Amendments 39 and 40

Moved by Earl Howe

39: Clause 20, page 15, line 10, at end insert-

"( ) Subsection (1) does not apply to any function of the Secretary of State of making an order or regulations."

40: Clause 20, page 15, line 22, at end insert-

"(6) In section 273 of that Act (further provision about orders and directions), in subsection (4)(b)-

(a) before paragraph (i) insert-

"(zi) section 7 about a function of a person other than the Secretary of State," and

(b) in paragraph (i) after "a function" insert "of the Secretary of State"."

Amendments 39 and 40 agreed.

Clause 22 : The NHS Commissioning Board: further provision

Amendment 41 not moved.

Amendment 42

Moved by Lord Warner

42: Clause 22, page 16, line 22, after "appropriate" insert-

"( ) the priority and scope for commissioning service redesign and reconfiguration in the light of the best clinical advice available,

( ) the priority and scope for transferring resources to adult social services to improve service integration and achieve best value for health services,"

27 Feb 2012 : Column 1098

Lord Warner: My Lords, so near, yet so far. Amendment 42 is very simple. It requires the Secretary of State to include in his mandate to the national Commissioning Board the requirement to set out two things. First,

in the NHS,

and secondly,

These are two big issues for the NHS and how it meets the Nicholson challenge of £20 billion of savings by 2015 and how it improves service integration. The proposals in this amendment are very much in line with the recommendations of the Health Select Committee in its two recent reports on public expenditure and social care, which were mentioned on the last group of amendments. As the Public Expenditure report said on page 30:

"The Nicholson Challenge can only be achieved through a wide process of service redesign on both a small and large scale".

It went on to say,

Since I put this amendment down, I am pleased to say that the Minister has responded in a most constructive way. On the first part of the amendment, regarding service reconfiguration, he has entered into most constructive discussions on this issue and the related Amendment 217 in my name and the names of the noble Lord, Lord Patel, and the noble Baroness, Lady Williams, regarding a pre-failure regime. The Minister has undertaken to have an alternative to that amendment prepared before Third Reading. I would be glad to hear more today on how that work is progressing.

On the second prong of the amendment, the Minister has had prepared an alternative approach for transferring money from the NHS to adult social care by amending Schedule 4. This gives the Secretary of State power to direct the board to make payments for community services, which, I understand, include adult social care. This is Amendment 148B, in the name of the noble Baroness, Lady Murphy. It would have been in my name as well if I had not been dallying in India when the noble Earl wanted to discuss it with me. I am very supportive of that amendment on the assumption that, as drafted, it is wide enough to cover adult social care, because that term is not mentioned specifically, and on the assumption that there are no vires issues with the Treasury on the matter of using NHS money for social care. Perhaps the Minister could provide some assurances on this when he responds.

These issues are important for the NHS and for patients in the particular financial and demographic challenges that services face. I am pleased with the Government's constructive response. In the mean time, in order that we may debate these issues, I beg to move Amendment 42.

Baroness Murphy: My Lords, I will interject here with regard to my amendment to Schedule 4, tabled as Amendment 148B in the supplementary hymn sheet.

27 Feb 2012 : Column 1099

First of all, I thank the Minister very much for the discussions that I had with him and the Bill team last week. As a result, I tabled this amendment. Unfortunately, I omitted to let the Whips' Office know that it was to be discussed with Amendment 42, otherwise they could have been tabled together.

As I understand it, the important thing about this amendment is that it addresses the issues that we have just spent another hour discussing of how in practice you get money flowing from health to social care, and how you promote integration of services through some practical mechanisms on the ground. Over the last 60 years, there has been too much money held in the NHS-I say this as a health service person-when it should have been better transferred in to social care services to support people with long-term conditions. It has been extremely difficult to get mechanisms that work well. The importance of this is that we do not have to have it repeated in the mandate, which was in the amendment tabled by the noble Lord, Lord Warner. I was very supportive of that, but it is much more flexible to have it as the Secretary of State's direction. It also covers wider organisations than adult social care, although we expect that to be the main route to which the Secretary of State would wish to ask for moneys to be transferred. My amendment is slightly superior in that respect to the amendment proposed by the noble Lord, Lord Warner. However, it does not address the most important issue that the noble Lord brought up in the first part of our amendment-that of the reconfiguration of services and how you can prepare and work towards dealing with issues around failing organisations and services. I know that, as the noble Lord said, the Minister has been looking at that issue and may be able to come back to us with some mechanisms for that-but on this one I wish to speak in support of my Amendment 148B, which addresses the Secretary of State's direction in Schedule 4.

Lord Patel: My Lords, I have added my name under that of the noble Lord, Lord Warner, and I would also have supported Amendment 148B under the name of the noble Baroness, Lady Murphy, if I had not been in India at the same time-not, I hasten to add, with the noble Lord, Lord Warner.

I merely wish to speak about reconfiguring hospital services. It is quite clear that in the long term demographic changes and the shifting burden of disease require a fundamental shift away from acute care in hospitals to supporting people with long-term conditions in the community. The recent financial pressures and shortages among some parts of the workforce and the need to improve quality and safety mean that changes to hospital services in some parts of the country are already a necessity. The Government have argued that service change should be locally led. In Committee, the Minister stated that,

I agree that clinicians and local communities must be fully engaged in the process of service change. However, local involvement and strategic leadership are not mutually exclusive. For example,

27 Feb 2012 : Column 1100

the reorganisation of the successful stroke services in London proceeded with strong support from clinicians and the public. It is not clear how strategic reconfigurations of specialist services will be led. Again in Committee, the Minister stressed that the NHS Commissioning Board,

A recently released paper outlining the design of the NHS Commissioning Board confirmed that involvement in large-scale reconfigurations will be one of the functions of the four regional sectors that will be established as part of the board. But I am not too sure whether the NHS Commissioning Board has the necessary capacity or experience to do that. The lack of clear responsibility for driving forward strategic reconfigurations of services is the most significant omission from the Bill. We need a clearer explanation about how these reconfigurations will be taken forward under the new arrangements, otherwise the risk is that the NHS will not be equipped to meet one of the bigger challenges, as is necessary to reconfigure some of the acute services.

6.45 pm

Lord Rea: Would the Minister look at the experiment mentioned by the noble Baroness, Lady Jolly, in Torbay, where there has been considerable merging of health budgets and social services? That was locally led, but would it not have helped to spread it further with an amendment such as this in place, so that it could be encouraged from the centre?

Baroness Thornton: My Lords, I support these amendments, and I do so because I agree with the noble Lord, Lord Patel, that there was a grave omission from the Bill that would allow strategic reconfigurations to take place that are not based on failing institutions. It was certainly not clear to us-and I rest on the authority of my noble friend Lord Warner on this-how, with the abolition of the SHAs from April 2013, strategic reconfiguration of specialist services would take place. Ministers have said, "Oh no-it's all going to be okay", but they have not explained how you would reconfigure the stroke services in London, as the noble Lord, Lord Patel, said, after the abolition of the strategic health authority. We support the amendments and hope that the Minister will do so as well.

Earl Howe: My Lords, we have had several lively debates on the importance of redesigning services if the NHS is to become more personalised and productive, and the noble Lord, Lord Warner, speaks with great insight and passion on this issue. He has tabled further amendments on this topic, which we will have an opportunity to debate in detail at a later stage.

The Government are clear that, as a basic principle, the reconfiguration of services is a matter for the local NHS and that decisions about service change should be driven by local assessment of need. The reconfiguration of services works best when there is a partnership approach between the NHS, local government and the public. What matters is that strategic decisions are

27 Feb 2012 : Column 1101

taken at the right level. We believe that our reforms will enable commissioners to make the changes that will deliver real improvements in outcomes for patients and the public. The Bill places clear duties on the Commissioning Board and clinical commissioning groups, which will underpin a locally driven approach to service redesign, clinically based and framed around the needs of patients. That includes duties to promote the NHS constitution and the involvement of patients as well as duties to secure continuous improvement in the quality of services and to reduce inequalities. These duties set important guiding principles against which the commissioning system will develop and oversee service redesign and reconfiguration. In addition, the NHS will continue to assure reconfiguration proposals against the four clear tests set by the Secretary of State, which are that proposals should have support from clinical commissioners; should be based on robust patient and public engagement; should be underpinned by a clear evidence base; and should be consistent with current and prospective plans for patient choice. The Bill and the four tests will ensure that any proposals for service change are based on a thorough assessment of local need, underpinned by clinical insight and developed through dialogue between commissioners, providers, local authorities, patients and the public. Of course, the board will have an important role in providing support and assurance to local commissioners, but we will not be replicating layers of top-down management.

With the clear legal duties set out in the Bill, the four tests and the support and assurance that will be available, there should be no need for the Secretary of State to prescribe through the mandate how the commissioning system should prioritise and determine the design of services. To do so would cut right across the clinically led local commissioning, which is at the heart of the Bill. Nevertheless, I recognise the importance of getting these arrangements right, and between now and Third Reading I commit to working with the noble Lord with a view to finding a formula designed to address the concerns that he has articulated. We are looking at a range of options. I hope to be able to say more about this when we reach his later amendment on the subject. I hope that for now he will find this rather broad assurance sufficiently strong to enable him to withdraw that part of the amendment.

I hope that the noble Lord will be able to withdraw the rest of Amendment 42 as well, because it also raises another issue. It is vital, especially in the current economic climate, for the NHS to provide financial support for adult social services where possible in relation to those services at the interface between health and social care. Here, I pay tribute to the noble Lord, Lord Warner, who has been a tireless advocate of social care at numerous stages of our proceedings, to ensure that this element of the equation-and that part of the Bill's title-is not overlooked.

The noble Baroness, Lady Murphy, has tabled Amendment 148B with a similar aim in mind. We are all, I think, aware of the impact that such services can have in helping people to live independently in their own homes and in reducing unnecessary hospital admissions-which is, of course, better for the individuals

27 Feb 2012 : Column 1102

involved and relieves pressures on the NHS. The last spending review included a commitment to provide £648 million in 2011-12, rising to £700 million by 2014-15, for these purposes. Early indications are that this funding has helped to promote integrated working between social care and health commissioners. We want this to continue. I can reassure the noble Lord and the noble Baroness that by virtue of paragraph 130 of Schedule 4 to the Bill the NHS Commissioning Board and CCGs will inherit the powers that primary care trusts currently have under existing legislation to make payments to local authorities towards expenditure on community services.

Generally speaking, our approach in this Bill has been to give NHS commissioners maximum autonomy in how the NHS budget is used. However, I have sympathy for the argument that it is legitimate that the Secretary of State should be able to determine the proportion of NHS funding that is to be transferred to local authority community services in order to secure closer working between the NHS and social services. I am not sure that the mandate is the right vehicle for this. However, I can see very considerable merit in the approach that the noble Baroness has taken with Amendment 148B. This amendment would give the Secretary of State additional powers to direct the board on the minimum amount that it should transfer to local authorities in a given financial year. The Secretary of State would be able to specify in the directions the bodies to which those payments should be made, the amount that should be paid to each body and the functions in respect of which the payments must be made, and to amend these instructions if necessary. It would essentially enable the current arrangements to continue.

The noble Lord, Lord Warner, asked whether the amendment was wide enough to cover adult social care; whether it was within vires; and whether the Treasury is content. The answer to all those questions is yes. Indeed, I am advised that the amendment would enable funding to be transferred to other community services, such as housing, if necessary.

The approach taken is in line with current practice, which is approved by and agreed with the Treasury. Importantly, this would represent only a minimum. The board would retain the power to make additional payments over and above those required by the Secretary of State if it chose. The CCGs would also retain their powers to make such payments. Although I think it makes sense for it to be the NHS Commissioning Board that makes these payments, it would also be vital that there is a dialogue between local authorities and clinical commissioning groups as to how the funding could be best used. Of course, both will be involved, as members of health and well-being boards, in setting the strategic framework for health and social care commissioning through the joint health and well-being strategy. In addition, the existing powers in Section 256 for the Secretary of State to give directions on the conditions that should apply to such payments would apply. This is helpful because it would provide a mechanism for ensuring that the agreement of the health and well-being board is obtained as to how funds are spent.

27 Feb 2012 : Column 1103

The noble Lord, Lord Warner, has spoken with great conviction about the Bill's importance, including the tangible duties to act to ensure that integration moves from being just an aim to being a reality-as, indeed, the Future Forum has emphasised that it must. I think that Amendment 148B meets all the criteria to ensure that that will be the case. I shall therefore be happy to support it if the noble Baroness should decide to move it. I hope that my noble friends will join me in supporting the amendment; I would urge them to do so. Given that commitment, I hope that the noble Lord, Lord Warner, will be prepared to withdraw Amendment 42.

Lord Warner: My Lords, I am grateful to the Minister for his explanations and reassurances. I certainly think that Amendment 148B is a better amendment than my provision on social care in Amendment 42. I am very happy also to accept his broad assurances that we will have a discussion and dialogue to see whether we can move forward on, in effect, a version of a pre-failure regime, while recognising the Government's commitment to local decision-making on redesigning and reconfiguring services. On that basis, I am happy to withdraw the amendment.

Amendment 42 withdrawn.

Amendment 43 not moved.

Amendment 43A

Moved by Lord Kakkar

43A: Clause 22, page 16, line 25, at end insert-

"( ) The mandate shall also require performance monitoring in primary care by the Board."

Lord Kakkar: The amendments in this group all deal with the question of monitoring performance in primary care. The first amendment deals with the question of the Secretary of State providing, as part of the mandate, clear guidance on performance standards for primary care. The second amendment deals with the NHS Commissioning Board paying due attention to these standards and ensuring that data are collected with regard to performance in primary care. The final amendment deals with the role of clinical commissioning groups, with particular reference to assisting the NHS Commissioning Board in discharging those particular responsibilities.

At the very heart of the Bill is an important and much welcomed understanding that, to deal with the demographic challenges and the change in the nature of clinical practice that our society will face in the coming years, there needs to be a move away from managing patients with chronic diseases in the hospital environment and ensuring that they are managed in the community and primary care environment. This, of course, is welcome and is an important recognition of the changing nature of disease that we will face in terms of delivering good clinical care in achieving the best clinical outcomes.

There is no formal mechanism in the Bill as it currently stands to ensure that data on the performance of primary care practitioners are collected on a regular basis; that there is an absolute obligation, as part of

27 Feb 2012 : Column 1104

the Secretary of State's mandate, to adopt a clear primary care outcome framework; that that framework sets clear standards which need to be achieved in primary care; and that data on the achievement of those objectives are collected regularly and transparently to enable patients to understand whether their general practitioners are performing to the highest standard.

This is very important because, in hospital practice, there has been an emphasis on the collection of outcome data for some years, such that audit is an absolute obligation, particularly on those who work in craft specialities and undertake procedures that may be attended by poor outcomes. We also know that in acute services-such as those for patients with acute myocardial infarction and stroke managed in the hospital environment-there is an obligation to collect data on those outcomes, which are increasingly available to other clinical colleagues, to patients and the public. This helps in a broader and fuller understanding of the performance of acute care trusts. However, when it comes to performance in general practice, these data are not routinely available.

7 pm

As more practice moves to the primary care environment, it will be increasingly important to ensure that when patients are managed for a much broader range of diseases and conditions in that environment, the outcomes achieved by those individual practices are both properly understood and monitored or reported in such a way that if services are commissioned in a primary rather than secondary care environment, those commissioning decisions are taken on the basis of objective outcome data. It is therefore essential that the mandate deals with the question of performance in primary care.

I know that, more broadly, the mandate will deal with the question and the obligation always to strive to improve the quality of care and, implicit in that, to achieve the very best clinical outcomes whatever the care environment. However, as there is now such an emphasis on transferring care out of the hospital and into the primary care environment, we need to be sensitive to what that environment will mean both for a number of practitioners and for their patients.

Unlike the hospital environment, where large numbers of clinicians tend to work together and there is an opportunity for a patient to be reviewed by a number of clinical teams at different stages in the natural history of managing their condition, patients in primary care will often be managed in single-handed or small general practices where they will not have the opportunity to be reviewed by a number of different doctors, including those in training, and where shortcomings in care will often not be understood or recognised by the patients for whom the care is being provided. It is therefore vital that we set high standards in what is expected in primary care and that we ensure that the metrics applied can be measured objectively and that the data are not only collected as a matter of obligation but reported in such a way that other clinicians and patients can understand them.

If the Bill's purpose is to be fully achieved-to ensure more movement from the secondary and tertiary care sectors into the primary care environment, particularly

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for the management of chronic diseases-it is essential that these types of data are made available; that the primary care outcomes framework sets specific standards; that there is an obligation to monitoring the achievement of those standards; and to have transparent reporting. It is important for the Government to try to ensure that those objectives are met. One of the safest and surest ways of doing so is to include in the Bill an obligation regarding these functions and obligations. I beg to move.

Lord Patel: My Lords, I support the amendment. I spoke at length in Committee on a similar amendment and my noble friend Lord Kakkar has covered quite extensively why we need some kind of primary care outcomes framework which assesses the performance of primary care. Primary care will be involved in prevention, diagnosis, treatment and long-term care of patients. Hitherto what we have had is QOF, which has already been found to be lacking in identifying the quality outcomes that demonstrate improvement in care. For example, in cardiovascular disease, evidence was presented from 1,000 primary care practice interviews and their performances as assessed did not show that there was improvement through QOF. Of course in certain other areas, there might be. The management of hypertension again shows no improvement. In a study carried out of chronic hypertensive patients, there is still a high incidence of complications related to hypertension. So we need other measures and in the absence of a primary care outcomes framework, we do not know how primary care will be performance managed.

Lord Walton of Detchant: My Lords, I have put my name to two of these amendments so ably proposed by my noble friend Lord Kakkar. I have been on the medical register now for 67 years. I am a registered medical practitioner and I actually have a licence to practise which allows me to prescribe-not that the opportunities of clinical practice in my present world are very widespread, except on the very rare occasions when I have been called upon to minister to one of your Lordships who may have been taken ill in the precincts of this House. The licence to practise will be subject later this year to a process of revalidation.

If I go back to the days-forgive me again-when I was president of the General Medical Council and served on a number of occasions on its conduct committee's hearings, it became perfectly clear that some of the doctors referred to the GMC were not actually guilty of serious professional misconduct. However, some of them who came before the conduct committee were in fact practising at a standard which was not adequate in a clinical sense. In other words, there was a question in a number of cases of their clinical competence. In those days the GMC began a process to examine whether, alongside the conduct procedures, we should introduce procedures to be able to identify doctors who were practising at less than an adequate standard of care. In the end, under the noble Lord, Lord Kilpatrick of Kincraig-my successor as president of the GMC-it eventually introduced performance procedures to assess clinical performance. Those performance procedures have continued and

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have been very effective in identifying and handling appropriately, often with retraining, doctors who were found to be practising at less than an adequate standard of performance.

The Minister may say that when, later this year, doctors will be able to retain their licence to practise subject to a process of full validation of their clinical competence, that may be enough. The fact is that I do not believe it will be, and it is therefore crucial that we have a mechanism in the Bill to deal with this potential issue. After all, over the past 40 or 50 years, there has been a massive improvement in the standard of general medical practice in the UK, following the introduction of compulsory vocational training. Every doctor wishing to be fully capable of being a general practitioner has to undergo, at a minimum, three years' vocational training. The improvement has been immense, but everyone will recognise that not all practices are of such a uniformly high standard. Some doctors in practices may be less competent than others.

The same may be true-who knows?-of clinical commissioning groups. There is clear evidence that most clinical commissioning groups or consortia of GPs will be providing a high standard of care in the community, but there may be a few that are not up to that standard. It is therefore crucial that we have a mechanism whereby the Secretary of State can be in a position, through amendments such as those proposed by my noble friend Lord Kakkar, to identify those practices and clinical commissioning groups that are not producing clinical care of the adequate and appropriate standard which we all expect and which our communities deserve. For this reason, some kind of monitoring of this sort under the mandate is essential.

Lord Rea: My Lords, as a former general practitioner I very much welcome this amendment. As the noble Lord, Lord Walton, has just said, the standard of general practice has certainly gone up enormously since vocational training started. However, a number of my colleagues are not up to scratch. The Royal College of GPs and the BMA would be the first to admit that all in the garden is not lovely. I would ask the proposers of the amendment, and the noble Earl, if he is minded to accept it, how the monitoring system will be set up.

As has been mentioned, there are already two different systems in operation to monitor the standards of clinical practice-in fact three, if we take the GMC competence system. However, as mentioned by the noble Lord, Lord Patel, QOF is not a very effective measure. Its standards are set far too low. We have yet to see whether revalidation will effectively identify weak practice. If this monitoring is going to be set up, would it not be sensible to involve the General Medical Council, the Royal College of GPs and the BMA in consultation in designing the performance monitoring system that will be adopted? It could be a very good idea. It is high time that there was a more effective system. Most GPs would welcome it enormously and only a few would regret it.

Baroness Finlay of Llandaff: My Lords, I would like very briefly to speak in support of these amendments and ensure that we do not confound QOF, revalidation

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and the principle of these amendments. They are three different things. The principle behind the amendment is really important because it will identify the range of practices. There was an interesting paper in The Lancet Oncology this week showing the variation in the number of times patients have attended a GP before diagnosis of some cancers like lung, pancreas and so on, whereas those where there has been much greater publicity, such as breast and melanoma, have been referred much more quickly and there is less variation.

Revalidation is about making sure that people are, in the broadest sense, safe to practise and it is hoped that it will filter out those who are really unsafe across the board. However, that is not just what we are talking about with these amendments. We are talking about trying to improve the spectrum of care, including care by those who will get revalidation and who may well be collecting QOF points, but to whom other clinicians in the area would not necessarily want to sign up as patients. So it is about driving up those lower standards to meet the higher standards that we expect. Those data in the public domain will be really important to help patients decide who they register with. I hope, therefore, that the Government will look favourably on the amendments. The amendments are coming from those of us on these Benches who are medically qualified. I should declare an interest as a fellow of the Royal College of General Practitioners.

7.15 pm

Lord Hunt of Kings Heath: My Lords, I would like to echo my noble friend Lord Rea and noble Lords from the Cross Benches on the importance of this group of amendments. At its best, primary care can be brilliant, but at its worst it can be absolutely appalling. The variation in primary care is probably wider than in any other part of the National Health Service. As the changes take place we can see that this may cause many problems in the future.

We are all agreed about the need for an integrated approach and for a smooth patient pathway. Clearly, primary care potentially has a very important role to play. However, it needs to step up to the plate. If acute hospitals are to reduce the scale of their operations, more will be expected of primary care. Yet acute hospitals are open every hour of the day: primary care is not. Indeed, there are often very big issues about how primary care can be accessed out of working hours. The out of hours services are not always as effective as they might be, and there are some practices where patients know that it is very difficult to get attention unless they turn up at the convenience of the doctor, and so they then end up at the accident and emergency department. As I read where the NHS is going, this is no longer going to be acceptable. If money is being taken away from acute care and more money is being spent on primary care, which must be the logical outcome of clinical commissioning groups, unless those clinical commissioning groups can ensure that GPs do what is necessary to ensure that primary care takes up the responsibility, we are going to end in great difficulty, where acute care services will continue to be demanded by patients and money is being spent on primary care but it is not doing the necessary job.

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Therefore issues around the monitoring and performance management of primary care become very important indeed.

The Government have decided not to place the contracts of GPs within clinical commissioning groups. I understand that because clearly there is another potential conflict of interest. They are to be held at the local offices of the national Commissioning Board. However, there are real questions to be asked about how bureaucrats, as the Government seek to call them-I like to think of them as managers-are going to handle those contracts. What will happen within a particular clinical commissioning group if there is a group of GPs who simply will not do what is required of them to make a contract work with a local hospital? For instance, there may be a risk-share arrangement with a local hospital, where essentially agreement is made on the contract price, but part of it is very much about demand management, where there is a risk share between the clinical commissioning group and the acute trust. That will depend on all the GPs within a clinical commissioning group doing what is necessary, playing their part and contributing to demand management measures. Frankly, there are a lot of GPs who will not have anything to do with that. We know that at the moment. It is happening everywhere, up and down the country, with GPs who do not give a damn about anything to do with demand management. What will happen? Who will be able to intervene in those circumstances? Clinical commissioning groups do not have many levers when it comes to poor performance among general practitioners. I suspect that the national Commissioning Board will not have the expertise either. That is why this group of amendments is so important. We all know that primary care can make a huge contribution to a good NHS in the future, but we have to admit that, of all parts of the NHS, we can probably also find the poorest quality of service as well. That is why we are looking for reassurance from the noble Earl that this new system will be able to deal with those poor performers.

Earl Howe: My Lords, I am grateful to the noble Lords, Lord Kakkar and Lord Patel, for their contributions to this debate and, indeed, to other noble Lords who have spoken. We have heard some very powerful and persuasive arguments. I have listened very carefully to them.

Amendments 43A and 43B highlight the concerns that I expect all of us in this Chamber share in relation to the need to ensure high-quality primary care for all patients. The noble Lord, Lord Hunt, made some very telling points in that regard. Of course, there can be no doubt that good primary care contributes to good healthcare outcomes overall. I fully agree that the NHS Commissioning Board should be held to account properly for its performance in commissioning primary care. I do not think, however, that the right way to achieve that is to prescribe that this must be part of the mandate. Our aim is that the mandate should have at its heart the NHS outcomes framework, which covers the range of care that the NHS provides. I make the simple point that good primary care will be essential to improvement against the NHS outcomes framework.

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More widely, the department will be keeping under review the performance of the board and the way that it carries out its functions, including its direct commissioning. What matters here are the accountability mechanisms and how those in the system are monitored and held to account. Just as the board will have a commissioning outcomes framework to hold CCGs to account for the quality of their commissioning, it will be important to have robust and transparent information to assess the quality of what the board commissions itself.

We come back to what the Bill already says: it places duties of quality on the Secretary of State, on the board and on CCGs, requiring each of them to exercise functions with a view to securing continuous improvement in the quality of services provided to patients. The Bill also sets out robust arrangements for holding those bodies to account for delivering quality improvement. As noble Lords will be aware, the Bill already requires the board to submit a business plan setting out how it proposes to exercise its functions, and a report setting how it has exercised its functions, to the Secretary of State on an annual basis. In turn, CCGs must also submit their commissioning plans and annual reports to the board. Both the board, in reporting to the Secretary of State, and CCGs, in reporting to the board, will be expected to demonstrate how they have fulfilled their quality improvement duty, including in relation to primary care. Consequently we expect, for example, that both the board and CCGs will wish to monitor the standard of care and services provided by all primary medical services providers in fulfilling their duties.

It is possible that we will need a dedicated objective relating to primary care in the mandate-I am not ruling that out. It would be better, though, not to prescribe that in primary legislation. What matters is that there are clear and effective accountability arrangements, and the Bill as it stands provides flexibility to ensure just that.

The noble Lords, Lord Kakkar and Lord Rea, asked about the QOF. I agree with the noble Baroness, Lady Finlay, that the QOF is a separate issue, but I can say that the whole of the QOF is kept under review in consultation with the profession to ensure that it reflects the best available evidence and supports continuous improvement in the quality of care for patients. Over the coming months we will continue to discuss with the profession and its representatives how to focus the QOF on securing better healthcare outcomes and what that means for existing GP contractual arrangements.

I turn to the final amendment in this group, Amendment 95A. The Bill already ensures that the board has the information that it needs to demonstrate how it has fulfilled its duties. CCGs are required to provide information to the board in the form of the annual commissioning plan and annual report. In addition, the board and CCGs are under a duty to co-operate. In the normal course of business we expect this to involve the sharing of information as necessary but, in the event that a CCG might have failed, be failing or fail to discharge any of its

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functions, the board's powers enable it to require any information or documents that it considers necessary from CCGs.

The noble Lord, Lord Hunt, posited the situation that there might be reluctant GPs who did not fulfil their part of the bargain, whatever that was, with the acute sector. There needs to be a way of investigating allegations that actions by GPs in their practices are adversely affecting a clinical commissioning group. Where a general practice is operating in such a way that it is a barrier to a clinical commissioning group meeting its functions, it will be for the commissioning group to work with the members of that general practice to support it to improve and contribute to the work of the commissioning group as a whole. Ultimately, if it is unable to do so, a clinical commissioning group may need to refer such cases to the NHS Commissioning Board, along with the evidence of the failure of the practice and details of any support that the commissioning group has provided to the practice to help it overcome any perceived difficulties.

Among other matters, the board may wish to consider if the practice's actions are in breach of the practice's primary medical services contract. Separately, the NHS Commissioning Board will have the power to investigate the suitability of individual GPs under the medical performers list provisions. As the noble Lord will know, this power is currently with primary care trusts.

In a nutshell, therefore, the Bill already imposes a duty on CCGs in respect of the mandate and allows the board to ensure that CCGs fulfil it. Further specific requirements in relation to providing information to the board are therefore unnecessary, so I hope that what I have said reassures the noble Lords, Lord Kakkar and Lord Patel, sufficiently to enable them to withdraw their amendment.

Lord Kakkar: My Lords, I thank the Minister for, as always, his thoughtful response and consideration of the amendments. I remain somewhat anxious about whether there is going to be sufficient attention and opportunity to deal with the question of performance in primary care and the management of that performance to ensure that the very best clinical outcomes are achievable for all patients across the country.

I welcome much of what the Minister has said with regard to potential further consideration of how mechanisms other than a specification in the mandate on the question of primary care performance might work. I wonder whether it might be possible for him to enter into further dialogue on this matter so that there can be clarity. It would be unhelpful for the future if a great emphasis were placed-in fact, if there were a momentum-on moving practice from the secondary care environment, where there is a relentless evaluation of clinical outcomes and which has done so much to improve clinical outcomes for our patients because of the attention paid to those matters, into a primary care environment where an objective assessment of outcomes was not always possible and where, as a result, what we all hope will be achieved through the Bill-a health gain for patients and population-might therefore inadvertently be lost. With the

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opportunity to have a further conversation with the Minister prior to Third Reading, I beg leave to withdraw the amendment.

Amendment 43A withdrawn.

Amendments 43B and 44 not moved.

Amendment 45

Moved by Earl Howe

45: Clause 22, page 17, line 9, at end insert-

"( ) Requirements included in the mandate have effect only if regulations so provide."

Amendment 45 agreed.

Amendment 46 not moved.

Amendment 47

Moved by Earl Howe

47: Clause 22, page 17, line 21, at end insert-

"( ) Revisions to the mandate which consist of adding, omitting or modifying requirements have effect only if regulations so provide."

Amendment 47 agreed.

Amendments 48 and 49 not moved.

Consideration on Report adjourned until not before 8.29 pm.

Consumers: Low-Cost Flight Information

Question for Short Debate

7.29 pm

Asked by Lord Mitchell

Lord Mitchell: My Lords, I had hoped that more noble Lords would be taking part in this debate, since I am sure that most of us in our time have remonstrated against the budget airlines. But it is quality not quantity that counts and I am sure that we can have a very interesting debate this evening.

The debate features internet bookings for budget airlines. This, in my opinion, is just a subset of what my right honourable friend Ed Miliband has referred to as surcharge Britain. We all know what that means: all those little extra costs that it seems everyone these days attempts to load on to an unsuspecting public. We see them on bank overdrafts and on credit card usage. We see them on mobile phone charges and on online shopping. In every direction you turn there seems to be somebody there trying to suck that extra tenner out of you.

The logic for the growth in surcharges is obvious. As used to be said when I was in business, it goes from the top line to the bottom line, from gross to net, without touching the sides. In basic business there is

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generally a cost associated with generating revenue. Staff, depreciation, rent, electricity and the like all make up the cost of goods sold. It is the usual model. But today the quest is to persuade the customer to part with his cash without there being any cost implication. As I say, what hits the gross revenue line also hits the net revenue line. It is nice work if you can get it. The budget airlines in this country are brilliant at extracting the maximum amount of revenue from the poor old traveller and my speech today addresses what I believe is another example of rip-off Britain, or should I more accurately say rip-off Ireland?

I must declare a regrettable interest. I use Ryanair quite frequently, not because I want to and not because it is the cheapest-it is not-but because it is the most convenient. We have a house in Umbria in Italy and Ryanair flies to Perugia just 40 minutes away from where we live. Indeed, it is the only airline to fly to Perugia from the UK, so I have no option but to drive to Stansted, disengage my brain and all my other senses, only to re-engage when I am drinking my welcome cappuccino at Perugia airport.

I am going to say less than complimentary things about the budget airlines and Ryanair in particular, but I must say one thing in their favour. Their punctuality is the best. You can almost set your watch by their arrivals and departures. This is much better than other airlines. I am sure that most of your Lordships have used the budget airlines. When you sit down at the computer to make your booking you need a quiet room, a wet towel wrapped around your head and indulgent family members who are not bothered by constant swearing.

I spend a good deal of my time in front of my computer-my career was in IT- and I like to think that I am pretty adept at ploughing my way through the most complicated of websites, but the budget airline websites have me beaten. Much that is within their sites is designed to trap you. Every time you make a mistake or click the wrong click it is going to cost you money. Of course, if you use their sites all day long you will get the hang of it, but for the occasional user it is a hazardous and expensive obstacle course.

Let me deal with Ryanair first. I booked a flight the other day from Stansted to Perugia for 30 July this year. The headline price was £86.41. The final price was £136.89. This is a 58.42 per cent uplift for practically no extra cost to them. Within the headline price is a series of costs that I cannot understand. Taxes at £33.17 are clear enough. I will come back to those later, but be prepared for a bit of a shock on this one. There are two levies that leave me bemused: the EU 261 levy and the ETS levy. The former is £2 and the latter 25p. I have no idea what these are, but I will show your Lordships why they are important.

We come to the add-ons beyond the headline price. There is something called online check-in. This costs £6 and I presume that it is for using the internet. This is typical Ryanair Catch-22. It charges you for using the internet, but you can only book using the internet. Insurance-how Ryanair loves travel insurance-in itself is a rip-off, but it gets worse. You might have thought that the default position for insurance would be negative. You go to a pop-up menu of countries of

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residence and nestling snugly between Latvia and Lithuania you will locate "don't cover me". It is easy to make a mistake. Ryanair could have given you a yes or no option, but after its incessant haranguing and playing to my insecurities about falling ill abroad I gave in and this time selected minimum travel insurance. That came to £6.99.

Then there is priority boarding. I always choose it, but I do not know why. It costs £5 and you are supposed to be boarded ahead of the milling masses, but lots of people now chose it and there is not much that is priority about it. If you have to take a bus to board the plane it makes no difference anyway. But £5 here and £5 there-it is all gross to net. I took priority boarding. I also chose to be notified by SMS text, this time for £1.50. There are no costs associated with SMS text. I then went totally berserk. I decided to check in a piece of luggage: 15 kilos for £25. If you exceed your weight by even one kilo it will cost you £20. It is little wonder that people approach the check-in scales in such a state of panic.

Finally there is payment. Using a debit card or credit card costs another £6. It is Ryanair Catch-22 all over again: you have to use a debit or credit card, you have no option, but it charges you. So that is it: £86.41 becomes £136.89, but it does not stop there. Two years ago some Mexican friends visited us. They arrived at Stansted and they committed Michael O'Leary's mortal sin. They had not printed out their boarding cards. They did not know that they had to. They had to go to another queue to get their boarding cards and were fined £60 each. The cost to Ryanair is zero.

The most modern airlines now send boarding passes to your smart phone. You can bet your boots that Ryanair will do everything it can to resist this development, not when it has such a nice little earner. Once again, it is gross to net. There are a few other little gems about Ryanair's terms and conditions. It charges £20 for an infant under two. All other airlines allow babies and toddlers on for free, especially since they do not take up a seat, but I guess a toddler weighs the same as a piece of baggage, so it makes sense to charge for it.

One thing has always puzzled me about Ryanair. How do you cancel a flight? I have looked all over its website and you cannot cancel a Ryanair flight. You can choose another date, for a fee of course. You can even change the name of the passenger, for a much bigger fee, but you cannot cancel. This prompts a question that I would like to pose to the Minister or even to Ryanair itself. What happens to the tax for those who are no-shows? I have talked about the airport tax and I have also mentioned the EU 261 levy and the ETS levy. This comes to £35.18. Where does it go? Ryanair says that you can write for a tax refund, which it will send you, minus its ubiquitous £6 administration charge. There is a slight problem, however, in that you have to write to Dublin.

You incur a UK tax charge that is levied by HMRC on a flight that originates in the UK, but if you do not take that flight you have to apply in writing for your tax refund to a company headquartered in a foreign country and on your refund entitlement it levies an administration fee. I would be interested if the Minister

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has any idea how many people ask for tax refunds from Ryanair on no-show flights. Could it be expressed as a percentage? My bet is that it is precious few.

This prompts another question. If I am a no-show and if I have not applied for my tax refund, where does the £35.18 tax go? If I have not taken the flight, it would seem to me that no tax should be due. It must go to somebody. Does it go to HMRC? It should not because the Revenue is not due to receive tax for flights not taken. Does it stay with Ryanair, perhaps in some suspense account? I do not know the answers, but I know that when I cancel a flight with British Airways the tax is refunded to my credit card immediately, and that when I attempt to cancel with Ryanair it is not. I simply want to know where the tax money goes, or maybe does not go.

To be fair, and for comparative purposes, I also booked a flight on easyJet, this time from Gatwick to Rome on the same day. Its headline price is £66.99 and it levies an administration charge of £9. Using a credit card, as you must, costs another £5. Insurance costs £9.53, taking one piece of luggage costs £15-this time for a 20 kilo bag-and priority boarding is £10.50. This comes to £112.02, an uplift from the headline price of 67.2 per cent-considerably more than Ryanair. However, in easyJet's defence, the headline price is cheaper.

It seems as though I am doing something of a hatchet job on Ryanair as well as easyJet. In truth, this is the case. They deserve it; they force unfair charges on the public. Who else levies administrative charges, and what serious business charges credit and debit card fees when you have no option but to use those cards? Mr O'Leary, in his blunt way, makes his case very strongly: "If you don't like it, don't fly with us". However, that is not good enough. When he said that he would charge £1 for usage of the lavatories, even though he meant it as a joke, most people believed him.

There are those who will argue caveat emptor: it is the buyer's risk. However, I contend that the Government have a duty to ensure, first, that these airlines set all their costs to the default zero position on their websites; and, secondly, that their advertising highlights the average real fare, not the base fare, as well as the voluntary charges that we are all forced to pay.

7.42 pm

Lord Black of Brentwood: My Lords, I draw attention to the various media interests in my entry in the register. In particular, in view of my comments this evening, I highlight my directorship of the Advertising Standards Board of Finance. I thank the noble Lord, Lord Mitchell, for securing this debate. As we escape from the clutches of winter and many people think about their annual holiday, this is a timely and important subject to discuss. Many hard-pressed travellers will have cause to be very grateful to him.

At the start of my remarks, it is important to highlight three general issues with regard to the information that people receive when booking flights online. First, unfair credit card charges are not solely the preserve of the airline operators. In recent months, I have cursed at my computer screen-which is not an

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unusual experience in view of my technical illiteracy, but is driven by a sense of injustice on these occasions-when I have had to pay credit or debit card surcharges when buying flowers, wine and chocolate. The latter two are certainly important components of life. This practice, if thankfully not widespread, occurs on too many websites and not just those of airlines.

Secondly, where airlines are concerned, this is not a practice that is restricted to the low-cost ones. Table B1 on page 58 of the OFT report of June 2011, which is very helpfully highlighted in the excellent briefing note produced by the Library for this debate, showed that debit card surcharges were also being levied by bmibaby, Air Berlin and Jet2 at that time, while Iberia, Virgin Atlantic and British Airways were also levying a range of credit card surcharges. Although I have not personally booked flights on all these lines-I obviously need to get out a little more-I suspect that they are all levied with different degrees of transparency. Some are admirable, and I particularly commend the British Airways site, which now identifies many key costs involved in your final fee, including the amount of tax that goes to the Chancellor. Transparency is key.

My third general point is that it is always regrettable when an issue such as this is taken as an opportunity simply to bash the low-cost airlines. I know that this is not a popular thing to do but I will briefly stand up for Michael O'Leary. In recent years, he and others have transformed the airline industry, opening up parts of Europe that once no one ever visited and making air travel affordable to many who could not afford it. Like the noble Lord, Lord Mitchell, I declare an interest as a regular Ryanair passenger to Perugia. However, I think I am 20 minutes nearer the airport than he is, so I get to the cappuccino a little sooner. When levying justified criticisms about how websites operate, we should not forget the contribution that the low-cost airlines make to the consumer.

The reason why passengers feel some injustice when booking holidays on low-cost airlines is that, unlike some other transactions, the booking of a holiday is a major expenditure for consumers, for which they have often saved hard and sacrificed. The levying of a surcharge, particularly if you are not warned about it in advance and are unable to make a meaningful comparison with other airlines, is painful and unfair. However, it is not just the lack of transparency over credit and debit card charges that can be so annoying. In such a dynamic sector as the airline industry, marketing campaigns and websites often sail too close to the wind in terms of providing clear and accurate information, not just about fares and charges but about the provision of free and discounted tickets, availability, travel periods, journey time comparisons, environmental claims, airline comfort and airport names. Those of us who know people who have been stranded for an hour and a half outside Barcelona Airport, thinking that they were going to Barcelona, will know what I mean.

Since the remit of the Advertising Standards Authority was widened in the spring of last year to cover digital advertising, marketing communications on company websites, including the websites of all airlines, are now covered by the provisions and protections of the mandatory advertising codes from the Committee of Advertising Practice. Travel advertising and marketing

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communication is one of the ASA's top 10 most complained about sectors. As a result, the ASA has over the years issued guidance to those involved in the travel industry to enable them to ensure that their communications keep within the codes and consumers are protected. In particular, I commend a recent guidance note for the travel industry, which was issued by the Committee of Advertising Practice. It was drawn to my attention by the noble Lord, Lord Smith of Finsbury, who does such an effective job as chairman of the ASA. It covers each of the key areas, setting out rules in a clear and straightforward fashion to ensure that consumers are protected. It is an excellent note.

The ASA is important in considering this issue because of the time that it will take for statutory regulation to deal with this area. I welcome the fact that the Government are consulting on draft legislation to bring forward the provisions of the consumer rights directive relating to above-cost surcharges. I understand that such a move will enable the Committee of Advertising Practice to tighten up its own rules even further. The CAP is currently bound by the unfair commercial practices directive, which is subject to maximum harmonisation.

I understand that the Government's aim in this area-rightly so-is to ensure that consumers have the information that they need to compare prices readily and that pricing practices are fair. The ASA already requires all taxes and other compulsory charges paid at the point of purchase of the ticket to be clear and up front, and its systems are robust, responsive and flexible. The ASA should remain the first port of call, with the Office of Fair Trading as its statutory backstop for this thorny issue, the tackling of which is of such importance to tens of thousands of hard-pressed travellers. I would be grateful if the Minister could bear those possibilities in mind when considering this issue.

7.48 pm

Lord Alderdice: My Lords, I am sure that it is not only in your Lordships' House but outside it that many will be gratified by the noble Lord, Lord Mitchell, securing this debate to draw attention to the problems of what are described in the Question as low-cost airlines but are probably more correctly described as no-frills flyers. They are no longer low-cost for many people, which is the issue that I want to focus on. As the noble Lord, Lord Black of Brentwood, indicated, the advent of these no-frills flyers introduced many people to the opportunity to go to places that they had not been to before, or had been to and wanted to return to much more frequently than they could previously afford. On the face of it, this is an excellent thing; it is the democratising of airspace in many ways. However, it has led to many unexpected, untoward and, in some cases, counterproductive effects for people.

First, it meant that many more people flew. For those who are concerned about the environment, this was not entirely a positive outcome. Indeed, one of the results was increased pressure on the Government to raise the taxation of all airlines to deal with the fact that more people were flying, and it would be a good idea to reduce the number though taxation for the environment's sake.

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However, the consequences went much further than this. The airlines were able to operate as low-cost in the first few years because they started off paying their staff much less than the established airlines did. They had smaller fleets and when they enlarged them they kept to the same models of aircraft, which were much cheaper for them to service and replace than the traditional airlines. However, when it became clear that, even with these benefits, it was not possible for them to keep their low prices, they tried to keep the reputation for low prices by the headline price being low and all the other additions being added in.

One could look at that as a simple, tactical sales device-outlined by the noble Lord, Lord Mitchell, so elegantly and in such detail that there is no need for me to go into it in great detail-but the purpose of the whole exercise is effectively to continue to deceive the population into thinking that these are low-cost flights when in truth that is no longer what they are. All sorts of things that one would deem to be the proper costs of any operator and that have been described by the noble Lord-their insurance, their administration, the provision of boarding cards and so on-were separated out as though somehow these were other charges. The idea that was put about by Michael O'Leary and others was that, in order to enable more people to be able to afford to fly, people should not have to pay for things that were only in the interests of some of the fliers. For example, if you do not want to bring many suitcases with you, why should you pay a large amount for those who are? That seemed like a noble argument-that everyone should have the possibility of flying without paying for things they did not want and that only some people would want. In fact, as has been demonstrated in this debate, that is not where we are now. It became more and more an operation of deceit which reflected a culture which had developed with some, but by no means all, of the no-frills flyers.

I became aware of this culture when I took a Ryanair flight-something I did not make a habit of doing before and made a determined effort never to do again-to France with my wife. Unfortunately, during the short time we were there we had an accident and she was unable to walk to the plane when we got back. She needed to have a wheelchair to take her to the plane. We never suspected that it would not be possible to get a wheelchair without booking in advance and paying for it, but that was absolutely the position of Ryanair. When we subsequently checked we could find no other airline in the world that was charging people for the use of a wheelchair, but that was the Ryanair position. When it was challenged-not by us, but by others-at a European level, the company lost but they found another way of putting a charge on: 50p for everyone to pay for the disabled.

To me, the issue was not that precise problem, though it was of itself significant; it was what it represented about the culture that had developed in Ryanair. It was not a culture that was concerned to democratise airspace-that had a feeling that ordinary people ought to have the chance to travel more, enjoy more holidays and see more of the world. It was a dishonest and uncaring culture for people who

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were simply seen as milch cows to be treated very much as milch cows and herded through in as large numbers as possible.

People find themselves in increasing difficulty because they started by believing that they could fly to Perugia or wherever and could get themselves an inexpensive home. That would mean they would continue to have to fly there and it became increasingly problematic for many of these people to maintain themselves. Added to this is the fact that, in many places, this is the only way to get to that particular area. Most of the airports subsidise Mr O'Leary. He actually asks to be paid to fly to their airports while most UK operators find they have to pay the British Airports Authority and others in order to maintain a service. When a local authority that pays Mr O'Leary the subsidy says it is not in a position to pay any more he simply, at the drop of a hat, stops flights to that area and all the people who have become dependent on those flights find that it is impossible for them to continue. That is just part of the culture which has developed.

One might say that it is up to people to watch out for themselves and that this is just one airline or a small number of them. This is not so. When you introduce this kind of commercial practice it becomes increasingly difficult for other airlines to function without adopting similar practices. This was the problem in the banking world. I remember asking the chairman of one bank if it was really the case that most of the people on the board of the bank understood the complex instruments that were now being used in banking. He laughed and said that hardly a single one had the remotest idea. All they knew was that the other banks were doing this and making a profit so they had no alternative but to go down that road or lose custom. That is what has happened in the airline industry, not only in the way of charging but also in the way of treating the customers. It is not just a question that the buyer should beware. The whole airline industry has been adversely affected by this negative, disrespectful way of treating customers which cannot be sustained economically without all the complaints and difficulties which have already been referred to.

It is serious, because it is like a virus which pervades things and deteriorates them, and that is exactly what has been done. It becomes very difficult to reverse the process unless there are some regulations or pressures that require operators to behave in a different way. Here is where government comes in. I have some questions for the Minister. Which? submitted an OFT super-complaint on credit and debit card charges in March 2011, leading to a promise from HMG just before Christmas last year that the Treasury would ban excessive card surcharges by the end of 2012, with a consultation in the early part of this year. On 8 February, the Financial Secretary to the Treasury, Mark Hoban MP, said:

"We have brought forward legislation to tackle excessive and opaque card charges with the aim of banning above-cost surcharges from mid-2014".

I am glad it is moving ahead, but it seems to have slipped by 18 months over the period of the consultation. Why has this delay arisen?

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It would be perfectly possible for the Government to press the airline operators-not just Ryanair-to differentiate out clearly those elements of their charges which are properly being paid to Governments as a tax from lots of other things that they describe as levies, surcharges and fees and which they bunch in as though they were being imposed on the airlines by the Government and other authorities. It is actually just a deceit because they are part of their own essential operating costs that would be absorbed by any other business. Is it possible for the Government to ensure a degree of transparency, clarity and honesty in these charges?

7.59 pm

Lord Young of Norwood Green: My Lords, I thank my noble friend Lord Mitchell for giving us the opportunity to debate this interesting issue. I must admit to feeling a bit inhibited about contributing to the debate as I do not have a property near Perugia-which is a matter of deep regret, as it is somewhere I have visited-but I will, nevertheless, do my best. It is an important issue and so we are grateful not only to my noble friend Lord Mitchell but to Which? for bringing the super-complaint to the Office of Fair Trading.

The complaint isolates some of the key issues and I will quote from it. It states:

"Which? considers that the following features individually, or in combination, significantly harm the interests of consumers: The practice of advertising incomplete or partial prices, by, at least, omitting surcharges for payment method from advertised prices, which, due to behavioural biases, means consumers are unable to effectively and efficiently shop around and make like-for-like comparisons".

Bearing in mind that we are talking about trying to book online, that is a very valid point. The complaint refers to:

"The lack of reasonably or practicably available alternatives to avoid or mitigate surcharges for payment method".

Again, all speakers in this debate have demonstrated that that is the situation. The complaint also mentions:

"The conduct or practice of retailers that impose a surcharge for payment method, hidden or not, that exceeds a reasonable estimate of the costs for processing consumers' payments".

That has been amply demonstrated. The complaint states:

"These features lead to widespread detriment, including: Price comparisons being much harder so weaken the competitive process between retailers ... Consumers making poor choices between competing passenger travel services and between other alternative goods and services from which they may choose ... Consumers spending more time and money searching the market than should be the case ... Consumers often being misled over actual prices and being frustrated at being asked to 'pay for paying' ... Paying for goods or services is not, in Which?'s view, an additional or optional feature of a product but a necessary pre-requisite intrinsic to the conclusion of a contract. Even when the retailer offers a number of alternative payment methods, that retailer retains a monopoly on the setting of the prices that the customer will pay for different payment methods".

That has also been demonstrated during this debate. It does not matter which way you turn, you will be surcharged whether you use a debit or credit card. We know that if you use a debit card, the transfer is almost instant. Which? in its super-complaint

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demonstrated beyond any doubt that such practices were detrimental to the interests of consumers and that there certainly was not a reasonable marketplace.

Which? went on to state:

"If any additional charges are to be introduced during the transaction, for payment method or other mandatory services, these should reflect only the reasonable additional costs incurred by the retailer as a result of the specific choice of payment method".

Again, we have heard that the charges do not reflect the additional costs but seem to be an opportunity to bump up the total cost of the booking. If consumers were fully aware, they would be able to,

of revealing the true costs. Which? continued:

"However, under real world market dynamics in a number of markets (including travel markets) this does not occur, and long term consumer detriment results".

I refer to the comments of noble Lords. My noble friend Lord Mitchell talked about the iniquities of budget airlines although I have to say that it is not necessarily only budget airlines that use such practices. We have had further reports that airlines such as Lufthansa and Swissair have decided to charge for using credit and debit cards. It is not just the budget airlines, although I know that we have focused on airlines that are, in theory, low cost. The noble Lord, Lord Black of Brentwood, brought that to our attention.

The noble Lord, Lord Alderdice, gave an analysis of how the low costs were achieved. He might also have mentioned low pay and conditions of staff, although I did not hear him say that. It is another intrinsic factor in achieving these prices. Like the noble Lord, I was hopeful when the Government, in a letter to the chief executive of the Office of Fair Trading, seemed to be optimistic. They referred to the consumer rights directive that is supposed to be a pan-European solution and stated:

"It requires that traders limit payment surcharges to the costs incurred by the trader in respect of a given means of payment. The Government will therefore consult, early in 2012, on draft legislation to bring forward the provision of the Consumer Rights Directive relating to above-cost surcharges in advance of the transposition deadline of June 2014".

We seem to have slipped a bit from that seemingly admirable move on the part of the Government. I would therefore welcome the Minister's response on why it does not look like consumers will see much benefit or progress before 2014.

I have dealt with what I consider to be the key issues, given that noble Lords have already set out the detail of the major problems in relation to online booking for low-cost airlines. I await the Minister's response.

8.06 pm

Earl Attlee: My Lords, I am grateful to the noble Lord, Lord Mitchell, for introducing this Question for Short Debate and to all other noble Lords who have contributed.

In an open free-market economy such as ours, with its age-old emphasis on enterprise and initiative, there can be no objection to firms choosing business models that suit their aims, even if it causes them reputational

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issues. My noble friend Lord Black of Brentwood described some of the benefits of low-cost airlines. They have been innovative and successful, and have grown into important players in the aviation industry, employing substantial numbers of people and utilising great amounts of capital. Schedule airlines, operating to different business models, are holding their own. I should therefore like to add to the premise of the noble Lord's debate that people buying scheduled airline tickets on the internet also need access to the information they require.

The UK aviation market is diverse and supports consumer choice. What suits a solo flyer with no baggage might not suit a family of four with hold baggage who would like a meal on their flight. The UK's aviation market has evolved to support these different needs. As a consequence of this diversity and choice, air fares can come with a range of extras, fees and charges. Airlines are required to publish on their websites the information about these fees and charges, but it can be hard for consumers to compare them when they are shopping around for the best price for an air ticket, as has been pointed out by many noble Lords.

The Government's position is to support the aviation consumer in two principal ways. First, there must be transparency about what is and what is not included in the price. The consumer must know how much to pay in total before he clicks to accept the deal. Secondly, adequate information must be provided for the consumer to make an informed choice on which airline to fly with, regardless of the business model that that airline follows. I will give examples in support of that position.

EU Regulation No. 1008 sets out common rules for the operation of EU air services. Crucially, it sets out the transparency requirements for the display of air fares. Prices are required to be displayed inclusive of all unavoidable and foreseeable taxes, fees and charges at all times. Optional services such as checked baggage or priority boarding are required to be offered on an opt-in basis only. These services should be clearly and unambiguously displayed at the start of the booking process. These requirements are designed to ensure that consumers are able to compare the prices of flights across a number of airlines and that consumers select only the optional extras that they require. The requirements are strongly supported by the Government.

I now turn to another specific proposal that will significantly help consumers. We wish to help purchasers to compare services from different providers on the basis of accurate information. Aviation markets can deliver best value only where objective service information is freely available so that passengers and freight owners have genuine choice between suppliers. We have therefore included in the Civil Aviation Bill currently being considered in Committee in another place a new information duty on the CAA either to publish, or to arrange for the aviation sector to publish, consumer information and advice that it considers appropriate to help people to compare aviation services. This new publication duty would allow the CAA to move into areas where it cannot always obtain information from public sources, such as delays, complaints, baggage handling and environmental performance. The CAA

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would be able to penalise companies that withheld the data requested. The CAA must also ensure that the benefits of providing information outweigh the costs, so that it does not duplicate existing information or provide data that consumers do not want. The best protection for consumers in terms of choice and value lies in the operation of a competitive market. Consumers need clear information on price and service quality in order to make informed choices, and to ensure that markets deliver consumer benefits in practice. I look forward to discussing these, and other, aspects of the Bill further when it is introduced into your Lordships' House.

We share consumers' concern about the high level of payment surcharges applied by some companies, and that often people are not aware of the level of these charges until almost the end of the booking process. This makes it difficult to compare prices and shop around for a good deal. It is not right that a business tries to hide the true cost of its services by implying that its prices are made up of elements beyond its control when they are not.

What are the Government doing? First, consumers are already protected against misleading pricing under the Consumer Protection from Unfair Trading Regulations. Secondly, as mentioned by my noble friend Lord Black of Brentwood, last December the Government announced their intention to consult on early implementation of the payment surcharges provision of the new European consumer rights directive ahead of their transposition deadline in 2014. The provision will ban businesses, in scope, from charging customers fees which exceed the costs for using that means of payment. The Government plan public consultation on early implementation within the next few months, with the aim that new UK rules could take effect by the end of 2012. The Government will publish guidance prior to the change taking effect to help businesses adjust their pricing strategies to comply with the provision. I stress that this work is about ensuring transparency in headline prices, and not about price control. The aim is to ensure that only the true cost of using a particular means of payment can be charged separately where a business wishes to do so.

I have been asked several questions. I will my do best to answer them, but if I fail, I will of course write in the usual way. On the general point about ticket transparency and how consumers can effectively compare prices, including hidden charges, the Civil Aviation Authority has published a table showing the optional charges which apply when booking with major airlines operating in the UK. This is a valuable tool which will assist consumers in making informed decisions when booking flights.

The noble Lord, Lord Mitchell, asked me when we will stop airlines charging huge fees for printing a boarding pass at check-in. The business model adopted by some well known carriers requires passengers to check-in online and print their own boarding pass. This is legitimate so long as people are clearly aware of it. There is no restriction on the level of charge that an airline may impose for this service. The sum of €40 has been widely quoted. This appears rather excessive, and is unlikely to reflect the true cost to the airline of

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printing a pass. This practice, along with the identity of the carriers which employ it, has been well published, including in your Lordships' House tonight. Wherever possible, consumers should take steps to avoid liability to pay the charge. If this appears unfeasible, it is perhaps a factor which they should take into account before booking the flight.

The noble Lord, Lord Mitchell, also talked about the EU 261 levy. EU Regulation 261/2004 gives air consumers rights to assistance and compensation in the event of their flight being cancelled or delayed for over three hours, or if they are denied boarding-that is, bumped off the flight for someone else. In April 2011, Michael O'Leary announced that Ryanair would impose a €2 EU 261 levy on its air tickets. This was marketed as a measure forced on the airline by the EU. In fact, it is a form of Ryanair self-insurance to pay for the obligations that Regulation 261 imposes on the airlines.

The noble Lord, Lord Mitchell, also asked how often consumers compare prices effectively, including hidden charges. I have mentioned the Civil Aviation Authority table. He also asked about the refund of taxes when passengers do not fly. Government taxes, such as air passenger duty, should not be paid if the passenger does not fly. Many carriers will refund this element of the fare on application. However, they may charge an administration fee for doing so and in practice this may swallow up most or all of the amount due to be repaid to the consumer.

My noble friend Lord Alderdice told us, with some justification, about his distressing experience of no-frills airlines. EU Regulation 1107/2006 gives those who are disabled or who have reduced mobility rights to travel. Wheelchair access to aircraft is not chargeable.

My noble friend also talked about the Which? super-complaint. In 2011, the Which? consumer magazine submitted a super-complaint to the OFT, calling for it to investigate excessive surcharges for paying by credit or debit cards.

My noble friend Lord Alderdice also asked about the delay in the implementation of the consumer rights directive until 2014. Although the directive will take two years to come into effect throughout Europe, it is due to be transposed into national law by mid-2014. The OFT has said that companies should be up-front about charges straight away, and the Government propose to consult on early implementation in the UK.

My noble friend also asked what assessment has been made of the effectiveness of Article 23.

Lord Alderdice: I asked whether what the Minister in another place said was true-that implementation would be delayed until the end of 2014.

Earl Attlee: My Lords, I think it is probably better if I concentrate on answering as much as I can and, if necessary, write to my noble friend.

Aviation is fundamentally an international business. The Government do not intend to introduce tighter restrictions on airline pricing policies in isolation. The European Commission has undertaken a fitness check on the fare transparency requirements, during which it

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has taken evidence from airlines, the travel industry, enforcement bodies and consumer groups. Its findings have yet to emerge but we understand that the evidence suggests that the rules are not enforced consistently across Europe.

In conclusion, we take this matter seriously. I am grateful to the noble Lord, Lord Mitchell, for posing his Question this evening.

Lord Young of Norwood Green: I do think that the noble Earl should clarify the situation because now I am confused. I thought that he had given us a more helpful answer when he said that the consultation on the payment surcharges provision would take place during 2012 and that the new rules would be introduced in 2012. However, the last comment that he made in response to the noble Lord, Lord Alderdice, left us somewhat confused. Will the Minister clarify whether the rules are likely to be introduced in advance of the European directive in 2014? What timetable are the Government working to?

Earl Attlee: The intention is that the Government will see the effect of these new regulations as early as possible. My speech was carefully crafted but if I have missed anything out I shall of course write to noble Lords to clarify any details as necessary.

8.19 pm

Sitting suspended.

Health and Social Care Bill

Report (3rd Day) (Continued)

8.29 pm

Amendment 49A

Moved by Baroness Williams of Crosby

49A: Clause 22, page 17, line 38, at end insert-

"Patients' interests to be treated as paramount

The Board must, so far as resources allow, exercise its functions on the basis that the interests of patients are paramount."

Baroness Williams of Crosby: My Lords, owing to the need to make progress I shall speak briefly, but my noble friend Lord Marks of Henley-on-Thames will be speaking in greater detail about the amendment.

It is short, perhaps deceptively short, but it has real significance and is related in this group specifically to Amendment 94A. The government amendments respond to aspects of these amendments, too. Amendments 49A and 94A set at the very centre of the Bill, which has the full support of all of us who want to see the NHS thrive, that the interests of patients should be paramount. The importance of that phrase is that in every single aspect of what we try to do, it shall always be the case that this is the way in which we think-whether it is how CCGs operate or how foundation trust hospitals operate. This has emerged in our debates increasingly as the central concept-the one to which we should always refer back. That will give us the guiding light that we need for the Bill.

It is significant because, in many cases, patients can be very vulnerable. They can be vulnerable through lack of information and in some cases by not being

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consulted. They can be vulnerable, as the noble Baroness, Lady Hollins, has mentioned, through the lack of advocacy by people who understand the basis of the choices they have to make. This phrase about the significance and the importance of patients' interests being paramount therefore also affects a recognition that where patients are vulnerable they need the help of counsellors, advisers and in some cases advocates, so the concept behind this covers those areas as well.

I want also to point out briefly that government Amendment 56 is helpful in spelling out the matters on which patients should be particularly consulted. I will not repeat them but the amendment is helpful in setting out very clearly issues of treatment and the way in which patients should be offered different forms of treatment and then to make choices among them.

I do not intend to keep the House. I shall conclude my remarks. Whatever side of the House we may be on, I hope very much that the concept of the paramountcy of patient interest will be something that all of us can support, understand and advocate with respect to the future of health services. I beg to move.

Lord Marks of Henley-on-Thames: My Lords, the reasons for Amendments 49A and 94A have been briefly-as she explained-and eloquently expressed by my noble friend Lady Williams of Crosby. One of the fundamental principles which the Government have assured us runs right through this Bill is that the NHS, as reformed by this legislation, will be committed to putting patients first. That is a critical matter for most of us in this House and the public at large. Why do I believe that this principle needs stating in the Bill? It is because the Bill introduces an entirely new structure for commissioning services, with commissioning by clinical commissioning groups within a framework established by the board to requirements and objectives set by the Secretary of State. However well understood here, this proposed structure is widely mistrusted outside this place.

I believe that a legislative statement that the commissioning process will put patients first is very important, both because it will enshrine in law this fundamental principle and because it will give the public an assurance that this is indeed the aim and purpose of the new commissioning process. My noble friend the Minister was kind enough to write to me in relation to this amendment to say that while he completely agrees that we must always put patients first, the Bill already provides for that and that there are "technical reasons" why our amendments should not be accepted.

The Minister is entirely right to point to the commitment to the comprehensive health service in the Bill and to the duties of the board and the clinical commissioning groups, now enshrined in the Bill, to promote the NHS constitution. I agree that those are powerful provisions. The NHS constitution is an important and extremely valuable document. It does indeed contain a commitment to putting patients first. At the back of the document in the expression of NHS values it says:

"Working together for patients. We put patients first in everything we do, by reaching out to staff, patients, carers, families, communities, and professionals outside the NHS. We put the needs of patients and communities before organisational boundaries".

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No one could fail to regard that expression of values as admirable, but it covers the whole sweep of NHS functions and is very general. The provisions that we seek by way of these two amendments are specific to the commissioning process. They will impose a binding obligation on the board and the CCGs of which they will at all times be aware. Moreover, our amendments are directed particularly at responding to what is probably the principal concern that members of the public have about these reforms: that the new commissioning process may lead to the marketisation of the NHS and that patients' interests may be lost in that process. I do not believe that, but I do believe that these amendments would help make it crystal clear that this concern is unfounded.

The other problem we face is this: all the evidence, even that emanating from within the NHS, suggests that there is widespread unawareness of the very existence of the NHS constitution, let alone of the detail of its provisions. At the very least, therefore, given the emphasis that we are putting on the NHS constitution, it is crucial for the Government to make it quite clear that a great deal is expected of the board and of CCGs in the exercise of their respective duties under the Bill to promote awareness of the NHS constitution. In addition, the department should commit itself to an even wider, more effective campaign to publicise both the existence and the content of that constitution.

As to my noble friend's second point, I regret that I do not understand the technical reasons which are said to require the rejection of these amendments. It is perfectly true that the NHS will always have to face resource constraints which may necessarily determine many, even most, commissioning decisions, but our amendments accept entirely that the paramountcy of patients is always subject to resource constraints. The board or a CCG must, so far as resources allow, exercise its functions on the basis that the interests of patients are paramount. Nor do our amendments, either expressly or impliedly, reduce the ability of commissioning groups or the board to prioritise the treatment of particular groups of patients where they think appropriate. They simply make the interests of patients in general paramount or, to use my noble friend the Minister's phrase, make sure that commissioners put patients first.

The use of that word "paramount" in these amendments was modelled on the Children Act 1989 and the principle which runs like a golden thread through that legislation that the interests of children are paramount. That legislation has been widely applauded for embodying that principle, which firmly governs its interpretation and its implementation. It is precisely because it is embodied in the legislation itself that that Act is so well respected.

I still hope that my noble friend the Minister might reconsider whether he is not prepared to accept in this Bill the expression of the principle which he has so often expressed: that, throughout the commissioning process, the interests of patients must be paramount.

Baroness Cumberlege: My Lords, my Amendment 142 has been grouped with this amendment. I have brought it forward because I am anxious that when we talk about "patient and public involvement" we should be

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clear as to exactly what we mean by it. I am grateful to my noble friend Lady Jolly, who has also put her name to the amendment.

I am also anxious that we embed what I will call PPI for shortness-patient and public involvement throughout healthcare in all its forms. I say so in the knowledge that few people understand what this means. However, no one understands it better than my noble friend Lord Howe. He was a doughty fighter for community health councils, those much beloved organisations that knew how to campaign and influence the delivery of services. The culprit sits before me on the opposition Benches.

When I was chair of the Brighton Health Authority I had a huge respect for my CHC. Indeed, we even commissioned it to carry out surveys within the NHS. The effect was electric: no punches were pulled and the pressure on us was irresistible. It really knew what was being delivered, where the glitches were and where services were inadequate and needed improving, and it was not shy in making our shortcomings very public indeed. The CHCs had power and could refer proposed changes in services directly to the Secretary of State. The subsequent inheritors of their responsibilities-patients' forums and LINks-have been systematically neutralised to ensure that they do not have the power to be really effective; that they are not inconvenient bedfellows; and that, despite the undoubted commitment of individuals, they can be largely ignored.

At last we have an opportunity to put matters right and to show that we have genuine credentials in making patient and public involvement a force for good, ensuring that patients and the public are the heart of their NHS. I was encouraged when in one of our earlier debates my noble friend, in answering an amendment, mentioned that the Secretary of State required four tests for the reconfiguration of services, one of which was robust PPI.

I had an interesting letter from my noble friend dated 2 February which again showed his clear commitment to effective PPI. However, the Bill does not seem to match up to that commitment. Different wording is used for PPI in different parts of the Bill-a court of law would surely assume different intentions-and the wording is weak in places. There are three types of involvement. The first is shared decision-making with individual patients on their care, to which the remainder of these amendments relate. The second is the HealthWatch England and local healthwatch structures through which patients and the public feed in their views-the way in which people start a conversation with the NHS. The third is PPI by the service in its decision-making-the way in which the service starts a conversation with local people and the subject of this amendment.

No business would attempt to plan its products or its services without doing market research. If it did, it would fail. We expect the same for the NHS. However, PPI is more important than just market research: it imports the values that we as a society expect from the NHS, making sure that it thinks as we think. PPI must be in the DNA of the service so that those who plan and run it feel as if they are planning and running it for their own families and looking after their own mothers in that hospital bed.

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The PPI requirement was introduced in the Health and Social Care Act 2001 in response to the Bristol Royal Infirmary public inquiry. At Bristol, between 1991 and 1995,

and up to 35 children under one died as a result. As Bristol concluded,

What an indictment. These are catastrophic failures and we must not forget them. Sadly, evidence shows that we have not yet succeeded in making the NHS as a whole think as we think. We need look no further than Mid Staffordshire.

8.45 pm

Bristol recommended that:

"The involvement of the public in the NHS must be embedded in its structures: the perspectives of patients and of the public must be heard and taken into account wherever decisions affecting the provision of healthcare are made".

The report goes on to say:

"The public's involvement in the NHS should particularly be focused on the development and planning of healthcare services and on the operation and delivery of healthcare services, including the regulation of safety and quality, the competence of healthcare professionals, and the protection of vulnerable groups".

My amendment defines what makes effective PPI across the commissioner, provider and regulatory system, as Bristol recommended. Triggers for the duty will vary depending on the body, and it must always be proportionate. Monitor is covered in my Amendment 166, which we will be debating later.

My noble friend explained to me in his letter that statutory guidance would cover these matters, as it does now. Mid Staffordshire has demonstrated that this approach simply does not work. Furthermore, the duty of autonomy in Clause 4, even as amended, gives all bodies in the Bill discretion to challenge anything-such as statutory guidance-as being unduly burdensome. We must therefore have crystal-clear, comprehensive requirements for effective PPI as explicitly defined on the face of this Bill.

There are three ways in which the clauses in the Bill fall short of this. The first is: telling, not asking. The duty can be met merely by providing information without getting any response or taking any notice of it. Involvement means not assuming that you know whether an issue is something patients only need to be told about, but asking them. The second is: theory, not reality. Patients are not required to be involved in finding out whether plans, proposals or decisions actually advantage or disadvantage patients in practice. The third is: nothing about us without us. Patients must be involved in all functions affecting patients, such as quality improvement or health inequalities, not just in commissioning.

However, the problems are greater than these. My noble friend's letter to me seems to suggest that, as commissioning and providing have been split in the Bill, PPI is to be similarly split. This would enable the PPI buck to be passed between commissioner and provider and leave no one responsible for guaranteeing that effective PPI happened if providers-private or NHS-failed to do it. Commissioners are likely to use

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the Department of Health model contracts that do require providers to involve patients; and NHS providers have their own statutory duty. So far, so good. However, once commissioners have granted such contracts, they can wash their hands of involvement by the private or NHS foundation trust provider because they no longer have ongoing responsibility.

Subsection (1) of my amendment defines the three involvement elements: giving information, seeking comment on it, and inviting participation in monitoring whether patient benefit emerges at the end of it all. For example, the duty now relates only to designing a commissioning specification for accident and emergency, not monitoring whether it actually works in practice. Subsection (2) involves patient representatives and carers as well as patients. Patients on mental health section may not be able to get involved in commissioning, but those who can represent their interests, as they have previously been on sections themselves, should be able to do so. The NHS outcomes framework, against which we expect commissioners to perform, includes:

"Enhancing quality of life for carers",

so we must make sure that they are involved. Subsection (3) gives the commissioners a lead responsibility for PPI across the local health economy to avoid buck-passing between organisations. Subsection (4) applies involvement to all the relevant functions of the NHS Commissioning Board and CCGs, subject to the existing proportionality limitation. The CCG should, for example, not attempt to address health inequalities without involving those who suffer them.

I have thought a great deal about this issue over many years, as has my noble friend the Minister, and over the past weeks he has been hugely generous with his time in talking to us about it.

Your Lordships have spoken often of the strengths of the NHS and the warm place that it has in the hearts of the people. I strongly support its remarkable ethic that whether you are young or old, black or white, rich or poor, you can get treatment, largely free at the point of use. But none of us can deny that its underlying problem is how little influence we, users and taxpayers, have in a near-monopoly service that is organised and run by those who work in it. We need to reorder the balance, and my amendment seeks to do just that.

Lord Harris of Haringey: My Lords, I have lost track, since I first became a community health council member in 1977, of how many reorganisations there have been of the National Health Service and how many have all said somewhere in the White Paper or in the preamble or in whatever else it might have been that the Government of the day were committed to putting patients first, or at the centre of the NHS. I recall White Papers with titles such as Putting Patients First, which were all about reorganisation of the health service and the administration. I recall successive Secretaries of State-many of whom are not in their place tonight, although they could be as Members of your Lordships' House-telling us proudly that their particular reorganisation was somehow going to ensure that patients would, for the first time ever, be at the

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centre of the NHS. So I can understand why the noble Lord, Lord Marks, and the noble Baroness, Lady Williams, thought that it might help to try to write that into the Bill. I can understand, too, how the Minister felt that it could be resisted-as, presumably, every previous ministerial occupant of the role that he currently fulfils has resisted writing it into the Bill in the past. But I suspect that simply having statements that say that the basis is that the interests of patients are paramount is not going to be sufficient. Indeed, I suspect that with some of the arrangements envisaged in the Bill, that may produce some genuine difficulties. If, for example, you are a private sector company providing services to the NHS your duty as directors is to the shareholders of that company. So I can see why it will produce a tension-and, no doubt, why the Government will resist the earnest endeavour of the noble Baroness and the noble Lord to get this into the Bill.

The amendments in the group in the Minister's name are rather helpful, however, because they are specific. They talk about the duty to promote the involvement in various stages of the process. They place a duty on the board and on CCGs to involve patients in the prevention and diagnosis of their illness and their care and treatment. The experience is that where there is that duality, when patients are involved in the assessment of the treatment and the sort of treatment that is to be followed for their illness, the way in which that treatment is then followed by the patient is far greater as a result of that involvement. What is more, patients are usually expert in their own conditions, particularly if they are long-term or chronic conditions. They will often know as much about it as their general practitioner or, indeed, many other people who are engaged in their care. So that principle of involvement is absolutely right. I rather suspect that the Minister's amendments will do far more by making it clear what the expectation is than rather grand statements about the interests of patients being paramount, as we have seen so many times in the past.

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