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Grand Committee

Thursday 17 March 2016

Arrangement of Business


1 pm

The Deputy Chairman of Committees (Baroness Henig) (Lab): If there is a Division in the House the Committee will adjourn for 10 minutes.

General Practitioners: Appointments

Question for Short Debate

1 pm

Asked by Earl Attlee

To ask Her Majesty’s Government what assessment they have made of how quickly an economically active patient should be able to secure an appointment with their GP and how that compares with other professions.

Earl Attlee (Con): My Lords, the Committee will recall the fabulous opening ceremony for the 2012 Olympics held in London and its NHS component. Interestingly, some young indigenous Brits take for granted our fabulous health service, free at the point of delivery. They do not really appreciate how clever we have been as a nation, but hard-working immigrants from other countries certainly do. We have much to be proud of and I salute the efforts of all those involved. Our European partners have a variety of health systems that appear to work for them. However, you have only to look at the political challenges with the health system in the United States to see the problems that we have avoided and to understand that their healthcare costs are considerably higher than ours. There is no doubt that the NHS is very good if you are seriously ill, which is one reason why I am not the slightest bit interested in private healthcare. However, we would be deluding ourselves if we denied that we have some serious difficulties with the NHS; the most obvious are A&E and ambulance services, but I want to concentrate on GP services, although they are related.

I recently had to move house from one parish to an adjacent parish, but which was in a different GP catchment area. My original surgery was co-located with a rather good convenience store and the nearest ATM to my house. The surgery met all my requirements, I never had any difficulty in securing an appointment when I needed one, and the practice premises were purpose-built and relatively new. My new surgery’s building is old and small and there was local evidence that appointments could be a problem, probably due to increasing demand from a growing and also ageing population. Your Lordships will not be surprised to hear that I did not want to register at that new, nearest surgery but I was told that I had to. I am sorry to say that my worst fears were realised. The administration of the surgery was relatively poor from the start.

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Clearly not all practices operate to the same standard—though I hope that my noble friend Lord Bridgeman will describe to the Committee how a good practice works.

Worse still, several weeks ago now, I developed some slightly worrying symptoms. However, my judgment was—correctly—that I was not an urgent case and I was not prepared to claim otherwise. Unfortunately I could not secure an appointment at all. Given that men are notoriously bad at presenting with unpleasant symptoms, how can it possibly be right to deny a patient an appointment with the doctor? The fact is that people who are fit, well and working ask to see the doctor only when absolutely necessary. All they need is a bit of maintenance from time to time to keep being productive and generating the money needed to fund the NHS.

Before suggesting to the Committee what is going on, I want to make it clear that I fully appreciate that GPs have to deal with a wide range of patients, many of whom have serious conditions or are even terminally ill. I feel that practices fall into the trap of believing that they are providing a service to a certain standard and that patients should be grateful for what they get. Surgeries do not regard themselves as being competitive, which means that there is no mechanism for them to individually determine the appropriate level of service, although no doubt they try hard. It also means that they cannot determine what services to offer or how to provide them.

Take the appointments issue. Suppose I rang my solicitor’s office and said that I had had a fairly worrying meeting with another businessman who claimed that I was infringing his patent. I do not think that the solicitor’s office would say, “Well, we have no appointments available for the next two weeks. Try again next Monday, but make sure you ring early because the available slots go quickly”. I suggest that any professional services outfit with that sort of ethos would not stay in business very long. I have to tell the Committee that that is exactly what I experienced with my new GP surgery and I doubt that this is unusual. This is why my Question compares GPs to other professions.

Or take blood tests. GPs no longer seem to take blood samples. A separate appointment has to be made, either with the practice nurse or with a local hospital. This is fine if one is retired, but if one is working it is another appointment to be made which conflicts with economic activity. It also tends to lower productivity, which we know is a general UK problem. I have not been to an A&E department for many years, but it seems to me that the majority of walk-in patients could equally well be dealt with by a GP surgery, and far more quickly than the four-hour target, which is itself an admission of total failure. At present, GP surgeries do not market themselves for that business because they do not need to.

Surely, a practice in a competitive environment would say, “Why wait at least four hours in an A&E department for a minor injury when, if you were registered with us, you could be on your way within an hour?”. I am not suggesting for a moment having mini-A&E centres. Serious injuries and life-threatening conditions are clearly a matter for a large A&E department with the appropriate range of facilities.

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Since the time when I was forced to change my GP the rules have changed, I am pleased to say, and with certain, sensible caveats one can register with whichever surgery one wants. I am pleased about this but there is still no evidence of any commercial competitive pressures between GP surgeries. I hope the Minister can tell the Committee what, if anything, he is doing to introduce competition between GP surgeries. Does he see this as being important, so that economic output is not lost due to a GP service that does not suit busy working people, especially if they work a long way from home? Does he agree that GPs should be doing more to relieve the unnecessary load on A&E departments?

1.08 pm

Lord Turnberg (Lab): My Lords, I am extremely grateful to the noble Earl, Lord Attlee, for bringing this important subject to debate. I fear that it is now widely acknowledged that the situation in primary care is dire. However, I have to say that my own general practice seems to be an exception; perhaps because it is in leafy Hampstead, perhaps because it has enough partners and staff to withstand the buffeting of the rest of the NHS, and perhaps because it has such excellent leadership. Or, most likely, because it has all three. Elsewhere, in much of the country, general practice lacks all three and the picture is less than rosy. Many practices are small, with two or three partners, and if one goes off sick, retires early or goes abroad, the remaining one or two are stuck in an almost unsustainable situation.

One young GP I know is struggling with just such a burden. She is about to lose her partner, who is retiring early, and she is now running her practice with little or no support. She is finding it impossible to attract any staff to join her and cannot find another GP to come into her practice. There are just too few around who want to work in a less than affluent part of London, despite the Government’s blandishments. It is very hard for her to find other staff too. Meanwhile, she is running around, sitting on committees and the local CCG, as well as dealing with the mound of NHS-inspired paperwork and trying to look after her young family at the same time. Working from eight in the morning until eight at night is an impossible burden to place on anyone. I fear that that is the experience of far too many GPs and it is not much wonder that too many are leaving early and too few are willing to join.

It is absolutely vital that the Government rethink their efforts to encourage and support GPs. Whatever they are doing now is clearly not working properly. Of course, every area of the NHS is suffering from underfunding but primary care, once the beacon of the service, is now merely a flickering candle. If there is anywhere that the NHS needs to see reignited, it is primary care. Of course, a move to larger group practices, with added support, where that can be achieved, would help. But too many practices are too small at the moment. Some GPs gain comfort from being salaried rather than self-employed. That at least cuts down their administrative burden. If it can be made a more attractive option—something the Government might pursue—it offers advantages to some.

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Finally, I will say just a few words about research in primary care. I express my interest as scientific adviser to the Association of Medical Research Charities, an organisation whose member charities well understand the valuable role that GPs can play in research. But at the moment too many GPs are so stretched and overworked that there is no way that they can even think about research in the face of everything else they are asked to do. If we are to achieve what Ministers, the Chancellor and even the Prime Minister have spoken about, which is to embed research in the NHS as a major function, and if we are to see what is mandated in the Health and Social Care Act 2012 on making research an inextricable part of the NHS, we are going to have to give GPs all the support necessary for them to be able to fulfil their part. We are still way off that and if, as I understand it, NHS England has not even signed off its research strategy for last year, never mind this year, what hope do we have that we will see any change here? Is there anything the Minister can do to persuade NHS England to do more to support research in primary care and, incidentally, stimulate it into publishing its long-awaited research strategy?

To return to the main thrust of my remarks, is there anything the Minister can do to persuade the Government to look at how we can get general practice out of the black hole it is heading for before it is too late?

1.12 pm

Lord Rennard (LD): My Lords, I declare my interests as in the register. There is of course much controversy at present concerning what I will call the Government’s preoccupation with the weekend working practices of junior hospital doctors but it seems to me that many people in need of medical support would have preferred the Government to keep concentrating on issues such as strengthening out-of-hours services for GPs and using modern technology to enable people more easily to interact with a GP.

Of course, much progress on these issues was being made prior to the general election and I am seeking some reassurance in this debate that that progress will continue. Just prior to the general election, it was announced that GPs in more than 1,400 practices across England would receive £550 million of government funding to reorganise their services so that surgeries could be open from 8 am to 8 pm, seven days a week. My good friend Norman Lamb, who was then the Care Minister, told me he hoped that some of this funding would lead to much greater use in those practices of patient consultations by videolink, email and telephone, together with a greater provision of online booking services. I hope that the Minister will be able to tell us about progress since that announcement last March.

That funding, however, was directed at slightly fewer than one in five GP practices in England so I hope that we might also hear more today about how the remaining 80% of GP practices can be supported in improving access for their patients. This is both very important in terms of improving patient care and essential if we are to avoid the crisis in our hospitals getting even worse. I would like to hear from the Minister about how the

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£250 million infrastructure fund, which was first announced in the 2014 Autumn Statement, is helping to improve and provide more integrated health centres and more use of technology. The Government’s press release at the time claimed that they would help to fund additional services, including on-site pharmacists, speech therapists, minor surgery and diagnostic tests. It was also intended to make it easier for GPs to return to the profession following a career break, encourage more medical students to take careers as GPs, and enable GPs considering retirement to work reduced hours in the interim. This timely debate will allow the Minister to describe, I hope, progress on these issues over the past 12 months.

However, we need to go much further and be much bolder in using new technology to improve access to GPs. Ten years ago I visited India and looked at the provision of health services in remote rural areas, where access to a GP, let alone a hospital, was bound to be extremely difficult. I was very impressed by the use of webcams in specially equipped vehicles that could tour rural areas and with the help of a trained nurse allow some basic tests to be undertaken and a face-to-face conversation to be held with a GP or even a consultant. This made me think about how we could do much more in this country, using new technology, to let people talk to a GP without necessarily visiting the surgery. As technology develops, those GPs or other people, including carers and family members, can monitor certain conditions remotely.

My own Fitbit tells me how many steps I have walked each day, and what my heart rate and my sleeping pattern are. While I do not wish to share this information with anybody else, it is easy to do so. I acknowledge at this point that it was active intervention by my own GP’s practice that led me to undertake a more active exercise regime and improve my own diabetic control. In time, I expect that my blood pressure and glucose levels will be monitored remotely by health professionals.

For some elderly or housebound residents, this could be a good way for GPs to help keep an eye on them without clogging up their surgeries, while enabling the professionals to determine properly whether or not an appointment is really necessary. At the moment, getting an appointment when needed is often very difficult. Getting access to a doctor at night is usually extremely difficult, but this was not always so. Something has gone wrong when people feel the need to turn up at A&E if they can or call an ambulance when they should really have been seen by a GP at a surgery or in their home.

These problems are well illustrated in the recent report by the Public Accounts Committee in the House of Commons, which highlighted the following facts. There are simply not enough GPs to meet demand. Deprived areas are particularly short of GPs and nurses. Finally, there is much variation in patients’ experience of getting and making appointments, with people who work full-time among those who are most disadvantaged.

It is also clear from that report that information about basic facts, such as services provided at GPs’ surgeries and the availability of those services, is sometimes difficult to obtain. The report also makes it clear that

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the Department of Health and NHS England do not have the data that they need to make well-informed decisions about how to improve access to general practice or where to direct their limited resources. In the long run, these issues come down to improving the way in which we try to do things, endeavouring to make efficiency savings. But without a doubt, funding is the major issue.

The results of the most recent general elections show people’s reluctance to pay higher levels of taxation and politicians’ reluctance to ask them to do so. This is in spite of the fact that people now expect a pension from the state for a much greater proportion of their lives than ever before; with this comes the probability of them needing greater provision of health and social care. Improving access to GPs and funding the health and social care services that we need may require the introduction of a hypothecated tax in future. I believe that all parties should be considering this option if they are to be honest about addressing these problems. I would welcome the views of the Minister on that.

1.20 pm

Viscount Bridgeman (Con): My Lords, I, too, thank my noble friend Lord Attlee for initiating this debate. We heard from him that in his view the conduct of the practice of which he is now a patient leaves something to be desired. He has also been good enough to indicate that I might be able to sketch out for your Lordships a somewhat contrasting view. These two interventions, from my noble friend and myself, have not been co-ordinated; we only exchanged views two days ago.

I and my family are fortunate to be patients of a practice in central London which tells a different story. This practice has a walk-in surgery open for an hour and a quarter in the morning and two and a half hours in the evening Monday to Friday, with the exception of Wednesday evenings. I have never had to wait more than 20 minutes to see a GP. The practice has first-class support in practice nurses and receptionists. Repeat prescriptions can be requested online—this is now fairly common among GP practices. Significantly, and in many ways this is the acid test, the practice has some of the lowest referral rates to A&E in central London. In other words, more patients can be treated for minor ailments in the surgery without going to A&E. The cost of an A&E admission is approximately £80. Your GP is paid that same sum to have you for one year, so if you go to A&E for a runny nose that is the same money paid out again.

In 2006, under the GP settlement, practices could opt for PMS premium status where for extra work undertaken they received extra pay. On the whole the more enterprising practices—including the one where I am a patient—took advantage of this offer. Now I understand that the latest proposal from NHS England is for this premium to be substantially reduced or eliminated over a period of four years to bring the funding of PMS practices in line with the GMS practices that did not take advantage of the 2006 premium. It would be interesting to know if my noble friend Lord Attlee’s practice is one of the latter. It is policy to recycle the resultant savings thus made back to CCGs and through them to the practices within their groups. Where PMS practices are in a group with a substantial

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number of other PMS practices, the clawback available to CCGs will be considerable and as I understand it there will be significant funding available for improved services and financial support. However, PMS practices that stand virtually alone within their groups will not enjoy the same level of support. Note also that all funding deriving from the cutback to PMSs will be available to both PMS and GMS practices—a further subtle discrimination against the former.

Let me attempt to be constructive with three examples of welcome initiatives instituted by NHS England. The first is integrated care: a structuring for the patient to formulate with his GP a health plan. In my case, this involved an hour-plus session with the doctor—just think of that length of time being made available in an NHS practice. As I understand it, that model draws on experience in the US and elsewhere where patients with planned maintenance prove to be much less of a demand on healthcare services. This is being funded by CCGs, which are investing very considerably in it. It is a nation-wide initiative and much to be welcomed.

Another development in our part of London is the rapid response teams under the control of local health trusts but funded by CCGs. These consist of doctors, nurses and paramedics and I understand they are extremely effective in saving GPs in practice from having to leave their surgeries to answer emergency calls. The noble Lord, Lord Turnberg, suggested the damage caused by such calls in terms of the time of doctors in small practices.

Thirdly, I draw attention to the development of GP federations, where GPs join together in a unique and largely unprecedented way. These are set up as limited companies and their mission is to bid for services that hospitals may wish to contract out. Examples I know about are smoking cessation clinics, cardiograms, testing patients on warfarin for anti-coagulation and looking after airways disease—in short, widely disparate procedures. I think we can assume that in all cases there will be cost savings for NHS England and any profits made by the federations will be available to their GP shareholders.

I revert to the subject of my noble friend’s debate. My question for the Minister is how NHS England is to reconcile the very different standards that are emerging from this short debate. The challenge for NHS England is how to bring the less adventurous practices up to an acceptable standard without effectively dumbing down the forward-looking practices which, as I have tried to illustrate, have the potential to introduce new, co-operative practices with a substantial contribution to cost savings.

My own NHS practice reckons it will lose around £400,000, resulting in a cutback to the PMS premium over four years. From the resulting benefits that are to be made available by the CCGs to the practice, and I have given three examples, it is estimated that the practice will reduce the loss to about £200,000. Why should any loss be acceptable in this of all branches of healthcare? This is one branch of healthcare which is showing real initiative, particularly in regard to enterprise and its financial viability. Surely the NHS is in danger of killing the goose that lays the golden egg. I shall very much welcome my noble friend the Minister’s comments on that. I am in danger of mixing my

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metaphors, but general practice is one of the jewels in the NHS, which has been made clear by all the speakers today. Let the entrepreneurial practices not only be an example to their less-motivated colleagues but also lead the way in taking advantage of the imaginative developments that NHS England has initiated—but free from the financial penalisation that many practices are now facing.

1.27 pm

Lord Hunt of Kings Heath (Lab): My Lords, I thank the noble Earl, Lord Attlee, for allowing us to debate this very important question and congratulate him on the quality and range of his contribution, which was extremely interesting. I echo his initial comments about the value of the National Health Service. However, he also referred to the considerable challenges we face, not least the amount of money that is being made available. I note the comments that the noble Lord, Lord Rennard, made and I will be most interested in the Minister’s response to his suggestion that we need to move to hypothecated taxation. Interestingly, we have a recommendation from the Liaison Committee—of which I am a member—which I hope will come to the House next week to establish a special Select Committee in the next Session looking at the long-term sustainability of the NHS. I think that that will be a very interesting discussion, not least because it is clear, as the noble Earl said, that alongside A&E and ambulance services, general practice is facing considerable pressure.

Like my noble friend Lord Turnberg I am very lucky to enjoy an exceptional GP practice, which is a small branch of a large inner-city practice. It is clear from the comments of noble Lords and from the regular GP patient survey that people’s experiences are very mixed. The noble Earl focused on economically active members of society, but his comments could have applied to all patients. Noble Lords are often fond of quoting the Commonwealth Fund’s international comparators, which do not always compare with the OECD research covering the same ground. I was interested in its latest report on public perception of primary care in the UK and the fact that there has been a dramatic drop in the positive view of how primary care works, with the percentage of those expressing satisfaction going down from nearly 50% in 2009 and 2012 to just over 20% in 2015. So there has no doubt been an appreciable change in attitude by the public in relation to GP services. The GP patient survey shows, for instance, that only 70.4% of patients find it easy to get through to someone at their GP surgery on the phone. This is down from previous figures. It also showed that 6.5% book their appointments online, up from 3.2% in December 2012. It is really disappointing that such a low number of people actually take advantage of online booking or, indeed, that such a low number of practices promote online booking. Obviously, it would make life so much easier if it were easier for people to do that, and it would deal with the problem that the noble Earl, Lord Attlee, described, about the differentiation between an urgent appointment and one that is important but does not have to take place within 48 hours. Many GP practices seem quite unable to devise a system to cope with those circumstances.

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It is also interesting that the GP patient survey showed that 23.1% see their preferred GP a lot of the time. We need to think through the implications of that, particularly with seven-day working, because I suggest that with the move into larger federations, which I support, the seven-day working concept inevitably means that people will have less opportunity to see their preferred GP—particularly, as we know, when many GPs do not want to work full time any more. That seems to me to depend on information, particularly electronic information, being available, so that a patient does not have continually to tell different GPs in a practice about their conditions, because they actually have systems where that is noted down.

I also note that in the survey 57.7% were happy with the amount of time that they had to wait for an appointment. Again, that is down—it is not a great figure. The overall satisfaction with GP opening hours, at 74.8%, is down and again not very satisfactory.

The noble Lord, Lord Rennard, referred to the PAC report on access to general practice, which came out only a couple of weeks ago. I thought that it was a very interesting report and, no doubt, the Government will respond in due course. But it showed that we have problems with retention and recruitment, that good access to GP care is too dependent on where patients live, and there is an unacceptable variation in patients’ practices and in the appointments system. Tellingly, it said that the Department of Health and NHS England do not have enough information—that is a point that the noble Lord made—on demand, activity or capacity, which one would have thought might have been of interest to NHS England. I think that it is clear that both the department and NHS England has really failed to ensure that staffing in general practice has kept pace with growing demand. I think that they have been complacent about general practitioners’ ability and, indeed, willingness to cope with the increase in demand caused by rising public expectations and the needs of an ageing population.

No doubt the Minister will tell us about recent initiatives, which are welcome in themselves, but a lot of changes will come about because GPs themselves will make them happen. I am really impressed by the large federations that have been established. There is one very large one in west Birmingham and the Black Country, which has had some incredibly impressive results in relation to access. It is through having a large enough federation that you can meet the work patterns of individual GPs, and it is through the simple use of phone and email to have much more flexible appointments. I do not know whether the noble Lord has read a report from David Pannell, the chief executive of Suffolk GP Federation, which complains that the department is not really giving support to the development of provider networks and federations and that the only initiative promoting working at scale was the Prime Minister’s GP access fund, which was doing little to diverge from the traditional model of contracting with individual practices.

The point being made here is that every single contract which is part of the PM’s access fund has been a traditional primary medical services or general medical services one with an individual practice. Would the

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Minister be prepared to have a look at this and to talk to the National Association of Provider Organisations? Its chair has commented:

“Whereas NHS England supported the vanguards programme, there has been virtually no support for the leadership of federations which are not part of a vanguard”.

I have quoted from a story in the Heath Service Journal and I have also looked at comments which have been made on it. One comment, which was anonymous—I do not know why—said:

“Brighton and Hove CCG have been developing a really innovative and ambitious contract with GPs working at scale which the LMC have supported”.

It may well be worth looking at that to see whether more can be encouraged.

Finally, I wonder if the development of federations means that the Government need to look at CCG governance. If you have a large-scale federation covering an area roughly the same size as a CCG, I can see a potential conflict of interest. The federation could dominate the election of members to the CCG board. The contracts should be at that level, not held by NHS England, so I wonder if we need to go back to the issue of CCG governance and have a majority of lay people on CCG boards. That would enable the Government to be much more proactive in supporting these federations. I am convinced that they are the only way we can deal with the problems raised by the noble Earl.

1.36 pm

The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con): My Lords, I also thank my noble friend for raising this issue. General practice has been a golden thread running through the NHS since 1948. It is worth reminding ourselves that although the situation may be dire in some parts of the country, as the noble Lord, Lord Turnberg, mentioned, the NHS is still almost unquestionably the most efficient, highest-value healthcare system in the world. Not long ago, I was with some people from the Mayo Clinic who made that point—we are very self-critical. It is right that we should be but also right that we should remember that much of what we do in the NHS is absolutely world class and we do it with very little resource. My noble friend Lord Bridgeman and other noble Lords made the point that the NHS is, in their own individual experience, absolutely first class. If you read the newspapers every day you might think that everything is going to hell in a handbasket but most people’s individual experience of the NHS is extremely good. I have not seen the Commonwealth Fund report to which the noble Lord, Lord Hunt, referred but I would like to.

We should be extremely concerned if confidence in primary care is diminishing. I will write to the noble Lord, Lord Turnberg, about research. I could answer his question if it was directed at specialist research, but I am not sure how much money or resource is going into research into primary care. The noble Lord, Lord Rennard, raised the issue of hypothecated tax. The argument for hypothecating tax for health is no stronger or weaker than doing so for education or overseas aid, or other areas. He will know, as well as I

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do, that the Treasury has wrestled with and discussed this issue for many years. Any decision will be made in the Treasury, not by me. I could argue both sides of the case with equal conviction and sincerity, so I cannot give the noble Lord the answer he might want to elicit from me.

The noble Lord, Lord Rennard, and my noble friend Lord Bridgeman raised the issue of variation. We have got thousands of GP practices and there will inevitably be variation. The question is how we reduce that variation and shift the curve to the right in terms of getting a great general practice. I happen to believe that one way of doing that is through networks and federations. The noble Lord, Lord Hunt, referred to Vitality in Birmingham. Unquestionably, it will spread best practice within that group. The good CCGs are measuring the performance of GPs in their area much more intelligently than they used to. My noble friend Lord Bridgeman mentioned that his practice has very low referral rates. That is exactly the kind of information that should be measured on a GP-practice basis across all GP practices in CCG areas. For example, I have seen the metrics that the CCG in Camden looks at. You can see very clearly what the referral rates are from practices. The outliers can be seen and you can manage that down. They have had some very good results. If noble Lords would like to look at the atlas of variation, or at the Right Care model that NHS England is using to try to identify variation on a disease on a population basis to drive down that level of variation, I can well recommend that they do that.

I have come to the view—it is almost a statement of the bleeding obvious—that of all the tools that we have in our toolkit to try to secure improvement, be it in clinical outcomes, performance of trusts or in general practice, the best is identifying variation. The crucial thing about variation is that you have good-quality data. The first thing when you shine a light on clinical practice, for example, is that the clinicians will dispute the data—often rightly—so you have to demonstrate that the data are good. If you can prove the data, GPs, psychiatrists, acute physicians, surgeons and the like will take that as a challenge, because they tend to be competitive individuals. They like their own practice to be better than anybody else’s. Variation based on good-quality data is essential.

I will take away the comments made by my noble friend Lord Bridgeman on PMS. NHS England is committed over the five years to increasing spend on primary care by some 25% in real terms, whereas in the rest of the NHS it will be more like 15%. There will be more resource relative to other parts of the NHS going into primary care. They will want to be sure that they are getting real value out of any premium payments made under the PMS contract, but I will take that away if I can and write to my noble friend on that matter.

Governance is an extremely important issue. I had not thought about it in terms of where a network of general practice is almost the same size as the underlying CCG, which raises another issue about governance. We thought about it in terms of conflict of interest and the award of contracts, but that is a very serious point. NHS England is looking at these governance issues. I will bring this aspect to its attention.

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I turn to what I had pre-prepared. My noble friend Lord Attlee is quite right that people should receive the right care from the right professional at a time convenient for them. However, we know that there is variation in people’s ability to access a GP and that those in full-time employment report lower levels of satisfaction with surgery opening hours than other groups. This is one of the reasons why, by 2020, everyone will be able to access routine GP appointments at evenings and weekends as part of our commitment to a seven-day NHS. That does not mean that every practice will be open seven days a week. We hope that by 2020 most general practices will be part of a network or federation and they will be able to offer that kind of service across the federation.

As I am sure my noble friend will understand, it is not possible to make a direct comparison between accessing GPs and other professionals such as solicitors, but he is, of course, right that people should be able to access a GP appointment when they need it. This is why the Government have already invested £175 million in the Prime Minister’s access fund to test improved and innovative access to GP services. I know that it is very spotty across the country still, but there is a growing understanding that the traditional model of GP practice—lots of small practices with two or three partners, as described by the noble Lord, Lord Turnberg —is not a viable model of delivering primary care for the future.

The tradition model is going to change. We will have networks and much bigger practices with 10 to 20 salaried partners supported by a much larger team of skilled people—pharmacists, physios, OTs, physician associates, prescribing nurses and the like. As well as providing extended hours, schemes are also looking at other ways of improving access for patients, including better use of telecare and health apps. This is an issue that noble Lords raised in the debate today. Not only will we see much more use of the telephone but, for example, the Hurley Group has an e-consultant system, and more people will use other ways of accessing primary care rather than being seen by the GP. This has a lot of legs, if you like. Apps such as Babylon, with which noble Lords will be familiar, and many other apps will make a face-to-face consultation with a GP less critical than it has been in the past.

My noble friend also asked about competition between surgeries. Here, I will point to what we are doing to increase choice for patients. In particular, my noble friend raised a concern about having to move from one practice to another when he moved house. I was pleased to hear that he is now aware of the steps that have been taken to make it easier for patients to exercise choice over which practice they are registered with. The GP contract for 2014-15 brought in a measure allowing GP practices to register new patients from outside their traditional boundaries, but without a duty to provide home visits for such patients, which seems reasonable in the circumstances. This measure is designed to increase flexibility in the system and the freedom that patients have to choose a GP practice that suits them. For example, commuters may wish to register with a practice close to their work as opposed to where they live or a patient who moves house may wish for continuity.

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I return to the technology point about booking systems raised by the noble Lord, Lord Hunt. Take-up may be low at the moment—I think that 6.5% of bookings are done online—but I have no doubt that it will grow. If you look at the number of people now ordering basic food from supermarkets online, that is the direction of travel and it will speed up as time goes by.

The noble Lord raised the issue of reducing pressure on A&Es. In January, there was an increase of 10% in A&E attendances on the previous year. This is putting huge pressure on hospitals because if the front end of the hospital is being flooded, it makes it increasingly difficult for it to meet its waiting times on elective surgery, for example. Delivering more care to people outside hospital will not only lower the cost but provide better care because going into A&E with a fairly minor problem is not a great way of delivering care.

The noble Earl raised an issue about blood tests. Examples of improved access to diagnostic tests can be seen in both the vanguard sites which NHS England is developing. They are part of the new models of care programme and access fund schemes. For example, a vanguard in Birmingham offers consultant-led outpatient clinics and diagnostic facilities, such as X-rays. We often talk about integrating social care with healthcare, but integrating healthcare is also not a bad way to go. We have talked in the past about collocating GPs in A&Es or just outside them, but there are also many specialist outpatient clinics that can be delivered in primary care settings, so long as the facilities are there. We hope that the £1 billion infrastructure fund that we have announced will deliver better facilities closer to where people live.

We have a lot to be proud of but we are inclined to dwell on areas where we are failing and forget sometimes where we are achieving great success. The workforce is a serious issue. We are committed to finding 10,000 new GPs or GP equivalents in general practice by 2020 and we have increased the number of training places by 3,500 from this year and going forwards. To be honest, there is a risk whether we will be able to get that number of people into general practice. However, without that kind of workforce commitment it will be difficult to deliver our ambitions.

So, it is a combination of technology, workforce and infrastructure. The five-year forward view is behind the thrust of the comments made by noble Lords and, if I am still here in 2021, I hope that I will be able to say that we have spread the best practice that exists in large parts of the country on a much wider basis. However, I am afraid that we will not have eliminated all variation.

1.51 pm

Sitting suspended.

Children: Maternal Care

Question for Short Debate

2 pm

Asked by The Earl of Dundee

To ask Her Majesty’s Government what steps they are taking to promote ongoing maternal care for children.

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The Earl of Dundee (Con): My Lords, I look forward to the comments and guidance of colleagues speaking today and thank them very much for their interest in this debate. In my remarks I would like to touch on three aspects: first, the obvious connection between an early solid quality of childcare and a later stability of adulthood; secondly, a distinction between the effect of childcare within the home on the one hand and that in day centres on the other; following from this and, thirdly, the case for giving better financial incentives to mothers to stay at home with their children if that is what they might prefer to do in the first place.

On how it may have induced quality or otherwise, childcare policy should of course be judged on several fronts, not least, when the child is a bit older, through early education itself and the extent to which that may have reached all income groups. Here the Government deserve credit for their commitment to a package of schemes. This includes 15 hours of free early education for all three year-olds and for around 40% of the most disadvantaged two year-olds, administered by local authorities; and 30 hours of free childcare a week, worth around £5,000 a year per child, to working parents of three and four-year olds. In a written government paper, replying to the Affordable Childcare report’s recommendations, my noble friend the Minister announced these and other measures; that government response also followed our debate last year on that report, moved by the noble Lord, Lord Sutherland.

All political parties agree the priority of giving the child from the start the best possible deal of security, confidence and education. Each political party seeks to raise such standards, acknowledging the connection between an early quality of childcare and a later stability of adulthood, while also recognising the enormous contribution that success in this way can make to reducing the problems of society, such as the current huge increase in mental health ailments.

The next point is the distinction between the effect of childcare within the home and that outside it in day centres. All of us are grateful for the availability and national distribution of day centres. Many of these are very good, as well as essential to working mothers. Daycare can also assist academic performance from low-income homes and, along with parent-infant therapy, even improve children’s emotional well-being. Yet it is misleading to assert that babies or toddlers need stimulation, education or friends. The truth is that at that age they develop best as a result of close supervision by and affection from a familiar responsive adult in the home. Every study reveals that the child’s emotional security develops in a far more assured way through maternal bonding than it can ever hope to do in day centres, however good these may be.

This leads to the choices of mothers themselves. Recent opinion polls show that 80% of them believe that one parent should be able to stay at home, while 88% of mothers with very young children have said that the main reason for returning to work is financial pressure. My noble friend the Minister may concur that if mothers and families express such views, they should be offered wider choices than those at present. The objective would not be to discourage mothers who want to work from so doing. Instead, the aim

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would be to enable those mothers who prefer to stay at home to do that rather than working simply because they consider that the family cannot otherwise afford for them not to do so.

Of course, there is also the distinction between maternal and family home care of children who are under three years old and that for older children. Does my noble friend the Minister therefore consider that if in better corresponding to family wishes much wider choices should be offered in general, the Government should also analyse much more sharply in particular how these preferences may differ in regard to home care for children under three years old and that for older children?

Most countries operate either a joint taxation system or an individual tax system which allows families the option of being taxed jointly, either by transferable allowances or credits. Will my noble friend the Minister agree to review the merits of certain expedients, including: a system of transferable personal allowances where a non-earning spouse would be able to transfer the whole or part of the basic income tax personal allowance to their earning spouse; income-splitting, under which for tax purposes families would be able to split family income in two and allocate half to each partner, as well as keeping both personal tax allowances; and child allowances, already practised by some countries, which allow an extra tax allowance per child? In fact, a recent OECD assessment notes that, apart from Mexico, the UK is the only developed country with a population of more than 10 million to apply tax based on individual income with no allowances for spouses or transferable allowances.

Perhaps inevitably, there are trade-offs inherent in any government policy that seeks on the one hand to promote child development and on the other to facilitate parental employment. For example, cheap low-quality childcare might help parents to work but would not meet the Government’s child development objectives. Yet, through adoption of some of these financial and fiscal adjustments as proposed, that anomaly reflected by trade-offs could be quite considerably redressed. Such steps would assist ongoing maternal care for children. As a result, to a greater extent children would become more secure, society more stable and, through choice rather than necessity, family employment much fairer.

2.07 pm

Baroness Barker (LD): My Lords, I thank the noble Earl for securing this debate today and for introducing it in such eloquent fashion. Early years, the early start in life and maternal support were a key priority for the coalition Government. It is good to have the opportunity to return to this issue. We do so in the week that a new all-party group has been set up. I am not really a fan of new all-party groups because there are thousands of them already, but this is the All-Party Parliamentary Group for Conception to Age Two—The First 1,001 Days. That shows the consensus which now exists around the importance of the first 1,000 days of a child’s existence. Throughout the mother’s pregnancy and up until the age of two, approximately, is the key formative stage in any person’s life, physically, mentally and

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socially. I am glad that we now have that consensus about the importance of interventions during that time to make sure children grow up happy, healthy and well adjusted.

Needless to say, midwives have a key role in assisting mothers. This House, under the repeated instruction of the noble Baroness, Lady Cumberlege, has over the years come to understand the continuing importance of midwives, not just in the support and information that they give to women during pregnancy but also in their ability to prioritise post-natal care plans with women so that they, once they come out of hospital, have in place a way to see them through what is sometimes the most demanding not to say frightening time in a parent’s life.

It is recognised by all parties that continuity in midwifery is extremely important. Quite often, one hears women talking not about the fact that they could not see a midwife but that they had to see different midwives. On each occasion they had to start from scratch and go through all sorts of details, so that by the time they got to end of a short consultation they had had very little time in which to have a proper discussion about the issues bothering them. In the light of the recent report by the noble Baroness, Lady Cumberlege, what impact does the Minister believe that the introduction of personal budgets, as she proposed, would have on the availability of midwives? What is his assessment of the impact that it might have on the training—and access to that training—of midwifery students, who are so important for the future?

On 1 October 2015, services for children aged under five were transferred from the NHS to local authorities, which are now required to make provision for maintaining the universal health visitor reviews as part of the healthy child programme—specifically, the antenatal promotion review; new baby review; six to eight week assessment; one year assessment; and two to two and a half year review. We know, because there is a lot of evidence now both from this country and abroad, that early intervention with disadvantaged families can have a profound effect on the life chances of a child. We know that the public health interventions that are needed have to be integrated at a local level with the NHS to ensure that the healthy child programme and family nurse partnerships can identify and work with those families who are most in need. We know that investment in health visitor programmes pays off in terms of the benefits that they bring to families and the way in which they enable children to thrive and not to need far more expensive interventions later on. The transfer of powers to local authorities is well founded in evidence. How will the programme’s implementation be monitored and evaluated in practice and when can we expect to see the initial results? When will we able to see figures, particularly in relation to the eradication of child poverty, which is a target by which this and all previous Governments are judged?

I touch briefly on mothers, work and childcare, which the noble Earl, Lord Dundee, alluded to. According to the Department for Education survey of parents in 2014-15, two-thirds of mothers—about 66%—were in employment and one-third of mothers were not working. About half of those non-working mothers agreed that they would prefer to go out to work if they could

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arrange good quality childcare that was convenient, reliable and affordable. Among the mothers who had returned to work in the previous two years, the most commonly reported factor that had influenced their return to work was finding a job that enabled them to combine work and childcare. The availability of not just childcare but of suitable childcare is the single biggest problem for working parents. It is quite often the case that it is impossible to find childcare for half a day. Yet, when children start at nursery schools, sometimes they go for only half a day, which leaves parents desperately trying to juggle work around the time they have to get back to pick up the kids. Equally, some parents have to work part time but can only arrange with their employers to work for, say, two full days. If they cannot find childcare to fit around that, their chances of moving back into work—as the majority wish to do—are severely hampered.

We in the Liberal Democrats supported the extension of free childcare, particularly to parents who were not in work: free childcare is a very early-stage intervention and makes a big difference to children in deprived communities. We also recognise the importance of the role of fathers and believe that shared parental leave should be the aim of all Governments, so that individual families can arrive at solutions that work best for them and their children. Will the present Government continue the work of the coalition in trying to work with employers to improve the availability of affordable high-quality childcare, so that those parents who wish to can continue to work while giving their children the best start in life, which is what the vast majority of parents in this country want?

2.15 pm

The Earl of Listowel (CB): My Lords, it is a privilege to follow the noble Baroness, Lady Barker. I think I can say that I agree with every word that she said. I was particularly pleased that she referred to the work of the noble Baroness, Lady Cumberlege, and the importance of the continuity of care from midwives, specifically from practices where midwives are there at the beginning of pregnancy, deliver the child and keep in contact for a short time after pregnancy. That is definitely the ideal situation. I am also grateful to the noble Earl for calling this important debate. Many of these issues have been raised with the Minister in the course of the Childcare Bill. A particular concern is that many babies in childcare are often placed with the least qualified and experienced staff. I hope the Minister will perhaps have a chance to look at that.

I would like to address three issues: family learning as a means of promoting ongoing maternal care for children; the particular importance of continual maternal care from conception to the age of two; and the impact of homelessness on maternal care. I hope to concentrate most of my remarks on the area of the Minister’s immediate responsibility, which is schools. I begin by welcoming the new investment in schools by the Chancellor. I am delighted that he has chosen to introduce the sugar tax and will invest the benefit of that in education. The Government have also committed to expand still further the number of academy schools. I hope I may encourage noble Lords of all parties or none to use any business contacts they may have to

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promote application for high-quality sponsorship. Whatever one may think of academies it is becoming clear that it is vital for our children that there are sufficient excellent sponsors.

On family learning, I suggest that continuing good maternal care throughout a child’s development is becoming increasingly important. On the one hand, fathers are becoming increasingly absent. By the 2030s about 30% of our children will be growing up without a father in the home. On the other hand, housing continues to be in short supply and children are being obliged to remain at school: they cannot move out. It is becoming increasingly important that mothers stick with their children through the difficult adolescent years. Family learning can strengthen maternal relationships through the early school years and so help mothers tolerate their teenagers later.

Family learning can also hit another number of important goals. It improves children’s educational attainment. It engages fathers more effectively in their families. It can help migrant families to settle well, and may help combat childhood and adult obesity. I developed an understanding of family learning by meeting foster carers who had benefited from the prepared reading developed by Dr Andrea Warman at the British Association for Adoption & Fostering. Many of the foster carers themselves had difficulties at school and were taught to draw on those difficulties in efforts to understand the challenges that some of their foster children experienced. The training package gave the foster carers the confidence to read regularly with their children, and the results were significantly improved literacy results for their foster children and a reduction in placement breakdowns—foster parents and foster children sticking with each other. John Coughlan initiated paired reading at the local authority at which he is director of children’s services in Hampshire. Early indications suggested that paired reading also reduced the breakdown in placements in children’s homes.

I then had the opportunity to meet mothers at one of the National Institute of Adult Continuing Education events to celebrate family learning. One mother had had a heroin addiction but was now able to work, thanks to the confidence that she had gained through family learning. Another mother had gone to get driving lessons following her success; another still described her joy at taking her son on a field trip to explore the natural history of a field and pond.

More recently, I spoke with the mother of a child who graduated from the Pimlico Academy, which the Minister established. The mother is the catering manager in a local secondary school and has a second, part-time job in a launderette. She is an immigrant of African origin; she said that in her country mothers will sell their jewellery to secure a good education for their child. Every school day, she and her son and daughter read together for 20 minutes, looking up any difficult words. She spoke of her pride in her daughter’s academic success. Now reading physics at a prestigious university, she gained 12 GCSEs, A*s or As, and four A-levels. Family learning arguably strengthens maternal bonds with children and certainly leads to significant increased attainment. If the Minister wishes to extend academic success to areas of generational deprivation, such as

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County Durham, he could do worse than to consult the National Institute of Adult Continuing Education and the Workers’ Educational Association. The WEA has spoken to me about how it would position its teachers near the primary school gates to engage parents as their children begin their education.

No doubt, the Minister is also concerned about childhood obesity. Only this morning I heard about a project led by North Eastern Electricity which provides parents with cooking classes so that they can avoid wasting money on takeaways and feed their children more healthily. We heard on the “Today” programme that many schools require their pupils to run a mile a day. Schools find that their pupils lose weight, sleep better and have more concentration in lessons. So it may be possible to offer opportunities to parents to learn about exercise and so encourage their children to walk, and to run with their children. In all the above, I remember my own family experience and the importance for me of learning with my mother and father things such as cookery, reading and other study.

I commend to the Minister NIACE’s report on family learning, chaired by my noble friend Lady Howarth of Breckland, the chair of the All-Party Parliamentary Group for Children. With the expansion of academies, free schools and early years care, and the additional funds, I hope that he may wish to weave family learning much more strongly into what he offers.

On the importance of the continuity of maternal care between conception to the age of two, which the noble Earl, Lord Dundee, emphasised strongly in what he said, I hope that I can pay tribute to the many parliamentary colleagues who have raised the importance of early years to successive Governments. I think particularly of the right honourable Iain Duncan Smith MP, Graham Allen MP, Andrea Leadsom MP and the vice-chair and offices of the All-Party Parliamentary Group for Conception to Age Two—The First 1001 Days, to which the noble Baroness referred. Then there are Tim Loughton MP, Frank Field MP and others. Following on last year’s report for the parliamentary group, Building Great Britons, we recently heard from health professionals from Croydon how their trust was enacting the report’s inquiry in building a seamless partnership between midwives and health visitors, so extending even further the continuity of care to which the noble Baroness referred. I commend the report to your Lordships and am very grateful for the efforts of midwives, visitors and other health professionals to provide excellent perinatal care to mothers.

As a society, we need to give every attention to perinatal maternal care, if mothers are successfully to make a strong, continued attachment to their infant, which is vital to their child’s future health, education, economic independence and own family. I applaud again the Government’s investment, and that of the previous coalition Government, in health visiting, and indeed the resurrection of that service.

In my final area, I would like to explore the importance of homelessness on maternal care. Here again the perinatal period is a particular concern, and I much appreciate the work that the London Scholars at the University of East London have undertaken in the last

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six months of the effects of homelessness on perinatal maternal care. I await those conclusions. I was grateful to the noble Lord, Lord Bates, for undertaking to the noble Baroness, Lady Lister of Burtersett, that the Government would review policy on those pregnant women in detention, awaiting immigration removal, on Report of the Immigration Bill. Regrettably, in recent years the number of homeless children has increased to 100,000 in England alone. The Government’s legislation on housing and planning and their investment are a golden opportunity to make more secure affordable housing available to families with low incomes. I declare my interest as a landowner and residential landlord.

Again, I am very grateful to the noble Earl for calling this important debate and look forward to the Minister’s reply.

2.25 pm

The Lord Bishop of Worcester: My Lords, I am also grateful to the noble Earl for securing this debate because I am utterly convinced about the importance of ongoing maternal care for children. I speak as the father of two adopted children. I have learned through experience and study how crucial is the relationship that children have with their mother. It is an essential and defining part of the process of perinatal life that a bond is formed between child and mother, regardless of the latter’s conscious attitude towards her baby.

Research shows that healthy development depends on the quality of attachment from primary carers during the first three years of life when the brain’s structural plasticity is most available to being shaped by interactions with parents. In systemic terms, there is a benign, recursive, interactional loop operating between parent and child such that the baby’s brain responds to parental input—love, care, et cetera—by developing and growing physically and psychologically. This in turn triggers the parent or carer to provide more love and care.

As the noble Earl has said, the Government deserve much credit for their determination to improve the lot of children. I do, however, believe that other measures would help significantly. With this is mind, I applaud the Motion which the noble Earl and others introduced to the Parliamentary Assembly of the Council of Europe in September 2015, advocating, among other things, financial assistance for maternal care in the home for a minimum of three years, ensuring that such a care subsidy is independent of paid work. The organisation CARE, summarising its latest annual review of taxation in this country, said:

“According to our most recent research, a single-earner married couple with two children on the average OECD wage are liable to 35% more tax than the OECD average”.

Of course mothers should be able to go back to work when they wish but CARE boss Nola Leach said, when the report was published:

“Stay-at-home parents are making an important investment in their children and yet at present they end up being discriminated against by our current tax system”.

I should add that I have nothing against single parents or working parents: I am one. However, I would like to see the tax break for couples, which was announced in April 2014, to be extended, along the

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lines that the noble Earl suggested, to a 100% transferable allowance, which would carry far more significance and would mean that couples could benefit to the tune of £2,000 a year. The campaigning group Mothers at Home Matter argues that it matters for families to have choices in care, so that all are able to choose what works for them in their unique circumstances. That will surely be for the good of all.

Mothers are also presently concerned about conditionality placed on households on the new universal credit. Will family responsibilities at home be properly factored in? How much pressure will there be on second earners to return to work? Preliminary research seems to indicate that more mothers will be “encouraged” to sign up for interviews when children are 12 months old, even when they have significant care responsibilities at home.

As has been intimated, our concern should not just be about the early years: it is important for someone to be there for children in the middle and teenage years as family circumstances and pressures change. The availability of decent, part-time, paid work, particularly during secondary school, is key to achieving balance for some parents with care responsibilities. We need, in sum, a greater recognition of the loving one-to-one care that babies need and of children’s need for family time at all ages. We need to do all we can to facilitate it.

At the same time, while ongoing maternal care is important, so is parenting in general. The noble Earl, Lord Listowel, pointed to the importance of family and family learning. Churches are also doing much to provide training on parenting, for which there is an appalling lacuna in our society. The Mothers’ Union runs and trains facilitators for its “passionate about parenting” course. A participant said:

“This parents’ group helped me in so many ways. We talked in small groups and helped each other, my children found my parenting handbook (a resource I was given that I could take away and read through at home) so I thought I had been busted. But it was great, after a few weeks my 18-year-old gave me a hug. The first in years and he wasn’t the teenager I was having problems with!”.

Similarly, Care for the Family runs many positive parenting programmes, and Alpha provides parenting children and parenting teenagers courses.

As the father of adopted children, I know that the separation of children from their mothers is immensely traumatic. It is referred to by adoption specialist Nancy Verrier as “the primal wound”. It takes a great deal of love on the part of adoptive parents to begin to heal this wound. That shows the importance of the maternal bond and maternal care. It can be done, as was done by my wife. Tragically, she died when my children were aged nine and 15. That brought home to me, by tragic means, the importance of ongoing maternal care.

It is, of course, not true to say that healthy adults cannot develop if they have experienced a lack of maternal care. There are alternatives to it; attachment from other loving and caring adults, most especially fathers, can be very nurturing and healing. These are important alternatives, but no substitute for ongoing maternal care.

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2.31 pm

Lord Watson of Invergowrie (Lab): My Lords, I thank the noble Earl, Lord Dundee, for initiating the debate. Perhaps he and I are the only two people in the Room who know that our titles are very closely associated—although maybe not in their level. Invergowrie is a village on the outskirts of Dundee, where I spent all but the first 18 months of my life. I have an affinity in that sense, if not with the noble Earl.

I should also say that my mother was a teacher. At that time, when female teachers got married they had to give up the job. That seems incredible these days. I am sure that that has brought a sharp intake of breath from the noble Lord, Lord Nash, but that is what happened. In that sense, what the noble Earl seeks happened in some way for some women because they were forced to give up what they had trained to do. They could take other employment, of course, but they could not follow their chosen vocation. I am obviously not advocating that and it is long in the past, but I certainly appreciate the noble Earl’s motivation in the debate. He introduced it in a manner that underlines his clear commitment to ensuring that every child has the best possible start in life. I hope he will forgive me if I say I will not comment on his fiscal proposals. As far as I am concerned there is quite enough in the education portfolio, so I will leave that to others.

As the parent of a child currently in reception, I can say from experience that I appreciate the benefit of the integrated approach to early learning and care promoted by the early years foundation stage framework. It provides a clear set of common principles and commitments for professionals to deliver quality early education and childcare experiences to all children. Some changes were made to the framework in 2014, which have strengthened standards for the learning, development and care of children from birth to the age of five, producing a uniformity that, in theory at least, offers all children the same opportunities. But, of course, I think we know that life is not like that.

There is no equality of opportunity for newborn babies. That is much to be regretted, because the first two years are crucial in shaping a child’s life chances. When a child is just 22 months old it can already be accurately predicted what her or his educational attainment will be at 22 years of age. The noble Earl said that studies reveal that a child’s emotional security develops in a more assured way through maternal bonding than in day centres or nurseries. I certainly agree that maternal—and, let us not underestimate it, paternal—bonding is essential from the minute the child draws its first breath. However, the extent to which bonding alone can sustain the crucial early development of a child depends to a great extent on the home environment to which the baby is introduced. That is where I part company with the noble Earl, because I am convinced that it is both unrealistic and, in most cases, unfair to expect the mother alone to keep the child at home and provide it with all the support that it needs in its first two years.

We have already heard the noble Baroness, Lady Barker, say that two-thirds of women either want or need to seek employment, but the reason I believe a

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mother needs support is that it may be her first child, in which case she is on a really steep learning curve, or if it is a subsequent child then, for obvious reasons, the time available to have sole responsibility for that child is limited, so she should seek support from a variety of sources. Not least among those is interaction with her contemporaries as mothers, in formal or informal group settings.

In 2010-11 report after report emphasised the enormous importance of early intervention, including the Tickell review of the early years and two reports by Graham Allen MP. At that time it seemed that a cross-party consensus was emerging to prioritise early intervention, but it seems that that soon evaporated, because the coalition Government began to cut early intervention budgets and poorer families have been suffering ever since. Hardest hit, in that sense, has been the network of Sure Start centres. When Sure Start was established by the Labour Government in 1998 the aim was to provide an accessible children’s centre in every community. Each centre would offer a wide range of high-quality services for families with children under the age of five. Sure Start was immediately popular and a network of some 3,500 centres was quickly established.

What was also established was that Sure Start works. There is comprehensive, independent evidence that it delivers quantifiable outcomes and that it is immensely popular with families. However, since 2010 funding has been cut by some 35% and over one-fifth of all children’s centres have now closed, meaning that Sure Start is approaching a point of no return. Last year the Government promised a consultation on the future of Sure Start. We still await this and I very much hope that the Minister can tell noble Lords today when it is likely to begin.

Sure Start was founded on the basis of extensive academic research. There is a plethora of evidence that demonstrates beyond doubt that Sure Start works. The national evaluation of Sure Start has been analysing the long-term development of 5,000 families who used Sure Start when their children were young. The evaluation has found clear evidence that children attending Sure Start centres are less likely to be overweight and more likely to be immunised; they have better social development and are less likely to offend in later life. Parents attending Sure Start centres provide more stable home environments and are more likely to move into work. It is a win-win situation for parents and children, yet the network is having to be dismantled.

Children’s centres have been found to be immensely popular with parents and evidence shows that they have been successful in reaching the parents who are likely to be the most disadvantaged. Also, the beneficial effects for parents persist at least two years after their last contact with Sure Start; often, social interventions do not have such a sustained impact. These findings have been reinforced by the children’s centre census produced annually by the charity 4Children. Its 2015 census found that from 600 responses 90% of parents reported that their children’s centre had a positive impact on their child and 83% reported that it had a positive impact on themselves. Tellingly, 80% reported that life would be harder for their family without their children’s centre.

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It has been suggested by Government, or perhaps by some of those speaking on their behalf, that Sure Start is dominated by the sharp-elbowed middle classes. Evidence completely contradicts this. Independent Oxford University research in 2015 found that disadvantaged families use children’s centres for an average five months longer than more affluent families. This is because,

“the open-access, walk-in activities encouraged vulnerable families to take part because they did not feel there was a stigma attached to using the Centres”.

The Government have attempted to conceal some of the cuts that Sure Start has suffered. In 2011 the ring-fence established by the Labour Government was ended. In 2013 Sure Start funding was merged into local authorities’ general funding, and we all know what has since happened to that, most recently in the Chancellor’s Autumn Statement and, indeed, in yesterday’s Budget. Last year the charity Barnardo’s called on the Government to act to stop the life being squeezed out of children’s centres as many local authorities face impossible stresses and strains on their budgets.

No doubt the Minister will note that the amount of free childcare for three and four year-olds is to be extended, which is an important step, even if it will perhaps not be quite as extensive as we were first led to believe. He will also refer to the fact that more children aged five are making good progress against the early years foundation stage profile, and that is, of course, to be welcomed. More children are reaching the expected level of development in maths and literacy as well as in the key areas of social and emotional development, physical development and language. That is all to be welcomed, but these are measurements of children at the age of five. The progress made by many of them could be much better and much more likely to be sustained if more of them had an early opportunity to benefit from the support provided in so many forms by children’s centres, whose value is widely appreciated. It is to be regretted that the Government do not appear to share that appreciation.

It surely goes without saying that maternal care is of prime importance to any child, but it must be enhanced by external influences: everything from health visitors to educational psychologists and the benefits of interacting with their contemporaries in a secure, welcoming setting. Children’s centres have a vital role to play in that, and I invite the Minister to acknowledge that.

2.40 pm

The Parliamentary Under-Secretary of State, Department for Education (Lord Nash) (Con): My Lords, I thank my noble friend Lord Dundee for calling a debate on this important subject and congratulate him on an excellent speech. I also thank other noble Lords who have contributed. My noble friend had a number of suggestions about how the overall system could be improved. Our provisions for flexible working and for parental and shared parental leave are now substantial. We have one of the longest periods of paid maternity leave in the EU and our rate of maternity pay exceeds the requirements of the EU directive. I am tempted to agree with the noble Lord, Lord Watson, about the point my noble friend made about financial incentives, but it is rather beyond my pay grade. On the tax

17 Mar 2016 : Column GC269

incentive to which he and the right reverend Prelate the Bishop of Worcester referred, I will write to him and refer the matter to Her Majesty’s Treasury.

I think we all agree on the importance of maternal care and attachment in early childhood and its implications for longer term social and emotional development. International and UK studies have shown that the foundations for virtually every aspect of human development—physical, intellectual and emotional—are laid in early childhood. The noble Lord, Lord Watson, referred to the importance of this. What happens to a child from the womb to the age of five has lifelong effects on many aspects of health and well-being from obesity, heart disease and mental health to educational achievement and economic status.

The noble Baroness, Lady Barker, referred to the importance of health visitors, and I am pleased to report that there are now 4,000 health visitors, which is nearly double the number there were in May 2010. This expansion supports effective, sustainable services that help families to give all children the best start and promote local communities’ health and well-being.

The evidence-based healthy child programme is the key universal public health service for improving the health and well-being of children. It aims to prevent problems in child health and development and to contribute to a reduction in health inequalities. The healthy child programme is the overarching service for the provision of interventions to strengthen parent-child relationships. Health visitors’ support can identify families who will benefit from extra help, including support for parents and children early in life. This can include referring families to specialist services, arranging access to support groups and practical support. I should mention here our extremely successful troubled families programme.

The noble Baroness asked about the introduction of personal budgets and the impact on midwives and on access to training for student midwives. The Department of Health and NHS England are considering all the recommendations of the maternity review and more detail on implementation will follow shortly. She also asked how the healthy child programme will be implemented and monitored post its transfer to local authorities and when we will get the initial results and figures, especially in relation to child poverty. The Department of Health has commissioned Public Health England to review mandation arrangements for the healthy child programme. Post transfer to local authorities, Public Health England is expected to report its findings later this year. The life chances strategy is expected to be published in July and will set out the Government’s plans for improving the life chances of all children. The strategy will introduce new indicators for measuring children’s life chances. The noble Baroness referred to childcare and I am delighted to report, as I have in the House, that 96% of three and four year-olds are accessing it and, of course, we have had a massive increase in childcare places over the past six years, an increase of nearly 250,000 places. I assure the noble Baroness that we will continue to push for more quality, available and flexible childcare.

The noble Earl, Lord Listowel, made a number of points in relation to this Government’s policies ranging from sugar tax to academies. I am extremely grateful

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for his support, and I share his great concern about absent fathers, a problem I see constantly in our schools. He also referred to obesity, and I was pleased that the Chancellor yesterday doubled the pupil sports premium for primary schools and created an extra fund for all schools to extend their day for activities, particularly sport.

There are also opportunities through schools for parents to learn more themselves and to work with their children. Good schools have been particularly good at involving parents in school life and bringing them in for assessment, and an effective use of IT can be helpful in this regard. The noble Earl referred to family learning, which is obviously integral to strengthening paternal relationships and widening horizons. I am delighted that following the spending review, the Government are protecting funding for the core adult skills participation budgets—in cash terms, £1.5 billion. This will support families that are socially disadvantaged and will build confidence and resilience.

I am grateful to the noble Earl for his comments on family and child homelessness, and I share his concern in this regard. The Government believe that the most important thing for a family who have become homeless is to resolve their housing crisis and get them into settled accommodation as soon as possible. To do this, the Government have invested more than half a billion pounds in the past five years, enabling local authorities to help nearly a million households in becoming homeless. I also remind the noble Earl that the number of children in temporary accommodation is just over 100,000, which I agree is far too many, but it remains well below the peak achieved in 2006, when it was more than 130,000.

The Autumn Statement announced real-terms protection for central funding for homelessness, demonstrating our commitment to this area. Further support was available in the Budget, which included £100 million to deliver low-cost, second-stage accommodation for rough sleepers, £10 million over two years to support and scale up innovative ways to prevent and reduce rough sleeping, doubling the funding for the rough sleeping social impact bond announced in the Autumn Statement from £5 million to £10 million, and other action to decrease the number of rough sleepers. I pay tribute to the right reverend Prelate the Bishop of Worcester. He referred to the work of the church in improving parenting skills and, of course, I pay tribute to the church’s work in the whole area of schools.

The noble Lord, Lord Watson, referred in detail to children’s centres. The Government are considering their policy in this area as part of the development of the cross-government life chances strategy and plan to publish details in the summer. At that point we will make clear how stakeholders and members of the public can contribute. We want a strong network of children’s centres, and we believe the debate should be about the effectiveness of those services. Quite a few centres have merged, and some have closed. The debate should be about the effectiveness of the services, not purely about counting buildings.

We have also substantially increased the money available for childcare. The 4Children’s survey of children’s centres suggested that more than a million families

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frequently accessed children’s centres in 2015. This estimate is unchanged since these statistics were first published in 2013. As the noble Lord, Lord Watson, said, the latest Early Years Foundation Stage profile data reveal that an increasing proportion of children are achieving a good level of achievement at the age of five, 66% in 2015 compared with 52% in 2013, which is a substantial and impressive increase. I thank all noble Lords for contributing to today’s very stimulating debate.

2.49 pm
Sitting suspended.

Royal National Orthopaedic Hospital: Redevelopment

Question for Short Debate

3 pm

Asked by Baroness Dean of Thornton-le-Fylde

To ask Her Majesty’s Government what plans they have for the redevelopment of the Royal National Orthopaedic Hospital, Stanmore; and in particular what the timings will be for that redevelopment.

Baroness Dean of Thornton-le-Fylde (Lab): My Lords:

“I am very grateful to have an opportunity of raising the question of the future of the Royal National Orthopaedic Hospital in Stanmore. I also appreciate the courtesy of the Minister in coming to the House to reply. I hope that he will respond positively to my remarks on the future of the hospital”.—[Official Report, Commons, 25/5/1984; col. 1413.]

I agree with those words, which are very relevant to today’s Question for Short Debate. However, they are not my words: I was quoting from the introductory remarks of Hugh Dykes—now the noble Lord, Lord Dykes, in this House—who was then the MP for Harrow East when he opened his debate on 25 May 1984, over 30 years ago. In his response, the Minister, the then Parliamentary Under-Secretary for Health, John Patten MP—again, now a Member of your Lordships’ House—referred to the noble Baroness, Lady Trumpington, then a Minister, answering a Question in the House of Lords on the same topic from Lord Diamond. I could have quoted from a debate in Westminster Hall sponsored by the current honourable Member for Harrow East, Bob Blackman, on 4 March last year, at column 347.

So the issue of the redevelopment of the Royal National Orthopaedic Hospital has been debated for 30 years. In that time there have been 13 independent reviews, all of which have concluded that the hospital should remain as an individual organisation, continuing to provide on the Stanmore site the excellent care that it has done for over 100 years of its existence.

The hospital has a national and international reputation for excellence and is the UK’s leading provider of specialist orthopaedic treatment and surgery. It is the nation’s largest provider of complex spinal surgery and it trains 25% of the nation’s orthopaedic surgeons. It is rated in the top 20% of hospitals in the national in-patient survey. Its 1,400 staff—70% of whom provide clinical services—look after some 15,000 in-patients

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and over 100,000 out-patient attendances every year. The care provided by the hospital is highly rated by the Care Quality Commission, which gave it outstanding for medical care, outstanding for clinical outcomes for patients, outstanding for innovative surgery to improve the quality of patients’ lives, and outstanding for the executive board, which it declared as,

“demonstrating leadership and vision for the hospital”.

It judged children and young people services as needing improvement, a factor being that the location of the wards for these patients meant that they had to be taken outside the buildings in order to access and return from theatre—one of the many reasons why a decision to proceed on the redevelopment is now, after over 30 years, not only pressing but urgent. A decision must be taken and acted on.

Indeed, the National Clinical Advisory Team review concluded that reprovision of services on the Royal National Orthopaedic Hospital site was urgent given the condition of the estate and the potential impact of quality of services of any further delay. That is not surprising as some of the buildings go back to the Second World War, built for the airmen defending our shores in that conflict. They are totally unsuited for today’s needs of a modern health service.

Another review concluded that some £50 million was required to be spent on the backlog of maintenance and repairs to bring it up to the required standards. That is more than the cost of delivery of the proposed development now being considered.

So how does it get done? It is not too surprising—those of us who have worked in the public sector will possibly have experience with projects—that the redevelopment of this hospital has gone through several iterations over 30 years. Hopes have been raised and then dashed for a variety of reasons. But now, with a strong executive leadership and vision commended by the Care Quality Commission, the hospital has the best chance yet to get the go-ahead. Some in the hospital and its partners say it is the last chance. One said to me, “Brenda, it is a bit like the Elvis song, ‘It’s Now or Never’”, and, frankly, that is how it is seen by many associated with the hospital.

The outline business case was approved by the NHS Trust Development Authority in March last year. It came, unsurprisingly, with conditions, all of which have been addressed. The full business case is scheduled to be officially approved by the hospital board on 30 March and then submitted to the TDA. The hospital is not asking the Government for enormous sums of money, just £40 million—yes, that is a lot of money in anyone’s terms but, when you put it in the big picture, it is not. Half of that £40 million would be repaid immediately as land is released to a private development partner. The balance of £20 million would be a loan to be repaid by the hospital over 20 years. This is not a PFI scheme; the hospital will not be tied into a project of crippling fees on a never-ending merry-go-round. The TDA has said that it needs eight weeks after receipt of the final business plan to approve the money. Against that promise, the hospital has planned on a contract signature to go ahead by the end of June with Balfour Beatty, which is lined up to start on the site in July this year.

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Mitigating the cost of the project will require some of the 112-acre site to be sold for redevelopment. Planning permission is in place and there is no local campaign against the project. It is all going in a positive direction, except for the decision. The hospital board submitted the necessary land sale part of the project to the NHS TDS Investment Committee in March this year, which was approved. The cost to build will be £42.5 million, which is why the initial £40 million investment is needed. The first build will be a ward block and completion of the first stage will allow for the sale of the land for redevelopment—decanting into the new building will release the land. This will bring in, according to the professional assessments, an estimated £20 million, which will be repaid immediately to the NHS.

The project is visionary and will secure not only world-class facilities for a hospital providing world- class treatments, but more than 300 new homes locally, including affordable housing, as well as staff accommodation for the hospital itself. The plans include a new private patient care centre, which will generate income from outside the NHS both nationally and internationally, as the hospital has international patients. Investment of £23.5 million, of which £16.5 million is from University College London, with the balance coming from the sale of the orthopaedic hospital land, will be used to build a new bioengineering hub, with UCL. This will increase the orthopaedic hospital’s role as a national research reference centre. In addition, the redevelopment will provide for the expansion of the current National Orthopaedic Alliance vanguard and getting it right first time programmes. All this will help to realise improved care and savings not just for this hospital but the wider NHS.

Before I close, I should cover the issue of the current financial position of the hospital. For the last six years it has been in surplus. This year, for the first time in quite a long period, as with the overwhelming majority of hospitals in the NHS, the hospital will be in deficit by circa £5 million—not the eye-watering amounts that we have seen elsewhere. That is for the year, not the month, as it is in some other parts of the NHS, particularly in London. It is most certainly not something that should cause a delay in approval to go ahead.

This hospital is not part of a big trust group; it is not, in that sense, a local hospital simply providing services for people in the area. It therefore has no active campaign group making a noise to make sure the development goes ahead. It is a national, and international, provider of excellent care. It deserves support in our UK national interest, with an ageing population needing the very services the hospital provides, because it is a centre of excellence leading the way in so many areas of speciality—and, yes, because it is so highly regarded internationally too.

I could put it no better than the statement of the Care Quality Commission itself, which said:

“The Royal National Orthopaedic Hospital is a recognised world leader in treating patients with complex orthopaedic conditions”.

My request today, and the purpose of this debate, is to ask the Minister and his department for their full and active support in getting approval for the final

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business case to go ahead. Furthermore, I ask the Minister for his department to commit and lend support to the eight-week timetable given by the TDA. I ask for support to be given in minimising the barriers to the April to June period, given the history of delay, and that a clear, yes or no, decision is given, not a maybe.

I thank all Members of the House who have given up their time today to take part in this debate; it is just one hour but it is very important. I look forward to their contributions as much as I do to the Minister’s.

3.11 pm

Lord Tebbit (Con): My Lords, I congratulate the noble Baroness, Lady Dean, on securing this brief debate on the future of the RNOH at Stanmore. I first came to know the hospital some 30 years ago when my wife was transferred there from Stoke Mandeville to continue her rehabilitation from the injuries she had suffered in the attempt by IRA/Sinn Fein to murder Prime Minister Thatcher. Indeed, until this year when the deterioration in her health has made the journey there from our home in East Anglia too arduous for her, my wife had continued to be a patient at Stanmore.

Through those years, we have also seen the development of the splendid charitable trust facilities to provide for both able-bodied and disabled people alongside the hospital, and they are an important part of the whole complex. Less happily, we have also seen the inability of successive Governments to get on with the long overdue replacement of the tatty, inefficient buildings which have hampered the skilled and loyal staff in their offering of the treatment needed by patients, not least the spinally injured ones, from around London and the Home Counties. We know that the extent of recovery from serious spinal injury is critically dependent on whether the patient can receive immediate care in a specialist unit. That is why Stanmore is so important to London and the Home Counties. I have lobbied many Ministers for many years over this rebuilding programme. At least it is now a great comfort that the most pernicious proposal—and I use that word as I usually use words, in its literal sense—of a PFI has been rejected. They are the most awful device which has ever been created in an attempt to dodge the rules of public sector accounting.

It seems, at last, that something like the charitable finance initiative, proposed by Mr Laurie Marsh and others, to finance the rebuilding of the hospital out of the profits from residential development of surplus land, is now to go ahead. I am, however, still concerned that—if I read the briefings right—the development of the surplus land is expected to yield only £20 million. That seems a pathetically small sum of money to come from the sale and development of residential land in the Stanmore area. It is extraordinarily small, and I hope that the Minister will look very closely at how that sum has been reached. Finally, I give heartfelt thanks for the great kindness and the care which my wife received at Stanmore, and I say to my noble friend Lord Prior, come on, for goodness’ sake get on with it.

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3.15 pm

Baroness Ludford (LD): My Lords, I, too, thank the noble Baroness, Lady Dean for this vital and timely debate. I am pleased to speak in the presence of the chairman and the chief executive. I am very glad to count myself among the friends of the RNOH. I have absolutely no experience or knowledge of the NHS, but I am speaking out of gratitude because my husband is a very appreciative patient at the Royal National Hospital, so I am in a similar position to the noble Lord, Lord Tebbit.

My husband has an NHS position, which I should mention: he is chair of Whittington Health, a trust in north London which consists of a hospital and community services. He was initially treated at the Whittington last autumn for a very serious, life-threatening infection and received the most marvellous and dedicated care from the medics there, whom he and I cannot thank enough. Thanks to them and his own fighting spirit, he pulled through, but his leg had to be amputated, so he passed into the care of the Royal National Hospital, Stanmore, initially as an in-patient for five days. To be frank, my only personal experience derives from being a visitor there for those few days.

I was, it is fair to say, aghast when I first saw the hospital. “It’s a bunch of Nissen huts”, I exclaimed, which is, of course, precisely what much of it is. I did not see the whole estate, but as it was built in the 1940s, I think that that was fair comment. We went in through a heavy, plastic door, which was all that kept the winter winds from the ward into which we entered directly. So my second thought on arrival was, “What on earth are the heating bills?”. My third thought was that, on a dark winter night, having to find the visitors’ loo outside, across the road and down some steps was less than congenial.

So my first point is that this is no way to treat a national, indeed, an international, centre of excellence. The staff are first class and deliver excellent care, as recognised by the “outstanding” rating given to the hospital by the Care Quality Commission in 2014 for its medical care, which includes the rehabilitation from which my husband is benefiting. However, the staff, the patients, their families and the community are being horribly let down by the appallingly bad, old and decrepit physical conditions. The CQC said the hospital’s premises were,

“not fit for purpose – it does not provide an adequate environment to care and treat patients”,

which is, no doubt, why the ratings for out-patients and children’s services were, “requires improvement”. I did not see the children’s wards but I am told that they are the worst of all.

What is it doing to staff morale and the ability to attract the brightest and the best that the powers that be are stalling over the green light for desperately needed redevelopment? With the best will in the world, the morale of patients and their families, at a time when they may be very vulnerable, whether after an amputation or for another reason, will not be increased by such grotty surroundings.

Secondly, I want to express deep frustration at the delay in getting the go-ahead from the NHS Trust Development Authority. This unelected quango—

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I use that term not to be abusive but as a statement of fact—seems to be the body on which everything now depends. It approved the outline business case a year ago, and I do not understand why it takes so much to get to the final sign-off and permission to borrow.

When the local MP, Bob Blackman, with whom I have been fortunate to have a word, initiated a short but very valuable debate a year ago, the Minister, Dr Daniel Poulter, rightly said of the RNOH:

“With the care it provides to its patients, it is one of the best centres in the world … a leader in the field of orthopaedics in the UK and worldwide”—

including through training and research, and—

“produces the very best possible care and results for patients … The RNOH is renowned worldwide for its clinical excellence”,

He said:

“I am aware that most of the buildings at Stanmore date from the 1940s, and many are no longer appropriate or fit for purpose for the high-quality care and excellent clinical outcomes that the RNOH provides for its patients”.

He agreed:

“The RNOH’s proposed redevelopment of the Stanmore site is key to ensuring that it can continue to improve the care it provides”.

I was a little worried by his comment that the RNOH,

“manages to maintain high standards of outcomes despite the condition of the estate ”.—[

Official Report

, Commons, 4/3/15; cols. 350-51WH.]

That is only through the heroic efforts of its staff, which no doubt cannot be taken indefinitely for granted. If they are being heroic about rising above their surroundings, I would prefer their heroic efforts to go into patient care.

Dr Poulter acknowledged the frustration at the delays, saying that due diligence was necessary to ensure financial viability. That is understandable, but the TDA has been on the case for three years, asking for more and more information. As we have heard, the deliberations have gone on for 30 years. Planning permission was received three years ago, which was, of course, the result of a transparent and democratic process by the London Borough of Harrow.

Given the high degree of centralisation of the NHS, I am bemused by the gap between expressed ministerial support and the lack of speedy output from the TDA. Surely the Government cannot be saying that they have no levers to encourage the TDA to get on with it. The medical case for a modern, state-of-the-art hospital seems unanswerable, and it seems that the financial case is equally sound and straightforward. It was given by the noble Baroness. The debate that Bob Blackman MP held was followed five days later by TDA approval of the outline business case. Let us hope that we, through this debate, thanks to the noble Baroness, Lady Dean, might have a similar catalytic effect on its final decision. I look forward to hearing from the Minister that this will indeed be the case.

3.21 pm

Lord Lansley (Con): My Lords, I am pleased to have the opportunity to contribute to the debate and to join colleagues in congratulating the noble Baroness, Lady Dean, on securing the debate and on the way she

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introduced it. She absolutely captured a sense of what the RNOH is and has been, and what it means for the patients whom it has looked after.

In that respect, I share with my noble friend Lord Tebbit a sense of gratitude for how the RNOH has looked after Margaret Tebbit. Indeed, it was at exactly the same time 30 years ago that I first got to know Stanmore because I was the Civil Service Private Secretary to my noble friend, who was then Secretary of State. When I was not carrying his box to and fro at Stanmore, I was learning about the hospital. About 25 years later, it was somewhat ironic that my noble friend was lobbying me as Secretary of State to secure the rebuilding of Stanmore. I believe he was right when he said that it would have been wholly wrong to have pursued the PFI route to secure the rebuilding of Stanmore. It was my responsibility in 2011 to say that that was not the way I thought Stanmore should go. I am pleased that that is not the way that the RNOH chose to go.

I will quickly say three things. First, I believe in specialist institutes in the NHS. That was not always the case. I remember that probably 25 or so years ago, Stanmore was being pushed to merge with Northwick Park. Subsequently, there were other proposals for the hospital to be absorbed into a large trust. All the evidence tells us that this is the wrong way to go. Amazingly, specialist institutes in the orthopaedic field, not just the RNOH but the Robert Jones and Agnes Hunt Orthopaedic Hospital in Gobowen near Oswestry, obtain excellent results. That is true for clinical outcomes and for innovation and research. When we introduced the friends and family test, I was especially struck by what fantastic numbers the specialist institutes, such as Stanmore and Gobowen, got on recommendations through the friends and family test from staff and patients. That is incontrovertible. That being the case, we have to find ways to support them where they are.

Secondly, the partnerships that they create are tremendously important. Papworth Hospital in my former constituency is going alongside Addenbrooke’s. It will remain a specialist institute but it needs to be alongside for clinical partnerships and research partnerships. Given its location, Stanmore does not need to move anywhere else for these partnerships to function. Indeed, as the noble Baroness said in introducing the debate, it has drawn UCL into an excellent bioengineering centre based at Stanmore. That is evidence of the partnerships that are integral to specialist institutes’ future success, not least because they need to be part of the academic health science networks to make that success work. Creating those partnerships is tremendously important and can secure its position.

Thirdly, and finally, however, we need to understand where the difficulties lie. RNOH is an extremely well-run hospital and has been for a very long time. The calibre of staffing and clinical leadership is excellent. For example, when we looked at MRSA bloodstream infections, notwithstanding the circumstances in which RNOH works, I do not think it has had such an infection for about seven years. That is a wonderful record. When you look at clinical leadership, Tim Briggs, a clinician at Stanmore, has been integral to the work that the noble Lord, Lord Carter, and his team are doing on delivering improvement and efficiency by demonstrating how it was done at the RNOH.

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However, since the NHS is the overwhelming customer for this work, it is very hard if the tariff does not support it. We must recognise that the heart of the issue lies in the prudential work done by the TDA—and before it by the strategic health authorities and others—to ensure that the project and the hospital are financially sustainable for the long run. Frankly, it is not just about asking, ‘Is this a good project?’ or, as my noble friend asked, ‘Do the numbers all stack up?’. I am sure that it can be afforded in the sense of borrowing being available, but what also needs to be affordable in the long run is the revenue to support it. That is where NHS England and Monitor, working together, need to bring in tariffs—not least through the latest iteration of ICD tariff structures when they get to them—that recognise the additional costs involved in the complex and specialised work done by hospitals such as the RNOH. Many big hospitals used to be able to carry such specialist work in the midst of very large amounts of routine work, but a specialist institute cannot do that. Indeed, many large hospitals cannot afford to do it now either. We need the NHS and Monitor together to design a tariff that recognises not only the quality but the cost involved in continuing to deliver this world-leading work.

3.27 pm

Lord Dykes (Non-Afl): My Lords, it is a great pleasure and honour to follow the former Secretary of State, whose analysis I agree with entirely. It is good to focus on these issues again. The analysis given by the noble Baroness, Lady Dean, who we thank for initiating the debate, was exactly spot on about the problems facing a hospital that I thought would be redeveloped and modernised years ago. I remember the speeches I made on this—one from 1984 was referred to, but there were many others after that. I had the great honour of being a member of the board of governors in the old days of the teaching hospital. Subsequently, I was chairman of the save the hospital action committee when there was a threat of closure in the 1980s. I had the pleasure of being president of the league of friends for many years.

When I first went to the hospital in 1972, I immediately fell in love with the place. Its history is magical, given what it achieved in the war, what it did for brave airmen and other servicemen and women who were injured—incredibly hideously sometimes—and its work of repair. Subsequently, in inadequate buildings, the amazing achievements of this hospital have been really stunning. I am so glad that the noble Lord, Lord Tebbit, was able to make his tribute to its work as well as to offer his analysis about the facts and figures. I remember exchanging correspondence with him when Margaret Tebbit went there for the first time. I was so glad about the treatment she received after that horrific incident. The noble Lord has been a good champion of the hospital ever since.

It really is now time. The analysis has gone on for so long. When I was defeated in the 1997 election, I never believed that it would take so long for this to get going. There is no reason for any further delay. The amounts of money are minuscule and modest. I also rather share the apprehension of the noble Lord, Lord Tebbit, about the amount of money to be realised by

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property sales. In that area, where property values are stupendous, if it is a free market syndrome—presumably it will be in the final analysis when the transaction is completed—then it should be done on a much higher basis. Maybe that can be looked at again, although I am not in any way criticising the present management team because it has dealt with this for a long time and knows all the ins and outs.

However, there is now no excuse or reason for any further significant delay. This is a magical specialist hospital with a wonderful history. It has a future that will be even greater. We are also getting to grips with new technology and new invention possibilities, particularly in spinal injury cases. An exciting scenario is opening up with the recent developments that have been announced in many parts of the world, including, of course, in the United States. That, too, is an opportunity for this hospital to shine again as it has done over so many years.

There is a lot of local loyalty. It is interesting that the noble Baroness, Lady Dean, said that there is no campaign against redevelopment, which there often would be if suddenly there was going to be an urban sprawl created around a hospital. Not a bit of it: there is a lot of local geographical loyalty and a history of support in the London Borough of Harrow as well. This hospital needs to remain separate but specialist, with modern buildings and new facilities, to build on patient care, especially that of physically injured children, which is a very important area.

I conclude by thanking the noble Baroness, Lady Dean, for this debate and repeat the sagacious advice of the noble Lord, Lord Tebbit, to the Minister to get on with it please.

3.30 pm

Lord Finkelstein (Con): My Lords, occasionally it happens in the House of Lords that after five people have spoken everyone else starts to repeat the arguments that have already been made. I am the sixth to speak and will do so briefly.

I start with the words of the Secretary of State for Health:

“I visited the hospital two years ago and it was clear to me then that the facilities on the site did not match with the world renowned status of RNOH. I am thrilled to announce the rebuild of the Stanmore site today. ... The urgent need for this rebuild has been apparent for many years now”.

Quite right too, except that the Secretary of State in question was Andy Burnham and the statement that he made was in 2010. The Health Minister said:

“I fully accept that the buildings at the hospital are not ideal at present. That is why the trust has made its proposals and the London regional office is currently considering them. … It would be very unfortunate if no progress was made on refurbishment over a number of years. We should look at this issue with some sympathy”.—[Official Report, 28/2/01; col. 1293-94.]

Quite right too, except that the Health Minister was the noble Lord, Lord Hunt of Kings Heath, and the year was 2001.

The Health Minister said:

“A detailed appraisal of the options for capital development at Stanmore should be undertaken”.—[Official Report, Commons, 18/3/1988; col. 1402.]

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Quite right too, except that the Health Minister was Edwina Currie and the year was 1988. In considering the future of Stanmore, the Health Minister said that,

“my hon. Friend will be familiar with some of those problems, including the very poor condition of some of the buildings”.—[

Official Report

, Commons, 25/5/1984; col. 1418.]

We have already heard that, and quite right too, except that the Health Minister in question was John Patten—as he was then—and the year was 1984. Another Health Minister said:

“My Lords, I am aware of the faintly unsatisfactory state of the Stanmore premises”.—[Official Report, 3/5/1984; col. 632.]

Quite right too, except that the Minister was my noble friend Baroness Trumpington and the year again was 1984.

The arguments have been made today and in the past, and for many years, for rebuilding Stanmore RNOH and they do not need my elaboration. They have been made for more than 30 years and they are so obvious that they make themselves. We now need action.

I have risen really just for one purpose, which is to add my name to those people demanding action and to add my sense of urgency to that of the others around the table. To have a world-class facility that requires action, to agree upon action and then not act is shameful. There is no point in saying that we are the builders if we do not build.

3.33 pm

Lord Hunt of Kings Heath (Lab): My Lords, mea culpa. The noble Lord certainly got me bang to rights. As noble Lords have heard, many noble Lords and Ministers have commented on the position of the RNOH. I start by paying tribute to it for its outstanding work. I certainly paid a ministerial visit. I do not know about the noble Lord, Lord Lansley, but I remember digging a hole in the ground there. Alas, I think that the hole is still there. I have no doubt he too has been to see the site to look at where the development would take place.

Clearly, a powerful case for this wonderful hospital’s development has been made by my noble friend. It is significant that the NHS TDA gave business-case approval a year ago. Therefore, it is absolutely right to press the Minister to say what on earth has happened and why the NHS TDA apparently, if not reversing its decision, does not seem to be able to take it any further forward.

I pay one other tribute to the RNOH and that is to the partnerships that are developing. We have already heard about UCL, but my noble friend Lady Dean is also aware of the work that is being done with the Royal Free. That is very encouraging in relation to the comments made by the noble Lord, Lord Lansley, about the importance of specialist hospitals working with other hospitals.

I shall put four or five points to the Minister. First, it is always risky to ask a Minister for a straight answer, but it seems to me that the time has come when a straight answer needs to be given. If it is no, no should be said, and the hospital can make other dispositions. It surely cannot be left in abeyance for another one, two or three years because it must be

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impossible for the people running this institution to know whether to invest any money in the current infrastructure, whether they should wait, what they should do about the staff and how they retain staff. An honest answer is required at the very least.

Secondly, is the state of the current public capital programme within the Department of Health having an impact? I know of the Department of Health’s financial difficulties towards the end of this financial year, and the five-year forward look at money for the NHS involves a transfer of capital to revenue. What has happened to the public capital programme? Is that the real reason that the NHS TDA cannot give approval?

The noble Lord, Lord Tebbit, and I probably disagree about PFI because, although some of the contracts were clearly badly negotiated, we have very fine buildings and hospitals as a result of it. However, if there is no public capital—and public capital is much less than was expected—and we do not use PFI, how are we going to see investment in health infrastructure over the next five to 10 years? It is a very serious question which the noble Lord, Lord Prior, is, no doubt, looking at very carefully.

I want to come back to the point made by the noble Lord, Lord Lansley. We have already heard of the number of reviews that have taken place. All have come to the conclusion that this hospital should be redeveloped on its current site, yet he will be aware that within the NHS managerial culture there is opposition to single-site specialty hospitals. I wonder whether at heart the issue is that, although Ministers and reviews have said this hospital should be redeveloped, the truth is that the managerial cadre at NHSE and in London do not think it should take place. That was always my suspicion. When I answered that debate in 2001, the distinct impression I had was that actually the powers that be, below ministerial level, simply did not want this to happen because they do not believe in specialist hospitals. The noble Lord mentioned Oswestry. He could have mentioned the Royal Orthopaedic Hospital in Birmingham as well, which is another stand-alone hospital. I have always got the impression that senior executives in NHS England now and before in the department think these hospitals should not be stand-alone and should move into DGHs. It is legitimate to ask whether this is the real reason. Given that NHS TDA officials almost all come from NHS managerial backgrounds, I ask whether this is the real reason, alongside the squeeze on capital.

The noble Lord, Lord Lansley, asked about the tariff. It is my impression that NHS England is not favourably disposed towards specialist services in general and that the squeeze on specialty tariffs is because of that. I remind him of the order that he forced through this House taking away the right of providers to object to tariff proposals. They can no longer use the arbitration system because they need commissioners to object as well, and frankly the chance of a commissioner objecting to any tariff proposals by NHS England is a little remote.

Finally, will the Minister arrange for the NHS TDA to meet parliamentarians to discuss this urgently? The NHS TDA has new leadership: its chief executive and its chair. Mr Ed Smith will bring a great deal of fresh

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thinking to the work of the NHS TDA, and I would appreciate an opportunity for noble Lords to talk with him further rather than either the decision being delayed for many more months or years or it simply not going ahead.

3.39 pm

The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con): I thank the noble Baroness, Lady Dean, for bringing forward this debate. I did not know anything about the history of Stanmore until today and the briefing I had beforehand. It has been an extremely good debate. I echo the words of my noble friend Lord Finkelstein that we have reached the stage where everything has been said but not everyone has said it. I fall into that category. Let me put on record that I agree with everything the noble Baroness said in her speech rather than repeating it, as I would otherwise have done.

I wish to address a number of points and themes. First, this is not a PFI. We need not today go into the pros and cons of PFIs, save to say that my sympathies are with my noble friend Lord Tebbit: many of them have been incredibly expensive. When he used the word “pernicious” I think he meant that not only were they expensive but they have hidden liabilities that should appear on the public sector balance sheet. He may like to know that the future costs of the PFI schemes for health alone total £79 billion. This includes some of the soft FM contracts but it is a huge liability that ought to be on the face of the public balance sheet but is not. I say that on PFI, but this is not a PFI scheme.

Secondly, my noble friend Lord Tebbit and others made reference to the land sales that are part of this scheme. We use our property resource in the NHS fantastically badly. I am not saying whether or not the £20 million assumption here is a low level of money but sometimes in the NHS, because we are in a hurry, we sell things off quickly, whereas if we had more time and could explore matters through a joint venture or a more creative arrangement we might be able to bring in a lot more money. That is something I would ask the management to look at, but not as a way of deferring this scheme. I am pleased that Rob Hurd and Professor Goldstone, respectively the chief executive and chairman of the RNOH, are here today listening to this. We do not deal properly with our massive property resource. In gross terms we have £40 billion to £50 billion-worth of property assets within the NHS, which we do not use very well. If we walk around London we can see some of our hospitals in prime residential areas. These are worth a huge amount of money which we could use to redevelop our real estate within the NHS.

Thirdly, Stanmore is not only a beacon of excellence but the work that Professor Tim Briggs is doing to spread his Getting It Right First Time scheme across the NHS is hugely important. If we are going to get long-term sustainable improvement for the NHS we must have clinical engagement. The work that he is doing through his exposure of variation in orthopaedic practice is hugely important. If we can spread the learning that he has gained in orthopaedics into other

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surgical and medical specialties, it will make a huge contribution to the massive saving programme that we need to achieve over the next five years. Related to that, the fact that the RNOH is leading the National Orthopaedic Alliance vanguard around the country with a view to franchising the excellence in the RNOH into DGHs and other hospitals around the country must be a good thing.

My noble friend Lord Lansley raised the issue about specialist institutions. I agree the evidence is that, from a patient and clinical outcome point of view, specialist institutions are extremely successful. However, there are two caveats to that. One is that they can become insular; and the second is that they can be high cost. Often they are relatively small institutions and, because the tariff does not favour complex specialist work, they can be a disadvantage to the tariff.

The RNOH has addressed that insularity issue in two ways. First, through the tie-up with UCL on the biomedical engineering facility; and, secondly, through developing its work with the Royal Free, which is very important. That may enable it to take some costs out of its existing institutions.

The tariff, which my noble friend also raised, is something that we should address with NHS England and with NHS Improvement to be sure that it does not favour just those more commodity or routine orthopaedic operations at the expense of the more specialised, complex operations. I think—and my noble friend will know more about this than I do—that, originally, the tariff was structured to encourage the private sector to come into the more routine, so to speak, orthopaedic business. It has disadvantaged the more specialist institutions, which is something that we need to address. If I were coming here to say, “No, we’re not going to do this”, I would have to deal with not just my noble friend Lord Tebbit but an even burlier character in Professor Tim Briggs. He is a fairly typical orthopaedic surgeon and saying no to orthopaedic surgeons is never a happy experience.

I am, as I say, leaving aside the speech I would have made because it would simply repeat what has already been said. The TDA received the trust’s revised outline business case in January last year. Following its review of the business case, the TDA required assurances on two strands of work to be completed. The first was the development of an interdependent estates strategy and land disposal business case for the Stanmore site. The second was the further development of the NHS England vanguard partnership with the Royal Free London NHS Foundation Trust as part of securing the long-term sustainability of the trust. In relation to the vanguard partnership, the trust plans to present a formal report to the TDA on progress ahead of the full business case submission. Negotiations with the Royal Free have gone well, with an MoU between the two organisations signed, which aims to identify the clinical synergies of the two organisations and how their working more closely together could strengthen the clinical model. Those discussions have gone extremely well.

An outline business case for the land sale has been submitted by the trust and approved by the TDA investment committee and will go to the full TDA board.

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That should not hold up this project. If there is a way of increasing the receipts from the land sale, then clearly the management will be trying to do so. A full business case containing Balfour Beatty’s final proposals for the redevelopment of the hospital is expected to go to the trust’s board on 30 March. In April, the trust is expected to submit a full business case to NHS Improvement for review. In June and July the full business case is expected to go to NHS Improvement’s investment committee and, following that, to the NHS Improvement board. Approval will allow the trust both to clear the site available for sale and to fund the part of the new facility not covered by the land sale receipt. Construction will be completed in December 2017, with the new facility opening to patients in February 2018.

To conclude, this is very much a priority project for the Department of Health and NHS Improvement. The Government fully support the redevelopment of the RNOH and are grateful to the contribution it has made to the Getting It Right First Time project, led by Professor Briggs. I am happy to arrange a meeting, as the noble Lord, Lord Hunt, requested, with NHS Improvement on this issue. If it is all proceeding according to plan, that meeting might not be necessary but, if there is a glitch, I am happy to come back for another debate, but we fully support this and can see no reason why it will not be given the go-ahead according to the timetable that I suggested. Before I sit down, is there anything that noble Lords would like to raise that I have not covered?

Baroness Dean of Thornton-le-Fylde: We are not often asked to intervene in a Minister’s contribution so I thank the Minister very much indeed and welcome his contribution. If the hospital reaches any glitches, will his door be open for a meeting with the CEO and chairman of the hospital?

Lord Prior of Brampton: Yes, any time. I should have said that I have not had a chance to visit Stanmore but I would certainly like to do that. We are fully behind this case. I will go to the hospital anyway, but I hope that this will go ahead on this timescale.

Baroness Dean of Thornton-le-Fylde: They hope to break the land—first spade in—on 7 July. How wonderful it would be if the Minister did it.

Lord Prior of Brampton: Perhaps at the same time we could fill in the hole dug by my predecessor.

The Deputy Chairman of Committees (Lord Brougham and Vaux): As an ex-patient of the hospital, I can say that the Committee stands adjourned until 4 pm.

3.49 pm

Sitting suspended.

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Occupied Palestinian Territories: Development

Question for Short Debate

4 pm

Asked by Lord Hylton

To ask Her Majesty’s Government to what extent they will implement the recommendations of the House of Commons International Development Committee in their report of July 2014, The UK’s Development Work in the Occupied Palestinian Territories.

Lord Hylton (CB): My Lords, I thank all the contributors to this debate. It may seem odd to discuss a Select Committee report of the other place one and a half years later. One reason is that a major war came between the report’s publication and the printing of the Government’s response. Also, the tunnels providing a lifeline to Gaza have been cut off. Another reason is that for many years British NGOs have worked very constructively in occupied Palestine. The report had 16 positive recommendations. I therefore ask to what extent violence in 2014 and since, with the collapse of the peace process, have made implementation difficult or impossible.

The UN organisations’ forecast that Gaza may become “uninhabitable” by 2020—just four years away—shows how things are getting worse. As for the West Bank, this was split into three by the Oslo accords of 1995. The Palestinian Authority is responsible only for Area A. It shares responsibility with Israel in Area B, while Israel totally controls Area C. I have personally seen a big sign saying, “Welcome to Israel” as one approaches the Dead Sea from Jerusalem. The temporary division into zones has become permanent. The Palestinian economy and revenue would be dramatically improved by good access to Area C.

The Department for International Development helps occupied Palestine in three main ways. First, it pays the salaries of many of the employees of the Palestinian Authority. This is understandable in view of the periodic withholding of Palestinian taxes by Israel. However, I would ask whether some of those employees in Gaza are now being paid to do nothing because of a failure to agree between the Palestinian Authority and Hamas. Secondly, DfID supports UNRWA in education, health and welfare for Palestinian refugees and their descendants. This reflects the absence since 1948 of a full peace agreement. DfID seems to expect UNRWA to make efficiency savings but how can this be done when the school population rises steadily and unemployment is sky high in both Gaza and the West Bank? Thirdly, DfID funds the health system, which has a chronic shortage of medical supplies. It tries to stimulate the Palestinian economy and assist selected NGOs. Will the Minister give us an update on these important sectors? Can he say something about land registration and title deeds?

I will mention some broad themes, trusting that later speakers will develop them. Water is a matter of life and death. Will Gaza have water safe to drink in four years’ time? A desalinator is urgently needed.

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In the West Bank, Israeli settlers use far more water per head than Palestinians. They also pay less per litre. In Area C, Palestinians are often refused permission for new wells.

Movement and access are critical. Some progress was being made by 2005. However, Gaza has never had the airport, seaport and secure link to the West Bank that it was supposed to have. It is blockaded and cut off from the outside world. Only minimum supplies are let in to sustain life without starvation. Access is equally important in the fragmented Areas A, B and C.

In illegally annexed east Jerusalem and the long-occupied West Bank, Israeli settlements are an obstacle to peace, as is the position on the ground of the separation wall. This is made worse by demolishing Palestinian houses, buildings and solar panels, et cetera, even some built with EU funds. The number of checkpoints is also unhelpful.

Israel has justified much intransigence because of threats from Iran, but do these amount to more than a paper tiger? The Hamas charter is often quoted, though this was written long ago and was never approved by the people. Homemade, unguided rockets have been seen as existential threats, so Hamas has been demonised. Little attention, however, has been given to Islamic Jihad, the Popular Front for the Liberation of Palestine and al-Qaeda or Daesh splinter groups, over which Hamas has only partial control.

I come now to our Government’s attitude to consistent illegality and disregard of international law. Successive Governments have treated Israel as a western ally, only making mild protests which are usually disregarded. There are seldom or never political, military or economic consequences following our protests. The nearest we have got is over the labelling of products from illegal settlers. Can the noble Lord tell us the latest news on labelling? Can British consumers always know where goods labelled as Israeli or Palestinian actually come from? Has the well-being of the Palestinian people, whether in east Jerusalem, Gaza or the West Bank, improved or slipped back since 2014? Have our considerable investments of money and thought been effective or have they barely staved off disaster?

I suggest that things are, in fact, getting worse. This explains the great frustration of the Palestinians who have recently expressed their anger by personal attacks on individual Israelis. Unless all sides quickly de-escalate and produce measures to build confidence, individual attacks may turn into collective ones. The demand for sanctions, boycott and disinvestment will grow throughout the rest of the world. What will HMG do to secure as great political priority for Israel and Palestine as they want to see for Syria and Iraq? Both are necessary if extremism, Islamism and terror are to be contained let alone ended. Israel, Palestine and the West all have equal interests in a just and sustainable peace.

4.08 pm

Lord Cope of Berkeley (Con): My Lords, I congratulate and thank the noble Lord, Lord Hylton, for this debate and on the way he has moved it. The Commons Select Committee report is interesting, but also now depressing. Although the report is only 20 months or so old, the situation it describes has got considerably

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worse. Its recommendations are even more valid, as the noble Lord has said. I have been visiting Palestine for family reasons for well over 40 years. Throughout that time, short periods of optimism have always been dashed as the situation has got progressively worse for the Palestinians, with more of their land illegally built over by Israel and more of the restrictions that shocked this Select Committee. Grinding poverty, artificially imposed by occupation, hinders peace. It can also suppress cultural development.

For example, I believe that music opens hearts and builds bridges. For that reason I am a trustee of the UK Friends of the Palestine Music Conservatory. To bring a positive note to this debate, I am delighted to tell noble Lords that the Palestine Youth Orchestra will be touring the UK in July and August, playing in Glasgow, Leeds, Birmingham, Cardiff and London. The tour will, of course, be a very special experience for the young people involved, whose lives are normally so appallingly restricted, but more than that, I hope it will also open British hearts and minds to their cultural achievements. Occupation crushes hope and without hope the future is, indeed, bleak for the holy land.

4.10 pm

Lord Judd (Lab): My Lords, I give real appreciation, once more, to the noble Lord, Lord Hylton. I declare an interest: in my past I was a Minister of State in the Foreign Office, responsible for the Middle East, among other functions; and I was, for some years, director of Oxfam, which has a long history of involvement in Gaza, Israel itself and the West Bank.

Some 61% of the West Bank is under full Israeli military control, as any of us who have been there can underline, with all the restraints that this brings—on agriculture, free movement of people and economic activity in general. On a human level, if Palestinians build essential structures, such as shelters, toilets or schools, without permits from the Israeli military, these are at risk of demolition. More than 98% of Palestinian applications were rejected between 2010 and 2014 and less than 1% of Area C has been planned for Palestinian development by the Israeli authorities.

The rate of demolitions in the West Bank has spiralled since the beginning of 2016, with 316 homes demolished in the first two months of the year, compared with 447 for all of 2015. It is essential that we in Britain, and our Government, directly challenge Israel’s inadequate and discriminatory permit and planning regime by initiating development projects that we believe are necessary in Area C, whether or not master plans have been submitted in these localities. While, of course, informing the Israeli authorities of our humanitarian strategies, we must move ahead without necessarily seeking prior approval from those authorities. DfID simply must move faster and more effectively to bring more humanitarian aid to vulnerable Area C, especially in the E1 area and the Jordan valley.

On Gaza, I will just say this in the time available: DfID’s approach should focus on building resilience and challenging the separation policy between Gaza and the West Bank. Support for longer-term development

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and investment in Gaza is essential. Very many Palestinians in Gaza, however, will struggle to move from aid dependency until the political and structural causes of their situation are addressed and their full range of rights is achieved.

Lord Gardiner of Kimble (Con): My Lords, may I interrupt? When 2 comes up on the clock, that is time. I am anxious to give as much of a reply as is possible within the time allocated to me.

4.15 pm

Baroness Ludford (LD): My Lords, I congratulate the noble Lord, Lord Hylton, on this debate. Of course we all hope for a peace agreement and a two-state solution, with Israel and Palestine living side-by-side in security, but sadly that is not happening yet. The government response said:

“Economic progress can never be a substitute for a political settlement, but it is vital that Palestinians see tangible improvements in their daily lives”,

and that,

“increased prosperity in the OPTs is firmly in Israel’s long-term interests”.

I agree with that. Will the Government tell us what more they are doing to fund people-to-people projects, which the report urged? We need more constructive dialogue, yet in DfID’s 2013 budget only £73,000—0.1% of the £70 million budget—was spent on coexistence. Will more such projects be funded in future?

I am pleased to congratulate the Palestinian teacher Hanan Al Hroub on winning the Global Teacher Prize for the work she is doing to combat violence. However, I was sad to see in the report that Palestinians in the audience pumped their fists in the air and chanted, “With our souls, our blood, we sacrifice for you, Palestine”, which rather spoiled the event.

I welcome DfID’s launch of the Palestinian market development programme, but a report by the Coalition for Accountability and Integrity has highlighted the amount of corruption in the Palestinian territories. This coalition is funded by several European Governments and the EU. Will the Government also fund this excellent organisation?

Are the Government taking steps to pressure the Palestinian Authority into ending awards to prisoners’ families, which give a perverse incentive to violence? The amount awarded increases with the period of imprisonment, which seems unrelated to poverty or the welfare of the family. We need to persuade it to change that system.

4.17 pm

Baroness Morris of Bolton (Con): My Lords, I, too, congratulate the noble Lord, Lord Hylton, and I declare my interests as set out in the register. The report clearly appreciates Israel’s security concerns but at the same time notes that the measures taken in the name of security actually make it worse. It is therefore sobering that this report was published just as the Israeli military’s Operation Protective Edge was beginning in Gaza.

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In the light of what we now know to be the impact of this military operation, irrespective of whether you feel it was justified, the claim in the committee’s conclusions that Israeli security measures can cause “very real suffering” is all the more true. Following the 2014 attacks, the UK Government generously reacted to the acute needs of the newly injured and disabled by providing access to limb reconstruction services in Gaza through a charity of which I am president—Medical Aid for Palestinians—in partnership with IDEALS. Teams of UK surgeons travelled to Gaza to undertake surgery on victims of the bombing and to train local surgeons in new techniques in this area. I am delighted to report that this work has now helped establish the first dedicated limb reconstruction unit in Gaza.

The UK has also been supporting projects in Area C of the West Bank. This vital work is helping sustain communities that face daily threats of eviction, demolitions and intimidation. In just the first few months of this year, more EU and internationally funded structures in Area C have been demolished than in the whole of 2015.

UK development work in the Occupied Palestinian Territories is a vital lifeline for Palestinians and for efforts towards peace. It is essential that the UK combines support for construction and service provision in the OPT with advocacy in our bilateral relations with our ally Israel to ensure that everyone is reminded that the UK supports the Palestinians’ right to statehood, just as we support Israel, and that if we are to achieve the peace that we all long for it is essential that the rights and livelihoods of Palestinians are protected.

4.19 pm

The Lord Bishop of Worcester: My Lords, I, too, am grateful to the noble Lord, Lord Hylton, for securing this debate. As someone who wants to see the flourishing of both Israel and Palestine, I welcome this report, although I am saddened by the situation that has developed since its publication. In their response to the report, the Government affirm their support of a two-state solution. If that is to remain a possibility, we surely need to do all we can to persuade Israel to end the demolition of Palestinian homes and the confiscation of Palestinian land throughout the West Bank, including east Jerusalem.

The noble Lord, Lord Judd, has drawn attention to the spiralling numbers of such demolitions. Abu Nwar is one of 46 Bedouin and herding communities that are targeted by the Government of Israel’s plan to relocate 7,000 Palestinians living in Area C, including in the contentious E1 area around Jerusalem, in order to allow for the expansion of Israeli settlements in the central West Bank. Diplomatic representatives visited Abu Nwar on several occasions, reaffirming that demolitions and settlement expansion in the E1 area were a clear red line for the European Union as they would effectively cut the West Bank in half, separate east Jerusalem from the rest of the West Bank and render the objective of a viable two-state solution unachievable.

If a two-state solution is to be viable, there is also a pressing need for a genuinely transformative peace process that is underpinned by international law, holds

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all to account and, crucially, is supported by mechanisms that allow both parties to understand the narratives of the other, not least the territorial expressions of identity that both express and promote.

Finally, as has been suggested, development work in the Occupied Territories cannot be separated from what is happening in Gaza and there needs to be an increased effort to help bring an urgent end to the blockade of Gaza and the collective punishment of the Gazan population.

4.21 pm

Lord Popat (Con): My Lords, I thank the noble Lord, Lord Hylton, for initiating this important and timely debate. Securing a sustainable future for the Occupied Palestinian Territories is essential to establishing peace in the Middle East. The International Development Select Committee’s report on the UK’s development work in the region outlines how we are helping that process. I welcome the committee’s report and the Government’s response. However, while I support the reasons for funding development of the Occupied Palestinian Territories, I have concerns regarding how the funding is used. Unsuitable use hampers the economic and political security of the region, making development a counterproductive objective in this case.

It is common knowledge that the Palestinian Authority’s Ministry for Prisoners’ Affairs provides salaries to all families of Palestinian prisoners held in Israeli jails. The Palestinian Government have been accused on a number of occasions of using UK aid to fund these salaries. The Palestinian Government have failed to provide evidence to the contrary and I am very uneasy with the idea that British aid could be used towards encouraging violent crimes. What steps have the Government taken to ensure that British funding is not used in this manner? We need to see this funding as an opportunity. Both the committee’s report and the Government’s response support a two-state solution in the region, leading to a safe and secure Israel living alongside a sustainable and sovereign Palestinian state.

Overall, I welcome the report in providing a foundation for peace. However, we must remember that:

“Economic progress can never be a substitute for a political settlement”,

and we must ensure that the recommendations put forward are carefully monitored to ensure that they are indeed used for economic purposes and not hijacked for ulterior motives.

4.23 pm

Baroness Ramsay of Cartvale (Lab): My Lords, one of the many important recommendations from the committee is to encourage the development of entrepreneurship and other economic activity in the Palestinian Territories. Of course, this was precisely the mandate given to the former Prime Minister, Tony Blair, in 2007 when he became the unpaid envoy of the quartet. It is a little-acknowledged fact that he had considerable success in such development, at least in the West Bank—of course, Gaza presented special difficulties because of Hamas. The West Bank benefited

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from an excellent growth rate from 2008 to 2011 and projected growth for 2016 is 3.9%.

In my recent visits to Ramallah—the last just three weeks ago—I witnessed the boom in construction and housebuilding. I have also frequently visited Rawabi, the exciting and both inspirational and aspirational new town on the West Bank now awaiting its first inhabitants. DfID’s funding of the Palestinian market development programme is an encouraging first step in this right direction. Can the Minister give any information about developments on this?

However, I have seen for myself the very disturbing contents of some of the Palestinian children’s TV programmes and reading material, which incite violence and hatred against Israel and Jews—and I mean Jews, not Israelis—and this is a really horrible sight. I agree completely with the committee’s recommendation that DfID should check on the misuse of its funds. With great respect to the Minister, the Government’s response to that recommendation is far too complacent.

4.25 pm

Lord Polak (Con): My Lords, I thank the noble Lord, Lord Hylton, for initiating this debate and refer noble Lords to my non-financial interests. As the noble Baroness, Lady Ludford, and my noble friend Lord Popat have said, the Palestinian Authority spends around 6% of its overall budget on paying salaries to Palestinian terrorists in Israeli prisons and to the families of suicide bombers. Will the Minister comment on whether the UK taxpayer is getting value for money?

The report also recommended the urgent address of the Gaza health sector, which it deemed in a situation of grave crisis. I have no doubt that nothing has changed and I wholeheartedly agree with the recommendations to reinstate the health sector as a key priority for DfID’s Palestinian programme. As we all know, trying to sort out and improve any health sector is difficult, but I will share with noble Lords a practical initiative which could be supported and that makes a difference to individuals and families. Save a Child’s Heart is an international, non-political NGO founded in 1996 for the sole purpose of improving the quality of paediatric cardiac care for children from areas in the world where there are few or no facilities and, thus, little or no chance of the child surviving. This NGO brings children to Israel for urgent heart treatment and surgery and, in addition, brings over the physicians and nurses from other countries and provides them with in-depth training so they can go back and continue this vital work. This all takes place at the Wolfson Medical Center in Holon, which I have visited on five or six occasions, often with Members of the other place.

Over 50% of the 4,000 children who received this life-saving treatment are from Gaza and the West Bank. On a Tuesday morning, there is a clinic for children from Gaza. I have been there and chatted to the worried parents whose children are ill and receive the chance of life from Save a Child’s Heart in Israel. Does the Minister agree that the clearly positive interaction between Gazan parents and children with the volunteer doctors and nurses in Israel is not only commendable but a worthy exercise in itself? Will he

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agree to meet me and explore ways that DfID could support and enhance this work which would help fulfil recommendations 33 and 34?

4.28 pm

Lord Turnberg (Lab): My Lords, if we in Britain want to play a useful role in aiding the Palestinians, it is unhelpful to be laying the blame for their difficulties on one or other side. Just as we have heard the onus being placed on Israel for all the Palestinians’ problems, so one could point to the many Palestinian failures to take opportunities offered over the years, most recently when Mr Abbas turned down Joe Biden’s proposals for bilateral negotiations a week or so ago. However, I am not convinced that pointing the finger does any good.

The saddest thing I heard when I visited Ramallah in the West Bank a couple of weeks ago was from Khalil Shikaki, who has been conducting opinion polls among the Palestinian public for many years. He collaborates closely with his Israeli counterparts and he found that support for a two-state solution, in both publics, was at its lowest ebb for many years. More depressing was that the reason it was so low was because the Palestinians thought that the Israelis did not want a two-state solution and the Israelis thought that the Palestinians did not want it either. They themselves would go for it if only the other side wanted it, too. It was a complete misunderstanding of the opposition’s view.

If we want to make a difference for the Palestinians, should we not try to shift opinion among the public towards peace? Should we not be encouraging a re-education towards an understanding of what the man in the street on the other side really thinks and wants? Can we shift the emphasis in the publicity campaigns being run, I fear, by the Palestinian leadership, away from extolling the virtues of terrorism and towards a greater understanding of the infinitely more valuable virtues of peace?

This is what at least some of our aid should be used for and there are innumerable examples of close collaboration at the grass-roots level that we should be fostering. I know of many good, below-the-radar examples in the medical and commercial fields. These are where we need to focus our support, instead of it being diverted to fanning the flames by the leadership as I fear too much of it is now. I look forward to the Minister’s reply.

4.30 pm

Lord Sheikh (Con): My Lords, I am glad that the Government have agreed to support the recommendations of the International Development Committee. Achieving lasting peace between Israel and Palestine must remain a significant priority for the international community.

In October last year in the other place, MPs voted by 274 to 12 on a Motion to recognise the state of Palestine alongside the state of Israel. We must all work to the establishment of a two-stage solution, with a viable sovereign independent state of Palestine living peacefully alongside a secure Israel. I ask the Minister: what is our current attitude in regard to recognition of the state of Palestine?

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I care about humanitarian issues and have been involved in facilitating four convoys of humanitarian aid being sent to Gaza following the Israeli invasion in 2009. I subsequently visited Gaza and saw for myself the devastation that has been done and tragically continues to this date. I have also visited Israel and the West Bank. I am very concerned about what is going on there with regard to stabbings and other killings which are being carried out by both sides. The cycle of violence appears to be unending.

There are commonalities between Islam and Judaism and it is therefore important that there is a dialogue between the two sides. I met with the acting ambassador of Israel last week and welcomed the positive statement he made about the passage of humanitarian aid to Gaza. We would, however, like to see a peaceful settlement and a lifting of the blockade. The UK and others must continue to support peace talks, keep hopes of the two-state solution alive and provide funding to support the Palestinian people and the development of a Palestinian state.

4.32 pm

Baroness Tonge (Ind LD): My Lords, I thank the noble Lord, Lord Hylton, for securing this debate but ask the Minister when we are going to have a debate on this problem which is not so time limited. I declare an interest as chairman of the board of the Welfare Association UK, which disperses aid programmes in the West Bank, Lebanon and Gaza.

I agree with all the recommendations and comments in the report but will concentrate on only one of them. Recommendations 27 and 30 express concern about the lack of adequate audit of the money we give which, among many other things, is used to pay 85,000 civil servants’ salaries and compensates prisoners’ families. I agree with many of the comments that have been made but I particularly refer to a recent report by the Israeli economist Shir Hever, How Much International Aid to Palestinians Ends Up in the Israeli Economy. He calculates that 78% of total aid to the Palestinians ends up in Israel via transport charges, taxes and the monopoly that Israel has to supply any materials or produce needed. For example, how much does the cement to repair the buildings destroyed by Israel cost us? A bit rich that. The World Bank, too, estimated that in 2013 the Palestinians lost $3.4 billion to Israel.

Can the Minister explain this and make sure that our aid goes directly to the Palestinians and not into the Israeli coffers? Would it not be more efficient and transparent if the bulk of our aid was disbursed via UNRWA, which has much experience and has made huge efficiencies recently? Despite this, it still has an $80 million deficit this year. Please help it. I have no time left now except to say that I have long been concerned that we help fund the illegal occupation by Israel of Palestinian land, which surely must make us accomplices in breaking international law.

4.34 pm

Baroness Rawlings (Con): My Lords, I thank the noble Lord, Lord Hylton, for giving us the opportunity to debate this report. The noble Lord, Lord Turnberg, spelled out clearly the importance of striving to find a constructive peace agreement rather than rewarding terrorists. I agree—be that anywhere in the world.

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The first recommendation of the 2014 report calls for the resumption of peace talks and hails US Secretary of State John Kerry’s,

“leadership in bringing the parties to the table”.

Can the Minister tell the Committee why the Palestinian leadership rejected this peace proposal last week? We all understand that it will be difficult for any deal to satisfy the sensitive nature of the demands of both sides but to reject out of hand another good faith deal offers little incentive to potential international investors.

Recommendation 27 of the report questions whether DfID is,

“taking adequate measures to prevent its funds from being misused”.

There is talk of building planned communities in Palestine as a viable option for developing the economy. The Israeli Government indicated support for the building of more planned Palestinian cities such as Rawabi, mentioned by the noble Baroness, Lady Ramsay, and projects such as the Ersal Commercial Center in Ramallah and the Al Jinan neighbourhood in the north of the West Bank. These are tangible initiatives which provide new business premises, jobs and homes for Palestinians facing youth unemployment that is hovering at 40%. My noble friend Lord Cope mentioned music. He is absolutely right, and I commend the West-Eastern Divan Orchestra. Surely it is through substantive projects such as these that the UK and the international community should be supportive. Has the Minister considered supporting planned communities as an option? Finally, can he confirm that the Palestinian Authority is giving its full backing to planned cities being built for Palestinians?

4.36 pm

Lord Gold (Con): The International Development Select Committee has proposed a number of positive recommendations concerning the UK’s development work in the Occupied Palestinian Territories, not least the resumption of peace talks between the Israelis and Palestinians. I am pleased that the committee recognised that Hamas’s charter continues to call for the destruction of Israel and condemned the continuous rocket attacks perpetrated from Gaza.

I, too, recommend and welcome the resumption of peace talks but for such an initiative to be successful some trust must be built up between the parties. As I have said before, in my view the starting point has to be a recognition by Hamas that Israel has the right to exist. If, as the noble Lord, Lord Hylton, said, the majority of Palestinians do not accept the charter, let them come forward and say that. No two-state solution can get off the ground without that.

Secondly, there has to be a stop to the continuing rocket attacks on Israel, which terrorise the civilian population. Unfortunately, since the publication of the committee’s report, the safety position in Israel has worsened, with a new threat of knife attacks, mostly on civilians going about their daily lives. Since September 2015 there have been at least 323 stabbings, shootings and car-ramming attacks. Fortunately, not all have resulted in fatalities but that does not reduce the seriousness of these terrible crimes. No wonder the Israelis fear that peace talks will get nowhere. The stabbings have to stop as well. If the terrorist activity

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ended, including the building of a new network of tunnels in Gaza, I believe that Israel would be more receptive to easing the travel restrictions and the movement of goods.

I recognise that the peace process has to be a two-way affair. In my view, if both sides genuinely want to achieve peace, Israel for its part must also move its position. The best way of doing that is that, simultaneously with the ending of terrorist acts, Israel should stop the building and expansion of settlements.

4.39 pm

Lord Robathan (Con): My Lords, I have visited the Middle East—Gaza once; Israel and the West Bank on many occasions—and I have seen for myself what the situation is. The most recent time I visited was last month with various other noble Lords and I understand that we were paid for by the Israeli Ministry of Foreign Affairs. I consider myself a friend of Israel, but a critical friend. In that, I should say that my wife has been stoned by settlers outside Hebron and I have been subjected to appallingly aggressive and intimidating action by border guards. I believe Israel can be both disproportionate in its military reaction and also vindictive and punitive to Palestinians. If they treated me badly as a visiting Member of Parliament, I can only imagine how border guards might treat Palestinians.

But it takes two to tango. Having visited the Palestinian Authority only a month ago, I was shocked by the governance—or lack of it—that we saw and heard about. We all know how corrupt the Palestinian Authority has been; the report shows some of that. I am afraid that Hamas is beyond the pale in its actions. We have to consider that the Palestinian Authority, Fatah and Hamas must get together as well. We cannot, as many people do, blame Israel alone. Both sides must sit down. We may assist— the Americans above all must assist—but it is foolish for some people in this country to bring out anti-Semitic comments, about which we heard. Indeed, I really regret the way that the Palestinian Authority sponsors and applauds anti-Israeli and anti-Semitic actions on the media.

4.40 pm

Lord Collins of Highbury (Lab): My Lords, I, too, thank the noble Lord, Lord Hylton, for initiating the debate. The Opposition remain firmly committed to a two-state solution that recognises the importance of security and stability of any final settlement. As the Government recognise, it is essential that the UK continues to support the talks, to keep the hopes of peace and the two-state solution alive, and to provide funding to support the Palestinians, especially in building the foundations of a sustainable economy.