Vol. 735 Wednesday No. 264 8 February 2012

PARLIAMENTARY DEBATES (HANSARD) HOUSE OF LORDS OFFICIAL REPORT

ORDER OF BUSINESS

Questions Dogs: Microchipping Gaza EU: Structural and Cohesion Funds Cyclists: Accidents Health and Social Care Bill Report (1st Day) Gaza Question for Short Debate Health and Social Care Bill Report (1st Day) (Continued) Written Statements Written Answers For column numbers see back page

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Lord Taylor of Holbeach: I assure the noble Lord House of Lords that we take this very seriously. It is an increasing problem. As the noble Lord said, there seven attacks a Wednesday, 8 February 2012. month on guide dogs. Sometimes, of course, the dogs carrying out these attacks are out of control; they are 3pm not even on a lead. The whole purpose of the policy will be to try to encourage responsible dog ownership. Prayers—read by the Lord Bishop of Chichester. I am very pleased with the contribution the noble Lord has made to the issue by asking his question today. Dogs: Microchipping Baroness Parminter: My Lords, the number of stray Question dogs in this country has risen to 126,000 and has been steadily increasing for the past four years. Does my 3.05 pm noble friend agree that compulsory microchipping Asked by Lord Hoyle would help local authorities with the spiralling costs of kennelling, and help them reduce the number of To ask Her Majesty’s Government whether they healthy dogs they have to put down each year, which will introduce the compulsory microchipping of was 6,000 in 2011? dogs. Lord Taylor of Holbeach: Yes, my Lords, I drew the The Parliamentary Under-Secretary of State, House’s attention to the enormous economic cost of Department for Environment, Food and Rural Affairs stray dogs; £57.5 million is spent by charities and local (Lord Taylor of Holbeach): My Lords, we are close to authorities in caring for and finding new homes for finalising a package of measures to tackle irresponsible stray dogs. That is part of the thrust behind our dog owners, and intend to make an announcement proposals, which, as I say, we will be announcing soon. In putting the package together, we have considered shortly. and set out the pros and cons of various approaches The Countess of Mar: My Lords— towards compulsorily microchipping dogs. The final package will cover future government handling of the Lord Renton of Mount Harry: My Lords— issue, as well as plans to improve standards of dog ownership. Baroness Anelay of St Johns: My Lords, I think that the mood of the House is that the noble Countess, Lord Hoyle: I thank the Minister for that reply. It is Lady Mar, has been waiting. Perhaps my noble friend very helpful in itself. Taking the old adage that there Lord Renton might speak after her. are no bad dogs, just bad owners, microchipping would The Countess of Mar: My Lords, does the noble certainly make for more responsible dog ownership. It Lord agree that if all puppies were microchipped would also make it easier for dogs that have strayed to before they were eight weeks old, it would ensure that be found by their owners. It would cut down on the they could be traced to their breeders, which would number of stolen dogs. As a Government who are prevent much of the iniquitous practice of puppy seeking popularity, it would be highly popular, as farming? 83 per cent of the public who have been surveyed support this. Lord Taylor of Holbeach: This is certainly a proposal that we are looking at, and I thank the noble Countess Lord Taylor of Holbeach: I am very grateful to the for her contribution. noble Lord for his support for what may indeed be included in the package. It might help the House to Lord Renton of Mount Harry: My Lords, perhaps I know that the cost of rehoming each stray is £1,100. may suggest to my noble friend that the Government The economic cost to this country of irresponsible consider very carefully before insisting on the compulsory dog ownership is enormous, let alone the human microchipping of dogs. Many dogs take badly to damage that can be caused by out-of-control dogs. having a chip in them; they get very sore and so forth. Surely anyone who cannot control a dog should not Lord Low of Dalston: My Lords, is the Minister have one; that should be the course. aware that attacks on guide dogs are now running at Lord Taylor of Holbeach: I am not sure that the over seven a month? The person who first drew this to respondees to the consultation share my noble friend’s my attention said, “What on earth are they doing view on the matter, and I am not sure that the Government putting a tax on guide dogs? Whatever next?”. But share it, either. We see microchipping as one measure actually it is a very serious problem. It can mean a we can take to address an increasing problem. The vulnerable person being left alone, in need of assistance, cost of stray dogs is something that we have discussed. and without a dog for a considerable period of time. The human cost of dog attacks is another matter that The dog may need to be treated, retrained or even the House should bear in mind in considering these withdrawn from service altogether. As each guide dog measures. costs £50,000 over its lifetime, this has huge financial implications. Will the Government consider making Lord Grantchester: My Lords, the House has heard attacks by dogs on assistance dogs a punishable offence many times before from the noble Lord that these in the same way as attacks on human beings? matters will be dealt with soon. May I press him again 253 Dogs: Microchipping[LORDS] Gaza 254

[LORD GRANTCHESTER] Baroness Northover: I have been replying to the on when “soon” may be? I was told that microchipping noble Lord on the issue of water so I am extremely had already started and that six databases were up and well aware of the situation. We are very concerned running. The information on the databases will be about the situation in Gaza and it is a tragedy that useful only if it is up to date and accurate. What plans people are living in such circumstances. Thirty-eight do the Government have to ensure that this will happen? per cent of Gazans live in poverty, 66 per cent depend on food aid, and, indeed, 90 per cent of mains water is Lord Taylor of Holbeach: Some 58 per cent of dogs unfit to drink. We are pressing the Israeli authorities are already microchipped on a voluntary basis. The all the time to try to address these problems. noble Lord asks about timing. When I say “very shortly”, I do mean “very shortly”, but the timing is Lord Avebury: My Lords, last week representations not within my gift. I have clearly flagged up the about this were made even by the UN Secretary-General, possibility of an expansion of microchipping in the which demonstrates once again the futility of all efforts responses that I have given today, and we are working by the international community to alleviate, let alone with everybody to make sure that this will happen. to resolve, the humanitarian crisis in Gaza. Can my Baroness Byford: My Lords, will the new compulsory noble friend tell the House what replies we have received system apply to dogs coming to this country? If not, to our repeated representations to the Israeli Government? what will the Government do about that? In particular, will the Israelis facilitate the onward delivery of $1.5 million-worth of medical supplies Lord Taylor of Holbeach: Yes, my Lords, the pet which were landed in the port of Ashdod by a Turkish travel scheme requires that all dogs coming to this aid agency last Saturday? country are microchipped. Baroness Northover: My Lords, the important thing Baroness Fookes: My Lords, as a former chairman is to seek a political resolution. It is only following of the RSPCA, perhaps I may point out that it has that that some of these problems will properly be been the wish of that society and many others that addressed. My noble friend is right to highlight some there should be compulsory registration for dogs, as of the problems that are occurring at the moment. We this is the only way to deal with manifold problems. have to emphasise yet again that it is in Israel’s future May I remind the noble Lord—although he will probably interest to make sure that these problems are properly not know—that in the House of Commons I tried addressed and that it will never be secure while this twice to get this introduced, well over 20 years ago? situation continues. Lord Taylor of Holbeach: This House always provides noble Lords with the opportunity to fulfil their ambitions, Lord Turnberg: My Lords, is the Minister aware and it may be that my noble friend will achieve just that. that medical supplies for Gaza are shipped by Israel to the Ministry of Health in the West Bank, which then Gaza has to deliver them to Gaza? There is considerable Question mistrust and poor communication between the two ministries of health, and that is one of the main causes 3.13 pm of the delay in the transfer of medical supplies. Is she Asked By Lord Warner aware of that? To ask Her Majesty’s Government what contact Baroness Northover: I am aware of that. The noble they have had with the Government of Israel regarding Lord is right that the division between Gaza and the the effect of Israel’s blockade of Gaza on children’s West Bank, both geographically and politically, is health. indeed playing a part here. We urge all sides to co-operate Baroness Northover: My Lords, the UK Government together to ensure that medicines get across and do get are very concerned about the impact of movement into Gaza. and access restrictions on the health of children in Gaza. We regularly press the Israeli authorities on the Baroness Deech: Is the Minister aware that around need to ease restrictions and to address the humanitarian 300 Questions have been tabled during this Session on situation. My right honourable friend the Secretary of Israel, Gaza and the associated areas, with, sadly, little State for International Development raised these issues effect? We have had only around 20 Questions on Iran, during his recent visit. 30 on Syria and only one relating to the Arab spring. Is the Minister confident that this House is seeing the Lord Warner: My Lords, I am grateful to the Minister widespread crises throughout the Middle East in for her reply. Is she aware that only 5 per cent of the perspective and that British representations on Gaza water coming out of Gazan children’s taps is drinkable are set in the context of the whole area? I find it very and the rest is not? Gastroenteritis is endemic among odd—maybe other Members do as well—that we have children in Gaza, about 70 per cent of whom are not had a debate on the Arab spring. anaemic. Is she also aware that doctors working in the main hospital claim that about 500 people have died as Baroness Northover: The noble Baroness is right to a result of the shortage of basic medication, many of flag up problems in other areas across the region. All whom are children? Can we not approach the Israeli these issues need to be addressed, and of course what Government with a greater sense of urgency to secure happens between the Israelis and the Palestinians also a change in the situation of these children who are plays out in those other areas. It is extremely important being collectively punished? that we seize these issues right across the region. 255 Gaza[8 FEBRUARY 2012] EU: Structural and Cohesion Funds 256

Lord Eden of Winton: My Lords, in her reply my 2020. The United Kingdom will achieve substantial noble friend referred to representations that the British savings from the EU budget only by not contributing Government have been making to the Government of to the structural fund budgets of all wealthier member Israel on this issue. That frequently is the form of states, but that would require unanimous agreement reply which is given on many other issues relating to by all 27. No other countries want to go down this Gaza and Israel. Does Israel give assurances in response road and we cannot unilaterally opt out of our treaty to those representations, and do Her Majesty’s obligation to contribute to the EU budget. Government ever follow up any undertaking given by the Government of Israel? When are we going to have Lord Vinson: I thank the Minister for her reply and any positive action to redress this wrongdoing? hope that we might eventually see some of her words turned into deeds. Meanwhile, does it really make Baroness Northover: The noble Lord is right: there sense to continue with this farcical monetary subsidy is a lot of communication all the time. There have been merry-go-round? Surely we as a great country are some shifts—some of the restrictions on crossings perfectly capable of running our own regional policy have been lifted to some extent—but it is nowhere near without the help of others. Would it not make sense to what is required. Therefore, constant pressure is needed. repatriate these powers, albeit unilaterally, and thereby However, I come back to one of my original points. It save billions of pounds which could be directed in a is necessary for both sides to see that it is in their much more positive and worthwhile fashion into exercises long-term interest to find a political solution. It is only that would create the many millions of jobs that this when we get people on to that path that we will start to country so badly needs today? crack some of the other problems. Baroness Wilcox: In the current EU budget period, Lord Davies of Stamford: My Lords, is there not a the United Kingdom has already spent almost half its ready solution available to hand? All that needs to allocation. If we stopped drawing down the remainder, happen in order for the remaining restrictions to be we would forfeit approximately £1.6 billion and have lifted is for the Hamas regime in Gaza to accept and to break live contracts with costly consequences. We adopt the quartet conditions; to accept existing would then not receive back 100 per cent of the agreements, including the Oslo accords; to recognise unclaimed funds—only two-thirds—due to the rebate the state of Israel, and to abjure violence. Do the process, which, of course, is a preferential deal for the Government think that any of those suggestions are United Kingdom that was politically hard-fought-for unreasonable; and if not, even though we do not have and must be protected by us. Any rebated funds to any relations with the Hamas regime directly, will they the United Kingdom would not necessarily be find a way of communicating that thought to it? available for economic development, so this important area of activity would suffer as a sharp drop in funding Baroness Northover: The noble Lord’s premise of a occurred. simple route rather defies the current situation. We welcome the reconciliation between the Palestinians, Hamas and Fatah, which we are monitoring very Lord Wigley: My Lords, would the Minister give an closely, and we welcome the moves towards elections. assurance that if this money was repatriated, those However, as the noble Lord and others will know, you areas within the United Kingdom now benefiting from have to take a balanced approach and recognise that European structural funds—such as a large part of one side will feel that you are not being fair if you Wales because of the low level of income per head—would demand X of them, and the other side likewise. That is continue to receive the benefit needed to stimulate why it is extremely important to try to bring the their economies? parties together and to seek a political solution which is in everybody’s best interests. Baroness Wilcox: In saying “if this money was repatriated”, I presume that the noble Lord follows on from the previous question asking us to repatriate it EU: Structural and Cohesion Funds now. The answer is: no, we won’t. Is that not what the Question noble Lord asked? I am sorry.

3.22 pm Lord Wigley: With the leave House, that was not Asked by Lord Vinson what I asked. If it is repatriated, can assurances be To ask Her Majesty’s Government whether they given? If they are not given, it is in the interest of these propose to seek the devolution to the United Kingdom areas to continue to get those funds from Europe. of regional spending under the European Union structural and cohesion funds so that the £9 billion Baroness Wilcox: I apologise for not understanding the United Kingdom currently receives from its the question at first. The answer is yes. £30 billion budget contribution to those funds can be self-administered and effectively targeted. Baroness Royall of Blaisdon: My Lords, at the special summit last month, a large sum of money—I do not The Parliamentary Under-Secretary of State, recall how much—was made available for tackling Department for Business, Innovation and Skills (Baroness youth unemployment in the European Union. Will the Wilcox): My Lords, the Government will seek significant UK apply for some of that money, or will it be spent cuts to the EU structural fund’s budget from 2014, only in the 25 states that have signed up to the new aiming at reducing it to zero in richer countries after treaty? 257 EU: Structural and Cohesion Funds[LORDS] Cyclists: Accidents 258

Baroness Wilcox: Interestingly, I do not have the Baroness Gardner of Parkes: Is the Minister aware answer to that question with me. I do so wish I did. I that more women cyclists are killed or suffer very would be delighted to respond to the noble Baroness serious injuries on these junctions than men? The by letter. reason, it is believed, is because the women wait at the red lights and the men go through them. Large vehicles Lord Pearson of Rannoch: My Lords, more worryingly, turning left have a degree of difficulty in seeing people. did we not send £10.2 billion in net cash to the For that reason, I would like his comments on the European Union for it to waste last year? That should so-called “Trixie” mirror—not named after me, and be compared to the mere £6.2 billion of our own nothing to do with me, I might add—which is proposed public expenditure cuts. Why do we need any of the for large lorries. Will he also suggest that the Government 75,000 fat Eurocrats in Brussels, who have little to do look into the possibility of the system just being but strangle our economy with their endless regulations introduced in Paris whereby at dangerous junctions and waste our money which could be better spent at they will have specific lights for cyclists? home? Surely the answer from the Minister to the noble Lord, Lord Vinson, should be that if we want to Earl Attlee: My Lords, the noble Baroness asked do what he so sensibly suggests, the only way is to me about the male/female ratio. We are aware of the leave the European Union. hypothesis. The figures for accidents are mercifully low but, unfortunately, increasing. It is difficult to Baroness Wilcox: The noble Lord has his own extract measurable data to formulate policy or make agenda which he is free to pursue. Fortunately, Her effective regulations. The noble Baroness also talked Majesty’s Government do not at the moment agree about “Trixie” mirrors; these mirrors are placed on with him. traffic signal posts and help HGV drivers to see cyclists on their near side in the blind spot at signalised Lord Swinfen: My Lords, how much is lost in junctions. The department provided approval to TfL administrative charges as our funds pass through Europe to extend the use of these mirrors across the cycle on their way back to this country? superhighway network, and it will consider further requests for “Trixie” mirrors by other authorities. Baroness Wilcox: I do not happen to have the Unfortunately, I was not aware of the situation in figures to hand on how much it costs us. I will happily Paris. write to the noble Lord. Lord Berkeley: My Lords, is the noble Earl aware Lord Harrison: Is it not in the British interest that that in the present mayor’s time in office accidents we support the help to poorer countries of the European have actually increased? It is thought that he has Union so that they can participate in the single market increased the free-flowing of cars and lorries through actively and bring their standards of living up so that the junctions, and reduced the time for pedestrians eventually British firms and services can be provided and cyclists to go across. He has also reduced the within the European Union for our benefit? amount of space on the road for cycle lanes, and things like that—in spite of bringing in the new “Boris bikes”, which of course we all welcome. Could that be Baroness Wilcox: I completely agree with the noble looked at? Do the Government think that the idea of a Lord. The aim of the structural and cohesion funds as £200 million fund from the Campaign for Better Transport set out in the EU treaty was to reduce disparities in London to help cycling facilities would help to between regions to create a more cohesive single European reduce deaths? market. Structural funds have helped to underpin enlargement of the European Union, opening up new markets in central and eastern Europe to British Earl Attlee: My Lords, it is true that, in 2011, 12 out companies. We have done very well by that. of the 16 cyclist fatalities in London involved a goods vehicle, with seven involving construction vehicles, but it is too early to see whether there are any undesirable Cyclists: Accidents trends. Both Transport for London and my department Question will study these matters very carefully indeed.

3.28 pm Lord Mackenzie of Framwellgate: Will the Asked By Baroness Gardner of Parkes Minister indicate what proportion of these accidents are caused by people jumping the red lights, as the To ask Her Majesty’s Government what plans noble Baroness, Lady Gardner, suggested, and what they have to reduce the number of serious bicycle the Government are doing to encourage the police to accidents in London. enforce the provision?

Earl Attlee: My Lords, I am sure that all noble Earl Attlee: My Lords, the last point is the important Lords will agree with me that every road accident is a one. It is an operational matter for the police how tragedy. With regard to the roads in London, under they enforce the law. Clearly, the mayor and other devolution it is for the mayor and Transport for London authorities will look closely at the police’s performance to decide their cycling priorities and allocate their in driving down road traffic casualties generally, but in budget accordingly. We will of course continue to particular those of cyclists, because they are vulnerable work closely with them to improve safety. road users. 259 Cyclists: Accidents[8 FEBRUARY 2012] Health and Social Care Bill 260

Lord Bradshaw: My Lords, the “Trixie” mirrors to Health and Social Care Bill which the noble Baroness, Lady Gardner of Parkes, Report (1st Day) referred, have to be fitted on traffic signals and have to receive the assent of the Department of Transport 3.36 pm under present regulations. Most authorities that wanted Relevant documents: 18th and 22nd Reports from to use them would have to submit a form to the the Constitution Committee. department for the Secretary of State or his representative to sign. Would the Minister look at that bureaucracy? He mentioned that the Government were re-examining Motion the regulations with a view to improving them by Moved by Earl Howe 2014, but I do not think that comes under the definition of “soon” that we heard on an earlier Question. That the Report be now received. Lord Owen: My Lords, before the House agrees Earl Attlee: My Lords, the noble Lord makes an that the Report should be received, I would like to important point about the need for the department to raise some important constitutional questions. On approve traffic signs. It is important that the traffic 4 April, the day the Prime Minister and the Deputy signs are consistent right across the United Kingdom Prime Minister embarked on their “listen and explain” to avoid a plethora of different designs of traffic experience and the legislation was paused, I wrote to signal, which would be very confusing to motorists. the then Cabinet Secretary, Sir Gus O’Donnell—now of course the noble Lord, Lord O’Donnell—and raised with him the fear that, because of the long drawn-out Lord Young of Norwood Green: My Lords, does the legislative process, discussion of the Bill in this House Minister agree that, without trying to lay blame on could be pre-empted. I also told him that I had consulted cyclists or lorry drivers, we want to promote safer the clerks in Parliament and it appeared that there was cycling and a greater awareness among lorry drivers? I no written convention that guides the Government on venture to suggest that the problem is not just in what is or is not acceptable to take in advance of Royal London, although I cycle practically every day so I am Assent. Obviously they cannot implement the legislation aware of it. For the Minister’s benefit, I can say that in full. the Paris experiment is about allowing cyclists to go Many of my concerns since then have been more through red lights where the situation is safe, so that than justified. I received a letter on 7 April from the will be interesting. Finally, could he give us any information then Cabinet Secretary that said: on the number of accidents where wearing a cycle “The Treasury guidance on ‘Managing Public Money’ sets out helmet would have improved the chances of a fatality how, in some circumstances and if … conditions are fulfilled, not occurring? departments can incur expenditure on the measures contained in a bill prior to Royal Assent. In addition, a department may take steps to prepare for implementation using existing statutory powers. Earl Attlee: My Lords, the Government encourage I have therefore discussed your concerns with Una O’Brien, as the use of cycle helmets but we think it undesirable, as Accounting Officer, in the light of this guidance. She has confirmed”— did the previous Administration, to make them this is important— compulsory because this could have the unintended “that the work currently underway is taking place under the effect of reducing cycling despite its undoubted health broad powers of the Secretary of State and NHS bodies under benefits. On the question of turning left, my noble existing legislation. For example, the arrangement of PCTs into friend Lord Spicer has an Oral Question about left management clusters and the creation of pathfinder consortia are turns coming up shortly. As part of my research on possible under existing powers in the National Health Service Act 2006. In addition, some of the changes currently taking place that, I have just had a working lunch with the chief would be required regardless of the Health and Social Care Bill. examiner of the Institute of Advanced Motorists. For example redundancies in PCTs reflect the longstanding challenge, which pre-dates the Bill, to deliver up to £20bn of efficiencies across the NHS over the next four years for reinvestment in Lord Cormack: My Lords, would the roads of London frontline services”. not be less congested and safer for cyclists, and indeed As a result of that, there has been broad acceptance in for us all, if there were restrictions on the hours in this House that on these controversial questions, some which delivery vehicles could operate? of which are already agreed, the Government are proceeding under existing legislation. Earl Attlee: My Lords, the noble Lord has asked a On 16 September I was informed by the chairman slightly wider question. There is a freight operator of the Constitution Committee that that committee recognition scheme—FORS, a membership scheme—that had briefly discussed the pre-legislative disappearance aims to improve freight delivery in London. It is free, of PCTs, and had in front of it my correspondence voluntary and open to any company operating vans or with the Cabinet Secretary, which I had made available lorries in the capital. It has been developed by TfL and to Professor Tomkins, one of its advisers. I was asked is a reward and recognition scheme with the aim of whether I would provide more information about changes improving safety and operational efficiency. that had been introduced following Second Reading of the Health and Social Care Bill but prior to it coming to the House of Lords. I enclosed an up-to-date Lord Roberts of Llandudno: My Lords— document in great detail that had been sent out for consultation by the Midlands and East Strategic Health Lord Brooke of Alverthorpe: My Lords— Authority, which I thought gave a pretty clear indication 261 Health and Social Care Bill[LORDS] Health and Social Care Bill 262

[LORD OWEN] While thanking the noble Lord for raising this of the anticipated massive changes to the whole concern, which I shall of course consider very carefully, architecture of the NHS, many of which seem as if as I always do, I hope the House will feel that it is they will be introduced despite the fact that the full unconstrained in how it presents amendments to the legislative process was continuing. Government and how it argues for them. We, in our I also drew attention to a speech that had been turn, will respond in a constructive manner, as I hope made in the other place by a Member of Parliament always to do. that had again raised the question of whether it was 3.45 pm proper to stop the legislation when so much was already being done and so much pre-emption had Baroness Thornton: My Lords, I think the noble occurred. Today I have written to the Constitution Earl has answered the question as far as it goes, but he Committee on this question because an MP drew my raises several points. First, this Bill did not need to be attention to a letter that says that people, in front of us at all because many of the changes that “are absolutely terrified of the chaos that will apply if the Bill is are taking place do not need primary legislation. Secondly, dropped altogether now. Restructuring is a nightmare, un-restructuring his colleagues in another place have constantly said could be even worse!”. that the Bill cannot be dropped because it has gone On today’s “World at One”, the chief executive of the too far. We are not in the same place now as we were at Foundation Trust Network warned of a no-man’s land the end of Committee; millions of people in the health if the Bill did not go through. service have now expressed their view that this Bill should not happen at all. Given that, do the Government This raises pretty big questions for legislation that have a plan B in case they need to withdraw the Bill? is still to go through all its stages in this House, and it Do they have people working on that in case the Bill is a matter of great concern to this House when it has to be dropped? considers reform. These conventions will become very much more important if we have an elected House of Lord Warner: My Lords, before the Minister responds Commons—which of course we have—and an elected to that question, will he consider later—if he cannot House of Lords, which I personally would like to see. answer now—the budgets for clinical commissioning There is no question that these conventions are important. groups? I understand from a meeting of the national There are two important points here. First, the Commissioning Board, which was held in open session House should be aware of the fact that the Constitution on 2 February, that Sir David Nicholson is reported as Committee is seized of the problem and may well wish having said that clinical commissioning governance is, to make judgments on it. Secondly, we should not feed in effect, moving on apace, and that more than 95 per the idea that legislation can reach us but we cannot do cent of clinical commissioning groups have now agreed anything about it because it has already been pre-empted. their constituent practices and geographies and are Whatever our views on the Bill, and it is controversial, already seeing benefits in their services from the work it is important on democratic grounds that we maintain that they have been doing. At the high level, around the position that legislation does not have full authority 50 per cent of the commissioning spend is already until it has gone through all its processes. That point delegated to clinical commissioning groups from PCTs needs to be reaffirmed. We should give no comfort to under various delegation schemes. That seems fair the opposite view in what we say in this House in the enough, but there is a final point on which I would remaining stages of the legislative process. welcome the noble Earl’s clarification. It says that the ambition is for all this to be so delegated to clinical commissioning groups by 1 April 2012. Will that The Parliamentary Under-Secretary of State, delegation still be part of the present powers, or is it in Department of Health (Earl Howe): My Lords, of anticipation of the legislation being passed in time? course, the noble Lord, Lord Owen, had no obligation to give the Government advance notice of the issue Lord Howarth of Newport: My Lords, has the noble that he has just raised. Nevertheless, I am sorry that he Lord, Lord Owen, not drawn our attention to a did not. I just say to him that everything that has particularly egregious example of a problem that is, happened to date in my department’s implementation however, long-standing? Have successive Governments of the transition programme has been done under the not taken the will of Parliament for granted following Secretary of State’s powers under the 2006 Act. This is Second Reading of measures and begun to spend all proper and lawful. However, this can go only so far. money and implement transitional arrangements on It is not a permanent solution, hence the need for the that basis? Has it not always been improper, and primary legislation that we are now debating. should Governments not be particularly careful when It has been the practice of successive Governments, they are well aware that the policies embodied in their once a Bill has passed through the other place, to do as legislation are highly contentious? I hope that we may we have done and make preparations for that Bill’s hear some considered reflections by the Government implementation. The previous Government did it on a on the generality of this practice, as well as on this number of occasions and we are doing so as well. particular incidence. It may be that the relevant Select Furthermore, we are doing so in a measured and Committees of both Houses of Parliament will want structured way. It is not an overnight process—it never to consider this problem. could be. It is being done over a period of years. It in no way pre-empts the will of this House, which has Earl Howe: My Lords, in answer to the noble made its views, to which the Government have listened Baroness, Lady Thornton, there is no suggestion that very carefully, known on a number of issues. the Bill could be withdrawn. We are clear that it is the 263 Health and Social Care Bill[8 FEBRUARY 2012] Health and Social Care Bill 264 right thing to do. Reform of the NHS is necessary and not agree with the objection that if the provision is in the national interest, and the measures in the Bill inserted at this point in the Bill, it must be inserted represent the best way forward. everywhere the issue arises. In his view, the definition The noble Lord, Lord Warner, asked me about the will carry that burden and make later repetition powers of delegation. All I can say to him is that the unnecessary. delegated budgets to which he referred are delegated The amendment would place an explicit duty on under existing powers, so there is no issue in law if that the Secretary of State to promote parity of esteem is what he was implying. However, I will endeavour to between mental and physical health services. The duty write to him if I have any further details for him on the would sit within his or her existing duty to improve the subjects that he talked about. quality of health services. It also clarifies that the The noble Lord, Lord Howarth, suggested that the Secretary of State has a duty to promote a health Government were beginning to spend money. In one service designed to secure improvements in the prevention, sense he is right because there have been redundancies diagnosis and treatment of both physical and mental in the NHS, but in another he misses the point. We illness. The amendment would put the Government’s have started to save a great deal of money. These own commitment to parity of esteem between mental measures will save £1.5 billion every year from the end and physical healthcare on a statutory footing and of this Parliament and around £3.2 billion during this make it clear that the Secretary of State is fully committed Parliament. We have begun to implement efficiencies to improving the nation’s mental health services and and improve patient care at the same time. I hope he the prevention and treatment of mental and physical will look at these issues in the round. illness and expects the NHS board and the CCGs to do the same. Report received. When the Government launched their mental health strategy, No Health Without Mental Health, in February Clause 1 : Secretary of State’s duty to promote 2011, the Minister for Care Services stated that he comprehensive health service wanted to see parity of esteem between mental health and physical health services. This was a recognition of the fact that, despite the prevalence of mental illness—one Amendment 1 in four people experience a mental health problem Moved by Lord Patel during their lifetime—mental health has never received the funding or attention it needs. Progress in improving 1: Clause 1, page 2, line 6, after “of” insert “physical and the quality of commissioning and services has been mental” much slower for mental health. Parity of esteem is not defined in the document itself. However, it would be Lord Patel: My Lords, it is a dubious privilege to reasonable to expect that this would mean a recognition speak to this amendment. I say “dubious” because the of the equal importance of mental and physical health noble and learned Lord, Lord Mackay of Clashfern, and the need to consider both aspects of people’s is on a well-deserved rest and recreation leave and the health when they present with either physical or mental noble Baroness, Lady Hollins, who is better qualified illness. I would expect this recognition to be evident in than me in this area, is unfortunately also detained on terms of access to mental health services and funding a lecturing commitment in Rome. However, I am for services proportionate to the disease burden. However, pleased to say that the noble Lord, Lord Alderdice, this has not been the case. whose name is also to the amendment, and who is much more knowledgeable on these matters than me, Over the past 10 years things have begun to improve. will no doubt speak later. For example, we have seen significant and very welcome investment in talking therapies under both the present The House will remember that when we discussed and previous Governments—£173 million in 2007-10 this issue in Committee there was widespread sympathy and £400 million from 2010-14. However, given that for and acknowledgement of the need to recognise mental health services started from a very low baseline, mental illness and accord it a similar importance as we simply cannot afford to go backwards—and talking that accorded to physical illness. The noble and learned therapies are only one aspect of mental healthcare. Lord, Lord Mackay of Clashfern, who tabled this During previous spending squeezes—for, example during amendment, wrote a note to me to say he was sorry the financial year 2005-06—mental health services that he would be away when it came up for consideration. have been unfairly and disproportionately targeted for He said that some time ago he was travelling with a cuts, perhaps because they do not enjoy the same level lawyer colleague who had been a chairman of mental of public support and understanding as other services. health tribunals for many years. He asked his colleague I admit that I often push for cancer services and what was his impression of progress in this field. The maternity services, so I pay regard to that. reply was that it was not great compared with that in other health fields. The noble and learned Lord’s view However, mental illness is a leading cause of suffering, is that it is desirable to emphasise the importance of economic loss and social problems, and it is time to mental illness and its treatment for the well-being of recognise and act on the plentiful evidence that good our people, and that it is wise to do so through this mental health underlines all health. Poor mental health amendment to this comprehensive Bill. He feels right is associated with diseases such as cancer, cardiovascular at the start of the Bill is vital to place to do so. disease and diabetes; and poor physical health increases Thereafter, the definition clause will carry this meaning the risk of mental illness. In the current climate of where appropriate. The noble and learned Lord does scarce resources, expenditure reduction, welfare reform 265 Health and Social Care Bill[LORDS] Health and Social Care Bill 266

[LORD PATEL] amendment, to which I have put my name. In many and cuts to legal aid—I might as well get all that ways, there is not much to say other than to support in—mental illness and mental health problems are him. However, when noble Lords say that in your likely to increase. However, while mental illness represents Lordships’ House, it is often because they actually 23 per cent of the disease burden, it accounts for only have quite a lot to say, and I shall say a few words. 11 per cent of the health budget. It is therefore vital On 2 November last year in Committee, your Lordships that mental health spending should be proportionate debated three amendments which would have placed to the need, and mental health must not be the poor the responsibility on the Secretary of State, the national relation of physical health. Commissioning Board and all clinical commissioning More than one-fifth of the population in England groups to regard mental health on the same basis as experiences a mental disorder at any one time. An even physical health. That is to say that they should give larger proportion experiences sub-threshold mental full consideration to all those suffering from mental disorder. Almost half of adults experience at least one illness in the same way as they would those suffering episode of depression during their lifetime. Only a from physical illness. quarter of affected individuals receive any intervention, except those with psychosis. Compared with people One reason for trying to insert such a commitment with no mental health problems, men with severe into the Bill was that, despite the efforts of the previous mental illness can expect to live 20 years less, and Government—to whom the noble Lord, Lord Patel, is women, 15 years less. A combination of lifestyle risk quite right to pay tribute—to address the needs of factors such as smoking and diet are higher, as are people with mental illness by allocating more money unnatural deaths such as those caused by suicide and for talking treatments, on which the coalition Government accidents. Poor physical healthcare contributes to this have substantially built, as the noble Lord said with premature mortality. If such a disparity of mortality reference to the legal friend of the noble and learned rates were to affect a large segment of the population Lord, Lord Mackay, out there in the real world, mental with less stigmatised characteristics, we would witness illness and problems of mental health do not get the an outcry against the socially unacceptable neglect of same attention and concern. As we said in the debate that group. in November, many people think of mental illness as a subset of illness, like cancer, diabetes, or whatever, but While the amendments cannot solve all this, creating it is not. It is a quite different aspect. When you fall ill an explicit duty on the Secretary of State would set a with something physical, something happens to you clear expectation that commissioners need to give full but your personality and your self are not affected; consideration to the mental health of those with physical but when you fall mentally ill, the very essence of your health problems, and to the physical health of those self is affected. That is a very different business. It with mental health problems—and to give full frightens people. They often turn away from paying consideration to mental as well as physical health. It is attention to it because they are so troubled by it. The simply not acceptable for the mental health needs of provision required is different. Often, much more than children and adults to continue to be neglected. is the case with other illnesses, a whole range of There is an imbalance between mental and physical services has to come together to provide treatment and health in both healthcare and health promotion in support. many places. A better balance could bring a number of benefits to people living with, or facing the risk of, Our concern in that debate—which was supported mental ill health. Health and social care policy should by noble Lords on all sides of the House; no one spoke be developed with mental as well as physical health against—was that all the efforts until now have been needs in mind. A duty to promote equality should less than fully successful in building up the regard and encourage policymakers at all levels of the system to esteem in which mental health and mental illness is consider mental health alongside physical health, rather held. So the proposition for the amendments was not a than making policy for the latter, and later adjusting belief that there was a particular technical flaw in the to fit the former. Bill which meant that mental illness would not be addressed; we are very much aware that it is addressed I know that the Minister is very involved with in the Bill. That is not the problem. The problem is: people in the area of mental health because I know how do we find a way continually to bring mental that he has been a patron of several charities related to illness to the attention of commissioners? The noble it, and he therefore has great sympathy towards recognition Lord, Lord Patel said, as was said in the November of mental illness and its treatment. I hope that his debate, that in times of financial pressure and austerity, answers to the amendment will be such that there will the tendency is to pull back financial commitment be no need to seek the opinion of the House, and I from those areas where there is least pressure. When look forward to his reply. I beg to move. people are physically ill, they can often nevertheless continue to exert pressure; but when people are mentally 4pm ill, they often do not give due regard to themselves, never mind press for the needs of others who are Lord Alderdice: My Lords, the noble Lord, Lord suffering from similar disorders. Patel, has characteristically underplayed his own grasp of this important area, but, as noble Lords have Our concern is not about those three specific heard, he has on his own behalf and on behalf of the amendments but the principle. The noble and learned noble and learned Lord, Lord Mackay of Clashfern, Lord, Lord Mackay of Clashfern, went away and and the noble Baroness, Lady Hollins, presented an produced a single amendment. The noble Earl was elegant, informed and very persuasive case for the kind enough to give a considerable amount of time to 267 Health and Social Care Bill[8 FEBRUARY 2012] Health and Social Care Bill 268 me and the noble Baroness, Lady Hollins, to discuss has a broken leg, you can locate the leg and take the the question. A concern was expressed by him and medicine. If somebody has even cancer, it may not be some people in the department that if one included curable but at least you have the knowledge of the this in one place, one would have to put it in every location or locations of the cancer and the topical place because otherwise the implication would be that treatment that is to be applied to it. it applied only to the issue to which it refers directly. I The problem for families who experience in their have to say that the noble and learned Lord, Lord midst mental illness is that no medicine can be applied Mackay of Clashfern, was wholly unimpressed with topically to the place where the hurt or illness is taking that argument. As he is a former Lord Chancellor, I place. The prognosis is uncertain, the mortality rate is think one takes that pretty seriously. depressingly high and usually at the hands of the sick The point is that we must find some way in which to person, and accessing good health service facilities is make it absolutely clear beyond peradventure that quite chancy, I am afraid. There is a real postcode concern for those who have mental health problems is lottery with mental health treatment. If, for example, every bit as great and the responsibility on commissioners you live in a remote rural area, only some therapies is every bit as great to ensure the proper provision of will be available and they may be the wrong therapies, services. One reason why this comes up as the very first particularly if the patient is a child or adolescent amendment at Report is that we want to ensure that in suffering from serious mental illness. Therefore, I simply all aspects of health care, mental health care is attended say to the Minister who, as has already been said, to: no health without mental health and indeed, as the cares deeply about these issues, that the adoption of Royal College of Psychiatrists’ report said, no public this very simple amendment, as the noble Lord, Lord health without public mental health. Walton, rightly described it, would send out such a It is regrettable that the Royal College of Psychiatrists, telling message of support to families who have to care of which I am a member, has over the past few days for people who suffer, perhaps temporarily, from mental been saying that the whole Bill should be set aside. illness that it would be seen as a declaration of purpose That is not really a helpful way of engaging in these by this Government. kinds of questions. The college knows perfectly well that the Bill is not going to be set aside—in fact, it Baroness Whitaker: My Lords, briefly, from a lay would not be at all helpful if it were. I have seen these perspective, I urge the Minister to take this amendment kinds of situations in other places, with people polarising very seriously. I will not rehearse what I said at Second in an unhelpful way. I appeal to the Minister, to the Reading from my experience on the board of the Royal College of Psychiatrists and to others who are Tavistock and Portman clinic or from other walks of interested and concerned in this field to find a way to life about how widely damaging and destructive it is get together again before the completion of the Bill to not to have parity, and how it needs to be explicit ensure that the concerns that we are expressing are parity to change culture and to erode the stigma and reflected in a cast-iron fashion. It is a question not of the neglect associated with mental ill health. If the these particular words or of this particular amendment Government are rash enough not to accept the but of receiving solid assurances so that we and those amendment—and I am quite sure that the noble Earl who care for people with mental illnesses, as well as is not like that—I hope that there will be a Division. If those who suffer from such illnesses, can be confident the debate lasts until five o’clock, when I am committed about the new NHS. to chairing a meeting, I hope that the House will accept my apology but I will return to vote. Lord Walton of Detchant: My Lords, in rising briefly Lord Newton of Braintree: I have two excuses for to support the amendment so ably proposed by my speaking. First, I have chaired two mental health noble friend Lord Patel and supported by the noble trusts and, although I no longer do so, I have a Lord, Lord Alderdice, I ask the Minister one very continuing interest of a non-financial kind. Secondly, simple question. In Clause 1(1)(a) the Bill talks about before my noble and learned friend Lord Mackay left the, for what was described as his well earned rest and “physical and mental health of the people of England”, recuperation, I was the nearest thing to anybody he and says that the health service must be “designed to anointed to take care of his interests while he was secure improvement” in that health. What on earth away, which includes this amendment. could the objection possibly be to inserting in I do not need to speak for long because I think that paragraph (b) at line 6 the unexceptional words listed this is a no-brainer. Everybody agrees on the importance in the amendment? They simply stress the crucial of mental health and endorsed the Government’s No importance of mental as well as physical illness. How Health Without Mental Health strategy. We are all on earth could this be construed as doing any damage keen on that—even the Government. Yet the little whatever to the Bill? It is something that I hope very birds tell me that the amendment will be resisted on much the Government can be persuaded to accept. the grounds that it is not necessary and does nothing to add to the 2006 Act. I spent a lot of years as Leader Lord Carlile of Berriew: My Lords, I should like to of the House of Commons and I got fed up with say a word on behalf of those who have had to care for Ministers who came to me on Private Member’s Bills family members—often a young member of the family— and other things and said, “It’s not necessary—we are who have suffered from severe mental illness. Those going to do this anyway”. They then proceeded to who have suffered that experience—and I am one—know immolate themselves on a bonfire for an amendment how marooned they feel when they find that someone that would have cost nothing and done no harm—it in their family has a serious mental illness. If somebody certainly would not have added anything—but would 269 Health and Social Care Bill[LORDS] Health and Social Care Bill 270

[LORD NEWTON OF BRAINTREE] 4.15 pm have pleased a lot of people. That is idiotic. It would Lord Ribeiro: My Lords, I follow the noble Baroness not cost the Government anything to do this and, as in saying that I am speaking not because I see this as my noble friend said, it would please a lot of people, an amendment that should be pushed to a vote, but so we should simply get on with it. If my noble friend rather because I see it as a probing amendment that has been told to resist it I will sympathise with him, would allow the Government and the Minister to but frankly if the noble Lord, Lord Patel, feels that he listen to the arguments being put today. should push it, I will push it with him. The whole thrust of the reforms is to provide care right across the community—secondary care, primary Baroness Meacher: My Lords, I support this care and, let us not forget, social care. The mental amendment very strongly and shall speak extremely health institutions started to be closed some 30-odd briefly. Others have spoken most eloquently and very years ago, and care moved into the community. The much made the case. My fear, too, is that the Minister ability to identify, diagnose and treat patients admitted will regard it as unnecessary. I have absolutely no into accident and emergency departments, often with doubt at all about the Minister’s commitment to mental psychotic diseases, is a major challenge. It certainly is health, but I believe that this is necessary because of for surgeons—for me in particular. As more psychiatrists the context in which the amendment is being posed—in are diverted to care in the community, the diagnosis other words, the Bill itself. What I mean is that the Bill and treatment of patients who appear in A&E is designed more than anything else to introduce departments is a challenge. It is quite difficult for privatisation of the NHS—slowly, slowly. It will not those of us who have not had psychiatric experience. I be done overnight, but in 10 years’ time we can be sure was very fortunate that my house officer rotated through that a substantial proportion of our NHS will in fact a psychiatric firm, so I had the benefit of somebody be in private hands. If we look across the world to the who was able to identify patients with psychotic illnesses US, Germany and other countries, we find that privatised and could advise me how best to deal with them. health services do not support mental health to the degree that we in the NHS have supported it in the It is important to identify the difference between past. That is the most fundamental argument in my physical and mental illnesses. I feel that this amendment view. We have to protect our mental health services, would make a difference by clearly stating that there is albeit that they have been a Cinderella relative to the physical illness and mental illness in this section. I very acute sector, but not to the degree that mental health much hope that the Minister will listen to the strength services are Cinderellas in other countries where private of the debate and come back with some answers. health dominates. Baroness Finlay of Llandaff: My Lords, I hope that That is my most important point. The only other the Minister will be able to break away from his brief part of the context is that the Bill will do nothing to and accept this amendment, because it is critical. As make the changes that we need in the NHS, such as my noble friend Lord Walton has pointed out, the first closures of redundant acute hospitals and redundant part of the amendment talks about physical and mental acute departments. I hope that this Government, unlike health, but the second part implies that prevention, many previous Governments of whatever hue, will diagnosis and treatment are of illness, and there is a take the leadership role and show that they support real danger of reading that as physical illness. The mental health. I appeal to the Minister not to say that most tragic situation is where physical illness is this is unnecessary. I appeal to him to agree that it is misdiagnosed as mental illness or mental illness is necessary and to give and show the Government’s misdiagnosed as physical illness. The consequences of commitment to equality of parity of mental health that for patients can be disastrous. and physical health in this country. In primary care, patients present with a completely undifferentiated picture. The general practitioner has Baroness Williams of Crosby: My Lords, my noble to start from scratch, sort out the different parts and friend Lord Alderdice made the strong point that in then refer to or consult other parts of the service, as the real world mental health is not regarded as being appropriate, if he needs to. My noble friend Lady on all fours with physical health. For the reasons Meacher suggested that those services are in imbalance, presented by my noble friend Lord Carlile and others, and I agree with her that there is a danger when clearly in the real world mental health is often hidden. funding is short that you will lose the mental health It is often an issue that people do not freely address component of services and that the culture change and it is vital that we send a clear signal from this that this Bill is meant to bring about will not happen. House that mental health is absolutely equivalent in A culture change is needed. Stigmatising labels have significance and importance to physical health, and been attached to people with mental illness for many that we believe that. years. People with learning difficulties do particularly I shall briefly say what has already been said. Will poorly in services overall. If we are going to take the the Minister at the very least consider taking this opportunities of this Bill, we have one with this debate back and looking at whether there could be an amendment: to flag up that there are mental and agreed amendment that would meet his difficulties? physical components to illness that need and deserve There may be drafting difficulties, but it would not in accurate diagnosis, the one as much as the other, that any way resile from the statement that this House they are interrelated, that one affects the other and believes that mental health is vital and we want it on that we cannot provide a comprehensive health service the face of the Bill. I plead with him to consider doing without due regard to the totality—to the holistic that. person who is the patient in front of us. 271 Health and Social Care Bill[8 FEBRUARY 2012] Health and Social Care Bill 272

The Countess of Mar: My Lords, I too support this Earl Howe: My Lords, we have had an excellent amendment very strongly, and I think the Minister debate to mark the start of Report and I am very knows why. pleased—and, I must say, unsurprised—that the spirit In my dealings with people with ME/CFS, I have of our debates in Committee has continued. I am found that many of them have been sectioned and put particularly pleased that we have started with a topic into wards that I can only describe as barbaric. There as important as the parity of esteem between mental was one recent case where the man had a very clear and physical health. physical illness and he spent nearly nine months in a Amendment 1, moved by the noble Lord, Lord hospital in Torbay—Torbay, the hospital that has been Patel, would ensure that the reference to “illness” in praised left, right and centre; but its mental ward is the description of the comprehensive health service not worthy of praise. If the funding is equal for mental refers to mental as well as physical illness. I am grateful and physical treatment, this will somehow redress the to all noble Lords for the powerful case they have balance. made for this amendment. I very much understand My mother was mentally ill for 17 years and she why this issue is of such importance to noble Lords, was treated barbarically by psychiatrists. She was hooked and why they believe that there is a declaratory value on barbiturates and she was given a leucotomy. I in inserting these additional words at this point in the thought those days had gone but we are not far from Bill. As the noble Lord, Lord Patel, will be aware from them with the things that I have seen with ME patients. our recent mental health strategy, achieving parity of esteem for mental illness is a priority for the Government. Lord Eden of Winton: My Lords, we have listened Therefore, I do not dissent in the slightest from the to many powerful and persuasive speeches. I am tempted central principle being argued for here. to go all the way with those who have advocated the The question I have asked myself since Committee inclusion of this amendment in the Bill, but I take up is whether the addition of these words would achieve the words of the noble Baroness, Lady Finlay, who what noble Lords intend, and whether they would add referred to the need for a cultural change. I think all real value. In a strictly legal sense, they will not add noble Lords would agree that there is the need for a value because legislation already makes it clear, through cultural change. I only question whether it is right to the definition in Section 275 of the National Health try to achieve that change through legislation. Surely Service Act, that any reference to illness in the Act what we are seeking to do is to change attitudes and shall include both mental and physical illness. Therefore, get people to understand that there is no difference wherever in the Bill the word “illness” appears, it between physical and mental illness. For that reason, I already refers to both mental and physical illness. think we need to hesitate before including words in However, as my noble friends Lord Eden and Lord legislation. What we need to do is to make people Alderdice said, what is required here—what really throughout the health service and everyone associated matters—are not words but concrete actions that will with the administration aware of the fact that there is result in changes in attitudes and behaviours. no difference between physical and mental illness, and that those with mental illness need to be treated on an Before I tell the House which way I am leaning on absolutely level footing with those with physical illness. the amendment, I will set out the steps that the Government have taken to that end. First, we are Baroness Thornton: My Lords, we on these Benches using the Bill to enhance the role of the NHS constitution. liked this amendment the first time round and we have This plays an important role in emphasising the not changed our minds. It may be symbolic in its prominence and importance of mental health. It already effect—in fact, we think it all the better for that. contains a strong opening statement about mental and Legislation should be the expression of policy and this physical health. It declares that the NHS is there, amendment flows from important policy commitments “to improve our health and well-being, supporting us to keep by successive Governments about the parity of policy- mentally and physically well, to get better when we are ill and, making at all levels of the system to consider mental when we cannot fully recover, to stay as well as we can to the end health alongside physical health. We give our very full of our lives”. support to the mover of this amendment and we urge Current legislation requires all NHS bodies and the Minister to accept it. providers to the NHS to have regard to the constitution. I have two other remarks to make. First, I always The Bill creates new duties on the NHS Commissioning listen extremely carefully to the noble and learned Board and clinical commissioning groups not just to Lord, Lord Mackay of Clashfern. Frankly, if he says have regard to it but to promote it. This is why we feel it is good enough for this Bill, that is good enough for that NHS bodies, staff, patients and the public will in me. Secondly, I agree with the noble Lord, Lord future be much more aware of, and hence responsive Newton, that it is a no-brainer. To the noble Lords, to, the NHS constitution and the parity of esteem that Lord Ribeiro and Lord Alderdice, and the noble Baroness, it champions. Therefore, I am afraid that I cannot Lady Williams, I say that we are on Report. This is not agree with noble Lords who implied that the Bill is the time for probing amendments. This is the time for silent on parity of esteem. We are giving greater taking decisions about what we want in the Bill. The prominence to the NHS constitution precisely because Minister had the opportunity to take this away and we want to see greater awareness of the values, including consider it after Committee, when the House was as parity of esteem, that it contains. united in its view about this matter as it is today. Secondly, we have used a range of operational Today I urge the Minister to accept this amendment levers to drive forward the importance of improving but, if he will not, the House needs to express its view mental health. Mental health is featured prominently about this matter if at all possible. in the NHS operating framework. We have updated 273 Health and Social Care Bill[LORDS] Health and Social Care Bill 274

[EARL HOWE] esteem between mental and physical health. I realise the NHS outcomes framework to include indicators that I have not been able to meet the noble Lord on for mental health outcomes in a holistic context. The precisely the same territory as he has proposed, but I public health outcomes framework has a set of key hope nevertheless that with the reassurances I have mental health and well-being outcomes identified for given, he will on balance be able to withdraw his national and local action. amendment. Thirdly, our mental health outcomes strategy makes it crystal clear that mental health services should have Lord Newton of Braintree: My Lords, perhaps I parity of esteem. We said in the document that it is our may say that if it was me who my noble friend was ambitious aim to mainstream mental health in England. referring to as being on his left, I am thrilled to bits by Furthermore, as noble Lords know, we titled the strategy, his rather more constructive response. I congratulate No Health Without Mental Health. I can tell the him. noble Lord, Lord Patel, that we are going further still Lord Patel: My Lords, I wish that I did not need to by looking to publish a full implementation framework speak at this point because I am really quite torn. I for the strategy in April this year. This will be co-produced know how sincerely all those who have spoken feel and jointly owned by national mental health organisations about this amendment, and about emphasising the in partnership with government. Work is under way to need to promote mental illness as having the same develop the content of the framework, including parity as physical illness. At the same time, I know consultation with a wide range of partners. My conclusion how sincere the noble Earl is, and therefore it is is that much work is afoot, as well as levers already in difficult not to accept what he has said and the promises the Bill, to deliver the parity of esteem between mental he has made. None the less, the comment made by my and physical health that we all want to see in clinical noble friend Lord Walton is the one that has affected practice. me most: what is the key objection to putting these I turn to the amendment. Should the noble Lord, two words at the front of the Bill to signify that mental Lord Patel, invite the House to add these words to the illness is as important in its management as physical Bill? I am afraid that I have concluded that the noble illness? Lord should resist the temptation. Having reflected In my professional life I have dealt with physical very hard on these words, I believe that they could be illness, but I was always deeply affected whenever I positively unhelpful to his case, as well as to the had a patient suffering from postpartum depression or business in which we are jointly engaged, which is the antenatal anxieties and sometimes psychosis; they were drafting of clear, economical and unambiguous legislation. the most difficult to deal with. I would then have to “Illness” is already defined in the Act and, for me, seek the assistance of my psychiatrist colleagues. these words are not only legally superfluous, they also suggest that there is a divide between mental and Lord Elton: The noble Lord said that his noble physical illness rather than a convergence. friend was awaiting an answer to his question as to what was the objection? I have understood my noble 4.30 pm friend to say that the objection was that it could The noble Lord may believe that little harm would actually make things more difficult because it would be done by his amendment, but I respectfully suggest imply that there is a distinction between the two forms to him that that may not be so. However, while I would of medical treatment, which is exactly what we wish to urge him to withdraw it, I can tell the House that I am negate. going to break away from my brief because my feeling has changed over the course of this debate. I agree Lord Patel: I did hear what the noble Earl said and that, given the nature of the Bill and the amount of I cannot say that I can accept that it would create time and discussion the House has dedicated to it, we difficulties if we included mental illness with physical could do more about the terms it uses, especially at the illness. I do this with a very heavy heart, but I know very start. In the light of that, and in response to the that if I do not push the amendment, others will do so. arguments made today, I would like to commit to On that basis, I think we should resolve the issue by undertake to do some further work to make clear the seeking to test the opinion of the House. Government’s commitment to parity of esteem. The 4.34 pm first thought I have had—and I do not dare look behind me to my left—is that there is potentially an Division on Amendment 1 important role for the Explanatory Notes to the Bill. I can confirm, because I shall see to it myself, that we Contents 244; Not-Contents 240. will be revisiting the Explanatory Notes to make it Amendment 1 agreed. clearer that, with respect to Clause 1, “illness” refers to both mental and physical health. That is a very easy Division No. 1 thing to do. CONTENTS Secondly, I would like to invite the noble Lord, Aberdare, L. Armstrong of Ilminster, L. Lord Patel, and possibly other noble Lords, including Adams of Craigielea, B. Bach, L. my noble and learned friend Lord Mackay of Clashfern, Afshar, B. Bassam of Brighton, L. if he is available, to have further conversations with me Ahmed, L. Beecham, L. and with my ministerial colleague Paul Burstow to Alliance, L. Berkeley, L. consider if there is anything further we could do, Anderson of Swansea, L. Bew, L. whether in the Bill or outside it, to promote parity of Andrews, B. Bichard, L. 275 Health and Social Care Bill[8 FEBRUARY 2012] Health and Social Care Bill 276

Bilimoria, L. Henig, B. Patel, L. [Teller] Stern of Brentford, L. Billingham, B. Hennessy of Nympsfield, L. Patel of Blackburn, L. Stevenson of Balmacara, L. Bilston, L. Hilton of Eggardon, B. Paul, L. Stoddart of Swindon, L. Blackstone, B. Hollick, L. Pendry, L. Symons of Vernham Dean, B. Blair of Boughton, L. Hollis of Heigham, B. Pitkeathley, B. Taylor of Blackburn, L. Boateng, L. Howarth of Breckland, B. Plant of Highfield, L. Taylor of Bolton, B. Boothroyd, B. Howarth of Newport, L. Ponsonby of Shulbrede, L. Temple-Morris, L. Borrie, L. Howe of Idlicote, B. Prashar, B. Tenby, V. Boyce, L. Howie of Troon, L. Prosser, B. Thornton, B. Boyd of Duncansby, L. Hughes of Stretford, B. Puttnam, L. Tomlinson, L. Bragg, L. Hughes of Woodside, L. Quin, B. Tonge, B. Brooke of Alverthorpe, L. Hunt of Chesterton, L. Quirk, L. Touhig, L. Brookman, L. Hunt of Kings Heath, L. Radice, L. Triesman, L. Brooks of Tremorfa, L. Hylton, L. Ramsay of Cartvale, B. Tunnicliffe, L. Browne of Belmont, L. Irvine of Lairg, L. Ramsbotham, L. Turnberg, L. Browne of Ladyton, L. Janner of Braunstone, L. Rea, L. Turner of Camden, B. Butler of Brockwell, L. Jay of Paddington, B. Reid of Cardowan, L. Walker of Aldringham, L. Butler-Sloss, B. Joffe, L. Rendell of Babergh, B. Wall of New Barnet, B. Campbell of Surbiton, B. Jones, L. Richard, L. Walpole, L. Campbell-Savours, L. Jones of Whitchurch, B. Robertson of Port Ellen, L. Walton of Detchant, L. Carlile of Berriew, L. Judd, L. Rogan, L. Warner, L. Chorley, L. Kakkar, L. Rowe-Beddoe, L. Warnock, B. Clancarty, E. Kennedy of Southwark, L. Rowlands, L. Warwick of Undercliffe, B. Clarke of Hampstead, L. Kerr of Kinlochard, L. Royall of Blaisdon, B. West of Spithead, L. Clinton-Davis, L. King of Bow, B. Saltoun of Abernethy, Ly. Wheeler, B. Collins of Highbury, L. King of West Bromwich, L. Sawyer, L. Whitaker, B. Colville of Culross, V. Kinnock, L. Scotland of Asthal, B. Whitty, L. Corston, B. Kinnock of Holyhead, B. Sewel, L. Wigley, L. Coussins, B. Kirkhill, L. Sheldon, L. Wilkins, B. Craig of Radley, L. Knight of Weymouth, L. Sherlock, B. Williams of Elvel, L. Cunningham of Felling, L. Laming, L. Simon, V. Wills, L. Darzi of Denham, L. Lea of Crondall, L. Singh of Wimbledon, L. Wilson of Tillyorn, L. Davies of Coity, L. Leitch, L. Smith of Basildon, B. Wood of Anfield, L. Davies of Oldham, L. Liddell of Coatdyke, B. Smith of Finsbury, L. Woolmer of Leeds, L. Davies of Stamford, L. Liddle, L. Smith of Leigh, L. Worthington, B. Desai, L. Lipsey, L. Snape, L. Young of Hornsey, B. Dixon, L. Lister of Burtersett, B. Soley, L. Young of Norwood Green, L. Donaghy, B. Low of Dalston, L. Stern, B. Young of Old Scone, B. Donoughue, L. Luce, L. Drake, B. McAvoy, L. NOT CONTENTS Dubs, L. McConnell of Glenscorrodale, Eames, L. L. Addington, L. Chester, Bp. Eatwell, L. McDonagh, B. Ahmad of Wimbledon, L. Clement-Jones, L. Elder, L. Macdonald of Tradeston, L. Alderdice, L. Colwyn, L. Elystan-Morgan, L. McFall of Alcluith, L. Allan of Hallam, L. Cope of Berkeley, L. Emerton, B. McIntosh of Hudnall, B. Anelay of St Johns, B. [Teller] Cormack, L. Evans of Parkside, L. Mackenzie of Framwellgate, Arran, E. Courtown, E. Evans of Temple Guiting, L. L. Ashdown of Norton-sub- Crathorne, L. Farrington of Ribbleton, B. McKenzie of Luton, L. Hamdon, L. Crawford and Balcarres, E. Faulkner of Worcester, L. Maginnis of Drumglass, L. Ashton of Hyde, L. Cumberlege, B. Filkin, L. Mallalieu, B. Astor of Hever, L. De Mauley, L. Finlay of Llandaff, B. [Teller] Mar, C. Attlee, E. Dear, L. Foulkes of Cumnock, L. Martin of Springburn, L. Baker of Dorking, L. Deben, L. Gale, B. Masham of Ilton, B. Bell, L. Dholakia, L. Gavron, L. Massey of Darwen, B. Benjamin, B. Dixon-Smith, L. Gibson of Market Rasen, B. Maxton, L. Berridge, B. Doocey, B. Giddens, L. May of Oxford, L. Birt, L. Dundee, E. Glasman, L. Meacher, B. Black of Brentwood, L. Dykes, L. Golding, B. Monks, L. Blencathra, L. Eaton, B. Gordon of Strathblane, L. Moonie, L. Bonham-Carter of Yarnbury, Eccles, V. Gould of Potternewton, B. Morgan, L. B. Eccles of Moulton, B. Grantchester, L. Morgan of Drefelin, B. Boswell of Aynho, L. Eden of Winton, L. Greengross, B. Morgan of Huyton, B. Bottomley of Nettlestone, B. Elton, L. Grenfell, L. Morris of Aberavon, L. Bowness, L. Empey, L. Grey-Thompson, B. Morris of Handsworth, L. Bradshaw, L. Erroll, E. Grocott, L. Morris of Manchester, L. Bridgeman, V. Falkland, V. Hall of Birkenhead, L. Morrow, L. Brooke of Sutton Mandeville, Falkner of Margravine, B. Hameed, L. Moser, L. L. Faulks, L. Hanworth, V. Myners, L. Brougham and Vaux, L. Feldman, L. Harries of Pentregarth, L. Neuberger, B. Browning, B. Feldman of Elstree, L. Harris of Haringey, L. Nye, B. Burnett, L. Fellowes, L. Harrison, L. O’Loan, B. Burns, L. Fink, L. Hart of Chilton, L. O’Neill of Clackmannan, L. Byford, B. Fookes, B. Hattersley, L. Ouseley, L. Caithness, E. Fowler, L. Haworth, L. Owen, L. Cameron of Dillington, L. Framlingham, L. Hayman, B. Palmer, L. Campbell of Alloway, L. Freeman, L. Hayter of Kentish Town, B. Pannick, L. Cathcart, E. Freud, L. Healy of Primrose Hill, B. Parekh, L. Cavendish of Furness, L. Garden of Frognal, B. 277 Health and Social Care Bill[LORDS] Health and Social Care Bill 278

Gardiner of Kimble, L. Newby, L. Ullswater, V. Watson of Richmond, L. Gardner of Parkes, B. Nicholson of Winterbourne, Verma, B. Wei, L. Geddes, L. B. Vinson, L. Wheatcroft, B. Wakeham, L. German, L. Noakes, B. Wilcox, B. Wallace of Saltaire, L. Glasgow, E. Northbourne, L. Willis of Knaresborough, L. Goodhart, L. Northbrook, L. Wallace of Tankerness, L. Willoughby de Broke, L. Goodlad, L. Northover, B. Walmsley, B. Young of Graffham, L. Grade of Yarmouth, L. Norton of Louth, L. Warsi, B. Green of Hurstpierpoint, L. O’Cathain, B. Wasserman, L. Younger of Leckie, V. Greenway, L. O’Neill of Bengarve, B. Griffiths of Fforestfach, L. Oppenheim-Barnes, B. 4.50 pm Hamilton of Epsom, L. Palmer of Childs Hill, L. Hamwee, B. Palumbo, L. Hanham, B. Parminter, B. Harris of Peckham, L. Patten, L. Amendment 2 Harris of Richmond, B. Perry of Southwark, B. Moved by Baroness Finlay of Llandaff Henley, L. Phillips of Sudbury, L. Higgins, L. Plumb, L. 2: Clause 1, page 2, line 6, at end insert “, and Hill of Oareford, L. Popat, L. “(c) in the education and training of health care Hodgson of Astley Abbotts, Randerson, B. professionals” L. Rawlings, B. Home, E. Razzall, L. Howard of Rising, L. Redesdale, L. Baroness Finlay of Llandaff: My Lords, this group Howe, E. Rees-Mogg, L. of amendments addresses education and training as Howe of Aberavon, L. Renton of Mount Harry, L. part of a comprehensive health service. The Government Howell of Guildford, L. Ribeiro, L. Hunt of Wirral, L. Risby, L. have given the Secretary of State, Hussain, L. Roberts of Llandudno, L. “a duty as to education and training” Hussein-Ece, B. Rodgers of Quarry Bank, L. that is now Clause 6. This is a welcome amendment Inglewood, L. Saatchi, L. James of Blackheath, L. Sanderson of Bowden, L. to the Bill that we originally saw, and I warmly welcome the Jenkin of Kennington, B. Sandwich, E. Government’s amendments, particularly Amendments 61 Jenkin of Roding, L. Sassoon, L. and 104, which will embed a duty to promote education Jolly, B. Scott of Needham Market, B. and training in the core duties of the board and the Jones of Cheltenham, L. Seccombe, B. clinical commissioning groups. Kilclooney, L. Selborne, E. King of Bridgwater, L. Selkirk of Douglas, L. My Amendments 63 and 105 are very similar. They Kirkham, L. Selsdon, L. specify that all providers, whether NHS or private, Kirkwood of Kirkhope, L. Shackleton of Belgravia, B. must train clinical staff adequately. They seek to ensure Knight of Collingtree, B. Sharkey, L. that private providers of services for NHS patients Kramer, B. Sharples, B. Lang of Monkton, L. Shaw of Northstead, L. cannot undercut NHS providers by failing to provide Lawson of Blaby, L. Sheikh, L. adequate training for their staff. All providers should Lee of Trafford, L. Shephard of Northwold, B. ensure that clinical and other skills are kept up to Lester of Herne Hill, L. Shipley, L. current standards and that future generations of clinicians Lexden, L. Shrewsbury, E. are also trained. I therefore hope that the Minister will Lindsay, E. Shutt of Greetland, L. [Teller] Lingfield, L. Skelmersdale, L. be able to provide assurances that that will be spelt out Linklater of Butterstone, B. Smith of Clifton, L. in regulation, if it is not already clear. I expect that he Liverpool, E. Soulsby of Swaffham Prior, L. may say that the Government’s amendments cover the Loomba, L. Spicer, L. points of my amendments as they refer specifically to Lothian, M. Stedman-Scott, B. Clause 6 and its comprehensive scope. If I am right, it Lucas, L. Steel of Aikwood, L. would seem that my amendments are not needed, as Luke, L. Sterling of Plaistow, L. Lyell, L. Stevens of Ludgate, L. the point is covered—but, as I said, I would appreciate Lytton, E. Stewartby, L. clarification. I hope, too, that the Minister can confirm McColl of Dulwich, L. Stirrup, L. that training must involve staff at every level, whether Macfarlane of Bearsden, L. Stoneham of Droxford, L. professionally qualified or not. MacGregor of Pulham Storey, L. Market, L. Stowell of Beeston, B. Let me turn to the lead amendment in this group, Maclennan of Rogart, L. Strathclyde, L. designed to place a duty on the Secretary of State to McNally, L. Swinfen, L. secure improvement, Maddock, B. Taverne, L. “in the education and training of health care professionals”. Magan of Castletown, L. Taylor of Holbeach, L. Mancroft, L. Teverson, L. There are currently almost 1.2 million staff in the Maples, L. Thomas of Gresford, L. NHS, of whom 52 per cent are professionally qualified. Marlesford, L. Thomas of Swynnerton, L. We have been told, in debating this Bill, that the Mawhinney, L. Thomas of Winchester, B. intention is for professional leadership in the NHS. Mawson, L. Tope, L. Mayhew of Twysden, L. Tordoff, L. These 600,000-plus staff must be able to take on that Methuen, L. Trefgarne, L. responsibility. Let me explain why this strategic overview Miller of Chilthorne Domer, Trenchard, V. and responsibility is needed at Secretary of State level. B. Trimble, L. The rationale behind the Bill, we have been told, is to Miller of Hendon, B. True, L. drive up quality and put patients at the heart of the Montrose, D. Trumpington, B. Morris of Bolton, B. Tugendhat, L. NHS. There is a need for all healthcare services to be Moynihan, L. Turnbull, L. learning organisations, constantly reflecting through Neville-Jones, B. Tyler, L. audit on whether they are reaching the required standards, 279 Health and Social Care Bill[8 FEBRUARY 2012] Health and Social Care Bill 280 ensuring that their staff are up to date with technical repeatedly catalogue a lack of standards and poor and scientific aspects of care delivery, and having a quality processes and repeatedly recommend education constant drive to having good attitudes and a culture and training of staff at all levels. The NCEPOD of responsibility and care for those who are vulnerable— report, Emergency Admissions: A Journey in the Right the patients and their families. These are fundamental Direction?, said that trainee doctors, to the ability to deliver a comprehensive health service. “need to have adequate training and experience to recognise Clause 1 has the Secretary of State’s duty to, critically ill patients and make clinical decisions. This is an issue not only of medical education but also of ensuring an appropriate “continue the promotion in England of a comprehensive health balance between a training and service role; exposing trainees to service designed to secure improvement … in the physical and real acute clinical problems with appropriate mid-level and senior mental health of the people of England”, support for their decision making”. and now, The Healthcare Commission report into the “in the prevention, diagnosis and treatment of”, substandard care in Mid Staffs states on page 45: physical and mental illness. It is impossible to achieve “From April 2008, there was only one permanent consultant, these without securing ongoing improvements through virtually no education and only limited supervision”. the education and training of all professionals. In his On page 46 it says: letter of 12 January, the Minister wrote outlining four “Senior members of the department said that there was a key elements of the new system proposed for education ‘non-existent culture’ with regards to education and training. and training, covering the plans for Health Education Additionally, several interviewees specifically mentioned that three- England, local education and training boards, the quarters of dedicated teaching sessions for junior doctors were transparent funding of the system and transitional cancelled, usually by managers on operational grounds”. arrangements. We will debate these later in detail, and There is a virtuous spiral of education, integration this amendment in no way detracts from the amendment and quality improvement. Learning across professional tabled by my noble friend Lord Patel, which is coming boundaries has been shown to foster integration as up later on in proceedings. All those amendments are healthcare professionals understand better what others compatible with putting the education and training of can offer in care, thereby driving up quality. They also health professionals at the very top of the Bill, in learn the limits of their own experience and different Clause 1, as they are part of the comprehensive package ways of doing things, to the benefit of all. that the NHS uses to deliver the best care to patients. If we are to have a constantly improving NHS, There are almost 98,000 medical and dental staff in education and training must be at its heart. If we are the NHS. Medicine and medical care is underpinned to expect GPs to commission properly, they will need by science. Medicine bridges the gap between science training to recognise poor commissioning advice. If and society. This science is constantly evolving; its we expect better care from the staff, we must ensure appropriate application to human health is a crucial that they are in a system that is driven constantly to aspect of clinical practice and care to achieve better improve. I beg to move. outcomes for patients. Medicine is distinguished by the need for judgment in the face of uncertainty. 5pm Much of medicine’s unpredictability calls for wisdom Lord Turnberg: My Lords, I put my name to as well as technical ability. Everything flows from Amendment 12 but I have shifted my allegiance to accurate diagnosis. A commitment to quality improvement Amendment 13, along with other noble Lords. However, allows crucial skills to be passed on to the next generation. I want to speak to the other amendments in my name We have heard much about the merits of competition. in this group. In doing so, can I say how much I, too, Doctors and those in many other disciplines in healthcare very much appreciate the government amendments in are almost inherently competitive, and they generally this group? want to be providing high quality service with better At the end of the day, education and training have outcomes and to be rated highly by their colleagues. to be provided within hospital trusts, in general practice That is the competitive spirit that the Government and—a slightly separate issue—in local authorities for should be able to exploit to drive up standards. Good public health consultants. At this level, local education attitudes are bred from good role models. and training boards are to be given responsibility for There are core values, behaviours and relationships overseeing the provision of all this education. Here, that underpin professionalism in relationships with local employers are to play a key role in the trusts. each patient, and these were exposed in the report by These local employers clearly have an interest in being the noble Baroness, Lady Cumberlege, Doctors in Society, able to plan for their manpower needs and in having on behalf of the Royal College of Physicians. The an influence on what sort of training their employees attitudes and values that healthcare professionals must should have to do the job that they want doing. be committed to in their day-to-day practice involve However, they are not in the best position to decide integrity; compassion; altruism; continuous improvement, the educational content of the programmes that the which means always learning; a desire for excellence; trainees go through. They are not best able to design and an ability to work in partnership with others in the training or education of an orthopaedic surgeon the wider healthcare and social care team. or cardiologist, for example. Patients certainly understand the meaning of poor Furthermore, they may have a conflict of interest professionalism and associate it with poor care. The when they are asked to make sure that the facilities for public are well aware that an absence of professionalism training are adequate to their trusts’ needs. Is there a is harmful to their interests. There have been too many full range of patients coming through the hospital to reports into inadequate care in recent years. They give trainees the necessary experience so that a specialist 281 Health and Social Care Bill[LORDS] Health and Social Care Bill 282

[LORD TURNBERG] we are grateful to the noble Lord, Lord Walton, for trained in one area can practise somewhere else? Are withdrawing his amendment at that time as that has there enough staff to enable trainees to have the time enabled major discussions to take place on the issue. they need for education? Will they have the time to Government Amendments 61 and 104 bring us to attend courses? Will it be in the trusts’ best interests the heart of who will be driving much of the education to allow the rotation of their trainees to other trusts? and training—that is, the national Commissioning In all these areas employers may have different Board and the local commissioning groups. In fact, priorities. For this reason, it is vital that we have the neither of these groups seems to have any responsibility input of those with particular expertise in and for education and training, even though, as the noble knowledge of education and training, and enough Lord, Lord Turnberg, rightly says, they will be right at independence to ensure that the training needs of the the heart of commissioning the healthcare required, trainee are met. whether it is in an NHS setting or a private, approved Hitherto, specialist postgraduate training has involved setting. That appears to be an omission in the Bill. the medical royal colleges in designing the curricula Although I have much sympathy with Amendment and educational programmes for trainees, and in setting 109 of the noble Lord, Lord Turnberg, and he is right and running the postgraduate exams and assessments, to point out that there is a requirement on private while the postgraduate deans are responsible for ensuring sector providers or, indeed, third sector providers, to that local conditions are right for trainees—that training engage in training, I hope that when the Minister posts are available and for funding those posts. With winds up on this group of amendments he will point the dissolution of the strategic health authorities, the out the advantages to those providers of engaging in postgraduate deans and deaneries are left in the air education and training. Indeed, he has privately assured and the local education and training boards are to be many of us that they are more than willing to do so taken over by the employing authorities. The amendments because they cannot become qualified providers unless in my name try to redress that balance by ensuring they are engaged in cutting-edge training and education. that the training boards have in their membership the independent voices of those—namely the universities— In Amendment 109, the noble Lord, Lord Turnberg, whose prime role is to help them with the activities. To raised the important issue of the involvement of this I would add the postgraduate deans and colleges. universities. It worries many of us that the universities Furthermore, it is important that the local education which have been very much at the heart of education and training boards, while quite reasonably including and training, particularly postgraduate education and local employers, should not be led by them. Boards training, appear to be sidelined in the new architecture should have sufficient independence to keep employing of the Bill. Frankly, that is unacceptable. It should not authorities focused on meeting the needs of trainees. be for local employers to decide whether or not they That is why I have tabled these amendments. want a university to be involved; it should be a requirement for universities to be involved. We must not have a I know that the Minister has given some reassurance situation where universities are regarded as predators from the Government along those lines in the letter in relation to education and training, as they are that he has written to some us. He said in his letter, fundamental to it. If research is a fundamental part of which I hope he will not mind my quoting back to the architecture of the Bill and of improving patient him: care, frankly, it is absurd to have universities outside “This framework will be maintained in the new system, with that remit. Therefore, I hope that when the Minister the LETBs assuming responsibility for the quality management responds he will assure us that universities are part of role at local level”. the solution—as the noble Lord, Lord Turnberg, rightly That bothers me a little. Quality management should said—and are not seen as part of the problem. be independent of the employers themselves. We now need to see something in the Bill that will give us the confidence that it will happen. Lord Walton of Detchant: My Lords, I have just My name is also attached to Amendment 105. Here counted that in the course of the past few weeks and we are concerned specifically that private providers months I have attended 28 seminars, group discussions should not be able to shirk their responsibility for and personal meetings with Ministers, the Bill team training. There is no doubt that training requires more and others. That was extremely useful. We have spent time and money. If private sector providers are able to a lot of time discussing education and training. I pay avoid training, they will have an unfair advantage over warm tribute to the Minister—the noble Earl, Lord NHS providers. Of course, there is much valuable Howe—and his team and colleagues for the way in experience and training to be gained from private which they have responded and listened to many of practice. For those reasons, I am happy to support this the concerns which we have expressed about these amendment, too. problems. The Government have tabled a number of very helpful and constructive amendments. However, I Lord Willis of Knaresborough: My Lords, I support seek to ascertain whether they meet all our concerns. government Amendments 61 and 104. As regards I know that the noble Lord, Lord Willis, will say Amendment 2, which the noble Baroness has introduced, that our earlier concerns about research and its role in Clause 6 adequately describes the duties of the Secretary the NHS have been completely met. I agree with him of State in relation to education and training. My entirely. We are satisfied on that point. However, in noble friend the Minister has done an incredibly important relation to education and training, I said at Second job in recognising the real anxiety that existed at Reading that since the health service began, undergraduate Second Reading about education and training. Indeed, training of doctors, medical students and dental students 283 Health and Social Care Bill[8 FEBRUARY 2012] Health and Social Care Bill 284 had always been the financial responsibility of the acknowledging the fact that newly qualified social universities, but that it had always been the responsibility workers were being placed in situations where they of the NHS to provide the clinical facilities in hospitals had too large a case load and were not being properly and general practices of the United Kingdom for the supervised. Fortunately, some steps have been taken to training of those undergraduate students. Of course, address this, but there is clearly still a long way to go in more recent years, the newer universities—the former on supervision of social workers, and the culture and polytechnics—have played a major role in the training state of morale of social workers has for many years of other healthcare professionals such as nurses, been eroded by the lack of attention to their professional physiotherapists, occupational therapists, speech and development. There was a time when there was good language therapists and others. That commitment has professional development; so it can happen, and it been totally accepted. could happen in the medical professions. However, postgraduate training of doctors, as the Perhaps I may draw attention to the experience of noble Lords, Lord Turnberg and Lord Willis, have teachers in Finland. This is particularly relevant to the said—those who are training to become physicians, Minister’s and the Government’s desire to increase surgeons, psychiatrists, and specialists in any branch autonomy within the health service and devolve of medicine—is the financial responsibility of the responsibility down to the professionals closest to the National Health Service and has been from the very front line. About 20 years ago, Finland reviewed its beginning of the NHS. At the same time, the NHS has education system and decided to emphasise the employed postgraduate deans who have been very professional development of its teachers. It decided to helpful and responsible in helping to provide that select its teachers very carefully, and now all practising training. It has also been monitored throughout by teachers have a masters qualification before practising the royal colleges and faculties that have provided the with children. Only one out of 10 applicants for teacher content and curricula for the training of these training places is accepted: there is huge competition groups of specialists. It is crucial that that interrelationship to get on those courses. A few years ago, when PISA of all these bodies be enshrined in the Bill, even when started publishing league tables of education system Health Education England comes into being. I am performance across the world, the Finns came out top mildly surprised that all the amendments grouped of the numeracy, literacy and science tables, not just in with Amendment 2 deal with education and training, one year but in successive years. Teachers are given a but so too do Amendments 13, 16, 62 and 106 that are huge amount of respect within their society, very good equally important and crucial to this whole programme. professional training and development, and are well I therefore ask the Minister whether he is satisfied recruited. There is no inspection of the education that in the amendments that the Government have system—teachers are so well trusted to do the best for tabled, or in regulations that he can assure us will children. follow, the responsibilities of the universities and I pay tribute to the noble Earl and colleagues for other institutions of higher education will be enshrined giving this the best possible attention in the course of and clarified. Is he satisfied that through the postgraduate proceedings in your Lordships’ House. deans and the clinical senates—wherever they are housed, or whether they are housed with the National 5.15 pm Commissioning Board and its outreach into parts of the country—the responsibilities of the royal colleges Lord Patel: My Lords, I pay tribute to the noble and faculties will also be enshrined, and the postgraduate Earl for how he has met our concerns in the Committee deans will thereby continue to supervise the programmes? debate on education and training. The noble Lord, Is he satisfied—and this is crucial—that independent Lord Walton, mentioned Amendments 13 and 16. To foundation trusts and any qualified providers that are me, Amendment 13 is crucial. The reason I degrouped providing NHS services will be required to accept them is because Clause 6 addresses the Secretary of responsibilities for the training and education of healthcare State’s responsibility for education and training. I professionals, just as NHS hospitals, general practices hope that we will have the debate about the issues that and other NHS institutions are? he raises when we debate Amendment 13. I agree with It is crucial that these issues are confirmed, and I the amendment of the noble Lord, Lord Turnberg— trust that the noble Earl will be able to tell us that in Amendment 16—which provides that universities need the government amendments, and in regulations that to take a greater part in education and training than may follow, all our anxieties about these major issues they have hitherto. will be accepted and covered to the benefit of the healthcare workforce and the National Health Service Lord Hunt of Kings Heath: My Lords, as this is a overall. new stage of the Bill, I should declare a number of interests which are also listed in the register; I am The Earl of Listowel: My Lords, I rise briefly to pay chairman of the Heart of England NHS Foundation tribute to the noble Earl, Lord Howe, and his colleagues Trust, a consultant and trainer with Cumberlege for giving this most important issue such great attention Connections, president of the British Fluoridation since the Bill arrived in this House. Society and of the Royal Society for Public Health. I wish to look at the experience in social work, I put my name to Amendment 2, tabled by the where there has been great deterioration in the attention noble Baroness, Lady Finlay, which has perhaps not given to the professional development of social workers. received as much enthusiasm as I would have wished I remember reading a letter from the noble Lord, Lord from noble Lords, who have pointed to Clause 6. Hunt, when he sat on the Front Bench a few years ago, Behind her amendment is real concern to ensure that 285 Health and Social Care Bill[LORDS] Health and Social Care Bill 286

[LORD HUNT OF KINGS HEATH] Commissioning Board; are they going to be aligned we will train enough health professionals in the years with the clinical senates; or are they going to float ahead and that they will be of sufficiently high quality. free? I think we should be told. There is some history here. I very much support devolving I also echo the words of the noble Lord, Lord as much as possible decisions about the commissioning Willis, regarding the role of universities. It should not of training places to local NHS organisations. I warmly be an option; they need to be round the table. It needs welcome the work of Dame Julie Moore and her team, to be what I would describe as a “hard partnership”. I who have produced the report. She is chief executive think we are all well aware of the issues and concerns of the UHB Foundation Trust in Birmingham and surrounding the quality and outcome of nurse training. brings a lot of expertise to that position. Some noble The noble Earl, Lord Howe, himself has often commented Lords will have been to a seminar where the report on issues such as dignity, nutrition and so on, where was debated. I have no argument with its general matters have been raised by patients and there is thrust, but we know from experience that when money concern about whether today’s nurses are getting the is tight, the NHS reduces the number of people that it kind of training that is required. It is very important trains and its training budget. That always happens that those who commission from universities do so in and, a number of years later, the NHS then pays the as vigorous a way as possible and hold those universities consequences. If we are to have a highly effective to account. However, equally there has to be a partnership. National Health Service in future, we need to recognise The noble Earl, Lord Howe, will know about the that the quality of our professional staff goes to the intention to expand academic clinical science networks. core of what we seek to do. Therefore, it is right that That is a very good example of universities and the the Secretary of State should be seen to have major health service coming together, and we need to encourage responsibilities enshrined in legislation. That is the that in the future. essential point of Amendment 2, whatever the technical Finally, the noble Lord, Lord Walton, raised a deficiencies to which noble Lords have kindly drawn point about the duty on any willing provider regarding our attention. training or research. I think that I have covered that, In that regard, let me say that I welcome the government but he also mentioned NHS foundation trusts. I am amendments in this area and the work of the noble not aware of any situation in which NHS foundation Earl, Lord Howe. Of course, he is also responsible for trusts are ignoring their responsibilities but I certainly research in the department, and I think that he well agree with him that, as they are more independent of understands how the education and training of our the Secretary of State than other parts of the NHS, professionals very much ties in to the research agenda. some assurances from the noble Earl in that regard I know that we will come to research later tonight. would be welcome. In relation to the other amendments in this group, I Lord Northbourne: I wonder whether the noble have already welcomed the government amendments, Lord could clarify a point for me. In his Amendment 62 but perhaps I may pick on Amendment 63. It is right he speaks of the “healthcare workforce”, whereas the that the national Commissioning Board should have noble Baroness, Lady Finlay, in her amendment talks regard to the promotion of training of clinical staff in of “healthcare professionals”. Are these identical groups any provider from which it commissions services. There of people? I am particularly interested in whether is essentially a parallel amendment—Amendment 104— nursing staff are included in one or both of those terms. which applies to clinical commissioning groups. The whole point here is to ensure that there is a level Lord Hunt of Kings Heath: My Lords, that is a very playing field. If, regrettably, the Government persist good point. As I say, it is always helpful when noble with this lunatic idea of a competitive approach Lords point out errors and omissions in the drafting within the health service, it is essential that when of amendments. Amendment 2 refers to “health care it comes to commissioning decisions all qualified professionals”, and I am clear that nurses must be providers contribute to education and training. It embraced within that definition. would be an absolute disgrace if clinical commissioning On Amendment 62, I would not detract from the groups and the national Commissioning Board started use of, to commission services from organisations that did “education and training of the healthcare workforce”. not play their full part in education and indeed research. I hope that the noble Earl, Lord Howe, will make it Earl Howe: We are not debating that amendment clear that that is what his Amendment 104 means yet. when it says, in parliamentary counsel terminology, Lord Hunt of Kings Heath: My Lords, the noble that clinical commissioning groups must, Earl, Lord Howe, has kindly reminded me that we are “have regard to the need to promote education and training”. not debating Amendment 62. It will be debated in a I take that to mean that the amendment does not later group, which allows me a little time to reflect on permit CCGs to place contracts with qualified providers the point raised. who do not make a contribution to education and Earl Howe: My Lords, this has been a very useful training. debate. Perhaps I can begin with a clear statement that Overall, I echo the words of the noble Lord, Lord the Government are committed to the education, training Walton, regarding the work of postgraduate deans and continuing development of the healthcare workforce. and his question about their future. Where are This is fundamental in supporting the delivery of postgraduate deans going to lie in the future? Are they excellent healthcare services across the NHS. I am going to lie in the local branch offices of the national pleased that so many noble Lords share that view. 287 Health and Social Care Bill[8 FEBRUARY 2012] Health and Social Care Bill 288

We are, however, in the rather odd position of light of that, I hope that the noble Baroness will feel having before us two groups of amendments on education reassured to some extent and feel able to withdraw her and training. Given that we still await a further debate amendment. on the subject today, I should like to reserve some of the detail of my remarks, if I may, for that debate, 5.30 pm when I address one of the amendments in the name of The noble Lord, Lord Walton, put particular emphasis the noble Lord, Lord Patel. However, to begin with, on the universities being involved in local education and for now, I think that it will be helpful if I set the and training boards. We wholeheartedly agree that it is scene. crucial that universities and other education providers First, I confirm to the noble Baroness, Lady Finlay, are integral partners in the planning, commissioning that we made clear in Liberating the NHS: Developing and delivery of education. Health Education England the Healthcare Workforce—From Design to Delivery, will set robust criteria for the establishment of the which was published recently, that we are committed local boards, and strong and meaningful partnerships to a national framework for education and training, with universities will be a key element of that assessment. with Health Education England providing national The core purpose of the local boards is to lead planning leadership and being directly accountable to the Secretary and education commissioning to ensure security of of State. supply of the local health and care workforce and to support national workforce priorities set by Health Health Education England will ensure that the Education England. They will have a number of functions healthcare workforce has the right skills, behaviours which I have detailed in a recent letter to noble Lords. and training, and is available in the right numbers to One of them will be to hold and allocate funding for support the delivery of excellent healthcare and health education and training. Others will be to commission improvement. It will work with a range of key partners, education and training, to secure quality and value including the medical royal colleges, professional regulators from education and training providers and to secure and the academic and research sectors. The national the partnerships that we want to see with clinicians, input and oversight will be there in all the areas which, CCGs, local authorities, health and well-being boards, rightly, the noble Baroness is concerned about. Health universities and other providers of education, research Education England and the wider education and training and innovation. At the same time, however, Health system will, as I said, remain accountable to the Secretary Education England will be overseeing that, securing of State, who will have a duty to secure an effective national coherence and greater transparency in the system for the planning and delivery of education and education and training investments that employers training in the NHS. Employers and healthcare make in their workforce. professionals will play a leading role in workforce planning and development through the establishment The noble Lord, Lord Turnberg, asked me about of local education and training boards, working with the role of the royal colleges and postgraduate deans. the education and research sectors. I shall have more We have no intention of tampering with national to say about that in a moment. standards. Professional regulators will continue to set professional standards. The royal colleges will continue I can reassure noble Lords straight away that to shape curricula and will work in partnership with postgraduate deans will continue to be a critically Health Education England to ensure that education important part of the medical training arrangements. and training reflect best practice and are of high The Government listened to the concerns expressed in quality. Professional regulators have a statutory Committee by a number of Peers that the Bill did not responsibility for setting standards and ensuring those go far enough in safeguarding the future education standards are met and maintained. The new system and training system. In this group of amendments, goes further because we have developed quality indicators which I shall speak to shortly, we have tabled a number that will bring quality to the heart of the commissioning of proposals designed to address the gaps that noble process. The education outcomes framework, which I Lords identified. will say a bit more about when I come to address the On Amendment 2, tabled by the noble Baroness, later amendments tabled by the noble Lord, Lord Lady Finlay, the Government have already introduced Patel, will set out the outcomes expected to achieve a duty for the Secretary of State to maintain an quality healthcare, education and training. Indeed, effective system for education and training. Our duty one of Health Education England’s key functions is to is more comprehensive than this amendment in that promote high-quality education and training that is it applies to the whole healthcare workforce and not responsive to the changing needs of patients and local just doctors. The noble Baroness asked about the communities. scope of Clause 6. Our duty applies to people who are Let me say a little more in answer to the noble employed, or who are considering becoming Lord, Lord Walton, about postgraduate deans. employed, in an activity which involves or is connected Postgraduate deans will remain critical to these training with the provision of services as part of the health arrangements. We expect local education and training service in England. This covers healthcare professionals boards to be able to demonstrate that their postgraduate at the centre of delivering healthcare, including doctors, deans will be able to act independently of any perceived dentists, nurses, midwives, pharmacists, healthcare conflict of interest that may arise between training scientists and the allied health professions. It includes and service priorities. There will be clear checks and registered and unregistered professions. It also covers balances in place and quality metrics to hold local non-clinical staff who are involved in, for example, the education providers to account for the quality of the commissioning or administration of services. In the education that they deliver. Postgraduate deans will 289 Health and Social Care Bill[LORDS] Health and Social Care Bill 290

[EARL HOWE] that they will feel able to support those amendments in have all the powers that they have now to respond to due course when they are moved and, for now, to concerns about the quality of training, to take action withdraw theirs. where required to improve standards and to assure the professional regulators and Health Education England that poor performance, if it occurs, is identified and Baroness Finlay of Llandaff: I am most grateful to tackled. In the new system, they will have what I hope the Minister for the amendments that he has tabled on will be the welcome support of the local education behalf of the Government, and for all the listening. and training board, and, if necessary, Health Education This short debate has demonstrated just how far we England, to challenge poor quality and behaviours. have moved, how much he personally has taken on We believe that the checks and balances will be there board and committed to improving education and in the system. training, and that the amendments that are there for us to approve later provide a scaffolding throughout The noble Lords, Lord Walton of Detchant and the Bill for education and training that was not there Lord Hunt of Kings Heath, asked about the involvement before. I fully accept that the amendment in my name of qualified providers other than NHS providers. All is probably in the wrong place in the Bill and that to providers of NHS-funded services will be expected to restrict it to professionals is too narrow—it is the participate in the planning and delivery of education whole workforce. Therefore, I beg leave to withdraw and training. Health Education England will allocate the amendment. funding for investment in the future workforce only to those that participate. We will be considering in future Amendment 2 withdrawn. weeks what additional duties we might place on all providers when we look at proposals for a future Bill on education and training. Amendment 3 The noble Lord, Lord Hunt of Kings Heath, referred Moved by Baroness Thornton to funding. Many respondents to the consultation 3: Clause 1, page 2, leave out lines 7 to 9 and insert— called for education and training funding to be protected. “(2) The Secretary of State must for that purpose provide or We agree, so we will ensure that Health Education secure the provision of services according to this Act.” England establishes transparent systems to make sure that organisations that receive MPET funding are held to account for using it for the education and training Baroness Thornton: My Lords, we originally put of the NHS workforce. down Amendments 3 and 4 in Committee back in the As I said, the Government have listened to the autumn. It has to be said from the outset that this is concerns expressed in Committee by a number of actually still a very bad Bill. Since Committee, the Peers. We have already introduced the duty on the context in which we are discussing this Bill has without Secretary of State to exercise his functions so as to doubt changed. It seems that it has no support from secure an effective system for education and training. anywhere except in the Department of Health—and Amendment 15 puts more flesh on that duty by specifying possibly not even from everybody there. It still has no the Acts that contain functions that must be exercised mandate. by the Secretary of State so as to discharge his education Going back on previous commitments to, and training duty. “no more top-down reorganisation of the NHS”, Building on that, we have tabled amendments to the Prime Minister and his Health Ministers, including strengthen links with the wider system. Amendments 61 the noble Earl, have adopted what we on these Benches and 104 place duties on the board and on CCGs to would like to term the “Attlee defence”, in deference have regard to the need to promote education and to the noble Earl, Lord Attlee—and I mean the training. These duties are designed to ensure that Government’s Earl Attlee, not ours, as it were. Last commissioners of NHS services consider the planning, March, during a debate on the Building Regulations commissioning and delivery of education and training (Review) Bill, in trying to explain the Government’s when carrying out their functions. position, the noble Earl came up with: “I gently remind the Committee that I answer for Her Majesty’s Nationally, Health Education England will work Government, not for the previous Opposition”.—[Official Report, with the NHS Commissioning Board to ensure that its 4/3/11; col. 1352.] strategic framework for education, training and workforce That is a remarkable statement. Perhaps the Minister planning reflects service commissioning priorities and could gently remind the Prime Minister and the Health that workforce development implications of innovation Secretary of their coalition agreement. and changes in the pattern and nature of services are It is significant that the Prime Minister has had to addressed and identified. As I indicated earlier, CCGs come to the Bill’s rescue today, not least because a will work with the local education and training boards Downing Street source yesterday was reported to threaten to consider the workforce implications of their local the very life of the Secretary of State—I think that the service commissioning decisions. words used were “taken out and shot”—for his failure The other amendments tabled in this group by to communicate the Bill and the Bill’s policy. We in the noble Lords are, I believe, designed to have much the Opposition have never advocated such a thing. Perhaps same effect. I hope that noble Lords will be reassured the Minister would like to comment on this particular by the vision I have set out for education and training version of the Secretary of State’s ultimate responsibility and by the amendments that we are proposing, and in his job. 291 Health and Social Care Bill[8 FEBRUARY 2012] Health and Social Care Bill 292

The Prime Minister’s words were also revealing in debate—the difference between these words and those that the Government intend to push this Bill through. that are before the House. I am giving the Minister I do not believe that that is a respectful way of referring notice that this remains a bit of a mystery. to the remaining stages in your Lordships’ House. It As with so much else in this unloved Bill, we are left begs a question that I should like to ask the Minister with the question: why? Why on earth did the original early in Report stage, which arises from what happened Bill propose a radical change to the role of the Secretary recently as regards the Welfare Reform Bill. Will he of State? The Minister in the Commons, Simon Burns, give the House notice now as to whether the Government was ready to die in a ditch for the wording. It was a intend to use the financial privilege mechanism to liberation ideology for him. Why, throughout the scrutiny strike down any amendments that this House might in the Commons, was the line rigidly held by coalition agree during the remaining stages of this Bill? Ministers and MPs, and why is the Secretary of State—I I have searched in vain for a precedent of legislation really do think the House needs to know the answer to that is so unwelcomed by those who have to deliver it, this question, but again I am quite happy to wait—now so incomprehensible to those on whom its consequences briefing royal colleges saying, “Actually, the changes will be wreaked and so difficult to explain in simple that noble Lords have agreed in their Chamber will terms. But even the Minister, who is acknowledged by make no difference to the Bill”? the whole House to be an outstanding performer and Our amendment and the others that deal with the someone who can normally enlighten us about most role of the Secretary of State are important and we matters in clear, plain English, has had to resort on have undoubtedly prised improvement out of, if not a many occasions to seeking to justify points of this Bill reluctant noble Earl in this Chamber, certainly out of in the managerial jargon of his boss, Mr Lansley, a reluctant Government. Many of these issues are which is as dense as the Bill itself. If any noble Lords proxy arguments about what kind of NHS we want. doubt that, I suggest that they need only to peruse the During the rest of the Report stage we will focus our record of the Committee stage. energies on the many other things that need to be We do not work in a sealed bubble in this Chamber changed, particularly in Part 3. These are part of the and I appreciate that the Government might prefer it if argument about why we do not want a full market, that were the case. But the public’s view of this Bill has why we do not want regulation along the lines of that shifted and hardened since we completed the Committee for the utilities or for the banks, and why we need to stage before Christmas. The views of those who have protect and preserve the tradition, well established engaged with this Bill for more than a year have and well understood, of the role of the Secretary of changed and we need to hear their voices throughout State. Report stage. I will be withdrawing the amendment, as I promised As we all know, the discussions around the role of the Minister I would, but I would like some answers to the Secretary of State have been of great significance. the questions that I have posed in these remarks. I beg What has emerged is that the reasons for changing the to move. role have never been made clear. As has been pointed out, there is a continuity around the role of the Secretary 5.45 pm of State which goes way back to the founding of the Baroness Williams of Crosby: My Lords, perhaps I NHS. I will not rehearse all the arguments that we may respond very briefly. The real argument that we heard in Committee and at Second Reading, and should be having is almost certainly on the next group which some of us have been rehearsing during the of amendments, and I have no intention of taking months between those stages and up to last week. The away from that debate in which, as we know, the noble reality is and always has been that the legal duty on Baronesses, Lady Jay and Lady Thornton, and other the Secretary of State is to provide services. Even noble Lords—although unfortunately not my noble securing the provision of services has been delegated and learned friend Lord Mackay today—will take to organisations which deliver that duty on behalf of part. It is an important debate that symbolises for me the public. Public accountability is and always has something of crucial significance, and that is that in been vital to maintaining public confidence in the this House we have moved towards all-party agreement NHS. Ultimate political accountability exists in the on the constitutional underpinning of the National person of the Secretary of State. Health Service; that is a great achievement. In no way can the Secretary of State argue that any I shall not take further from what the noble Baroness, failure to provide necessary NHS services is not his or Lady Jay, will want to say—except that perhaps I shall her responsibility. The argument that if there is an follow her on this issue—beyond saying that I am issue the Secretary of State must work through failure deeply saddened that over the past day or two we have regimes, regulations and directions to others is not seen what I believe to have been a far-reaching and good enough. As the Health Select Committee and radical attempt in this House to try to present an many noble Lords, including the noble Lord, Lord all-party consensual underpinning for the National Mawhinney, said in Committee, it would not be believed Health Service being turned into what one can only anyway. describe as the most petty of political rows whose We will be moving to the alternative wording in the seeming intention is to try to acquire political balance next debate. We on these Benches have supported the for one side or the other. That is a great shame. process that has led to that wording. However, I should I think that many of us believe that the wording like the Minister to explain—I would be very happy to which has been accomplished— although I note the hear that explanation when he responds to the next commitment of the noble Baroness, Lady Thornton, 293 Health and Social Care Bill[LORDS] Health and Social Care Bill 294

[BARONESS WILLIAMS OF CROSBY] aware that we are retaining the wording of the NHS to the word “provide”—means that we can be satisfied Act 1946, where appropriate. For example, the Secretary with the constitutional group. We do not need to of State retains his duty to, change the wording and what is now set out in the Bill “continue the promotion in England of a comprehensive health after this long exercise is in fact legally watertight. I service”, say that because some of the most distinguished lawyers and his duty to, in this House were part of the drafting process, including on the Labour side the noble and learned “secure that services are provided”. Baroness, Lady Scotland. On the Conservative side The reason for our removing the 1946 duty on the we had the outstanding figure of the former Lord Secretary of State to provide services himself is that it Chancellor, my noble and learned friend Lord Mackay fails to reflect the reality of the way that NHS services of Clashfern, and on my side, among others, my noble are delivered. In general and for many years, the friends Lord Clement-Jones and Lord Marks of Henley- Secretary of State has not himself exercised functions on-Thames. All these lawyers put their heads of providing or commissioning services. The functions together in order to establish a basis on which we are delegated to SHAs and PCTs. Under the Bill, could agree, and I would suggest to the noble Baroness, however, this function will be conferred directly on a Lady Thornton, for whom I have a great deal of dedicated NHS Commissioning Board and CCGs. respect, that if the word “provide” did not surface Indeed, as my noble and learned friend Lord Mackay during that exercise, it is because it is to a great extent of Clashfern has pointed out previously, there has at odds with the facts at the present time as to who never been a straightforward duty to provide services. actually provides services for the NHS, and of course The requirement was framed as a duty to, that has changed radically in recent years. It has changed radically because of steps taken not only by “provide or secure the … provision of”, the present Government but also by the previous services. In practice, Ministers or the NHS bodies Government, when a great deal of provision came responsible for exercising the Secretary of State’s functions from newly established elements in the private sector, have usually exercised the second option, securing the including intermediate treatment centres. Efforts were provision, rather than the first, actually providing. made to bring about an extensive network of hospitals The Secretary of State—that is, the Department of to look at how far private treatment could be accepted Health—has not provided NHS services directly for and it was done on the basis of trying to bring new many years. Our policy is that the Secretary of State providers on the scene, which the noble Lord, Lord should neither provide nor commission NHS services. Darzi, among others, has talked about. I am probably It is clear from these amendments that the Opposition one of those who are more “old-fashioned” in their are harking back to a centralist, top-down approach. view of the privatisation of the NHS, which I certainly They sometimes say that they want clinical commissioners, would not support. That is not the same as talking but these amendments contradict that. They would about the competitive providers who under the previous not create a system of clear responsibility but instead Government and the present one have made some one where Richmond House was always right. That contribution to the services of the NHS. model has been tried to the point of exhaustion and I say with great respect to the noble Baroness that has been found wanting. In contrast, the Bill establishes this pair of amendments is unnecessary. I think that, a framework in which the Secretary of State no longer legally, the existing wording now stands up and has has the powers to provide or commission NHS services. the precious boon of having been supported by all Instead, those functions are conferred on other bodies parties in this House and those who sit on the independent in the system. An amendment to Clause 1 to impose a Cross Benches. We should therefore move on to the duty on the Secretary of State to provide services—or next group of amendments and be able, among other a duty to exercise his functions so as to provide things, to celebrate our achievement, which I hope will them—is simply not consistent with that framework. enable the National Health Service to flourish and When this issue has been debated previously, one of survive into the rest of this century. the main arguments against losing the duty to provide was that it would result in reduced accountability to Earl Howe: My Lords, as my noble friend has Parliament for provision. Although that has never correctly reminded us, the next debate will give us the been our intention, we have, as I said, tabled amendments opportunity to discuss the package of amendments to put beyond doubt the matter of ministerial designed to clarify the Secretary of State’s accountability accountability. Given that the Secretary of State does for the health service. I recently completed a series of not provide services directly, and that the amendments meetings with Peers from across the House to understand we will debate shortly clarify beyond doubt the Secretary their concerns about this and related issues. Thanks to of State’s continued accountability to Parliament, it is the efforts of so many here today, including the noble not clear what an amendment to reinstate the duty to Baroness, Lady Thornton, I am pleased to say that we provide would achieve in practice. have sufficient consensus to table a series of amendments If these amendments are about ensuring that the on this matter. I very much look forward to discussing Secretary of State takes the steps required to secure them when we reach subsequent groups. the proper provision of NHS services, I simply reassure Amendments 3 and 4, tabled by the noble Baroness, the noble Baroness that the Bill already does this. It Lady Thornton, seek to reinstate the duty to provide. I requires the Secretary of State to, do not wish to dwell too long on what I have said on “exercise the functions conferred by this Act so as to secure that previous occasions, but the noble Baroness will be services are provided”. 295 Health and Social Care Bill[8 FEBRUARY 2012] Health and Social Care Bill 296

That is a strong and onerous duty, sufficient to ensure 6pm that the Secretary of State discharges his responsibility Baroness Jay of Paddington: The Minister has clarified for the NHS. the difficulty that I was in, partly because of the In explaining these amendments, the noble Baroness intervention from the noble Lord, Lord Lester, but repeated her call for the Bill to be withdrawn on the also because of what the noble Baroness, Lady Williams, grounds that nobody supports it. I acknowledge that said. As I understand it, all their remarks are posited there are opponents of the Bill but she must also on the basis that the subsequent amendment, acknowledge that many in the medical community and Amendment 5, will be accepted by the House. When in the wider public support our reform programme. We they refer to the terms of the Bill, they are referring to know that clearly from the listening exercise last year the Bill as it now stands and not as it will, I hope, be when many thousands of people contributed their views. amended in the conclusion of our next debate. Those views about the principles of what we are trying to achieve came through loud and clear. In the main, Earl Howe: I am grateful to the noble Baroness, the concerns revolved around implementation. Webelieve who is of course quite right. that we have addressed those concerns in amendments I have been handed a note, which says that when I to the Bill and in other announcements that we have said that there would be no legally enforceable duties made that are non-legislative in nature. We continue to on quality improvement, I should have clarified that believe that our plans for modernisation are essential if that would have a follow-on. I should have said, “across we are to put the NHS on a sustainable long-term the NHS system”. footing. I will explain a few ways in which that is true, The noble Baroness, Lady Thornton, referred to and will try to do so in clear, layman’s language without potential privilege responses from the Commons. My resorting to departmental technical speak. noble friend the Leader of the House made a Written Without the Bill, Ministers would remain free to Statement last Thursday about the financial privilege continue to micromanage the NHS. There would be of the House of Commons in which he drew attention no legally enforceable duties to tackle health inequalities to a paper by the Clerk of the Parliaments, available in as the Bill introduces such duties for the first time in the Library. I think that questions about procedure this country. There would be no legally enforceable may be best directed to my noble friend, but I shall do duties on quality improvement because it embeds quality my best to assist. The Clerk of the Parliaments makes improvement throughout the system. There would be it clear in his paper that, no duties on NHS organisations to involve patients in “until the Commons asserts its privilege, the Lords is fully entitled decisions about their care. Failing organisations would to debate and agree to amendments with privilege implications”. continue to be propped up using taxpayers’ money—the That is what we should do. I would much regret it if Bill tackles that problem in a creative way. Governments the House thought that I was trying to restrict its role would be able to prioritise the private sector over the of revision. The Marshalled List sets out more than NHS—the Bill ensures that such behaviour is prohibited. 100 amendments in my name, tabled in response to Patients would continue to lack the means to hold the debate in Committee, and if the House agrees to those NHS to account because the Bill gives patients real amendments I can assure noble Lords that the power by establishing HealthWatch so that the interests Government will encourage the other place to accept of patients and the public can be championed throughout them. the NHS. Withdrawing the Bill would cause disruption The essence of the noble Baroness’s question is and chaos at a time that the NHS most needs certainty about privilege reasons for the Commons rejecting about the future. As has been said today, the NHS is amendments proposed by this House, and on that I already in a state of change. That cannot be sustained can say two things. First, any amendment with indefinitely because it puts additional strain on implications for public expenditure might involve privilege, management capacity and creates additional cost. but that is a matter for the Commons alone. Decisions on financial privilege are for the Speaker of the Commons Lord Lester of Herne Hill: Does my noble friend on advice from the Clerks of that House. If the Commons agree that one of the vices in the amendment is that it reject a Lords amendment in which the Speaker has would encourage judicial review proceedings and legal determined that privilege is engaged, the only reason uncertainty? I say that as somebody who has taken that it can send this House is a privilege reason. There advantage of the old wording to bring successful is no discretion. judicial review proceedings in Northern Ireland. The Secondly, this debate is by its nature premature. I advantage of what we now have in the Bill is that it will hope that our debate and dialogue will lead to this Bill not place judges in the position of seeking to run the being sent to the Commons in a form that that House health service, instead of Parliament, Ministers and will accept. Until we see how Report unfolds, it is too the health authorities themselves. early to speculate on the reaction from the Commons. One cannot have a reply to a question until the question Earl Howe: I defer completely to my noble friend, has been asked. who is right to point out that one thing that we wish to avoid is a charter for a legal action and judicial review. Baroness Thornton: My question was actually about I believe that we have avoided that because of the way the Government’s intentions. That was a very enlightening in which accountability is now described in the Bill—or and helpful remark about privilege. The Speaker of will shortly be described, when the amendments are the Commons will not presumably, by and large, take passed. It is accountability primarily through the Secretary a view on privilege unless the Government ask him to. of State to Parliament. I thank the noble Lord for his So my question was about the Government’s intention observations. on this matter. 297 Health and Social Care Bill[LORDS] Health and Social Care Bill 298

Earl Howe: I have taken advice on this, and I believe “( ) The Secretary of State retains ministerial responsibility to that what I am about to say will not mislead the House Parliament for the provision of the health service in England.” as I have been given this advice on authority. It is not for the Government to do anything; it is not within Earl Howe: My Lords, I beg to move Amendment 5. our power to do anything. The noble Lord, Lord As noble Lords will be aware, and as I stated during Martin, who spoke last week on this matter, is par our discussion on the previous group of amendments, excellence an authority on this. A view is taken by the a number of concerns were raised in Committee over the Clerks in another place on the amendments passed in clauses relating to the Secretary of State’s accountability this House as to whether privilege is engaged. The for the health service. Since our collective discussion in Speaker is then advised. The Government have no role November to withdraw amendments on this issue, in that process at all; it is a Commons privilege, not the pending a period of discussion and reflection, I have Government’s privilege. been meeting noble Lords to understand their concerns. I hope that what I have said will persuade your Alongside the conversations that I have had with Lordships that the course down which the Opposition Peers, both individually and in groups, we have held would wish to take us is the wrong one. The Bill, once two all-Peers seminars to try to reach consensus on amended—if that is your Lordships’ wish—through what changes might be made to bring clarity. I am the amendments that have been jointly agreed on a very grateful to all those who invested time and effort cross-party basis, will therefore be fit for purpose in in this matter, which I know so many are passionate clarifying beyond peradventure the Secretary of State’s about. accountability for the health service and the exercise I would particularly like to thank the noble Baroness, of his powers. With that, I hope that the noble Baroness, Lady Jay, and her colleagues on the Constitution Lady Thornton, will feel able to withdraw her amendment. Committee, who articulated their concerns about ministerial accountability so coherently in their two reports and proposed amendments. I believe, as had Baroness Thornton: I thank the Minister for that been suggested already, that the process that we have response. I made it clear in my opening remarks that I gone through has revealed the House of Lords at its would not seek to push the amendments to a Division, best—working together to improve the Bill and achieve although the remarks of the noble Baroness, Lady common ground. This amendment deals with the Williams, and the Minister made me wonder whether I overarching accountability of Ministers for the health ought to do so, because certain things that were said service, as set out in Clause 1. At this stage, we are were not justified. taking this amendment on its own, but there are First, the noble Earl took us through a list of things further amendments on related themes to follow. We that without the Bill would not be happening. On should perhaps look at this amendment in that context. almost every single one, I thought that without the Bill However, I think I am right in saying that Clause 1 you could do all those things. You do not actually has attracted the most attention from Peers, and quite need this Bill to do most of the things that the noble rightly so. It gives the Secretary of State a duty to, Earl listed as being desirable objectives. I am sure that we would agree about most of them being desirable “continue the promotion in England of a comprehensive health objectives. service”, The noble Earl mentioned the listening exercise as wording that can be traced back to the original 1946 being proof that this is not the unloved Bill that I NHS Act. Amendment 5 makes it clear that the Secretary would suggest it is. Only yesterday, a former special of State will retain ministerial responsibility to Parliament adviser to Downing Street said that the listening exercise for the health service. It has been this question of was a tactic as part of managing the Bill. Frankly, I ministerial responsibility that has been such a cause of was horrified by that. If I had been Professor Steve concern, and I am sincerely grateful to the noble Field or one of the 40-odd people who, with every Baroness and the Constitution Committee for drafting good intention of doing a public service unpaid, gave this amendment which, I hope, should serve to put their time to take part in that listening exercise, I everyone’s minds at rest on this issue. would think that it was really shocking. So I think that Noble Lords will recall the original suggestion made the noble Earl should be careful about praying the by my noble and learned friend Lord Mackay, which listening exercise in aid in explaining how loved or used “ultimate responsibility to Parliament”. I should unloved this Bill is. explain that we have gone with the formulation “ministerial It is time that we moved on. I intend to reserve my responsibility to Parliament” because it more clearly praise for the next debate and leave my criticisms in refers to the constitutional principle of ministerial this debate. I intend to withdraw my amendment, even responsibility. That is to say: Ministers are responsible, if the noble Earl will not withdraw the Bill. accountable and answerable to Parliament for their policies, decisions and actions—and, indeed, those of their departments. The principle is recognised by Amendment 3 withdrawn. Parliament and the courts, and, as the Constitution Committee notes, in the Ministerial Code. The amendment Amendment 4 not moved. reflects the position that as a result of the principle and the duties and powers imposed by NHS legislation, the Secretary of State for Health is responsible and Amendment 5 accountable to Parliament for the health service in Moved by Earl Howe England, even if he or his department do not directly 5: Clause 1, page 2, line 9, at end insert— provide or manage NHS services. It has never in fact 299 Health and Social Care Bill[8 FEBRUARY 2012] Health and Social Care Bill 300 been the Government’s intention to diminish ministerial Government rejected that proposal and on that occasion responsibility to Parliament, so I can offer my the noble Earl—rather differently from what he has wholehearted endorsement of and support for this said today, but I entirely understand his change of amendment. I hope that your Lordships will feel able position—echoed the Secretary of State, Mr Lansley, to do so as well. in insisting that although the Bill changed the forms and systems of accountability he, the Secretary of Baroness Jay of Paddington: My Lords, I am grateful State, would continue to have overall responsibility. to the Minister for the way in which he introduced this Those were, in a sense, the terms of the amendment amendment because, as he graciously expressed, this is proposed in Committee by the noble and learned not really a government amendment but an amendment Lord, Lord Mackay of Clashfern. by the Constitution Committee, which it invites your The Government also wanted to make it clear that Lordships to agree. Of course, with a government Ministers should not try to micromanage the health Minister at the head of those supporting the amendment, service and that primary responsibility for service I hope that will in itself be unarguable. It is right that provision under their changes would be devolved to the Constitution Committee’s position should be explained independent organisations. Again, the Minister has a little more in the context of this first amendment in referred to that this afternoon. However, as we know, relation to the Secretary of State’s responsibilities, and it became very clear during Second Reading and the I am glad that it has been put in a group on its own. It subsequent Committee that many noble Lords, in is a very significant amendment, and not just because every part of the House, stood with the Constitution it alters fundamentally the expression of the Secretary Committee in its anxieties. Although they may not of State’s responsibilities from the original Bill. It is have shared them exactly, they did have their concerns. also significant because of the process by which it has As the noble Earl, Lord Howe, has rightly said, he been reached—the Minister has already alluded to very helpfully suggested that this should be taken off this, and I certainly express my enthusiasm for the the Floor of the House, and has tried very strongly to process—and in which the House has undertaken this try to reach the consensus which we have, I hope, come work. to before this next stage of the Bill. I pay tribute to The terms of the amendment are simple but very him for that. powerful: The Constitution Committee, as the noble Earl “The Secretary of State retains ministerial responsibility to said, was invited formally to look at the issues again. Parliament for the provision”— We duly did so, and our second report was published that is always the difficult word— just before Christmas. In it, we continued to argue the “of the health service in England”. constitutional necessity for an explicit reference to It is simple but powerful because, frankly, so is the ministerial accountability to be in the Bill. We therefore concept of ministerial responsibility, although we argue propose the wording and concept of Amendment 5, about it all the time. It is a basic concept which, as the which is before your Lordships. I hope that those in Minister has said, has been expressed in all NHS the House who have had the time to read it have found legislation, and quite rightly in my view, since the first it useful to look at Appendix 1 of the December Act 60 years ago. Without wishing to appear to give a report, which sets out our understanding of ministerial civics lesson to the House, it is worth saying that the responsibility as it applies to the duties of Secretaries Constitution Committee has agreed that, in its terms, of State. Although I hope it will not take long, perhaps individual ministerial responsibility means that Ministers I might quote somewhat extensively from that appendix must be accountable and answerable to Parliament for because it covers some of the points which have been their—and their departments’ and agencies’—policies, raised by noble Lords in debate, and which the decisions and actions. I think that is widely accepted. Government relied on until they decided to accept this There is no constitutional distinction between ministerial amendment. responsibility, accountability and answerability; they The appendix says: are all aspects of the same constitutional fact. “It is essential to bear in mind that (i) what ministers are This Bill was worrying, because it was the first in constitutionally responsible to Parliament for and (ii) what ministers which there was not an explicit provision on political themselves do may not be the same. The distinction matters in the and legal accountability. The Constitution Committee, context of the Health and Social Care Bill for the following as the noble Earl said, raised serious concerns about reason: removing from the Secretary of State the duty to provide this in the initial report that we gave to the House health services does not mean that the Secretary of State no longer remains constitutionally responsible to Parliament for the before Second Reading. There we said that the Bill, if provision of health services. Likewise, a provision to the effect enacted in its present form, risks, that the Secretary of State remains constitutionally responsible to “diluting the Government’s constitutional responsibilities”, Parliament for the provision of health services does not mean that for the NHS. It is worth reminding your Lordships the Secretary of State must himself provide the services. It is that those responsibilities which the Minister should because of a failure to bear this distinction in mind that much of retain embrace the accountability to Parliament for the confusion about this matter has arisen”. the vast public expenditure that the NHS undertakes, One other important point in the appendix is worth and the provision of its multitude of services. repeating. In addition, “there is a constitutionally significant difference between ministerial 6.15 pm responsibility to Parliament and the accountability of a public At that stage, the Constitution Committee suggested body (such as the NHS Commissioning Board)”— that an easy solution was simply to retain the unambiguous as it will be— wording which exists in the present 2006 Act. The “to a minister. In constitutional terms the latter”— 301 Health and Social Care Bill[LORDS] Health and Social Care Bill 302

[BARONESS JAY OF PADDINGTON] say a word not quite on his behalf—that would be that is, the new independent bodies— lèse-majesté—but at least in his interests, as he has “can never be a substitute for the former”— been referred to a lot. I congratulate the noble Baroness that is, the responsibility to Parliament—because in and her committee on what has been a remarkably the latter case the body in question does not have any productive role since the endless debates on these accountability or reference to Parliament. matters that we had at the beginning of Committee. It That clearly sets out the problems which the is a great tribute to her. She will not have been able to Constitution Committee felt expressed an answer to do this on the whole of the Bill, as she implicitly the problems that have arisen all around the House. acknowledged just now, but to have produced this The noble Earl, Lord Howe, has already explained degree of sweetness and light on this issue is a near- why the Government have decided to support Amendment miraculous achievement for which she deserves our 5. Again, I must pay very warm tribute to his flexibility thanks; she certainly has mine. and availability during all the meetings and exchanges Along with that go thanks to others, including my of letters that have taken place since the Committee noble and learned friend and many others who have stage. The noble Earl has been enormously generous taken part in those meetings, not least—as the noble with his time, both to the Constitution Committee and Baroness has said and as I want to say—the Minister, to individual Members. Most importantly, he also who has successfully shifted people, who seemed two made it possible for the Bill team officials from the or three months ago to be dug in a trench in which Department of Health and parliamentary counsel to they were going to die, to accept the terms and the hold discussions with the legal advisers to the Constitution realism of the amendment. That is a great credit to Committee. I thank those legal advisers, Professor him and ultimately to the colleagues at the other end Richard Rawlings and Professor Adam Tomkins, for of the Corridor who allowed him to persuade them. their sterling work on the constitutional detail of all As the noble Baroness said, we can regard this as a this and for formulating various alternative proposals real success for the collective wisdom of this House. I before the committee itself decided to agree Amendment just hope that that will be sustained during the rest of 5, which is tabled today. I was delighted when on 1 the discussions on the Bill. February, after several iterations of the content and wording of this amendment since Christmas, the Minister Lord Owen: My Lords, I shall not detain your wrote to all Peers saying that the Government supported Lordships, but the noble Lord, Lord Hennessy, has not only the spirit but the letter of the Constitution asked me to speak on his behalf. I find no reason to Committee’s recommended change to Clause 1. disagree with anything that has been said, particularly I notice that the Minister used the expression “the by the noble Baroness, Lady Jay. House of Lords at its best”. I am always wary of our The Minister and I are going to disagree on substantial tendency to be self-congratulatory, but the process of parts of the Bill—and a profound disagreement it achieving consensus on this important amendment is—but right from the moment when the noble Lord, has been an example of House of Lords effectiveness. Lord Hennessy, and I negotiated with him, he always It demonstrates a useful extra role for Select Committees, accepted that this was an important constitutional and I hope that that can be used again in different and parliamentary point. He expressed readiness to contexts. It has also demonstrated the virtue of informal enter into a novel arrangement, which we very nearly cross-party analysis, discussion and agreement. reached, but instead it has come around by another As we all know and as my noble friend Lady mechanism. At all stages, he has treated all of us, Thornton has rightly drawn attention to again today, Peers and the House itself, with the greatest respect, this is an extremely controversial Bill with an unhappy courtesy and diligence. For that, I thank him on behalf history and possibly an unhappy future. However, on of everyone. the fundamental issue of maintaining ministerial responsibility to Parliament for our biggest public Lord Mawhinney: My Lords, having taken up your service, Amendment 5 has achieved that. To put it in Lordships’ time both at Second Reading and in shorthand terms, it has at least made it less likely that Committee, I want to chip in at this significant point the NHS will become simply a giant quango. I will not in this particularly significant clause. The noble Baroness, be surprised if my noble friend Lady Thornton on the Lady Jay of Paddington, dealt beautifully, succinctly Front Bench says again that nothing can be done to and with clarity with the constitutional importance make the Bill acceptable, but in the spirit of improvement and relevance of the amendment. I pay tribute to the I commend Amendment 5 to the House. work that she and her colleagues have done and the clarity with which she was able to persuade us in her Lord Newton of Braintree: My Lords, I assure the contribution. House that I rise only briefly. On this occasion, unlike Colleagues will recall that I did not take the two amendments ago, I have three excuses for doing constitutional high ground in my concerns about what so, not just two. The first is that I do not always want was originally expressed. I started from the other end to be a troublemaker. The second is that I and my of the spectrum. Whatever we may say constitutionally noble friend Lord Mawhinney expressed the view at and whatever the professorial advice, my former an earlier stage that resistance to an amendment of constituents did not believe a word of it. They expected this kind would be absurd because the amendment the Secretary of State and Ministers to be responsible. reflects the reality of the world. The third I have That was the argument from the grass roots that I already referred to: that in the absence of my noble tried to deploy to persuade the Minister to look at this and learned friend Lord Mackay, I feel that I need to again. I think that I was maybe the first—I was 303 Health and Social Care Bill[8 FEBRUARY 2012] Health and Social Care Bill 304 certainly one of the first—to suggest that all this We are discussing much more than even Clause 5. A should be taken away from Committee, we should not whole range of substantial constitutional amendments be tempted into a vote and we should think further go a long way to sustaining what the noble Lord, Lord about it. Hennessy, expressed wonderfully when he spoke about I am delighted with the outcome on behalf of all this constitutional move a long time ago. In particular, my former constituents and indeed everyone else in the amendments put the concept of the NHS constitution the country, because we are now all on the same page. at the centre of the future of the NHS. At Second We are all now saying the same thing. Some of us have Reading, the noble Lord, Lord Hennessy, used a phrase arrived there by high constitutional means, others about the 1946 Act that I thought was absolutely from the grubby reality of the streets. The Secretary of right. He said that it was as close to institutionalised State is the boss and is held accountable. He gets some altruism as we have ever come. “Institutionalised altruism” credit for the successes and all the blame for the is a wonderful phrase. It reminded me—my memory failures. That is how it has always been and, thanks to goes back this far—of another phrase used by another this amendment, it is how it will continue to be. great warrior for the NHS, Professor Richard Titmuss Everyone will think that this is a great outbreak of of the London School of Economics. He gave a book success and common sense. that he wrote about blood donation the wonderful title The Gift Relationship. I pay tribute to the Minister. My noble friend Lord Newton has just said that the Minister’s colleagues It is appropriate to say to those who talk about will also have had to have been persuaded to this society that a good society must be underpinned by point. I hope that I will not diminish the sense of the concept of mutual altruism within it. Nothing satisfaction in the House if I say that perhaps the represents that more clearly than the National Health Minister will have had a more important part to play Service has done. I very much hope that all those who in that process than the debates in this House. share that view will, within their own parties, make it Whether or not this is your Lordships’ House at its clear that there is a greater responsibility on us than to best, I do not care to judge. However, I will tell those indulge in party back-slapping and bickering; and that of your Lordships who have not had the privilege of is to make sure, between all of us, that the NHS thrives serving in the other place that this could never have and looks after the health and care of the people of happened there—never have happened. That is because England, and of Britain more widely. the other place is infected with a degree of party However, having said that, I want to say two further political commitment that is frequently, though not things. As the follow-up report of the Constitution always, spared at this end of the Corridor. Incidentally, Committee indicates, there was a distinct gap following for those who do not share my view and would like to the letter that was originally sent by the noble Earl, see an elected Chamber, I gently point out that if what Lord Howe, about the constitutional changes. I am saying is true, this amendment today would never Subsequently, on 2 November, when we were in the have been possible in the new, so-called “modernised” early stages of Committee, there was a substantial Chamber that is envisaged. shift by the noble Earl and the department, away from I refer to the introduction of the noble Baroness, a somewhat small-scale response to this much more Lady Thornton, to the previous set of amendments. I generous and widespread response on all the constitutional pray in aid the fact that she said that she would take issues, some of which we have still to debate later this responses in this debate rather than in the previous evening. The reason why was so important—and the debate. She mentioned me by name and I thank her for reason why the House of Lords should not sell itself that. She reflected accurately what I have just explained short—is that in that gap between 10 October and at some length. However, I will give her something else 2 November, the very imaginative House of Lords that she can quote accurately in the future. I congratulate moots were held, with all Peers invited, led by the my noble friend the Minister. He has done an excellent noble Earl, Lord Howe. These shifted the whole situation job, not for the benefit of the party, the Government further towards the concept of a constitutionally shared or even the health service, but for the country. I am settlement. That was a contribution by many Members among those who feel indebted to him for what he has of this House of all parties and, including the Cross- done and the spirit that he has adopted. I hope that, Benchers, of none. It was significant. It expressed the on reflection, the noble Baroness will realise that her serious attempt to reach a conclusion that was based introductory three minutes of an extremely party political on consensus in this House. I hope that consensus will nature were seriously out of sync with the consensus last. mood of the House at this time. In passing, I mention that we need to look at the whole package to see just what an amazingly substantial and imaginative idea it is. Although we will no doubt 6.30 pm go on to argue, as we should, about the issues that Baroness Williams of Crosby: My Lords, may I, remain out there—such as competition, conflicts of too, say a word or two about this brilliant process? It is interest and others on which we have strongly held important to say that at the moment we are discussing views—we should, in sitting down this evening, be Amendment 5, for which the noble Baroness, Lady very pleased to be able to say that we have achieved Jay, has a large and commendable share of responsibility. this much with the great help of the Constitution However, the constitutional agreement that we have Committee and others. Those who took part have reached goes a great deal further, embracing Amendment 6 every reason to feel that they have been part of a and the amendments to Clauses 4 and 12, which we substantial experiment that I hope will be followed will discuss a little later. further in Parliament, not least in this House. 305 Health and Social Care Bill[LORDS] Health and Social Care Bill 306

Lord Laming: My Lords, may I briefly add my Patients are telling me that we are seeing the fragmentation thanks to the Minister and the Constitution Committee? of responsibility for the commissioning of healthcare Its second report was particularly helpful. To follow and that services are suffering as a result of the financial the point made by the noble Baroness, Lady Williams, squeeze; for example, diabetic specialist nurses are it is right to see Amendment 5 in the context of some disappearing and patient education is being cut. The coherence over how this accountability will work, not things that are important for the quality of care are just at ministerial level but at board level. There will be being removed. further amendments. At this stage, suffice to say that I am experiencing a huge loss of momentum in the Constitution Committee looked at these matters in getting any change implemented in the care for people the broadest possible way to ensure that—whether in with diabetes. Whenever I speak to the Secretary of terms of autonomy or commissioning—there would State, he tells me that it is no longer his responsibility be a coherence to the way in which accountability and that I should talk to the NHS Commissioning would continue to be established in the National Health Board. However, when I speak to the NHS Service; and, in particular, that those responsible for Commissioning Board, staff say, “We are still working commissioning and other important work follow through out how we do this”. When you talk to clinical their tasks in relation to ministerial accountability to commissioning groups, they are still not clear about Parliament. the framework in which they are operating. Therefore, The second report of the Constitution Committee we are losing one, two or three years of headway on was a model of how such matters can be dealt with issues where there needs to be real improvement for coherently, succinctly and very clearly. We are indebted patients. to the Minister for giving us the opportunity to consider Because of the preoccupation with reform, we are that more carefully; and to the Committee for its seeing a lack of real focus on the task in hand, which is work, which took us forward enormously and has how we make the health service more efficient. The brought us to where we are today. I am grateful and I Minister and the Secretary of State have repeatedly support the amendment. told me that these reforms will deliver that necessary improvement in care and efficiency. However, my Baroness Pitkeathley: My Lords, far be it from me experience over 40 years leads me to believe that that is to cast a pall over the House of Lords at its best. I join not the case. In saying that, I am not making a others in being glad about the consensus and in political point; I speak from my knowledge of what is congratulating the Constitution Committee. I also happening in healthcare. We will continue to try to congratulate the Convenor on the part that he played improve the Bill because we are good and honest in getting the consensus. It is a privilege to follow him. toilers in the House of Lords, but we are trying to I join the noble Baroness, Lady Williams, in hoping improve something that is deeply flawed. that the consensus can continue but I have to remind the House of how the Bill is viewed out there. It is Baroness Thornton: My Lords, we must be thankful deeply unpopular with many of the people who will be to my noble friend Lady Jay and the Constitution required to make it work. They will make it work Committee for their initial work and their second because that is what the workforce of the health report, which has enabled us to reach the point that we service does and always has done in the most difficult have. I am grateful to my noble friend Lady Pitkeathley of situations. However, it is looking to us to make and the noble Baroness, Lady Young, for saving us those difficulties as few as we possibly can. Therefore, from the gloopy treacle of self-satisfaction into which in congratulating ourselves on reaching where we have we were sinking, to which my noble friend Lady Jay on this issue, let us remember the task before us. referred. I, too, thank the noble Lord, Lord Laming, the Baroness Young of Old Scone: My Lords, I am Convenor of the Cross Benches, for chairing the seminars afraid that I will be even more discordant. I do not that have been referred to. We all know that chairing want to denigrate the congratulations that have been seminars attended by opinionated Members of this offered to the noble Baroness, Lady Jay, and her House and lawyers is not an easy task. He did an colleagues and the process that has been gone through excellent job and led us gently towards the consensus to reach agreement on this amendment. However, I that has resulted in the amendments being tabled that share the view of the noble Baroness, Lady Pitkeathley, we are discussing. I pay tribute to the noble Baroness, that we must not forget not only how deeply unpopular Lady Williams, the noble Lords, Lord Hennessy and the Bill is but that it is flawed. Lord Owen, whose wisdom brought the great importance I had not intended to speak on this amendment but of this issue to the attention of the House. I cannot let the moment pass as I think that the noble We support this amendment as it is clearly an Baroness, Lady Jay, referred to a spirit of improvement improvement on what was in the Bill originally. We are that she was seeking in moving this amendment. However, still perplexed as to why we could not simply have kept we have to remember that the improvement is a bit like the 2006 wording, but we are where we are. However, I trying to paint the face of a harlot; at the end of the wish to repeat the question that I have already put to day, it is still the face of a harlot, no matter how the Minister. The Secretary of State has let it be improved. We are seeing real impacts on healthcare in known that he does not think that this measure makes this country as a result of the Bill, as we speak. I come a difference. That shows no respect for the work that from a background of having run health services for we have undertaken and the place in which we find 20 years. I have also been the regulator for health and ourselves. Therefore, I should like clarification on that social care and am now part of a patients’ organisation. point. We need to know why that is the case. This 307 Health and Social Care Bill[8 FEBRUARY 2012] Health and Social Care Bill 308 measure constitutes a significant change because, as I Clause2:TheSecretary of State’s duty as to think the noble Baroness, Lady Williams, said, it will improvement in quality of services have repercussions on other parts of the Bill. I welcome that and hope that it is the case. We need to look at the changes proposed in this and the following amendments Amendment 5A as they should make easier our job of testing other Moved by Baroness Royall of Blaisdon parts of the Bill against them. 5A: Clause 2, page 2, line 33, at end insert, “and report I say to the noble Lord, Lord Mawhinney, that this annually in Parliament on the progress towards their development” is still a very political Bill. The noble Lord’s party and the Liberal Democrats pushed the original drafting on the Secretary of State’s powers through the Commons. Baroness Royall of Blaisdon: My Lords, I shall I have tried to keep my remarks about the highly speak also to Amendment 255A. Both amendments politicised nature of the Bill separate from this debate relate to quality standards. because I thought it was important that we should The Government must ensure that the newly structured also recognise the work that has gone on and the NHS delivers high-quality care to all patients across consensus that we have reached in this House. That is England. The much disputed reforms must not create due to a combination of clarity, wisdom and our a situation that amplifies the differences in quality of consideration of the Constitution Committee’s report. care that patients receive in different parts of the I compliment noble Lords on my own Benches because country—that is to say, an amplified postcode lottery we were determined not to accept the well meaning would be intolerable. Clear national guidelines, such and imaginative original proposal of the noble and as the quality standards being produced by NICE, are learned Lord, Lord Mackay of Clashfern. We had urgently needed to define the quality of care that local very trenchant support from noble Lords such as the authorities and clinical commissioning groups should noble Lord, Lord Owen. The Minister, in his wisdom, achieve. took these clauses off the Floor of the House and we However, the delayed development of NICE quality are now where we are. That is a great credit to everybody standards for prostate cancer, as well as recent decisions concerned, including my own party. Therefore, we are not to recommend new treatments for men at the end very happy to welcome this amendment and hope that stages of the disease, threaten to leave prostate cancer it bodes well for our future discussions on Report. behind and increase the variation in the quality of care that men receive across the country. Historically, men 6.45 pm with prostate cancer have suffered from a legacy of Earl Howe: My Lords, I think that it only remains neglect. Although recent improvements have been made for me to thank noble Lords who have spoken in this in the quality of care that men receive, this progress is debate. I listened with care and respect to the noble at risk, and that is unacceptable. Patients should receive Baronesses, Lady Pitkeathley and Lady Young, as I the same high-quality care regardless of where they always do. I understand their concerns. I think that live. I am, as ever, grateful to the excellent Prostate some of them are misplaced but they are right that any Cancer Charity for its help and support. transition brings with it uncertainty and a certain The Bill presents an opportunity for NICE to establish amount of disruption. That is regrettable but all I can national quality standards that set out the quality of say is that the picture painted by the noble Baroness, care that patients should receive across England. Having Lady Young, is not representative of the whole of the these standards in place for prostate cancer and other NHS. She is right; there are difficulties. However, we conditions will ensure that clinical commissioning groups are very confident that they can be resolved in short and cancer networks will be able to benchmark the order. services that they commission and evaluate the quality The noble Baroness, Lady Thornton, asked me of care that they provide. The standards will also help whether the Secretary of State believes that this local authorities to scrutinise health services effectively amendment makes a difference. Yes, he does because and allow patients to check that they are receiving he recognised that this House perceived a lack of higher quality care. The quality standard for prostate clarity in the Bill. He welcomes the fact that this cancer was prioritised for development in 2011 in the situation has been resolved by means of consensus. Government’s Improving Outcomes: A Strategy for Therefore, I reassure her on that point. I thank all Cancer. However, this has been delayed by NICE and noble Lords who have spoken so supportively in favour the quality standard for prostate cancer will now not of this amendment, especially the noble Baroness, be published until the end of 2013 at the earliest. I am Lady Jay, whose work, along with that of her committee, extremely concerned that development of quality proved so indispensable to the consensus to which I standards is already being delayed for priority areas, have just referred. I thank the noble Lord, Lord Owen, and this could be an indication of future delay and for all that he said. I thank the noble Lord, Lord barriers to driving up the quality of care within the Laming, for his contribution not just today but in his new NHS. role of chairing the all-Peer seminars that brought us When guidelines on prostate cancer care have to this conclusion. I thank my noble friends Lord been delayed in the past, it has led to men with Newton and Lord Mawhinney and the noble Baroness, prostate cancer reporting a significantly worse experience Lady Williams, for their wise and generous observations; of care than men with other common cancers. We and, indeed, I thank the noble Baroness, Lady Thornton, cannot afford to repeat those mistakes, particularly in once again. I commend the amendment. the light of the new localised approach to healthcare Amendment 5 agreed. set out in the Bill. The Minister’s response to my 309 Health and Social Care Bill[LORDS] Health and Social Care Bill 310

[BARONESS ROYALL OF BLAISDON] not go far enough, and we called for their strengthening, amendment in Committee was disappointing, given particularly so that CCGs and other parts of the that he said it will take five years to develop the full set structure would be required not simply to “have regard” of quality standards. While the six months suggested to the need to reduce health inequalities but to act to in that amendment is a tight timescale, five years is too secure real improvements in terms of access to health long to wait for these crucial benchmarks of quality services as well as outcomes. It is also critical that care. those bodies should account publicly for their progress This amendment to Clause 2—which outlines the in so doing. Secretary of State’s duty to improve the quality of I thank very much my noble friend the Minister for services—would require him to report annually on the listening and acting. The nub of these amendments is progress towards the development of quality standards. that they shine a clear spotlight on health inequalities This would help. It is not an onerous requirement and by introducing real transparency and accountability at would help ensure that the standards are prioritised national and local levels. I very much hope that the and that Parliament could scrutinise their progress. amendments will be instrumental in changing the Quality standards are meant to be patient-facing culture so that things such as sharing good practice in documents and an amendment to Clause 233 that tackling health inequalities become a key part of workforce would require the NHS Commissioning Board and/or training and very much part of the currency of everyday the Department of Health to maintain a publicly language in the NHS. available information source of each quality standard These amendments have the potential to make a would also help. This would allow patients and reality of the words in the public health White Paper professionals to see real-time information and scrutinise that spoke of, the progress of these important standards. I beg to move. “improving the health of the poorest, fastest”. It is for those reasons that I support these amendments, Baroness Masham of Ilton: My Lords, I strongly and I thank the Minister for tabling them. support the amendment. Yesterday, I went to a meeting on prostate cancer, a disease that 10,000 people a year Lord Harris of Haringey: My Lords, I support the die from unnecessarily because of late diagnosis. I amendments in this group because I believe that it is should like to tell noble Lords a small story about a important that we look at the mechanisms that will be friend of mine. He went three times to his local surgery embedded in the Bill, assuming that it eventually in north Yorkshire and was sent away. His son was receives Royal Assent in some form, and that will in worried because there were symptoms, so he took him practice drive change in the direction that we all want. down here to London. He was diagnosed with prostate That includes improving the quality of the care offered, cancer straight away in a private clinic, but it had gone and it means addressing the issues of health inequality through to his bones because of late diagnosis. The to which the noble Baroness, Lady Tyler, referred. treatment is much more expensive, so if only there was One of the omissions from the Bill is that, apart a standard throughout the country. Therefore, this is a from placing some general duties on the various bits very important amendment. of the NHS, there is very little about demonstrating Baroness Tyler of Enfield: My Lords, I also support how those duties will then be exercised or creating a the amendment on prostate cancer, which is a very mechanism for assessing that. The amendment, which important area. However, I wish to support the talks about reporting annually to Parliament on the government amendments in this group—Amendments 68, progress made, seems an essential first step in making 112 and 144, to which my name is also attached. These sure that that happens. amendments all relate to reducing health inequalities The reports on inequalities will be increasingly and, in a nutshell, create a new duty on the Secretary important in this area. However, Amendment 112, of State, the NHS Commissioning Board and the dealing with CCGs’ annual reports on how they have clinical commissioning groups to report annually on discharged their duty to reduce inequalities, raises their progress in tackling health inequalities. another question, and this comes back to the issue of As this is Report stage I will not rehearse the stark what will be the catchment areas of individual CCGs. statistics on life expectancy that we heard during earlier Unless there is far more central direction than I have stages of the Bill. We also heard compelling accounts understood—and perhaps the Minister can reassure of what needs to happen to improve health outcomes us on that—it seems likely that there will be, to use an for those particularly vulnerable and disadvantaged unpleasant term, ghettoisation in some CCGs. groups whose patterns of usage of the health service often take a different form from those of other sections 7pm of the population. These groups include the homeless, In some local authority areas, the easier bits of the those with mental health problems and others whom patch will have one CCG and another will cover the we heard about earlier. others. That is likely to mean that the areas covered by As I recognised in Committee, the explicit duties on those two different CCGs are rather more homogeneous health inequalities which the original version of the than might otherwise be the case. If one CCG covered Bill placed for the first time on the Secretary of State, that area, the duty to make progress on health inequality Commissioning Board and CCGs were landmark duties. would be clearer. If we are talking about smaller They certainly represented a major shift from the populations served, it is more likely that they will be current position. However, as a number of noble Lords, homogeneous and that there will therefore be less me included, argued in Committee, those duties did inequality to address. The question will be whether 311 Health and Social Care Bill[8 FEBRUARY 2012] Health and Social Care Bill 312 there will be enough pressure within the system to Lord Hunt of Kings Heath: My Lords, the government ensure that the inequalities in health outcome between amendments on health inequalities are welcome. I different CCG areas will be addressed. It is all very take this opportunity to ask the noble Earl about well to place a duty on a CCG which covers, say, the clinical commissioning groups. Has he given further people of Tottenham in north London, where there consideration to the links between health and well-being are tremendous problems of health status, life expectancy boards and clinical commissioning groups? He will and so on, to report on what it is doing to eliminate recall the debate in Committee, when what I thought health inequality in its patch, but if the nature of that was a persuasive argument was made that to ensure patch is such that it is already deprived in terms of that the links between clinical commissioning groups both economic indicators and health outcomes, what and local authorities taking on public health will be the driver to ensure that the inequality of that responsibilities were as strong as possible, it would be area compared with others is addressed? a good idea if a local authority nominee from the Who will own the strategy within regions and parts principal local authority served on the board of the of the country to address issues such as health inequality clinical commissioning group. and clinical standards? If the answer is that that this My noble friend Lord Harris suggests in his comments will all be done by the NHS Commissioning Board, about population coverage by clinical commissioning that is a wonderful answer and tells us what an important groups that there will be a grammar school-type impact, body the NHS Commissioning Board will be. How a creaming off of patients by some clinical commissioning will that be operationalised? What mechanism will groups so that the remainder will be left in other drive that? Before you know it, you are talking about a clinical commissioning groups. There will be areas of regional and area infrastructure no less baroque than a city or locality where the health inequalities and anything we have seen in the past. Otherwise, it cannot morbidity and fatality ratios will cause a great deal of happen. What will be done to operationalise the drivers concern. It would be good to hear some assessment to make the improvements happen? It will not be of that from the noble Earl. We have seen mapping of sufficient to place a duty on everyone to report on clinical commissioning groups in different parts of the what they have done, although that is valuable and country and they look weird and wonderful. They are worth while in itself. What will be the duty to address not aligned to electoral wards and it will be very issues between localities? You can address all the inequality difficult to plan sensible provision of services because you want within those areas, but if the outcomes are there is no geographical alignment. already much lower in those areas, will there be enough infrastructure around the NHS Commissioning Board I also ask the noble Earl, Lord Howe, to follow on to address the problem of the inequalities between the from the remarks of the noble Baroness, Lady Finlay. different areas? We hear very little about primary care performance in our debate, but when I think back to the original speeches made by Mr Lansley, the whole purpose of Baroness Finlay of Llandaff: I support all the the reforms is about GP performance. The argument is amendments. I am glad to read the government that GPs are responsible for most expenditure through amendments, which will obviously be accepted across referrals or prescribing, and that if you give them the the House, but the other amendments are also important. budget, they will therefore be much more responsible I draw attention to one aspect. I do not understand in their behaviour. We have yet to be told how a how we can expect GPs to do it all. We are expecting clinical commissioning group will influence the behaviour them to lead on commissioning. I have been asking of GPs within it. I know that that is a concern among about that extensively and have had conversations the leaders of clinical commissioning groups. with the Royal College of General Practitioners but have not been able to find a clear example where If, for example, a clinical commissioning group has general practitioners have led commissioning across a reached an agreement with providers, NHS trusts and comprehensive range of services for some time and NHS foundation trusts, on a shared risk approach to that has been demonstrated to be successful. I would demand management—which I hope will be the outcome be very grateful to hear that I am completely wrong; of most of these agreements—what on earth do you that would be reassuring to know; but I am worried. do if some GPs do not exercise responsibility over their referral or prescribing performance? We know As I said earlier, patients present completely that the variation in quality among GPs is very wide. undifferentiated to general practitioners. The diagnostic What are the levers that will bring poorly performing burden on GPs to get it right is huge, because they are GPs to the table? The leverage that clinical commissioning the point of entry. They are either the gatekeeper or groups have is very limited. On balance, I think it the gate opener. Their role should be the gate opener, would have been better if they had had the contracts and there are real conflicts if they are charged with of GPs. I know that there is an issue about Chinese being the gatekeeper at the same time. Unless the walls and conflicts of interest, but the fact is that the diagnosis is accurate, everything that follows fails. I contracts of GPs will be with the branch office of the am concerned that the inequalities and range of standards national Commissioning Board. Therefore, the levers to date will not be improved by the increased workload that the clinical commissioning groups have are likely burden on general practitioners. I wonder if that, in to be very limited. part, is behind some of the objections emerging from GPs who have previously been quiet about the Bill, Then we come to the issue of, for example, prostate because they are becoming frightened that they cannot cancer. I very much agree with and support my noble fulfil their clinical duty as well as their managerial friend Lady Royall on the need for quality standards commissioning duty. and I hope that NICE will get a move on in relation to 313 Health and Social Care Bill[LORDS] Health and Social Care Bill 314

[LORD HUNT OF KINGS HEATH] already set NICE a challenging programme to produce this. However, as my noble friend Lord Harris said, the quality standards and we have to recognise that, if underpinning an argument about prostate cancer is it is to do the job well, it cannot be done in a hurry. the question of how you make such a standard work However, we continue to believe that the programme at the local level. If there is to be a quality standard, I is ideally placed to deliver a steady stream of quality doubt very much whether it will simply be confined to standards over the agreed timescales. That will lead to what an NHS hospital, a clinical commissioning group a comprehensive library of quality standards, to which or a GP is expected to do. The quality standard will she referred, within five years. Of course, I understand look at an integrated approach at the local level which that that timescale is disappointing. However, I simply will straddle various features of the architecture of the say that, while the quality standard for prostate cancer, NHS locally. It might even have some regional aspects in particular, is clearly important, there are many too where an input needs to be made. things that we can do, and are doing, to improve the Therefore, the question is: who on earth at the local care of cancer patients in the NHS, and we have level is supposed to sign that off? Who is going to take recently debated some of those in your Lordships’ the leadership role? The clinical commissioning groups House. will be far too small to do that within a locality, so either they will come together and agree a strategy that will cover a sufficiently large population or, as I suspect, 7.15 pm the national Commissioning Board will have to do it Perhaps I may turn to the amendments that the itself. I think that we will come on to these debates noble Baroness tabled. I appreciate that many people when we deal with the role of the national Commissioning have an interest in the programme of developing NICE Board. We have all been highly entertained by the quality standards and in NICE’s work generally. We paper produced by Sir David Nicholson showing the have thought about this and I hope that I can provide less bureaucratic approach that the Government have some reassurance. adopted in relation to the health service with the First, the Bill already states that NICE must lay various layers of bureaucracy that are being brought before Parliament an annual report setting out how it in. However, I am still left completely clueless about is exercising its functions. This will provide a clear who at that sub-regional level, where so many critical mechanism for patients, clinicians and other interested decisions have to be made, is going to take responsibility. parties to see how it is taking forward its various We know that in relation to prostate cancer much functions, including its role in developing quality standards. more needs to be done. Secondly, the Secretary of State must also produce The noble Earl will remember the debates that we an annual report on the performance of the health had on prostate cancer 10 years ago. He will remember service in England. We tabled amendments ahead of the controversy over testing and how noble Lords this Report stage to ensure that, in particular, that were very keen to put their point of view across. That report will give his assessment of how effectively he has rather gone away and I think that it has been has discharged his duties regarding improvement of replaced by a much more informed debate about a quality and reducing health inequalities. cancer on which we know we could do very much more and on which we know there has to be education Thirdly, the Secretary of State will also have a duty in the public domain. to keep under review the effectiveness of NICE’s exercise of its functions, and he can include his views on this in I very much support my noble friend in what she is his annual report. This could include his views as to seeking to do but it also raises the issue that the noble how well NICE has performed its functions in relation Earl’s amendments touch on—that is, the architecture to developing quality standards. surrounding how a quality standard is implemented in the future, assuming that NICE is able to produce that Therefore, although I have a good deal of sympathy standard as quickly as possible. with the noble Baroness in what she seeks to achieve, I suggest that in fact her amendments are unnecessary. The noble Lord, Lord Harris, asked me about Earl Howe: My Lords, I am grateful to noble Lords clinical commissioning groups and referred to their for some very valuable contributions to this debate, geographic coverage. He will know that each CCG will which has ranged quite widely. I think that the first be accountable for the outcomes that it achieves against thing we can all do is agree on the importance of the commissioning outcomes framework, which is under reducing health inequalities and developing NICE development. The CCGs will be supported in their quality standards, which was where we began with the efforts to improve quality by the NHS Commissioning noble Baroness, Lady Royall. She is right that the Bill Board, whose job it will be to issue commissioning presents a major opportunity to drive up quality in the guidance, informed, among other things, by NICE NHS, not least through the development of NICE quality standards. quality standards. I do not agree with the noble Lord that CCGs are The noble Baroness expressed her concern about likely to be ghettoes. Across many clinical areas, they the time that it is likely to take for this library of will collaborate to serve the needs of patients over an quality standards to be rolled out. I completely understand area wider than that of just a single CCG. What is not her desire to have NICE working quickly and effectively stated in the Bill but I hope is implicit in all that the in producing quality standards. Against that, I simply Government have said is that there will be transparency say that we have to balance the need for speed with the in all this. Once you measure results, there is, ipso need to produce standards of a high quality. We have facto, an incentive to improve those results. 315 Health and Social Care Bill[8 FEBRUARY 2012] Health and Social Care Bill 316

The noble Lord, Lord Hunt of Kings Heath, asked Lord Harris of Haringey: May I just clarify? Will me how a CCG can influence improvement in primary there be nothing between the board at national level? care when it is the board that is commissioning the Will it look right across the country and say, “We will primary care. I simply remind him that CCGs have a address these inequalities”? Will there be nothing, for duty under the Bill to support the NHS Commissioning example, at the London level, to address inequalities Board in its quality improvement functions with respect between different parts of London or will it simply be to primary care. Indeed, one of the key benefits of driven nationally? That is a recipe for not necessarily CCGs as we see it—and we know this from a practice- making the best decisions in particular areas. based commissioning which has been in place for a number of years—is the ability for peer review and peer pressure to drive up quality. Earl Howe: The noble Lord will know, because the NHS Commissioning Board authority has published The noble Lords, Lord Harris and Lord Hunt, its proposals, that the board will be represented sectorally. asked me who will lead the local strategies. Health and There will be field forces in all parts of the country. well-being boards will be the bodies that will produce My vision of this, and that of Sir David Nicholson is a joint health and well-being strategy, and that will be that in the areas in which the board operates it will designed precisely to address issues such as health take a view across a region and look at how outcomes inequalities, which involve different services working vary between local authority areas. The board will be together. CCGs must have regard to these strategies in very powerfully placed to influence the kinds of addition to reporting annually on health inequalities, inequalities that the noble Lord has spoken of. It is as through the amendments in this group. important for noble Lords to understand that the board will not be a collection of people sitting in Lord Harris of Haringey: I just want to make sure Leeds. The majority of its staff will be a field force. I that I understand the point that the Minister is making. hope that that is helpful. Let us compare two localities in London. I mentioned Tottenham, so compare that with, say, the residents of Totteridge. They are very different socioeconomic Lord Rea: Does the noble Lord accept that to groupings with very different health outcomes. What smooth out inequalities costs money? Therefore, the is the mechanism for addressing health inequalities CCG in Tottenham should get more per capita than between Tottenham and Totteridge? Who will be the CCG in Totteridge. At the moment allocation is responsible for addressing inequalities between areas made according to an index that takes deprivation that are just a few miles apart but which have very into account to some extent, but not enough. How will different characteristics and very different social outcomes? that be administered under the new system? The health and well-being boards are borough-based. Tottenham is in the London Borough of Haringey Earl Howe: The advisory committee for resource and Totteridge is in the London Borough of Barnet— allocation which exists at the moment will advise on neighbouring boroughs that are very different in the allocation of resources according to a very detailed composition. What will be the overarching structure formula. That applies to the NHS and public health. that addresses those inequalities? There will be a separate ring-fenced budget that specifically takes account of deprivation. That budget will be held Earl Howe: Localism lies at the heart of our approach by Public Health England and passed down to local to these issues. Although I have no doubt that authorities to use at a local level. We are very clear that conversations and comparative analyses will take place deprivation and health inequalities must be reflected between different health and well-being boards and in terms of the budgets that CCGs and local authorities different local authorities, in the end it is the responsibility receive. I hope that I can reassure the noble Lord on of health and well-being boards to look to their that point. catchments. As I said, the outcomes that are published, Government Amendments 68, 112 and 144 set out both in terms of the NHS performance and public a requirement for the Secretary of State, the board health and social care, will in themselves incentivise and CCGs to report annually on their work to improvement, if the local authority and the health and reduce health inequalities. We had a great deal of well-being board work together as they should. This is helpful and interesting discussion on reducing health a joint enterprise between public health, social care inequalities in Committee and as a result of those and the NHS. discussions, we felt that it was important to bring We shall no doubt experience the effect of comparative forward three amendments on the reporting requirements. work between local authorities once the early implementer Amendment 144 requires the Secretary of State to groups have bedded down and begun their work. Both include in his annual report an assessment of how the board, however, and the Secretary of State will effectively he has carried out these duties, meaning have duties in relation to inequalities. They overarch that Parliament will hold him to account. I have tabled everything that happens and I suggest that that will parallel government Amendments 68 and 112, which ensure that a system-wide and strategic approach is require the commissioning board and CCGs to report taken, for example, through setting objectives in the on how effectively they have fulfilled their inequality board’s mandate in relation to inequalities. These could duties. We believe that this will ensure that our objectives feed down very easily to CCGs through commissioning to reduce health inequalities and improve quality of guidance issued by the board. I hope that that gives care are embedded throughout the system from top to the noble Lord a summary, or at least a flavour, of bottom. I hope that noble Lords can support those how we envisage this working. amendments when I move them. 317 Health and Social Care Bill[LORDS] Gaza 318

Baroness Morgan of Drefelin: I wonder whether the Lord Wallace of Saltaire: My Lords, we have Minister could clarify something for me. I very much extraordinarily tight timing for the dinner-hour debate. support the line of argument around the amendments. I remind noble Lords that when the figure “2” appears However, I am interested to know whether, if the on the clock, that is the end of their time for a Secretary of State has a duty to report back on the two-minute speech. I am told that the European exercise of these duties, does that say anything about Parliament has entire debates where everyone makes the importance of reporting on his other duties? Is a two-minute interventions, but I am sure the House of hierarchy being created? That is a point for clarification. Lords can do better than that.

Earl Howe: There is no hierarchy but the Secretary 7.33 pm of State will be bound to report to Parliament and, in doing so, he must show that he has exercised his Lord Warner: My Lords, it gives me no pleasure functions in a way that fulfil his statutory duties under this evening to be raising the issue of Israel’s blockade the Bill. Parliament will no doubt hold him to account of Gaza and its consequences for the 1.7 million for having done so. He must demonstrate across the Palestinians who live there, 50 per cent of whom are piece that he has had regard to those duties. children. Three years ago, the Israeli military was conducting Operation Cast Lead that took the lives of over 1,000 Palestinians, razed whole neighbourhoods Baroness Royall of Blaisdon: My Lords, I am grateful to the ground in East Gaza and destroyed many to the noble Earl, Lord Howe, for his reply, and for the Palestinian factories. I have seen at first hand the support for my amendments around the Chamber. I devastation caused by that operation and heard locals’ have a couple of comments. First, in terms of quality accounts of the military behaviour towards unarmed standards, like the noble Baroness, Lady Finlay, I civilians on my two visits to Gaza. Since Cast Lead, wonder about a GP’s ability to fulfil his duties both as Israel has occupied Gaza’s territorial waters, leaving a clinician and a commissioner. Currently GPs often only three nautical miles for Palestinian fishermen, find diagnosis quite difficult and I am concerned although the Oslo agreement provided for 18 nautical about them having to commission as well as diagnose. miles. Fishermen who approach the boundary are If they do not fulfil their tasks as both clinicians and liable to be shot, detained or sprayed. Israel has also commissioners, the patients will suffer. created a military buffer zone on Gaza’s northern and My noble friends Lord Hunt and Lord Harris eastern borders which it is estimated has confiscated asked who takes the leadership and responsibility for 30 per cent of Gaza’s arable farming land. People are ensuring that quality standards are adhered to when regularly shot at and sometimes killed in this buffer they are brought forward by NICE. The Minister said zone. Israel has addressed its security concerns by that localism is one of the answers. I find that a confiscating Gaza territory rather than use its own frightening prospect rather than a reassuring one. I land in order to create the buffer zone. think it is a recipe for chaos rather than quality, but Israel has seriously restricted the flow of goods and perhaps that is a personal view. people in and out of Gaza. According to UN figures, I pay huge tribute to NICE, which I think does during the first two years of the blockade, 112 containers excellent work, but I recognise that it is very stretched. on average entered Gaza from Israel daily, compared It has immense burdens and responsibilities. I hope with 583 before the siege. Even after Israel said it had that this very short but excellent debate will be a eased the siege in May 2010, the daily number rose to catalyst for swifter action in terms of quality standards, only about 150. Apart from the Rafah crossing from but I recognise that there is always a balance to be Egypt, where the Egyptian military has effectively struck between quality and speed. However, in five imposed its own controls, as I have experienced twice, years, an awful lot of people can die while waiting for Israel controls all other border crossings. I am informed quality standards. Having said that, I am grateful to that Kerem Shalom is now the only functioning crossing the Minister for his response, and I beg leave to point and that the Israelis have started to demolish withdraw the amendment. Kami, which previously had the largest capacity. This may encourage more materials and goods coming Amendment 5A withdrawn. through the illicit and primitive tunnels between Egypt and Gaza, which I have also seen in operation. These Consideration on Report adjourned until not before tunnels regularly collapse and kill people. It is estimated 8.35 pm. that about 250 adults and something over 50 children have been killed or seriously injured in the tunnels. Gaza Israel has imposed a tightening blockade on Gaza Question for Short Debate that has effectively created the largest open-air prison in the world and represents a collective punishment of 7.32 pm Gaza’s civilians. My understanding is that this is in direct violation of Article 33 of the fourth Geneva Asked By Lord Warner Convention, but perhaps the Minister can confirm To ask Her Majesty’s Government what that and say whether he disagrees with any of the facts arrangements they have in place to monitor the I have given so far. I would also welcome any light he impact on humanitarian aid for the population of can throw on the current situation on Israel-Gaza Gaza of the blockade by the Government of Israel; crossings and on whether there have been any and what representations they have made to the improvements in the flows through Rafah since I went Government of Israel about the blockade. through there last July. 319 Gaza[8 FEBRUARY 2012] Gaza 320

What has all this meant economically and socially? I have set out these data to give a picture of what A flourishing fishing industry has been brought to its Gazans face day in, day out. Half the population are knees, and farming has been unnecessarily restricted. children who have done nothing to justify this treatment After destroying some 1,300 Palestinian factories, Israel by Israel, whatever their genuine security concerns. As now prevents the import of machinery and raw materials the Israeli columnist Gideon Levy said, to enable the Palestinians to rebuild their manufacturing “this time we went too far”. capability, particularly in textiles and furniture in which I carry no torch for Hamas but it did win a fair and they specialised. Businessmen have spoken to me about democratic election in 2006. It also looks as though the difficulties of establishing the banking services Fatah and Hamas may have reached agreement in that would support an export trade. An industrial recent discussions in Qatar on a unity Government. sector that used to account for 40 per cent of national Does the Minister not think that the time has come for income in Gaza now employs about 15,000 people. the international community to take a more robust Gaza’s infrastructure is falling apart. Rebuilding stance with Israel over its conduct in Gaza? Its behaviour the homes, schools and other public buildings destroyed is self-defeating. Young Gazans are growing up with by the Israeli military is seriously curtailed by Israeli no hope. Why should they not turn to the extremist restrictions on the importation of cement, steel and elements in Hamas for their role models, to match other building materials. Governments and private Israel’s own extremism? What further action are the donors see their aid efforts frustrated by these restrictions. Government prepared to take with international partners Gaza’s water, sewage and healthcare systems are on to get the Israelis to change course and how much the verge of collapse. Only some 5 per cent of the worse do things have to get in Gaza before the water coming out of Gaza’s taps is fit to drink. Sea international community acts decisively? water is filling the gaps in the Gaza aquifer and could In his speech to the European Court of Justice on soon wreck it. Waste water projects are being delayed, 25 January, the Prime Minister said that he supports, so huge amounts of sewage have to be pumped into “the spirit of freedom … across the Arab world”. the Mediterranean Sea. Lack of fuel means that eight Gaza is part of that world, so what tangible and to 12-hour blackouts are common. Nitrate levels in effective support can it expect from the UK and its EU water are rising dangerously and are said to be causing partners while the United States seems self-preoccupied an increase in cancers. Gastroenteritis is now a way of and unwilling to focus on Palestine? life for Gaza’s children, 70 per cent of whom are said to be anaemic. A visit to Gaza’s 650-bed main hospital is deeply 7.41 pm depressing. It reveals crumbling and unfinished buildings, Lord Trimble: My Lords, I was attached as an poor equipment and doctors who have run out of international observer to the Israeli Turkel commission, surgical sutures, gloves and disposables. Surgery, including which considered the “Mavi Marmara” flotilla incident. heart operations, is interrupted by power cuts and the The House of Lords Library note on this debate omits lack of fuel for emergency generators. Doctors have reference to the Turkel commission, but it mentions told me that about 500 patients have died unnecessarily the Palmer panel, which considered the Israeli and in recent years from lack of medication, including Turkish investigations for the UN. Palmer said: many children. On my visit last July, I saw people to “Israel faces a real threat to its security from militant groups whom this would happen, including children with in Gaza. The naval blockade was ... a legitimate security measure sickle cell anaemia. On that visit, the Gazan Minister ... and its implementation complied with the requirements of of Health estimated that the hospital regularly lacks international law”. 150 to 200 basic drugs, including things as simple as Palmer says the flotilla “acted recklessly” and that paracetamol. The latest figures I have been given are there are, that Gaza’s hospitals are at “zero stock levels” for “serious questions about the conduct, true nature and objectives 178 of 480 essential drugs, with another 69 at low of the flotilla organisers”. stocks. Not all these problems in Gaza’s healthcare Israel was entitled to stop the flotilla, but Palmer is system can be laid at the door of differences between right to criticise the plan. However, he is on weaker Ramallah and Gaza, regrettable though they are. ground in criticising the use of force by the IDF. In an annexe, we examined each use of force by IDF personnel In 2000, only about 10 per cent of the population and found them prima facie justified, except for a was dependent on humanitarian aid. Now it is about handful of cases where there was insufficient material. 75 per cent. Over half the households face food insecurity Unfortunately the annexe was classified. It should be defined as inadequate physical, social or economic published. access to food. Since the blockade, the number of The blockade was an extension of the land crossings Palestinians living in abject poverty has tripled to policy to prevent military supplies entering Gaza, and 300,000, and I know from having seen some of those wages indirect economic warfare, limiting Hamas’s households, that it really is abject poverty. The ability to attack Israel. This affects the civil population unemployment estimates vary from about 25 per cent but is legitimate unless it causes a humanitarian crisis. to 35 per cent for the whole population and rise to We spent 40 pages examining this. I will give noble somewhere between 40 per cent and 60 per cent for Lords a few quotes: young people, but the aid dependency figures that I “The Gaza Strip Economic Committee (a representation of have just given suggest that the higher estimates may the Palestinian Authority) ... receives requests from private market be nearer the mark. UNRWA has done and continues forces and importers in Gaza ... Ordering the goods and determining to do a fantastic job, but it is now struggling to secure priorities between the parties requesting the entry of goods is the resources needed from donor countries. done by representatives of the Palestinian Authority”. 321 Gaza[LORDS] Gaza 322

[LORD TRIMBLE] Gaza? That was the view stated in the other place last Lists of goods are then delivered to the Israeli summer, confirming the view expressed at a high level authorities. within the Red Cross in Gaza just a few weeks before “Between the various requests, the order of priorities for entry the Statement in the House of Commons. Of course, is as follows: (1) medical supplies and medicine; (2) requests by there is a case for continuing humanitarian aid to be international organisations ... (3) agricultural materials; (4) the delivered to Gaza, which the Government support balance of supply capacity for the private market … No evidence and indeed I strongly support. was presented before the committee to the effect that Israel prevents the passage of medical supplies apart from those ... This is the second time today we have discussed prohibited for security reasons … when the relevant Israeli authorities Israeli-Palestinian relations in this House, and we will are notified of a shortage of any medical supplies, there is an have an opportunity to discuss them again tomorrow organised system for replenishing those supplies … there is no afternoon. As chairman of the Anglo-Israel Association, quota limiting the amounts of foods that are allowed to enter the in principle I can only welcome this interest in the Gaza Strip”. region. None the less, as is so often said in this Strictly speaking, there is no humanitarian crisis. House, there is an issue in the Middle East about proportionality and, quite rightly, I have heard many 7.44 pm Members of your Lordships’ House raise issues about Lord Parekh: My Lords, I do not think I need to the proportionate nature of Israel’s response. However, argue at length that the Israeli blockade of Gaza is to be proportional is also a requirement on this House. unlawful because it violates Israel’s general obligations Since 2009 there have been 200 Questions asked about as an occupying power; that it is unethical because it is Israel, predominantly critical; not one in which the causing immense hardship to a large number of people, lead Question even mentions Hamas or displays any including ordinary civilians, and amounts to collective curiosity about Hamas, still less about the role of Iran punishment; and that it is counterproductive because in the region. it only builds up hatred and animosity and damages Those of us who support strongly a two-state the long-term interest of Israel. Therefore, Israel needs solution think it is essential to engage with to be thinking more in terms of generosity and better mainstream Israeli attitudes and opinions, not to be understanding of the aspirations of the people of too focused on this or that particular personality at a Gaza. There are large numbers of people in Israel who high level in the Israeli state. The difficulty here is that are already thinking along those lines. the House is in danger of becoming essentially an We think in terms of putting pressure on Governments. echo chamber on this matter, and not doing what we My own experience of India’s policy in Kashmir, to need to do, which is to face up to where mainstream which I was strongly opposed, convinces me that no Israeli opinion is and to look at the dilemmas that Government can put pressure on another Government. Israel faces in the struggle to bring about a settlement There are limits to what any Government can do. in the Middle East. Therefore, I have more or less completely given up on our own Government, the quartet or the international community putting pressure on Israel. Even if they 7.48 pm did—I do not think they will, but even if they did—I Lord Patten: My Lords, while I certainly do not do not think they have much chance of success. They assert that I see no blockades, I certainly see some would simply force the Israeli Government to become facts. In 2011, Israel issued 3,893 medical permits for more intransigent and more uncompromising. Gazan children to go to be treated in the West Bank or Ultimately, the pressure has to come from within Israel itself, according to parental choice. On aid and the country itself and from those of us outside who trade, 2012 opened with more than 85,000 tonnes of wish Israel well and whose record of standing up for it civilian goods being delivered to Gaza through the from time to time is beyond reproach. Therefore, it is Kerem Shalom crossing between 1 and 9 January the friends of Israel abroad, outside, who ought to be alone. On average, about 47,000 tonnes are delivered persuading the Government of Israel that this is not each week, with horticultural and agricultural goods the way to go, trying to make representations, and of high quality such as flowers, strawberries and tomatoes through newspaper articles and in other ways making going in the other direction—and that is good. it clear to the public opinion here and in Israel that Civilian goods do flow but they flow in parallel this is not the way to go. with a real blockade against arms, munitions and Once again taking the Indian treatment of Kashmir some dual-use materials that can be misused, exactly as a guide, ultimately the pressure came from Indians the kind of blockade we would be employing to protect settled abroad. In the same way, in the case of Israel, the United Kingdom if we suffered persistent attack ultimately it is not only those of us who are well from some near neighbours—I guess. disposed to Israel but the great Jewish community, Gaza is experiencing poverty and needs much help. with its enormously impressive record of fighting against However, those needs are best addressed by the all forms of injustice, which will have to make its voice international community working with Israel to better more loudly heard than seems to have been the case so meet those ends while at the same time explicitly far. and publicly appreciating what seem to me at least to be Israel’s somewhat understandable security needs in 7.46 pm the region. I hope that Her Majesty’s Government Lord Bew: My Lords, first, will the Minister confirm agree with this and I equally hope that my noble friend in his reply that it is now the view of Her Majesty’s will make that clear at least in his response to this Government that there is not a humanitarian crisis in debate. 323 Gaza[8 FEBRUARY 2012] Gaza 324

7.49 pm The powerlessness of the Palestinians in Gaza to work, manufacture, import, export and travel freely is Baroness Blackstone: My Lords, I welcome the a shocking waste of human ability. We should be improvement in access to Gaza to provide humanitarian spending our hard-earned tax money on human aid. However, the facts are clear: the people of Gaza development and not on subsistence for people who are suffering greatly because of the blockade and have are clever, well skilled and entrepreneurial, and who to fall back on humanitarian aid, rather than providing have so much to offer to the world. Add to that the for themselves and their families through normal economic long-term issue of critically low medicines and medical activity. In other words, a vicious circle is at work here. supplies, the worsening situations around power cuts The people of Gaza are unable to obtain building and voltage fluctuations, which disrupt life-saving materials to repair and maintain their homes, or to equipment, and you can only marvel at the amazing reconstruct the seriously damaged infrastructure. They resilience of the Palestinians. are unable either to import or export enough goods to sustain anything like a normal economic life. As a I do not know one person who does not wish to see result, unemployment is greatly increased. Around a secure Israel but the effective siege and occupation half of young people are out of work. of the Palestinian people is no way to achieve it. A My noble friend Lord Warner mentioned fishing. young woman from Gaza who I recently had the Some 85 per cent of fishing waters, which is an important pleasure of meeting said to me, “All we want is to be source of food in Gaza, are inaccessible as a result of able to play our part as global citizens”. I hope that the blockade. Such fishing as there is takes place in that day is not too far away but in the mean time I polluted waters as a result of a deteriorating waste hope that we will do all that we can to ensure the infrastructure. In turn, that has a serious effect on decent and fair treatment of Gaza’s people. health, including the health of children. Existing treatment plants are inadequate so large amounts of sewage are 7.55 pm discharged into the sea. Nearly one-third of houses Lord Ahmed: My Lords, I thank my noble friend are not connected to the sewage network and have to Lord Warner for providing this opportunity, even rely on totally inadequate cesspits. though we have only 120 seconds. The right honourable This environment can lead only to an embittered David Miliband, the former Foreign Secretary, wrote people and, in particular, to large numbers of embittered recently that, young men who are denied some of the most basic “Gaza has become the land that time—and the wider international requirements for human needs. It cannot be conducive community—forgot”. to the long-term security of the Israeli people, which I I do not want to mention the UNRWA figures of high and many others in this House of course want to see, unemployment and poverty. My noble friend has already to force these appalling conditions on the Palestinians mentioned the 300,000 people who live on less than $1 of Gaza. I ask the Minister in his reply to say what a day. While Israel put forward proposals to ease the Her Majesty’s Government are doing—of course, working blockade, it was estimated that only two trucks per with Israel and the international community—to seek day were allowed to leave Gaza between November a change in this policy so that vital improvements to 2010 and May 2011, which was nowhere near Israel’s the infrastructure, which continues to deteriorate, can commitment of nearly 400 trucks per day. It was be secured. worse still between May and November 2011 when no 7.52 pm trucks left the Gaza Strip to export any goods from the territory. Baroness Morris of Bolton: My Lords, I never know quite where to start with the plight of the remarkable The crux of the matter is that, while we can hope people of Gaza, except to say that my visit there in for the prosperity and peace of the Palestinian people, 2010 made a profound impact on me. I declare an this will remain an impossible target if the blockade interest as president of Medical Aid for Palestinians continues to imprison the Gazan population. The UK and other interests as set out in the register. I thank Government pledged £26.8 million after Operation the noble Lord, Lord Warner, for this debate. Cast Lead; yet three years later there has been little improvement in the lives of the Gazan people who I well remember visiting an UNWRA food distribution struggle to find employment, rebuild their houses and centre. Queuing for their quarterly ration of basic export their goods. Simple day-to-day tasks, such as goods were proud men, women and children. Among the quality of schooling, remain impossible and the those to whom we spoke were graduates, skilled people population is still reliant on the UN for so many of its and many who had run small businesses. They were needs. However, these problems can be alleviated if not queuing because there had been a famine, a flood the illegal blockade is removed and people could develop or an earthquake. There had been no natural disaster. naturally into prosperous partners in the Middle East. They queued because they belonged to around 800,000 Without its removal the blockade will continue to people in a population of some 1.7 million, of which ensure that all life is suffocated out of the territory and more than half were children, who depend on the its inhabitants. international community for food aid. The collective punishment of the blockade means 7.56 pm that people cannot lead the sort of economic lives, as the noble Baroness, Lady Blackstone, said, that most Lord Palmer of Childs Hill: My Lords, this of us take for granted. Eight out of 10 men, women Question for Short Debate, introduced by the noble and children now rely on some form of international Lord, Lord Warner, is like many questions and assistance. referenda. It is significant not only for what he asks 325 Gaza[LORDS] Gaza 326

[LORD PALMER OF CHILDS HILL] settlement to the Palestinian issues. The rival factions but for what he does not ask and for the way in which Hamas and Fatah have now agreed to form a new the question is phrased—rather like the First Minister unity government in West Bank and Gaza which I of Scotland’s suggested referendum question. The believe will help to achieve a peaceful settlement. question seeks to put any blame on the state of Israel. Israel is a mighty military power, but it must now be When the Minister replies, I hope that he will also magnanimous and arrive at a two-state solution whereby address the real sufferings of the peoples of Gaza it has a guarantee of security and nationhood, but in because of the policies and belligerence of Hamas and return it must ensure that Arabs are fairly treated and Islamic Jihad. have full independence. Israel’s actions are a reaction to a real threat to Israel’s security by groups in Gaza which deny Israel’s 8.01 pm right to exist and threaten the lives of Israeli citizens—Jew Lord Turnberg: My Lords, I fear that this debate and non-Jew alike—on a daily basis. Since Israel withdrew has too readily become polarised and has clearly depended from Gaza six years ago, withdrawing and removing on what sources of information you rely on to form from Gaza every single Israeli settler, terrorists have your views. However, there is little doubt that the fired more than 7,000 rockets and mortars into Israel. Palestinians in Gaza are under considerable stress and Almost 1 million Israeli citizens are under threat from the dilemma for Israel is how it can help relieve that Quassam rockets, Grad rockets and mortars, which burden, so far as it is in its control, and at the same terrorise cities, schools and hospitals. time prevent the terrorist activities of Hamas. Despite Do not get me wrong: there is suffering and deprivation that background, over the past year Israel has in fact in Gaza. But it is wrong to blame only Israel. The opened up its crossings to all but a limited number of problem is not only of Israel’s making, as suggested by items, and now over 30,000 tonnes of civilian goods the Question of the debate. The people of Gaza suffer— are delivered every week; and while it is true that there and they do suffer—because of the belligerence and is a shortage of drugs and medical supplies, the causes extremism of Hamas and Islamic Jihad. These of that shortage are rather more complex. organisations are not only anti-Israel, up until now I understand that the Ministry of Health in the they have also been anti-Fatah and anti the Palestinian West Bank has the task of distributing medical supplies Authority. When Hamas took control, they murdered to Gaza and that there is distrust and a disconnection and injured supporters of Fatah. So we look with between the two ministries of health in Ramallah and interest at the agreement this week of a unity government, Gaza. Internal conflicts and poor communication seem which could not even find a prime minister as well as a to be at least part of the problem. Dr Nabil Bargouni, president. It is against this background that a large the director of the emergency room at Al-Nasser part of the problems exist. Hospital in Gaza City, has confirmed as much; and Tony Lawrence, head of the WHO in Jerusalem, has 7.58 pm said: “Israeli authorities are not blocking the entry of drugs and Lord Sheikh: My Lords, after the tragic death of disposables into Gaza. They recognise these are priority items for eight Turkish humanitarian workers in 2010 our Prime humanitarian needs”. Minister David Cameron said in Ankara that the Of course the results are the same and these shortages situation in Gaza has to change and that humanitarian are devastating, but an Israeli blockade cannot always goods and people must flow in both directions. He be made the culprit, and meanwhile sick children from further commented that Gaza must not be allowed to Gaza flood into Israeli hospitals at over 700 a month, remain a prison camp. Yet nearly two years later, there with very few permits being refused. When I visit still remains crude restrictions to the flow of humanitarian Israeli hospitals I see a large number of Palestinian goods and people. Gaza experiences chronic shortages children with their parents in the wards; it is hard to and innocent women and children are suffering. For miss them. example, Al-Shifa hospital lacks basic medicines and essentials such as baby milk. No one doubts that the citizens of Gaza are having a terrible time, but Israel cannot be held wholly responsible Last month, the United Nations submitted its for this unhappy situation. annual report on the humanitarian situation in the Palestinian territories. The report describes the continuing 8.03 pm desperation, including chronic food insecurity, isolation, and failing health and education services, all directly Lord Hylton: My Lords, I have visited Gaza twice linked to the ongoing blockade imposed by Israel. The in recent years and there can be no doubt that health is report states that the blockade amounts to collective now the top priority. This turns on supplies of water, punishment of the population and affects every aspect food, drugs and medical equipment. Also, it is essential of life in the Gaza strip. The blockade has not prevented that Israel should never delay, turn back or arrest the attacks against Israel; its only success is in creating a sick so that they die before reaching hospital outside stark reminder of the impotence of the international Gaza. We can say with confidence that the blockade of community. Gaza is an illegal collective punishment contrary to It is time for the UK to take a lead in developing the fourth Geneva Convention, and in fact it is now a clear and open strategy for the lifting of the being challenged by Turkey in the International Court blockade of Gaza. We cannot continue to believe of Justice. ourselves to be a just and moral actor in the international Her Majesty’s Government have been pressing for arena until we play a role in helping to arrive at a an end to the closure since June 2010 under UN 327 Gaza[8 FEBRUARY 2012] Gaza 328

Security Council Resolution 1860. This is all the more That is an easy, unfair and simplistic view to take. We necessary since the exchange of Corporal Shalit. When should continue to support the work of the quartet will the Government achieve what they are asking for? and other international organisations, but let me make EU sanctions on Israel could surely speed up the it clear to this House: Israel does not target citizens, process, and of course we recognise that a prosperous unlike Hamas, which sadly does target citizens in Gaza is in Israel’s real national interest. many parts of Israel.

8.05 pm 8.09 pm Baroness Tonge: My Lords, the noble Lord, Viscount Eccles: My Lords, I am sure that the key Lord Turnberg, said that this debate was becoming to the future lies in economic development because at polarised, and indeed it is. It is dividing between those the moment the level of such development in Gaza is who have been to Gaza, some of us several times, and very low. I am grateful to DfID for some statistics. In those who have not and therefore have not seen for 2006, there were some 100,000 jobs in the private themselves what is going on. I would say to those sector, but there are now 30,000. Exports of horticultural noble Lords who complain about rockets “raining” products have recommenced to Israel and the West down on Israel—in fact, there are very few at the Bank, but they are at a tenth of what they were in moment—that if they want to stop those rockets, lift 2006. So the challenge is to redevelop the small business the siege of Gaza, stop the blockade and recognise the sector and export performance which Gaza has achieved legitimately elected Government of the Palestinians, in the past. If there is a longer-term future, perhaps it which includes Hamas. lies in a switch of development finance investment and Huge damage has been done to agricultural land in aid investment by engaging multinational companies Gaza. Fifty thousand acres have been laid waste and sympathetic to the Palestinian cause and acceptable in what land is left is largely polluted and without irrigation. the region to set up subsidiaries in Gaza. That may be Even the food that it manages to produce cannot be a dream, but it has been done many times before. The exported in many cases to Israel or the West Bank. As people of Gaza have the skills and the education to we have heard from the noble Lord, Lord Ahmed, two play their part and the finance is there. It only needs a trucks a day go out to the European Union; and switch from aid to development finance investment. $50,000 a year is being lost to the Gaza economy. The future could be positive, but it requires the cessation of both violence and the threat of violence from We have heard about the problems created by the wherever it comes. fishing limits. Two fishermen were killed and 12 injured recently trying to catch food. Fish within the three-mile limit are poisoned and too small. Catching them wrecks 8.06 pm their health and future stocks. Lord Janner of Braunstone: My Lords, does this As a consequence of these actions by Israel and House recognise that Israel is the only long-standing other effects of the blockade, Gaza is dependent on democracy in the whole of the Middle East? In my aid from the EU and our country. This country alone view, it continues to play an important role in the spends £86 million per year in Gaza and the Occupied international community. It is a bridge between Europe Territories. It is morally right to help the people of and the Middle East, and the instability of the region Gaza, but it is morally wrong that we should have to has always been a major problem for Israel. Last year, do it as a result of the actions of the allegedly friendly Israel’s Government continued to relax their restrictions and democratic state of Israel. We are subsidising the on the Gaza Strip, and this has significantly improved blockade and colluding with Israel in breaking the humanitarian situation there. Gaza’s economy has international law. I hope that our Government are begun to grow and Israel continues to allow Gaza a aware of this. greater availability of food, medicines, consumer goods and construction materials. Humanitarian support is 8.11 pm vital to the suffering citizens of Gaza, and in July last Lord Ahmad of Wimbledon: My Lords, there is a year, Israel’s Government approved 13 new projects, desperate need to resolve the Israeli/Palestinian conflict including four new clinics and the restoration of five to ensure everlasting peace across the region. existing hospitals and clinics. On the plight of the civilian population in Gaza, I This House must remember that Egypt also has like other noble Lords welcome the easing of elements border controls on the Gaza Strip and only reopened of the Israeli blockade in June 2010. It has resulted in its Rafah border crossing on 28 May last year, but some visible signs of recovery in Gaza, but is it enough? there are hundreds of illegal smuggling tunnels under There remains a desperate need for the further easing the Gaza-Egypt border that the Hamas regime uses to of restrictions to movement and access for the sake of rain terror over Israeli citizens. Until Hamas denounces the Gazan economy but, more importantly, for its terrorism, it must be treated as the supporter of such people. actions. Israel’s security must remain paramount, and However, achieving what is desired by the majority it cannot and should not be expected to put its citizens of citizens, be they Israeli or Palestinian, which is a at risk. permanent lasting and peaceful resolution, requires a Humanitarian aid is vital, and I acknowledge courageous effort on both sides. I therefore call upon what other noble Lords have said. Some Members my noble friend the Minister to use his good offices to of this House will no doubt place all the blame on raise with President Abbas, in his new role as leader of Israel. Indeed, some have already done so and some the unity coalition across the West Bank and Gaza, who will be speaking after me probably will do so too. the need to ask Hamas to lay down its weapons and 329 Gaza[LORDS] Gaza 330

[LORD AHMAD OF WIMBLEDON] in Syria, noble Lords are yet again debating criticisms acknowledge that peace can be achieved only if it of Israel. We do this with astonishing regularity; we recognises Israel’s right to exist as a nation. At the do it even though Israel is one of the few countries in same, I ask my noble friend to raise with the Israel the world, and certainly the only country in the Middle Government the desperate need to raise blockades East, which protects freedom of expression, freedom and restrictions, not just on the borders of Gaza but of religion, the rule of law and democracy for all its on the West Bank, to facilitate a fluid access of materials. citizens. The freezing of settlement-building also remains an These criticisms are made, as we have heard today important step forward in building bridges, both literally from many noble Lords, simply without any recognition and in terms of political dialogue. that Israel is a country whose enemies are seeking to The easing of restrictions in Gaza has paid some bomb its civilians into oblivion. Such a country is dividends, as I have said. We are seeing hospitals being entitled to defend itself by seeking to prevent, as Israel constructed and schools appearing, as well as a 50 per does, the transport of weapons. cent increase in employment, albeit from a low base. I A more relevant Question, if I may respectfully say have visited the West Bank and there is hope. It is on so, than that posed by the noble Lord, Lord Warner, that that we should focus. When one sees towns emerging would be to ask the Minister whether he will make such as Rawabi, near Ramallah, one feels hope for a representations not to the Government of Israel but new dawn. Perhaps I may end with the words of Rabbi to the leaders of the unfortunate Palestinian people Menachem Mendel, who said of the crisis: living in Gaza. Will the Minister say to those “Our only way out is to learn compassion without cause. To leaders that it is time for them to abandon the care for each other simply because that ‘other’ exists”. futile attempts to secure the destruction of Israel? Will he say to those leaders that it is time for them 8.13 pm to focus on improving the education, the health and the prosperity of their people? Will he tell them Lord Judd: My Lords, there is nothing much more that it is not Israel which is the obstacle to improving fundamental to life than water. We have heard of the the living conditions of the people of Gaza? disastrous state of water supplies in Gaza, with only 10 per cent of the water coming from the Gaza coastal aquifer, the only source of fresh water in Gaza, being drinkable. 8.17 pm The Strategic Foresight Group pointed out in May Lord Triesman: My Lords, there is understandable, 2011 that, at the current rate of depletion, the Gaza tangible concern about the blockade. Provision of aquifer will become unusable by 2016 and damage will only goods defined as, be irreversible by 2020. Against this, Israel has approved “vital for the survival of the civilian population”, the entry of materials for only four water, sanitation was always too narrow to provide for a viable society and hygiene projects in Gaza, with a total value of and the needs of a normal life. It is difficult to build a $3.75 million. A further 13 projects, worth $74.5 million, democratic and sustainable society in those circumstances which would benefit more than 1.4 million Palestinians, capable of fulfilling any kind of realistic role in a are still awaiting approval. peace process. We also know of the damage being done to health, The increased movement in recent months of goods the impact on life expectancy and the disease and services in and out of Gaza is welcome, but I affecting children. We also know of the stunting of accept that it is not enough and there is a need for an education. We know of the catastrophic effects on accelerated programme for step change. production and on trade, and the consequences for However, your Lordships should feel uncomfortable employment. if that was all that was concluded tonight in relation We hear about the constant bombardments of Israel to the Question of the noble Lord, Lord Warner. being carried out by elements in Gaza. These cannot Israel’s security cannot and will not be wished away be condoned, but every day there is ruthless aggression on this basis. We know that food, fuel, construction against the people of Gaza—that is the reality. How is materials, people, cash and even livestock were moved that going to promote moderates in the Government through the network of smuggling tunnels, but they of Gaza who will work constructively for peace? How were also the route taken by significant quantities does that help the people of Gaza to be self-confident? of weapons, particularly many thousands of rockets. Aggression in any form is not acceptable, but we must Those rockets are routinely fired into Israel. recognise that we cannot be held to ransom by the Candidly, neither this Government, the Israeli repeated veto by the United States of anything effective Government nor any Government could allow such which would help bring about a solution. We need to assaults to continue without trying to deny the work very hard with our European partners in enemy access to those munitions. No population circumventing the intransigence of successive US would ever tolerate having to shield their children Administrations. or themselves night after night in air raid shelters. It is of course tragic that preventing these attacks will never easily be focused on the people firing the 8.16 pm weapons without there being an impact on the wider Lord Pannick: My Lords, people outside this House population, but I do not accept that taking steps may be puzzled at the fact that, as the latest example represents a policy of collective punishment. I simply of appalling state violence in the Arab world continues do not accept that that is a credible definition. 331 Gaza[8 FEBRUARY 2012] Gaza 332

We require a balance of these decisive factors. with unemployment well over 28 per cent and youth First, a relaxation of the blockade and far greater unemployment at 38 per cent. The figures may well be sophistication in weapons interception is important if higher than that. the quartet is to be successful. Secondly, every international Like your Lordships, the Government are obviously pressure is needed to ensure that Hamas does not concerned at the broader human costs of the current succeed in prosecuting violence against the people of situation. We are deeply concerned about the horrific Israel, whose right to a secure state Hamas denies. The reported shooting of 29 children between March 2010 peace process will only work if it reaches in both and December last year near the border fence between directions. Gaza and Israel. We have raised and continue to raise these issues with the Israeli authorities. We are concerned about reports of abuses carried out under Hamas rule 8.20 pm in Gaza, including arbitrary detention, mistreatment, The Minister of State, Foreign and Commonwealth intimidation of civil society and the use of the death Office (Lord Howell of Guildford): My Lords, I penalty. As I have already intimated, we are also very congratulate the noble Lord, Lord Warner, on promoting concerned at the all too frequent exchanges of rocket this important debate. As has been remarked on, this fire and air strikes between Gaza and Israel. We is the second time today that we have addressed the consistently urge all sides to show restraint and work issue and we will address it again tomorrow. No one to reduce tensions. can accuse your Lordships of lack of focus or interest. I obviously cannot physically cover all the many I know that for many speakers it has been a rushed job points raised in the time available. I read with great but it is amazing what punch and wisdom can be put interest the report of the noble Lord, Lord Warner, on into two minutes. Many wise and effective points have his visit last July with the Council for European Palestinian been made—of course, not all of them agreeing with Relations. It painted a very grim picture. We are each other. I will make some points in a general concerned at the deterioration in the quality of healthcare context before coming on to details. in Gaza as a result of Israeli movement and access The Government agree that the restrictions on restrictions, and political and institutional separation movements of goods and people, including access to between the West Bank and Gaza. The shortage of agricultural and fishing areas, do tremendous damage essential drugs is now critical. We have urged and will to the economy and living standards of ordinary continue to urge Israel to enable uninterrupted access people in Gaza. As a result, industry in Gaza is for medical supplies, personnel and patients from and currently a quarter of what it was before the restrictions into Gaza. The World Health Organisation confirmed and agriculture a half. We recognise and welcome the the detrimental impact of movement and access fact that the volume and range of goods entering restrictions on children’s health. There has been an Gaza has increased somewhat over the past year but increase in stunting in children under five resulting much more still has to be done. In close co-ordination from malnutrition. Some 65 per cent of mothers of with our European partners and the Office of the pre-schoolers report a negative impact on their children’s Quartet Representative, we will continue to press the mental health. Israeli Government at ministerial and official levels to ease access restrictions. When I say we will continue to What are we doing about that? This legitimate press them, we maintain an almost daily and continuous question comes up again and again. UK financial pressure and seek responses. In particular, we want an assistance has supported the Palestinian Authority to increase in imports of construction and raw materials, the tune of £87 million in 2009, 2010 and last year. both for private sector and international projects; an About half of that goes into Gaza to support services increase in exports; a relaxation on movement of there. We work with the UN Relief and Works Agency people, particularly between Gaza and the West Bank; to provide primary healthcare and hospital care to and an extension of the fishing zone from three to Gazans. The Relief and Works Agency is delivering 12 miles, which the noble Lord, Lord Warner, and real improvements in children’s health. That includes other noble Lords mentioned. 100 per cent immunisation of the under-fives and progress to reduce child mortality. We also support the I make this quite clear to those noble Lords who UN Access Co-ordination Unit to facilitate the transfer made the point: we understand Israel’s legitimate of medical equipment and personnel into Gaza. Of security concerns over Gaza. One could not fail to course, we work with the European Union and the understand the facts when one sees the amount of World Food Programme. I am told that DfID helps rocketry that continues. However, the current 24 UN agencies and 132 non-government agencies. restrictions are ineffective in stopping the flow of The activity from the United Kingdom to support the illicit goods into Gaza. As was graphically described, people of Gaza in the challenges they face in all those these goods enter anyway through the tunnels and aspects is considerable. I am sure we can always do thereby generate income for Hamas. There are advantages more. We are always searching for new ways to develop for Israel in reducing the restrictions. In the Government’s our programmes. view, any easing would strengthen the moderates in Gaza and lower the dependency of the population on The House can be assured that Her Majesty’s Hamas. It would provide better opportunities within Government will continue to work extremely hard Gaza for education, jobs and legitimate interactions with our partners to encourage Israel to ease the with the outside world. It is in Israel’s long-term restrictions further. We will also continue our important security interests to have a stable and prosperous support through DfID for the people of Gaza, as I Gaza, which we have certainly not got at the moment have just described, including our work to address the 333 Gaza[LORDS] Health and Social Care Bill 334

[LORD HOWELL OF GUILDFORD] “(1) In exercising functions in relation to the health service, key access constraints, promote economic growth and the Secretary of State must have regard to the NHS provide support to the poorest and most vulnerable Constitution. parts of society. Of course, all these actions are (2) In this Act, “NHS Constitution” has the same meaning overshadowed by the bigger fact that the longer-term as in Chapter 1 of Part 1 of the Health Act 2009 (see answer to the problems faced by the people of Gaza, section 1 of that Act).”” and the rest of the Occupied Palestinian Territories, lies in reconciliation. Lord Hennessy of Nympsfield: I shall speak also to Amendment 150, which is in my name on the Marshalled That includes reconciliation between Fatah and List. These amendments are a product of the conversations Hamas, resulting in free and fair elections in 2012 and chaired by my noble friend Lord Laming, designed to the formation of a new Palestinian Authority composed bring the highest possible level of consensus to what of independent figures who will continue the excellent the noble Earl, Lord Howe, calls the suite of clauses work on state-building and uphold the quartet principles. dealing with the accountability of the Secretary of We welcome recent moves in this direction. We are State. I am very grateful to my noble friend for his aware of reports that Fatah and Hamas have agreed sensitive chairmanship of the discussions and to the and that President Abbas will become Prime Minister. Minister for generously accepting the argument—that It is a bit too early to make a detailed assessment of the special essence of the National Health Service these changes but in our view it is important that any as distilled in the NHS constitution be enshrined in new Palestinian Authority should be composed of the Bill. independent figures, will uphold the principle of non- violence, is committed to a negotiated, two-state solution With this new status, the NHS constitution will and accepts the previous agreements of the PLO. We shine even more, both as a beacon for all involved in also look to the Palestinian Authority to continue the healthcare, whatever their place in the proposed new important progress on state-building achieved in recent mixed economy of service provision, and as a statement years. We have made it consistently clear that we will of enduring values, which occupy such a central place engage with any Palestinian Government who show, in how we wish our services to be undertaken and how through their words and actions, that they are committed we conceive of ourselves as a people. to the above principles. I shall not detain your Lordships long, as I am We also welcome the aim of reconciliation between confident that these amendments, for all the friction Israelis and Palestinians. That is what we must work and division that other clauses have generated, are for. We encourage both sides to build on their recent ones that embrace the views of the vast majority of talks in Jordan. We will continue to do all we can to your Lordships as they do the country they serve. But support and encourage negotiations which lead to a I must also express my gratitude to the noble Lord, sovereign, viable and contiguous Palestinian state, living Lord Darzi, and his colleagues in the last Labour in peace and security alongside a safe and secure Israel Government, for commissioning the wide consultation and its other neighbours in the region. When those whose streams of thought fed into the NHS constitution conditions develop, the people of Gaza and their when it first appeared in January 2009. It managed to present condition can really, tangibly improve. Until contain the key principles in seven well worded paragraphs, we have those conditions, we will be prevented from which I shall not recite as your Lordships have the text moving in the right direction. I do not have time to go to hand and will be familiar with its ingredients. into the wider issues of the Middle East peace process The Bill, when an Act, will take a great deal of or the many problems that trouble your Lordships, bedding down, and it will take the second coming for such as the settlements issue that continues to be, in the rifts between the political parties and the anxieties our view, an illegal operation. I hope that I have expressed by so many health professionals to be indicated our determination and hands-on approach assuaged—and perhaps not even then. However, with to the problems. This is one of the sores and tragedies the NHS constitution in its prominent place towards of the modern world that can be resolved with the top of the statute, we shall have a touchstone, not determination, if we really work hard to do so. just for aspiration and inspiration but for behaviour and conduct, a shared talisman for the tougher moments 8.30 pm when the implementation of this Bill throws up its inevitable problems and controversies. When we find a Sitting suspended. lustrous patch of consensus on the NHS’s road from 1948, as represented by the NHS constitution, we Health and Social Care Bill should cherish it through thick and thin, for we are Report (1st Day) (Continued) never better as a country than when we concentrate on those things that unite us rather than divide us. I beg 8.35 pm to move. Baroness Thornton: My Lords, I am very pleased to Amendment 6 put my name to this amendment and I congratulate Moved by Lord Hennessy of Nympsfield the noble Lord, Lord Hennessy, on his tact and diplomacy 6: After Clause 2, insert the following new Clause— in getting us to this point, and in getting agreement to “The Secretary of State’s duty as to the NHS Constitution have the constitution mentioned in the Bill, and in After section 1A of the National Health Service Act 2006 such a prominent part of it. In preparing a few supportive insert— remarks, I had a look at the constitution because I was “1AA Duty as to NHS Constitution working for my noble friend Lord Darzi in a similar 335 Health and Social Care Bill[8 FEBRUARY 2012] Health and Social Care Bill 336 role to the one the noble Baroness, Lady Northover, Clause3:TheSecretary of State’s duty as to reducing has—as his support and his Whip—when we were inequalities working towards the constitution, and when it was discussed and adopted across government and Parliament. Amendment 7 The importance of having it in the Bill is there in various key parts of the constitution, which are worth Moved by Baroness Finlay of Llandaff mentioning on the record here because we need to 7: Clause 3, page 2, line 40, at end insert— remember them as we move forward to discuss this “, and Bill in all its glory in the next five or six weeks, or however long it takes us. The constitution says: (b) the Secretary of State should by regulations set out a clear system of recourse for patients, or other concerned “The NHS is founded on a common set of principles and individuals, who do not believe that an equitable service values that bind together the communities and people it serves— is being commissioned either for their condition or in patients and public—and the staff who work for it”. their locality, or both.” It goes on to say that it, “establishes the principles and values of the NHS in England. It sets out rights … and pledges which the NHS is committed to Baroness Finlay of Llandaff: My Lords, the amendment achieve”. seeks to ensure that there is a system of recourse for It says: patients or other people who are concerned and who “AllNHS bodies and private and third sector providers supplying do not believe that an equitable service is being NHS services are required by law to take account of this Constitution commissioned either for their condition or in their in their decisions and actions”. locality. One of the difficulties that patients have is to That is a very important part of why this needs to be challenge decisions once they have been made without in the Bill. a prohibitively expensive legal challenge. As a result, The final part which I would like to draw to your many decisions are made by commissioners that are Lordships’ attention is point 6 of the guiding principles effectively unchallengeable, for example on service in the constitution, which is a commitment, configurations where the public are not consulted “to providing best value for taxpayers’ money and the most properly or in fact feel that they have not been consulted effective, fair and sustainable use of finite resources. Public funds at all. for healthcare will be devoted solely to the benefit of the people Some clear system of recourse is required that will that the NHS serves”. give patients a meaningful chance to challenge decisions That is exactly right. It is not the shareholders of that they think are wrong, poorly consulted on or companies and not individuals who might seek to inadequately evidence-based, or that might even have make a profit but the people whom the NHS serves, ignored the evidence that is there or the guidance that and the taxpayer. goes with it. In such an instance, a system of recourse would be to allow people to challenge where they The Parliamentary Under-Secretary of State, Department believed that services had not been provided fairly or of Health (Earl Howe): My Lords, I am very grateful to equitably. I expect that the Minister will say that there the noble Lord, Lord Hennessy,for tabling these important is always healthwatch and that they could go to their amendments and for the eloquent way in which he local one, but how is that loop closed? What are the introduced them. As he said, they seek to require the powers to influence the commissioning decision? How Secretary of State to have regard to the NHS constitution are patients who feel that they have really not been when exercising his functions in relation to the health provided with the service that they need able to appeal, service. I say to him in all sincerity that I very much be listened to or have a fair hearing? They may be welcome his contribution throughout this debate. I refused or their points may be accepted, but that loop identify myself entirely with the enthusiastic remarks for patients needs to be closed and there need to be that he addressed towards the constitution itself, which clear pathways. is a most succinct and inspiring document, and I agree with him that we have reached a very workable and satisfactory outcome to the question that he originally 8.45 pm posed to me and to the House. I fear that just saying that they can go and complain I fully support these amendments. It is right that we locally, or that they can go to their local healthwatch, continue our commitment to the principles set out in is not going to be enough. They may find that they are the NHS constitution. I hope that these amendments in a long queue or in a complaints system that they together provide noble Lords with reassurance of the find difficult. I hope that the Minister might respond Government’s continued commitment to the core that guidance and regulations will deal with this and principles and values to which the noble Lord and the will provide clear pathways for patients and others noble Baroness have referred. I commend them to the who wish to question decisions. I beg to move. House. Lord Beecham: My Lords, I welcome the noble Lord Hennessy of Nympsfield: I am grateful to the Baroness’s amendment, particularly because it extends noble Baroness, Lady Thornton, and the noble Earl, the implicit obligations under Clause 3 from the individual Lord Howe, for their kind remarks. Earlier, a noble to the locality. It includes individual access, of course, Lord—I forget who—thought we were mired in the but it speaks in terms of an equitable service being treacle of consensus. All I can say is: long may we be commissioned either for the individual patient’s condition stuck in this particular pot of treacle. or in their locality, and that enhances to a considerable Amendment 6 agreed. degree the provision of Clause 3 and its proposed 337 Health and Social Care Bill[LORDS] Health and Social Care Bill 338

[LORD BEECHAM] groups, and that those local commissioning groups amendment to the 2006 Act. The drafting of proposed will have a great deal of autonomy over the new Section 1B is a little odd, it might be thought. The services that they commission—for example, the drug intention is clearly good, but, pathways that they permit—in treating particular patients. “have regard to the need to reduce inequalities between the people This amendment appears to say that if the treatment of England”, given through the commissioning pathway of one is a slightly curious phrase. It might be asked, between commissioning group is different from that of another the people of England and what? The drafting could commissioning group, you would therefore have recourse be improved by the time we get to—actually it will not, to action if you felt, for instance, that the drug regime as we are on Report. Perhaps it is capable of being in one group was unacceptable. Perhaps I could have improved, let us say. clarification on that. It is important because there will The noble Baroness has touched on the broader be that sort of difference in provision, regardless of issue of the locality, which raises issues of how the whether we agree to the local commissioning group Government might pursue their objectives, which are position. shared by all sides of the House. There are different organisations in the new structure that will have a Lord Northbourne: My Lords, I intervene briefly to responsibility to promote equality, which will include support the noble Baroness, Lady Finlay, because I the clinical commissioning groups and the health believe that there will be real problems. The immense and well-being boards. Some mechanism ought to complexity of the Bill will lead to tremendous delays provide accountability for both those bodies. In and a great deal of misunderstanding among people particular, the need to promote equal treatment in a who feel, rightly or wrongly, that they have failed to patient-centred service ought to be very much part of get the service or treatment to which they are entitled. the joint strategic needs assessment that should be I hope the Minister can say something about the undertaken by the health and well-being boards, and possibility of some sort of short-circuit response, whereby ought to influence the commissioning. We hope that people who feel that they have been ill treated can, if these regulations will establish that connection and, as necessary, have some kind of help and encouragement the noble Baroness has suggested, lay down a clear to make contact with the right people to resolve their structure, though not one that is too prescriptive—a problem. pathway, as she usefully put it, for patients, individually or, as it were, collectively, to raise the issues that Earl Howe: My Lords, this has been a very useful concern them through healthwatch. short debate. As the noble Baroness, Lady Finlay, There is another route that I hope the noble Baroness said, her amendment seeks to provide appropriate will agree would be helpful. Local authorities retain recourse for individuals who believe that the the duty of scrutiny of local health services. For that commissioning of services for either their condition or matter, inequalities can arise on the social care side of their locality is inequitable. It would insert a new the health and social care world. Local authorities paragraph in the Secretary of State’s inequality duties. therefore provide an additional route that would repay The noble Baroness spoke with considerable further consideration. It ought to be feasible for a persuasiveness on this amendment but I will suggest to health and scrutiny committee, and I serve on one in her that it is unnecessary and explain why. my own authority, to have regard to the level and type The Bill and existing legislation already provide a of complaints regarding not only equitability but the number of mechanisms for exactly the kind of recourse standard of service in all parts of the health and social that the noble Baroness seeks. She foresaw that I care services in that locality. Therefore, it would be would talk about local healthwatch and I will. Local useful if the Minister could liaise with the Local healthwatch, which will replace local involvement networks Government Association, perhaps to produce some from April 2013, will provide local people with the kind of working model for dealing with this aspect. opportunity to have their views on their needs and For example, it may be that the Centre for Public experiences made known to commissioners and providers Scrutiny could, in conjunction with the department, of health and social care services and others. One of the LGA and HealthWatch itself, representing patients, the roles of local healthwatch will be to make reports come up with a model that authorities could adopt and recommendations about how local care services and promote among their populations to provide clear could or ought to be improved. To ensure that these recourse for dealing with difficulties and complaints have real clout, the Bill requires the people who receive about either individual treatment or collective provision such reports and recommendations, such as the NHS that is a matter of local concern. Commissioning Board, to have regard to them in I hope the Minister will accept the thrust of the exercising any function relating to care services. amendment and, even if it is not built into the Bill, We then have a further avenue for recourse because that action can be taken to fulfil the aspirations that HealthWatch England will also provide the NHS the noble Baroness has outlined. Commissioning Board, among others, with the views of people on their needs for, and experiences of, health Lord Willis of Knaresborough: My Lords, briefly, I and social care services and on the views of local should like some clarification on this amendment, and healthwatch and others on the standard of provision I hope that the Minister will be able to provide just of services and on whether or how the standard could that in summing up. There seems to be a real difficulty or should be improved. Where the board is provided here. The architecture of the Bill says that we should with advice, it must inform HealthWatch England of have a Commissioning Board and local commissioning its response, or proposed response, to the advice. 339 Health and Social Care Bill[8 FEBRUARY 2012] Health and Social Care Bill 340

However, if an individual feels that a CCG, or the regard to the need to reduce inequalities, and amendments board, or any other body in the future health service, we have tabled would ensure that they would have to has neglected their responsibility with regard to tackling report on how they had fulfilled those duties. inequalities, they can do several things. They may raise With those remarks in the round, I hope that the the matter directly with the organisation itself, specifically noble Baroness is perhaps more reassured than she by pursuing a complaint through the NHS complaints was at the outset of the debate, and that she will be procedure. Where not satisfied with the response at a willing to withdraw the amendment. local level, they may refer the matter to the Health Service Ombudsman. As a last resort—I emphasise 9pm “last resort” because I do not want noble Lords to feel Baroness Jolly: Before the Minister sits down, will that this process would be run of the mill—as the he clarify whether the same processes that he has just NHS constitution makes clear, should an individual outlined would apply to people in receipt of specialist feel that local resolution has not been possible, and in services that are commissioned by the NHS the event that the Secretary of State or an NHS body Commissioning Board, not by local CCGs? is failing to comply with its legal duties, there would be a right to seek legal redress by means of a claim for judicial review. Earl Howe: My Lords, where a service is commissioned by the NHS Commissioning Board—and let us imagine There is a central issue here. CCGs will be under a that it is a specialised service—the patient’s recourse statutory obligation to arrange for provision of care to should be to the board. However, of course, the board meet the reasonable requirements of the people for will be represented at a local level rather than only whom they have responsibility. The local authority’s centrally, and we expect that the board will be represented health and well-being board, the membership of which in health and well-being boards and in the discussions will include the CCG or CCGs, will assess local population that take place there. It would therefore be possible for needs, and will develop a strategy to meet those needs. a patient to address their concerns, in the first instance, Local healthwatch will also be a member of that to the health and well-being board, which would have board and be able to input into the strategy. There will the ability and power to communicate directly with the be a duty on the CCG, the local authority and the NHS Commissioning Board, if that was felt to be NHS Commissioning Board to have regard to the appropriate. However, as I said, the patient would be relevant assessment and strategy when exercising functions. able to go straight to the board in those circumstances. This would include the function of preparing commissioning plans. The NHS Commissioning Board Lord Harris of Haringey: I appreciate that this is will have a duty to perform an annual assessment of very bad manners, given that I missed most of the how well each CCG has fulfilled its duties in the debate. The Minister has just said—although perhaps previous financial year. This will include, in particular, I misinterpreted him—that the NHS Commissioning an assessment of how well it has taken account of Board will have a representative on every local health assessments and strategies under Section 116B of the and well-being board. If so, how will those individuals Local Government and Public Involvement in Health be known or accountable? Is that not the most Act 2007. extraordinary bureaucracy? He seems to have made a My noble friend Lord Willis rightly said that we most extraordinary statement. should expect that there will be differences between CCGs in their commissioning policies. Of course he is Earl Howe: My Lords, we are at Report stage and I right, because each CCG will be bound to formulate hope that the noble Lord will forgive me if I do not policies for commissioning that reflect the needs of reply at length. The point I was seeking to make was their constituent populations. I do not think that we not about representation on the board but involvement should shy away from variation that is considered and in the health and well-being board’s wider deliberations. that genuinely reflects that diversity in population. It is entirely open to a health and well-being board to What we do not want, clearly, is postcode and random invite a member of the Commissioning Board to be a variations which have no relationship to the needs and permanent member, but I am not saying that we are requirements of local patients. prescribing that. We should not forget either that the Health Service Commissioner has power to investigate complaints Baroness Finlay of Llandaff: Perhaps I may seek a that are not resolved locally and to make recommendations tiny bit of clarification. The noble Earl spoke about as a result of those investigations. It is very rare for the ombudsman as being almost a final port of call. those recommendations not to be implemented but, in Will the Minister confirm that the ombudsman would extremis—and this is not often done—the Health have the ability to investigate any organisation that is Service Commissioner is able to lay a report before providing services to patients if it is in receipt of any Parliament. NHS money whatever—not only if the care for an individual patient is commissioned from it but if it is We believe, therefore, that there is already a clear receiving a block grant? In particular, I have in mind system of recourse where patients are concerned that services such as those provided by hospices that may an equitable service is not being commissioned either be receiving a block grant but do not have a specified for their condition or their locality, and the Bill strengthens contract per patient, and it may be that its patients the ability of patients to make their views heard. The want to question what is going on or that they have a Bill also introduces, for the first time ever, duties on concern that they wish to express and take further. the Secretary of State and commissioners to have Apart from the local complaints service within the 341 Health and Social Care Bill[LORDS] Health and Social Care Bill 342

[BARONESS FINLAY OF LLANDAFF] service. I will speak to each of the amendments tabled organisation, it is really important that such patients in my name, as well as the amendments tabled by the have the same ability as other patients to have oversight noble Baroness, Lady Thornton, which seek to remove through the ombudsman. I know that we have discussed the duties of autonomy on the NHS Commissioning this previously, and I am seeking clarification today Board and the Secretary of State. on that issue. Amendments 8 to 10 and 52 to 54 concern the autonomy duties placed on the Secretary of State and Earl Howe: The answer to the noble Baroness is the board. Government Amendments 8 and 53 re-phrase that all NHS-funded care would come under the umbrella the duties of autonomy on the Secretary of State and of the ombudsman. It is not about organisations; it is the Commissioning Board as duties to, about whether that person is or is not an NHS patient “have regard to the desirability of”, and about the care that they are receiving as an NHS patient. autonomy, rather than duties to, “act with a view to securing”, Baroness Finlay of Llandaff: This is Report; I do such autonomy.The desirability of autonomy is therefore not want to and fro. I will assume that that covers a factor for the Secretary of State and the board to part-funding of care by charities as well as where care consider when exercising their functions, rather than is fully funded by the NHS, so the same will apply. an end which they must seek to secure or promote. I am grateful to the Minister for setting out the That should allay the fears of those who felt that the processes so clearly. It will be very helpful for autonomy duties would prevent Ministers and the patients, patient groups and charities in particular to board intervening when they needed to. see that laid out. For clarification, of course there In addition, changing to a duty to have regard will be local variation, different drug regimes and necessarily means that the autonomy duties are subsidiary different ways of doing things. Equipoise is around to the primary duties of the Secretary of State in the evidence base. The problem is where there is no Section 1 of the NHS Act: to promote the health provision or gross differences. That is where patient service and to exercise his functions so as to secure the groups are concerned. I beg leave to withdraw the provision of services. To that extent, there is no further amendment. need to state that the duties of autonomy are “subject to” his Section 1 duties. However, government Amendment 7 withdrawn. Amendments 9 and 54 make a further change to address this point. Rather than simply say that the Clause 4: The Secretary of State’s duty as to autonomy duty is “subject to” the duty of promoting promoting autonomy the comprehensive health service, they set out an explicit test, which makes clear that promoting the health service and securing the provision of services Amendment 8 takes priority over autonomy, if there is ever a conflict Moved by Earl Howe between the duties. We think that this more clearly indicates how the Secretary of State and the board 8: Clause 4, page 3, line 5, leave out from “must” to end of line should resolve any tension between autonomy and the 6 and insert “have regard to the desirability of securing, so far as consistent with the interests of the health service—” interests of the health service. I hope that noble Lords will agree that this provides helpful clarity and avoids Earl Howe: My Lords, I shall speak also to any possible doubt. Amendments 9, 34, 53 and 54. Having said that I would address the amendments This group of amendments deals with the role of of the noble Baroness, Lady Thornton, I think that on the Secretary of State in the health system. As noble reflection it would be discourteous of me to do so Lords will be aware, our proposals for the NHS involve before she has introduced them. I shall therefore retain a fundamental shift in the balance of power away my remarks for later in the debate if she chooses to from politicians to patients themselves and to doctors speak to those amendments. Meanwhile, I beg to and other professionals. Greater local autonomy is move. one of the key things that will enable local front-line services to become more responsive and innovative, in Lord Marks of Henley-on-Thames: My Lords, perhaps turn delivering greater efficiency and quality. The Bill I may explain why I support the Government’s makes clear that Ministers are responsible, not for amendments on the autonomy clauses to which I have direct operational management, but for overseeing added my name—that is, Amendments 8, 9, 53 and 54. and holding to account the national bodies in the The autonomy clauses were at the heart of the system—backed by extensive powers of intervention Government’s consultation with other noble Lords in the event of significant failure. about the Secretary of State’s duties. During Committee The amendments we are debating here cover some and thereafter, at the very helpful discussions that we of the key concerns raised by the Constitution Committee have had with my noble friend the Minister and with and Peers from across the House, as part of our wider Peers across the House and, indeed, at the meeting of discussions about ministerial accountability. These are lawyers in which I took part with my noble and the autonomy duties on the Secretary of State and the learned friend Lord Mackay, the noble and learned Commissioning Board and the link between the functions Baroness, Lady Scotland, and the lawyer advising of clinical commissioning groups and the Secretary of your Lordships’ Constitution Committee, a substantial State’s duty to promote the comprehensive health consensus was reached. 343 Health and Social Care Bill[8 FEBRUARY 2012] Health and Social Care Bill 344

The concerns that we sought to address, which I 9.15 pm regarded then and still regard as significant, were A number of Peers have spoken of the need to avoid twofold. The first was that I believed there would be micromanagement and of the desirability of expressing an inherent conflict between, on the one hand, the that in the Bill. There was much discussion as to Secretary of State’s duties under Clause 1 to promote whether micromanagement was a word that could be a comprehensive health service and to exercise his usefully employed in legislation. The Government’s functions so as to secure services and, on the other amendments maintain the commitment to avoiding hand, an unfettered duty to promote the autonomy of micromanagement but do so in a way in which the others. Secondly, if the Bill went unamended, there flaws in the unamended Bill are rectified. I suggest that would exist a risk that a Secretary of State who was they represent an elegant and effective solution to a unwilling to intervene when things went wrong would difficult and challenging problem. I believe that the be handed a justification for inaction. Such a hands-off way in which this solution has been reached brings Secretary of State could say, “I will not intervene great credit to this House, as others have said today. I because I am bound by my duty to promote autonomy”. should like to say how much I have personally appreciated In my view, with the Bill as it stands it would be very the opportunity to work with my noble friend the difficult to mount a successful legal challenge to such Minister,and officials and draftsmen from his department, a failure to intervene. as well as other Peers from across the House who have Those were the two flaws in the Bill that the all brought us to this compromise. These are amendments amendments were required to address. In relation to that we can support and not lose the commitment to the board, the unamended Bill was flawed in exactly avoiding micromanagement. That would disappear if the same way as it is in relation to the Secretary of we accepted the amendments tabled by the noble Baroness, State. Lady Thornton, so we should oppose them. I briefly express support for Amendments 34 and The consultations that we held outside the Chamber 35, which neatly tie in the CCGs into the Secretary of during Committee led to the formulation of the State’s duty under Clause 1 and the objectives and Government’s amendments. As the Minister has pointed requirements stipulated by the Secretary of State for out, the effect of Amendments 8 and 53 is that the the board. In that way, the line of responsibility from duty to act with a view to securing autonomy is the Secretary of State through the board to the clinical reduced to a duty to have regard to the desirability of commissioning groups exercised through the mandate securing it. That is still subject to the limitation that is maintained and clarified. This has been very important the duty applies only so far as it is consistent with the because the amendments embed the mandate in the interests of the health service. Therefore, what is currently line of responsibility by which the Secretary of State an absolute duty to follow the autonomy line is to be exercises his constitutional responsibility for the provision replaced with a more nuanced and, I suggest, a more of the health service. It is also consistent with the new appropriate obligation to accord to the desirability of arrangements for provision introduced by the Bill. autonomy its proper place in the balancing exercise This establishment of responsibilities was something which all discretionary decision-making involves. that we were very concerned to see in the Bill. Again, it However, it is Amendments 9 and 54 that are is a tribute to the House that the procedures we decisive in addressing the concerns that we identified. adopted have achieved a structure that is both clear Those two amendments provide that in the case of and internally consistent, while being effectively conflict between the Secretary of State’s or the board’s co-ordinated. duties in relation to autonomy and their overarching duties under Clause 1 or the board’s overarching Baroness Jay of Paddington: My Lords, the House duties to secure the provision of services, those will be aware that the second report of the Constitution overarching duties will prevail. Those four amendments Committee on this Bill suggested amendments in this taken together fully address the two flaws of which I area, precisely for the reasons well outlined by the spoke and, I suggest, completely resolve the issues that noble Lord, Lord Marks, and as expressed by the Minister. they pose. We were concerned that the way in which the Bill was I turn now to the two amendments of the noble originally framed would dilute that line of responsibility Baroness, Lady Thornton, directed at deleting the two through the Secretary of State and that the provisions autonomy clauses. Indeed, at the earlier stages of this on autonomy were such that that link would be broken, process, I believed that the autonomy clauses could or at least threatened. and should be deleted from the Bill. However, my view I wish to explain briefly why, although the committee now is that with the problems that they presented produced amendments that are very similar to the having been addressed, we should support the government ones tabled by the Government and supported by the amendments and retain the two clauses as amended. noble Lord, Lord Marks, I have not put my name to Promoting autonomy is, in principle, to be welcomed them. That is simply because the wording of the as many who have spoken from all sides of the House government amendment is not as simple as the one both on Second Reading and in Committee have that the Constitution Committee supported and wished stressed. It is fundamental to the architecture of the to see in the Bill. We suggested: Bill, and its great merit that it establishes a clear, “Subject to sections 1(1) and 1(3)”, decentralised structure for the health service. It is which we discussed on government Amendment 5, entirely welcome that future commissioning decisions, “and so far as is consistent with the interests of the health service, in particular, will be made locally to meet local needs, the Secretary of State must, in exercising functions in relation to locally assessed. that service, have regard to the desirability of securing”, 345 Health and Social Care Bill[LORDS] Health and Social Care Bill 346

[BARONESS JAY OF PADDINGTON] Clause 4 was misguided and should be abandoned. I et cetera. Clearly that is very close to the wording of can see the case, which was put very well by the noble the amendment tabled by the Government. The Lord, Lord Marks, for retaining Clause 4 with these Constitution Committee is particularly grateful for more controlled features. Listening to this debate, I the phrase “having regard to”, as the Minister has have a number of concerns. explained. We were not in a position to discuss the There is genuine concern that there might be a change in formulation that has occurred, and we have really rogue clinical commissioning group, but listening yet to listen to my noble friend Lady Thornton, but as to the noble Baroness, Lady Finlay, has revived my there were members of the committee who, like me, concern that somewhere along the line, if we are not would prefer to see this clause deleted, I have not put very careful and are too controlling, we will stop the my name to this amendment although I understand initiatives that we want from commissioners as the that it is very close to the one that the committee NHS faces considerable challenges. As the House originally suggested. knows, I do not have the same fear that other Members of your Lordships’ House have about third- Baroness Finlay of Llandaff: My Lords, I wish to sector or independent-sector providers, so I would not raise some questions because I have put my name to want anything in the peace that we see breaking out the amendment suggesting that Clause 4 be deleted. here to inhibit creative clinical commissioning groups The Government’s guidance notes published with the setting off on new paths for new types of services amendment that has been tabled appear to make the simply because major people in the NHS have not duty of autonomy subject to the Secretary of State, woken up to the need for significant change. I hope but there is ongoing concern that there remains the that the Minister can reassure me that, in accepting risk that the clause could be used by clinical commissioning this more nuanced version of Clause 4 on autonomy, groups to justify not providing a full range of services we are not really inhibiting the creativity of clinical or putting inappropriate services out to tender. While commissioning groups to bring in new players, even local organisations should have the freedom to respond if it may seem a rather radical idea when they start to appropriately to the health needs of the population, do it. local commissioners should not be able to act totally Finally, as the Minister knows, I have a mild obsession autonomously and commissioners must have regard with the whole issue of a pre-failure provision in this to national guidance. In his closing summary, the legislation, which we will come to later. One of my counsel to the chair in the Francis inquiry pointed out continuing concerns is that we do not want to end up that there is a need for far greater standardisation of with a situation where we are restricting the ability of operating and quality standards in the NHS and close the National Commissioning Board to begin to monitoring of compliance. intervene—to tackle failure at the local level—simply Concern about the inclusion of Clause 4 continues because autonomy requires people to flounder along to lead to some uncertainty, confusion and concern as long as they like on the grounds that it is all about about how competition would be applied in the new localism. I hope the nuanced version of Clause 4 that system. Phase 2 of the Future Forum recommended we are getting is still accepted as something that would that the Government clarify the rules on choice, enable the National Commissioning Board to intervene competition and integration. The concern is that if the when there was a total failure by providers and restraint on autonomy is not as tight as it possibly commissioners at the local level to tackle the problems ought to be, services could fragment. The Government of clinical and financial unsustainability. need to clarify that integration will trump competition. I ask the Minister to clarify that the national Commissioning Board will be prepared to intervene if Lord Harris of Haringey: My Lords, every time I clinicians feel that the type of competition that is look at Clause 4—[Laughter.] I cannot understand being proposed could fragment services. We have heard what my noble friends find so amusing, but every time quite a lot about commissioning along whole-care I look at this particular clause—if that makes it easier pathways, such as musculoskeletal services and mental for them—and particularly listening to the remarks of health services, and in whole-function areas, such as the noble Lord, Lord Marks of Henley-on-Thames, I community services. There is concern that where this have been confused as to what problem the Government has happened in the east of England with musculoskeletal think they are solving by the clauses on autonomy. and respiratory pathways, there is a sense that they There is apparently a concern about micromanagement. should have been put out to tender more than they There is a desire to have local innovation, flexibility have been. There is concern that there are times when and local responsiveness. What is it about the current whole-care pathways should not be subject to competition. arrangements in the NHS that necessarily prevents The difficulty with the clause is that it leaves in doubt local innovation, flexibility and local responsiveness? how much integrated whole-care pathways, which may Why are we having these discussions? If there is a not leave complete autonomy to different parts of the concern from the Government that they are system, will trump competition between different parts micromanaging, they have a solution—they stop of the system. micromanaging. Again, what are we trying to do here? However, once you include, Lord Warner: My Lords, I had not intended to “the desirability of securing, so far as consistent with the interests intervene in this group of amendments, but I want to of the health service”— make a couple of points and leave a question with the or whatever form of words you choose to have—this Minister. I have always been in the camp that feels that principle of autonomy, you are setting up an automatic 347 Health and Social Care Bill[8 FEBRUARY 2012] Health and Social Care Bill 348 conflict. If the form of words that the Minister and Baroness Thornton: My Lords, when we were having the noble Lord, Lord Marks of Henley-on-Thames, our negotiations on this part—on which I was very have put their names to was in the Bill, does this mean happy to take part, even if I was regarded on some that the Secretary of State will be intervening when issues more as grit in the oyster than as co-operative there are clear cases of postcode lottery? That presumably help—they were about these issues, including is the implication. Or is the Secretary of State now autonomy. I have not changed my view. I shall speak going to say that in fact a postcode lottery is what this to Amendments 10, 36 and 52. legislation is designed to create? We should be clear what these clauses are trying to prevent. What is the We have no problem with the concept of autonomy. problem that they are trying to solve? In principle our position is that autonomy has to be earned, and that it should be able to be taken away The noble Lord, Lord Marks of Henley-on-Thames, as well. That formed the principle and the basis on was moving in his description of how the Secretary of which the foundation trusts were established. However, State would weigh these difficult issues of the possible we part company with the Government on their view conflict between, of autonomy, and we are not completely convinced by “the desirability of securing, so far as consistent with the interests the point made by the noble Lord, Lord Marks of of the health service”, Henley-on-Thames. On first sight of the Bill it seemed autonomy and the priorities of the fundamental role that autonomy was to be presumed and that each part of the NHS. This is a balance that has to be weighed. of the service would be subject to less interference He talked about this line of accountability that will from the other parts in a way which could be exist between the NHS Commissioning Board and the detrimental. There would therefore be less performance CCGs—these tentacles that the NHS Commissioning management, and giving various bodies more powers Board will put throughout the NHS. They will be with less need to sign off an agreement could mean unaccountable and anonymous, and individuals will that there would be less co-operation. Bodies acting in be operating at regional or at local level. their own interests via a market process will mean that There will be an army of people operating as the the motivation could be something that does not have tentacles of the NHS Commissioning Board. They the NHS and patients at its heart, and that there is less will be informing the Secretary of State so that he can planning and system management, which sometimes exercise his judgments about the balance between actually is required. That is how you deal with things autonomy and meeting the principles of the NHS. I like postcode lotteries. Youhave to collect the information, wonder whether the Secretary of State is creating the compare it between different parts of the country most extraordinary bureaucratic monster to solve a experiencing different levels of deprivation, and then problem that could be easily solved simply by resisting you have to take decisions which are about planning his tendency to micromanage. how to use your resources to ensure that people are not disadvantaged. So there are some very good reasons why planning and systems need to be in place. 9.30 pm The original briefing on the Bill stated that CCGs Baroness Jolly: My Lords, I support the government would not have PCTs or SHAs above them to performance amendments in this group, which are also in the name manage them and that the commissioning bodies were of my noble friend Lord Marks. They represent the not meant to performance manage but only to step in last in a suite of 10 amendments which came out of if there was a danger of failure. Again, that was the the process so eloquently described by many noble original briefing. It is not surprising that when we first Lords in earlier debates today, and which take us from discussed this in Committee there was general agreement the Secretary of State right through the board to across the House that the Bill would be better off CCGs, accountability and micromanagement, tentacles without Clause 4 and what was then Clause 10 but is and all. now Clause 12. Like everyone else I should like to state my thanks, Since then the Constitution Committee has done and on my Benches there are two people to whom I what I think is really rather a good job. Although I owe particular thanks. My noble friends Lady Williams was not deliriously happy about it, I was prepared to and Lord Marks worked very hard from last March to live with the draft produced by the committee. However, make this happen. In association with many others, I do have problems with the draft that the noble Lord, including my noble and learned friend Lord Mackay Lord Marks, and the Minister have brought to the of Clashfern and the noble Lord, Lord Hennessy, who House. The provisions are not strong enough and is no longer in his place, they worked extremely hard at some of the dangers that we originally expressed about getting these amendments together. I hope that the problems with the autonomy clauses still exist. noble Lord feels comfortable and confident about the Furthermore, I take very much to heart the questions expression he used in Committee about the DNA of that both of my noble friends have raised. From NHS Bills, and that he feels that that DNA is now different points of view they have asked pertinent weaving through this suite of amendments—from the questions and shown up the problems with the autonomy 1940s to the 21st century. The noble Baroness, Lady clauses. That is why, certainly in the process of our Jay of Paddington, and the Constitution Committee negotiations on Clause 4, I reserved my position to played such a vital role, and my noble friend the come to the House and explore whether what we Minister smoothed the way. As I say, however, I thank actually wanted to do was delete it completely at this in particular my noble friends Lady Williams and stage. On Clause 12, for the sake of consistency we feel Lord Marks. that it should also be deleted. However, I have to say 349 Health and Social Care Bill[LORDS] Health and Social Care Bill 350

[BARONESS THORNTON] that temptation because, frankly, Parliament expects that because of the amendments that were accepted in them to do it. That is what the system has expected of the process of our negotiations, we feel less strongly the Secretary of State. This is a burden on commissioners about it. and clinicians, and, in the end, it does not well serve I am not any more convinced as a result of this the interests of patients. It is all very well for the noble debate that our original position is not the right one—that Lord to say, “Well, just stop”, but the system encourages if we cannot have the Constitution Committee’s version it and the duties on the Secretary of State are there to of Clause 4, we should delete the whole clause. Obviously encourage it. I will listen to the Minister’s summing up of the debate, but at the moment I remain convinced that our Baroness Thornton: I cannot resist saying that the position is indeed the correct one. noble Earl’s right honourable friend Mr Lansley has dabbled and intervened on at least 12 occasions since the Bill started. He is on the record as saying on one of Earl Howe: My Lords, the noble Baroness, Lady those occasions that certain managers should be sacked. Thornton, has spoken to Amendments 10 and 52, Is the noble Earl saying that that will cease when this which, as she has said, would remove altogether the Bill is on the statute book? autonomy duties on the Secretary of State and the board. The noble Lord, Lord Harris, asked me what Earl Howe: I am saying that the Secretary of State the problem is that the Bill is trying to solve in this will not have the ability to micromanage the health regard. The duty is intended to promote a culture of service as he does at the moment. Whether the examples fostering local autonomy rather than to outlaw specific cited by the noble Baroness constitute micromanagement, practices; but without a focus on autonomy, it is if my right honourable friend is just expressing a view, possible that the mandate from the Secretary of State I rather question. to the board or the framework document from the The autonomy duty is a necessary part of the Bill board to CCGs could impose disproportionately because it places a duty on the Secretary of State to burdensome requirements on the system. The Government consider the expertise of those in the health service believe that local operational autonomy is essential to while recognising that there will be circumstances in enable the health service to improve the outcomes of which they must be able to step in to protect the care for patients, provided that autonomy is within the interests of health service patients. That is the balance framework of clear ministerial accountability. that we are trying to strike. The noble Baroness will be aware, because I have The noble Baroness, Lady Finlay, asked whether said it before, that we are aiming to free those closest the autonomy duty would allow a clinical commissioning to services to take decisions that are right for patients, group to justify not commissioning the full range of free from central micromanagement by either the services. The autonomy duty does not apply to CCGs; Department of Health or the NHS Commissioning it is a requirement on the board and the Secretary of Board. The amended duties, with the caveat that the State. If a CCG chooses not to commission services interests of the health service take priority, achieve the and the board considers that this is not consistent with right balance between autonomy and accountability. the interests of the health service, the board can Without the clause, a future Secretary of State could intervene to direct a CCG. If the board fails to intervene choose to ignore one of the fundamental principles of when necessary, the Secretary of State has power to the Bill, which is that those closest to patients are best intervene. Finally, the Secretary of State can set out placed to take clinical decisions. Without the clause, a services which CCGs must commission, and he can do future Secretary of State would be free to use his that in the standing rules if he considers it necessary. extensive powers to micromanage the NHS. The The CCG’s key duty is to arrange services as it considers autonomy duty is a necessary part of the Bill, placing necessary to meet all reasonable requirements of the a duty on the Secretary of State to consider the population that it is responsible for, and the amendments expertise of those in the health service while recognising do not change that in the slightest. that there will be circumstances— 9.45 pm Lord Harris of Haringey: My Lords, the noble Earl It might be helpful to say a little more about seems to be saying that you cannot trust your own Amendment 34. I rather skirted over it in my introductory Secretary of State not to micromanage unless they are remarks, although my noble friend Lord Marks spoke effectively forbidden from doing so. We have all talked to it very eloquently. We have tabled Amendment 34 to of the Secretary of State’s accountability to Parliament. make clear the link between what CCGs do and what Surely the principle is that an accountable Secretary of the Secretary of State does in the exercise of his State will be under enormous pressure from Parliament functions. CCGs will be required to act consistently not to micromanage. If it is such a central issue of with the discharge by the Secretary of State of his policy, Secretaries of State should simply be told not duty under Section 1(1) of the National Health Service to do it, rather than requiring an Act of Parliament. Act when exercising their duty to commission services under Section 3. Our amendment goes even further by requiring CCGs to act consistently with two additional Earl Howe: I challenge the noble Lord to think of things: first, the discharge by the board of its duty to one Secretary of State, with the distinguished exception promote a comprehensive health service; and, secondly, of my right honourable friend Mr Lansley, who has the objectives and requirements of the Secretary of not succumbed to the temptation of micromanaging State’s mandate to the board. This addresses concerns the NHS. No Secretary of State has been able to resist raised by several noble Lords, including my noble 351 Health and Social Care Bill[8 FEBRUARY 2012] Health and Social Care Bill 352 friend Lord Marks, who rightly said that there should complexities that are being set up and strengthened, as be a clear link between CCGs and the mandate. The the Minister has agreed, make the whole thing so amendment also applies this duty to the powers of incredibly complicated and bureaucratic that the clinical commissioning groups to commission services underlying policy positions are being totally distorted. under Section 3A, as well as their duty under Section 3, so that it covers all the NHS services that they commission. Earl Howe: I do not share that view at all. I do not The amendment does not mean that it is for an think that the autonomy and accountability arrangements individual clinical commissioning group to determine are as complex as the noble Baroness seems to suggest. how best to promote the comprehensive health service Autonomy and accountability are two sides of the and then act consistently with that view. On the contrary, same coin; one confers autonomy in exchange for the Secretary of State remains responsible for determining accountability. That is the model that we have adopted how best to discharge his duty to promote—in part and the one that I would hope that Parliament would through the mandate to the board but also through wish us to adopt, given that substantial sums of public the exercise of his other functions. The clinical money will be at the disposal of commissioners throughout commissioning group must then act consistently with the NHS. I therefore do not see that the metaphor of how the Secretary of State performs that duty. When tentacles employed by the noble Lord, Lord Harris, is making decisions about the commissioning of services— actually very appropriate. It implies that there is an for example, when deciding whether to withdraw that organisation holding those in the health service in a service—a clinical commissioning group would have grip. That will not be the case. The role of the board is to bear the Secretary of State’s duty in mind and act to support local commissioners; it is to be there as a consistently with how he is performing that duty. To resource to promote guidance, supported by the quality take a practical example, it would not be consistent for standards that we were debating earlier. It is not—I a clinical commissioning group to withdraw a service repeat not—a replica of the kind of line management if the Secretary of State had indicated that the service that the NHS has seen to date. was a vital part of the NHS that should be available to Amendment 8 agreed. all patients throughout England. The noble Baroness suggested that the duty of autonomy threatens care pathways. I simply cannot Amendment 9 agree with her. As I have set out extensively on previous Moved by Earl Howe occasions, both integration and competition are tools 9: Clause 4, page 3, line 11, at end insert— at the disposal of commissioners to deliver high-quality “( ) If, in the case of any exercise of functions, the Secretary of care to patients. The autonomy duty would not alter State considers that there is a conflict between the matters mentioned that in the slightest. in subsection (1) and the discharge by the Secretary of State of The noble Lord, Lord Warner, asked whether what the duties under section 1, the Secretary of State must give we are doing here would somehow inhibit CCGs from priority to the duties under that section.”” bringing in new players. No: where commissioners Amendment 9 agreed. believe that new providers would serve the interests of patients, they will have the ability to bring in such new Amendment 10 not moved. providers. Nor does it interfere in the slightest with the ability of the board to support CCGs in the event of Clause5:TheSecretary of State’s duty as to research distress. I hope I have covered the questions that have been asked. I thank noble Lords for their valuable contribution Amendment 11 to this debate. Once again, I thank the noble Baroness, Moved by Earl Howe Lady Jay, for her good offices in bringing us to this 11: Clause 5, page 3, line 16, leave out “have regard to the need point. I hope that my remarks and the amendments to” tabled will reassure noble Lords that the interests of the health service are and always will be at the heart of Earl Howe: My Lords, we come to an issue that the Bill. exercised us on more than one occasion in Committee— the issue of health-related research and the use of Baroness Jay of Paddington: The noble Lord may research evidence in the health service. My noble be surprised to hear me ask this question because, as friend Lord Willis and others urged me to look again he kindly said, I have been very determined that the at the Bill’s drafting, having expressed a concern that provisions on accountability and parliamentary there was a need to strengthen the duties on the responsibility et cetera should be strengthened in the Secretary of State, the NHS Commissioning Board Bill. However, I listened to what my noble friend Lord and CCGs to promote research, and the use in the Harris said about what he described as the “increasing health service of evidence obtained from research tentacles” of these links between the various providers when exercising their functions. and the Secretary of State. Is the Minister not becoming Government Amendments 11, 60 and 103 are a concerned—as I would in his position—that all this response to that concern, and I hope that they will be new accountability and these links undermine the welcome. The Government are absolutely committed basic policy positions of the Bill? That is why, for to promoting research throughout the health service. example, my noble friend Lady Thornton suggested By tightening the wording around the duties, we believe that it would be cleaner—if that is the word—to that the amendments send a powerful signal of that remove the whole of Clause 4 from the Bill. The commitment. I beg to move. 353 Health and Social Care Bill[LORDS] Health and Social Care Bill 354

Lord Willis of Knaresborough: My Lords, it is a very We also sought in Committee a requirement to pleasant duty to know that amendments proposed in report on that activity. How telling it would be if Committee have been accepted by the Government in patients asked the commissioning groups or their local their totality. I thank the Minister for doing that. GP, “What is the activity in the cause that I have?”? Amendment 11 removes from the Secretary of State We had that wonderful debate earlier on prostate the idea of “having regard to the need to”, and gives a cancer. That is the way in which we will get research clear duty to promote research—and that is the case in developments brought into the clinics and into GPs: Amendment 60, with commissioning boards, and in by patients being able to query what is happening in Amendment 103, with the local commissioning groups. research. In thanking my noble friend the Minister, I The broader research community—from the Wellcome ask him whether, in responding to this short debate, he Trust; the Academy of Medical Sciences; and members will outline to the House very clearly how we are going of the organisation that I chair and declare an interest to make this work. How will we make that duty to in, the Association of Medical Research Charities—is promote research into having an NHS that is world-class incredibly grateful to the Minister for persuading his in terms of its research? How will it work? colleague, the Secretary of State, to accept far stronger policy on the duty to research. I also put on record my Lord Warner: My Lords, I intervene briefly to echo thanks to noble Lords on all sides of the House, everything that the noble Lord, Lord Willis, has said. including Cross-Benchers and Front-Benchers, for We should not rest on our laurels as regards research. I supporting this. It is very rare that you get such an do not want to go over the ground of micromanagement, area, which will clearly make a fundamental difference but the NHS is very quick indeed to forget its to patients, bringing the latest research to the bedside responsibilities on research—and I say this as a Minister as quickly as possible—and to get the whole House to who was responsible for NHS research and development support that. under the previous Government. We do not want to The result of this, if we make it work, will be the go back over the micromanagement debate, but the only research-led health service in the world. That is mandate is a critical issue if the NHS is really to keep an incredible achievement in your Lordships’ House research at the forefront of its thinking. and in many ways surpasses some of the debates that That is because at local level, too often on the we have had about other areas, which frankly will not provider side of the NHS research is forgotten. It is a make a great deal of difference. I include the debate on Cinderella service which comes second to service delivery, Clause 4, which we have just had. I know that Members and we end up seeing that people at senior levels and on the Labour Benches like debating Clause 4; it gives at local level absolve their responsibilities in this area. them a feeling of déjà vu. However, in reality, for us as Nothing is a better example of that than the way in a nation to say that we have a research-led health which local ethics committees and the people around service, where we can bring our huge clinical research them have inhibited the advance and the speedy base very quickly to patients, gives us an opportunity development of research. I do not think that the not only to deliver wonderful healthcare but to use Secretary of State can absolve himself of these that as an economic generator right across the world, responsibilities here with just this duty. Year in, year and to bring high-quality healthcare to people who out, he will have to use the standing rules and the desperately need it. In fact, they need it a great deal mandate to make sure that the NHS’s nose is kept to more than we do. the research grindstone in the very way that the noble In order for that to work and for these to be more Lord, Lord Willis, has said. I hope that the Minister than simply words in a Bill or rhetoric in this House, will be able to convey some of that back in the there have to be mechanisms to ensure that the duty department as well as on the Floor of the House. which we have now agreed for the Secretary of State—or which I hope we will agree—concerned with the 10 pm commissioning board and the commissioning groups, is actually brought to bear. There is nothing left in the Lord Patel: My Lords, my name was on many of Bill which gives me the comfort of saying that is going the amendments of the noble Lord, Lord Willis of to happen. Knaresborough, in Committee about promoting research. As someone who has been involved in or trying to do We asked in Committee whether the commissioning clinical research for many years—I declare an interest board, and indeed the commissioning groups, should as a member of the council of the Medical Research have to include in their commissioning plans what Council—I commend the Government and welcome activity is taking place in research. If we get the health the amendments. They open up the possibility for research authority up and running—I commend the commissioning groups to promote research in many Minister for all that he has done in terms of the special ways, such as promoting clinical trials and encouraging health authority—and if we start to get the 70-day the development of tissue banks, proper bioinformatics permissions for clinical trials in, we will have a Rolls-Royce and proper audit and record-keeping. That will open system, if I may use that analogy, for bringing research up the field of stem cell therapy, bioinformatics, programmes right through into our hospitals for our regenerative medicine and genomics, which will be patient development. However, unless we are able to very good for the NHS. have that built into the commissioning plans, and unless the commissioning board and the Secretary of State drive that—and this House and another place Baroness Morgan of Drefelin: My Lords, I, too, put hold him accountable for that duty—quite frankly, it my name to the amendments in Committee that have will be a hollow gesture. helped to precipitate this very welcome government 355 Health and Social Care Bill[8 FEBRUARY 2012] Health and Social Care Bill 356 amendment and the support of the Minister. I do not network some of that work can be reduced. I know want to repeat what has already been said but I want that there is to be an announcement at, I think, the to make one point: we in the House of Lords have end of March about how these clinical networks are to worked hard to promote the importance of research in be developed in the future. That is a very important the NHS, and we will take a strong interest in the way of enhancing research. mechanisms that I am sure the Minister will describe There is no question that the more we do in research, in a moment, and indeed later on Report, to see how the better the outcomes not only for patients but for this duty will be promoted and evaluated. There are the UK’s reputation and economic well-being. Healthcare also important mechanisms in this House through the research is surely an area to which we need to give Science and Technology Committee, and I hope that great priority. The noble Earl, Lord Howe, is of course many of the noble Lords who are on that committee responsible and we are very glad that he is leading this will bear that in mind when it comes to looking at how work. However, there is no doubt that, welcome though this welcome duty is put into practice. these amendments are, we should be given some assurance that the Government will now take them forward into Baroness Finlay of Llandaff: My Lords, I would the new situation with enthusiasm. also like to formally record an enormous welcome to these changes to the Bill. What has been said in particular by the noble Lords, Lord Willis and Lord Earl Howe: My Lords, I begin by saying how much Warner, is very pertinent regarding the need to keep I agree with the remarks of the noble Lord, Lord questioning. The one thing now that can happen is Hunt. There are two very good reasons why research that those who are actively involved in research can needs to be promoted in the NHS. The first is that it is actually question if they get blocked, in a way that for the good of patients. The other is that it is potentially they could not before. I think that they will be very for the good of UK plc. If we can attract investment bright and questioning people who will make it known in translational and clinical research to this country, if they are not able to do the research that they see it will be a major advance. The sad truth is that in needs to be done for the improvement of clinical recent years the UK has been slipping back in the services. international league table as a location for clinical research. The Government are determined to reverse Indeed, if we can speed up the processes, perhaps that trend, as were the previous Government. We are we can create an environment in which all patients and trying our best to build on the foundations that the relatives understand that a research-rich environment previous Government set. is one that drives up standards of care, and therefore that they are not being experimented on but are being Noble Lords have asked me to explain how the invited to participate when there is equipoise in the Secretary of State’s duty to promote research will highest standards of monitoring that they could possibly work in practice. I shall try to do so in a few words. have. The governance around research processes in The Secretary of State will use the mandate to set this country is potentially second to none. We may priorities for the health service, based on his legal then regain some of those external trials that up until duties. One of those duties is to promote research now have, sadly, been bleeding from our shores. The within the health service, which is shared by the board amendments are incredibly important and their universal and CCGs. What are the tools at the Secretary of welcome is very appropriate. The Minister is to be State’s disposal? The National Institute for Health personally congratulated. Research—the NIHR—which is headed by Professor Dame Sally Davies, provides transparent, competitive Lord Hunt of Kings Heath: My Lords, from the funding to support clinical and applied health research, opposition Benches we too welcome the amendments, the training and development of health researchers, which very much reflect the debate that we had in systems to support research and the NHS infrastructure Committee on the importance of research. The Chief for research. The NIHR will continue to be part of the Medical Officer has paid a visit to Birmingham over Department of Health. Its budget of £1 billion is held the past two days; he gave a lecture at Birmingham centrally by the department. The Chief Medical Officer University and visited my own trust to discuss research will remain responsible for the NIHR and its budget. and the role of the NHS in it. My noble friend Lord The second main route that the Secretary of State Warner has put his finger on it: the question to the uses, and will continue to use, to support research, is Minister is how we make sure that the NHS makes a through the NHS. Since the NHS was established, its sufficient contribution in future to the development patient care budget has funded the patient care costs and support of research. The Minister will know that of patients who are taking part in research in the the Chief Medical Officer is a passionate advocate of NHS, as set out in existing guidance. In the future, the research and excellence in the NHS, and that is to be NHS Commissioning Board and clinical commissioning warmly welcomed. groups will ensure that these costs continue to be met There are some issues that need to be tackled. We through these arrangements. The research costs of have already heard about the issue of getting approval these studies are paid by the Government and charity for clinical trials. We still have the problem, which has research funders such as the Medical Research Council, been with us for many years now, of local committees the NIHR, Cancer Research UK and the Wellcome taking far too long and repeating work by other Trust. The NHS benefits greatly from the evidence committees. I understand that there are some issues provided by this research. around the fact that, because foundation trusts are Let us not forget, too, that the Secretary of State separate legal entities, they have to go through the will be held to account for what he does. He must process themselves, but if they join a clinical academic report annually to Parliament on the performance of 357 Health and Social Care Bill[LORDS] Health and Social Care Bill 358

[EARL HOWE] I hope that that has given noble Lords a clear the health service. There is an expectation that he will outline of how this is all going to work. We regard report on how he has fulfilled his statutory duties. these duties as extremely important. These amendments are extremely important, as my noble friend said. I am That brings us to the duties placed on the board. In in no doubt that both the health service and its patients the document we published, Developing Clinical will be better off as a result of them. Commissioning Groups: Towards Authorisation, we set out the early thinking on the authorisation process. Amendment 11 agreed. The document highlights that as part of the process CCGs will need to demonstrate how they will exercise important functions, such as the duty to promote Clause6:TheSecretary of State’s duty as to research, and the NHS Commissioning Board will education and training seek consistency in the way in which CCGs exercise these duties. Furthermore, a CCG’s commissioning Amendment 12 not moved. plan, and its annual report, as well as the board’s annual assessment of the group’s performance, will Consideration on Report adjourned. cover the exercise of all the CCG’s functions, including the duty to promote research. House adjourned at 10.11 pm. WS 17 Written Statements[8 FEBRUARY 2012] Written Statements WS 18

£1.9 million transferred to the Home Office in Written Statements respect of approved contribution to ODA-eligible UK Border Agency (UKBA) funding. Wednesday 8 February 2012 £0.9 million transferred to the Defra in respect of the Technical Contribution fund for the International Department for International Atomic Energy Agency. Development: DEL £10.0 million transferred to Defra in respect of DfID in respect of the overall ODA and international Statement climate finance management strategy. An ODA/GNI target of 0.56 per cent was set out in DfID’s CSR10 Baroness Northover: My right honourable friend settlement letter, as was a climate change spending the Secretary of State for International Development target of £275.0 million. (Andrew Mitchell) has made the following Written £7.1 million transferred to Department of Energy Ministerial Statement. and Climate Change (DECC) in respect of the overall Subject to parliamentary approval of the necessary ODA and international climate finance management supplementary estimate, the Department for International strategy. Development’s departmental expenditure limit (DEL) £3.0 million transferred from the Department for will be reduced by £13.0 million from £7,880.3 million Education to DfID in respect of a forecast underspend to £7,867.3 million. on ODA eligible budget. Within the DEL change, the impact on resources £247.0 million transferred internally from DfID’s and capital are as set out in the following table: RDEL budget to DfID’s CDEL budget in order to facilitate the deposit of the IDA 16 £300.0 million Change New £’000 DEL promissory note. This represented the first deposit Non- Non- towards the 16th replenishment of the International Voted voted Voted voted Total Development Association, the arm of the World Bank

Resource -309.0 31.9 5,341.3 867.9 6,209.2 whose funding provides people with education, healthcare, DEL clean water and access to economic opportunities in of which: around 80 of the world’s poorest countries. The UK Administration -11.6 0 111.2 0 111.2 has pledged £2.664 billion to cover the period from budget July 2011 to June 2014. Depreciation 21.0 21.0 budget Voted Summary Capital 264.1 0 1,658.1 0 1,658.1 DEL Net RDEL transfer to OGD’s -£30.1 million Total -44.9 31.9 6,999.4 867.9 7,867.3 Transfer to non-voted RDEL to support EC -£31.9 million DEL attribution Transfer to DfID CDEL from DfID RDEL -£247.0 million The change in the resource element of DEL arises Subtotal voted -£309.0 million from: Voted Non-voted Transfers out to other government departments, including those relating to the jointly managed conflict Adjustment to the total of EC attribution pool. These sit on Department for International Based on updated information of 2009 outturn Development’s baseline but is shared between the made by EU directly on behalf of the UK the figure Department for International Development, the Foreign for the outturn of the 2009 EC attribution was and Commonwealth Office and the Ministry of Defence. £31.9 million higher than outlined in the 2011 main Budget transfers relate to expenditure managed by estimate. As such, an adjustment is required to reflect these other government departments. the new estimated amount for the non-voted EC £4.5 million transferred to the Foreign and attribution total. Commonwealth Office in respect of the tri-departmental £31.9 million transferred from DfID in respect of a conflict pool. This was funded from the original conflict forecast underspend on ODA eligible budget. pool allocation of £256.0 million, and £4.0 million Non-voted summary was funded from DfID RDEL (given unforeseen pressures in Libya). Increase in EC attributed aid £31.9 million £4.0 million transferred to Foreign and Commonwealth Subtotal non-voted £31.9 million Office in respect of the tri-departmental conflict pool. Total reductions in RDEL £277.1 million This was in addition to the £4.5 million outlined above and was a result of unforeseen pressures in Libya. £2.1 million transferred to the Foreign and The change in the capital element of DEL arises Commonwealth Office in respect of approved funding from: to the Returns and Re-integration Fund. Voted £2.6 million transferred to the Department for Internal transfers from DfID RDEL to DfID CDEL, Environment, Food and Rural Affairs (Defra) in respect and transfers of CDEL from OGD’s as part of previously of approved funding for DARWIN project. stated RDEL to CDEL swaps. WS 19 Written Statements[LORDS] Written Statements WS 20

£10.0 million CDEL received from Defra in respect movements, recognising the weakening of the euro of the overall ODA and international climate finance against sterling, but also to reflect doubts over the management strategy. recoverability of certain balances where the countries £7.1 million CDEL received from DECC in respect are in default or are expected to be given debt relief of the overall ODA and international climate finance status. management strategy. Expected net income from the sale of assets disposed £247.0 million internal transfer from DfID RDEL of in the financial year is £1.6 million, and is Capital to DfID CDEL. The majority of this internal swap is AME. This is included below. used partly to fund the £300.0 million promissory note AME voted summary to IDA 16, summarised earlier. DfID’s contribution to IDA, like many other donors, is made by way of Increase in utilisation of provisions -£10.9 million promissory note to enable the organisation to enter Increase in provision £3.4 million into commitments with the support of the promissory Income in AME Capital -£1.6 million note but to ensure effective cash management and Subtotal voted £9.1 million avoid large unutilised cash balances. Voted Summary No AME non-voted adjustments have been made Transfer to DfID CDEL from DfID RDEL £247.0 million AME non-voted summary Transfer from OGD’s to DfID CDEL £17.1 million Subtotal voted £264.1 million Sub total non-voted £0 Total decrease AME £9.1 million

Non-voted No CDEL non-voted adjustments Firearms Non-voted Summary Statement

Subtotal non-voted £0 Total increases in CDEL £264.1 million The Minister of State, Home Office (Lord Henley): My right honourable friend the Secretary of State for DfID’s annually managed expenditure (AME) budget the Home Department (Theresa May) has today made is used to fund amendments to provision requirements the following Written Ministerial Statement. and also fair value adjustments to financial instruments, Today I am launching a consultation on whether we notably DfID’s existing loan portfolio. DfID’s significant need to change existing legislation or sentencing powers provisions include contributions towards the International in relation to the importation and supply of illegal Finance Facility for Immunisations (IFFIm) and Advance firearms. The consultation will run until 8 May 2012 Market Commitments (AMC). and a consultation paper is available on the Home Voted Office website. A copy of the consultation document will also be placed in the House Library. Adjustments have been made to reflect updated expectations of provision requirements and utilisation The United Kingdom has some of the toughest of provisions based on revised information. The most firearms laws in the world, sending a clear message notable of these are in IFFIm and AMC provisions. that society will not tolerate gun crime. However while DfID’s provision requirements for IFFIm represent gun crime represents only a small proportion of all the net present value of committed payments to cover recorded crime, it has a serious impact on the communities the UK share of currently issued bonds. This year affected by it. We believe that individuals who, while bond issues are expected to be lower than originally not using the firearms themselves, are responsible for forecast, due to lower anticipated demand for bonds making them available to other criminals should face as a result of the global economic circumstances. tough and appropriate sentences. AMC’s provision represents committed payments to fund supplier agreements signed to produce vaccines That is why in our Ending Gang and Youth Violence to meet demand. The value of agreements signed in report the Government committed to undertaking the year is now lower than forecast at main estimate further work to assess whether it is necessary and stage and a reduction in AME is expected for this proportionate to introduce new offences for the supply reason. and importation of firearms. The Government want to ensure that appropriate offences and sentences are These reductions are offset by an expected increase in place to address gun crime and support practitioners in AME to cover fair value adjustments in loans, in their work. Before committing to any action we which are now treated as AME by way of the clear line want to ensure that we have correctly identified whether of sight reform. The majority of DfID’s loan debtor the existing legal framework is sufficient. represents DfID’s share of a euro-denominated portfolio of loans given to developing countries, which is We are therefore seeking views on whether current administered by European Investment Bank (EIB). It laws are robust enough to ensure that those who is expected the valuation of this outstanding balance import, or supply firearms to criminals face tough and will reduce due to a combination of exchange rate appropriate sentences for their crime. WS 21 Written Statements[8 FEBRUARY 2012] Written Statements WS 22

Freedom of Information The Treasury has conducted its annual indexation exercise of the cost of Oral and Written Parliamentary Statement Questions so as to ensure that these costs are increased in line with increases in underlying costs. The revised The Advocate-General for Scotland (Lord Wallace costs, which will apply from today, are: Oral Answers of Tankerness): My right honourable friend the Attorney- £450; Written Questions £164. The disproportionate General has made the following Written Ministerial cost threshold (DCT) for Written Questions will increase Statement. to £850. I have today given the Information Commissioner a certificate under Section 53 of the Freedom of Information Search and Rescue Helicopter Service Act 2000 (the Act). The certificate relates to the decision Statement notices dated 12 September 2011 (ref. FS50347714) and 13 September 2011 (ref. FS50363603). It is my Earl Attlee: My honourable friend the Parliamentary view, as an accountable person under the Act, that Under-Secretary of State for Transport (Mike Penning) there was no failure by the Cabinet Office to comply has made the following Ministerial Statement. with Section 1(1)(b) of the Act in these cases by withholding On 13 July 2011 the Department for Transport copies of the minutes of the Cabinet Ministerial Committee commenced a procurement competition for search on Devolution to Scotland and Wales and the English and rescue helicopter services to replace the existing Regions (DSWR) from 1997 and 1998. contracted Maritime and Coastguard Agency (MCA) The consequence of my giving the Information capability. The procurement process has now concluded, Commissioner this certificate is that the commissioner’s and I wish to inform the House of the results. decision notices, which ordered disclosure of most of A contract has been signed to operate search and the DSWR minutes, cease to have effect. rescue services from Stornoway and Shetland with A copy of the certificate has been laid before each Bristow Helicopters LTD. A separate contract has House of Parliament. I have additionally placed a been signed with CHC Scotia LTD to operate search copy of the certificate and a detailed statement of the and rescue services from the Maritime and Coastguard reasons for my decision in the Libraries of both Houses, Agency bases at Portland and Lee on the Solent. the Vote Office and the Printed Paper Office. Operations under both contracts will commence by This is only the third time the power under Section the time the existing MCA service contract expires, 53 (otherwise known as the veto) has been exercised and will continue until June 2017. Both contracts will since the Act came into force in 2005. In that time, be managed by the MCA. central government has released an enormous amount As I announced on 28 November, procurement is of information in response to FOI requests—including now under way for longer-term arrangements that will in October 2010 the minutes of the Cabinet discussion see search and rescue contracted nationally. Operations of the Westland affair. will commence under these longer-term arrangements My decision to exercise the veto in this case was not during 2015 and the future contractor for the UK will taken lightly but in accordance with the statement of assume responsibility for the MCA capability during government policy on the use of the executive override 2017 as it relates to information falling within the scope of Section 35(1) of the Act. I have placed a copy of that Terrorism: Finance policy in the Libraries of both Houses. Statement In line with that policy, I have both assessed the balance of the public interest in the disclosure and The Commercial Secretary to the Treasury (Lord non-disclosure of these minutes, and considered whether Sassoon): My honourable friend the Financial Secretary this case meets the criteria set out in the statement of to the Treasury (Mark Hoban) has today made the government policy for use of the veto. following Written Ministerial Statement. I consider that the public interest falls in favour of Following consultation with other relevant departments non-disclosure and that disclosure would be damaging and agencies, the Treasury are today publishing the to the doctrine of collective responsibility and detrimental Government’s response to David Anderson’s first report to the effective operation of Cabinet government. on the operation of the Terrorist Asset-Freezing etc. I have concluded, in light of the criteria set out in the Act 2010. This will be laid before the House today as a Government’s policy, that this constitutes an exceptional command paper. case and that the exercise of the veto is warranted. A detailed explanation of the basis on which I arrived at Lord Sassoon: My honourable friend the Financial the conclusion that the veto should be used is set out Secretary to the Treasury (Mark Hoban) has made the in my statement of reasons. following Written Ministerial Statement. Under the Terrorist Asset-Freezing etc. Act 2010 Questions for Written and Oral Answer: (TAFA 2010), the Treasury is required to report quarterly Costs to Parliament on its operation of the UK’s asset-freezing Statement regime mandated by UN Security Council Resolution 1373. The Commercial Secretary to the Treasury (Lord This is the fourth report under the Act and it covers Sassoon): My honourable friend the Economic Secretary the period from 1 October 2011 to 31 December 2011. to the Treasury (Chloe Smith) has today made the This report also covers the UK implementation of the following Written Ministerial Statement. UN al-Qaeda asset-freezing regime. WS 23 Written Statements[LORDS] Written Statements WS 24

Follow up to independent reviewer’s report EU Reg(EC) al-Qaeda regime Following recommendations made by David Anderson TAFA 2010 2580/2001 UNSCR 1989 QC, the independent reviewer, in his report on the (ii) Amended (ii) 5 operation of the Terrorist Asset-Freezing etc. Act (iii) Revoked (iii) 0 2010 published on 15 December 2011, the Treasury has revised the content and format of the quarterly Specific Licences report to provide additional information. (i) Issued (i) 4 (i) 0 (i) 1 This report has been revised to take account of the (ii) Revoked (ii) 9 (ii) 0 (ii) 2 independent reviewer’s recommendation to publish 1 This figure reflects the most up-to-date account balances more information about the operation of the domestic available and includes approximately $64,000 of suspected terrorist funds frozen in the UK. This has been converted using asset-freezing regime. This information can be found exchange rates as of 04.01.12. in the table and text below. In accordance with the recommendation at paragraph 11.5 of the independent reviewer’s report, the lists at the end of this Statement The key areas of activity during the quarter were: provide a breakdown by name of all those designated the Treasury made five new designations under by the UK and the EU in pursuance of UN Security TAFA 2010. These were in respect of Hamed Council Resolution 1373. Abdollahi, Manssor Arbabsiar, Abdul Reza Shahlai, The Treasury has also decided to report more fully Ali Gholam Shakuri, and Qasem Soleimani; and on the operation of the EU asset-freezing regime in were the first new designations made under TAFA the UK under EU Regulation (EC) 2580/2001, which 2010. The five individuals were subsequently listed implements UNSCR 1373 against external terrorist under EU Regulation 2580/2001; threats to the EU. Under this regime, the EU has two reviews of existing designations were completed responsibility for designations and the Treasury has during the quarter, which resulted in the delisting of responsibility for licensing and compliance with the Ismail Bhuta and the renewal of designation of regime in the UK under Part 1 of TAFA 2010. Bilal Abdullah; The Treasury has published its response to the nine licences were revoked following the delisting independent reviewer’s report today (8 February 2012), of Ismail Bhuta; and and the next quarterly report will provide an update the decrease in balances since the last quarter on implementation of other recommendations that follows delistings made and licences issued (under impact on the operation of the asset-freezing regime which frozen funds have been released). in the UK. The Al-Qaeda (Asset-Freezing) Regulations 2011 Additional information, where available, is also were introduced in November to replace the Al-Qaeda provided for the al-Qaeda regime in the revised and Taliban (Asset-Freezing) Regulations 2010, following format adopted to meet the independent reviewer’s the split of the al-Qaeda and Afghanistan regimes recommendation. agreed by the UN in June 2011. The following table sets out the key asset-freezing Legal challenges activity in the UK during the quarter ending 31 December Two legal challenges against designations made 2011: under both the Terrorism (United Nations Measures) EU Reg(EC) al-Qaeda regime Order 2009 and TAFA 2010 were ongoing in the TAFA 2010 2580/2001 UNSCR 1989 quarter covered by this report. There were no specific developments during the quarter in the cases brought Assets frozen (as at £33,000 £11,000 £72,0001 31/12/2011) by Zana Rahim and Ismail Bhuta. No new challenges Number of 70 10 39 were made against the Treasury during the quarter. accounts frozen in UK (at 31/12/11) Proceedings New accounts 000In the quarter to 31 December 2011, no proceedings frozen were initiated in respect of breaches of the prohibitions Accounts unfrozen 4 0 2 of the Act or the Al-Qaeda (Asset-Freezing) Regulations Number of 42 51 343 designations (at 2011. 31/12/11) (i) Designated persons under TAFA 2010 by name2 (i) new designations 551 (during Q4 2011) Individuals (ii) Delistings 1 1 1 1. Hamed Abdollahi (iii) individuals in 15 0 3 custody in UK 2. Bilal Talal Abdullah (iv) individuals in 5073. Habib Ahmed UK, not in detention 4. Imad Khalil al-Alami (v) individuals 14 26 242 5. Abdula Ahmed Ali overseas 6. Abdelkarim Hussein al-Nasser (vi) groups 8 (0 in UK) 25 91 (2 in UK) Renewal of 1 n/a n/a 7. Ibrahim Salih al-Yacoub designation 8. Manssor Arbabsiar General Licences 9. Selman Bozkur (i) Issued in Q4 (i) 0 10. Usama Hamdan WS 25 Written Statements[8 FEBRUARY 2012] Written Statements WS 26

11. Nabeel Hussain 12. Abderrahmane Djabali 12. Tanvir Hussain 13. Sofiane Yacine Fahas 13. Zahoor Iqbal 14. Hasan Izz-al-Din* 14. Umar Islam 15. Khalid Shaikh Mohammed* 15. Hasan Izz-al-Din 16. Fateh Moktari 16. Parviz Khan 17. Farid Nouara 17. Waheed Arafat Khan 18. Hoari Ressous 18. Osman Adam Khatib 19. Noureddine Sedkaoui 19. Musa Abu Marzouk 20. Abdelghani Selmani 20. Gulam Mastafa 21. Sofiane Senouci 21. Khalid Mishaal 22. Abdul Reza Shahlai* 22. Khalid Shaikh Mohammed 23. Ali Gholam Shakuri* 23. Ramzi Mohammed 24. Qasem Soleimani* 24. Sultan Muhammad 25. Mohammed Tinguali 25. Yassin Omar 26. Jason Theodore Walters 26. Hussein Osman Groups and Entities 27. Zana Abdul Rahim 1. Abu Nidal Organisation (ANO) 28. Muktar Mohammed Said 2. Al-Aqsa Martyrs’ Brigade 29. Assad Sarwar 3. Al-Aqsa e.V. 30. Ibrahim Savant 4. Al-Takfir and Al-Hijra 31. Abdul Reza Shahlai 5. Babbar Khalsa 32. Ali Gholam Shakuri 6. Communist Party of the Philippines, including 33. Qasem Soleimani New People’s Army (NPA), Philippines 34. Waheed Zaman 7. Gama’a al-Islamiyya (a.k.a. al-Gama’a al-Islamiyya) Entities (Islamic Group—IG) 1. Basque Fatherland and Liberty (EtA) 8. Islami Büyük Dogu Akincilar Cephesi (IBDA-C) (Great Islamic Eastern Warriors Front) 2. Ejercito de Liberacion Nacional (ELN). 9. Hamas, including Hamas-Izz al-Din al-Qassem 3. Fuerzas Armadas Revolucionarias de Colombia (FARC) 10. Hizbul Mujahideen (HM) 4. Hizballah Military Wing, including External Security 11. Hofstadgroep Organisation 12. Holy Land Foundation for Relief and 5. Holy Land Foundation for Relief and Development Development* 6. Popular Front for the Liberation of Palestine— 13. International Sikh Youth Federation (ISYF) General Command (PFLP-GC) 14. Khalistan Zindabad Force (KZF) 7. Popular Front for The Liberation Of Palestine 15. Kurdistan Workers Party (PKK) (aka Kongra-Gel) (PFLP) 16. Liberation Tigers of Tamil Eelam (LTTE) 8. Sendero Luminoso (SL) 2 17. Ejército de Liberación Nacional (National For full listing details please refer to http://www.hm-treasury.gov.uk/ * d/terrorism.htm. Liberation Army) (ii) Persons designated by the EU under Council 18. Palestinian Islamic Jihad (PIJ) Regulation (EC)2580/20013 19. Popular Front for the Liberation of Palestine Persons (PFLP)* 1. Hamed Abdollahi* 20. Popular Front for the Liberation of Palestine— * 2. Rabah Naami Abou General Command (PFLP-GC) 3. Maisi Aboud 21. Fuerzas armadas revolucionarias de Colombia (FARC)* 4. Abdelkarim Hussein al-Nasser* 22. Devrimci Halk Kurtulu Partisi-Cephesi—DHKP/C 5. Ibrahim Salih al-Yacoub* (Revolutionary People’s Liberation Army/Front/Party) 6. Manssor Arbabsiar* 23. Sendero Luminoso (SL) (Shining Path)* 7. Kamel Arioua 24. Stichting al Aqsa 8. Mohamed Asli 25. Teyrbazen Azadiya Kurdistan (TAK) 9. Rabah Asli 3 For full listing details please refer to http://www.hm- 10. Mohammed Bouyeri treasury.gov.uk/d/terrorism.htm 11. Noureddine Darib * EU listing rests on UK designation under TAFA 2010

WA 61 Written Answers[8 FEBRUARY 2012] Written Answers WA 62 Written Answers Assisted Dying Question Wednesday 8 February 2012 Asked by Lord Alton of Liverpool To ask Her Majesty’s Government whether they Afghanistan intend to ensure that the recent Council of Europe Question agreement that “euthanasia, in the sense of the intentional killing by act or omission of a dependent Asked by Viscount Waverley human being for his or her alleged benefit must To ask Her Majesty’s Government whether they always be prohibited” (Resolution 1859/2012) is have successfully negotiated exit routes for military reflected in the domestic laws of the United equipment to be used during or following the phased Kingdom. [HL15230] withdrawal from Afghanistan in 2014. [HL15179] The Minister of State, Ministry of Justice (Lord The Parliamentary Under-Secretary of State, Ministry McNally): Council of Europe Resolution 1859/2012 is of Defence (Lord Astor of Hever): Current exit routes limited to the question of advance directives, living from Afghanistan are by air only, following closure of wills and continuing powers of attorney. It aims to the surface route through Pakistan in response to the empower people to record their wishes regarding their Mohmand cross-border incident in November 2011. medical treatment for a time in the future when they The likely duration of the border closure is not yet may lack the capacity to consent to or refuse a particular clear; however, this is not currently a cause for concern treatment. The relevant domestic law in that area is and planning is ongoing to utilise alternative routes the Mental Capacity Act 2005. should the Pakistani border remain closed in the longer Euthanasia, commonly understood to be the term. We await the results of Pakistan’s internal intentional taking of life albeit at a person’s request or discussions over this issue, and will engage with it for a merciful motive, is prohibited in England and regarding the re-opening of its borders in due course. Wales by the law of murder. The Government believe Negotiations are also under way to establish surface that any change to the law in this emotive and contentious and air exit routes through and over the central Asian area is an issue of individual conscience and therefore republics. In summary, there are a range of exit routes a matter for Parliament to decide rather than one for from Afghanistan which are subject to continuous government policy. review and development. Aviation: Fuel Prices Armed Forces: Aircraft Question Questions Asked by Lord Mawhinney Asked by Lord West of Spithead To ask Her Majesty’s Government what is the To ask Her Majesty’s Government how many rate of VAT levied in each member state in the times since November 2010 Tornado aircraft have European Union on aviation fuel; and how these been called for and used ordnance in support of compare to that in the United Kingdom. [HL15111] United Kingdom ground forces in Afghanistan. [HL15144] The Commercial Secretary to the Treasury (Lord Sassoon): VAT at 20 per cent is applicable to retail The Parliamentary Under-Secretary of State, Ministry sales of aviation fuel used for commercial flights within of Defence (Lord Astor of Hever): RAF Tornados are the UK and private pleasure flying. The VAT rates tasked by the NATO combined air operations centre applied by EU member states are as follows: in a variety of roles across Afghanistan. Tornado aircraft have used ordnance in Afghanistan on Member State VAT rates 33 occasions since November 2010. Of these, 17 were in support of UK ground forces requesting close air Belgium 21 support. Other nations’ aircraft also are available to Bulgaria 20 provide close air support, including to Task Force Czech Republic 20 Helmand. Denmark 25 Germany 19 Asked by Lord West of Spithead Estonia 20 To ask Her Majesty’s Government how many Greece 23 flying hours have been completed by Tornado aircraft Spain 18 based in Afghanistan. [HL15145] France 19.6 Ireland 23 Italy 21 Lord Astor of Hever: I am withholding the information requested as its disclosure would, or would be likely to Cyprus 15 prejudice, the capability, effectiveness or security of Latvia 22 our Armed Forces. Lithuania 21 WA 63 Written Answers[LORDS] Written Answers WA 64

Member State VAT rates matter of compliance with building regulations so the question of dropping BREEAM does not arise in that Luxembourg 15 context. Hungary 27 Individual government departments and their agencies Malta 18 are required, under the greening government Netherlands 19 commitments, to embed the government buying standards Austria 20 within their contracts. These standards incorporate Poland 23 the BREEAM methodology and ratings in relation to Portugal 23 procuring new buildings (or major refurbishments). In Romania 24 respect of public bodies outside government departments Slovenia 20 and agencies, the common minimum standards on Slovakia 20 construction encourage them to use BREEAM when Finland 23 procuring new buildings. It is a feature of the common Sweden 25 minimum standards that they are kept under review and refreshed as necessary. Under the 1944 Convention on International Civil Aviation almost all bilateral air service agreements Care Services: Means-testing include standard provisions exempting airlines from national taxes and customs duties on a range of aviation- Question related goods, including parts, stores and fuel. Asked by Lord Lipsey To ask Her Majesty’s Government whether, if a Blasphemy person places their home into a trust for the benefit of themselves and others, that home is then excluded Question from consideration in the application of the means Asked by Lord Lester of Herne Hill test for long-term care. [HL15347]

To ask Her Majesty’s Government why the The Parliamentary Under-Secretary of State, Department common-law offence of blasphemy is maintained in of Health (Earl Howe): For residential care, the National Northern Ireland but not in the rest of the United Assistance Act 1948 sets the framework within which Kingdom, in the light of the recommendation by local authorities assess what people can afford to the United Nations Human Rights Committee in contribute towards the cost of residential care. Income paragraph 48 of General Comment 34 on freedom and capital assets, including, in certain circumstances, of opinion and expression, and the obligations a care home resident’s former home, are taken into imposed on the United Kingdom by the International account in making this assessment. Covenant on Civil and Political Rights and the A local authority may also consider whether residents European Convention on Human Rights. [HL15181] have deliberately deprived themselves of assets to avoid paying charges. If a local authority considers that a Lord Shutt of Greetland: Since the devolution of resident has placed an asset into a trust with the sole policing and justice in Northern Ireland, policy relating aim of avoiding or reducing charges for residential to the law on blasphemy in Northern Ireland is a care, it may decide that the resident has deliberately matter for the Department of Justice. We have, however, deprived themselves of the asset. In such cases, it may drawn the recommendations referred to by the noble treat the asset as still being owned by the resident and Lord to the attention of the Northern Ireland Department take its value into account when assessing the resident of Justice. for charges.

Building Regulations Church of England: Salaries and Benefits Question Questions Asked by Lord Mawhinney Asked by Lord Jones of Cheltenham To ask Her Majesty’s Government what is their To ask Her Majesty’s Government whether they estimate of the number of Church of England will review their decision to drop the Building Research clergy who are paid (1) more than £35,000 per Establishment Environmental Assessment Method annum, or (2) less than £35,000 per annum, who are (BREEAM), in the light of their agenda to become in receipt of state benefit other than child support. the “greenest Government ever”. [HL15303] [HL15109] To ask Her Majesty’s Government what is their The Parliamentary Under-Secretary of State, Department estimate of the number of Church of England for Communities and Local Government (Baroness Hanham): clergy who are paid (1) more than £35,000 per BREEAM is a suite of voluntary environmental annum, or (2) less than £35,000 per annum, who are assessment methods developed by the Building Research in receipt of housing benefit. [HL15110] Establishment for use by those developing, procuring or using a range of building types. BREEAM is not The Parliamentary Under-Secretary of State, Department and has not been endorsed by the Government as a for Work and Pensions (Lord Freud): The department standard which we expect all developers to aim for as a does not keep such information WA 65 Written Answers[8 FEBRUARY 2012] Written Answers WA 66

Coastal Pathways that any risk with regard to toxicity would be included in the participant information sheet. GTAC has further Question advised that the stem cell lines deposited in the UK Asked by Lord Fearn Stem Cell Bank would have passed all relevant safety tests. The committee would expect that should any To ask Her Majesty’s Government which sections research participant require any further information of coastland in Cumbria and Merseyside have coastal about any trial in which they participate, that information paths. [HL15265] would be made available directly to them by either the chief investigator or a member of the research team. The Parliamentary Under-Secretary of State, Department for Environment, Food and Rural Affairs (Lord Taylor of Holbeach): A coastal access audit Energy: Forecasts and Estimates undertaken by Natural England in 2008-09 estimated Questions that 114 kilometres of the coast of Cumbria (34 per cent of the total length) and 38 kilometres of the coast Asked by Lord Kennedy of Southwark of Merseyside (Liverpool, Sefton and Wirral) (35 per cent of the total length) had a secure, satisfactory path To ask Her Majesty’s Government what is their along it. Some parts of both coasts have locally promoted latest assessment of the amount of energy that will routes, including the Cumbria Coastal Way and the be derived from wind power in the United Kingdom Allerdale Ramble in Cumbria, and the Sefton Coastal by 2025 and 2050. [HL15197] Path and part of the Trans Pennine Trail in Merseyside. To ask Her Majesty’s Government what is their Natural England is currently developing proposals latest assessment of the amount of energy that will for a coastal route under Part 9 of the Marine and be derived from nuclear power in the United Kingdom Coastal Access Act 2009 along a 33-kilometre stretch by 2025 and 2050. [HL15198] of the coast between Allonby and Whitehaven, Cumbria. To ask Her Majesty’s Government what is their Natural England expects to consult on its draft proposals latest assessment of the amount of energy that will for this stretch of the coast later this year. be derived from hydroelectric power in the United Kingdom by 2025 and 2050. [HL15199] Embryology To ask Her Majesty’s Government what is their Question latest assessment of the amount of energy that will be derived from waste in the United Kingdom by Asked by Lord Alton of Liverpool 2025 and 2050. [HL15200] To ask Her Majesty’s Government further to the To ask Her Majesty’s Government what is their Written Answer by Earl Howe on 10 January 2012 latest assessment of the amount of energy that will (WA 22-3), what information the Medicines and be derived from natural gas in the United Kingdom Healthcare products Regulatory Agency and the by 2025 and 2050. [HL15201] Gene Therapy Advisory Committee hold regarding the most recent tests for chromosomal alterations Baroness Stowell of Beeston: The latest DECC estimate and the extent to which such data would be made for projected primary demand for natural gas in 2025 available on request to participants in the clinical is 870 TWh1. This is based on DECC’s Updated Energy trial at Moorfields Eye Hospital as part of the and Emissions Projections, published in October 2011, process of ensuring informed consent; and what available at: http://www.decc.gov.uk/en/content/cms/ consideration they have given to the case for additional about/ec_social_res/analytic_projs/en_emis_projs/ quality controls set out in a new report in the en_emis_projs.aspx. Journal of Clinical Investigation. [HL15114] However, these estimates do not include additional policies to meet the 4th carbon budget (2023-27) as set The Parliamentary Under-Secretary of State, out in the Carbon Plan, published on 1 December Department of Health (Earl Howe): As I advised the 2011. noble Lord in my Answer of 10 January 2012, these In the Carbon Plan, DECC published a range of are matters for the Gene Therapy Advisory Committee possible scenarios (based on modelling by Redpoint (GTAC) and the Medicines and Healthcare products Energy) for electricity generation from wind, hydroelectric, Regulatory Agency (MHRA). I understand this issue waste and nuclear in 2030 (see here: http:// has been raised directly with both bodies. www.decc.gov.uk/assets/decc/11/tackling-climate- The MHRA has confirmed that it cannot release change/carbon-plan/3702-the-carbon-plan- information on tests for chromosomal alterations because delivering-our-low-carbon-future.pdf, page 73). The they are provided by the manufacturer in confidence. analysis considered a range of decarbonisation scenarios The MHRA does not have a role in reviewing patient consistent with meeting carbon budgets and the 2050 goal. information for clinical trials and does not hold the This finds that depending on assumed possible build information requested regarding informed consent. rates new nuclear contributed anywhere from 10 to GTAC would not have specifically discussed whether 15 GW by 2030 in the scenarios modelled. Actual the results of the most recent tests for chromosomal build rates could make this range higher or lower: alterations should be made available to participants. industry has announced ambitions to build 16 GW of The committee would always consider and require nuclear by 2025. CCS contributed as much as 10 GW WA 67 Written Answers[LORDS] Written Answers WA 68 by 2030 in the scenarios modelled. This should not be cost reductions. It is important to stress that these are seen as an upper limit to the potential of CCS—more not projections, but some of the possible scenarios to could be deployed if costs reduce quickly. The analysis meet our carbon budgets and 2050 target. showed that renewable electricity could provide 35 to In addition, the Carbon Plan sets out four plausible 50 GW by 2030, with the upper end assuming either pathways towards 2050. Details of these pathways are high electricity demand or significant cost reductions. set out in annexe A of the Carbon Plan: http:// However, the Committee on Climate Change’s renewable www.decc.gov.uk/en/content/cms/emissions/ energy review suggests that we could have over 55 GW carbon_budgets/carbon_budgets.aspx. of renewable electricity capacity by 2030, subject to These were produced using the 2050 pathways resolution of current uncertainties such as cost reductions calculator tool, which supports users in exploring and barriers to deployment. It is important to stress these and other pathways in great detail. It is available that these are not projections but some of the possible at: http://2050-calculator-tool.decc.gov.uk/. scenarios to meet our carbon budgets and 2050 target. Based on the four plausible pathways set out in the In addition, the Carbon Plan sets out four plausible Carbon Plan, solar photovoltaic panels and solar thermal pathways towards 2050. Details of these pathways are could together produce between 0 and 27.4 TWh of set out in annexe A of the Carbon Plan: http:// electricity and heat in 2050. www.decc.gov.uk/en/content/cms/emissions/ carbon_budgets/carbon_budgets.aspx. However, the calculator explores the boundaries of what would be physically possible for each technology, These were produced using the 2050 pathways representing level 1 as little or no effort to reduce calculator tool, which supports users in exploring emissions, to level 4 as extremely ambitious changes these and other pathways in great detail. It is available that push towards the physical or technical limits of at: http://2050-calculator-tool.decc.gov.uk/. what can be achieved. Level 4 for solar PV is an The range of primary energy demand by type from extremely ambitious level of deployment without the four pathways is shown in Table 1 below. precedent anywhere else in the world, equivalent to 2 2 10m per person, or covering all south-facing roofs of Table 1: Energy by source in the UK, 2050 (TWh) domestic properties. Level 4 for solar PV would yield Natural gas 90 to 189 140 TWh of electricity by 2050, as set out in the Waste 107 to 194 answer given by my honourable friend the Minister of Wind power 63 to 288 State for Climate Change to the honourable Member Hydroelectric power 5 to 7 for Stockton North on 21 November 2011 (Official Nuclear power 110 to 525 Report, col. 42W). Source: 2050 Calculator (December 2011) 1 Includes all fuel used for transformation into other forms of energy (eg, electricity, heat or transportation). This is energy Ghana before conversion losses. Source: Updated Energy and Emissions Projections, October 2011. Question 2 Wind. hydroelectric and nuclear are electrical energy delivered Asked by Lord Avebury to the grid. Natural gas and waste are primary energy used for transformation into other forms of energy (ie, electricity, and To ask Her Majesty’s Government whether they heat). will have discussions with the Government of Ghana, the Economic Community of West African States and the African Union, on the monitoring of the Energy: Solar Power Ghanaian elections in December 2012. [HL15226] Question The Minister of State, Foreign and Commonwealth Asked by Lord Kennedy of Southwark Office (Lord Howell of Guildford): The UK maintains close contact with the Government of Ghana on a To ask Her Majesty’s Government what is their wide range of issues. This will include the monitoring latest assessment of the amount of energy that will of this year’s elections there. In addition, we regularly be derived from solar power in the United Kingdom engage with ECOWAS (the Economic Community of by 2025 and 2050. [HL15196] West African States) and the African Union about their election monitoring missions. Ghana’s elections will form part of those discussions. Baroness Stowell of Beeston: In the Carbon Plan, DECC published a range of possible scenarios (based on modelling by Redpoint Energy) for electricity Gypsies and Travellers generation from renewables in 2030 (see here: http:// www.decc.gov.uk/assets/decc/11/tackling-climate- Questions change/carbon-plan/3702-the-carbon-plan- Asked by Baroness Whitaker delivering-our-low-carbon-future.pdf, page 73). The analysis considered a range of decarbonisation scenarios To ask Her Majesty’s Government, further to consistent with meeting carbon budgets and the 2050 goal. the Written Answer by Baroness Hanham on The analysis showed that renewable electricity could 12 January (WA 108), what plans they have to provide 35 to 50 GW by 2030, with the upper end identify how many of the local authorities who assuming either high electricity demand or significant completed their assessment of the accommodation WA 69 Written Answers[8 FEBRUARY 2012] Written Answers WA 70

needs of Gypsies and Travellers according to the by employers, and our proposed new system of assured Department for Communities and Local Government’s voluntary registration will assist them in taking local 2009 internet search have provided new sites. responsibility for the quality of their staff. [HL15194]

The Parliamentary Under-Secretary of State, Department Health: Mesothelioma for Communities and Local Government (Baroness Hanham): Questions The Government have no plans to conduct such an exercise. I refer the noble Lady to my reply to her on Asked by Lord Alton of Liverpool 16 January 2012 (Official Report, col. WA 115), in which I explained that the Government believe that To ask Her Majesty’s Government how many local planning authorities are best placed to assess the United Kingdom citizens are believed to have died needs of their communities and we are therefore placing from mesothelioma and asbestos-related diseases responsibility for Traveller site provision back with since the collection of such figures began; and what them. is their estimate for the number of fatalities over the next 20 years. [HL15315] Asked by Baroness Whitaker To ask Her Majesty’s Government, further to The Parliamentary Under-Secretary of State, Department the Written Answer by Baroness Hanham on for Work and Pensions (Lord Freud): No single source 16 January (WA 115-16), what proposals they have of information provides a basis for estimating the to monitor the use local authorities are making of total number of deaths from mesothelioma and asbestos- the Government’s £47 million for over 750 new or related diseases in the United Kingdom. refurbished pitches for Gypsies and Travellers by Detailed statistics for deaths in Great Britain due to 2015. [HL15195] the asbestos-related cancer, mesothelioma, and the non-cancerous disease, asbestosis, have been collected Baroness Hanham: The Homes and Communities since 1968. Deaths due to other forms of cancer (lung, Agency is responsible for administering the Traveller laryngeal and stomach cancer) attributed to asbestos Pitch Funding programme and monitoring the use of exposure have to be estimated because individual cases funding awarded to local authorities and registered are usually clinically indistinguishable from cases due providers. The expectation is that Traveller Pitch Funding to other causes such as smoking. These estimates are is based on payment by results at completion. associated with considerable statistical uncertainty. The delivery of Traveller Pitch Funding allocations Combining the statistics from these different sources will be monitored through the agency’s established suggests there have been approximately 80,000 deaths programme management framework with regular provider in Great Britain due to asbestos-related diseases over quarterly contract review meetings forming part of the period 1968-2009. This total includes approximately this process. 38,000 mesothelioma deaths attributed to asbestos and a similar number of asbestos-related lung cancers. Health: Clinical Physiologists It also includes approximately 2,750 asbestosis deaths Question and several hundred laryngeal and stomach cancer deaths. Asked by Baroness Masham of Ilton Projections of future deaths are uncertain and currently To ask Her Majesty’s Government, in the light available only for mesothelioma. The latest predictions of their decision to regulate public health consultants, suggest there will be between 33,000 and 49,000 why they have not decided to regulate clinical mesothelioma deaths in Great Britain over the next physiologists who undertake sensitive work. 20 years. [HL15359] Asked by Lord Alton of Liverpool The Parliamentary Under-Secretary of State, Department To ask Her Majesty’s Government what is the of Health (Earl Howe): We are proposing to regulate a average life expectancy of those who contract small number of non-medical public health specialists mesothelioma, from the time of diagnosis until to ensure that the existing regulatory system covers all death. [HL15316] the professionals that it was originally intended to cover, closing a small anomaly that has developed over time whereby some public health specialists who are Lord Wallace of Saltaire: The information requested not medical practitioners are not subject to compulsory falls within the responsibility of the UK Statistics statutory professional regulation. Authority. I have asked the authority to reply. This move will ensure that there are consistent Letter from Stephen Penneck, Director-General for standards across medical and non-medical public health ONS, to Lord Alton of Liverpool, dated February 2012. specialists at a time when they will become increasingly As Director General for the Office for National important leaders in local communities. Statistics, I have been asked to reply to your recent For unregulated occupational groups such as clinical questions asking: physiologists the Government consider that the key to What is the average life expectancy of those who ensuring high quality and consistent care is good contract mesothelioma, from the time of diagnosis recruitment, training, delegation and effective supervision until death (HL15316). WA 71 Written Answers[LORDS] Written Answers WA 72

It is not possible to provide estimates of life expectancy Table 2. Number of deaths where asbestosis was the underlying cause, for persons who are diagnosed with mesothelioma, United Kingdom, 1974-20001,2,3 from the time of diagnosis until death, since with a Deaths condition is not recorded on the death certificate. 1976 39 Relative cancer survival estimates for 21 common 1977 46 cancers are published on the Office for National 1978 44 Statistics website: www.ons.gov.uk/ons/publications/ 1979 47 all-releases.html?definition=tcm%3A77-21521. 1980 49 As mesothelioma is not one of the 21 common 1981 56 cancers, survival figures are not available from routine 1982 49 publications. 1983 54 Table 1 below provides the number of deaths registered 1984 55 where the underlying cause of death was either: 1985 63 mesothelioma; pneumoconiosis due to asbestos and 1986 60 other mineral fibres (therefore including asbestosis); 1987 62 or pleural plaque with presence of asbestos in the 1988 54 United Kingdom, between 2001 and 2010 (the latest 1989 66 year available). 1990 72 Asbestosis is the only asbestos-related condition 1991 73 that can be identified prior to 2001, using the International 1992 64 Classification of Diseases. The classification used to 1993 64 code cause of death. Table 2 provides the number of 1994 68 deaths registered where asbestosis was the underlying 1995 72 cause of death in the United Kingdom between 1974 1996 67 and 2000. Figures for deaths registered before 1974 are 1997 74 not readily available. 1998 68 The Health and Safety Executive (HSE) has developed 1999 73 4 a statistical model to estimate the future burden of 2000 68 deaths caused by mesothelioma in Great Britain up to 1 Figures were extracted for deaths where the underlying cause the year 2050. HSE predicts that the number of male was recorded as “Asbestosis”. Underlying cause of death was deaths caused by mesothelioma will reach a peak in defined using the International Classification of Diseases Eighth Revision (ICD-8) code 515.2 for the years 1974-1978 and Ninth the year 2016 with a subsequent rapid decline in revision (ICD-9) code 501 for the years 1979-2000 (1979-1999 in mortality and estimates that 91,000 mesothelioma deaths Scotland). will have occurred by the year 2050. Further information 2 Figures are based on deaths registered in each calendar year is available at www.hse.gov.uk/research/rrhtm/rr728.htm. and include deaths of non-residents. 3 Figures are not consistent with those presented in Table 1 due Table 1. Number of deaths where mesothelioma or another asbestos-related to differences between ICD revisions. disease was the underlying cause of death, United Kingdom, 2001-20101,2 4 Deaths in Scotland were classified using the International Deaths Classification of Diseases Tenth Revision (ICD-10) in 2000, a 2001 1865 year earlier than the rest of the UK. No figure for deaths due to asbestosis in Scotland is included in the overall UK figures for 2002 1929 2000 as the equivalent ICD-10 code is not comparable. 2003 1942 Source: Office for National Statistics, National Records of 2004 2019 Scotland, Northern Ireland Statistics and Research Agency 2005 2077 2006 2152 2007 2182 2008 2310 Housing: Mortgages 2009 2522 Question 2010 2492 Asked by Lord Willoughby de Broke 1 Underlying cause of death was defined using the International Classification of Diseases Tenth Revision (ICD-10) code C45 To ask Her Majesty’s Government what is their Mesothelioma; J61 Pneumoconiosis due to asbestos and other assessment of the proposal in the European Union mineral fibres; J92.0 Pleural plaque with presence of asbestos capital markets directive IV that mortgagors who 2 Figures are based on deaths registered in each calendar year are 90 days in arrears should be considered in and include deaths of non-residents default. [HL15121] Source: Office for National Statistics, National Records of Scotland, Northern Ireland Statistics and Research Agency The Commercial Secretary to the Treasury (Lord Table 2. Number of deaths where asbestosis was the underlying cause, Sassoon): As part of the European Commission’s United Kingdom, 1974-20001,2,3 legislative proposals for the capital requirements directive Deaths (CRD) IV, the Commission proposes harmonising the internal ratings-based (IRB) approach to the definition 1974 26 of default that would apply to all credit institutions. 1975 57 One of the conditions proposed by the Commission WA 73 Written Answers[8 FEBRUARY 2012] Written Answers WA 74 requires institutions to consider a borrower as having Majesty’s Inspectorate of Constabulary (HMIC); the defaulted on its credit obligations if the borrower is Police Federation; the Police Service of Northern Ireland more than 90 days in arrears. (PSNI); and ACPO (Scotland) Crime Business Area. CRD IV is currently being negotiated by the European The Serious Organised Crime Agency (SOCA) has Council and the European Parliament. While the also responded. The National Offender Management Government are still considering the potential impact Service (NOMS) is an executive agency of the Ministry of the proposed requirement, this proposal should not of Justice. It has been fully involved in discussions on impact on lenders’ treatment of individual borrowers the content of the Green Paper. who are struggling to keep up with their mortgage Asked by Lord Lester of Herne Hill repayments. The Government are clear that repossession should always be a last resort. To ask Her Majesty’s Government, in relation to the 27 cases referred to in paragraph 11 of annexe J to the Green Paper on Justice and Security, what Internet: Broadband proportion of those cases they consider could be Question fairly resolved only by means of a closed material procedure. [HL15241] Asked by Baroness Quin To ask Her Majesty’s Government when they Lord McNally: It would not be appropriate for the expect the whole of Northumberland to have access Government to comment on the detail of ongoing to superfast broadband. [HL15138] litigation. However, paragraph 11 of appendix J (page 63) of the Justice and Security Green Paper states that the Government estimate that “sensitive information Baroness Rawlings: The Government have set a is central to 27 cases (excluding a significant number target for all broadband projects to be completed by of appeals against executive actions) currently before 2015. the UK courts, and in many of these cases judges do Northumberland County Council has submitted a not have the tools at their disposal to discharge their draft local broadband plan. All local broadband plans responsibility to deliver justice”. are scheduled for approval by the end of April 2012. The councils should be ready to enter into procurement by end of July 2012 and have completed procurement Legal Aid, Sentencing and Punishment of by the end of 2012. Once procurement is complete the Offenders Bill rollout of infrastructure upgrades can commence. Questions Asked by Lord Alton of Liverpool Justice and Security Questions To ask Her Majesty’s Government what estimate they have made of how much public money will be Asked by Lord Lester of Herne Hill saved under the changes to the way in which mesothelioma cases are dealt with in the courts To ask Her Majesty’s Government whether they provided for in the Legal Aid, Sentencing and will publish the responses to the public consultation Punishment of Offenders Bill; and how much the on the Justice and Security Green Paper. [HL15180] processing of such cases has cost in the past 12 months for which figures are available. [HL15314] The Minister of State, Ministry of Justice (Lord To ask Her Majesty’s Government, further to McNally): There are no plans at present to publish the statement by Lord McNally on 30 January responses to the public consultation on the Justice and (Official Report, col. 1434) that changes to the way Security Green Paper. The Government will, of course, mesothelioma cases are in future handled in the publish a summary of the views expressed in the courts in the Legal Aid, Sentencing and Punishment consultation, and of those who responded, in due of Offenders Bill will “squeeze out from the system course, in line with the code of practice on consultation. the inflation that went to lawyers”, what this inflation Asked by Lord Lester of Herne Hill consisted of; and how much money they have identified as wrongly claimed by lawyers who have acted in To ask Her Majesty’s Government what responses such cases in the last year for which figures are they have received from the police and prison services available. [HL15317] to the Green Paper on Justice and Security. [HL15240] The Minister of State, Ministry of Justice (Lord McNally): I was referring to costs in civil litigation Lord McNally: Responses to the consultation on generally, which the reforms in Part 2 of the Legal the Justice and Security Green Paper have been received Aid, Sentencing and Punishment of Offenders Bill are from the Metropolitan Police Service (MPS); Kent intended to address. A general liability insurer has and Essex Serious Crime Directorate and the Counter indicated that in 1999 claimant solicitors’ costs were Terrorism Intelligence Unit; Wiltshire, Lancashire, equivalent to just over half the damages agreed or Northamptonshire and Cambridge Police Constabularies; awarded at 56 per cent. By 2004, average claimant the Association of Chief Police Officers (ACPO) Crime costs were 103 per cent of the damages. By 2010 Business Area; the Association of Police Lawyers; Her average claimant costs represented 142 per cent of the WA 75 Written Answers[LORDS] Written Answers WA 76 sums received by the injured victims. The NHS Litigation Money: Pound Sterling Authority has reported similar rises in the amounts paid to claimant lawyers. This substantial rise in claimant Question costs is largely due to the way in which conditional fee Asked by Lord Wigley agreements have worked since the Access to Justice Act 1999. To ask Her Majesty’s Government whether they The Ministry of Justice does not record costs data will publish a table showing the value of the pound by type of case and so is not able to break the figures in each year since 1992 against an index of 100 for down into mesothelioma and other claims. the value of the pound in 1974. [HL15384] The proposed reforms in the Bill will introduce proportion and fairness to the current CFA regime Lord Wallace of Saltaire: The information requested and should be welcomed. Once our changes take falls within the responsibility of the UK Statistics effect, I believe that meritorious claims will be resolved Authority. I have asked the authority to reply. at more proportionate cost, while unnecessary or avoidable claims will be deterred from progressing to court. Letter from Stephen Penneck, Director-General for ONS, to Lord Wigley, dated February 2012. Asked by Lord Alton of Liverpool As Director General for the Office for National To ask Her Majesty’s Government, further to Statistics (ONS), I have been asked to reply to your the remark by Lord McNally on 30 January (Official Parliamentary Question asking if the ONS could publish Report, col. 1431) in connection with the Legal Aid, a table showing the value of the pound in each year Sentencing and Punishment of Offenders Bill that since 1992 against an index of 100 for the value of the “I am quite sure that the insurance industry has pound in 1974 [HL15384]. been lobbying on this Bill”, whether officials at the ONS already publishes information on the value of Ministry of Justice encouraged the Justice Secretary the pound in one year compared to others covering to attend insurance industry events and to provide 1977 to 2011 in table 33 of the detailed Consumer details of any events and meetings which were held Prices Index and Retail Price Index Reference with the industry. [HL15318] tables available at: http://www.ons.gov.uk/ons/rel/cpi/ consumer-price-indices/december-2011/cpi-and-rpi- detailed-reference-tables.xls. Lord McNally: Departmental officials advise the It is recognised that certain users may be interested Justice Secretary on a number of matters, including in comparisons for earlier years and therefore instructions any stakeholder events to which he is invited. Since the are provided alongside the published data so that Government’s consultation on Proposals for Reform users can make comparisons back to 1947. Table 1 of Civil Litigation Funding and Costs in England and provides the analysis you have requested. Wales—Implementation of Lord Justice Jackson’s Table 1: Value of the pound in 1992 to 2011 when the value of the pound in Recommendations, officials have corresponded and met 1974 = 100 with a wide range of stakeholders, including claimant pence and defendant representatives. The Justice Secretary has not attended any meetings or events to discuss the 1974 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 Legal Aid, Sentencing and Punishment of Offenders 100 20 20 19 18 18 17 17 17 16 16 Bill held by the insurance industry. 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 16 15 15 14 14 13 13 13 12 12

Local Involvement Networks NHS: Patient Satisfaction and Value Question Question Asked by Lord Harris of Haringey Asked by Lord Condon To ask Her Majesty’s Government what was the cost of putting out to tender contracts to act as To ask Her Majesty’s Government how they assess the value for money, operational effectiveness hosts to local involvement networks. [HL15253] and patient satisfaction of new hospitals such as the new Pembury Hospital, Kent. [HL15289] The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): The information requested is The Parliamentary Under-Secretary of State, Department not collected centrally. The costs to local authorities of of Health (Earl Howe): Capital investment proposals administeringandmonitoringcontractswithhostorganisations in the National Health Service are considered on a are likely to have varied according to the nature of case-by-case basis and assessed against key approval their area and each local authority’s infrastructure. criteria set down by the department and Treasury. The department allocated £10,000 to each local Each proposal is subject to a value-for-money test authority in 2007 to help with the initial set-up of which compares the risk adjusted, whole-life costs and local involvement networks including the procurement benefits of a public capital-funded option (known as of the host organisation to support them. the public sector comparator) with one provided under WA 77 Written Answers[8 FEBRUARY 2012] Written Answers WA 78 the private finance initiative (PFI). PFI involves a Lord Sassoon: I refer the noble Lord to paragraph 3 private sector consortium raising finance either through of my Answer provided on 10 January 2011. Universities a loan from a bank or from the capital markets (bonds). are not classified to the public sector. Accordingly, NHS trusts report key financial information to the neither they nor the University Superannuation Scheme department on a monthly basis, and detailed financial are consolidated in the whole-of-government accounts, information on a quarterly basis. The financial information as it consolidates only public sector bodies. is signed off locally by the organisation’s chief executive and director of finance, and by the strategic health authority cluster chief executive and director of finance. Piracy In addition, the NHS performance framework includes the financial assessment of NHS trusts. This is monitored Question on throughout the year, and reported on a quarterly Asked by Lord Hylton basis. As part of the national patient survey programme, To ask Her Majesty’s Government whether they run by the Care Quality Commission, patients are will propose a system of courts, with nearby remand asked about their experience of receiving NHS services. and post-conviction prisons, to try pirates captured Their responses are used to produce quantitative, in the Indian Ocean and adjoining seas. [HL15270] comparable data which can be used to benchmark organisations. The Minister of State, Foreign and Commonwealth Office (Lord Howell of Guildford): We are working with key states in the Indian Ocean region to build Pensions prosecution and prison capacity.Our work with Seychelles, for example, has included the provision of support Questions from the UK Crown Prosecution Service to help prosecute Asked by Lord Laird suspected pirates captured at sea. The UK, alongside other international partners, provides funding to the To ask Her Majesty’s Government, further to United Nations Office of Drugs and Crime, which the Written Answer by Lord Sassoon on 5 December completed work on a new prison block at Seychelles’s 2011 (WA 128-9), why the Northern Ireland Office Montagne Poisee in September 2011, providing the and the Northern Ireland Housing Executive are Seychelles with additional capacity to cope with prosecuted listed as “other unfunded” pension schemes in the pirates and piracy suspects. We will continue to support Whole of Government Accounts Unaudited Summary this work, and similar work with other regional states, Report for the year ended 31 March 2010, and not to help build sustainable prosecution and detention within the Principal Civil Service Pension Scheme facilities to tackle and deter piracy in the Indian and the Northern Ireland Local Government Officers’ Ocean. Superannuation Committee respectively. [HL15100]

The Commercial Secretary to the Treasury (Lord Pneumoconiosis etc. (Workers’ Sassoon): The Northern Ireland Office and the Northern Compensation) Act 1979 Ireland Housing Executive participate in several pension Question schemes. The Northern Ireland Office is included in the Principal Civil Service Pension Scheme (PCSPS) Asked by Lord Wigley or the PCSPS (Northern Ireland) scheme for the majority of its employees. The Northern Ireland Housing Executive To ask Her Majesty’s Government what public is included in the Northern Ireland Local Government expenditure has been incurred under the provisions Officers’ Superannuation Committee scheme for the of the Pneumoconiosis etc. (Workers’ Compensation) majority of its employees. Act 1979 in each of the past five years. [HL15383] Both the Northern Ireland Office and the Northern Ireland Housing Executive also participate in other The Parliamentary Under-Secretary of State, Department unfunded pension schemes and so were included in the for Work and Pensions (Lord Freud): The amounts of list of other unfunded pension schemes in my Answer compensation payments made under the Pneumoconiosis on 5 December 2011. etc (Workers’ Compensation) Act 1979 for the past full Asked by Lord Laird five years is as follows:

To ask Her Majesty’s Government, further to Year Amount Paid the Written Answer by Lord Sassoon on 10 January (WA65-6), why the pension liabilities of the University April 2006 to March 2007 £25.9 million Superannuation Scheme are not included in the April 2007 to March 2008 £27.4 million 2009-10 whole-of-government accounts, given that April 2008 to March 2009 £33.0 million expenditure in England on grants and subsidies by April 2009 to March 2010 £35.2 million the Higher Education Funding Council, Learning April 2010 to March 2011 £38.3 million and Skills Council and local authorities to further Note education institutions is included. [HL15101] Expenditures are expressed in millions, to one decimal point. WA 79 Written Answers[LORDS] Written Answers WA 80

Schools: Academies following an order of the court, the Admiralty Marshal will be able to recover any expenses incurred by him or Question on his behalf in accordance with the undertakings Asked by Lord Willis of Knaresborough made by the claimant’s solicitors at the time of their application for the warrant of arrest. To ask Her Majesty’s Government how many academies have been established since May 2010. [HL15274] Somalia: Piracy The Parliamentary Under-Secretary of State for Question Schools (Lord Hill of Oareford): Since May 2010, Asked by Lord Chidgey 1,377 academies have been established. Of these, 1,243 have converted to academy status and 134 have become To ask Her Majesty’s Government what estimate sponsored academies. they have made of how many Somali pirates have been jailed each year since 2009, and in which countries; and how many have been released without Schools: Profit-making having been taken into custody. [HL15228] Question Asked by Baroness Jones of Whitchurch The Minister of State, Foreign and Commonwealth Office (Lord Howell of Guildford): The United Nations To ask Her Majesty’s Government in what Office on Drugs and Crime reports that there are circumstances private organisations will be able to currently in excess of 1,000 individuals who either run state schools for profit. [HL15238] have been convicted and imprisoned or are being processed through the criminal justice systems of some The Parliamentary Under-Secretary of State for 20 states. Some 70 convicted pirates have already Schools (Lord Hill of Oareford): State-funded schools completed their sentences and have been released. cannot be profit-making. All schools can outsource In the last two years, 42 pirates in total have been specific services or any range of services to a third transferred to other states by the Royal Navy for party and many schools do this and have done so for prosecution. decades. There are no limitations on whether such In addition between April 2010 and February 2012, contractors can make a profit. a total of 60 further suspected pirates were encountered by the Royal Navy during boarding operations. Following Shipping: “Westwind II” detailed analysis of all physical evidence and witness statements, these suspects were released as it was assessed Question that a successful prosecution was unlikely.The subsequent Asked by Lord Hylton destruction of any pirate equipment and weapons found serves as a disruption measure and prevents To ask Her Majesty’s Government why the cargo their future use. Prior to April 2010, information on ship “Westwind II”was arrested in Portland harbour; the number of individuals encountered by the Royal and whether they will intervene to ensure that the Navy who were suspected of piracy is not held centrally. crew receive their unpaid wages and are enabled to In 2009, the European Union Naval Force conducted return home. [HL15183] 16 disruption operations, of which five resulted in a subsequent prosecution of suspected pirates. In 2010, The Minister of State, Ministry of Justice (Lord they conducted 49 disruption operations, of which McNally): “Westwind II” was arrested by the Admiralty four resulted in a prosecution. Finally in 2011, Marshal (an employee of Her Majesty’s Courts and EUNAVFORconducted 18 disruption operations, two Tribunals Service) pursuant to an arrest warrant issued of which resulted in prosecution. by the Admiralty Court on the application of Shellfish Since the beginning of the North Atlantic Treaty Ltd. The vessel was arrested in order to establish Organisation’s (NATO) Operation Ocean Shield in jurisdiction and as security for Shellfish Ltd’s claim 2009, it has disrupted in the region of 500 suspected against the vessel. The Admiralty Marshal is providing pirates, 80 of whom are being or have subsequently food, water and fuel to those members of the crew been prosecuted. who remain on board in accordance with an order granted by the Admiralty Registrar on 10 November 2011. However, Her Majesty’s Government are not responsible for paying the crew’s wages. The owners of White Phosphorus the vessel retain responsibility for paying and repatriating Question the crew in accordance with their contracts of Asked by Lord Hylton employment. The vessel will remain under arrest until the vessel To ask Her Majesty’s Government why a is sold or released by the claimants. If an order is phosphorus artillery shell has been approved for made for the sale of the vessel by the court, the use by NATO forces, in the light of international Admiralty Marshal will be entitled to recover expenses restrictions on the use of white phosphorus. from the proceeds of sale. If the vessel is released [HL15222] WA 81 Written Answers[8 FEBRUARY 2012] Written Answers WA 82

The Parliamentary Under-Secretary of State, Ministry World Health Organisation: Awards of Defence (Lord Astor of Hever): White phosphorus munitions are not prohibited under current or likely Question future international agreements. UK and NATO armed Asked by Lord Crisp forces use all munitions at their disposal according to applicable international humanitarian law. Such use is To ask Her Majesty’s Government what assessment governed by the principle of avoiding unnecessary they have made of the World Health Organisation suffering. Innovations in Health Worker Migration Award announced on 1 February 2012; and whether they will be nominating the United Kingdom or any UK Armed Forces use white phosphorus munitions other candidate for an award. [HL15349] only to obscure the battlefield, provide illumination or for signalling, not for anti-personnel use. The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): The Government are committed to the ideals expressed in the World Incendiary weapons, those primarily designed to Health Organisation (WHO) Code of Practice on the set fire to objects or to cause burn injury through the International Recruitment of Health Workers and action of flame, heat, or a combination thereof, are welcome initiatives such as the WHO award scheme to illegal in attacks on the civilian population or ensure that migration of health workers does not civilian objects, and limits are placed on attacks on compromise healthcare in developing countries. The military objectives located within a concentration of Government have yet to decide whether to make a civilians. nomination.

Wednesday 8 February 2012

ALPHABETICAL INDEX TO WRITTEN STATEMENTS

Col. No. Col. No. Department for International Development: DEL ...... 17 Questions for Written and Oral Answer: Costs ...... 21

Firearms ...... 20 Search and Rescue Helicopter Service ...... 22

Freedom of Information...... 21 Terrorism: Finance ...... 22

Wednesday 8 February 2012

ALPHABETICAL INDEX TO WRITTEN ANSWERS

Col. No. Col. No. Afghanistan...... 61 Housing: Mortgages ...... 72

Armed Forces: Aircraft...... 61 Internet: Broadband ...... 73

Assisted Dying...... 62 Justice and Security ...... 73

Aviation: Fuel Prices...... 62 Legal Aid, Sentencing and Punishment of Offenders Bill...... 74 Blasphemy ...... 63 Local Involvement Networks...... 75 Building Regulations ...... 63 Money: Pound Sterling...... 76 Care Services: Means-testing ...... 64 NHS: Patient Satisfaction and Value ...... 76 Church of England: Salaries and Benefits ...... 64 Pensions...... 77 Coastal Pathways...... 65 Piracy ...... 78 Embryology ...... 65 Pneumoconiosis etc. (Workers’ Compensation) Act 1979 .. 78 Energy: Forecasts and Estimates...... 66 Schools: Academies ...... 79 Energy: Solar Power ...... 67 Schools: Profit-making ...... 79

Ghana...... 68 Shipping: “Westwind II”...... 79

Gypsies and Travellers ...... 68 Somalia: Piracy...... 80

Health: Clinical Physiologists ...... 69 White Phosphorus ...... 80

Health: Mesothelioma ...... 70 World Health Organisation: Awards...... 82 NUMERICAL INDEX TO WRITTEN ANSWERS

Col. No. Col. No. [HL15100] ...... 77 [HL15138] ...... 73

[HL15101] ...... 77 [HL15144] ...... 61

[HL15109] ...... 64 [HL15145] ...... 61

[HL15110] ...... 64 [HL15179] ...... 61

[HL15111] ...... 62 [HL15180] ...... 73

[HL15114] ...... 65 [HL15181] ...... 63

[HL15121] ...... 72 [HL15183] ...... 79 Col. No. Col. No. [HL15194] ...... 69 [HL15253] ...... 75

[HL15195] ...... 69 [HL15265] ...... 65

[HL15196] ...... 67 [HL15270] ...... 78

[HL15197] ...... 66 [HL15274] ...... 79

[HL15198] ...... 66 [HL15289] ...... 76

[HL15199] ...... 66 [HL15303] ...... 63 [HL15314] ...... 74 [HL15200] ...... 66 [HL15315] ...... 70 [HL15201] ...... 66 [HL15316] ...... 70 [HL15222] ...... 80 [HL15317] ...... 74 [HL15226] ...... 68 [HL15318] ...... 75 [HL15228] ...... 80 [HL15347] ...... 64 [HL15230] ...... 62 [HL15349] ...... 82

[HL15238] ...... 79 [HL15359] ...... 69

[HL15240] ...... 73 [HL15383] ...... 78

[HL15241] ...... 74 [HL15384] ...... 76 Volume 735 Wednesday No. 264 8 February 2012

CONTENTS

Wednesday 8 February 2012 Questions Dogs: Microchipping ...... 251 Gaza ...... 253 EU: Structural and Cohesion Funds...... 255 Cyclists: Accidents ...... 257 Health and Social Care Bill Report (1st Day) ...... 260 Gaza Question for Short Debate ...... 317 Health and Social Care Bill Report (1st Day) (Continued)...... 333 Written Statements...... WS 17 Written Answers...... WA 6 1