Health and Social Care Bill

My Lords, I have some amendments in this group to which I would like to speak. The first is Amendment 62A, a probing amendment which seeks a government response. This amendment would require the Secretary of State to report annually on the steps taken in relation to the duties listed in the Bill. Currently we have the Chief Medical Officer’s annual report, which is excellent and provides an enormous amount of information particularly on matters relating to public health. However, given this Bill and the dramatic changes we will see in the delivery of healthcare across England, it seems important that we should have regular annual reporting that can be tracked from year to year against a specific set of headings. Over the years this would create comparators that could be used to see whether the quality and health improvements on which the Bill is focused are being achieved. Similarly, I have amendments about undertaking an audit of healthcare providers’ processes and outcomes in terms of how they improve public health and implement the public health advice they receive. Amendment 71A, another probing amendment, suggests changing the wording of the provision so that there is an obligation to consider diagnosis and treatment rather than diagnosis or treatment, as the Bill currently provides. I tabled this amendment because I was somewhat horrified to see that the Bill provides a requirement to consider treatment but not to ensure that the diagnosis guiding the treatment is correct. Treatment for the wrong condition will result in morbidity and mortality related to the treatment plus progression of the underlying condition. I wonder whether that might not be a drafting issue which the Government might be inclined to look at again. I have taken further advice on my Amendment 69A and have decided not to press it. I can therefore spare the Minister the trouble of trying to respond to it. However, perhaps I may give a little evidence in support of this pressure to require reporting and audit at every level. There is high-powered and strong evidence from public health itself. Public health is a competency set, not a separate discipline. All public health practice needs epidemiology, biostatistics and a commitment to organisations and community understanding, with a focus on prevention and the implementation of evidence into practice. Evidence is not just a matter of, ““Yes, there is evidence””, or, ““No, there is not””. There is a hierarchy of scientific evidence in relation to public health. It is important to understand that there are five criteria in relation to the reporting requirements that I am asking for. First, there may be evidence of no benefit. Secondly, there may be no evidence of benefit. Thirdly, there may be uncertain evidence of benefit. Fourthly, there may be evidence of efficacy. Fifthly, there may be evidence of both efficacy and effectiveness, which means that these interventions would incontrovertibly improve efficacy and seem feasible for large-scale implementation based on effectiveness trials. So that is very high-level evidence, and the others are hierarchies right down to the first I listed, which was a reason for decommissioning and stopping the use of an intervention. Perhaps I may give some examples of where that hierarchy has influenced clinical practice and the reason why public health cannot be divorced from clinical practice. Even though this has been put on local authorities and will have a strong influence, I hope it will not become divorced from clinical practice. It needs to be linked to commissioning by GPs for the following reasons. First, it has been demonstrated that general practitioners and clinicians can save money if they provide advice on health in the consultation as well as dealing with the presenting complaint. Secondly, involving clinicians in detecting alcohol problems as part of a routine consultation has been shown to save money and lives. Thirdly, in nurse-led clinics there is evidence of cost-effective secondary prevention when they are used for targeted areas such as coronary heart disease. They can be extremely effective. Fourthly, drug treatment is a public health issue and there needs to be close working in the clinical setting to make sure that the use of drugs in conjunction with the appropriate use of pharmacy advice can maximise health benefit. Fifthly, primary care itself is more effective where public health is involved in the way that primary care is delivered. A very powerful trial conducted in the USA has shown that to be the case. Last but not least, high-tech interventions that at first sight might seem expensive, when properly evaluated in public health terms, have been shown to save lives and money, so they become an investment for savings. Those are just some of the examples of why we need public health right at the heart of the changes, but we also need the monitoring that public health can bring to ensure that things that should happen are happening.