Health and Social Care Bill

My Lords, I am tempted to open by invoking, if not the Health Protection Agency, then perhaps the protection of the local environmental health department, because conditions in this Chamber, at this temperature, are hardly conducive to anyone’s good health. However, that is a matter perhaps for the House authorities to look at. I rise to express the view that Clause 53 should not stand part of this Bill and to support my noble friend Lord Warner’s Amendment 260. I do the latter on the basis that that would be a fallback position, because I entirely concur with the view expressed in particular by the noble Lords, Lord Turnberg, Lord Patel and Lord Walton, and the noble Baroness, Lady Finlay, who have of course such a distinguished history as leading clinicians in these and other medical fields. Part of the thrust of the argument is the need to maintain not only a functioning organisation which has, as we have heard, an international reputation, but also to ensure that any such organisation has the requisite degree of independence from Government—that is, the right and in fact the duty, as the noble Lord, Lord Turnberg, made clear, to advise the Secretary of State and the Government generally without fear or favour. Amendment 260 would create an executive agency for the Health Protection Agency. It is arguable that executive agency status would not of itself lead to the required or desired degree of independence whereas perhaps a special health authority would conceivably achieve that. There is a difference of view from the Government about the status of a special health authority. Their preference for Public Health England is that it should be an executive agency. They argue that a special health authority would not be appropriate. They point to analogous situations of agencies created for the Medicines and Healthcare products Regulatory Agency and curiously, by way of analogy, the Met Office, as organisations which are deemed to have sufficient independent status, albeit operating as executive agencies of their respective departments. Neither of those arguments can be sustained. The role of Public Health England is a much wider one than either of the two bodies to which their document published earlier this year refers. A regulatory agency is not the same as an organisation which has to advocate and oversee a wide range of services, such as Public Health England would be required to do, and the Met Office is hardly an organisation which is required to be independent of Government in preparing its weather forecast. The analogy is somewhat ludicrous. There is also, of course, the very important point made by noble Lords about the need for independent status in order to attract some of the funding, both charitable and contractual, on which in particular the Health Protection Agency is critically dependent and which might be endangered by its absorption into Public Health England in a way which would make it clear that it is no longer independent. That is not to say that the creation of Public Health England in the form of a special health authority would not of itself be desirable. The bringing together of a range of functions under the auspices of Public Health England, although not, I would argue, the Health Protection Agency, would be welcome. A number of professional bodies have commended the principle but clearly have reservations about how the new structure would work. The Association of Directors of Public Health, for example, makes it clear that Public Health England should include health protection and emergency planning, health improvement and health services in its main areas of work and, in addition, provide an independent science base and advice to the Government and the devolved Governments. One of the arguments against creating a special health authority was that it would not be able to deal with devolved Governments. I would have thought that that is something that the Government could deal with relatively easily. The role of Public Health England should also support the national Commissioning Board and provide support for local directors of public health. However, the association expressed concerns about the role and status of directors of public health. We recently discussed some of those in Committee. It also had concerns about the input into the national Commissioning Board and the lines of accountability. We will have Public Health England, the clinical commissioning groups, the directors of public health and various other functioning arms of the National Health Service, and it is not clear how the relationship would work and, in particular, what the role of Public Health England would be. The association has argued strongly for consolidating public health capacity into Public Health England with overall responsibility for improvement, protection and promotion of health care, and for public health intelligence and analysis. A number of questions arise in respect of the position of the Health Protection Agency. There is a need to maintain capacity within the service and particularly for robust arrangements for emergencies and for interim arrangements, pending the completion of the reorganisation. Perhaps the Minister, when replying, could indicate how far the department has been able to explore the issues of capacity and the position in relation to the provision of those emergency services. The point was also made that clarity is needed about responses to incidents at local, sub-regional and regional level. Again, perhaps the Minister could indicate how far discussions have gone and what proposals there are for ensuring that that response at the various levels indicated would be guaranteed by the new arrangements. There is also an issue about the role and responsibilities of the directors of public health and local health protection units. Again, perhaps the Minister, if she is not able to reply to that point tonight, could write to noble Lords about that. A point was raised which I almost have to apologise for raising yet again, which is the position of second-tier authorities in connection with their responsibilities under the auspices of the Bill, and in particular their relationship with Public Health England. Concerns were also raised in a joint statement recently issued by the Local Government Association, the BMA, the Faculty of Public Health, the Association of Directors of Public Health, the NHS Confederation and even the Royal College of Midwives, a broad grouping, all of which have reservations, even though generally approving the thrust of the Government’s policy. In particular, the case was made for public health arrangements to be organised at the different levels, at the ““supralocal level”” as they call it—that is to say, a conurbation area rather than just the individual local authority area—and at a subnational level. They supported an integrated model in which large local authorities might host subnational functions on behalf of Public Health England; in London, for example, where there is an elected mayor, or in Greater Manchester, where there is a combined authority, and perhaps other cases where authorities could come together. Again, it would be interesting to learn whether the department sees that as a potential way forward. There is another serious range of issues around public health observatories, which have suffered a significant loss of capacity, according to the Select Committee’s report. It would appear that 40 per cent of their staff are on fixed-term or temporary contracts and are unlikely to be retained. That is a very significant reduction in staffing of the public health observatories. It appears that 45 per cent of the capacity is likely to be lost by 2012. There is particular concern about the regional aspect of public health observatories. On a previous occasion I invited the noble Earl, Lord Howe, to indicate whether the future of the observatory in the north-east was secure, and I seem to recall that he thought that it was. Again, it would be helpful if we could hear what the Government’s view is of the position of the public health observatories, which are an important ingredient in the provision of public health. In this context, the King’s Fund pointed to the risks of the reorganisation creating a less effective local public intelligence network and significantly higher costs to directors of public health. There is another organisation that has been identified as one that has uncertainties about its future: the United Kingdom Association of Cancer Registries, an organisation for cancer intelligence that, again, agrees in principle with the proposals. Its director, noting that the organisation’s future would lie with Public Health England, said when he was giving evidence that he did not know yet what the structures would be and that there was uncertainty leading to the risk of losing skilled staff. It is interesting that the word ““risk”” crops up on the day when we have discussed risk registers. Perhaps in the fullness of time we might learn whether or not that particular risk is one of those identified in the registers which we spent an hour debating today. The Select Committee, again broadly approving the thrust of government policy, expressed its concern in terms that I referred to in the previous debate, saying: "““We are concerned at the lack of clear plans for Public Health England to be established at the regional level. The idea of ‘sub-national hubs’, in some … undefined … alignment with the sub-national structures of the NHS Commissioning Board and the Department for Communities and Local Government does not seem to us adequate … Public Health England needs a clear structure of regional accountability””." I hope that the Minister will be able to indicate what kind of accountability and regional structures it is envisaged should be implemented. In summary, the preference of the Opposition would be to see the Health Protection Agency preserved with independent status and to see Public Health England created as a special health authority, guaranteeing, at least to a degree, its independence, which cannot be guaranteed when, in the words of the Minister in the other place, it is simply another form of embodiment of the Secretary of State. For these reasons, the Opposition support the amendments. I will not be asking the House to divide now but this is a matter to which, in the absence of a positive response, we may well have to return on Report.