Health and Social Care Bill

My Lords, I will speak to Amendments 121, 122, 123, 125 and 126 in my name. I will also comment on the Government's Amendment 124. Amendment 121 covers the appointment of a public health specialist. It states: "““The individual so appointed must be a registered public health specialist who has a broad range of professional expertise in public health””." When we debated this in Committee I made it clear that while doctors—public health specialists who are trained in medicine—not only do medical training at undergraduate level but do several more years of training in public health before they are given a certificate of completion of training that allows them to be registered on a GMC register of public health specialists. The situation is similar for public health dentists; they go through similar training. The problem is that non-medical public health specialists—of whom there are many—do not go through any specific training. Registration is voluntary. We will come to registration issues at a later date. The amendment states that those appointed must be registered public health specialists with a broad range of professional expertise in public health, which they must demonstrate at the time of appointment. I hope that the noble Baroness, Lady Northover, will comment on that. The noble Baroness was absolutely right to say in her opening speech that the Government had listened. I am grateful to both the noble Earl and the noble Baroness for the time they took to meet me, and to meet representatives of the Faculty of Public Health. I declare an interest as an honorary fellow of that faculty. As a result, the Government have brought forward amendments and produced a document, which I will refer to at a later stage, that is very helpful in identifying the role of public health doctors in a local authority. Amendment 125 is linked to this issue. It concerns the appointment of directors of public health. It states: "““Any registered public health specialist or other person who is employed in the exercise of public health functions by a local authority or is an executive agency of the Department of Health shall be employed on terms and conditions of service no less favourable than those of persons in equivalent employment in the National Health Service””." If we are to appoint directors and consultants of public health in local authorities and attract high-calibre individuals, we will have to make sure that they are not disadvantaged by taking a job in a local authority. The amendment merely alludes to that. Currently all specialists in the NHS, be they physicians, surgeons, obstetricians, paediatricians or other specialists, are appointed by an advisory appointments committee. The constitution of that committee is statutorily determined. The committee includes a representative from the appropriate college faculty. In this case it would be the Faculty of Public Health. Why is that necessary? The Bill states that appointments will be made with the presence of representatives from Public Health England. I have no objection to a representative of Public Health England, who works closely with the director of public health, being on the appointments committee. However, it is important that an external person should be nominated by the faculty to the appointments committee—as happens with other specialists—because external adjudicators will make sure that the person appointed has the appropriate training and experience. The Government's Amendment 124 concerns appointments of public health specialists. It states: "““A local authority must have regard to any guidance given by the Secretary of State in relation to its director of public health, including guidance as to appointment and termination of appointment, terms and conditions and management””." The important question is: will the guidance be followed? How will the department make sure that the guidance is followed? What does ““have regard to”” mean in this situation? Why can we not have the same arrangements as for other specialists in the NHS? I recognise that foundation trusts can offer different terms and conditions to the people they employ—but they do not do so, because before they became foundation trusts they were NHS hospitals, and they were used to appointing consultants through the process that I described. Local authorities do not have this experience. Therefore, it is more important that they should start off by using the same system as for the appointment of consultants in the NHS. Amendment 123 would require the consent of the Secretary of State to the dismissal of a director of public health. The Bill states that the Secretary of State would be advised. Why is this not adequate? It is likely that a director of public health, who will have responsibility, when it comes to the health of the population that a local authority serves, for making appropriate plans for both preventing disease and responding to emergencies, may come into conflict in particular with councillors who may not like the idea of certain statutory or other requirements and who may dismiss them, despite the fact that they may be doing the right thing. Therefore, it is important that the Secretary of State should have all the information and should agree to the dismissal, rather than just be advised of it. Amendment 122 states: "““The director of public health shall be a person for whom the head of the paid service is directly responsible and shall be required to report directly to the authority as to the exercise of the post””." This may now be redundant. Perhaps the noble Baroness will reassure me that that is so because the Government have declared that the director of public health will be appointed at senior officer level, and therefore will be directly accountable to the chief executive, as head of service in the local authority. Amendment 126 is the key amendment in this group. The Bill is quite unclear on how the response to an emergency will be handled, and who will be responsible for making sure that the response is appropriately carried out. The confirmation given in the document that I referred to, Public Health in Local Government, produced by the Department of Health between Committee and Report, was very helpful. The document says that the director of public health will, "““continue to provide a coordination role to protect the health of the local population when transferred to local authorities””," and I welcome that very strongly. However, although the document provides a great deal of detail about the way in which health protection and emergency preparedness and response are to be addressed under the new system, and clarifies the responsibility of the director of public health within the local authority, the picture at the local level is fragmented, with responsibility resting not with the local authority but across the NHS and Public Health England. I believe this fragmentation places public safety at great risk. In Committee, the Minister affirmed the need to deal, "““quickly, decisively and in a co-ordinated way with sudden threats to public health””," and asserted that, "““the establishment of the position of director of public health within local authorities will strengthen considerably their capacity to respond to emergencies””.—[Official Report, 5/12/11; col. 533.]" I agree, but we must ensure that when incidents occur all the respondents are prepared and fully understand the parts they play. As it stands, the Bill is unclear about the roles and responsibilities of directors of public health and local authority functions in planning for and dealing with an emergency. It is essential that there be clarity over who within the various local agencies involved has the lead responsibility for ensuring that the response to an emergency or outbreak is effective and appropriate. It is important to establish in this legislation that this responsibility lies at the local level with the local authority—and on its behalf the director of public health—for ensuring that plans are in place. What the Bill currently provides is not sufficient. The local authority has to be in charge. The inclusion of this amendment in the Bill would remove any doubt or ambiguity and make clear that local authorities will be responsible for protecting and improving the health of their populations at all times, including during outbreak and emergency situations. Of course, the local authority will not normally deliver the response itself—that will normally be provided by Public Health England and supported by the NHS and others in the local community—but the local authority will be responsible for ensuring that an effective, appropriate and integrated response is delivered. It will be able to hold Public Health England and its outposts to account for the local service it provides. There are two examples that might help demonstrate how this may happen. Let us assume it is next winter and a school has two pupils who develop meningitis. Both have group B infection and one dies. Public Health England recommends the vaccination of all 1,800 pupils in the school. The director of public health agrees this recommendation, as does the local authority. However, there are no school nurses to deliver the immunisation as the commissioner has decided not to commission a clinical service for school nursing. Another example: three pupils in one secondary school have all developed infectious tuberculosis. Public Health England recommends that all pupils in the school are screened. The director of public health and the local authority agree this decision. However, commissioners have reduced the TB nursing and clinical support services. They now no longer have sufficient staff to enable the students to be tested. How will the disconnect between the advice of the director of public health and commissioning be breached? These two scenarios illustrate the difficulties posed by the proposed new system. While the director of public health may be given accountability for emergencies, in these clinical emergencies the response has been delivered through the NHS—it is a different scenario. To date, the director of public health has director-level responsibility for NHS resources and so can ensure that these resources are used where necessary to deliver a public health response. However, in the new world neither the director of public health nor the local authority will have any control over either NHS resources or the commissioning decisions. These examples illustrate the tensions that are as yet unresolved in the design of the new public health system. While I am absolutely delighted with the document the Government have produced, there is some way to go in making sure that we do not fall through this lacuna again about the preparedness for the health of the local population. If the noble Baroness is not minded to accept these amendments—and I will not be surprised if she is not—perhaps she might accept that there is an issue here to be addressed. One way might be to push for a vote, but I am not going to do that. I would much rather she accepts that there is an issue to be addressed here, and is willing to work with the Faculty of Public Health to make sure that the appropriate mechanism is put in place.