HL Deb 02 December 1998 vol 595 cc496-515

3.7 p.m.

Debate resumed on the Motion moved on Tuesday last by Lord Clinton-Davis—namely, That an humble Address be presented to Her Majesty as follows:

"Most Gracious Sovereign—We, Your Majesty's most dutiful and loyal subjects, the Lords Spiritual and Temporal in Parliament assembled, beg leave to thank Your Majesty for the most gracious Speech which Your Majesty has addressed to both Houses of Parliament".

Baroness Hayman

My Lords, the Government are committed to renew and modernise the institutions of Britain. This Queen's Speech represents a major step forward in meeting this objective, not least in its proposals for home and health affairs, which we shall concentrate on today.

In my opening remarks, I intend to focus on health issues and my noble friend Lord Williams will deal in more detail with home affairs when he closes the debate. The whole House will look forward to the maiden speech of my noble friend Lord Warner from whose wide experience in these fields I am sure we all have much to learn.

This summer we celebrated the first 50 years of the National Health Service. Its enormous achievements are acknowledged. But today it faces formidable challenges: advances in medical technology, changes in demography, work patterns and family life and growing public expectations. Our pride in the achievements of the past 50 years should not make us wish to stand still but rather should reinforce our determination to ensure that the necessary changes take place to ensure the equal success of the National Health Service in the next century as it has enjoyed in this.

It is now one year since the Government published their plans to replace the internal market and rebuild the health service. Substantial progress has already been made to implement those plans and the NHS Bill will build on that work.

The plans begin a 10-year programme that the Government have now backed with the biggest cash injection that the NHS has seen in 50 years, amounting to an average real terms growth of 4.7 per cent. for the next three years. That is investment for lasting success which will bring demonstrable improvements year on year.

We have made good progress across the board in implementing our plans to build a modern and dependable NHS; for example, in developing the new primary care groups. Their establishment is not dependent on new primary legislation. There are 481 groups already in place and they will become live from April 1999.

Primary care groups are borne out of the experiences of what general practitioners, nurses and managers have been doing over the past few years, despite the obstacles provided by the internal market. Their three key functions are to improve health, commission high quality care by developing long-term service agreements with trusts, and develop high quality primary care services. Primary care groups will cut bureaucracy by abolishing thousands of commissioning and fundholding groups. They will put local doctors and nurses in the driving seat in delivering services.

The NHS Bill will end GP fundholding. It will also take the primary care group model further. Primary care groups who want to be independent and are capable of being so will be able to apply for primary care trust status. Those trusts will allow for the integration of community and primary care services in a way never possible before—they will shatter the old boundaries between services.

Raising standards in the quality of NHS care is at the heart of the Government's drive to modernise the NHS. Our proposals are set out in the consultation document A First Class Service, published in July, and have been warmly supported.

All patients who are treated by the NHS want to know that that they can rely on receiving high quality, safe and effective care when they need it. And, overwhelmingly, they do receive it. But as we have all seen, when things go wrong the consequences can be appalling.

The NHS Bill will place a duty of quality on NHS trusts and PCTs to support clinical governance. It will also establish a new external body, the Commission for Health Improvement, to tackle organisational failures as well as ensuring that a system of clinical governance develops in a way that will prevent many of today's problems from repeating themselves in the future.

The Bill will also include measures to strengthen existing systems of self-regulation of the healthcare professions by ensuring that they are more open, responsive and publicly accountable. The Government are discussing the detail of the measures with the professions. Perhaps I may make it clear right now that we will work with the professions not against them, to ensure that the protection of the public is at the forefront of changes to the law. The professions cannot provide effective self-regulation without continued responsibility for the register; the standards of education for entry to the professions; guidance on standards of conduct and professional performance, and for the fitness to practice procedures.

The Government are committed to renegotiate the Pharmaceutical Price Regulation Scheme with the pharmaceutical industry and are currently conducting negotiations with representatives of the industry. The Government regret that there is increasing non-compliance with the voluntary agreement. The Bill will contain powers to ensure compliance with the new agreement when reached. Those powers will not affect those companies committed to complying with the PPRS but are necessary to secure compliance from other companies that might choose not to abide by it.

Partnership is key to the Government's plans for modern health and social services. Instead of the fragmentation and bureaucracy of the internal market, the Government are building a system of integrated care, based on partnership. Services should be built around the needs of those who use them, but all too often the traditional boundaries that exist between services can be a major obstacle to this. In the discussion document Partnership in Action, we set out our plans to make partnership a reality by removing barriers in the existing system and introducing new incentives for joint working. Those plans go with the grain of what the NHS and local authorities are seeking to achieve. They have been warmly received.

The Bill will include a substantial package of measures to promote partnership. It will place a new duty on NHS bodies to co-operate with one another and with local authorities. Development of the first health improvement programmes is on track and these will be given statutory underpining. Section 28A powers from the 1977 National Health Services Act will allow for the extension of powers to transfer money from health authorities to social services—within the context of the health improvement programme—to include a wider range of local authority services, and allow for reciprocity. The Bill will also make permissive provision to allow the NHS to enter into pooled budgets, lead commissioning and integrated provision, and the powers in the local government Bill will enable those arrangements to be extended across all local authority functions.

We are committed to create modern and dependable social services. On Monday, my right honourable friend the Secretary of State for Health outlined proposals in another place to ensure that we have social services which are convenient to use, can respond quickly to emergencies and provide top quality services for those who need them. Those proposals reflect the priorities within the local government Bill—to which my noble friend Lord Whitty alluded on Monday—so that a duty of best value on local authorities will secure continuous improvement in the delivery of services.

The White Paper, Modernising Social Services, proposes to lay down new standards of delivery and performance, so that people who need help from social services are treated with dignity and provided with what they need in a way which promotes rather than diminishes their independence. As a result of the comprehensive spending review, £1.3 billion will be made available over the next three years to support the modernisation which is necessary to take those changes forward.

This Government are committed to attack the root causes of ill health, improving lives and saving the NHS money in the process. Early next year we will publish a public health White Paper developing the proposals contained in the Green Paper Our Healthier Nation, which we published in February. Those proposals will be informed by the results of the independent inquiry into inequalities in health, which published its findings last week.

Smoking is the leading cause of preventable illness and premature death in the UK today. The Government plan to publish a White Paper before the House rises for the Christmas Recess. The proposals will announce how we intend to implement the EC directive on tobacco advertising to deliver our manifesto commitment to ban such advertising. The White Paper will set out a package of measures designed to reduce smoking—a key component in achieving our wider public health goals.

A short Bill will be introduced with the intention of helping hospitals in England, Scotland and Wales better recover the costs of treating the victims of road traffic accidents. The present system can trace its origins back to the 1930s, pre-dating the National Health Service. Under the current scheme when a patient, who has received treatment following a traffic accident, makes a successful claim for personal injury compensation against the holder of a motor vehicle insurance policy, then hospitals have the right to seek payment of part of the costs of treating the victim from the compensator's motor vehicle insurance policy.

Although hospitals currently have the right to seek payments, problems arise because there is no agreed administrative procedure for undertaking the recovery of those charges. The results, not surprisingly, are patchy. We estimate that the NHS undercollects the amount which is due by a very large margin.

The Road Traffic (NHS Charges) Bill will introduce centralised collection of NHS charges by using the system already established for the recovery of state benefits from compensation payments. That will relieve hospitals of the administrative burden, while at the same time giving the insurance industry a single point of contact and an administrative system already familiar to them.

Turning to home affairs, the Immigration and Asylum Bill will implement key elements of the comprehensive strategy for reform set out in the recent White Paper. For far too long, changes in immigration legislation and policies have been made in a piecemeal fashion. The result is a system which is slow and outdated and in which huge backlogs have been allowed to develop. This is unfair to genuine applicants and encourages others to exploit the system. The Bill is vital to deliver the fairer, faster and firmer system to which the Government are committed.

The Government made a manifesto commitment to bring forward a Freedom of Information Act, which will lead to more open government and form a key part of our constitutional reform programme. A draft Bill will be published early next year for public consultation and for scrutiny by the House of Commons Select Committee on Public Administration.

The Government will also bring forward a Youth Justice and Criminal Evidence Bill to create a new form of sentencing for young offenders and to provide measures to protect vulnerable or intimidated witnesses when giving evidence in criminal trials.

We shall also introduce a Bill to provide a free vote to equalise the age of consent, and to provide provisions to protect children from abuse from those in a position of trust. In response to concern expressed in both Houses during the previous Session, the Bill will also provide a limited criminal offence to protect young people when they are particularly vulnerable or the position of trust particularly strong, for example in education or residential care.

The Government strongly welcomed the fifth report of the Committee on Standards in Public Life, chaired by the noble Lord, Lord Neill, on the funding of political parties. The report provides a valuable framework for implementing the Government's manifesto pledges to require disclosure of large donations and to ban foreign funding of political parties.

A draft Bill will be published before the Summer Recess next year. The Government then intend to put robust rules on the funding of political parties into place before the next general election.

The European Parliamentary Elections Bill is familiar to Members of your Lordships' House. It provides for elections to the European Parliament to be conducted using the simple regional list system. Great Britain will be divided into nine large regions, each returning between four and 11 MEPs. Registered parties will be able to put forward a list containing up to as many candidates as there are seats to be filled in a region. The elector will cast his vote either for a party's list of candidates, or for an independent candidate. The votes are then counted and the seats allocated in such a way to reflect each party or independent candidate's share of the vote. In the case of parties, seats are allocated to candidates in the order in which they appear on the party list. For example, if a party wins two seats in a region, they will be allocated to the first two candidates on the list.

As I said at the introduction of this speech, the Government are committed to renewing and modernising the NHS and social services and to bring in this process with the investment necessary for reform. The measures identified, along with the measures we shall take on home affairs, will help us to make considerable progress this Session in delivering our specific manifesto pledges relating to health, but also to the Government's wider agenda to modernise and renew our National Health Service.

3.23 p.m.

Earl Howe

My Lords, I should like to begin by expressing my appreciation to the Government and the usual channels for allowing time for a fifth day of debate on the gracious Speech and for giving the House, in the process, the opportunity to direct its attention to issues relating to health and home affairs.

While there are obvious areas of convergence between those two subjects, one cannot pretend that the potential field of interest is not a wide one. Looking at the list of speakers—including, I am pleased to say, the noble Lord, Lord Warner—I have little doubt that today's debate will reflect that fact. The noble Lord, Lord Williams, to whose lot it has fallen to sum-up all five days of the debate, has my good wishes and a measure of sympathy, although not too much of the latter.

By contrast, on this Front Bench matters are delightfully clear cut. My own contribution will be devoted exclusively to health issues. My noble friend Lord Henley, who will wind-up the debate from these Benches, will concentrate on home affairs. I shall not anticipate his remarks but I should like to assure the noble Lord, Lord Williams, that we await with interest the three Bills promised from his department: that is, the asylum Bill, the age of consent Bill, and the Bill relating to criminal justice. As always we will, in this House, give those Bills the thorough examination they warrant. I dare say that some will prove more controversial than others.

The Government's reform of the health service was heralded a year ago in the White Paper, The New NHS. At the time of the original announcement I remember describing the proposals—in so far as I then understood them—as being bold. But I think that everybody recognised, perhaps not least the Government, that much needed to be done to flesh out the proposals and prepare the ground for their implementation within the health service before they could be considered fit and ready to be brought to Parliament. In the intervening months, that preparatory process has been occurring, enabling us all to appreciate rather more fully the shape of things to come. Now, in the gracious Speech, we are promised a Bill which will usher in proposals for reform which are not simply bold but also some of the most far-reaching that the NHS has seen in its 50-year history.

I have always said that we, from these Benches, have no antipathy to change in the health service. Indeed, we stand ready to support and encourage the Government in introducing new ideas which will work to the benefit of patients and make the NHS more efficient. So I start from a base of wanting to be positive about the Government's plans. The noble Baroness the Leader of the House referred in her speech to, decentralised arrangements based on partnership, quality and efficiency".—[Official Report,25/11/98; col. 26.] In the abstract, these are unexceptionable aspirations. But how are they to be achieved?

I want to focus my remarks today almost entirely on primary care. As the Minister explained, the Government's intention is to bring to an end the system of GP fundholding and in its place establish a structure of GP collectives or primary care groups. The Government's main criticisms of fundholding, if I am not misrepresenting them, are twofold: that it is bureaucratic and administratively costly; and that it has created a two-tier system of patient care. Those propositions merit close examination in their own right, but to assess the way fundholding is actually working it is surely right to look at it in the round.

The rationale for fundholding, when the previous Government introduced it in 1991, was to give GPs greater financial and clinical autonomy, and in so doing deliver a better standard of care to patients. Today, I do not think there is much dispute that that approach has been vindicated. Fundholding has enabled GPs to secure shorter waiting times for their patients' operations; to develop new specialist services; to develop surgical procedures within the practice itself, so avoiding the need for hospital visits; and to improve surgeries and waiting rooms.

The BMA stated that: fundholding is a good model for encouraging consumer accountability in the NHS". The Audit Commission, in a report of March this year, pointed to: more services for patients at practice premises, improved communication with hospitals and more cost-effective drug-prescribing". The OECD has reported that: fundholders have been more prepared to diversify providers, challenge hospital practices and to demand improvements". GP fundholders are enthusiastic proponents of the system. Even The New NHS White Paper concedes that: GPs … have used the fundholding system to sharpen the responsiveness of hospital services and to extend the range of services available in their own surgeries". I was glad to see that in the White Paper because, if one were to judge solely from the public pronouncements of Ministers in another place, one would be forgiven for supposing that the advantages and benefits which fundholding has unquestionably brought, in terms of quality of care and access to care, have been overlooked or ignored by the present Government.

The issue, therefore, is whether those manifest advantages are outweighed by the perceived disadvantages—bureaucracy and two-tierism. A great deal of academic time and effort has been devoted to securing answers to that question. I cannot hope to traverse the entire scope of such work—even if I knew it!—but it is perhaps interesting to look at the views of one particular authority, Professor Howard Glennerster, who was, incidentally, at one time an advisor to the Labour Party. The professor has examined the extent of the bureaucracy in fundholding and, not surprisingly, he has found that there are indeed management costs associated with it. But his conclusion was that any extra administrative costs are outweighed by the efficiency improvements which the system produces. In simple terms, he is talking about value for money. That is why I believe it is quite wrong, as the Government now seem to be doing, to point an accusing finger at the administrative costs of fundholding and completely ignore what it achieves in the round.

The other criticism of fundholding—that it has created an unfair, two-tier system in primary care—is, I think, rather a strange one. It amounts to saying, "Never mind the 60 per cent. or so of patients who are reaping the benefits of fundholding; there are the 40 per cent. who are still looked after by non-fundholders, and for their sake the only thing to do is to sweep away the entire system". I might be able to warm to that argument, illogical though it is, if the prospect on offer as an alternative to fundholding amounted to a general levelling up of standards as opposed to a levelling down. I should like to spend a few moments looking at primary care groups, or PCGs, to see whether they seem likely to pass that test.

Primary care groups, to remind your Lordships, will consist of groups of 50 to 100 GPs in pre-defined regions, supported by nurses, social service professionals and others, including lay representatives, who will be able to commission health services for their patients from hospitals. Unlike fundholding, the system will not be voluntary and PCGs will, therefore, cover the whole country and all patients. When primary care groups were first announced last year there were those who thought that they amounted to a sort of "fundholding writ large". That is a misconception. The first difference is that a GP will no longer be able to act individually for his patient in commissioning hospital services, as in fundholding. He can only take action as a member of a PCG, in conformity with the arrangements laid down by the PCG management board and the health authority. Noble Lords may think that this is not a very significant point. But, in practice, PCGs will not have a meaningful choice when it comes to the selection of trusts to commission services for their patients. They will be locked into long-term service agreements with local hospital trusts, which will virtually dictate where referrals are to go.

The other important feature of PCGs is the way in which resources will be allocated. At the moment, a fundholder has every incentive for efficiency, because efficiency savings can be ploughed back into more and better services for patients. But in a PCG a doctor will have almost no incentive to generate savings at a practice level, because any efficiency gains will simply be swallowed up by the whole group. Not only is that a retrograde step in itself; it also gives rise to the problem of the free rider. If one practice within the group is inefficient, then the entire group will suffer the financial consequences.

All this will serve to do several things. Practices will no longer have the flexibility they now have to be innovative and to refer patients to a wide choice of hospitals and consultants. They will be less efficient. They will much less easily be able to, sharpen the responsiveness of hospital services"— to use the phrase in the White Paper—so as to drive forward improvements in hospital performance. Moreover, as a patient living in a particular area, you will have no choice but to register with the PCG which covers the area where you live. At the moment, you are almost always able to choose your fundholding GP if you believe that will improve the level of service that you receive. However, under the Government's proposals, you cannot.

There is another aspect of primary care groups which resonates, I have to say, with a particular irony. The Department of Health envisages a four-point scale of PCG responsibilities. The first point in the scale, at the basic level, is a PCG which is merely an advisory body to the health authority. It would have no devolved responsibilities and no decision-making ability. The next point upwards would be a PCG which would have a devolved responsibility for managing the budget, but only as a part of the health authority, which would retain overall control. The third level of PCG would be one with structural independence from the health authority, but which would still be accountable to it for everything it did. The fourth, fully adult version of the PCG is the primary care trust—independent, and able to commission or provide community health services for patients.

So there will be four possible levels of PCG. Each successive level will have a progressively greater ability to manage its own affairs. I believe that if the experience of fundholding has demonstrated anything, it is something very simple: namely, the greater the autonomy of a GP, the better the patient care. It seems to me to follow from that those PCGs which are merely advisory bodies to health authorities will not be able to provide levels of service that are equivalent to the more advanced and autonomous PCGs. Certainly, PCGs can aspire to climb up the ladder of seniority over time, but the practical result of the structure that I have described will be a patchwork quilt of primary care groups, in four colours—if you like—spread over the country with an unequal distribution of colours. You as a patient, living in a particular area, will have no choice but to register with the PCG covering your home area. Never mind if in the next village there is a practice belonging to another PCG which you like the look of rather better. If it is the wrong side of the boundary line, too bad. So much for the much-trumpeted criticism that fundholding has created a two-tier system for patients. Whatever the validity of that criticism—and I am bound to say that I think it has been overplayed—the reality is that the Government's own proposals will create a four-tier system, with the quality of care determined, in the final analysis, by postcode.

In brief, the measures that we shall be asked to consider are not really about building on the best of what we have at the moment. They are, I fear, about a levelling down of standards; an erosion of choice; and a curb on efficiency. That is quite a heavy price to pay for some of the features of PCGs which, in fairness to the Government, do represent a step forward: the closer involvement of nurses in commissioning health services, for example; and the promise of greater integration between healthcare and social services.

If I express this fear about the quality of care differing by postcode and choice being eroded, I am simultaneously conscious of not having done the question full justice. The whole issue of clinical governance is unfortunately too huge for me to cover today, and must wait for another occasion. But there are features of the Government's proposals in that area which suggest a very much greater element of control on GPs exercised from the centre than anything we have seen hitherto. The treatment guidelines from the National Institute for Clinical Excellence will need to be enforced with a very light touch if they are not to erode a doctor's freedom to decide what treatment is in the best interests of his or her patient—a freedom threatened in any event by the arrival of something else that is new; namely, cash-limited prescription budgets. These are the reasons why the other much talked-about justification for PCGs—that they will facilitate better strategic planning in the delivery of healthcare—has, to me, more than a ring of newspeak about it.

Unfortunately, these are not the only problems. Primary care groups will command enormous budgets which will need managing. Who will manage them? At the moment the answer seems to be that it will be the GPs and nurses themselves who will be in charge of this money. Are they adequately trained to do this? I should like to ask the Minister what the total cost of that management input is likely to be. Can he confirm that the figure calculated by both the King's Fund and Professor Alan Maynard of York University that the administrative cost of PCGs will be about £150 million per year? Perhaps I may suggest to the noble Lord that that is rather more than the current cost of running fundholder practices. We hear a lot about the need to reduce bureaucracy in the NHS, but what seems to be happening at the moment is the worst of all possible worlds: large numbers of professional managers being made redundant, at considerable cost, in anticipation of the changes to come; and the prospect of doctors, many untrained for the task, being paid a fee to manage PCGs. Every day that a GP spends round a board table is a day spent away from his patients. At a time when there is a nationwide shortage of GPs, primary care groups will dilute the time that doctors have available to devote to patient care. That cannot be a sensible ordering of priorities.

The future shape of primary care in Britain is a sine qua non for a successful NHS. The Bill, when it comes before us, will reveal whether and to what extent we can be confident of that success. From these Benches, we shall wish to ensure that, for the Government to carry the day, they will do so on the merits of their arguments.

The Minister of State, Home Office (Lord Williams of Mostyn)

My Lords, before the noble Lord, Lord Clement-Jones, addresses the House, your Lordships may have noticed that my noble friend Lady Hayman is not at all well. She means no discourtesy. I am sure that we wish her a speedy return to reasonable health as well as to your Lordships' House.

3.40 p.m.

Lord Clement-Jones

My Lords. I join the noble Earl, Lord Howe, in expressing our appreciation for this opportunity to debate health and home affairs issues today. My noble friend Lord Dholakia and I will be dividing our responsibilities in similar fashion. I am sorry that the noble Baroness is not present. I was going to suggest a controlled experiment because I noticed that she was battling with a heavy cold. Professor Warburton of the University of Reading has carried out some experiments and has found that enjoyment even in small doses boosts the effective of the immune system. We do not yet have any evidence of what effect speeches in this House have on the immune system but I was going to suggest that if the noble Baroness sat through the debate she might feel better at the end of it. It would depend on the quality of course.

It is significant that in the 50th anniversary year of the NHS we should be facing a major Bill to reform it. My own celebrations of the golden anniversary of the health service took place slightly early, in March this year, when at St. Thomas' Hospital across the river my wife Jean gave birth to our first child, Harry. As noble Lords will imagine, I felt very much at home at the National Childbirth Trust lobby across the way in Westminster Central Hall only today. I very much hope that Ministers will listen with some interest to what it has to say.

Especially in this anniversary year we need to be clear about what kind of health service we want to see for the next 50 years. This Government use the word "modernisation" at every opportunity. My noble friend Lord Rodgers pointed out earlier that the word of itself is entirely value free. We must be clear, therefore, about the underpinning values that will inform the NHS for the next 50 years. We can say "yes" to modernisation, but only if it leads to better patient care and a diminution of health inequalities. There needs to be greater public accountability over the commissioning of services, improvement of standards and greater consistency, but throughout, I believe, retention of the human side of medicine. Those will be the tests for my party of any proposals that come before the House.

We welcome many of the Government's intentions, particularly in the face of some of the disastrous 1991 reforms introduced by the previous government. In particular, we support the drive for quality with improved clinical governance and a new clinical emphasis on evidence-based medicine. We welcome the recognition that health inequalities must be tackled, leading to a focus on public health and preventive as well as hospital medicine.

We also welcome further resources being made available for the NHS, but we do not fool ourselves that Christmas for the NHS has arrived in quite the same way as the Secretary of State would have us believe. He is keeping extremely tight control over the purse strings, not least with the so-called modernisation fund. The Government's obsession with waiting lists has meant that more than £1 billion—10 times more that originally anticipated—is being spent on relatively minor operations. In addition, what the Government are failing to do is to look at the whole picture. There are still huge delays in people waiting for a consultant's appointment. Only after they have been seen, and it has been confirmed that they need an operation, do they actually appear on those waiting lists.

We welcome change in commissioning away from competition and towards co-operation, although in our view this does not go far enough. We will want to look carefully at the legislation. We believe that primary care groups and primary care trusts should be part of an integrated social services and health authority commissioning structure going beyond the partnership proposals produced by the Government. We are concerned about the cost of PCGs and PCTs and how they will operate. Management costs have been cut in health authorities at the same time as they are supposed to give support to setting them up. Will the PCGs and PCTs become too GP dominated? How will new patterns of care involving nurses and pharmacists evolve with this level of control? As it is, we are concerned about the timetabling for setting them up. In addition, much more clarity is needed over commissioning of tertiary care in areas such as mental health and oncology.

The new Bill will also deal with several aspects of clinical governance in the NHS. This is clearly a vital area if we are to avoid further Bristol cases. The Secretary of State has talked about, an integrated approach to the raising of standards". Yet there is considerable uncertainty, particularly among the medical profession, about the balance to be achieved between "clinical governance" and self regulation. There seems to be considerable potential overlap between the respective roles of the General Medical Council, the new commission for health improvement, the National Institute for Clinical Effectiveness, the hospital trusts, the Royal Colleges and the Audit Commission.

The medical profession is beginning to take the question of clinical governance extremely seriously. I welcome the profession's acceptance of the concept of revalidation for specialist hospital doctors. However, the GMC as a body needs to ensure that appropriate mechanisms are implemented as soon as possible. What of NICE itself, too, in terms of determining best clinical practice? I wish Professor Rawlins well, but so many hopes and expectations have been piled on NICE that it is difficult to see quite how he will do his job. How will he operate with a budget of only £9 million, the figure which has been widely quoted? I note Professor Rawlins' distinguished background but I hope that NICE will have a wide remit well beyond drugs and technologies and that it will also include other aspects of health, including the whole area of equity of access.

One of the great disappointments of this Government is their failure to grasp the rationing nettle and admit that rationing takes place in the NHS. As a result, there is a large hole in the middle of the NHS reforms. Viagra and Zenical are but recent examples which have made it quite obvious that the NHS cannot fund every form of treatment. But any clinician or health manager will tell you that rationing exists in all kinds of ways in the NHS. I am personally acutely aware of what difficult choices have sometimes to be made, but these should not simply be laid at the doors of doctors or local managers. We need to install a transparent system, such as a standing conference, which can openly debate priorities on a national basis.

We know of the huge problems involved with nurse recruitment. I welcome the assurance given on training places by the Secretary of State in his speech in the other place. He highlighted that new nurses are not necessarily as well equipped with the practical skills as they would like to be and he has asked the UK Central Council for Nursing, Midwifery and Health Visiting to look at this. The technical quality of our nurses, as a result of Project 2000, is, I am sure, excellent, but it is in the area of practical management and caring skills where I agree that the Secretary of States's initiative is needed. However, I feel that a highly skilled cadre of people who were persuaded that nursing was to have a more academic and technical content and an improved status have in many ways been sold a false prospectus. Any hospital doctor will tell you that nurses' pay is a disgrace. One said to me only last week that if pay was not raised substantially he doubted the future of the health service. I urge the Government to recognise in all their actions in the NHS the reality of that fact.

On the medical side, I can see a different set of problems. There is a massive shortage of doctors. The combination of the Calman training reforms and the new deal restricting junior doctors' hours to 56 means that continuity of care is provided only by consultants. The problem will be exacerbated by a reduction to 48 hours under the working time directive. Yet there is a bow wave of trained hospital doctors coming through the service for whom there are no consultants' jobs. The NHS urgently needs to increase the numbers of consultants but at the same time to re-define their role. This needs to be done ahead of the absurdly slow evaluation being conducted over three years. We may well need different categories of consultants to reflect the training that has been received as many of the new consultants may not be qualified to "stand alone" after full training.

On the public health side, we welcome the Government's acceptance of the link between income, family, social environment and health, and their commitment to health improvement plans and a partnership between local authorities and health authorities. The excellent Acheson Report has also tackled the priorities to be pursued. However, there are questions surrounding health improvement programmes and involvement of the voluntary sector and how primary care groups will relate to them. As Sir Donald Acheson pointed out, health improvement programmes will be the key way in which priorities and objectives for reducing inequities will be agreed. It is vital that the way in which these are drawn up includes input from the widest possible range of sources at local level.

In public health generally we need to recognise the realities of devolution to Wales, Scotland and Northern Ireland. If we have a mechanism through health improvement programmes, and perhaps, as Sir Donald has suggested, a new duty on public health directors to produce "equity profiles" for combating health inequalities, we also need to have new methods for co-ordinating information on best practice and standards across the whole of the UK, for example through a public health commission.

As regards the pharmaceutical price regulation scheme, this is an area where we shall look closely at the detailed proposals of the legislation. Is what is being proposed simply a stick to beat any recalcitrant pharmaceutical company in negotiations, or will a detailed scheme be proposed? We back the creation of a fourth hurdle in the existing scheme so that clinical effectiveness must be demonstrated; but there may well be a case for going further—while still recognising the contribution that UK pharmaceutical companies make to employment and the economy—and moving towards a price per product formula.

There will be debated on Second Reading in the Commons next week, and thereafter in the Lords, the NHS charges Bill referred to by the Minister. We are not yet convinced of the validity of this proposal. We believe that it is important at least to establish that those charges levied on behalf of the NHS by the CRU will not simply be clawed back by the Treasury. We need to establish how the bureaucracy of collection will operate. We believe that the estimate of costs for collection may well be optimistic. But if the new mechanism is being set up by the CRU, why not follow the logic of the Law Commission's consultation paper issued in 1996 in full? Why should not the Bill include reference to occupiers' liability insurance, employers' liability or product liability? Why simply stick to road traffic? Is not this a lost opportunity?

What of some of the non-events of the Government's legislative programme? Let us take the food standards agency. It is no secret that the Government's failure to include legislation in the Queen's Speech is a massive disappointment to many of us. My party fully supported the White Paper, its aim to provide proper protection for the public and its recommendations for proper enforcement powers for the new agency, which would be independent but subject to overview by the Department of Health. My party awaits a full statement from the Government on their intentions now that there is no prospect of a Bill in this Session.

A further blow for those of us who are passionate about food safety is the delay in bringing forward freedom of information legislation. Your Lordships may recall Sir Donald Acheson—the former Chief Medical Officer I have mentioned already—telling the BSE inquiry that information about possible BSE contamination of medical products such as vaccines had been withheld from him while he was Chief Medical Officer because of secrecy imposed by the present medicines legislation. It is clear that delay in bringing forward a freedom of information Bill will allow this dangerous kind of secrecy to continue. In the midst of a number of positive proposals for reform by the Government in the area of health, that is a serious blot on the Government's record.

3.54 p.m.

Lord Warner

My Lords, in rising to make my maiden speech, I am only too aware of Shakespeare's rather gloomy remark that, crabbed age and youth cannot bye together". Nevertheless I will risk making some remarks on the measures relating to children and young people in the Government's legislative programme.

I should at the outset declare an interest. Recently I became Chairman of the Youth Justice Board for England and Wales, established under the Crime and Disorder Act 1998. It will come as no surprise if I say that I support strongly the measures in that legislation for reforming the youth justice system. The board has begun the task of focusing hard on the new statutory aim of preventing offending by young people. Our emphasis will be on earlier intervention with youngsters who offend and trying to change their behaviour for the future. But the 1998 Act left some unfinished business. At present the youth courts do not do enough to help change offending behaviour by young people. In my view, the Government are right to want them to do more. I welcome the decision to bring forward legislation in this Session which will create a new sentence for youngsters convicted for the first time in a youth court; namely, a referral to a youth offender panel. These new panels will work with young offenders by drawing up a contract to include programmes and activities that will address the causes of offending behaviour.

This change is completely consistent with the new approach the Youth Justice Board is encouraging and that will be a feature of the local youth offending teams now being established across the country. I am confident that by the time these youth court changes are enacted, the local structures and programmes will be well advanced through youth offending teams to make these changes work well on the ground.

But these further legislative changes are only part of the wider reforms needed to tackle the problem of social exclusion presented by many of the troubled and troublesome youngsters who are the concern of the Youth Justice Board and youth courts. Social exclusion, of course, is not a topic that one immediately associates with this House, although perhaps familiarity with the concept will increase as this Session progresses. Indeed there has been a recent example in this year's State Opening of Parliament, when people turned their backs on Silver Stick in Waiting and the Gentleman Usher to the Sword of State and told them they were no longer wanted. That is the problem for many of the youngsters I am talking about. The world has turned its back on them. Typically they have been excluded from school, placed in public care or are homeless. Nearly 40 per cent. of young prisoners have been in public care. About two-thirds of young prisoners were unemployed and most of them have no educational qualifications. Your Lordships may occasionally trip over some of these youngsters as they sleep in shop doorways. Many have been victims of abuse and crime themselves. Many will form a large part of tomorrow's resident population of our prisons and our psychiatric hospitals.

It is to the enormous credit of this Government that they are trying to tackle the problems that many of these disadvantaged young people face. Initiatives such as the New Deal, behaviour support plans in schools, the anti-drugs strategy, the work of the Social Exclusion Unit and a more coherent family policy that supports parents and tackles children living in poverty do much to help. So, too, will the improvements, backed by extra resources, that are to be made for children in public care and the improved support they will get when they leave public care.

A former Member of this House, the late Lady Faithfull, was a formidable champion of the interests of children and young people. Today I would like to acknowledge her contribution. If she had been with us today, I am sure that she would have said that many of the disadvantaged young people I have been talking about need help and support as well as having their offending behaviour checked. This help and support has never been more necessary than when children are themselves the victims of crimes, sometimes within their own families.

That is why I welcome the Goverment's intention to legislate in this Session to provide more support and protection for children who are witnesses. As a former director of social services I have seen what some children involved in sexual abuse trials have had to endure in the courts. Too often, our pre-occupation with protecting the rights of defendants has caused the courts to treat children as witnesses very insensitively and to repeat through the judicial process the very abuse that they have already suffered. The result has often been that too many offenders go scot-free because prosecutions fail when children cannot face the ordeal of being a witness.

In conclusion, I hope that when this House comes to consider the youth justice and witnesses Bill in more detail, noble and learned Lords will give full weight to the needs of children as witnesses and the importance of reforming youth courts so that offending behaviour by young people can be tackled more effectively.

4 p.m.

Lord Ashbourne

My Lords, it gives me great pleasure to congratulate the noble Lord, Lord Warner, on his admirable maiden speech. He has wide experience, having worked in the Home Office and in social services departments. In the past he worked in the office of the noble Baroness, Lady Castle, who is in her place to welcome her protègè, if I may, with no disrespect, put it that way. I believe that when he worked in her office he was known as one of "The Three Musketeers"; the other two being the Home Secretary and Janet Anderson, MP. The noble Lord has a wide background of experience and I have no doubt that he will make some signal contributions to your Lordships' deliberations in the future. We offer him a very warm welcome to the House.

I must now apologise most profoundly. I regret that I shall not be able to stay until the end of the debate. I have a long-standing engagement with some people from abroad, and I shall have to leave before the end. However, I shall read Hansard most carefully to see what has been said.

I was disappointed that the gracious Speech contained nothing about the role and importance of the traditional family. The Government's recent consultation document entitled Supporting Families starts with these words: Families are at the heart of our society. Most of us live in families and we value them because they provide love, support and care. They educate us, and they teach right from wrong. Our future depends on their success in bringing up children. That is why we are committed to strengthening family life". I must declare an interest. I am chairman of the Lords and Commons Family and Child Protection Group, a Back-Bench group of parliamentarians from both Houses, formed some years ago because MPs and Peers were worried by attacks on the traditional family and the erosion of family values.

We strongly support the initiative of Her Majesty's Government in stating their support for marriage. Indeed, paragraph 8 of the introduction to Supporting Families states: But marriage is still the surest foundation for raising children and remains the choice of the majority in Britain. We want to strengthen the institution of marriage to help more marriages to succeed". It is in the family that we learn the virtues of self-discipline, selflessness, loyalty, moral discrimination, hard work, planning for the future, integration and socialisation. So the traditional family is not a lifestyle option but the fundamental building block of society. A stable society needs strong families centred around the marital bond. Even more importantly, the family is a vital line of resistance against totalitarianism. So I am disappointed that Her Majesty's Government are reluctant to defend the traditional family unit more robustly.

The gracious Speech ends with a prayer that the blessing of Almighty God might rest upon our counsels. I hope, trust and pray that Almighty God will answer that prayer. I pray that He will continue to give this House the courage to stand up to the Government when they are wrong. That is our constitutional duty before God, the monarch and the people of this land. It is a duty from which we must not shrink.

4.4 p.m.

The Lord Bishop of Winchester

My Lords, I too congratulate the noble Lord, Lord Warner, on his maiden speech and on his important observations, made from his considerable experience. I had hoped to be able to invite your Lordships to join me in welcoming the right reverend Moderator of the General Assembly of the Church of Scotland and his party, but he has just left the seats below the Bar.

I want to refer to two paragraphs in the gracious Speech, both the remit of the Secretary of State for Home Affairs. First, there is mention of a Bill to modernise the law on immigration and asylum, following the White Paper, Fairer, Faster and Firmer. Like the Church of England Board for Social Responsibility, and following a debate in the General Synod last November—the results of which were notified to the Secretary of State—I welcome many of the Government's principles and intentions. I welcomed also many of the proposals set out in the White Paper, including the points clearly made at the beginning and throughout concerning the strengths and benefits that this country has received from immigrants and those who have been granted asylum over the years, especially in recent years. I welcome the recognition of the injustice and cruelty of many aspects of the present system which is admitted to be chaotic and to compromise a network of unsatisfactorily linked arrangements. I welcome the sense of the need to take steps to make the arrangements less open to abuse, some of which undoubtedly is professional and systematic. I welcome the commitment to make the whole range of procedures fairer and faster. That is urgent. Although it would destroy the alliteration, I would prefer to use a phrase like "more just". The word "firmer" smacks uncomfortably of populism.

However, there remain deep concerns about the White Paper among many organisations active in this area, including the Church of England Board for Social Responsibility and the Churches Commission for Racial Justice. I want to highlight a few of those.

A crucial point is that clearly all the processes should be undertaken faster. The enormous backlog has to be dealt with—and dealt with as quickly as possible on every possible ground. However, will sufficient staff be provided, especially in the next few years, to enable that backlog to be dealt with properly, on which so much else in the White Paper hangs? Will the staff be trained sufficiently in many respects, including the recognition of trauma, and even torture, and in racism awareness? Will the staff be of the appropriate gender? When "faster" is the watchword—and justifiably so—are there points at which the procedures may have to take place so fast that it may be difficult for those concerned responsibly to gather the material that will be needed, especially when those at the heart of the matter may be traumatised?

We need to look hard at the conduct and process of the first interview on arrival, about which many of those working in that area have the greatest anxieties at present. We need not only accuracy and efficiency, but also compassion and justice in what, understandably and yet often destructively, remains a culture more of disbelief than of open-mindedness.

What happens if those most in need of asylum, as well as those most abusing the system, have been turned back by more and more efficient airline liaison officers at points of departure? It matters not only where the airline liaison officers are located, but also where they are not. There are some countries where it would be regrettable if such people were located and worked too efficiently.

I appreciate the reasons for proposing in the White Paper a largely cashless system, one that runs on benefits in kind. I appreciate, too, the wish to spread those awaiting consideration under these processes around the country, out of London. However, I wonder whether the White Paper has taken sufficient heed of the administrative costs of the new procedures and, still more, their possible effects on the welfare, self-respect and just treatment (and the speed and accuracy of that treatment) of those who will be the subject of asylum and immigration procedures. There are potential difficulties in regard to access to lawyers who are unreasonably congregated in London. There are difficulties in the locating of vulnerable people in out-of-the-way localities, in estates and areas already under pressure for other reasons, where there is not adequate support and from which people may easily drift back to London and become vulnerable through exploitation, or worse.

Lastly, in relation to this section, there is a range of questions surrounding detention. The White Paper speaks admirably of a presumption in favour of temporary admission or release. But there remains, especially in Chapter 12, a strong emphasis on detention. More than a whiff of that emphasis is caused by a continuing sense that detention has to be there as a deterrent and for a wide range of categories of asylum seekers. There are founded, documented anxieties about how deeply unsatisfactory are the present regimes in detention centres, firmly fixed as they are within the prison system, even if some are not strictly speaking prisons. I shall not go into detail, but those who know most about this aspect are very discouraged, particularly by Chapter 12.

There is a great deal to be supported in regard to the Government's will, intention and principle in this matter and many of their proposals. However, there are serious questions to be raised, especially in regard to the resources to be made available for the education and training that will be offered to the human elements in those resources. It is important to state that if those resources are not made available, the cost, which will be considerable, will continue to be suffered by those who are caught up in the system, many of whom are profoundly and multiply vulnerable.

I note the paragraph in the gracious Speech: Parliament will be given an opportunity to vote on the age of consent. The Bill will strengthen the protection of young people from abuse of trust". I warmly welcome the latter in principle. I am grateful for the opportunity given to many organisations and individuals, in the Churches among others, to participate in the Government's two linked studies which will inform this section of the Bill. I look forward to being able to study it in detail.

The Church of England, along with the other Churches and major workers with children and young people, recognises the deep seriousness of this range of questions. It has done a great deal of work on its own processes in recent years, and continues to do so. I regret, although I was expecting, the former leg of that paragraph relating to the reintroduction of the Bill to lower the age of consent. I anticipate that I am by no means the only Member of this House who is no more convinced now than I was in July that this is a wise or caring proposal. I do, however, appreciate the Government's difficulties following the ruling of the European Court of Human Rights in the Sutherland case. Nevertheless, I ask that when this part of the Bill comes before both Houses, those who bring it forward and support it take the trouble to argue their case and respond to the arguments and concerns that I and many others have raised.

When the matter came before the other place and this House in June and July, there was much use of admirable and important words and concepts such as "justice", "discrimination", "anti-discrimination", and "modernisation". All are critically important concepts and activities. However, it is extremely important that we do not allow our minds and critical faculties to be numbed when certain words which have become slogans on many sides of our society are used. I hope that we and those bringing forward the legislation will not allow our senses to be relieved of the need to weigh and respect evidence in these matters, to respond to argued cases and to recognise and evaluate social trends and influences upon our society, particularly in relation to those growing up within it.

Finally, notwithstanding the criticism of the Bishop of Edinburgh in the November edition of the Parliamentary Monitor, I do not believe that either your Lordships or the public would want those who are called to sit on these Benches to retreat from our responsibility, in this or any other matter, to seek to offer advice, whether on the side of change or on the side of the status quo, on what we discern to be, as the Prayer Book puts it, godly government.

Lord Hunt of Kings Heath

My Lords, before we move to the Statement on local government revenue finance, I should like to take this opportunity to remind the House that the Companion indicates that discussion on a Statement should be confined to comments and questions for clarification. Peers who speak at length do so at the expense of other noble Lords.