Health Protection Agency Bill [H.L.]

HL Deb 05 January 2004 vol 657 cc33-54

4.20 p.m.

Second Reading debate resumed.

Lord Turnberg

My Lords, I am afraid that I have to bring us back from Libya to the Health Protection Agency. The creation of the HPA clearly is a vitally important initiative. It has focused attention on the need for a comprehensive system to protect the population from infectious diseases—on which 1 will focus—and on other environmental hazards.

If ever there was a subject for us to be taking seriously this is it. Almost every time the Government are blown off course by unexpected events, often it turns out to be some infection or other—be it AIDS or SARS or even flu or CJD or bio-terrorism with anthrax and the like. If it is not human infection, it is animal infection, such as mad cow disease or foot and mouth disease. All those infections created great anxiety and cost billions to the Exchequer, which had not been calculated for, quite apart from the suffering that they caused.

No one can doubt the importance of the HPA. Here, we have a chance to enhance our capacity to deal with all those threats. But we must get it right. The least we might expect is an improvement on what went before, not that what we had was so deficient. Here I express an interest as past chairman of the board of the Public Health Laboratory Service, which I believe was regarded widely as a model of an integrated system. The epidemiological analysis was and is carried out by the disease control centre, from which all the advice for action to practitioners in the field emanates. It is closely linked to a laboratory network around the country where all the tests on patients and samples was done and the results are reported to the centre.

That worked well. For example, even the director of CDC Atlanta in the United States lauded and envied our system, and we led the field in Europe. I am therefore not so starry eyed as my noble friend the Minister that all this has happened since the HPA came into being. But, of course, it was far from perfect. I had the pleasure to serve on your Lordships' Select Committee on Science and Technology under the wise chairmanship of the noble Lord, Lord Soulsby. Its report, too, emphasised where some of the difficulties lie and where we should expect the HPA to take up the cudgels.

The two major problems that beset the HPA's predecessors and which must be addressed if it is to succeed were, on the one hand, starvation of funds, so that they were unable to do the jobs that they desperately wanted and needed to do, and, on the other hand, a degree of interference and micro-management by the Department of Health, which was hard to bear for much of the time and sometimes became intolerable.

What should we be looking for in the Bill? First, it must ensure that the HPA has the capacity to deal not only with current known threats but also with sudden surges of infection outbreaks. Hitherto, there have been many occasions when capacity was sorely stretched and, sometimes, even overwhelmed, even though we know that we can expect the unexpected every year.

The HPA needs a first-rate IT system so that information about the nature of outbreaks—for example, where they are occurring or linking an unusual case in one part of a country with one in another—is transmitted rapidly to those in the field who have to trace sources of outbreaks and take action. An effective IT system is the vital nervous system for the HPA, which is so dependent on rapid information flows. Currently, its systems are nowhere near as good or as integrated as is necessary. That is despite repeated requests for funding by the HPA's predecessor. We must ensure that the HPA is not similarly deprived.

The HPA needs resources to invest in research and development. It is heavily dependent on new technologies and techniques to keep ahead of infections that are constantly evolving and changing. I am concerned that research is mentioned only tangentially in the Bill. Greater emphasis must be put on education and training too. The HPA must have the capacity to engage in international collaboration activities as well as parochial UK activities. Viruses and bacteria do not seem to need passports.

All those activities are self-evident; some are indicated in the Bill. But those requirements have been obvious for years. The major reason that they have not been achieved as well as they should is because successive government policies have diverted funds to front-line clinical activities, such as waiting list initiatives and the like, and away from public health. Some people might think that the £50 million to £60 million per year provided by the Department of Health for the PHLS—which, interestingly, contrasts with the £170 million that we heard about for advertising—is so small as to suggest an unthinking disregard for the dangers that come from neglecting our defences against infection. But that was and, I believe, still is the level of support.

There is no hint of more funding. Indeed, the Chief Medical Officer has clearly stated that the change to the HPA is to be achieved without additional funds, which is reiterated in the Explanatory Notes to the Bill. The Bill suggests that the Secretary of State will take note of how much external support the HPA will earn when determining its government grant, so the more that it earns externally, the less the Secretary of State will need to provide. That does not seem to be entirely satisfactory.

One aspect of funding that is not mentioned in the Bill is that which primary care trusts now have to provide. All those laboratories previously run by the PHLS and now taken over by NHS trusts must be funded for public health functions by the PCTs. All the surveillance work, the very specialised types of testing and rapid reporting are the responsibility of PCTs. But it remains to be seen how seriously those responsibilities will be taken when they are sorely pressed by more acute clinical demands. Individual patients always take precedence over the more nebulous need for public health protection.

I turn now to the relationship between the Department of Health and the HPA. Is it likely to be anything like the enviable relationship of government to the Food Standards Agency? That would be a marvellous model. Unfortunately, there is nothing in the Bill which suggests that the HPA will be allowed to get on with the job without undue interference by the department. Of course, with a subject of such overwhelming national importance, the Government must be involved and must be informed. There is no doubt about that. But the Bill is absolutely stiff with directions by the Secretary of State. Does it need all this close monitoring? The HPA is full of highly dedicated, highly expert and responsible people. I know them well; they were all on the PHLS. I cannot believe that this degree of monitoring and managing can be justified. The HPA deserves better.

Perhaps I may say what I believe is needed in the Bill. First, there should be less emphasis on direction by the Secretary of State. Secondly, there should be greater emphasis on the role that the HPA should have in research and development and in education and training. It should be required, rather than simply permitted, to participate in international collaborative activities of importance to the UK and elsewhere. Of course, the HPA must be adequately funded for all those roles.

The HPA should also be given the facility to influence PCTs, perhaps through their directors of public health and through the memoranda of understanding—if they have sufficient teeth—so that they take seriously support for public health laboratory functions. Further, the Bill should make it obvious that the Secretary of State cannot penalise the HPA by cutting its funds if it earns more from other sources.

I finish by saying that, ultimately, the HPA will be able to meet all these vital responsibilities only if it is adequately resourced. It will struggle to achieve all the welcome principles embodied in the Bill unless that is the case. Here is an opportunity to make a real difference from what went before.

4.30 p.m.

Lord Soulsby of Swaffham Prior

My Lords, this debate follows closely the publication of the Science and Technology Committee report, Fighting Infection, which I had the honour to chair; the Government's response to that report; the debate on it in this House; and, again, the Government's response. All identified that the Health Protection Agency is an important and urgent development.

This debate on Second Reading is the time to identify the most important issues that have surfaced from individuals and organisations which have a stake in the success of the Health Protection Agency. Additionally, it is time to address those issues that were identified by the Select Committee and others, but which have not been given the emphasis one would have hoped for in the Government's response to the committee report.

It has always been envisaged that the HPA would play a major role in bringing together the various strands in the provision of health services. Indeed, in reply to the debate on the Select Committee report, the noble Lord, Lord Warner, stated that, the Health Protection Agency is the first of its kind in the world. Its creation is an essential, ground-breaking development for the protection of health in this country".—[Official Report, 8/12/03; col.618.] We hope very much that that will be the case, but it is essential that this ground-breaking development does not founder for want of appropriate funding. I should say that alarm bells began to ring when I read the Explanatory Notes, in particular paragraph 32, which states that: The Bill does not entail additional public expenditure or changes to public service manpower". That was repeated by the Minister opposite this afternoon.

With respect to the first recommendation made in the Select Committee report, the Government agreed that there was room for the improvement of management and indicated that the integration of expertise would enable the Government to get more from the same resources not only as a result of economies of scale, but by building synergies between different disciplines. Precisely what is meant by that is not clear, but if the HPA is to do its work well—and all welcome and wish it well in this respect—then wishes and welcomes are not sufficient and there must be a capability of launching the HPA in such a manner that it can deal with what is expected of it.

Previous speakers have indicated that much needs to be done, while in opening the debate the Minister remarked that much has already been done. An example of a proposed important area for the HPA is for it to take specific and primary responsibility for the integration of surveillance related to human, animal and food-borne infection. It is possible that that can be accomplished under subsection (2) of Clause 4, headed "Functions: supplementary". It allows the agency to do, anything which is thinks is…appropriate for facilitating…the exercise of its functions". I regard that as a particularly wide remit for any organisation. A clear statement of the respective roles of the HPA and the Department of Health as perceived by the department would be beneficial, as well as of the responses of the department to recommendations made by the HPA. I hope that that would be a two-way process. This is important in view of what is expected of the HPA.

Contrary to the stated expectations of the Government, much of what is envisaged will entail an increasing level of manpower, and where there is a consequent loss of manpower in seeking to meet those aims, it is unlikely that it will be achieved without any further cost whatever. As the noble Lord, Lord Turnberg, pointed out, there are surges of expectation and necessities to be met in health situations that must be accommodated. One of those is bio-terrorism, We do not know where it may hit, but we must be prepared. Obviously such needs cannot be met at the expense of reductions elsewhere. The agency must be capable of meeting surges of action.

One development that would fit into the concept of integration of expertise is that of infection centres. The proposal was not given much support in the Government's response, but it has received wide support elsewhere, in particular from the Colleges Committee on Infection and Tropical Medicine. The point is made that all areas should have access to a critical mass of expertise in the prevention and management of infectious problems. The Government would prefer to see the formation of looser networks, as suggested in the Department of Health's response. However, we share the view of the British Infection Society that the infection centre concept is the optimal way to develop surge capacity able to deal with acute demand, as was adequately demonstrated recently with SARS, West Nile fever and influenza.

One area of particular concern is that of vaccine research, development and production The Government's response to the House of Lords inquiry agreed that there has been a significant deficit in the UK capacity for vaccine production. A secure supply of vaccines in the event of a national or global pandemic is essential. Previously, the HPA Porton Down facility was identified as an essential component of preparedness. Further, the HPA has commented that it would be imprudent not to have a vaccine capability there. The Select Committee recommendation on this point has yet to receive a fair wind.

One wonders whether the wide range of functions and capabilities listed in Clause 4 would allow the HPA to go ahead with Porton Down vaccine development, or would the HPA still have to be a supplicant to the Department of Health for funding for this facility? The need for a flu vaccine to meet a pandemic situation is well illustrated by the present position in the United States, where the national supplies of flu vaccine are insufficient to immunise target groups. Comments made on 12 December last in the New York Times include: For the first time in recent memory there may be less vaccine than people want and certainly far less than would be needed to vaccinate all 185 million for whom the vaccine is recommended or suggested". One topic which has become prominent recently is that of the supply of academic clinicians and, in particular, medical microbiologists. I know that this question was put to the Minister during our previous debate on these issues. He stated then that action was being taken and it is to be hoped that some attention can be paid to it under one or other of the rubrics of the Bill.

I make a final comment on a matter referred to by the noble Lord, Lord Turnberg; that of the status of the HPA. It is important that this is clarified with respect to the Department of Health and the Government. We have recommended that the HPA should be considered an independent body, as is the case for the Food Standards Agency. I understand that this concept is under consideration and perhaps the Minister can comment on the progress of those deliberations.

We all believe that the HPA is a crucial development for the provision of healthcare across a wide spectrum of activities. It has much important work to do. We must get it right. For this to be accomplished, there must be provision of appropriate funding and facilities to allow it to work.

4.40 p.m.

Baroness Masham of Ilton

My Lords, the first piece of legislation to be discussed by your Lordships in the new year is the Health Protection Agency Bill, which I consider to be of the utmost importance. I was concerned to read in the Explanatory Notes that from April 2003 the agency will be created as a special health authority and that subsequently, when legislative time allows, as a non-departmental public body which will be able to carry out a wider range of functions. Surely with something as important as this Bill, the Government should be able to make time available as a priority when they believe the need is there. My concern is the importance that the Government are giving the Bill. Perhaps the Minister will give it a rating out of 10—with 10 being the most important.

The HPA will have three main functions relating to health: the protection of the community against infectious diseases and other dangers to health; the prevention of the spread of infectious disease; and the provision of assistance to any other person who exercises functions in relation to these matters.

The HPA is also given powers in regard to radiation protection and the publication of information on such matters. A requirement for co-operation with other agencies is also included in the Bill. With new and continuing threats from infectious diseases, environmental hazards and the need for health emergency planning, this must be a top priority.

With so many vital duties included within the Bill—such as the provision of services in the event of the deliberate release of chemical and microbiological agents and poisons—I hope that other health issues which may not seem so dramatic will not be neglected. Terrorism is causing world-wide alarm, but we must not downgrade the urgency of tackling the disturbing rising rates of infection.

Under much pressure, the Government have developed a sexual health and HIV strategy and an infectious disease strategy. The pressure must be kept up to try to make hospitals and the community safer for vulnerable people. Sloppy hospital hygiene and complacency over the danger of MRSA have now become a fear for people needing invasive procedures. Will the HPA be able to recommend standards to help control infections?

Sometimes it seems that people working in public health have not been given the appropriate status for the important work they do. The Bill may well increase the workloads of doctors and nurses working in public health as data collection for the purposes of surveillance of the spread of disease is vital. But if the job is to be done properly it will take more time and more personnel. It must be done accurately.

Infectious diseases currently present a real threat to the nation as a whole. Although there was a reduction in the number of people with infectious diseases in the latter part of the 20th century—largely thanks to the increased use of vaccinations and antibiotics—recent years have seen a rise in the prevalence of certain diseases. In particular, levels of infection from tuberculosis and HIV/AIDS, which had been stable or in decline, have seen a recent increase. The HPA is particularly concerned that treatments for diseases, including cancer, reduce the strength of the immune systems of certain individuals to infectious disease.

With modern air travel the countries of the world are now very close to each other. This was highlighted by last year's outbreak of SARS, which originated in a district in China where humans live close to animals and fowls, such as pigs and chickens, and the danger of the disease being spread by civet cats seems once more to be a threat. Given the problem of TB in cattle, BSE, CJD, and many other infections which can be passed from animal to human, the problem of leptospirosis—Weil's disease—which is passed by rats, and rabies in dogs and foxes, will there be a veterinary section of the Health Protection Agency?

I am told that in May this year there is to be a government veterinary surveillance strategy review. Over the years there have been some deficiencies in surveillance. Is it not the case that many other countries regard this requirement as fundamental?

Some noble Lords may remember Baroness Walton, who, a few years ago, died of CJD. She was a great loss to your Lordships' House. There is a need for research and development in so many of these serious conditions.

In a recent case in America, quick surveillance traced where a cow with BSE had come from and quick quarantine of the farm took place. Can the Minister assure the House that our surveillance and tracing policy will be improved? If the noble Lord does not know the answer in regard to my question about the veterinary section of the HPA, perhaps he will write to me.

It seems as important to have a good IT system with which to pass information round at local, regional and national levels in the veterinary world as it is in the medical and human systems. Given the increasing resistance to antibiotics it is vital to have a reliable monitoring system in place and good overall co-ordination. What assurances can the Minister give that, given its broad scope, the agency will not become submerged in red tape and that responsibilities will not be confused?

As the agency was formed following the amalgamation of a number of different units there have been problems in relation to working practices. Difficulties have been experienced with the establishment of common systems, with ensuring that there is appropriate accommodation for all and with the creation of a unified information technology system. It seems that the Government have some sorting out to do to ensure that there is smooth and efficient co-ordinated management before the HPA becomes a non-departmental public body.

In ending, I should like the Minister to explain what part the Health Protection Agency will have in blood safety. Just before the House recessed for Christmas, your Lordships were given a Statement on a case of CJD from a blood transfusion. Since then, there has been a case of BSE in a cow in the United States. Many blood compounds are imported from the USA, as they had been considered safer. It may be that blood, which is vital to save lives in many cases of accidents and operations, could be made even safer after this new development. What is the Government's view on synthetic blood?

With so many changes in the National Health Service and so many different bodies doing different things, perhaps the Government would give some publicity, so that the public understand who is doing what. I hope that your Lordships will agree with me that the Bill needs careful scrutiny to see that we give the population of England and Wales the very best health protection.

4.51 p.m.

Lord Chan

My Lords, like other noble Lords, I welcome this Bill to establish the Health Protection Agency, but with some worries about the Bill as presented today. I was especially impressed by my experience of working with the agency's communicable infections directorate. That came about because of the inordinate delay of more than four weeks before a ministerial Statement was made about SARS in the United Kingdom, at the end of April 2003.

In early May 2003, a month after the agency came into existence as a special health authority, I had the opportunity to work with the HPA on SARS. Professor Angus Nicoll, director of communicable infections, came to see me on 6 May because of my Written Questions about advice for Britain's Chinese community and my concerns about the inappropriate quarantine of Chinese children in boarding schools. That evening, the noble Baroness, Lady Masham, led a dinner-hour debate on SARS and tuberculosis, in which a number of noble Lords took part.

I outlined my concerns in Hansard, vol.647, No. 86, saying: In Britain we have had only six probable cases, and all have recovered. However, high levels of fear are present in the Chinese community, particularly as they watch satellite television from Hong Kong and erroneously assume that precautions recommended there, where SARS infection is still active, should be implemented in Britain".—[Official Report, 6/5/03; col.1031.] At that time, fears of SARS had also drastically reduced the number of diners in Chinese restaurants in London's Chinatown.

A week later, I met two members of Professor Nicoll's department working on SARS, and we discussed a draft of a press release for the general public containing information aimed at the Chinese community. A further draft press release was written after more discussions with people in London's Chinatown community, and published on 23 May 2003.

That experience convinced me of the need for the Health Protection Agency during an outbreak of an infectious disease, even though we in the UK were not particularly affected. It demonstrated the value of an independent national agency that could give advice to the NHS in an emergency. Hospitals and primary care staff were assisted on the clinical diagnosis of patients and isolation procedures. The HPA also provided appropriate information for members of the public, particularly people who had been in countries where SARS was spreading.

In April 2003, as the Minister has said, the HPA sent public health specialists to centres in countries where SARS was epidemic in order to study infection control

measures, particularly in Beijing, Hong Kong and Singapore. That was important because of the fears generated here, in the Chinese community, and the scaremongering that arose about people carrying SARS from affected countries into the UK.

After the SARS outbreak subsided in the summer, I had another meeting, in mid-July, with a team from the HPA, to consider community research in case of a recurrence of SARS in the winter. Funding for that research had to be generated from outside the HPA, but no indication was given whether the NHS would contribute. Like the noble Lord, Lord Turnberg. and others, I am concerned that funding for research and development in the HPA is still inadequate.

It is significant that a new case of SARS—the first since July 2003—was diagnosed last week, and the diagnosis confirmed today, in Guangzhou, southern China, where the first cases of SARS were reported in 2003. My concern is whether the NHS, particularly in primary care, is today better prepared to deal with a SARS outbreak than it was 12 months ago.

Clearly, the Health Protection Agency is essential for the maintenance of the public's health. The HPA's efficiency is increased by its regional centres in England. The downside of the current arrangements, including the two-part implementation of the restructuring of the HPA, has been the upheaval of staff in its regional centres. In addition, the primary care trusts are expected to fund the work of the regional centres of the HPA, but many primary care trusts are struggling with debts. Further, public health units in primary care trusts are also small and fully stretched in coping with the issues of health inequalities. Therefore, there is an air of crisis management in public health in primary care trusts, especially in parts of the north west, where the HPA is expected to collaborate with the primary care trusts on issues such as surveillance, diagnosis, management and control of outbreaks.

With such a wide-ranging agenda, it is unlikely that the HPA can be expected to work well without the prospect of additional funding. If the HPA is to be independent and effective, the Bill is to be welcomed; but if it is to be involved in the community where protection is expected, it must be allowed to function with adequate resources.

4.57 p.m.

Lord Clement-Jones

My Lords, this has been an extremely well-informed debate. Each noble Lord, in his or her own expert way, has most helpfully cast a spotlight on different aspects of the Bill, dispelling any notion that it is simply a legal formality. Talking of spotlights, this House in the past month has emphasised the importance of good microbiological surveillance and infection control—in the debate on the Science and Technology Committee report, Fighting Infection, through government reports, such as the Government's response to that report and the Chief Medical Officer's Winning Ways report on reducing healthcare-associated infection. Before breaking for the Recess, we had the Government's Statement on a suspected case of vCJD infection, which the noble Baroness, Lady Masham, mentioned, which could have been passed on through a blood transfusion.

There are other major challenges. The noble Lord, Lord Fowler, highlighted in his extremely interesting speech the current crisis in sexual health. In addition, we have a TB crisis in some areas of the country. The test of the Bill is whether it will ensure that the new agency is up to those challenges and whether it will help the agency to have the powers and resources to carry out its mission of disease prevention and control, strengthening its ability to address emerging threats and public health emergencies.

One key consequence of the Bill, which we on these Benches thoroughly support, is to bring together the HPA and the NRPB—the National Radiological Protection Board. We believe that the incorporation of the CAMR—we must now call it HPA Porton Down, I think—and cementing the partnership that already exists between the HPA and the NRPB should ensure that the HPA can comprehensively deal with public health threats from terrorist acts. But the reality of the Bill is that the HPA is already in existence and its progress can be assessed. The HPA is now eight months old. As the Minister emphasised in his opening speech, it has been operating as a special health authority since April 2003.

The Minister was extremely upbeat in his statement about how the HPA was operating, but according to the chief executive, Dr Pat Troop, although the agency has progressed significantly in a short time, much work still needs to be done to create a single organisation. So we should not be complacent about the way in which the agency is taking shape.

It is important that the Health Protection Agency does not lose any surveillance capacity or its ability to respond during the process of giving it more independence. It is vital that there is cohesion in key areas as it attempts to bring in and merge its various component organisations, such as the PHLS and the CAMR. I welcomed the Minister's tribute to the PHLS, and not simply because the noble Lord, Lord Turnberg, for whom I have considerable respect, is here. It performed an extremely valuable function. It was not the failure of the PH LS that gave rise to the Getting Ahead of the Curve proposals, but a desire to build upon existing success.

The HPA published a five-year plan in August last year and identified no fewer than 12 strategic goals. That is a very ambitious programme. The very notable first goal was to reduce the impact of infectious diseases. This is quite a formidable list of strategic goals, but particularly welcome was that of providing the public with authoritative and impartial information and advice. The PHLS did that extremely well for professionals and opinion-formers such as myself. However, I very much hope that the HPA will extend that role, and when I come to talk about resources, that will be a significant aspect.

Any purveyor of information must be trusted. I have considerable reservations, as has the noble Lord, Lord Fowler, about the Government's ability to hold back information and insist that the HPA does not deliver certain information. I have severe doubts about whether the public will trust the HPA if there is a hint of a suspicion that it is holding back information about particular situations.

Given that, it is the first goal which continues to attract considerable attention, especially in the context of our NHS trusts—the issue of healthcare-associated infection. If the HPA can co-ordinate efforts across the board to reduce the number of infections acquired in hospitals, it will be a notable and welcome achievement. But there has for some time been a major crisis regarding hospital-acquired infection. The noble Baroness, Lady Masham, made the case extremely well. My worry is that many health professionals in the NHS seem resigned to MRSA as a fact of life. That seems deeply worrying.

What is the truth of the matter? The Government seem to publish a new strategy on dealing with hospital-acquired infection every few months. The last one was in December. One has only to look back at past Department of Health press releases. One issued on 9 June 2003, for instance, said: The Chief Medical Officer Professor Sir Liam Donaldson is spearheading a new Government drive to tackle healthcare associated infections …particularly those acquired in hospitals". Another issued in December 2003 said: Health Secretary John Reid today published plans for a crackdown on healthcare acquired infections, including antibiotic-resistant infections—so-called superbugs". Holding these up to the mirror, one would find it very difficult to see much difference in what actual strategy was being proposed. So what is new? Perhaps the Government should spend some time not simply issuing good PR about how they plan to tackle MRSA and other hospital-acquired infections but making sure that their plans were implemented. I am sure, and I hope, that the HPA will have a considerable role in that process.

Although the HPA will have many significant advantages because of the way in which the various bodies are being brought together in addressing a wider area of public health issues, we on these Benches question, and continue to question—as the noble Lord, Lord Chan, did—the wisdom of transferring the PHLS microbiology laboratories across to NHS trusts last year. The excellence of the PHLS has long been envied by countries that lack such a system, including the United States. In the US, federal agencies such as the centres for disease control have relied on individual public health laboratories in various states and cities for information, many of which have outdated facilities and capabilities. Now, just when we are hiving off these microbiology laboratories, public health officials in the US are looking to create a nationwide system that would reduce the current fragmentation in their own network.

We need to ensure that we are not sacrificing high levels of excellence or creating a fragmented, unresponsive system as a result of giving public health laboratories to the NHS trusts. Throughout this debate, noble Lords have expressed concern, as did the Select Committee, regarding NHS laboratory funding, specifically the point that PCTs may fund microbiological testing at meagre levels that maintain the laboratories but do not allow them to thrive and develop. Careful observation will be necessary to maintain the high standards we enjoyed with the PHLS.

Last month. the noble Lord, Lord Warner, said: Steps have been taken to ensure that all the laboratories transferred to NHS trusts are appropriately resourced and motivated to continue to meet their public health responsibilities". My Lords, how? The noble Lord went on to say: We intend that standard national operating procedures will be put in place throughout the NHS microbiological pathology service so as to improve quality and ensure consistency of reporting arrangements". —[Official Report, 8/12/03; col.617.] Should these not be in place by now?

In the Government's response to the Select Committee, we learnt that a new inspector of microbiology is to be created, who will eventually come under the CHAI. This seems a rather strange appointment to make. If those laboratories were still within the HPA, there would be no need to appoint an inspector of microbiology. Is it not a pure fix that the Government now finally recognise that, having deconstructed a perfectly satisfactory network and put it into the NHS where it will have the possibility of fewer funds, they now need a regulator, an inspector, to make sure that the whole system does not go pear shaped? That seems to be a patch that the Government have had to create because of the flaw in their own policy. I very much hope that the Government will think again before they go full steam ahead with that particular proposal.

Evidence that laboratories have received adequate resources and maintained high quality should be gathered and made available as soon as possible. If the Government plan to carry on with the inspector of microbiology, I hope that the remit of that inspector will be wide enough to ensure that it relates to resourcing as well as to the clinical functioning of those laboratories.

There are other issues. Noble Lords have raised some very important ones regarding resourcing. The RCN supports the Bill but it has raised issues of human resources, such as the limited availability of already overstretched public health nurses and the new system's reliance on nurses to report unusual incidences of disease.

Today noble Lords raised fundamental financial issues, particularly the noble Lord, Lord Turnberg. The Minister said that no additional resource would be provided for the HPA, as though that were a great virtue. What assurance can the Minister give that the HPA's corporate plan will be fully resourced and that it will receive adequate resources to put that corporate plan into effect? What answer is there to the questions of the noble Lord, Lord Turnberg, on IT and R&D?

We on these Benches support the Bill in principle. However, as the noble Lord, Lord Fowler, pointed out, there is a wider political dimension. Public health with all its many challenges needs to be given much greater importance. We have not had a senior Minister for public health since Tessa Jowell. As public health involves so many different policy aspects, there is even a good case for a Cabinet Minister of public health who has the authority to work with other government departments. Furthermore, the Minister of public health should, as the noble Lord, Lord Fowler, suggested, be obliged to make a public response to the HPA annual report.

Much mention has been made in the Government's response to the Fighting Infection report to a review of public health law. Not only is this important for disease registries—the noble Baroness, Lady Finlay, was absolutely right to highlight their importance—but also the HPA will be central to any new powers. We have been promised a review of public health law for some time. Can the Minister now give more details of the review? When will it start? What will its timetable be?

Finally, a couple of extremely pertinent questions were raised regarding the nature of the HPA. I refer to the level of independence of the HPA. As a number of noble Lords asked, will it have the same status as the FSA, or will the Government fall again into the trap of micromanaging an agency, as the noble Lord, Lord Turnberg, fears? The noble Lord, Lord Soulsby, raised the very pertinent question of whether the HPA will have a vaccine development capability. Along with a number of other noble Lords, I am being lobbied on that issue to an increasing extent. I have considerable concerns about our vaccine development capacity. Is the Minister convinced that our current arrangements are adequate for our needs? I look forward to hearing the Minister's reply.

5.12 p.m.

Earl Howe

My Lords, this debate has been an interesting and worthy start to our proceedings in 2004. In common with other noble Lords I should like to express my thanks to the noble Lord, Lord Warner, for the clear and helpful manner in which he introduced it. As he said, we are dealing with a Bill of considerable importance and underlying substance, to which from these Benches I am happy to extend a general welcome. However, the style of that welcome has to be somewhat cautious. While the Bill may not exactly deliver us into the realms of high political controversy, it would be odd if there were not features of it which caused us a degree of hesitation and, indeed, disquiet. I shall come to those shortly.

In looking at a Bill of this kind it is helpful to set the scene, as the Minister did. As might be expected, the scene from where I am standing looks rather different from the one described by the noble Lord, Lord Warner. Looking at the wider picture I would be the first to acknowledge that in certain areas the Government's public health record has been quite good; perhaps the best examples of that being the vaccination programme against meningitis and the immunisation of vulnerable groups against influenza. Unfortunately, though, one cannot say the same thing universally. The persistent prevalence of tuberculosis, particularly in London, is quite simply a disaster. The same could be said for hospital acquired infections which are rampant in the NHS but, interestingly, rare in the private sector. HIV/AIDS has dramatically increased in the past couple of years and shows no sign of abating. Where is the strategy to tackle it? I have not seen it.

In sexual health more generally, cases of chlamydia have gone up by 78 per cent in four years. Gonorrhoea has increased by 86 per cent in five years, yet, as my noble friend Lord Fowler pointed out, there is a shortage of consultants, health visitors and facilities in all those disciplines.

Perhaps the most worrying area of all, however, is that of diabetes linked to obesity. No fewer than 38 per cent of adults are now overweight, as clinically defined, and 20 per cent obese. If present trends continue, a quarter of the population will be obese by 2010, with massive consequences for human health and NHS resources. I have not met anyone who thinks that the Government have a credible plan to frustrate those predictions. We can only live in hope that, even if belatedly, they will produce one.

Whatever Ministers may have been doing on the public health front, it has certainly not been enough. Rather too much attention has been devoted during the past few years to reorganising the health service and rather too little to the serious problems presented by transmissible infections.

My mentioning the reorganisation of the health service is not irrelevant. I am sure that many of us can wholeheartedly sign up to the concept of devolving the power downwards from Whitehall and of promoting local accountability and local priority setting on the part of doctors, nurses and managers. That is definitely the positive side of shifting the balance of power.

However, that blueprint is in danger of coming apart in those areas that demand a broader-based approach, chief of those being specialised commissioning and public health. The delivery of public health protection has to be local, but the overarching activities of research, surveillance and planning require a comprehensive, population-based approach, not fragmentation. Those activities do not fall naturally into the laps of PCTs. As the Health Select Committee in another place pointed out, PCTs tend to focus almost exclusively on commissioning and diagnostic and treatment services in an essentially reactive context.

The reason for concern is that when it comes to expertise in public health, PCTs are finding that the jam is spread very thinly among them. When we read, as we did recently, of the CMO speaking of the need for more public health training for trust managers, the thinness of the jam becomes even more apparent. The jury is still out on whether PCTs will succeed in fulfilling that particular aspect of their role in the way that everybody wants.

Therefore, the creation of the Health Protection Agency as a national body that takes the lead on surveillance, research and planning across the UK and across a broad front has always been a logical concept. A body that looks strategically at the threats to public health, engages in horizon scanning, prepares for emergencies, conducts relevant research and advises government seems to have a natural place in the scheme of things.

It is therefore reassuring to see that one of the key roles of the HPA is to give support to PCTs in the planning and delivery of public health measures at a local level. My goodness, they need that. They need it in particular to cope effectively with the control of infection, sometimes in uncharted situations where speed is of the essence. Sixty per cent of all ill health is due to infectious disease. Those of us who listened to. or read, the debate led by my noble friend Lord Soulsby on 8 December last year will have been struck by how very apt a precursor it was to the subject matter that we are debating today. I recall in particular the speech of the noble Lord, Lord Oxburgh, who so clearly spelled out what is difficult about framing public health policy in the 21st century; that is, that the backcloth against which public health professionals operate is constantly changing. Not only is it constantly changing, but it is also unpredictable in many respects. The rapid movement of people and goods across the world, population growth in third world countries, and climate change together almost guarantee the creation of new and virulent pathogens that can wreak havoc in developed countries such as our own unless we are extremely vigilant.

The HPA will be the eyes and ears of the nation for threats such as those, and the voice of the nation in terms of how we should deal with emergencies when they occur. Of course, we already have the Health Protection Agency as established as a special health authority. It is early days yet, but it seems to have got off to a satisfactory start. As we have heard, the Bill establishes the agency on a different footing as a non-departmental public body and expands its statutory remit in a number of ways. I have little problem with the idea of reconstituting the agency as an NDPB. Indeed, as it currently is, its glaring shortcoming is that its remit is confined to England and Wales. For an area of activity such as public health that is no respecter of boundaries on a map. that makes no sense.

That shortcoming will be addressed in the proposed change of status, although not entirely so. We cannot unwind the clock on devolution, and I shall not argue that we should. However, even the most ardent admirer of devolved government has to concede that the administrative contortions with which the agency will need to contend that are directly consequent on devolution are, at the very least, not conducive to its efficiency or coherence. I have not attempted to quantify the proportion of the Bill devoted to the different arrangements that will apply in England, Wales, Scotland and Northern Ireland, but it is quite substantial.

Perhaps the biggest question mark in the Bill—here I diverge slightly from the noble Lord, Lord Clement-Jones—hangs over Clause 3 and the related provisions. It always sounds persuasive to hear the argument that if one can bring similar expertise that was previously dispersed across several organisations under the umbrella of a single body, that can be only a good thing. However, it is not an argument that in every case should be taken as read. The counter-argument to it is that, by doing away with a discrete centre of excellence, we lose focus, risk an erosion of the expertise and the research base, and inevitably erode intangible assets such as international reputation.

In an area as important as radiation protection, those concerns should be taken seriously. I read the response of the National Radiological Protection Board to the Government's consultation document. The clear message that emerged was that the NRPB was not convinced by the arguments for change and favoured remaining as it is, although with full co-ordination with the agency. I cannot believe that that can he dismissed merely as special pleading. I have not spoken to the NRPB and I apologise to it if my interpretation of its words is wrong, but I give the Minister notice that we shall come back to the concerns on that issue in Committee.

We do not need to dwell too long on what is now a fait accompli, namely the disbanding of the PHLS and the distribution of its laboratories between the agency and the NHS, but we need to debate the consequences of that decision. One argument in favour of integrating allied expertise within a single agency is that it creates surge capacity for dealing with emergencies. For the agency, that may prove true and valid on one level, providing that it is resourced properly, a point made by many noble Lords. However, when it comes to laboratory capacity, the story is not so simple.

The agency may persuade itself that it has access to the laboratories now run by the NHS, but the fact remains that it no longer controls those laboratories. As the report of your Lordships' Science and Technology Committee pointed out, the ability to direct activity within a managed network of laboratories such as existed under the PHLS was decidedly beneficial. It enabled resources to be directed in a co-ordinated manner, and provided inbuilt surge support when problems occurred. The HPA will have a job on its hands to ensure that the essential public health functions of the laboratories, especially in times of emergency but including their surveillance functions, are not disrupted by competing pressures from the acute healthcare sector.

Lastly, I turn to the agency's international role, which will be extremely important. International collaboration is essential in the fight against infection. The reputation of our national body for impartiality and expertise will be key to its effectiveness on that front. That is why we should look severely askance at the ministerial powers of direction which pepper the Bill. In specific circumstances where speed of action is essential to the public interest, there may be a case for a limited power of direction. But otherwise, we must question the necessity for it. We shall do exactly that when we return to the Bill in Committee.

For now, I shall conclude on as positive a note as I can. It is important that we wish the agency well in its vital tasks that lie ahead. At the conclusion of the Bill I hope that we may all emerge reassured and as confident as possible that both the legislative base and the prevailing conditions are set fair for the agency to achieve the full range of its objectives. I look forward to our further deliberations towards that end.

5.26 p.m.

Lord Warner

My Lords, we have had a wide-ranging and well informed debate and I am grateful to noble Lords for their contributions. I begin by making a small correction to my opening speech. I said that the Secretary of State intended to delegate future appointments to the NHS Appointments Commission. I had overlooked the fact that the Secretary of State has no power to do that in relation to Northern Ireland, Scotland and Wales. To avoid allegations that I have misled the House, I felt that I should correct that point.

The noble Lord, Lord Fowler, spoke powerfully about HIV/AIDS. I thought, in passing, that he was a shade unkind to the Government. We are committed to tackling the increasing rates of HIV and sexually transmitted disease infections. Over the past two years we have invested over £35 million in specialist STI clinics, including an additional £15 million that was recently announced by John Reid. So, there is a real attempt to improve capacity. We believe that the HPA's sophisticated surveillance provides the opportunity, as the noble Lord acknowledged, for a comprehensive picture of the HIV/AIDS epidemic that allows us better to target our prevention efforts and planned services for those people infected or afflicted by HIV/AIDS.

The noble Lord, Lord Fowler, and other noble Lords also raised the issue of whether the HPA would be able to decide of its own volition to publish particular reports or information. No doubt we will debate the matter in Committee, but we believe that Clause 7 makes it clear that it is for the HPA to make the decision on whether or not to publish particular information or reports. As I understand the position, that is on a par with the arrangements that were put in place for the Food Standards Agency; so, it is the body itself which determines whether or not to publish particular information. There is no question of sinister characters such as John Reid or myself overruling the agency in that matter. Indeed, only the Food Standards Agency and the HPA are in that position. The Secretary of State has no power of direction in relation to the publication of that information. I hope that that reassures noble Lords over the agency's independent ability to publish that information.

The noble Baroness, Lady Finlay, raised a number of points, and I am grateful for her recognition of the prospect of advances offered by the Bill. I hope that I can give some reassurance to her and to a number of noble Lords who raised the question of resources. I can assure the House that I shall keep going for five minutes at least. I hope that my response to the noble Baroness, Lady Finlay, on the issue of resources will deal with many of the concerns raised by other noble Lords.

I believe that possible confusion over what I said relates to the questions of what counts as public expenditure and the period to which it relates. In my opening remarks, I said that the Bill contains no proposed increase in new public expenditure commitments. However, the 2002 spending review settlement already contained provision for an approximate increase of £25 million per year between 2003 –04— the current year—and 2004–05 and 2005–06. Thus, the old SHA would have had that increase in provision, and the plan is to carry that through to the Health Protection Agency. Therefore, the Explanatory Notes are written as they are because that is already factored into the spending plans of the bodies involved. If that caused confusion, I apologise. However, I place clearly on the record that the intention is to plan for a £25 million or so increase in the provision between 2003–04 and 2004–05.

The noble Baroness, Lady Finlay, raised the question of radiological protection in relation to Wales. The intention is that the HPA will continue to provide the same level of service in Wales, as it will in Northern Ireland, without charge in this area. Therefore, there is no intention whatever to reduce the level of service. If the level of service costs a little more, that will be provided for in the budgetary arrangements which I mentioned. I hope that the noble Baroness is reassured on that point.

My noble friend Lord Turnberg raised a number of points, including the issue of resources, and I hope that I dealt with those. At this point, I pay tribute to the work carried out by my noble friend as chairman of the Public Health Laboratory Service. As referred to by a number of noble Lords, I acknowledge that it was not a sense of failure on the part of the PHLS that caused us to move towards the agenda of establishing a Health Protection Agency. There has been enormous commitment within that organisation in terms of public service and a great deal is owed to the PHLS.

My noble friend Lord Turnberg raised a number of issues relating to micro-management, staff and research. On the subject of micro-management, I say to my noble friend that, as I believe I have tried to make clear on a number of occasions, we are reducing the size of the Department of Health by about 38 per cent. Therefore, even if there were a wish on the part of the staff of the Department of Health to micro-manage this new service, their capacity to do so would be substantially reduced. Certainly so far as concerns this Minister, as a responsible Minister with departmental management duties in the Department of Health, I can say that there is no wish on our part to move into the field of micro-management.

A number of noble Lords raised the issue of research and staffing. I refer them to a piece of work to which the agency has already committed itself in terms of key gains. Two of these key gains are to develop a more knowledgeable and skilled health protection staff and to increase research into health protection. So there is a real commitment by the embryonic agency to tackle the issue of skilled staff, which is not easy—no one claims it is—and the issue of research.

The noble Lord, Lord Soulsby, raised a number of issues on vaccines. What I will say, which may not totally reassure him, is that we have, as I said in the earlier debate, on several occasions considered the whole issue of a centrally funded strategic vaccines facility. However, the evidence has yet to convince us that there is a case for allocating the funds required—approximately £30 million—or that there is an adequate description of exactly what such a centre would provide. Development and production of a new vaccine takes many months and is not a first-line response to a new or emerging infectious disease.

The Department of Health values the HPA Porton Down's work in drafting the emergency vaccine facility's business case. After very serious consideration and discussions with the Ministry of Defence, it has decided to define wider UK requirements more carefully before proceeding. This work is in hand with a number of partners, including the Health Protection Agency. I think that that is our current position on the whole issue of vaccines.

The noble Lord, Lord Soulsby, also raised the issue—as I understood him—about why the HPA is not established on the same basis as the Food Standards Agency. The FSA is a non-ministerial department, which is of course a Crown body and therefore part of the Government; the HPA, as a non-departmental public body, is not a Crown body and is therefore not a part of government. That was a decision taken, but it reflects the high level of independence of the HPA. That, taken together with the point I made earlier about its ability to publish its information no matter where the chips fall, is an important part of that independence.

The noble Baroness, Lady Masham, raised a number of issues relating to HCAIs and MRSA, as did the noble Lord, Lord Clement-Jones, and a number of other noble Lords. I think that the position is fairly clear. The Government have made an attempt to produce a strategy; they did so last year.

In December the Chief Medical Officer published a new action plan. It is not just a press notice, it is the CMO's action plan giving new emphasis and more detail about what needs to be done to try to crack this extraordinarily difficult issue of healthcare associated infections. The situation is not unique to this country, many countries have problems with HCAIs. Winning Ways: Working together to reduce Healthcare Associated Infection in England, for example, lists a number of changes which we hope will produce a better response within the healthcare field. In particular, there is a requirement for every trust to have a director of infection prevention and control who reports at board level. That is a new initiative to try to get at the local level someone clearly responsible and accountable for tackling this particular area of difficulty. These are not easy problems to tackle, as noble Lords know, but the Government are on the case and trying to make progress through the work of the CMO.

The noble Baroness, Lady Masham, asked what part the HPA will play on blood safety. The National Blood Authority is of course responsible for blood supply. It works closely with the HPA on risks from blood-borne infections. The noble Baroness also asked whether there would be a veterinary section in the HPA. The answer is no, but the agency will be responsible for taking an overview of all relevant surveillance systems, including those for animals, which is of course the responsibility of Defra. We are very conscious of the risks posed by zoonosis infections that can be spread from animals to humans.

The noble Lords, Lord Chan and Lord Clement-Jones, and the noble Earl, Lord Howe, raised the issue of PCTs. PCTs are new bodies and, like all new bodies, they will take time to move to full effectiveness. We are now in a situation where 75 per cent of NHS resources are distributed through PCTs. They can prioritise public health in a way that is possibly a little different from the way it was done in the past and, as I tried to say in my opening speech, they will be well supported by the HPA. There is a relationship there. The new memorandum of understanding that I mentioned which is being drawn up between the HPA and the PCTs demonstrates the kind of good working relationship that is being developed.

I mentioned some of the key objectives that the agency has set for itself. Another objective, as the agency itself puts it, is to ensure, From Cumbria to Cornwall, the same high standards of response to an outbreak or incident. The HPA is conscious of the need to ensure greater consistency in the response at local level to public health issues.

I was sorry to see the noble Lord, Lord Clement-Jones, picking over the bones of the PHLS. I was gratified that the noble Earl, Lord Howe, showed a slightly more statesmanlike approach to this particular issue. This is now, as far as we are concerned, water under the bridge. The decision has been taken and the laboratories have been transferred to NHS trusts, although the HPA retains eight laboratories that it runs itself. I am not sure there is a great deal of merit in going over that ground again.

All NHS-run microbiology laboratories are being required to seek accreditation, and, as the noble Lord, Lord Clement-Jones, said, there will be a new inspector of microbiology whose role is to champion and promote high quality clinical and public health microbiology. The inspector will look after both the former PHLS laboratories, which provide routine microbiology services, and also a much larger number of laboratories—approximately 300—providing the same sorts of services that were already under local NHS management. There is therefore a prospect of driving up standards across a wider number of laboratories, rather than just concentrating on the former Public Health Laboratory Services laboratories, important though they were.

I think I have dealt with most of the points that the noble Lord, Lord Clement-Jones, raised in regard to my remarks on similar points raised by other noble Lords. We will have to wait for the business plans from the new agency. I was not trying to be complacent in my opening remarks, which the noble Lord, Lord Clement-Jones called "upbeat". I was trying to get across the message that, in eight months, the new agency has done pretty well in trying to tackle some of problems that it faced. It is worth pointing out, if I dare say it again, that these changes are being introduced in a context where NHS spending is increasing by 7 per cent in real terms over a five-year period. We are therefore introducing these changes in a period of relative plenty, compared with previous eras.

The National Radiological Protection Board did say what the noble Earl said it said in its response to the consultation exercise, but, again, it has moved on. I am sure that he will want to make his own inquiries about that, but it has moved on and accepts that the changes to be made are sensible. It has been reassured by Scotland's attitude in its willingness to continue to use those services, which provide benefit to the devolved administrations.

I have dealt with most points that the noble Earl raised in responding to other noble Lords. He raised the subject of obesity; we know that that is a serious problem. I tried to set out to the House the Government's thinking on that in a debate not long before Christmas. If I have failed to answer any points, I shall read Hansard and write to noble Lords.

On Question, Bill read a second time and committed to a Grand Committee.