Health Bill

My Lords, I too thank the Minister for introducing the Bill. At last your Lordships have the opportunity to consider in detail the Health Bill—not the Health Improvement and Protection Bill as it was originally entitled. Clearly, the part of the Bill that has attracted the most attention in the other place is Part 1, dealing with the ban on smoking in enclosed public places. More observant noble Lords will have noticed that my noble friend Lord Clement-Jones, who is part of our DCMS team, is back on a free transfer to the health team because he took the tobacco advertising Bill through this House very successfully and therefore has some form on the subject. I should like simply to make two points and to leave most of the other matters to my noble friend. The first is that the smoking ban is a matter of considerable public interest and one on which there has been extensive and well informed public debate. Public opinion, not least as it is reflected by the number of commercial companies that have already introduced voluntary bans, is quite clear and in some respects ahead of Parliament. Should there be a difference between the two Houses on the matter of a ban, I believe that the views of the elected Members of another place should take precedence. I do not believe that this is a matter on which this House has the right to overrule those down at the other end. Secondly, this is a matter of public health. The role of government should be to protect individuals who for whatever reason cannot exercise free choice about whether to work or to be in a smoke-free environment, and to address health inequalities. That will be the basis of the Liberal Democrat contribution to this debate and it reflects our policy on the matter. I too wish to concentrate on the other parts—the anorak parts—of the Bill, which have received very little attention. However, these parts have important consequences for primary and secondary healthcare. The most substantial part of the Bill, as the noble Baroness, Lady Cumberlege, said, is the introduction of a code for infection control. The incidence of infection in healthcare settings has been the subject of extensive political debate, not least during the previous general election, which proved conclusively that the public were not thinking what the Conservatives were thinking. The second national prevalence survey of infection in hospitals, in 1996, estimated that 9 per cent of all inpatients had a healthcare-associated infection. The National Audit Office report in February 2000 reported that healthcare-associated infections were possibly responsible for up to 5,000 deaths per year and the associated cost was £1 billion per annum. Since then there have been a number of initiatives, mostly information and education materials for healthcare professionals, such as Fighting Infections,Winning Ways, Towards Cleaner Hospitals and, in June 2005, the NHS Modernisation Agency’s infection control initiative Saving Lives Given all that activity, the fundamental question which the House has to ask is what difference will be made by a code of practice that, by the Government’s own admission, will place on the NHS a regulatory burden of £34 million annually. When making up their minds, noble Lords might like to consider that the Bill’s regulatory impact assessment makes clear that the data on which the code is built is from 1997. Moreover, in the intervening period there has not been a fully reliable system of surveillance of incidence of infection, nor of the implementation of infection control practice within hospitals. Perhaps the greatest concern is that there is a dearth of information about the effectiveness of different infection control measures. There is evidence that infections transmitted by hand can be countered by the use of alcohol rubs, and infections in catheter care, which are extremely prevalent, can be reduced by the introduction of aseptic non-touch techniques. In addition, programmes such as UCLH’s screening of all patient admissions has worked well, in that it has identified the prevalence of MRSA in other environments such as care homes. One wonders whether greater investment in pilot projects such as that and the eventual roll-out of successful infection control techniques would represent better investment of resources. Furthermore, one must ask whether the penalties for non-compliance with the code of practice will simply lead trusts to divert their resources from other means of fighting infection—such as high standards of laundry, ensuring that staff have changes of uniform and facilities in which to change, and 24-hour cleaning services. The noble Baroness, Lady Cumberlege, gave an example; I shall give another. A few years ago, a friend of mine who was in a major London teaching hospital went for a bath and returned to find that her bed had been given to, and was occupied by, another patient. Bed occupancy rates are extraordinarily high in some of our major hospitals. We do not want another lot of centrally set targets that are of no use to front-line staff in trying to combat problems as they meet them. A number of organisations have commented on the limitations of the proposals. The RCN has criticised the definition of healthcare associated infection within the code of practice. That organisation states:"““The definition as currently drafted appears to confuse what a HCAI is with how you come to acquire such an infection””." That is an important distinction when one is attempting not just to identify but to control infection. Many organisations have criticised the fact that the code of practice will not apply to non-NHS facilities such as independent care homes. That is remarkable, given the incidence of MRSA among care home residents. Our policy has been to give those in the front line the support and freedom of action to do what is necessary to fight infection where it occurs. We would ensure that information and training would be available to all staff to enable them to implement effective good practice. Staff would have discretion to close wards or set up isolation units as necessary. We would also ensure that effective systems of feedback and monitoring were in place, so that a sound evidence base of practice could be built. In 2003, the Government gave £12 million of pump-priming money to pharmacists to set up a system of surveillance of the use of antimicrobials. That money is coming to an end and I would like to know whether that extremely successful project will be extended. Our view is that a code of practice, which is to be introduced immediately, whether trusts are ready or not, and which focuses on processes rather than outcomes, is likely to be of limited use; but we accept it as far as it goes. The new measures on supervision and management of controlled drugs are to be welcomed in that they incorporate many of the findings of part four of the Shipman inquiry. No system should be designed on the basis of the actions of one extraordinarily evil man; however, reform is necessary. We welcome the proposals in the Bill to the extent that responsibility for medicine management remains within organisations but wish to ensure that there are clear lines of accountability. We note the responsibility placed on the Healthcare Commission to review performance of each NHS organisation. However, I would also like to ask what role the Royal Pharmaceutical Society inspectorate will have in monitoring and policing the actions of NHS bodies. After all, that is the body with the relevant experience. The proposals to change the control on supervision of pharmacists, as the Minister has said, are the subject of some concern. Pharmacists do not simply fulfil prescriptions; they play a very important role in talking to patients and checking for adverse drug reactions, which are often not obvious until repeat prescriptions have been issued. To do that, pharmacists need face-to-face interaction with the people they serve. The proposal that registered pharmacists may oversee more than one pharmacy has caused some concern. We seek to scrutinise in detail the provisions on the review of the General Ophthalmic Services. We are concerned that the Bill may limit access to general optometry, which is vital not just for eye care but for diagnosis of conditions such as brain tumours or glaucoma. Furthermore, we seek to probe exactly what constitutes additional and enhanced services under the GOS contract. Will conditions such as glaucoma be part of those additional and enhanced services? I have one minor question to the Minister. The administration of the social care bursary scheme is to be moved to NHS bodies. I am not clear from the limited statements in the Explanatory Notes why that is possible or necessary. Why should one discipline issue bursaries for another? With the exception of the smoking ban, this is not a strategic Bill. The noble Lord, Lord Warner, called it a diverse range of provisions. I would call it a collection of bits and pieces. It needs improvement and bits of it may well need protection during its passage through this House. Overall it has our support, but we will seek to strengthen it as it passes through your Lordships’ House.