Health Bill [HL]

My Lords, I have struggled for quite a while to find an opening line, which is always terribly important when you are speaking in this House. The best that I can come up with is that the Bill is paved with good intentions, as was the road to hell. The Bill is certainly full of good intentions, but I am not quite sure, because of its lack of detail and rather nebulous quality, just where it will lead us. I suspect that it will depend hugely on secondary legislation and regulations that will be published later. I must express my irritation and reservations on that count, because we have so little input into that part of the process. Something is glaringly obvious in the constitution section. The Minister reminded me of it when he said that the future of the NHS depends on local involvement and engagement. Indeed it does, so why is there no mention of local authorities or local government, particularly social services provision, in the Bill? The constitution for the NHS is all very well, but I thought that we were heading towards joined-up care for patients. I thought that we wanted health and social care to be as one. Having a constitution just for the NHS, without any mention of what is probably for most people an even more important part of their care, is a very sad omission. I hope that we can address that during the Bill’s passage through this House. I am also concerned about legality. The rather beautiful Handbook to the NHS Constitution says in its overview—it does not have a page number—that this, "““empowers staff, patients and the public by setting out existing legal rights and pledges””." Why then are the Government not afraid of legal action if certain rights are not fulfilled? For example, page 38 of the handbook talks about the right to be treated with dignity and respect, but I refer to the remarks of the noble Lord, Lord Naseby, about mixed-sex wards. If I go into hospital and find myself surrounded by male patients all behaving badly, as men always do, is that not abuse of my dignity and respect and could I not sue the health service for not having regard to it? I probably could and so I am quite worried. That is just one example, but the same probably applies to access to records and to the safety of our records. I have never understood why patients cannot hold their own records. Whether the health service has them or not, why cannot we be the owners of our own records? It is our body; they are our records. Why cannot we be responsible for them? There is also the right to choose. I was extremely sad to see that, under the right to choose which service we would like, maternity services are not to be included. We have heard so much in recent years about the right to choose birth at home, birth on birthing stools, birth in water, birth in the air, birth wherever you can think of it; we have this right to choose how we wish to give birth to our babies, but apparently it is not to be included in the rights. Another point on the constitution is that there is a missed opportunity under the obligations section. I have always felt that somehow in this country the NHS has allowed people to hand over their bodies and their health to the health service; it is no longer their responsibility because, whatever they do, the NHS will put it right. We could have had a stronger feel to the obligations. The handbook talks about taking responsibility for, "““your own, and your family’s … health and well being””." Yes, but perhaps there should also be warnings, not that the NHS will not treat you but that your treatment in the NHS may be delayed if you are too fat, if you are a heavy smoker or if you drink too much and have a hobnail liver. These things could have been pointed out under obligations. Vaccination of children is great hobbyhorse of mine. In many countries, children are not allowed to go to state schools unless they have been vaccinated. I do not see why that could not have been in the section about patient obligations. We are losing our herd immunity in this country. That is very dangerous and very worrying and we should do something about it. The idea behind quality accounts is wonderful. I know that in many trusts clinical teams already look at their work, evaluate their work and are prepared to report on the outcomes of their work. However, we must be distinct about this. I am not clear whether the clinical teams will produce the quality accounts, whether the trusts will publish them or whether the primary care trust as commissioners will publish them on what has been going on in its area. The handbook says that these accounts will be on display. Will we have a little display chart in every ambulance and every clinic saying, ““Breast cancer for this team is nil per cent survival””? Of course, that is totally impossible, but it is a bit scary if we are going to have these things on display without any explanation for the patient. I am worried that these accounts will be used as league tables or ultimately as targets and that people will try to choose because of the results. What about value added? We do that in school league tables. What about the clinical teams that operate on less healthy patients because they feel that they must, compared with the clinical teams that may choose the patients who will give them the best outcome? I am concerned about that. I am also concerned that a new management line will be set up. Having worked in the health service for more than 30 years, I can see a director of quality looming on the horizon, with sub-directors, managers, managers’ PAs, teams and ladies with clipboards—in the last trust in which I worked, they were referred to as the ““country casuals”” and went round assessing, evaluating and counting; they were not very popular. It would be a waste of health service money if we were to set up another management line within each trust. There is so little detail in the section on personal budgets that I can hardly comment. Will patients be able to top up? Will there be a list of approved services where they can purchase their care? I presume that we will have to await regulations for the detail, but where is the evaluation of the direct payments that have been made in social care in recent years? Who will evaluate any pilots? What say will this House and the other place have on the regulations on personal budgets, which are terribly important, as they represent a drift towards a totally new system of delivering healthcare in this country? It is important to do it slowly and carefully to see where we are going. What a wonderful idea the innovation prizes are. I conjured up last night an image of a young Mr Darzi on the podium receiving his innovation prize, weeping with joy and lost for words. However, there is no detail. We must be very careful that the prizes go to the right people. I shall not enlarge on that, but we must be very careful. Last but not, I suspect, least in this debate is the contentious issue of tobacco. To declare an interest, I regard myself as a smoker. I smoked; I have not smoked for decades; but I know that if I had a cigarette, I would become a smoker again. Therefore, I welcome any attempt to prevent me from seeing the things, hearing about them, being tempted by them or being put in a place where others are smoking and I might feel the urge again. I welcome any initiative. I declare that interest because it is very important. I regret that we do not have any comprehensive strategy for reducing the damage to heath caused by smoking. It seems that we have just put a few measures on advertising and display in a Bill. I have certainly received more briefings on this issue than on anything else in the Bill. It raises huge passions, as we have already seen. It is a missed opportunity. My party and I support most of the measures in the Bill. The proposal on vending machines is pointless. I can well remember as a student trying to find late at night the vending machine that still had some Embassy tipped in it. They were the most revolting things, but if you are addicted to smoking, you will smoke anything in the end. Vending machines surely have to go. They should not be anywhere. I am a little concerned about the effect on small businesses if they are not allowed to display cigarettes. I agree that there must not be advertising displays, but if there were no cigarettes on display, would it not lead to a culture sous table, with one getting one’s cigarettes when the man has his back turned or when the policeman has gone out of the shop? I do not like the feel of that. It is not an adult way of dealing with the issue. However, I am sure that we shall spend a lot of time in Committee debating the purchase of tobacco. To end on a contentious note, the missed opportunity here is in how we treat all drugs. Tobacco and alcohol are far more damaging than, for instance, cannabis, which has just been moved into class B. I cannot understand the thinking in this country—and the West generally—on drugs and how we should use and control them. It is a missed opportunity not to set up a royal commission on all drugs, including alcohol, tobacco and all currently illegal drugs, so that we can assess the harm that they do to individuals, the cost to the health service, the damage to society and, in the case of illegal drugs, the damage worldwide to other countries’ economies and crime rates. This is an interesting Bill. The more one looks at it, the more interesting it gets. I am sure that it will get more interesting in Committee and I look forward to tonight’s debate.