My Lords, I rise in this packed Chamber at this late hour to discuss these regulations. I say that light-heartedly, but the raft of regulations going through the House as a result of the Health and Social Care Act 2012 is incredibly important. The fact that the regulations are being very effectively scrutinised by this House demonstrates the commitment to getting the implementation of the 2012 Act right, so my comments this afternoon on behalf of the Liberal Democrats are meant to be helpful to the Minister. I will do my best.
There is significant support for these regulations, not least because there is significant agreement among the political parties that the direction of travel for local authorities to be at the heart of a renewed emphasis on public health is absolutely right. It always struck me, as a former council leader, as bizarre that I had responsibility for the efficient collection and disposal of refuse but that protecting and promoting the health of the people whom we represented was a peripheral activity. Indeed, when the Government introduced the scrutiny committees, supported by the Labour Party,
they emphasised the importance of local politicians taking an interest in health. That engagement—certainly for my local area—was incredibly helpful and supportive. I regard this as the next step. Local authorities should be involved in the scrutiny of health, and most activities from economic generation to housing and education are all part and parcel of improving public health; they are not separate silos.
Before I deal with some of the specific regulations within this SI, I raise an issue which is not in the regulations but which requires a response from the Minister. I refer to public health research, and he will not be surprised that I raise it. In some ways, public health research has gone under the radar—I confess a lack of emphasis myself—yet if we are to improve public health, and local authorities are going to be at the heart of that agenda, it is crucial that research is part of it. Traditionally, local authorities have not funded, nor have they been responsible for research in public health. That resource has come from the primary care trusts and SHAs.
Currently, 187 public health clinical academics with honorary contracts, and 26 academic dentists with honorary NHS contracts are working in England. Of those, 56 clinical academics and four dentist academics are part or wholly funded by PCTs and SHAs. However, that funding—some £15 million—has now been swept up by being transferred to the Commissioning Board, which, as the Minister knows, does not have a mandate to honour the honorary contracts determined by the Follett principles. In fact, public health research is not in the Commissioning Board’s mandate. That responsibility, rightly, lies with Public Health England. Fifteen million pounds is of course a relatively small sum—loose change to the Commissioning Board—but it is the main source of funding for vital public health research which can be commissioned by public health directors in local authorities. If we are serious about local authorities commissioning research—and I think that these regulations are serious about that interface—they must have access to research capacity.
This is an urgent issue, which is why I raise it at the beginning of my remarks. The existing honorary contracts legally run out on 31 March, and continuity over existing research programmes is absolutely crucial unless we are to see the abandonment of key strands of public health research. Will the Minister say what plans he has to resolve this very small but important issue? In particular, will he instruct the Commissioning Board to transfer the £14.7 million of public health funding that it has obtained from PCTs and SHAs to Public Health England as an interim measure until a more secure funding stream can be found for public health research?
Continuing the theme of research, perhaps I may seek clarification on two other matters in the current regulations. This SI gives local authorities powers as directed by the Secretary of State which are in effect transfers of existing powers. They are largely welcomed and give much needed continuity. Therefore, I do not think that there is any argument about the transfer of those powers. However, a person who has one or more of the declared morbidities will be checked on a more regular basis—that is, if you have hypertension, you
will be checked annually. However, will the broader health check given to eligible persons be carried out on non-eligible persons on a five-yearly basis or will it be in the sequence of their morbidity? In other words, if you have hypertension and are checked annually, will you have all the other health checks at the same time, will you have to wait for five years to have them, or will you not get those other checks? The regulations do not make that clear. This is important because the health check data obtained via Regulation 5(3) is valuable not only for individual patients but for research groups.
Indeed, with regard to the information obtained under Regulation 5(3), will the data automatically be made available in an anonymised format, with open access for research groups, but allowing for patient opt-out? If so, will it be the responsibility of the Department of Health, the NIHR, the Commissioning Board or Public Health England to prescribe a format for data collection and storage? I make that point because, if the information is collected in different formats, it becomes less valuable in terms of interrogating it for effective research.
Let me move on to Regulation 6, which I am somewhat confused by the thinking behind. While I fully understand why services such as abortion, sterilisation and vasectomy should be moved into the NHS, given their “clinical and surgical nature”, surely the same could be said about specialist STD management and specialist contraception services, which carry significant clinical risks—not to mention a minefield of legal and ethical dimensions. For instance, IUD insertion management can be an incredibly invasive and difficult issue. The decision to ask local authorities to exclude HIV patients from other sexual health services and treatment for other STDs appears to be at odds with offering patients a comprehensive sexual health service. Why are we separating those out? There is confusion over the implication for people who move out of an area to be tested for HIV, for instance—a more likely scenario in places such as London, Manchester and Birmingham, where specialist clinics with the latest technology quite rightly are emerging. Yet there is confusion over where people will be treated if they are tested elsewhere and how that will be cross-charged.
Who will have responsibility for treating an HIV person with another STD? Will patients continue to have the right to access sexual health services, including related treatment and care, wherever they choose in England, regardless of their place of residence? Will there be no loss either in expertise or in the infrastructure needed to commission complex sexual health services, and will those services and pathways of care be fully integrated? I ask that because small authorities may not have the capacity to be able to have that range of services. Will they therefore be able to commission those services elsewhere and send people from one local authority to another? Will the pressures on local authority budgets not simply result in a diminished quality or availability of care?
How do we guarantee that what we are promising in the regulations can be delivered, given the pressure on budgets? For instance, 25% of the budget for public health is likely to be spent on promoting and supporting
the treatment of sexually transmitted diseases and sexual health. That represents a huge amount of the budget, and for some authorities, particularly in large, deprived urban areas, the proportion could be even greater. Will there be a seamless integrated pathway of care for people living with HIV? We cannot ask such people to be treated differently to any other group in the population, and that is what these regulations appear to be saying. Perhaps the Minister can give me some comfort on that.
As regards Regulation 8, health protection is at the core of the new arrangements and, as I said earlier, none of us, of any political persuasion, do not very strongly support the direction of travel of the Government. Local authorities are enthusiastic about this role of being responsible for health protection. However, an effective response to an early outbreak or emergency requires clear roles and responsibilities, strong leadership and timely intervention. This regulation does not appear to do any of those things. Indeed, rather than building on the DoH guidance of September 2012 on health protection in local government, in which the Government clearly stated that local authorities would be expected to ensure that partners have effective plans in place and that the director of public health would have a leadership function, these regulations give local authorities no more responsibility than requiring other bodies to draw up plans and requiring the local authorities themselves to issue guidance. There is nothing here to say whether plans will be mandatory or optional. That is hardly encouraging if a major crisis develops with potential or actual loss of life. Would the director of public health have a recourse in law to say, “Not me, guv, I asked them all to issue guidance and they did so and therefore my responsibility is over.”?
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Will the Minister assure me that local authorities, through their directors of public health, will have an active role in protecting health at local level and a statutory responsibility for leadership? Will that role include giving local authorities responsibility for ensuring that all local partners have health protection plans in place and that the local response is co-ordinated effectively? If they are given that mandatory requirement, they will do it. Will he confirm that he will issue guidance to that effect? If the local authority will not be responsible for ensuring that plans are in place or that local responses are co-ordinated, will the Minister explain who will be responsible within those local areas, if it is not the director of public health?
On Regulation 9, I strongly welcome the powers of local authorities to cross-charge for services they offer. I think that that is absolutely right and proper as this will help those authorities which develop specialist services. If one authority in London offers a specialist service for diagnosing sexual health problems and that attracts clients from the rest of London, I think that is a good thing. It is right to have a Rolls Royce service and cross-charging for that seems to me important to sustain a revenue stream.
I am pleased—as I am sure everyone else is—that no service which is currently free will in future be charged for and that no new health service will be charged
for either. However, it would be useful for my noble friend to repeat those assurances for the record. The draft regulations state:
“Where a local authority exercises its functions under section 2B of the Act, it may make and recover charges in respect of any of the steps which are prescribed under this regulation”.
I appreciate that Regulation 9(3) clarifies this with regard to future services to improve public health. However, in what circumstances does the Minister envisage that a service to improve public health could be charged for? He mentioned training in his opening remarks. If, for instance, a new contraception service is introduced, would there be a charge for training people to provide that service? Who would pay for that training? Would it be the local authority or the Department of Health? Where would the budget come from? It is conceivable that a new treatment may become available and yet the local authority or, indeed, individuals would have to pay for the staff delivering that treatment to be trained. Will the Minister provide assurances that public health services provided by local authorities will remain subject to the provisions of Section 1(3) of the National Health Service Act 2006 and be free at the point of delivery, and read that into the record? Will he confirm that powers under Section 2B of the Health and Social Care Act 2012 will not be used to impose charges for services that are currently provided free and that individuals will face no further charges for services for improving an individual’s health?
Finally, I come to Part 4 of the regulations, concerning the interface between Healthwatch England and service providers. I am not going to rerun the debates on Healthwatch England, but it is disappointing that we see its role in these regulations only with regard to premises. In other words, Healthwatch can make sure a counselling room is clean and tidy with the necessary flowers and fish tank, but the fact that the person delivering the service may be unqualified, incompetent or even dangerous, or all three, is of less consequence. I exaggerate—not for the first time—but there is nothing in these regulations about the regulation of public health specialists other than medics. The Government made a commitment last January to regulate, by statute, the registration of public health specialists from backgrounds other than medicine and dentistry and acknowledge regulation as a key part of the infrastructure of the new English public health system which starts in April 2013.
We understand, from a letter from Anna Soubry, the Minister for Public Health, that there is, as yet, no planned date for this work, which could take at least two years to complete, and that there are no plans to start until the department’s work on,
“a number of high-priority programmes”,
was completed. The implication is that public health regulation is not a priority, particularly where it concerns individuals other than medics in delivering those services. There is an increasing number of individuals and organisations offering health-related services who are not regulated, trained or accountable, and that is clearly unacceptable. Regulation will provide a crucial mechanism for identifying problems at an early stage and providing opportunities for these to be addressed. The public have a right to be assured that, if things go
wrong, there will be accountability, sanctions and procedures to prevent future mistakes. Can the Minister provide reassurance that the statutory regulation of public health specialists from backgrounds other than medicine and dentistry will be in place by the end of 2014, which seems a reasonable timescale? When will work actually commence on the necessary processes for ensuring the implementation of this statutory regulation?