I express my thanks to the noble Lord, Lord Willis, for his comprehensive contribution this afternoon. He has covered quite a lot of the questions that I would have asked and there is no point in repeating them. However, I should like to pick up some specific points.
First, in relation to sexual health, like the noble Lord, Lord Willis, we welcome these regulations, particularly the very important principle of the maintenance of open access. HIV has never respected local authority boundaries, nor have other sexually transmitted infections. I have spoken in the Chamber of my concerns about how the new system of commissioning and fragmentation can put at risk regional and sub-regional co-ordination of HIV prevention work. This morning, I visited Positive East, a community facility based in the East End, which does excellent work in a number of boroughs in the east of London. It also participates in outreach and preventive programmes across London and it remains particularly concerned about the future. I appreciate that, while HIV Prevention England is commissioned by Public Health England to run a national HIV programme and local authorities will commission local HIV prevention and testing services, there remains a gap in regional co-ordination. This was highlighted in a health Question in the other place on 15 January, when the Minister assured Members of Parliament that this regional work would continue, but the detail on whether there would be national leadership remains unclear.
What steps will the Government take to encourage co-ordination of sexual health services across boroughs and localities? For example—this was raised by the noble Lord, Lord Willis—25% of HIV prevalence in the UK is in London, which previously had an integrated pan-London programme for HIV prevention. What measures have been put in place, as the noble Lord has already said, to facilitate cross-charging between sexual health clinics for out-of-area residents?
An issue which arises from these regulations is the concern that has been expressed about the pressure on budgets and, certainly, consistency across the country. I am acutely aware that, come the local elections, there will be not so much prioritising of these important issues. This could be a concern. I do not think that sexually transmitted infections have been the highlight of many party manifestos, but they are important issues in public health.
There is no mention in the regulations about the quality of open access health services and the minimum expectation that the Government have of locally commissioned sexual health services. The Minister has repeatedly said that the answer lies in localism—in local circumstances—and that these issues are best
addressed locally. However, there is a requirement to ensure that there is proper maintenance of standards on these issues.
Will there be any obligations or duties on local authorities to promote HIV prevention? Currently there are no known incentives on prevention, only on tackling late diagnosis, in the new public health outcome framework.
The other issue which I am particularly concerned about and which I have raised in the House is the question of HIV testing. This is highly fragmented under the new NHS arrangements. I have asked the noble Earl before, and I repeat: how will the Government ensure that HIV testing recommendations from NICE and the British HIV Association are consistently implemented across the country? In some areas of high prevalence it is recommended by NICE that HIV testing should be routinely offered in primary care settings. Will this be implemented? How will this work be funded and provided?
The noble Lord, Lord Willis, also touched on the issue of the treatment of people living with HIV and the treatment of other sexually transmitted infections they may have. I am not sure how that will be covered.
I am also concerned about the question of offering services and treatment through self-management, if you like, for people living with HIV. That is one of the key things I saw at Positive East today. This is not only about the supply of drugs and treatment but about employment advice, general housing conditions and other issues that we have already covered in debates in the Chamber. The funding and support of those activities concerns me. Where is it going to fall? Who is going to take responsibility? Fragmentation is a real worry.
I shall not cover specific local government issues around public health because the noble Lord, Lord Willis, has covered them excellently. However, I wish to pick up on some of the points that the Minister raised in relation to local Healthwatch and its access. We had a major debate on Healthwatch this week, which preceded the Statement on the Francis report on Mid-Staffs. Given the measures outlined in these regulations, will the department review them in the light of the recommendations made by Francis? Issues were raised by Francis which, I suspect, are not adequately covered by the regulations, particularly with regard to access.
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The Minister referred to wanting to have a clear separation of the CQC role from that of Healthwatch. As a patient organisation, particularly in the light of the Francis report, Healthwatch needs to be certain that the CQC is doing its job. It is not a neutral thing. It is not a case of saying, “We’re happy, we don’t need to do that because the CQC is doing it”. Local Healthwatch is not the regulator; it is the voice of the patient. It is the patient who is everywhere and is able to see everything. The idea that we can limit access in the way that is being suggested in these regulations is not altogether clear. Certainly, NALM has raised some of these issues with me. There is an exclusion,
“in respect of any premises, or parts of premises, if the presence of an authorised representative on those premises, or those parts of premises, would compromise … the effective provision of care services”.
What does that mean? What is the role of local Healthwatch? Would the CQC be excluded on the same basis? These are points that NALM has raised with me.
There is another issue about parts of premises that are excluded. We talk about the communal parts of the premises, but there is an exclusion,
“in respect of any premises, or parts of premises, at any time when care services are not being provided on those premises or those parts of premises”.
When premises are closed in order, for example, to renovate or decorate, sometimes it would be highly appropriate for a local Healthwatch to look at the progress of such renovation or at whether it has been done to an appropriate standard, particularly if there have been complaints or issues before.
There is another exclusion,
“if, in the opinion of the services-provider, the authorised representative in seeking to enter and view, or observe the carrying-on of activities on, premises is not acting reasonably and proportionately”.
The Minister mentioned this point but, in the light of the Francis report and what we have heard of Mid Staffs, who is making that judgment about “reasonably and proportionately”? A representative of NALM made the point to me that he was reported by a nursing home manager simply for taking notes as he walked around. That was considered to be not reasonable. I think it is reasonable and proportionate. That concern has been raised by LINk representatives.
LINk representatives have raised other points about areas of premises that might be considered out of bounds. If we are talking about community facilities, then what about kitchens? You go to see the quality of care of social care residents and you are told that you can go into the living or lounge area—and you can see how neat and tidy that is—but you are not permitted to go into the kitchen or other areas where quality really matters. I am not sure about the logic of that.
That covers all the major points. I reiterate that in general terms, as the noble Lord, Lord Willis, has represented it, my party shares the consensus about how important these changes are in terms of public health. We welcome the regulations, but we think that the issues that have been raised with us and that I raised today should be addressed.