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Archive for the ‘Labour Party’ Category

Thursday
Mar 8,2012

The report of the Parliamentary Joint Committee on the National Security Strategy (of which I am a member) has just been published.

Its key findings are that:

  • There is no evidence that the NSS has influenced decisions made since the Strategic Defence and Security Review. If the current strategy is not guiding choices then it needs to be revised.
  • There should be an “overarching strategy”, a document designed to guide government decision-making and crisis management both at home and on the international stage.
  • The Government’s assertion that there will be no reduction in the UK’s influence on the world stage is “wholly unrealistic in the medium to long term” and the UK needs to plan for a changing, and more partnership-dependent, role in the world.

The Committee also expressed concern about the operation of the National Security Council concluding that it did not operate always at an appropriately “broad and strategic” level.  For example, it became deeply involved in essentially operational issues during the operations in Libya.  Moreover, it failed to consider the national security implications of the Eurozone crisis or the possibility of Scottish independence.

Wednesday
Mar 7,2012

Yesterday there were five votes in the House of Lords on the competition sections of the Health and Social Care Bill.  The amendments were all defeated by the Government and, despite all the LibDem huffing and puffing over the last few weeks, not a single LibDem Peer voted for any of them.

The first amendment which would have placed a duty on the Secretary of State in respect of standards of adult social care was defeated by 261 votes to 203 – with 66 LibDems voting with the Tories against the amendment.

The second amendment which would have protected the NHS from the worst effects of competition (and was originally moved by a LibDem peer) was defeated by 275 votes to 188 with 66 LibDems voting with the Tories.

The third amendment which would have retained Monitor’s role as the independent regulator of NHS Trusts was defeated by 255 votes to 183 with 65 LibDems voting with the Tories.

The fourth amendment which would have tried to limit “anti-collaborative” behaviour in the NHS was defeated by 221 votes to 171 with 58 LibDems voting with the Tories.

The fifth amendment which would have enabled NHS commissioners to determine the most effective way of delivering NHS services without necessarily putting them out to the market was defeated by 203 votes to 157 with 52 LibDems voting with the Tories.

In none of the divisions did a single LibDem vote with Labour to protect the NHS.

Tuesday
Mar 6,2012

Dave Hill’s London Blog in The Guardian can usually be relied on for serious comment and analysis of London issues. And last week he posted two important posts on the issue of serious gang-related violence in London.

The first highlighted the post-code rivalries between gangs in North-West London:

“Page 81 of my London A-Z shows the streets, parks and stations at the intersections of north Westminster, north Kensington and Brent. But it offers no clues to the alternative cartography that shapes the lives of many people living there – an unofficial map of an urban landscape scarred by violence and divided by fear. …

Territories have been defined and the borders between them guarded and sometimes breached. Incursions resulting in chasings, beatings and robberies are frequent. …

Some who live in the area concerned, including some who are young, are barely touched by this wired, short-fused youthful world. They and it are largely invisible to each other: people move freely and routinely to and from work, local schools, community facilities and places of worship just like anywhere else. Yet an awareness of that other side of neighbourhood life has filtered down even to primary school children. And on the streets young people in particular, even if they have little or no direct connection with it, are acutely conscious of it: at worst, cowed, menaced and controlled. …

 In this increasingly less subterranean world the streets are an excitingly dangerous playground – a place that’s more available, more plausible and more rewarding than the alternatives of education, conformity and long-term, steadier rewards. Yet though that playground may be larger than those at primary school, it is both limited and limiting too. The horizons of those playing crazy, deadly games there don’t extend geographically, intellectually or emotionally even as far as A-Z pages 80 or 82.”
The second cited a report from the Centre for Crime and Justice Studies at Kings College, “Young People, Knives and Guns”, which concluded that:
“focusing on weapons themselves can be a distraction from addressing the underlying causes of violence and that the most effective interventions engaged instead with “the big questions of disadvantage and social exclusion” along with addressing individual, family and neighbourhood problems. It also found that in the United States locally-based strategies where a variety of agencies work closely together to combine different prevention and suppression approaches have been more effective than “enforcement-led interventions by agencies operating in isolation.””
Later in the same post, Hill describes the experience of youth and community workers he had met:
“There was a strong consensus that every neighbourhood affected and individual involved is different, and that responses should be tailored accordingly. A unified view was also expressed that police officers with listening ears who know a neighbourhood well are an asset, but that vanloads of territorial support group members sent in from elsewhere to conduct stop-and-search blitzes can cause more problems than they solve. Far better that police energy was put into co-ordinating activities across borough lines and building trust with the communities they serve.

There was a general frustration that funding for anti-youth crime and violence projects is too often short-term and under threat, making the sustained action required far more difficult to implement. Outreach work, personal development and gang mediation schemes were all thought to have beneficial effects, so why couldn’t they be backed with more consistency and on a larger scale?”

Certainly my perception for what it is worth is that gang-related violence seems to have got significantly worse in London in the last couple of years or so.  This is not intended to be a political point because I am not sure that there is a simplistic cause and effect between political decisions or for that matter policing decisions and changes in the levels of violence or gang-related activity.
I am also told that at least one magistrates court in London checks through the lists of cases coming up so as to ensure that cases involving rival gangs are scheduled on different days to stop fights breaking out on court premises.
However, what is clear is that a number of things that are happening will clearly be making the situation worse – what the Centre for Crime and Justice Studies call “the big questions of disadvantage and social exclusion”.
Thus, a worsening economic situation with fewer opportunities for young people will create an increasing sense of hopelessness and futility fostering a breeding ground for both extremism and for gangs.  In this context, scrapping the Educational Maintenance Allowance seems a particular folly and which is why Ken Livingstone’s pledge to restore it in London makes sense.
Similarly, cutting local authority budgets will both increase local joblessness but is also likely to mean that specialist youth and community provision will be lost – again hardly helpful in this context.
Tackling the environment in which gangs flourish is the key.  Too often in too many parts of London for too many young people being part of a gang is the only way of having any security – both physical and emotional.  These are not easy issues to tackle, but it is obvious that some policies will make things worse.
Friday
Feb 24,2012

Normally any late change to the order of business in the House of Lords is agreed through the “usual channels“.  This is to make sure that the relevant spokespeople are available.

I understand that the Government are trying to schedule a vote on the Welfare Reform Bill for late on the evening of Wednesday 29th February.  This is part of the “ping pong” procedure and will be when the House of Lords considers the reversal by the House of Commons of the Lords’ amendment on the so-called “bedroom tax“.

Normally Consideration of Commons Amendments is given priority in the order of business and is usually taken immediately after Question Time, when the House is at its fullest.  This, of course, is the second time that the Bill has been returned to the Lords by the Commons, which means that, if the Lords rejects the latest Commons amendment, the two Houses are moving firmly into constitutional crisis territory.  All the more surprising therefore that the Government are trying to take this vote late on Wednesday.

However, is it surprising?

Or is it yet another cynical manoeuvre by the Conservatives and LibDems to make major changes in the benefits system without proper debate and adequate scrutiny?

Tuesday
Feb 14,2012

Here is my speech from tonight’s debate on NHS bureaucracy:

“My Lords, it is an enormous pleasure to follow the noble Lord, Lord Fowler. I was particularly taken with his support for the principle of ring-fenced funding, which I trust the Minister will take into account when, a little later, we come to consider local healthwatch organisations.

Earlier today, we had a Question on the initiatives that had been taken in London on stroke care. I did not get an opportunity to pose this question but I was interested in who, in the absence of NHS London driving the process, would have taken the quite difficult decision to reorganise stroke care in London, given that it was opposed by a lot of the local providers and local organisations. This question also came up during the first day on Report when we looked at who would make decisions on reconfiguring services and who would make decisions when services were not adequate or when there were issues of equality of healthcare to be addressed. At one point, the Minister said,

“The CCGs will be supported in their efforts to improve quality by the NHS Commissioning Board”.—[Official Report, 8/2/12; col. 314.]

Later on, when I probed him on this, he said that “the board”—that is, the NHS Commissioning Board—“will be represented sectorally”. I was not quite sure what he meant, but it being Report stage I could not challenge him. He said:

“There will be field forces in all parts of the country … The majority of its staff will be a field force”.—[Official Report, 8/2/12; col. 316.]

I do not know how a majority can be a field force, but there we are. Later on, he said:

“However, of course, the board will be represented at a local level rather than only centrally, and we expect that the board will be represented in health and well-being boards and in the discussions that take place there”.

When I questioned whether that meant that they would be members, he said:

“It is entirely open to a health and well-being board to invite a member of the Commissioning Board to be a permanent member, but I am not saying that we are prescribing that”.—[Official Report, 8/2/12; col. 340.]

I took that to mean that the NHS Commissioning Board will be sitting at the centre of the National Health Service with its tentacles going out to all parts of the health service. The Minister did not really like that. He said:

“The role of the board is to support local commissioners; it is to be there as a resource to promote guidance, supported by the quality standards that we were debating earlier”.—[Official Report, 8/2/12; col. 352.]

If the noble Earl does not like the metaphor of tentacles reaching out across the health service, perhaps a better metaphor would be to see the NHS Commissioning Board as some sort of Spanish Inquisition, reaching out to the local clinical commissioning groups and to the health and well-being boards, saying, “We are here to help”, which is no doubt what the Spanish Inquisition said in its heyday, and, “We are a resource to promote guidance”, which is also what I suspect that the Spanish Inquisition might have said in its heyday. I have to ask whether what we have before us is really a less bureaucratic structure when it has this enormous inquisition-like structure sitting in the middle of it, promoting things at a local level.

We are replacing a fairly simple, basic idea: the Department of Health in the middle with a series of strategic health authorities and below those the PCTs. I believe that the previous Government should have done more to reduce the number of PCTs and I know that my noble friend Lord Warner worked very hard, in his various incarnations, to try to achieve just that. There are too many PCTs, but we did not need this Bill to reduce the number of PCTs. Nor did we need this Bill to give those PCTs clinical leadership. All that was required was to appoint local doctors, local clinicians, to lead those PCTs, and that could have been done from the Department of Health. You did not need this Bill to reduce bureaucracy and to simplify that fairly straightforward structure; you did not need this Bill to give clinical leadership; and you certainly did not need the top-down reorganisation, which I think we were promised we would not have.

Instead we shall have the Department of Health at the centre and the Secretary of State, who will not micromanage but who will have instead the NHS Commissioning Board. No doubt the Secretary of State, like some latter day Henry II will say, “Who will rid me of this rebellious CCG?”, or, “Who will require something to happen in a local provider?” and popping up like some—I am mixing my metaphors—Torquemada will be the chief executive of the NHS Commissioning Board, Sir David Nicholson, who will say, “Ah, right, this is something that we will take on; it is not something that you, Secretary of State, should be micromanaging yourself; we, the NHS Commissioning Board will micromanage it through our network of clustered strategic health authorities, through our commissioning support groups and through the 300 CCGs, not forgetting these wonderful bodies, the clinical senates”. No doubt this is my failure rather than anyone else’s, but I have yet to understand exactly how the clinical senates will operate. I rather suspect that they will be like the Deputy Prime Minister’s proposals for a replacement for your Lordships’ House: they will be costly, rather powerless and part of this panoply of structures.

Throughout all this, there will be the field forces of the NHS Commissioning Board, not reaching out like tentacles, but being there as a resource to promote guidance and to make things happen. Apparently from this Bill, which allegedly will reduce bureaucracy—this morning I heard a government apologist on the radio saying that the Bill is all about reducing bureaucracy—we will have this network of individuals who will work with, or even sit on, local health and well-being boards, working to encourage and promote guidance and advice and working with clinical commissioning groups. They will be individuals who will, largely, be anonymous, invisible and unaccountable, except upwards to the NHS Commissioning Board. I am not sure that I accept that this will be a less bureaucratic structure but I am quite sure that it will be a much less clear and accountable structure than anything we have had before.

Recently, I was in a meeting with a number of London MPs who were talking about how these new arrangements will work. The question they wanted answered—this is the Henry Kissinger question—was who do we phone to talk to when some issues takes place which is not soluble by an individual clinical commissioning group or is not simply an issue that relates to one provider? Where do we go? Presumably, we ought to go to this anonymous individual, anonymous representative of the NHS Commissioning Board. No one will know who that person is. That person will not be accountable and presumably will not be supposed to talk to Members of Parliament.

The question that I hope the noble Earl will answer about where the Bill is going—I accept the comments of the noble Lord, Lord Fowler, that it may not be perfectly drafted—is: how baroque will the structure be underneath the NHS Commissioning Board? How will that structure of individuals and field forces, which will manipulate what happens in local CCGs and in local health and well-being boards, work? How will a field force be held accountable, visibly and locally to the population who will be affected by the decisions of those influenced by that local field force?”

And here is Sir David Nicholson, Chief Executive of the NHS Commissioning Board:

david_nicholson020310.jpg

And, of course, he is nothing like Tomas de Torquemada, the Grand Inquisitor of the Spanish Inquisition:

Torquemada.jpg

But then nobody expected the Spanish Inquisition did they?

Monday
Feb 13,2012

The amendment I signed to place a statutory duty of candour when something goes wrong on those providing health services was defeated in the House of Lords this afternoon by 36 votes with 198 in favour and 234 against.

164 Labour Peers voted in favour along with 1 LibDem and 33 cross-benchers and others.  137 Tory Peers voted against the amendment, along with 61 LibDems and 36 cross-benchers and others.  LibDem Baroness Tyler of Enfield who also signed the amendment nonetheless voted against it

My speech (with interruptions) was as follows:

Lord Harris of Haringey: My Lords, my name is down in support of the amendment. I want to make it clear at the outset that it is substantially different from the amendment put forward in Committee and has taken on board a lot of comments and points made during the helpful debate at that time.

As far as I am concerned, the origins of this go back to my meeting 18 years ago with William Powell about the death of his son, Robbie, when I was director of the Association of Community Health Councils. Mr Powell was concerned about the failure of the system to give him and his family answers as to why his son had died. Mr Powell is still campaigning for a change in law to place a requirement for some sort of duty of candour. Interestingly, that case eventually reached the European Court of Human Rights in May 2002. In its judgment, the court made it clear that at present there is,

“no duty to give the parents of a child who died as a result of their negligence a truthful account of the circumstances of the death, nor even to refrain from deliberately falsifying records”.

Most of your Lordships would find that a pretty shocking and appalling statement in this day and age, but that is where we are as far as the law is concerned and it remains a continuing consideration.

In September, as chair of the Independent Advisory Panel on Deaths in Custody, I had a listening day with a group of families whose relatives had died while detained under the Mental Health Act. Those families reported a lack of information from NHS trusts. One family reported that they,

“were unaware of any investigation, everything was released in drips”.

Another family claimed:

“They didn’t disclose anything, it was a battle to the end”.

Another said that

“the shutters came down as soon as I started asking questions”.

One parent explained that it was like being,

“in a void whilst waiting”.

These are parents or families of people who have died while in mental health care.

Even more alarming for families was the misinformation frequently provided to them.  They thought that there had been a whole series of flaws in the way that the cases of the deaths of their loved ones were investigated. One said:

“The first time I had opportunity to speak to anybody was the consultant. Nobody told me about the investigation. I told the consultant that I wanted a meeting with nurses and see what happened …  Consultant and matron came for the meeting with no pen and paper. I was the only one taking notes. After that the matron told me that she would try to get answers for me. I asked how she would remember 20 questions which I asked as she was not taking notes. It took three years for them to give this evidence”.

The problem is that most families feel that the investigations are not independent, and many of them feel that they are presented with lies. The problem is that the existing system does not work. It is not adequate as it presently stands.

The amendment has been significantly changed. It now relates explicitly to organisations rather than individual practitioners. The background is that there is currently no statutory requirement for organisations that provide NHS services to tell a patient, carer, or representative when something has gone wrong during their care and treatment that causes harm. The issue is left to guidance and a non-binding requirement in the NHS Constitution to have regard to the principle of openness. This has allowed cases to occur where NHS organisations have withheld such information from patients, delayed its release or, worse still, actively covered it up.

I understand that the Government have agreed that a duty of candour is required, but their preferred route is a contractual duty built into the standard contracts between commissioners and some providers of NHS services. Patient organisations and others do not believe that that is sufficient. It would not include all NHS providers—for example, GPs, dentists, pharmacists, and so on do not have such contracts—and it would not create access to the sanctions which the Care Quality Commission has at its disposal. Under the Government’s proposal, as the noble Baroness, Lady Masham, said, the duty would apply only to incidents which are already being reported through official systems, so it would be useless in preventing cover-ups.

The amendment would require the Secretary of State to create a statutory, enforceable duty of candour by amending the registration regulations of the CQC. All healthcare providers would then have to comply with them to be registered. Of the issues raised in Committee, the most important, raised by several noble Lords, including the noble Lord, Lord Winston, who I do not think is in his place at the moment, and the noble Lord, Lord Walton, was that that might overlap or conflict with the clinicians’ professional duties and the existing arrangements under the General Medical Council and other codes of conduct organised by regulatory bodies. The proposal in the amendment is for a statutory duty of candour placed on organisations, not on individual health professionals. It therefore complements, rather than duplicates or confuses, the duties in health professionals’ codes of conduct.

Indeed, Harry Cayton, the chief executive of the Council for Health Regulatory Excellence, has said:

“We support the introduction of a duty of candour in the CQC’s registration requirements, which would mean that the ethical responsibility of health professionals would be shared by organisations delivering healthcare services”.

Frankly, at the moment, doctors and nurses can be put in an impossible position where they would want to honour their ethical and professional obligations but are told by managers and lawyers within the organisation for which they work not to be fully open with patients. That would put them in the position of a whistleblower. This duty would remove that conflict for those individual professionals.

Of course, the amendment is not designed to get in the way of culture change. Several noble Lords said that we want culture change. No one disagrees. The point is that this will support the process of culture change. There is no argument for not setting out in regulations what is by any reasonable assessment as important and essential a standard of quality and safety as the others already set out in CQC regulations.

Lord Walton of Detchant: In relation to candour, the noble Lord may know that the General Medical Council published guidance just two weeks ago making it incumbent on doctors not to sign a contract or agreement that prevents them giving information which might be detrimental to the organisation that employs them. In other words, gagging orders are no longer accepted by the GMC as being part of a contract into which doctors can enter.

Lord Harris of Haringey: I am grateful to the noble Lord, Lord Walton, for that. It is an extremely important step forward and it recognises that there is an existing problem that requires the GMC to take that stance. I think that there is a distinction between gagging clauses and the sort of persuasion and pressure that may be applied to clinicians behind the scenes under such circumstances. This amendment focuses on the organisation’s responsibility and on how the managers and lawyers within an organisation should meet those obligations of candour.

I know that there has been some concern—I think that the Minister has expressed it at various points—about whether the CQC would be able to cope with regulating this duty of candour. It is worth making it clear that there is no question of asking the CQC routinely to monitor every incident with patients; it is simply about the expectation that it will be there as the backstop.

There is already a duty in the CQC’s statutory registration regulations to report to the CQC incidents that cause harm, but it is a duty which requires the organisation to report the incident to the CQC and not to the patient. It is rather anomalous that there is an obligation requiring an organisation to report something to the CQC but not to the patient at the same time. Quite clearly the CQC should have this information and be able to respond to and deal with it.

The point is that the CQC has always said that it could regulate this requirement if the Department of Health so wished. I think that there has been some recent correspondence with the Department of Health which has recognised that the CQC is currently under considerable resource constraints. However, I have seen copies of e-mails released under the Freedom of Information Act—

Baroness Wall of New Barnet: I thank the noble Lord for giving way for the second time. I certainly support the amendment but I worry about the examples that he has used. The cases that he has put forward and the experience of the patients and families concerned are horrendous and outrageous, but what I found troubling and certainly did not recognise at all was when he went on to say that the coercion, rather than gagging, that might take place inside, for instance, a provider trust such as my own—Barnet and Chase Farm—would discourage people from being anything but frank. I have now been the chair of Barnet and Chase Farm for five years. The chair is at the end of the process and during the process has the opportunity to talk to people. I hope that my trust is not unique but in five years I have never known that kind of culture at Barnet and Chase Farm. The noble Lord is looking askance but I ask him to trust me. From my experience—and I hope that it is not a lone experience—I can assure him that that culture does not exist inside my trust; nor, I am sure, does it exist in others. In fact, the opportunity to come clean is used by my trust in the whole way in which patients are dealt with and, indeed, when patients tragically die. If what the noble Lord is saying does happen, then the amendment is absolutely crucial. However, I do not recognise it.

Lord Harris of Haringey: I am grateful to my noble friend for that intervention. She has highlighted the fact that there are different practices around the NHS. Quite a number of trusts take a very positive approach, as she has described, whereby the natural assumption is that you are open because that is what the Department of Health would expect. However, the number of instances where that is not always the case and not always the culture that is adopted, is striking. That was, for example, reflected in the group of families that I met whose family member had died while being detained under the Mental Health Act; it was reflected in the case of Robbie Powell; and it was reflected in a large number of the other cases that the patient organisations which the noble Baroness, Lady Masham, listed, have come across.

So there are two cultures within the NHS and we need to ensure that the culture within the NHS is the best. That is why a statutory duty of candour would support the process, rather than hinder it. It would not cut across the position of the individual professions—indeed it would support it—and, as the noble Lord, Lord Walton, has highlighted, there has been much recognition by the General Medical Council that this is an issue—

Baroness Whitaker: I apologise for interrupting my noble friend. Perhaps I might add something to the other side of the balance. I am aware of two very recent cases—one of a death and one of a hospital-acquired infection—where information was covered up. It is not simply the case that there is a uniform culture of candour.

Lord Harris of Haringey: I am grateful to my noble friend for that reinforcement. I regret that, within some NHS trusts and some provider organisations, there is not the same approach. There is a concern that it is better to keep a patient, or the family of a patient, in ignorance and hope that the whole matter goes away. The purpose of the amendment is not to penalise the individual clinician—we all recognise that accidents happen—but to foster the culture of openness that the department wants to see; it wants to ensure that that duty is reflected, not only as far as the individual professionals are concerned, but also as far as the organisations are concerned. Otherwise, too often the lawyers and managers will say, “In the interests of the trust, let us try to keep this quiet”. I am glad to hear that it does not happen in every instance, as I am sure it does not, but the purpose of the amendment is to provide a statutory framework that will make it quite clear to all those who might otherwise be tempted to cover up these incidents that they must say, “This is important and we have to be open”.”

Thursday
Feb 9,2012

After the excitement of the Government’s defeat in the House of Lords yesterday afternoon by a margin of four votes (with the Convenor of the Liberal Democrat Peers, Lord Alderdice,voting against an amendment he had both signed and spoken in favour of) on the principle of mental health issues being given greater priority within the NHS, the rest of the days proceedings might have been a bit of a damp squib.

However,the later debates illuminated what a dog’s breakfast the whole Health and Social Care Bill has now become.

For example, at one point I tried to elucidate what would be the mechanisms to drive up quality in local healthcare provision and how would health inequalities between commissioning group areas be addressed, saying:

“My Lords, I support the amendments in this group because I believe that it is important that we look at the mechanisms that will be embedded in the Bill, assuming that it eventually receives Royal Assent in some form, and that will in practice drive change in the direction that we all want. That includes improving the quality of the care offered, and it means addressing the issues of health inequality to which the noble Baroness, Lady Tyler, referred.

One of the omissions from the Bill is that, apart from placing some general duties on the various bits of the NHS, there is very little about demonstrating how those duties will then be exercised or creating a mechanism for assessing that. The amendment, which talks about reporting annually to Parliament on the progress made, seems an essential first step in making sure that that happens.

The reports on inequalities will be increasingly important in this area. However, Amendment 112, dealing with CCGs’ annual reports on how they have discharged their duty to reduce inequalities, raises another question, and this comes back to the issue of what will be the catchment areas of individual CCGs. Unless there is far more central direction than I have understood—and perhaps the Minister can reassure us on that—it seems likely that there will be, to use an unpleasant term, ghettoisation in some CCGs.

In some local authority areas, the easier bits of the patch will have one CCG and another will cover the others. That is likely to mean that the areas covered by those two different CCGs are rather more homogeneous than might otherwise be the case. If one CCG covered that area, the duty to make progress on health inequality would be clearer. If we are talking about smaller populations served, it is more likely that they will be homogeneous and that there will therefore be less inequality to address. The question will be whether there will be enough pressure within the system to ensure that the inequalities in health outcome between different CCG areas will be addressed. It is all very well to place a duty on a CCG which covers, say, the people of Tottenham in north London, where there are tremendous problems of health status, life expectancy and so on, to report on what it is doing to eliminate health inequality in its patch, but if the nature of that patch is such that it is already deprived in terms of both economic indicators and health outcomes, what will be the driver to ensure that the inequality of that area compared with others is addressed?

Who will own the strategy within regions and parts of the country to address issues such as health inequality and clinical standards? If the answer is that that this will all be done by the NHS Commissioning Board, that is a wonderful answer and tells us what an important body the NHS Commissioning Board will be. How will that be operationalised? What mechanism will drive that? Before you know it, you are talking about a regional and area infrastructure no less baroque than anything we have seen in the past. Otherwise, it cannot happen. What will be done to operationalise the drivers to make the improvements happen? It will not be sufficient to place a duty on everyone to report on what they have done, although that is valuable and worth while in itself. What will be the duty to address issues between localities? You can address all the inequality you want within those areas, but if the outcomes are already much lower in those areas, will there be enough infrastructure around the NHS Commissioning Board to address the problem of the inequalities between the different areas?”

In reply, the Minister, Earl Howe said:

“The noble Lord, Lord Harris, asked me about clinical commissioning groups and referred to their geographic coverage. He will know that each CCG will be accountable for the outcomes that it achieves against the commissioning outcomes framework, which is under development. The CCGs will be supported in their efforts to improve quality by the NHS Commissioning Board, whose job it will be to issue commissioning guidance, informed, among other things, by NICE quality standards.

I do not agree with the noble Lord that CCGs are likely to be ghettoes. Across many clinical areas, they will collaborate to serve the needs of patients over an area wider than that of just a single CCG. What is not stated in the Bill but I hope is implicit in all that the Government have said is that there will be transparency in all this. Once you measure results, there is, ipso facto, an incentive to improve those results.

The noble Lord, Lord Hunt of Kings Heath, asked me how a CCG can influence improvement in primary care when it is the board that is commissioning the primary care. I simply remind him that CCGs have a duty under the Bill to support the NHS Commissioning Board in its quality improvement functions with respect to primary care. Indeed, one of the key benefits of CCGs as we see it—and we know this from a practice-based commissioning which has been in place for a number of years—is the ability for peer review and peer pressure to drive up quality.

The noble Lords, Lord Harris and Lord Hunt, asked me who will lead the local strategies. Health and well-being boards will be the bodies that will produce a joint health and well-being strategy, and that will be designed precisely to address issues such as health inequalities, which involve different services working together. CCGs must have regard to these strategies in addition to reporting annually on health inequalities, as through the amendments in this group.”

Shortly afterwards, I intervened to try and clarify the point and this was the exchange:

“Lord Harris of Haringey: I just want to make sure that I understand the point that the Minister is making. Let us compare two localities in London. I mentioned Tottenham, so compare that with, say, the residents of Totteridge. They are very different socioeconomic groupings with very different health outcomes. What is the mechanism for addressing health inequalities between Tottenham and Totteridge? Who will be responsible for addressing inequalities between areas that are just a few miles apart but which have very different characteristics and very different social outcomes? The health and well-being boards are borough-based. Tottenham is in the London Borough of Haringey and Totteridge is in the London Borough of Barnet—neighbouring boroughs that are very different in composition. What will be the overarching structure that addresses those inequalities?

Earl Howe: Localism lies at the heart of our approach to these issues. Although I have no doubt that conversations and comparative analyses will take place between different health and well-being boards and different local authorities, in the end it is the responsibility of health and well-being boards to look to their catchments. As I said, the outcomes that are published, both in terms of the NHS performance and public health and social care, will in themselves incentivise improvement, if the local authority and the health and well-being board work together as they should. This is a joint enterprise between public health, social care and the NHS.

We shall no doubt experience the effect of comparative work between local authorities once the early implementer groups have bedded down and begun their work. Both the board, however, and the Secretary of State will have duties in relation to inequalities. They overarch everything that happens and I suggest that that will ensure that a system-wide and strategic approach is taken, for example, through setting objectives in the board’s mandate in relation to inequalities. These could feed down very easily to CCGs through commissioning guidance issued by the board. I hope that that gives the noble Lord a summary, or at least a flavour, of how we envisage this working.

Lord Harris of Haringey: May I just clarify? Will there be nothing between the board at national level? Will it look right across the country and say, “We will address these inequalities”? Will there be nothing, for example, at the London level, to address inequalities between different parts of London or will it simply be driven nationally? That is a recipe for not necessarily making the best decisions in particular areas.

Earl Howe: The noble Lord will know, because the NHS Commissioning Board authority has published its proposals, that the board will be represented sectorally. There will be field forces in all parts of the country. My vision of this, and that of Sir David Nicholson is that in the areas in which the board operates it will take a view across a region and look at how outcomes vary between local authority areas. The board will be very powerfully placed to influence the kinds of inequalities that the noble Lord has spoken of. It is important for noble Lords to understand that the board will not be a collection of people sitting in Leeds. The majority of its staff will be a field force. I hope that that is helpful.”

So the NHS Commissioning Board will have an army of staff, active in every region and locality “influencing” local Commissioning Groups.  (This army will, of course, be anonymous and unaccountable – except at national level through the NHS Commissioning Board and the Secretary of State will try to imply that none of what happens is anything to do with him.)
A later exchange on another amendment amplified the point:
Baroness Jolly: Before the Minister sits down, will he clarify whether the same processes that he has just outlined would apply to people in receipt of specialist services that are commissioned by the NHS Commissioning Board, not by local CCGs?

 

Earl Howe: My Lords, where a service is commissioned by the NHS Commissioning Board—and let us imagine that it is a specialised service—the patient’s recourse should be to the board. However, of course, the board will be represented at a local level rather than only centrally, and we expect that the board will be represented in health and well-being boards and in the discussions that take place there. It would therefore be possible for a patient to address their concerns, in the first instance, to the health and well-being board, which would have the ability and power to communicate directly with the NHS Commissioning Board, if that was felt to be appropriate. However, as I said, the patient would be able to go straight to the board in those circumstances.

Lord Harris of Haringey: I appreciate that this is very bad manners, given that I missed most of the debate. The Minister has just said—although perhaps I misinterpreted him—that the NHS Commissioning Board will have a representative on every local health and well-being board. If so, how will those individuals be known or accountable? Is that not the most extraordinary bureaucracy? He seems to have made a most extraordinary statement.

Earl Howe: My Lords, we are at Report stage and I hope that the noble Lord will forgive me if I do not reply at length. The point I was seeking to make was not about representation on the board but involvement in the health and well-being board’s wider deliberations. It is entirely open to a health and well-being board to invite a member of the Commissioning Board to be a permanent member, but I am not saying that we are prescribing that.’

So there will be – or at least can be – NHS Commissioning Board staff “influencing” or even sitting on local Health and Wellbeing Boards.

By now I was becoming even more curious about the extraordinary reach of the NHS Commissioning Board and in a debate on the proposed duty to encourage “autonomy” for local NHS bodies I pursued the topic again:
“My Lords, every time I look at Clause 4—[Laughter.] I cannot understand what my noble friends find so amusing, but every time I look at this particular clause—if that makes it easier for them—and particularly listening to the remarks of the noble Lord, Lord Marks of Henley-on-Thames, I have been confused as to what problem the Government think they are solving by the clauses on autonomy.There is apparently a concern about micromanagement. There is a desire to have local innovation, flexibility and local responsiveness. What is it about the current arrangements in the NHS that necessarily prevents local innovation, flexibility and local responsiveness? Why are we having these discussions? If there is a concern from the Government that they are micromanaging, they have a solution—they stop micromanaging. Again, what are we trying to do here?However, once you include,

“the desirability of securing, so far as consistent with the interests of the health service”—

or whatever form of words you choose to have—this principle of autonomy, you are setting up an automatic conflict. If the form of words that the Minister and the noble Lord, Lord Marks of Henley-on-Thames, have put their names to was in the Bill, does this mean that the Secretary of State will be intervening when there are clear cases of postcode lottery? That presumably is the implication. Or is the Secretary of State now going to say that in fact a postcode lottery is what this legislation is designed to create? We should be clear what these clauses are trying to prevent. What is the problem that they are trying to solve?

The noble Lord, Lord Marks of Henley-on-Thames, was moving in his description of how the Secretary of State would weigh these difficult issues of the possible conflict between,

“the desirability of securing, so far as consistent with the interests of the health service”,

autonomy and the priorities of the fundamental role of the NHS. This is a balance that has to be weighed. He talked about this line of accountability that will exist between the NHS Commissioning Board and the CCGs—these tentacles that the NHS Commissioning Board will put throughout the NHS. They will be unaccountable and anonymous, and individuals will be operating at regional or at local level.

There will be an army of people operating as the tentacles of the NHS Commissioning Board. They will be informing the Secretary of State so that he can exercise his judgments about the balance between autonomy and meeting the principles of the NHS. I wonder whether the Secretary of State is creating the most extraordinary bureaucratic monster to solve a problem that could be easily solved simply by resisting his tendency to micromanage.”

And this prompted further exchanges:

Earl Howe: My Lords, the noble Baroness, Lady Thornton, has spoken to Amendments 10 and 52, which, as she has said, would remove altogether the autonomy duties on the Secretary of State and the board. The noble Lord, Lord Harris, asked me what the problem is that the Bill is trying to solve in this regard. The duty is intended to promote a culture of fostering local autonomy rather than to outlaw specific practices; but without a focus on autonomy, it is possible that the mandate from the Secretary of State to the board or the framework document from the board to CCGs could impose disproportionately burdensome requirements on the system. The Government believe that local operational autonomy is essential to enable the health service to improve the outcomes of care for patients, provided that autonomy is within the framework of clear ministerial accountability.

The noble Baroness will be aware, because I have said it before, that we are aiming to free those closest to services to take decisions that are right for patients, free from central micromanagement by either the Department of Health or the NHS Commissioning Board. The amended duties, with the caveat that the interests of the health service take priority, achieve the right balance between autonomy and accountability. Without the clause, a future Secretary of State could choose to ignore one of the fundamental principles of the Bill, which is that those closest to patients are best placed to take clinical decisions. Without the clause, a future Secretary of State would be free to use his extensive powers to micromanage the NHS. The autonomy duty is a necessary part of the Bill, placing a duty on the Secretary of State to consider the expertise of those in the health service while recognising that there will be circumstances—

Lord Harris of Haringey: My Lords, the noble Earl seems to be saying that you cannot trust your own Secretary of State not to micromanage unless they are effectively forbidden from doing so. We have all talked of the Secretary of State’s accountability to Parliament. Surely the principle is that an accountable Secretary of State will be under enormous pressure from Parliament not to micromanage. If it is such a central issue of policy, Secretaries of State should simply be told not to do it, rather than requiring an Act of Parliament.

Earl Howe: I challenge the noble Lord to think of one Secretary of State, with the distinguished exception of my right honourable friend Mr Lansley, who has not succumbed to the temptation of micromanaging the NHS. No Secretary of State has been able to resist that temptation because, frankly, Parliament expects them to do it. That is what the system has expected of the Secretary of State. This is a burden on commissioners and clinicians, and, in the end, it does not well serve the interests of patients. It is all very well for the noble Lord to say, “Well, just stop”, but the system encourages it and the duties on the Secretary of State are there to encourage it.

Baroness Thornton: I cannot resist saying that the noble Earl’s right honourable friend Mr Lansley has dabbled and intervened on at least 12 occasions since the Bill started. He is on the record as saying on one of those occasions that certain managers should be sacked. Is the noble Earl saying that that will cease when this Bill is on the statute book?

Earl Howe: I am saying that the Secretary of State will not have the ability to micromanage the health service as he does at the moment. Whether the examples cited by the noble Baroness constitute micromanagement, if my right honourable friend is just expressing a view, I rather question.

 …

Baroness Jay of Paddington: The noble Lord may be surprised to hear me ask this question because, as he kindly said, I have been very determined that the provisions on accountability and parliamentary responsibility et cetera should be strengthened in the Bill. However, I listened to what my noble friend Lord Harris said about what he described as the “increasing tentacles” of these links between the various providers and the Secretary of State. Is the Minister not becoming concerned—as I would in his position—that all this new accountability and these links undermine the basic policy positions of the Bill? That is why, for example, my noble friend Lady Thornton suggested that it would be cleaner—if that is the word—to remove the whole of Clause 4 from the Bill. The complexities that are being set up and strengthened, as the Minister has agreed, make the whole thing so incredibly complicated and bureaucratic that the underlying policy positions are being totally distorted.

Earl Howe: I do not share that view at all. I do not think that the autonomy and accountability arrangements are as complex as the noble Baroness seems to suggest. Autonomy and accountability are two sides of the same coin; one confers autonomy in exchange for accountability. That is the model that we have adopted and the one that I would hope that Parliament would wish us to adopt, given that substantial sums of public money will be at the disposal of commissioners throughout the NHS. I therefore do not see that the metaphor of tentacles employed by the noble Lord, Lord Harris, is actually very appropriate. It implies that there is an organisation holding those in the health service in a grip. That will not be the case. The role of the board is to support local commissioners; it is to be there as a resource to promote guidance, supported by the quality standards that we were debating earlier. It is not—I repeat not—a replica of the kind of line management that the NHS has seen to date.”

The reality is that the mechanism to micro-manage will be there – through the personnel (tentacles) of the NHS Commissioning Board – but presumably the micro-management will be deniable by the Secretary of State.
What a way to run a Health Service. 

 

 

 

 

Wednesday
Feb 8,2012

The Mayor of London and his policing surrogate, Deputy Mayor Kit Malthouse AM, are keen to introduce a pilot scheme in London whereby the courts could impose on offenders, whose offences were alcohol-related, a requirement that they be compulsorily tested for alcohol daily for a three months period with a positive test meaning arrest and appearance again in court.

Data in the US, where such schemes have been in place for eight years, show that reoffending rates after alcohol monitoring more than halved when compared with traditional sentences of fines or custody – with 99 per cent of tests being negative, and two-thirds of those on an alcohol monitoring scheme having perfect compliance throughout the whole period of the scheme.

This evening in the Lords, the distinguished cross-bench peer, Baroness Finlay of Llandaff, proposed a series of amendments that would permit such a pilot, saying:

“My Lords, this set of amendments concerns an alcohol monitoring requirement and is modified from those tabled in Committee on the Police Reform and Social Responsibility Bill. The alcohol monitoring requirement requires an offender to abstain from alcohol and be regularly tested to ensure compliance as part of any community or custodial sentence. It would provide an additional option—a new tool—for the courts.

These amendments would not stop responsible social drinking. They aim to deal with irresponsible, anti-social alcohol abuse and its devastating consequences. When I tabled these amendments previously, the Government’s response was that they would pilot the idea in October, using existing legislation for low-level crimes. October has come and gone. Where is the pilot? Anyway, this is needed for middle and high-level crimes, not just low-level crimes.

I should explain why we need primary legislation to undertake a proper pilot. London wants to do a pilot and will fund that pilot. The proposal has wide support. London Councils, which represents all 32 London boroughs, has written to Ken Clarke supporting the scheme. The chair of London Councils is Mayor Jules Pipe, the Labour elected mayor of Hackney. The scheme’s project board has representatives from Her Majesty’s Courts Service, London Probation, Public Health and the Crown Prosecution Service involved in developing the pilot. Consultation has involved domestic violence victims, Refuge, Women’s Aid, domestic violence offenders, health leads and those with an interest in the night-time economy from transport to addiction support services.

Today, I spoke to Bernard Hogan-Howe, the Metropolitan Police Commissioner, who is “fully supportive” of the proposal. He commented that alcohol is a precursor to crime in about 80 per cent of crimes in London and that after six o’clock at night you can smell the problem in the police cells. Violence against the person offences account for 64 per cent of Metropolitan Police alcohol flagged offences and criminal damage accounts for some 11 per cent of alcohol flagged crime. We should remember that only about 10 per cent of offences get flagged as alcohol-related even though, in recent British Crime Surveys, victims believe offenders to be under the influence of alcohol in about half of all violent incidents. The commissioner wants this to be a mandatory scheme. Voluntary schemes do not work because you need to support those who most need it and who are unlikely to recognise that need without compulsion. He wants this measure to act as a driver for better health as youth binge drinking is now a common cause of end-stage alcohol-induced liver failure in those aged under 25. We have a major social and health problem.

The Metropolitan Police view this measure as an additional tool against drink-driving and domestic violence. The proposed alcohol monitoring requirement has the potential to reduce reoffending for alcohol-related crime, particularly drink-driving and domestic violence, and contribute to long-term behavioural change of offenders. …

Courts need a different sentence to tackle alcohol-related crime because what we have is just not working. Custody tears families apart and single large fines damage the children in the home more than the offender. Neither custody nor fines address behavioural change. London wants to pilot this scheme in relation to offences of violence against the person, drink-driving and domestic violence. It is recognised that developing a scheme in relation to domestic violence would require particular care to ensure that the safety of the victim, including any dependants, is an integral part of the scheme.

These amendments will enable the court to take enforcement action on alcohol-related violence and to monitor compliance, particularly regarding middle-level offences such as common assault, offences against the person, threatening behaviour and domestic violence. How would it work? Pre-court screening aims to identify alcoholics whose needs are so great that the scheme would not be suitable for them. Alcohol monitoring as part of a suspended sentence, a community sentence or post-release licence would be an alternative to custody when the magistrate is satisfied that the offender understands the demands, which are no alcohol and daily testing.

Evidence suggests that the period needs to be 12 weeks to achieve real behavioural change. The court would order the offender to pay for each test—usually £1, which is less than such offenders are paying for their drinks. Let us get this in proportion: £2 a day is less than the cost of one pint of beer in a pub or two pints from many supermarkets. The cost of the monitoring to the offender is very low compared with the amount that they are normally spending on their huge alcohol intake—even when that is irregular. Testing would be done by either a private company or voluntary third-sector agency using paid staff, not volunteers. It will not tie up police constable time.

For the pilot, test centres would use existing court and probation premises near transport hubs. The initial alcohol test would be taken with a standard breathalyser. If it is positive, a second test would be taken with evidential standard equipment and mouthpiece. Breaches, which might be through a positive breath test, non-attendance or non-payment, would be dealt with using standard processes, with a swift and modest sanction such as an extension of the monitoring period in the first instance. Non-payment will need a flexible approach, particularly for those on benefits, and will be specified in the protocol. I have gone through the draft protocol but I shall not delay the debate by going through its minutiae.

The amendments are compatible with our human rights law—in particular, Articles 5 and 8, and habeas corpus. Let me be explicit: there is no compulsion on an officer to arrest a person for non-compliance and no compulsion to detain on arrest. An officer may arrest a person only when it satisfies the test of reasonableness and proportionality in Article 5.1(b).

In London alone, almost 9,000 cases would be suitable for the scheme. Between half and a quarter of these are people who are employed. The scheme would allow them to present for testing on the way to and from work, without any risk to their job. For offenders with anger and aggression issues, counselling and family support have the greatest chance of success when the participants are sober.

Existing orders that relate to offences for low-level crimes and have been used in cases of alcohol abuse do not have a success story attached to them. The alcohol-monitoring requirement would be appropriate for medium to high-level offences that require appearance at a court for sentencing. Existing orders were discussed with the Home Office and Ministry of Justice officials, but were considered inappropriate by those who want to pilot this scheme in London because, for example, drink banning orders keep people out of an area but do not halt the abuse, and are non-enforceable. Conditional cautions need to be voluntary, involve an admission of guilt and are managed by the police. The police do not want to use conditional cautions because they do not have the manpower and do not feel that such cautions are appropriate. Anti-social behaviour orders are civil orders to tackle harassment, alarm or distress to one or more persons not in the same household, and therefore do nothing to tackle domestic violence. Community sentencing could require attendance but not testing by breathalyser. Penalty notices for disorder do not require an admission of guilt, and do not count as convictions. The current fine of £80 is suitable only for minor offences.

I am sure that the Minister will say in response that the Government plan a pilot under community sentencing, just as they did previously for low-level offences, by using tagging for secure continuous remote alcohol monitoring—SCRAM devices that detect alcohol in sweat. These devices are not yet type-approved by the Home Office. They are bulky, are fixed around the ankle, and make a buzzing sound every 30 minutes as they sample the sweat. The offender cannot travel without prior permission because they have to be near the base station to download data daily. The wearer has to connect the device to the mains to recharge and cannot bath, use household cleaning or personal hygiene products that contain any alcohol at all, because that would give a false positive reading—and the device is in place for three months. As for the collection of the £1 test cost, the principle of hypothecation locally is already in place for asset seizures. The police can already hypothecate when the money is there.

We have an epidemic of alcohol abuse in this country. We cannot carry on doing what we are doing. It just is not working. These amendments would allow a full pilot to take place in a small area. London wants to do that to discover how well it works or not, and to iron out any problems. These amendments are essential to allow that pilot to happen. I beg to move.”

The amendments were supported by speeches from all parts of the House: Liberal Democrats, Lord Avebury and Lord Carlile of Berriew; Conservatives, Baroness Jenkin of Kennington and Baroness Newlove (whose husband was kicked to death in an alcohol-fuelled murder); Labour, Baroness Dianne Hayter, Lord Willie Bach (from the front-bench) and myself; and Cross-bencher, Baroness Howe of Idlicote.

Unanimity had broken out, until the Government spokesperson, Baroness Northover (a Liberal Democrat, but no doubt a Conservative Minister would have said the same as they did when the same proposal was raised a few months ago) rose to respond.

She offered supportive phrases:

“we very much support the principle of the intention of the noble Baroness and other noble Lords who have contributed to this debate.”

Supporting “the principle of the intention” is a bit like those non-apology letters you get saying “we are sorry you found it necessary to complain”.

And promised two non-statutory pilots (which would be unlikely to reach the most serious offenders) – in due course = when the Government has published its alcohol strategy and gone throughout the approval process for the technology it wants to use.

And, of course, the Government wants

“to hear the views of the judiciary, professionals within the criminal justice system and the public on the proposals. We will therefore be consulting in parallel with the pilot schemes to ensure that we give full consideration to the purpose, effect and benefit of sobriety schemes as we develop work further.”

A long grass job.
She was not keen to apply the pilots in domestic violence cases either because as she rather strangely put it:
“We have reservations about sobriety schemes being applied to domestic violence offenders because, if you like, alcohol does not cause domestic violence although, of course, it may very well increase its severity and/or frequency.”
Apparently, it is not a priority to reduce the severity or frequency of domestic violence.
In any event, she made it clear she expected the amendments to be withdrawn and this is eventually what happened, although Baroness Finlay did warn:

“I will not press my amendment tonight, but I look forward to further discussions, and I must warn the Government that if I do not get satisfactory answers I intend to bring this back on Report.”

On a previous occasion the Mayor’s Office thought they had got agreement from the Government to go ahead.  They will not be pleased to be rebuffed again.

 

Tuesday
Feb 7,2012

The last hour of business in the House of Lords last night was given over to a – by Lords’ standards – bad-tempered debate on an amendment to the Protection of Freedoms Bill.

The Government is proposing that certain categories of people who work closely with children need not be checked to see if they are on the barred list that says whether they are known to be a danger to children.  In particular, they will not be checked if they are subject to “supervision”.

The amendment was moved by Lord Bichard, who led the inquiry into the Soham murders, who said:

“Everyone in this House understands that one of the most difficult responsibilities for any Government is to manage risk, whether that risk is the security of our nation or the safety of the most vulnerable members of our society. It is one of the most difficult responsibilities because very few risks of any significance can be entirely eliminated, and decisions must therefore be made about what is an acceptable-sometimes an unavoidable-level of risk, and what action is proportionate in seeking to minimise that risk.

That is why I emphasised two things when I published my report on the deaths of Holly Wells and Jessica Chapman at the hands of Ian Huntley in Soham: first, that we cannot create a risk-free society; secondly, that the steps we take to minimise risk should be proportionate. For those reasons, I very much sympathise with and support the Government in seeking to strike the right balance in this very difficult area. Some reduction in the level of bureaucracy associated with vetting and barring is necessary and achievable, and I welcome the Government’s attempts to do so. However, I cannot agree that these clauses strike the right balance, even with the amendments tabled by the Minister or by other noble Lords in this House. That is why I am moving this amendment.

To be clear, these clauses relate to those who train, supervise, teach or instruct children outside a specified place, such as a school or a children’s home, or to those who are unpaid volunteers in whatever setting. In such circumstances, a person will not in future need to be CRB checked if they are under the supervision of another person who is engaging in a regulated activity and is therefore subject to CRB checks. We can, and probably will, debate how close or intensive that supervision should be. My contention, inconvenient though it may be for those of us who want to reduce the level of bureaucracy, is that no amount or quality of supervision can be sufficient to prevent someone developing a bond of trust with a child that he or she can then exploit at a time when they are free of that supervision. That is how grooming takes place.

The internet provides enhanced opportunities for the bond of trust, once established, to be inappropriately exploited. Therefore, the focus of our concerns should be not on the quality, intensity or nature of the supervision but on whether the person involved in training, instruction, teaching or supervision presents a risk to the child. They should therefore continue to be subject to checks that can help establish whether
they are a risk to children. This will hold out some hope that we can prevent them gaining privileged access to children.

We know that checks cannot be foolproof, but surely we owe it to our children to take reasonable and quite simple steps to prevent those whom we know are a risk from gaining privileged access to children, even if they are subject to supervision. They must do that because children assume that adults who are trusted to offer guidance or instruction to them can be trusted-not just in limited circumstances such as the youth centre or playing field but wherever they are encountered. That is why supervision can never be enough, and why sometimes we have to place the safety of our children before our desire to minimise regulation and bureaucracy. I hope that that is what we will do this evening. If we do not, I fear that we will very quickly find that dangerous adults will realise that there are some settings and some ways in which it will be easier in future for them to gain access to vulnerable children. The people we are talking about are manipulative and clever. They will take advantage of those opportunities.”

Finally, I hope that the Minister will at least be able to confirm this evening that the Act will do nothing to prevent organisations, with their local knowledge, making checks where they think they are required. For example, a school with its local knowledge will be able to carry on checking volunteers if it believes that that is necessary and good practice.”

In support, I said:

“It is unfortunate that we are debating these amendments at this time of night in a fairly sparse Chamber. I fear that in a few years time people will look back on this debate and say, “Why did Parliament not do more? Why was Parliament so happy to allow those changes to go through without further checks and cautions?”. I am therefore grateful to the noble Lord, Lord Bichard, for his amendments. He is quite right to say that a balance has to be struck and that no system will necessarily protect all children against abuse and against predators. However, the omission that is being created by this Bill is enormous. It is saying that if a volunteer, or someone working with children, is subject to supervision, they do not have to be checked at all. The reality is that parents send their child to a school or a club because they assume that it is a safe place. They assume, therefore, that the people who will be in contact with their child at that school, that club or that activity are also safe. I suspect that unless they pore over the details of our debate, which I am sure is not the case, they will assume that all those people are being checked against these registers and lists. Of course they will not be. They are volunteers or they are under the day-to-day supervision that is envisaged.


The reality is that children coming into contact with those adults will again assume that they are safe. The bond of trust, and it does not have to be a very strong bond, will be built up and created. When they see that individual elsewhere, perhaps in the town centre, loitering near their school or wherever it may be, they will assume that that person is as safe for them there as in the supervised context. That is why such an important gap is being created by this legislation. I know that the Government have moved significantly in terms of the amendment they have tabled about supervision being,

“as is reasonable in all the circumstances for the purpose of protecting any children concerned”.

I wonder whether that is really going to be sufficient. Is it really going to provide the protection that is needed? Is it, for example, going to ensure that the individuals concerned never offer their e-mail address, their Facebook page or their BlackBerry messenger identity to children? How can it do that if that offer is made not on the premises of the school or the club or outside the activity concerned? There will be no way of knowing whether that happens. However good the supervision may be inside that school, that club, or during the activities concerned, there will be no way of preventing that bond of trust being created and therefore the vulnerability of that child meeting that individual again outside that school, that club, or that activity. That is where the danger is going to be created.

As I said, most parents will assume that that school, that club or that activity is safe. They will assume that the people there, whom their child will encounter, will be safe, but the Government in this legislation are removing that security in saying, “We’re not guaranteeing that. All we’re guaranteeing is that physically while your child is in that environment, those people are supervised and therefore no abuse can take place”. The real, persistent danger of people who are extremely clever and extremely manipulative in getting access to children is not that they are going to do whatever they do in front of other adults or in the school or club or during the activity time. They will want to do it away from those settings, and they will do it because they have built up that bond of trust. I appeal to the Minister. It may be that he can give us enough reassurances about what,”

    “all the circumstances for the purpose of protecting any children concerned”,

will amount to, but I doubt whether those assurances can ever protect that trust. The only way that that can be achieved is by not drawing this distinction in this way but by accepting the amendment moved by the noble Lord, Lord Bichard.”

It was also supported by Baroness Howarth of Breckland, former Chief Executive of ChildLine, who said:

“I want to concentrate on the people who are likely to abuse. I declare an interest as the vice-chair of the Lucy Faithfull Foundation, of which I have been a trustee for some 20 years. It is the organisation that pioneered the work in grooming and understanding the nature of abusers.

As the noble Lord, Lord Bichard, said, there is no doubt that these individuals will see this as open season on children-and I choose my words carefully. I have probably been involved with more of these men than most-some women, but mostly men-and so I know just how deceitful, clever, manipulative and strategic they are. They have a long view. These individuals do not just move in, see a child and think they are going to abuse them; they plan their moves carefully. There has been talk about building trust, but when a teacher can systematically abuse a child in a classroom, as in a recent case, noble Lords should take that as an example of what these kind of individuals can do, and then recognise that there are others right across the country who are thinking at this moment, “Will there be another opening for me to reach a child?”.

I have also worked with victims of that abuse. Imagine it was your son or daughter who had been buggered or raped by one of these people, who had gained their trust. The child or young person involved believes that they are implicated-the trust means that they carry the guilt. This is why often these youngsters will not come forward early, but if you talk to rape crisis lines or the people who deal with adult abusers, time after time they will tell you how the guilt kept them from telling. Research may show that if you talk to young people there is less of it, but many youngsters will not say that it is happening to them because they have that guilt.

As far as supervised access is concerned, anyone who has recently been to any of the youth provision that is around will know how hectic it is-properly so, for young people enjoying themselves-and that “supervision” is a strange word. In fact, you are just about maintaining the peace in some of these organisations. It is very easy for these individuals to make contact with the young people. As has already been said, modern technology makes it even easier.

I can see the Minister sitting there thinking, “We have heard all this before; we have our position”. But I would say to him that if you really care about our nation’s children and what happens to them in their adulthood after these incidents have happened, when they are unable to make relationships, when their marriages break down, when they have problems with their own children, when they end up in mental hospitals or in prison-if you look at any of those cohorts you will find that a lot of these youngsters have been abused-then you will find a way to absolutely ensure that it is not as loose as this. Anyone who is likely to abuse a child must be able to be checked so that certainty can be held by a parent and indeed by the child-and in some ways by the individual themselves because the abuser’s life is destroyed as well if they are not helped to not go through all of this. I hope the Minister will do so.”

 The Government Minister, Lord Henley, had a difficult time in replying to the debate, but resisted accepting the points made:
“9.45 pm

The Minister of State, Home Office (Lord Henley): My Lords, the noble Lord, Lord Rosser, asked that I should take particular note of what the noble Lord, Lord Bichard, said in moving his amendment. I can give him, the House and the noble Lord, Lord Bichard, an assurance that I will do that. Our time goes back a long way to when I served with the noble Lord, Lord Bichard, in the former Department for Education and Employment and I hope that we both have a great deal of respect for each other.

I echo the introductory words of the noble Lord, Lord Bichard, when he said-this is important-that we cannot completely eliminate risk. We understand that. He also made the point that we must be proportionate in how we manage these matters and accept that we must try to reduce bureaucracy as and where we can. I was grateful for the wise words of the noble and learned Baroness, Lady Butler-Sloss, when she referred to the need to reduce the unnecessary CRB checks that were taking place.

It is important for us to remember that it is a question of balance. It is one that we can never get absolutely and completely right and we will probably have to go on arguing almost until the cows come home before we can resolve these matters. We should try to get it right, but the balance will be perceived differently between one individual and another.

By way of background, I reiterate that the Government believe, as do many outside bodies, that by scaling back the scope of regulated activity, and thus disclosure and the barring scheme, we can strike a better balance between the role of the state and that of employers or other organisations in protecting the vulnerable. Both have a role to play.

Clause 64 and the amendments to it provide that certain activity, which would be within the scope of regulated activity in relation to children when unsupervised, will not constitute regulated activity when it is subject to day-to-day supervision. An example was given to me-I think by my noble friend Lady Walmsley-of a technician in a school. He certainly would be covered. The amendments take us back to the wider scope of regulated activity as it existed under the previous Administration.

Baroness Walmsley: In a letter to the noble Baroness, Lady Randerson, of 1 February, the noble Lord suggested that an IT technician would not be regulated.

Lord Henley: The noble Baroness has caught me out and has got the letter that I wrote. I shall have to look again at the letter I sent to my noble friend and check that. I take back what I said but my understanding is that that is not the case. However, obviously I have got that wrong.

Baroness Butler-Sloss: Would the technician be covered?

Lord Henley: My Lords, if my letter-written with the great authority of myself-said that he would not, obviously he would not. However, my understanding-I have obviously got it wrong and I will have to look very carefully at that letter-is that he would be covered in a school. Perhaps I may look at the letter and then get back to my noble friend.

Baroness Randerson: To clarify the situation, my recollection of the Minister’s letter is that he would be covered in a school but not in a college.

Lord Henley: I am grateful to my noble friend for that correction. My noble friend Lady Stowell has just reminded me that there is a strong distinction between schools and FE colleges. For that reason I think it is very important. Oh, dear, I have to give way to the noble Lord, Lord Harris. Can he wait and let me finish my remarks? Calm down, as they say. I shall look very carefully at what I said. Obviously there is an important distinction between the two. I now give way to the noble Lord.

Lord Harris of Haringey: All I would ask is that when the noble Lord is looking very carefully to clarify that distinction he also looks at the situation of the large numbers of volunteer assistants in schools and volunteers used for out-of-school activities linked to the school-for example, to interest children in science, since we have been talking about technicians, but it could also be in art or other activities-to see whether they would be covered.

Lord Henley: Of course I will look at those matters and respond to my noble friends Lady Randerson and Lady Walmsley. I will even send a copy of that letter to the noble Lord, Lord Harris, in due course.

Let us return to the amendments because that is the important thing to do. I suspect this might now have to be the last amendment that we can deal with. In putting forward the amendment, the noble Lord has questioned whether we are confident that any supervision would be adequate to protect these children. In making the case for these amendments, reference has been made to the concept of secondary access. Some commentators imply a unique causal link between initial contact with the child and later contact elsewhere if the first is the place where most work is regulated activity. We do not accept that premise. Initial contact may happen where regulated activity takes place or it may happen in some other setting, such as a leisure centre, library, church or wherever. In our view, one type of setting does not offer significantly more help than any other for seeking contact with the same child later and elsewhere. Whatever the setting, we believe that parents have the primary responsibility for educating their child in how to react to an approach from any adult if it goes beyond that adult’s normal role. I give way to the noble Baroness.

Baroness Howarth of Breckland: Is the Minister seriously suggesting that, if there was a CRB check showing that an individual was dangerous to children, it would not be noted because this was supervised contact? That person could then contact a child through all the known mechanisms, which parents are totally unable to deal with, and abuse that child. Do the Government believe that it is acceptable that that should happen?

Lord Henley: My Lords, I accept the noble Baroness’s great experience in these matters. She is pointing to an occasion where a CRB check has been taken out on an individual and it becomes clear that they are not suitable to be employed in the school or wherever. In that case they are not going to be. So I do not quite see the point that she is making. Do I give way to the noble Baroness again? We must get this right.

Baroness Howarth of Breckland: I was saying that the Government do not take responsibility for secondary contact. The problem is that we are not necessarily talking about a school; we are talking about youth facilities where trust is built up between a young person and a child and where supervision may take place but not the kind of supervision that can have oversight at every moment. A CRB check might well show that one of the volunteers in that setting is dangerous. At the moment those CRB checks would be taken up. But the person concerned might make contact outside the primary setting. That at the moment is covered and children and young people are safe. Under the new situation it seems to me that they will not be safe.

Lord Henley: I do not accept that. Let me see if I can get this right. I think what the noble Baroness is trying to imply is that any number of checks will provide the safeguard. I do not think that safeguard would be provided by a CRB check in the particular case that she outlines because we have now moved on to some secondary setting. Does the noble Baroness follow me?

Baroness Howarth of Breckland: To clarify the point, if a CRB check has not been taken out because this is a supervised setting and the volunteers are supposed to be supervised, and the person is actually an abuser who could have been identified by a CRB check, under the new provisions will that person no longer be checked and therefore be able to build up a position of trust with a child which, in a secondary setting, they could abuse?

Lord Henley: Will the noble Baroness accept that there is also a role for the parents in terms of the guidance that they offer their children in that role as well? That was the point that I was trying to get over. I shall give way again.

The Archbishop of York: I go back to the Soham murders. Huntley happened to be a caretaker and these girls trusted him because he was the caretaker and they had seen him in school. On that day, there was no supervision. What happened to those girls? I would rather be on the side of stricter rules and in time try to water them down a bit than assume that, because someone is in a supervised role, they cannot do something worse when they are in an unsupervised role. The word “supervision” is very loose. Unless it is tightened up, people like me will still be left worrying about what happened to those girls. The caretaker was not in a supervised role at that particular point and that is when he did it.

Lord Henley: My Lords, on the contrary, it would be covered now, and following the changes that we are going to make it would still be covered. He was not covered by what was in place before and that is how he slipped through the net. That is why the noble Lord, Lord Bichard, was asked to set up his review into these matters and why the changes were made. The point that we are trying to make is that the changes have gone too far-this was the point also made by the noble and learned Baroness, Lady Butler-Sloss-in terms of the bureaucracy involved. As the noble Lord, Lord Bichard, put it, one can never totally eliminate risk and there has to be a degree of balance in how one deals with these matters. One must be proportionate. Merely to think that any number of checks imposed by the state is going to eliminate all risk is, I suspect, a wish too far. I give way to the noble Lord.

Lord Harris of Haringey: My Lords, I am grateful to the noble Lord. He said a few moments ago that there is a responsibility for parents in this. The difficulty is that the normal assumption of parents will be that every person whom their child comes into contact with in a club or other activity is safe. So presumably what the noble Lord is saying is that, in the guidance that will explain what all this means, parents will be provided with a list. It will say, “The following people whom your child comes into contact with have been checked and the others on the list have not been checked. Please advise your children not to have any contact outside this activity”. That is the implication of what the Minister is saying. Of course parents have a responsibility, but what the Government are doing is creating a situation in which parents will think that an environment is safe, but it is not because some individuals will not have been checked and those individuals may build up a relationship of trust with a child that they could choose to abuse at secondary contact.

Lord Henley: The noble Lord may say what he wishes, but he should not try to put words into my mouth, which is what he is trying to do. He is trying to suggest that we could tell all parents exactly who is safe and who is unsafe. Obviously we cannot do that. What we are trying to do is create a system that will provide the necessary safeguards but does not make parents feel that their children are automatically safe. Parents must still have the duty of looking after their children by warning them of potential dangers. They should not assume that merely because someone has been CRB-checked, merely because the process has been gone through and merely because every box has been ticked, which is what the noble Lord seems to suggest, all is safe.

Lord Harris of Haringey: My Lords-

Lord Henley: I am not going to give way to the noble Lord. I am going to get on with my speech. If the noble Lord will allow me to do so, I will continue.

These amendments seek to preserve what we believe is a disproportionate disclosure and barring scheme that covers the employees and volunteers far more than is actually necessary on this occasion for safeguarding purposes. In so doing, it subjects all the businesses, organisations and whatever to unnecessary red tape and discourages volunteering. The noble Lord, Lord Bichard, also made the important point of whether it would still be open to schools, organisations and businesses to continue to check volunteers and others. Of course they can, and we will ensure that they are still able to request the enhanced CRB certificate when necessary. We want to emphasise the importance of good sense and judgment by the managers on the ground when they look at this issue. That is at the heart of our proposal and it is why we think we have got the balance right. The noble Lord, Lord Bichard, is now looking somewhat quizzical but no doubt we can have further discussion about this between now and another stage.

The right thing is to get the correct balance in how one looks at these things. The noble Lord asked about schools and what they could do. This gives local managers the ability to determine these things flexibly and make extra checks. With the various interruptions I have had, I appreciate the slight muddle I got into earlier over the letter to my noble friend Lady Walmsley. There has been a degree of confusion here.

Baroness Walmsley: Will my noble friend give way?

Lord Henley: Can I just continue these matters? I hope that I have answered most of the points that the noble Lord put forward and that he will feel able to withdraw his amendment.

Baroness Walmsley: I am grateful to my noble friend. Could he just clarify one point? The volunteers we are talking about here are the volunteers who see children on a regular basis. That is correct, is it not?

Lord Henley: Correct.

Baroness Walmsley: I have one second point before my noble friend rises to answer. I accept that people who are not regulated can still be CRB-checked but the employer cannot get barring information. Unless the person has committed a crime and got on the police records in that way, the employer who voluntarily carries out a CRB check still does not know if that person has been barred. I understand that Sir Roger Singleton claims that 20 per cent of the people on the barred list have never been in contact with the police. Could my noble friend clarify that?

Lord Henley: May I write to my noble friend on that final point to make sure that I get it right? I will make sure that I look at my letter with the greatest care before sending it off to make sure that I have got it right. No doubt we will come back to this at a later stage. Meanwhile, I hope that I have satisfied the noble Lord, Lord Bichard, and that he is able to withdraw his amendment.

Baroness Butler-Sloss: Could I just put one question to the Minister? I preface it with the fact that I congratulated the Government-and still do-on the laudable effort to cut through a great deal of this red tape. I said that I share the concern right round the House about secondary access. I urge the Minister to go away and look at what we have said. It may be that some areas of secondary access could be differentiated from others-I do not know. He said that he might talk about it later. I urge him to do so.

Lord Henley: My Lords, if the noble and learned Baroness asks me to do that, then of course I will. It is obviously very important to get these things right-I want to get them right. Again, it is always a question of getting the balance right. That is what we are trying to do this evening. As I said, I suspect that the noble Lord may want to come back to this at a later stage. We will see. In the mean time, I hope that he is prepared to withdraw his amendment.

Baroness Hamwee: My Lords, at the risk of straining my noble friend’s patience-he has been very patient-he offered to come back on points that have arisen today. It is obvious that we are going to continue this subject with the next group of amendments, which we will come to next week. It would be extremely helpful if the noble Lord responded, as he has offered to do, not just before Third Reading but before we return to this next week. He may not wish to give an undertaking to that effect but I leave him with that thought. As the debate has gone on, I have made more and more notes on his Amendment 50A, which will be the first amendment next Wednesday.

Lord Henley: My Lords, I do not know whether it will be next Wednesday when we come back to this. I remind the House again that we are on Report not in Committee, and I think I have been interrupted and intervened upon more than one would expect. I will try to write to my noble friend before the next day on Report on this Bill. Whether it will be next week, I do not know.”

I hope we will be able to return to the issue at Third Reading, although for procedural reasons it is not clear whether this will be possible.
Tuesday
Feb 7,2012

The amendment I have signed to the Health and Social Care Bill that would place a “duty of candour” on NHS trusts has been highlighted in a letter from patients’  organisations to the Daily Telegraph today.

The amendment I have signed would require NHS bodies to tell patients when they make errors and cause harm.  According to the Telegraph report, the letter:

“the Government is merely “paying lip service” to the principle in its health bill, and that clauses meant to ensure trusts are more open will be “next to useless in preventing cover ups.”

Since April 2010 trusts have been legally obliged to provide anonymised reports of incidents causing significant harm to the National Reporting and Learning System.

However, they are not required to tell patients or the close family members, and the bill does nothing to address that.

Peter Walsh, of the charity Action against Medical Accidents, one of the 10 groups behind the letter, said: “The current situation means health organisations can effectively cover an incident up from a patient or family member, so long as it sends off an anonymised report.”

The letter also notes the duty of care, as envisaged in the Health and Social Care Bill, would not apply to GPs or dentists and “would only relate to incidents which had already been notified to official bodies”.”

The amendment which is currently signed by myself, the independent cross-bench peer, Baroness Masham of Ilton, and the LibDem, Baroness Tyler of Enfield, would make it necessary for healthcare organisations registered with the Care Quality Commission “to take all reasonable steps to ensure that a patient or, in the event of death or incapacity, their next of kin, are fully informed” of such safety incidents.