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I thought that the visit to Washington resulted in a major discussion between the President and the Prime Minister, and that is part of a constant assessment which must take place. In the context of that assessment, I have no difficulty at all in saying to the House that we have been very much more forward-leaning in talking to Syria and Iran and in trying to engage them in this process in a constructive way than, in my judgment, the United States has been, and I believe that we should continue to be so. If there is a difference about the extent to which we should do it, or the rapidity with which we should do it, I believe our position is right. The region cannot do without the major players, who can be so disruptive, taking part in processes that may be more constructive; hence the force of the point made by the noble Lord, Lord Howell, about not antagonising them too much in the process, if I can paraphrase him in that way.
I conclude my comments on the important points and questions raised by both noble Lords by saying that these are acutely difficult times. There should be no attempt to pretend otherwise. I do not suggest for a moment that, for example, four provinces with a significant part of the population are not still among the most difficult of all the problems that are faced, because I agree with that analysis. We see a willingness on the part of the Government of Iraq to stand up, to do the job that is required and to take over with assistance and our assurance that we will not abandon them before we know they can actually do the job. That is not a bad principle to guide what we do. How fast it may succeed, and whether it will succeed, are matters on which we will be tested—I accept that. However, if we believe that the democratic process in Iraq should be given every chance of succeeding in the interests of the people who have been oppressed by a brutal dictatorship for a very considerable period in recent history, then let us give it that chance. Let us have the honesty to say to the people of Iraq that we stand for democracy and we intend to fight for democracy.
5.56 pm
Lord Foulkes of Cumnock: My Lords, I thank my noble friend for repeating the very full and very clear Statement made by Des Browne in another place. It is
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Lord Triesman: My Lords, on the last point, I believe that there is huge support everywhere for the forces of the United Kingdom and huge admiration for what they do. My personal opinion is that providing encouragement and boosting morale are never amiss, however difficult the circumstances. That is an important point. However, I would never say of either the Opposition Benches or the Cross Benches that they have disregard for the interests of our forces.
My noble friend’s other points strike a very real chord with me. I believe that we would be criticised and the Prime Minister would be hounded mercilessly if he did not talk to the American allies or to President Bush. Someone would say, “He has not gone to Washington for 6 months, 9 months or a year to hold discussions”. The demand would be that we should make those journeys, see people in the various capitals and ensure that the work is done. We should therefore expect those who believe that the democratic project is of genuine importance to the United Kingdom to be a little more upfront in saying that it is important to stay and see the job through rather than insisting, as I sometimes feel is done in the background, that it is all so disastrous that withdrawal with our tail between our legs is the only option.
Lord King of Bridgwater: My Lords, does the Minister recognise that it is precisely because we care for our Armed Forces and support them to the hilt that we express our concerns, on their behalf as much as anybody else’s? I very much regret the comment of the noble Lord, Lord Foulkes, which was entirely contrary to the spirit of your Lordships’ House and the recognition of the challenges facing our Armed Forces. There is no suggestion that the Prime Minister should not speak to President Bush. It is vitally important that he does. We are having this Statement today because of an urgent Question tabled by the shadow Foreign Secretary in another place suggesting that it might be a good idea if the Prime Minister spoke to Parliament as well as to President Bush. Is not the striking feature of the Iraq Study Group the
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Lord Triesman: My Lords, I hope I have said enough to convince the House that I believe that support for the Armed Forces is shared on all sides. Today’s Question may well have been tabled by the Opposition, but I draw to your Lordships’ attention the fact that—aside from our frequent debates in this place, especially over the past 22 days—there have been 60 debates on Iraq since mid-2003 in the other place. It is scarcely short of debates on Iraq. Whether people regard the debates as satisfactory, or having the outcome they would have wished, is an entirely different matter from the frequency or seriousness with which the other place takes these discussions. The other place has recently decided that the time has not come for the kind of review or study that the noble Lord has just urged. That time may well come, but the House of Commons has decided that that moment is not this moment.
Lord Craig of Radley: My Lords, I thank the Minister for repeating the Statement, which is interesting in that it was a statement by the Secretary of State for Defence. I understand why the Minister is responding to this debate. Inevitably, however, the questions and discussion have moved further away from the Armed Forces than perhaps they should at this difficult time for them. My reading of the Statement is that the Armed Forces will be expected to stay there pretty well at the current level, albeit the job may change somewhat. Do the Minister and the Government recognise that the Armed Forces have been committed way above defence planning assumptions for a considerable time? There is no reduction in the likely requirement for effort in Afghanistan. It will not conceivably be possible to continue at the current level of overseas deployment without lasting damage to the Armed Forces. I hope that the Government will take that into account in the Armed Forces’ long-term interest.
Lord Triesman: My Lords, I share the view that we must be concerned about the difficulties of lengthy, extensive commitments. I hope I have made it clear to the House that our intention is that, as we move to Iraqi takeover of security, the Armed Forces will be drawn back from the front line. Once we have seen whether the Iraqi forces can stand up to the difficulties they face, there should be a real prospect of our forces being drawn down. I recall pointing out to the House just over a week ago that the overall number of forces committed in theatre reduced slightly in the last year. Of course, I would hope that
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Lord Garden: My Lords, the Iraq Study Group was not the only body advising the American President. He has now had advice from another group which is composed predominantly of retired senior military officers. I believe he received the advice yesterday. Does the Minister know what that advice was, and can he confirm reports from some members of the group that it was effectively completely contrary to the advice of the Iraq Study Group and apparently met with the approval of the President and the Vice-President? Under those circumstances, how does the Minister see the strategy going ahead, if we think the Iraq Study Group has got it right but the President thinks that his retired military advisers have got it right?
Lord Triesman: My Lords, I am always extraordinarily cautious about commenting on retired military personnel—they always at least purport to know more than the rest of us mortals. I am aware of the report although I have not been able to study it in detail; the Iraq Study Group’s report is the document which we have been studying. The ministerial teams in the FCO and I am quite sure in the MoD and across government will be studying the two reports together and looking at the comparisons. In these circumstances I can well imagine people arguing fiercely about the different perspectives that have emerged. I cannot say that everyone will end up agreeing, and I have no reason to believe that they necessarily will. But until we do the study, I cannot tell you that we will not.
Lord Eden of Winton: My Lords, the Statement made welcome reference to the increase in the size of the Iraqi armed forces and to their success in recruitment, but it made little reference to the Iraqi police forces. I think it is widely known that they are not totally reliable and have been substantially infiltrated by insurgent elements. Can the Minister tell the House anything about the state of the Iraqi police forces, whose activities are most important in curbing the horrors that are going on there?
The Minister also referred to the need to get the peace process back on track. He talked about the consequences of what happened in Lebanon. Do the Government fully understand what great damage has been done to the peace process and particularly to Lebanon as a result of the Israeli action, which the President and the Prime Minister appeared to condone? They certainly did not make any protest against it or any attempt to halt it. The damage has been far reaching, not just in its physical impact on Lebanon but also in its effect on the political situation there. We are yet to see what could develop as a result of the danger arising from the strength of Hezbollah as a result of Israeli action.
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Lord Triesman: My Lords, in all debates on problems across the Middle East there has been widespread recognition that there were serious rocket and other attacks on Israelis from southern Lebanon and that the Israelis responded. We consistently said that it would be wholly unacceptable to the United Kingdom if the response were disproportionate. I do not believe that there can be anybody who does not know that the United Kingdom expressed strong views to the combatants on both sides, or that unless we dealt with both sides there could be no prospect of cessation. I do not accept the argument that we damaged the peace process by doing that, although I am clear that the conflict set the peace process back a long way. I can only hope, as others do, that it was a significant wake-up call and at least alerted people. The Palestinian President and the Prime Minister of Israel have tried to find ways of talking again, rather than seeing those problems recur.
On the question of the police in Iraq, there is plainly some influence and action by militia forces infiltrating the police forces, which is a very serious matter. Prime Minister Maliki has committed himself to tackling the security issues and the sectarian forces behind them and to promoting national reconciliation. As a result, a process of reform is taking place in the ministry of defence and the ministry of the interior, which controls the police. I do not for a moment suggest that it will be an easy process to deal with, because some of the conflicts are between Shia groups, let alone conflicts between Shia and Sunni. They are being played out in police forces as well, but I submit that we have as much responsibility to assure the Iraqi people of quality in the police force as we do in security and military terms.
Lord Wright of Richmond: My Lords, I apologise to the Minister for not being here for the Statement. I add to the questions asked by the noble Lord, Lord Eden. I do not know whether our failure to call for a ceasefire in Lebanon—indeed, even worse, our apparent encouragement of the Israelis to continue their military action for a further week—has damaged the peace process, but does the Minister agree that it has severely damaged our influence in the Middle East?
Lord Triesman: My Lords, every Foreign Office Minister who has responded to that question during the course of the conflict and subsequently has made the point that we believe that both sides should cease firing at each other, but that a unilateral pause by one side was unlikely to be sustainable as a matter of practical reality. I do not accept that that was an encouragement to one side to continue. The truth was that people were going to try to defend themselves. The question of proportionality arose in that context as long as rockets were being fired. It needed both sides to stop, and that was the appeal that the Government made.
Baroness Williams of Crosby: My Lords, I was in the United States on Friday and Saturday, when the statement was made by the Iraq Study Group. It
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None of us would deny the importance of discussions between the Prime Minister and the President but, given the importance in a democratic country of having a representative voice in one’s head of government, why does the Prime Minister feel unable ever to express any public view that has any difference from the United States, even on an occasion such as this, when the Iraq Study Group was of crucial importance in widening out the possible solutions to the dreadful fiasco that we have in Iraq?
Lord Triesman: My Lords, the noble Baroness, Lady Williams, may be putting the point a little unfairly. The Prime Minister said that we believe that the Iraq Study Group has gone along strategic lines with which in many significant respects we agree. It may be that others do not agree with it and have either said that they do not agree with it or did not say enough to show that they agree with it. Everyone can draw their conclusions. I do not know that it is necessary to put it in other terms or to open a breach that might become unnecessarily wide. There is an argument going on. There is another report, which may win more support among at least some in Washington. We have made our position clear. If it is not wholly aligned with other people's positions, all I can say is that it is our position.
Viscount Waverley: My Lords, there was certainly ambiguity when the Minister in an earlier response talked about safeguarding democracy, when the West often does not accept free and fair elections in the region or elsewhere. Have the Iranians and Syrians submitted thinking and proposals for peace in Iraq? If so, what might they be? Secondly, would the Minister clarify what constitutes civil war?
Lord Triesman: No, my Lords, I will not clarify what constitutes civil war. During the past 10 days I have been supplied with endless academic tracts, more or less none of which agreed with each other. Although I feel that I am being drawn back into being a more successful academic than perhaps I was when I was doing the job, I do not know that it is a great advantage to the House to rehearse the argument here.
On Iran and Syria, the discussions are really only just beginning—certainly so with Syria and increasingly, I believe, with Iran—about what the role might be. It is too early to answer that question, although there is a very important question about how to get them engaged. I believe that everywhere we accept free and fair elections. If the reference was to Hamas, as I suspect it was, let me say that there is no
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Earl Attlee: My Lords, is the Minister aware that I strongly support the comments of the noble and gallant Lord, Lord Craig, on exceeding defence planning assumptions? We are seriously damaging our Armed Forces in the long term. There are two buzz-words or phrases in British military doctrine: the comprehensive approach and effects-based planning. What is the desired end state in Iraq for the militias and armies, as agreed with the Iraqi Government? That seems to be rather at odds with the concept of a free and democratic society.
Lord Triesman: My Lords, I have no difficulty agreeing that the militias have no alignment with the idea of a free and democratic society. They would rather shoot people than encourage them to vote. There are a number of militias, and the prospects for engaging any of them by potentially drawing them into security forces on a legitimate basis, and holding weapons that are legitimately held under the control of a single authority—namely, the state—in relation to the use of violence, must be an option with some of the militias, as it is in resolving similar conflicts in other parts of the world. In some cases, I fear that it may not come to that; that is why the Iraqi Government and their forces must be in a position in which they can deal with those militias. In saying that, I do not for a second underestimate the difficulty, but that is the bottom line—the reality.
Health: Clinical Decisions
6.17 pm
Baroness Greengross rose to ask Her Majesty’s Government whether the indirect social costs of clinical decisions are being met by government departments other than the Department of Health.
The noble Baroness said: My Lords, I welcome the opportunity to discuss this important issue. The entire thrust of the Government’s health policy is towards prevention and early intervention and, in their care policy, towards maximising independence, autonomy and dignity. The guidance, therefore, that NICE issued last November on treatment for Alzheimer’s disease is illogical on two grounds. Withdrawing the drugs in the early stages of the disease clearly undermines the strategy on prevention. In the appeal statement, NICE stated,
- “the appraisal committee is not required to consider the broad clinical priorities of the Secretary of State”.
Should we ask how the clinical priorities are to be met when NICE’s guidance acts in the opposite direction?
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For early-stage Alzheimer’s sufferers, that decision also puts doctors in an invidious position, knowing that their patients have to get worse before they get treatment. Equally, the decision undermines the Government’s dignity in care priorities. In the introductory preamble to the dignity in care campaign, launched barely a month ago, some elderly people were quoted as saying that they felt neglected or ignored while receiving care. They felt that they were worthless or a nuisance and that they cost too much. It would be hard to imagine a more graphic example of a decision that was calculated to lead to a loss of dignity than the withdrawal of treatment that NICE acknowledges is clinically effective in the early stages of Alzheimer’s. If there had been serious doubt about the clinical effectiveness of these drugs, there would have been no outcry. However, the decision is not being taken on clinical grounds. This is particularly poignant, given that dementia strips the sufferer of so much autonomy and dignity.
NICE has an essential role and does an excellent job within its current remit, but issues arising from this decision should be re-examined, as they go to the heart of what the debate is about. Published figures do not include costs that are exported to other government departments, such as benefit costs to the DWP or care home costs to the Department for Communities and Local Government. NICE has acknowledged, for instance, that it had not accurately represented the true costs of long-term care, which are between £355 and £520 a week for full-time institutional care. Given regional variations, this is seriously inadequate. If these costs are to be factored into the decision, they must be accurately assessed in the first place. Surely one of the prime aims of treatment is to delay the moment when expensive institutional care is required.
We know that, if we can put off the need for full-time residential care for a reasonable period in the early stages of Alzheimer’s disease, many people, usually the very elderly, will die from some other cause before they need to go into an institution. That could save a considerable amount of money, and surely that must be taken into account, too. Equally, NICE has acknowledged that more research is required, and there is clearly a need for greater clarity about the ability of these drugs to slow progression. Why not continue to make these drugs available and monitor the outcomes so that we may know more and reach a more informed decision?
We know that if these drugs are not prescribed until the later stage of Alzheimer’s, some patients will instead be given powerful sedatives that are less acceptable and more costly. NICE acknowledges that that is outside the scope of its decision-making, but this cannot be ignored. NICE also recognises that QALYs—quality-adjusted life years—are a very blunt assessment tool for dementia and, even taking into account the compensation mechanisms that have been introduced, we know that they lead to unfair outcomes for older people in many cases.
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