§ 3.33 p.m.
§ The Parliamentary Under-Secretary of State, Department of Health (Baroness Hooper)
My Lords, I beg to move that the House do now resolve itself into Committee on this Bill.
Moved, That the House do now resolve itself into Committee.—(Baroness Hooper.)
§ On Question, Motion agreed to.
§ House in Committee accordingly.
§ [The CHAIRMAN OF COMMITTEES in the Chair.]
§ Clause 1 [Regional and District Health Authorities]:
Lord Winstanley moved Amendment No. 1:
Page 2, line 4, at end insert—
("(2A) It shall be the duty of the Secretary of State to ensure that appointments under Schedule I do not give prominence to one political party or opinion.").
§ The noble Lord said: I am sorry that with this very first amendment, which stands in my name and that of the noble Lord, Lord Ennals, I should cause party politics to raise its ugly head so very early in our discussion of the Bill. That is particularly regrettable as so many Members of the Committee from all parties have met together on a regular basis in the hope of dealing with the Bill on an entirely non-party and non-political basis and thereby making improvements to it to the benefit of the National Health Service, about which we are all concerned.
§ However, the matter which I raise is of some importance. It concerns the manner in which people are appointed to very important posts as chairmen of health authorities and so on.
§ It has been my experience in many years of working in the National Health Service, both in hospitals and in general practice, that over and over again with a change of government very able health authority chairmen suddenly disappear to be replaced by people whose qualifications for office appear to be no more than their own personal political affiliations. It may well be that some of them do a very good job. However, I have always been concerned not so much about the people who have been appointed to the bodies following a change 113 of government but about the people who have been removed from them. Members of the Committee on all sides of the Chamber will know of people who have given excellent service as chairmen of health authorities in various parts of the country who have suddenly, unexpectedly and regrettably been removed from office for no understandable reason. It may be that in some cases there is a perfectly understandable reason, but if the reason is party politics that is not acceptable. We should say so in the Bill.
§ I am delighted that the noble Lord, Lord Ennals, added his name to my amendment. I hasten to say that it is not aimed at one political party. I am sure that all political parties have been guilty of using their right to make appointments in a way which has been pDlitically advantageous. I certainly know that the Conservative Party has done so recently in relatiol to some committees. I also believe that the Labour Party did so on occasions. I am prepared to accept that a long time ago the Liberal Government, when there was one, did the same. I recollect that within my lifetime, when I was a small boy, David Lloyd George used patronage to very great political effect. However, that is another matter.
§ I am very glad that the noble Lord, Lord Ennals, has added his name to the amendment, because this is not a party matter. It is a matter of principle. Appointments to offices of immense importance for the success or failure of the National Health Service—to health authorities, family practitioner committees or the new family health service authorities-should be made on the basis of the suitability for office of the individual concerned rather than his party political affiliation.
§ My experience of the matter is in part anecdotal. I have looked on from the outside and wondered why A or B had been removed and why they had been replaced by C and D. My noble friend Lady Robson, who served with such great distinction as chairman of a regional health authority, has more personal experience of the matter. She may be able to tell your Lordships' Committee more about the subject.
§ I hope to hear a favourable response to the amendment when the government spokesman replies I shall say no more at the moment. I beg to move.
§ Lord Ennals
I am happy to support the amendment standing in the name of the noble Lord, Lord Winstanley. I was delighted to see it when it appeared on the Marshalled List. It is a very appropriate amendment with which to start our debate 3. As the noble Lord wisely said, over the past few weeks and months an attempt has been made to agree some measure of all-party approach to some of the amendments which will come later in the course of the Committee stage. Members of the Committee will have looked at some of the amendments and seen how broad is the basis on which they appear.
The principle enunciated by the noble Lord must be right. It must be right that people should be appointed according to their abilities, their 114 experience and their skill and not on the basis of their political party, although there may be times when an incoming Secretary of State would find that appointments have been very unbalanced in a party political sense and he might want to set the balance right. Certainly a Secretary of State taking up his post now would want to do so.
It is important that there should be a balance. The political parties will argue over what should be adopted as their policy to ensure the growth, expansion and improvement in the quality of service for the vast majority of our nation who depend upon the National Health Service. A far higher proportion of Labour voters may be dependent on the National Health Service than Conservative voters, who may be more dependent on the private sector, but we are all dependent on the National Health Service for a range of services which I need not go into. There is nothing wrong with having political arguments about the best way to organise the National Health Service. Although in Committee all the arguments will not be on an all-party basis, some may well appear to be.
There was a recent case in which the current Secretary of State, in appointing health authority chairmen, disposed of most of those with Labour or Liberal connections and brought in a significant number of people of Conservative views, so there is now no balance. I suppose that the most obvious of such decisions has been that to sack one of London's most efficient, popular and successful district health authority chairmen, Dr. John Dunwoody. I have never heard any criticism in the district of which he is chairman that he has sought to use his political influence to the advantage of his party. He is an absolutely dedicated man and I mention him only because he is a good example. I am not running down his successor whom I happen to know and respect and who is a noted Conservative politician. It is perfectly obvious what is being done and it is utterly wrong.
The policy of any Secretary of State should be to choose the best person. I recognise that it is not always easy to know who is the best person, but it is wrong to make appointments on a political basis. I sought to maintain a balance and to ensure that the right people were chosen. I have to admit when I was Secretary of State that I was often under considerable pressure from my own Back-Benchers to appoint particular people because of their Labour Party position or to sack people because they were Conservatives. I sought not to do that.
I see one good example. I am delighted that Mrs. Julia Cumberlege will shortly arrive in the House. She will be a great addition to the House; she is a woman of great ability. The fact that she is a Conservative has nothing to do with the matter; but she is a noted Conservative. I am proud of that fact because I appointed her. I appointed her because of her abilities, skills and experienceand her appointment has been fully justified.
The noble Baroness may say that the amendment is not necessary. She may say that we must trust her right honourable friend, but in view of recent appointments I do not trust him in that respect. Sometimes there are situations which should be 115 written into a Bill. The noble Baroness should remember that if by any chance—I shall not say mischance—there were to be a change of government, this amendment, if accepted, would apply as much to a Labour Secretary of State as it would to a Conservative one. The principle is right.
§ Baroness Seear
Before the noble Lord sits down, will he say whether he agrees that the use of the word "balance" in his speech is inappropriate in terms of the amendment? I thought that the point of the amendment was that we should get rid of the idea of people being there on a party political basis, so surely balance does not come into the matter. It is a case of either that or merit, not both.
§ Lord Ennals
I thought that I stressed the quality, skill and experience aspects. If a Secretary of State were to find on analysis that, for example, 85 per cent. of health authority chairmen were Conservatives, he would feel that there was something wrong. I am not saying what he would do; that responsibility does not fall upon me. But I should want to ensure that we had the best possible people. I totally support both the principle and the wording of the amendment.
§ 3.45 p.m.
§ Lord Jenkin of Roding
I agree with the noble Lord, Lord Ennals, in almost everything that he has said, but not with his amendment. I probably made more appointments of health authority chairmen than any other Secretary of State because it fell to me to appoint the 190 new district health chairmen when the areas were abolished and the districts were to be set up. I entirely endorse the proposition that one should choose people for their quality, abilities and experience and that politics should not enter into the matter at all.
I also agree with the noble Lord that that approach is not always popular with one's supporters. He mentioned John Dunwoody, who was one of my appointees. I appointed him to a district. I entirely agree with what the noble Lord said about him. Perhaps I may also mention Sir Sidney Hamburger, who was re-appointed regional chairman in the North-West to the total disapproval of every Conservative Member of Parliament in the North-West. I came under enormous pressure not to re-appoint Sir Sidney Hamburger. I reappointed him because he was an extremely good regional chairman. I cannot remember whether I appointed the noble Baroness, Lady Robson of Kiddington. If I did, I am proud of it—but she shakes her head. Perhaps it was someone else who came after me who appointed her.
Perhaps I may mention one or two other appointments that I made including Mr. Eric Moonman, who had been a prominent and able member of the Labour Party. I re-appointed Dr. Ivan Clout to a district health authority in Surrey, again to the total opposition of all the Conservative Members of Parliament for Surrey.
I accept the principle that politics should not enter into the appointment one way or the other.
116 Secretaries of State have increasingly looked for people with business experience as we have moved progressively from health authorities looking rather like local authorities with a large amount of representative membership to their becoming, as the proposals in the White Paper have it, much more like executive boards. There will therefore be a natural tendency to look for people with a strong business background. In those circumstances there may be a tendency for more of those people to have voted Conservative.
In many cases one simply did not ask what a person's politics were. People came with a good record. I am sure that the noble Baroness, Lady Seear, has, as so often, put her finger on the point; namely, that one may agree with everything that we have said about the absence of political bias being highly desirable and totally disagree with the amendment because it brings in political bias by requiring a balance or, as the amendment puts it rather negatively, that the Secretary of State should ensure that appointments,do not give prominence to one political party or opinion".If one finds that one is appointing or re-appointing 200 district health authority chairmen—in many cases one does not know their politics—and then discovers that, having appointed the best people, there are 70 per cent. from one party and 30 per cent. from another, must one then change some of those appointments so as to obtain something nearer 50-50? That is what the amendment means.
I hope that my noble friend on the Front Bench will endorse the principle that politics should notenter into the matter, but say that the amendment would not be the way to achieve that end. The best way is to ensure that Secretaries of State are prepared to resist the political pressures and appoint the best people.
§ Baroness Robson of Kiddington
As I have been mentioned, perhaps I may be allowed to quote some personal experiences, having been a regional chairman appointed originally by the noble Lord, Lord Joseph, at the end of 1973. I should like to pay tribute to his appointments of regional chairmen because, as far as I can see, there was absolutely no political bias in those appointments.
The Committee will probably know that it has been the custom for regional chairmen to meet at regular intervals prior to meeting the Secretary of State. In the early life of the reorganisation of the health service there was certainly never any political feeling among the regional chairmen. It was perhaps because we all felt that the appointments had not been made on a political basis.
In 1974 there was a change of government. It was not the noble Lord, Lord Ennals, but probably his predecessor who began what I would call the habit of appointing, when the opportunity occurred, chairmen of area and regional health authorities who had the same political views as those of the government in power. That caused the co-operative feeling among the chairmen to change somewhat. Once or twice it began to give a political bias to the discussions. With the further change of government in 1979 that attitude towards appointing a supporter 117 of the Government in office increased. I am sorry that the noble Lord, Lord Jenkin, did not have an opportunity to decide whether or not to reappoint me. For personal reasons I had to resign at the end of 1983, as no doubt he remembers. So he did not have to make up his mind as to whether or not a Liberal would be acceptable for a third term.
I am trying to say that the political bias in the appointments changed the relationship between the regional chairmen. I do not think it was a good influence on the way in which they worked together. However, when I unfortunately had to resign, which I very much regretted, I was asked by the noble Lord, Lord Jenkin, whether I could make any recommendation for a successor. I put up a name. With all due respect to the noble Lord's remarks about no political bias, the first question that he asked me was, "Do you know what his politics are?" That does not sound as though it were not a slightly politically biased question. I was also asked, "How many MPs in the region does he know?" I could not answer that question either.
My attitude was that I had recommended that person because I felt that from among all the people I knew he was the only one who could do the job. It had never occurred to me to ask him about his politics. I believe that that is the way in which appointments should be considered. I think it is essential to have an amendment of this kind to make certain that we guard against the kind of thing that happened in the past. It happened under a Labour Government and under this Government. I want to see appointed the people who can do the job.
§ Lord Auckland
I intervene in the debate with some diffidence because I have served only on a House committee and as president of a league of friends. Although I support the principle behind this amendment, I can see enormous difficulties in its implementation. I live in the Mole Valley which is a Conservative area, at the present time anyway. Where the late and lamented gentleman the Member for Ebbw Vale who initiated the National Health Service lived, there is a very strong Labour catchment area. In two such areas how is one to obtain suitable political appointments? That is my first point.
The noble Lord, Lord Ennals, mentioned Mrs. Julia Cumberlege. In my area of Epsom we are having what one distinguished former Prime Minister described as certain local difficulties in moving certain sections of our local hospital to another hospital. Ironically that move comes from a very distinguished person in the health service who is shortly to become a Member of this Chamber. I mention that because I believe that if this amendment is accepted there will be enormous cross-party differences when not only appointments but transfers of services from one hospital to another are made.
On that basis, although I support the principle of the amendment, I believe that its implementation would raise enormous problems.
§ Lord Boyd-Carpenter
Before the Committee makes a decision on this amendment one should look a little further not just into its purpose but at its likely effect. I think that most of those who have listened to this debate agree with the general philosophy that has been expressed from both sides of the Chamber, to the effect that appointments should be made on merit and irrespective of the political alignment of the people appointed. But the terms of the amendment that the Committee is asked to accept make clear that that will not be possible because it will impose a duty on the Secretary of State, apparently regardless of anything else, to make sure that the appointments do not give prominence to one political party or opinion.
Let us take the possible situation—indeed, the probable situation in many parts of the country—that most of the suitable appointees for posts are members of one party or another. In parts of the South of England there is very little doubt that a fairly high proportion of those suitable for appointment will more or less hold Conservative views. I am certain that in many other parts of the country the overwhelming proportion of those suitable for appointment will be of Labour Party views. It may even be so in the remoter stretches of outer Wales with people who hold various brands of Liberal views. The Committee therefore must look very carefully at this issue.
The amendment lays down that political alignment apparently should be the dominating factor in the decision on appointment. Let us take one of the examples that I gave, of an area in which the suitable people are overwhelmingly of the Labour Party. As I understand the amendment, the Secretary of State would not be able to appoint a good many of them but would find that the dominant consideration which he must apply, regardless of the respective abilities and merits of the people to be appointed, would be to have a political balance on that authority. Nobody wants that. Before the Committee decides upon this amendment, it ought to consider what would be its effect—not the intention nor the excellent motives behind it. That effect seems to me to be perfectly clear and very damaging.
§ Baroness Phillips
I believe that this amendment is necessary and very timely. As politicians we have all been guilty of allowing politics into almost every walk of life. I have always felt it wrong that one should ask about the politics of a potential magistrate, but that is done.
The Committee has talked about balance—that there must be some of these and some of those. Politics have crept into everything. When I was Lord Lieutenant—and I thought it was a tribute to me that they did not know my politics—I was often asked, "Are you one of us?" I used to reply, "Now which 'us' do you mean? I am a woman—that's obvious. I am a Catholic—that is another group. I am a socialist—yet another group. How many more do you want?
Politics have crept into our public life in a very insidious way. This is one way in which we can—I think for the first time—make it clear that people must be appointed for their abilities and on their 119 merits and not with a view to their age, sex, colour or political views.
§ 4 p.m.
§ Lord Ross of Newport
Perhaps I may make one point. In my part of the world, there are still Liberals—and it is not the deepest part of Wales. Our local chairman of the area health authority did not know until about seven days before his term of office expired whether or not he would be reappointed. Certainly everyone who served in that authority felt that that was outrageous. I put great pressure on the successor of the noble Lord, Lord Jenkin, to make a decision one way or the other. The chairman was reappointed for two years. Expedition in the making of appointments is an aspect that ought to be discussed during this debate. One knew that a search was being made to appoint someone else who held rather different views. In fact, someone else could not be found, and he was reappointed for two years. After the two years expired, sure enough, he was ditched.
We all know that in recent years far more party politics have come into the appointment of people in public office, whether in the health authority or outside. Patronage has become too widespread and it really must stop.
§ Baroness Hooper
I was interested to hear the experiences quoted by the noble Lord, Lord Winstanley, and others. I begin by agreeing completely with those who have said that party politics should not be the criterion in these important appointments.
In spite of what has been said by some, I must stress that appointments to health service bodies made by the Secretary of State and regional health authorities have never been made and so far as concerns this Government will not in the future be made on party political grounds. I cannot speak for appointments that have been made to the district health authorities in the past by local authorities. In fact, the changes in health authority membership which we propose in this Bill are a firm move away from any representative type of appointment or political bias.
The problem at present is that many health authority members tend to regard themselves asrepresentatives of the body which nominated them or, in the case of some district health authority members, the local council which appointed them. This has led to fundamental confusion as to whether health authorities are representative or management bodies. We believe that the Government's proposals will remove this confusion by creating smaller authorities of which the actual managers will also be members for the first time. There will be slimmer, more effective management bodies that will provide a single focus for effective decision-making. They will be unhindered therefore by the tendency of members to feel that they need to represent a body or indeed a political viewpoint.
Moreover, I must also point out that we simply do not have that information. Routinely—and I emphasise "routinely"—neither regional health 120 authorities nor Ministers at the centre ask about the political allegiance of candidates for appointment. As I have said, we do not propose to do so in the future.
§ Lord Peston
Perhaps I may intervene. We ought to conduct the debate on a basis of realism. Is the noble Baroness saying that her department is not bombarded with letters from all and sundry, in her case from members of her own party, drawing her attention to the politics of the people whom she is considering? If she is, there has been a miracle in Whitehall since the last time that I was involved.
I am not for a moment impugning her motives. But the suggestion that somehow one is unaware of the politics of people is so preposterous that I cannot believe we can conduct this discussion on that basis.
§ Baroness Hooper
I believe that the implication of the amendment is that that information should be routinely collected. That is what I am aiming to disprove with my argument. Certainly it is not routinely collected as of now. One cannot of course prevent anybody who so chooses from writing with views on any subject.
I believe—and I agree with those who have already stated so—that the aim is and must be to appoint the best person for the job in each case. People of various party political persuasions—indeed, some of none—have been appointed. That will continue. We do not know the political affiliation, if any, of most appointees. I believe that it would be wrong to try to collect that information, which the amendment implies that we should do. My noble friend Lord Boyd-Carpenter has very clearly pointed that out.
I believe the Committee would agree that it would be quite improper for me to comment on the appointment of named individuals. I simply reiterate that all appointments are made on the basis of personal qualities and experience of the individual concerned, not for any sexual or political reason. I believe that some of the examples that have been quoted this afternoon bear that out.
I hope therefore that I have said enough to persuade the movers of the amendment that, as my noble friend Lord Jenkin of Roding has said, the amendment is unnecessary and raises the question of political bias. That is why we cannot accept it.
§ Lord Ennals
I am very surprised at the reply of the noble Baroness. She seems to think that slimmer and more effective bodies are less likely to have a political chairperson appointed. We shall argue later about how slim or how efficient a body should be. However, I entirely agree with my noble friend's intervention. Any Secretary of State, whatever his political party, must be under great pressure to make appointments or not to make appointments, or to ensure that someone who has held a political point of view is not reappointed. I find it quite staggering for the noble Baroness to say that her department and her Ministers do not know. I am sure that the noble Lord, Lord Jenkin, would take the same view that I have done. Of course it is known.
This is an absolutely essential amendment. Anyone who has analysed what has happened in 121 recent appointments will see that there has been a very significant swing from one particular party, or no party, to another party.
The noble Lord, Lord Boyd-Carpenter, surprised me when he suggested that there were certain areas of the Country in which it would not be possible to find someone who had the experience, competence and skill to become chairman either of a regional health authority or of a district health authority except by making a political appointment.
§ Lord Boyd-Carpenter
The noble Lord misunderstands me, I am sure unintentionally. I said that there were areas in the country where the great majority of suitable appointees would, because of the general set-up there, be of one party or another and the effect of the amendment that he was supporting would be to prevent some of them being appointed by insisting on, above all, as a priority a political balance.
§ Lord Ennals
If I misunderstood the noble Lord, I am sorry. However, I do not think the logic of what he has said is conclusive. I believe that appointments should be made on the basis of skill and not on the basis of political commitment.
§ Lord Ennals
That is the purpose behind the amendment. I very strongly hope that it will be passed. We may make some further adjustment at Report stage to ensure that appointments are made on the basis of merit and not political allegiance. That might be a better way of proposing it.
I hope that we shall vote on an amendment that lays down a very important principle at the beginning of the Bill. I congratulate the noble Lord on having placed it at the beginning. I hope that he will decide to divide the Committee in order that it can express its view.
For once I am not in total disagreement with the noble Lord, Lord Boyd-Carpenter. I accept that the amendment could have been better worded. For any deficiencies that it may have, I apologise. I am responsible.
The intention is precisely that which I announced and which many people have understood. However, I accept, as the noble Lord, Lord Boyd-Carpenter, has stated, that its wording could require the Secretary of State to consider party political affiliation in order to achieve balance, and so on. That was not my intention. It is a very early stage of the Bill. We have later stages. If we carried the amendment and it is defective, it can very easily be altered. I am quite sure that the Government are capable of finding a better form of words.
I have listened to what the noble Baroness said. I was reassured about her opinion; but I already knew it. I am not reassured about what is happening. I accept that much of my recent experience is anecdotal because I am no longer in active medical practice. However, I have received information from sources in various parts of the country which I regard 122 as being reliable. It shows that in recent years there has been a large increase in the number of people removed from appointments for apparently political reasons and in the insertion of other people for reasons which at least appear to be political. That belief may be unfair to the Secretary of State responsible but that is what appears to be happening.
The noble Lord, Lord Jenkin of Roding, made an admirable speech which I was delighted to hear. I am sure that he acted in the way he described. He is to be congratulated on appointing Sir Sydney Hamburger as chairman of Manchester Regional Health Authority. Sir Sidney was a splendid chap who the noble Lord said remained in office. However, it is my understanding that he was later removed from office for reasons which were widely believed to be political. That was reported as being so in the local press, although perhaps wrongly.
It is most important that the public should be encouraged to understand that such appointments are not made on a party political basis. At this stage I should like the Committee to enunciate the general principle behind the Bill. If the amendment is badly worded or defective—and possibly it is—it can be altered at a later stage. Members of all parties have decided that they wish to keep party politics out of our debates during this stage and later stages. Therefore, it would be admirable at this first opportunity to take a decision showing that we do not want party politics to play any part in the running of the National Health Service. In those circumstances I wish to test the opinion of the Committee.
§ 4.11 p.m.
§ On Question, Whether the said amendment (No. 1) shall be agreed to?
§ Their Lordships divided: Contents, 85; Not-Contents, 141.124
|DIVISION NO. 1|
|Addington, L.||Graham of Edmonton, L. [Teller.]|
|Banks, L.||Grey, E.|
|Birk, B.||Hampton, L.|
|Blackstone, B.||Harris of Greenwich, L.|
|Blease, L.||Hatch of Lusby, L.|
|Bonham-Carter, L.||Houghton of Sowerby, L.|
|Boston of Faversham, L.||Hughes, L.|
|Bottomley, L.||Hunt, L.|
|Broadbridge, L.||Irvine of Lairg, L.|
|Burton of Coventry, B.||Jacques, L.|
|Callaghan of Cardiff, L.||Jay, L.|
|Campbell of Eskan, L.||Jeger, B.|
|Carmichael of Kelvingrove, L.||Jenkins of Hillhead, L.|
|Carter, L.||Jenkins of Putney, L.|
|Cledwyn of Penrhos, L.||John-Mackie, L.|
|Cocks of Hartcliffe, L.||Leatherland, L.|
|David, B.||Listowel, E.|
|Dean of Beswick, L.||Llewelyn-Davies of Hastoe, B.|
|Dormand of Easington, L.||Lloyd of Kilgerran, L.|
|Ennals, L.||Longford, E.|
|Ezra, L.||Lovell-Davis, L.|
|Falkland, V.||Macaulay of Bragar, L.|
|Fisher of Rednal, B.||McCarthy, L.|
|Foot, L.||McIntosh of Haringey, L.|
|Gallacher, L.||Mais, L.|
|Meston, L.||Robson of Kiddington, B.|
|Milner of Leeds, L.||Rochester, L.|
|Milverton, L.||Ross of Newport, L.|
|Mishcon, L.||Russell, E.|
|Molloy, L.||Sainsbury, L.|
|Monkswell, L.||Seear, B.|
|Morris of Kenwood, L.||Serota, B.|
|Nicol, B.||Stallard, L.|
|Oram, L.||Stoddart of Swindon, L.|
|Peston, L.||Strabolgi, L.|
|Peterborough, Bp.||Taylor of Blackburn, L.|
|Phillips, B.||Thomson of Monifieth, L.|
|Pitt of Hampstead, L.||Tordoff, L. [Teller.]|
|Ponsonby of Shulbrede, L.||Underhill, L.|
|Prys-Davies, L.||Williams of Elvel, L.|
|Rea, L.||Winstanley, L.|
|Ritchie of Dundee, L.||Winterbottom, L.|
|Adrian, L.||Hankey, L.|
|Airey of Abingdon, B.||Havers, L.|
|Aldington, L.||Hayter, L.|
|Alexander of Tunis, E.||Henderson of Brompton, L.|
|Allerton, L.||Henley, L.|
|Ampthill, L.||Hertford, M.|
|Annaly, L.||Hesketh, L.|
|Arran, E.||Hirshfield, L.|
|Auckland, L.||Hives, L.|
|Beaverbrook, L.||Holderness, L.|
|Belhaven and Stenton, L.||Hooper, B.|
|Beloff, L.||Howe, E.|
|Belstead, L.||Hunter of Newington, L.|
|Birdwood, L.||Hylton-Foster, B.|
|Blake, L.||Ilchester, E.|
|Blatch, B.||Jenkin of Roding, L.|
|Boardman, L.||Joseph, L.|
|Borthwick, L.||Killearn, L.|
|Boyd-Carpenter, L.||Kimball, L.|
|Braye, B.||Lauderdale, E.|
|Bridgeman, V.||Lawrence, L.|
|Brougham and Vaux, L.||Layton, L.|
|Burton, L.||Lloyd-George of Dwyfor, E.|
|Butterfield, L.||Long, V.|
|Buxton of Alsa, L.||Lucas of Chilworth, L.|
|Caithness, E.||Luke, L.|
|Caldecote, V.||Lyell, L.|
|Campbell of Alloway, L.||McColl of Dulwich, L.|
|Campbell of Croy, L.||Malmesbury, E.|
|Carnegy of Lour, B.||Mancroft, L.|
|Carr of Hadley, L.||Margadale, L.|
|Clanwilliam, E.||Marsh, L.|
|Clifford of Chudleigh, L.||Massereene and Ferrard, V.|
|Colville of Culross, V.||Merrivale, L.|
|Constantine of Stanmore, L.||Mersey, V.|
|Cottesloe, L.||Mountevans, L.|
|Crook, L.||Moyne, L.|
|Cullen of Ashbourne, L.||Munster, E.|
|Davidson, V. [Teller.]||Murton of Lindisfarne, L.|
|Denham, L. [Teller.]||Norfolk, D.|
|Dormer, L.||Nugent of Guildford, L.|
|Eden of Winton, L.||Orkney, E.|
|Effingham, E.||Orr-Ewing, L.|
|Elibank, L.||Park of Monmouth, B.|
|Ellenborough, L.||Penrhyn, L.|
|Elliot of Harwood, B.||Platt of Writtle,B.|
|Erne, E.||Porritt, L.|
|Erroll of Hale, L.||Reay, L.|
|Ferrers, E.||Renwick, L.|
|Flowers, L.||Rochdale, V.|
|Fortescue, E.||Romney, E.|
|Gainford, L.||St. Davids, V.|
|Gardner of Parkes, B.||St. John of Fawsley, L.|
|Gibson, L.||Saint Oswald, L.|
|Gibson-Watt, L.||Seebohm, L.|
|Gisborough, L.||Sempill, Ly.|
|Grantchester, L.||Shannon, E.|
|Gray of Contin, L.||Shaughnessy, L.|
|Greenway, L.||Skelmersdale, L.|
|Haddington, E.||Slim, V.|
|Hailsham of Saint Marylebone, L.||Smith, L.|
|Stevens of Ludgate, L.||Torrington, V.|
|Stodart of Leaston, L.||Trumpington, B.|
|Strathclyde, L.||Tryon, L.|
|Strathmore and Kinghorne, E.||Ullswater, V.|
|Sudeley, L.||Vinson, L.|
|Swinfen, L.||Walton of Detchant, L.|
|Swinton, E.||Wise, L.|
|Terrington, L.||Wyatt of Weeford, L.|
|Thurlow, L.||Young, B.|
§ Resolved in the negative, and amendment disagreed to accordingly.
§ 4.20 p.m.
Lord Walton of Detchant moved Amendment No. 2:
Page 2, line 12, after ("member") insert ("but this shall not prevent their re-appointment under Part 1 of Schedule 1 to this Act")
§ The noble Lord said: I trust that this amendment will prove non-controversial. The requirement in Clause 1(4) is that any person other than the chairman of a regional or district health authority shall, at the appointed day, cease to be a member of that authority. Of course, the intention is that the members of the authorities appointed from the appointed day shall constitute a new authority.
§ Throughout this country there is a very considerable reservoir of knowledge, experience, dedication and expertise among those who have served—some for very long periods and others for much shorter periods—as members of regional or district health authorities. I believe that it would be very sad for the National Health Service if those people who have given such sterling service on a voluntary basis for many years were to be totally excluded from membership of the new authorities. Therefore, the purpose of the amendment is simply to write into the Bill the fact that such individuals shall not be prevented, even after their membership of existing authorities ceases, from being appointed to the new authorities.
§ The amendment is not only crucial from the point of view of ensuring continuity; it is important in order that the expertise of those individuals shall not be lost. I beg to move.
§ Lord Ennals
I have put my name to the amendment and I support it. We are talking not only about chairmen of regional and district health authorities and family health service authorities in England and Wales. We are also talking about all those who serve as members—thousands of outstanding people up and down the country who serve voluntarily as members of health authorities. Many of those people have made the National Health Service as good as it is and we wish to retain their services.
The Government are proposing that there should be much smaller health authorities comprising five executive or employee members and five non-executive members plus a non-executive chairman. They have said no more than that those members will be chosen on the basis of the skills and experience which they can bring to the authority. However, critics expect and fear that in large part the outsiders will be businessmen. There is nothing 125 wrong with businessmen. There are some businessmen on health authorities at present and we should continue to use their skill and experience on the new authorities.
However, I should like to quote a letter from Mrs. Cumberlege. I have already referred to her but I do so now in her capacity as chairman of the South-West Thames Regional Health Authority. My former general practitioner, Dr. Mel Henry, a GP in the area of Richmond, Twickenham and Roehampton, serves on that district authority. He wrote to Mrs. Cumberlege to say how much he had valued working on the health authority and that he would be delighted, if given the opportunity, to serve again. I have kept in touch with Dr. Henry; he was an admirable and very able member of the health authority.
He received a letter from Mrs. Cumberlege which said:There is just one problem about membership of authorities in the future in that it is intended not to mix up the provider (ie, GP) role with that of the purchaser (ie, DHA) and as a consequence I am afraid I cannot be optimistic about being able to recommend you, or any other practitioner or consultant, for membership. I am sorry to disappoint you but I felt it better to be straight about it now rather than lead you to expect something that I know I shall not be able to deliver".I do not know how many existing members of health authorities have received similar correspondence from regional or district chairmen. That letter was unfortunate in two respects. It seems to confirm the impression that the Secretary of State is planning a clean sweep to bring in a new type of member with little knowledge of the National Health Service or indeed of the needs of patients and the community.
However, I ask myself: who could have approved such a letter? No chairman of a regional health authority would write a letter like that unless it had been approved in some way by the department. There must have been a steer in relation to the letter. It contains an assumption that the legislation before us is already on the statute book and that principles can be laid down which have not yet been debated in this Chamber. I find that very disturbing.
I do not make a personal criticism of Mrs.Cumberlege. As regards the earlier amendment, I have already said how much I respect her and her abilities. However, I fear that the Secretary of State is giving the impression I have outlined. That is why my noble friend and others have put their names to the amendment. I hope that the Minister will feel bound to accept it.
§ Baroness Cox
I shall not detain the Committee for more than a few moments but I wish to explain why my name is attached to the amendment. I hope that it provides clarification and that the Minister will be able to accept it. Surely it must be the intention that there should be provision for some continuity of experience and expertise. If that is the case, then the amendment is clearly necessary. It would do a great deal to allay anxieties about the ambiguity of the Bill as it stands. I hope that my noble friend can respond sympathetically to the amendment.
§ Lord Carr of Hadley
Before my noble friend replies, I wonder whether one of its supporters can enlighten the Committee as to the exact intention of the amendment. I see much objection to reappointment of people within their own district. I see no objection to their reappointment in other districts where a potential clash of interest and principles would not arise. Does the noble Lord wish to ensure that a person not reappointed in one area is nonetheless qualified to be appointed to another authority in a different area?
§ Lord Walton of Detchant
The intention is simply to write into the Bill the necessity of making it open for individuals who may have served on health authorities in the past to be available to be appointed to health authorities in the future. That is the purpose of the amendment.
§ Baroness Hooper
I understand the concerns expressed by the mover of the amendment. Therefore, I am very pleased to be able to reassure the Committee on the matter with which it is concerned. I believe however that the amendment—and I hope that I shall be able to explain this—is unnecessary.
There is absolutely nothing to prevent current members of health authorities being considered for reappointment as non-executive members of the reconstituted health authorities; indeed, we expect that a number of them will be. That is certainly in the interests of continuity, as was suggested by my noble friend Lady Cox. At the same time, I must emphasise that all the new appointments will be made purely on the basis of the personal contribution and experience which the individuals can bring to the work of a particular authority. I believe we all agree that appointments should be made only on that basis, as was brought out in our previous discussion.
Perhaps I may take this opportunity to pay tribute to the effective contribution that health authority members have made all over the country to the running of the National Health Service in recent years. With the smaller number of members and the introduction of some fresh blood, it will clearly not be possible for all current members to be appointed to the new style authorities. That will in no way be a personal reflection on their performances. We sincerely hope that many of them will continue to be involved with the health authority and that it will continue to benefit from their experience.
With regard to the point raised by the noble Lord, Lord Ennals, GPs will only be excluded from membership of district health authorities if they are practice fund holders. There would then be a potential conflict of interest as they would be direct purchasers of services. The appointment of the non-executive members of district health authorities will be a matter for the appropriate regional health authority acting within the terms of the new legislation, which is currently under consideration, but it will also be subject to departmental guidance. All non-executive members will be appointed on the basis of the individual skills and experience which they can bring to the authority.
127 The letter from Mrs. Cumberlege, to which the noble Lord referred, was, I understand, sent without reference to the Department of Health. As I explained, GPs will only be excluded from membership of district health authorities if they are practice fund holders.
Change is always unsettling for people who have been involved with an organisation for some time. Nevertheless, I am sure that it will be agreed that the government reforms, which will create smaller authorities and bring together executive and non-executive members to provide a single focus for decision-making, will increase the efficiency of health authorities and bring about the end for which we all earnestly hope—the maximum benefit to the patient. I therefore trust that the noble Lord who moved the amendment will feel able to withdraw it in the light of my reassurance that it is unnecessary and that there will be nothing to prevent current health authority members being considered for reappointment as non-executive members of the reconstituted authorities.
§ 4.30 p.m.
§ Baroness Masham of Ilton
Before the noble Baroness sits down, perhaps I could ask who the executive members will be and what sort of officers the authorities will have. I serve on a regional health authority and we have a very good mix. We have men and women. However, almost all the senior officers of the authority who are the present advisers are men. Will it be of benefit to patients if there is an imbalance of more men than women, as I think will happen?
I should also like to say that the businessmen who come on to the authority are the ones who understand the National Health Service least of all. They have hardly used the health service; they are generally healthy men who take quite a long time to understand how the authority runs. There is fear that fewer women will be serving in the health service in the future.
§ Baroness Hooper
I shall do my best to reassure the noble Baroness. In the department, when we are looking at names and nominations, we are always anxious to ensure that there is a very good mix in every sense of the word. I certainly anticipate that in making appointments to the new bodies, those who are making the appointments, whether from the centre or at regional health authority level, will be guided by the principle that they shall have the best possible mix of background and experience. And that includes a fair representation of women.
§ Baroness Phillips
It is perhaps a little unfortunate that the noble Baroness used the words "new blood". This is one of the "in" things, it is not? There are three magic words in our society; new, young and free. It does not necessarily follow that the new blood will be any better than the old blood that has gone before. Change is not always for the best. We live in a very changed society and I should certainly not say that many of the changes that we are seeing are for the best. To start with, this particular Bill will change things, but not for the better.
128 The suggestion was a little unfortunate: we all know the devastating feeling one has when one is pushed off a committee. Those are the only words one can use. It is not the same as being told by an employer that one is to lose one's job; in that case a reason has to be given. I recall being on the Consumer Council and as soon as the noble Baroness, Lady Oppenheim-Barnes, as she now is, came in, four of us were pushed off What had we in common? Not our lack of experience with consumer affairs. We all happen to be socialists—a pure coincidence, I am sure.
The words should be written into the Bill. It is all very well for the Minister to say that it will not happen. An advertisement will say that those who applied before may re-apply; otherwise, people tend to think that they have tried once, did not receive a reply and therefore will not try again. This is exactly the same situation. People who come off the authority will not expect to be reappointed; yet they are probably extremely valuable people. We want people of quality and dedication. We have had them in the past. The Government should think very carefully before becoming too hooked up on this "new blood" idea, particularly if it is to be all male.
§ Lord Jenkin of Roding
The noble Baroness voiced a very sound conservative principle when she declared that not all change is for the best. As we might perhaps put it on this side of the Chamber, the burden of proof rests on those who advocate change. We might invite the noble Baroness to cross the Floor at some time; she will find herself among friends.
When I heard the speech of the noble Lord, Lord Walton, I looked again at the Bill, because it did not seem to me that it contained anything to stop the reappointment of competent people who were eligible for reappointment. My noble friend on the Front Bench has entirely reassured me on that point. I certainly support the idea of smaller authorities and the proposition that within any particular district it would not be right to have providers and authorities sitting together; they will be faced with impossible conflicts of interest.
Subject to that, I hope that those with experience and who remain eligible will be fully eligible for reappointment. My noble friend has given the reassurance that we seek on that point. In those circumstances there is really no need to press the amendment.
§ Lord Monkswell
I wonder whether I may raise a point which the Minister mentioned regarding the possibility of GPs being on the health authorities. Part of the argument is that those who are budget holders should not be on the authority because effectively they will be employing themselves in some respects. However, we are in a situation where there are no budget holders and there will not be any budget holders until after the introduction of the new authorities. We are thus in a position of being asked by the Government to say that we will only pick health authority members who are not going to be budget holders. We do not know who they will be and therefore almost by definition the 129 Government will exclude all GPs because they might become budget holders. There is concern about that philosophy and attitude of mind. In effect we shall see the total exclusion of GPs from health authorities.
We all recognise that GPs have made a significant contribution as members of health authorities. Perhaps I may expand a little on that point. We do not argue about GPs being members of family practitioner committees, where in effect they are employing themselves. Therefore the argument that as budget holders they should not be members of a district health authority does not hold water. The providers of the service have always been involved in running the service. One should not discriminate against some providers by saying that they should not be involved in overseeing the service. That is a new idea from the Government. It is almost a new principle, and it is being introduced without the sanction of Parliament and without any real consideration by Parliament. This is not the way to seek change, especially in such a significant institution in our British way of life as the National Health Service.
§ Baroness Hooper
I am grateful to the noble Lord for emphasising this point because it is important to reassure people and to allay any anxieties which may have arisen as a result of the introduction of these proposals. I should like to reaffirm that it is not intended that GPs as a group should be excluded from regional health authorities or district health authorities. We shall bear that very much in mind when issuing guidance. I should also point out that no appointments will be made in this respect until after the Bill receives Royal Assent. As to the point raised by the noble Baroness, Lady Phillips, to which my noble friend Lord Jenkin to some extent replied, it is in the nature of things that fresh blood must be introduced from time to time. That is recognised even in your Lordships' House.
§ Lord Walton of Detchant
I agree entirely with the noble Lord, Lord Jenkin, that there is nothing in the Bill to preclude the appointment to health authorities of those who have served on such authorities in the past. The purpose of the amendment was to fulfil a probing function. In the light of the clear and unequivocal assurances that we have received from the Minister, I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ 4.45 p.m.
§ On Question, Whether Clause I shall stand part of the Bill?
§ Lord Peston
I put down my name to oppose the Question as a means of probing an aspect of the Bill which I find somewhat arcane. In the Explanatory and Financial Memorandum of the Bill there is a straightforward sentence which I can understand. It states that Clause 1,streamlines the procedures for altering the boundaries of regions and districts".130 I assume that Clause 1(3) deals with streamlining. It refers us to the schedule. I confess that I cannot make head or tail of any of the wording of the schedule, but that is the only part of the Bill that could remotely refer to streamlining. I hope that I am talking about the right part. I want to ask about the streamlining procedures. I am probing at this stage rather than tabling an amendment in the hope that I can have some explanation of what the Government have in mind.
The boundaries of regions and districts are extremely important. Indeed the way the Government's proposals work in practice will certainly depend on the boundaries of the regions, the districts and the FHSAs. Nothing makes this point more clearly than a consideration of the way fund-holding practices will work. What a fund-holding general practitioner can do, and for that matter what someone who is not a fund holder can do, will depend on definitions of boundaries. In other words, it will depend on which region or district he is in. This point also applies to self-regulating trusts. We cannot regard the question of boundaries as a trivial matter.
This leads me to the actual questions that I wish to raise under this heading. First, can the noble Baroness say what "streamlining" means? What do the Government have in mind? Can she say in particular what problems with the present National Health Service Act have led to the requirement for streamlining? Secondly, how will the new method of streamlining work in practice? What will happen? Thirdly, have the Government any proposals for streamlining particular medical practices and hospitals?
I have taken this opportunity to raise the issue of streamlining. As I have found it rather esoteric, it may well be that the noble Baroness will also find it rather esoteric. She may feel that she does not want to plunge into giving me a definitive answer at this moment. But it would be helpful to me if she could give a definitive answer at some time before Report stage. Purely theoretically, it seems that the kind of worries I have had about the ordinary NHS side of the boundary question and streamlining will also apply, perhaps even a fortiori, to the community care side, where again the region, the district and the FHSA that one happens to be in seems to be the relevant matter. I raise these points as this stage solely for information and enlightenment but with a view in due course if I do learn enough about the subject to table amendments.
§ Baroness Hooper
I am grateful to the noble Lord for explaining the investigatory nature of his intervention. I shall do my best to give him an adequate answer. If it is not adequate I shall be happy to supplement it further at later stages.
The intention behind making new arrangements for boundary changes in Clause 1 is to remove the requirement on the Secretary of State to consult on an order varying the boundary of the health authority, including an order establishing a new one or abolishing or merging an existing one. At present a somewhat wasteful duplication of consultation is involved in the process. This is where the 131 streamlining comes in. The regional health authority consults widely on the principle of boundary change or merger but the Secretary of State is then required to repeat this consultation, concentrating on the content of the order, not the principle. There will continue to be thorough consultation but there will also be a removal of the possibility of duplication.
The clause simply aims to make the process quicker and more comprehensible to those consulted and, it is to be hoped, to all of us. A single consultation exercise will be undertaken by the regional health authority. The wasteful and confusing duplication of consultation exercises will therefore end. It should not be seen as a green light for widescale district health authority mergers. The reforms of health authority membership are not about wholesale restructuring but are designed to concentrate management attention where it matters. The regional health authority will be expected to consult widely at local level before putting proposals to the Secretary of State. He will consider them only where there is a compelling case for a change. I hope that my explanation is helpful to the noble Lord.
§ Clause 1 agreed to.
§ Clause 2 [Family Health Services Authorities]:
Lord Winstanley moved Amendment No. 2A:
Page 2, line 43, at end insert ("but appointments to the Family Health Services Authorities shall reflect the importance of continuity of service").
§ The noble Lord said: This amendment is not dissimilar to that moved by the noble Lord, Lord Walton, in relation to Clause 1. Clause 2 deals with the new family health services authorities which were the family practitioner committees. In turn they were the executive councils and local committees. I speak as one who served as a member of the Lancashire Executive Council and the Lancashire Local Medical Committee before both of those organisations were reorganised and subsumed under the new title of family practitioner committees. Therefore, I know a little about the running of these bodies. I worked very closely with a family practitioner committee with which I was under contract in general practice.
The amendment moved by the noble Lord, Lord Walton, was to ensure that there was nothing to debar the reappointment of people to health authorities. I do not ask for that because my amendment merely requires that,
appointments to the Family Health Services Authorities shall reflect the importance of continuity of service".
§ The noble Lord, Lord Jenkin of Roding, in the course of an earlier intervention said that those who propose change have a duty to demonstrate the advisability of the change. I say to him that I am not opposed to change but I have some belief in the principle of the inevitability of gradualness. Therefore, I prefer changes not to be too dramatic. I should not like to see suddenly wiped out a family practitioner committee containing some very valuable members with great experience and its replacement by people with no experience of running a family practitioner committee or what is now to be called a family health service authority.132
§ Continuity of service is very important. If the experienced people who have served for some years are suddenly removed and replaced by people with very little experience, the likelihood is that the new people will tend to do exactly what the chief officer tells them to do. To my mind that is not an ideal family health service authority. I believe that continuity is important. In making these appointments I hope that proper consideration will be given to this matter. We have a new system with all kinds of new procedures taking place as regards the general practitioner services, quite apart from the new contact. If we suddenly have totally new committees administering these bodies without any continuity, the departure of experienced people who have served on those committees would be a bad development.
§ I hope that I shall receive some reassuring words from the noble Baroness when she comes to reply. I beg to move.
§ Lord Monkswell
I am currently a member of the Manchester Family Practitioner Committee. I have to tell the Committee that over the past six months or so there has been the introduction of general managers to family practitioner committees as opposed to administrators. In some cases the original administrators have become the new general managers, so there is continuity of service in that respect. However, on a quite significant number of occasions there has been the replacement of the original administrator by a new person as general manager.
In my experience that has led not to difficulties, because that would be too strong a word, but to a need for education of the new general managers, which is necessary in the sense that the new general managers have come from outside the health service. They have not been aware of the traditions and the ways in which the National Health Service has worked, besides the particular emphasis and importance of aspects of service in the family practitioner committee arena.
It has been vitally important for the established members and chairpersons of the committees to be available to give advice and guidance to the new general managers of the family practitioner service. Given that context, the amendment which the noble Lord, Lord Winstanley, has moved is doubly important. Not only do we need a general sense of continuity in the National Health Service but also in the very specific context of the family practitioner service and what is to be called the family health service authority. We have very special circumstances. The introduction of the new general managers reinforces the need for continuity among the membership of these new advisers. I support the noble Lord in his amendment. I hope that we can get some understanding from the Government of the need for this continuity.
§ The Parliamentary Under-Secretary of State, Department of Social Security (Lord Henley)
I can assure the noble Lords, Lord Winstanley and Lord Monkswell, that we shall not be throwing away the valuable experience of existing members of family 133 health service authorities, as my noble friend has already said as regards both regional and district health authorities. I am sure that many lay members will be reappointed and others will be well placed to contribute to the work of the authority in other ways; for example, by serving on sub-committees. We share the concern of both noble Lords as regards continuity. If they look at Working for Patients, paragraph 7.24 they will note that it is stated that:The Government will ensure that the new lay membership will preserve a measure of continuity with FPCs as currently constituted".Nothing in the Bill jeopardises that.
I emphasise that the main objective in selecting members for the new authorities will be to enable the best people to be appointed for the job. Where the appointing authorities can achieve this and maintain continuity they will obviously wish to do so. However, there is no need for this to be a legislative requirement. Indeed, if we were to state it in legislation here we could inadvertently cast doubt on our ability to maintain continuity elsewhere. I hope with that in mind and in the light of those assurances that the noble Lord will not press this amendment to a Division.
I am most grateful to the noble Lord for his observations and reassuring remarks. I accept what he has said as being his intentions and no doubt those of his department. I hope that time will no: show that my confidence has been misplaced. It will be disastrous if we later find that the family health services in a certain area are being run by a committee comprised of members who have had no experience of running them and with a general manager who comes from outside and is also without experience. That would mean that the family practitioner services were being run by the Secretary of State or by his minions in the department. That is something which has to be avoided because it is certainly not the right way to run family health services.
I am grateful to the noble Lord for his reassurances. I shall await with interest reassurance from what actually happens. I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ 5 p.m.
Lord Kilmarnock moved Amendment No. 3:
Page 3, leave out lines 7 to 9.
§ The noble Lord said: In moving this amendment I am speaking also to Amendments Nos. 37B, 37C, 95, 102, 103ZA and 105. I believe that in doing so it will be for the convenience of the Committee. This series of amendments derives from remarks that I made at Second Reading in which I criticised the Bill for perpetuating and reinforcing the demarcations between the district health authority and the family practitioner committee—now to be called the family health service authority—made directly responsible to the regional health authority.
§ I suggested that it would make better sense to amalgamate the family health service authority with the relevant district or districts, thus breaking down the artificial division between the family 134 practitioners, the hospitals and the community health service. This is not only SDP policy. In their eighth report the House of Commons Social Services Select Committee reaffirmed their recommendation, contained both in their first report of 1986-87 and in their fifth report of 1987-88, that the functions of DHAs and FPCs should be merged.
§ The case for the merging of their respective functions is strong as both bodies have an important public health role and the FPCs are currently subject to annual and full four-yearly performance reviews, and the health authorities are also required to produce an annual report, which could lead to unnecessary duplication. There are many population based services such as child health surveillance, immunisation and vaccination which are currently provided both by GPs and DHAs, and so amalgamation of services should provide useful rationalisation.
The Government's response has been rather ambiguous. Responding to the Social Services Commitee's eighth report they stated that in their view the amalgamation of FPCs and DHAs would not be in the interests of the health service. However, the White Paper Working for Patients states in paragraph 3.20 that as more and more hospitals opt to become self-governing some DHAs will cease to be viable and will need to consider
the possibility of sensible mergers with neighbouring Districts. Larger Districts might eventually become candidates for mergers with Family Practitioner Committees".
§ These amendments would facilitate that development.
§ I turn now to the amendments themselves. Amendment No. 3 would leave out Clause 2(6), which as at present written precludes the possible amalgamation of DHAs and FHSAs by preventing the inclusion of a family health services authority in the expression "health authority", as defined in the principal Act, which restricts that definition to regional and district health authorities; so it would be necessary to remove that to pave the way for possible amalgamations.
§ Amendments Nos. 37B and 37C to Schedule 1 would make DHAs responsible for appointments to FHSAs rather than the regional health authorities, thus making for a better co-ordination between the two main providing arms of the service.
§ Amendments Nos. 102, 103ZA and 105 taken together have the effect of shifting the direct responsibility for the functioning and financing of the family health services authorities from the regional health authority to the district health authority, with the object of achieving better co-ordination, as I have already explained. It would be in everybody's interests—consultants, GPs, nurses and community health workers—to ensure that patients receive the most appropriate care, not necessarily in hospital. It would also provide an incentive to health authorities as a whole to invest in health promotion and stimulate a wider range of GP services, which might include the rehabilitation of GP or community hospitals to reduce expensive and unnecessary stays in acute hospitals.
§ I have deliberately jumped over Amendment No. 95, which is also grouped with this series, to which 135 I now revert. This is intended to open up the possibility of an entire district health authority becoming a self-governing NHS trust, as referred to in Amendments Nos. 102 and 103ZA. This ties in with our desire to amalgamate family health services with district health authorities because as a result of this amendment family health services authorities could merge either with an existing DHA or with those that had taken the decision to become self-governing.
§ Amendment No. 95 is a probing amendment, as are all the others, because it is very important to establish at an early stage in the discussion of the Bill what attitude the Government propose to take to the applications they have received from NHS bodies and units other than from single hospitals to become self-governing NHS trusts.
§ I have here a list, which I believe to be fairly up-to-date, of units which have applied for NHS trust status. It is quite a long one so I certainly will not go through it all, but it includes not only free-standing hospitals but also such units as Cornwall primary care services, Great Yarmouth and Waverley priority services; a number of units concerned with mental health, for example, the Newcastle mental health unit, Cornwall mental handicap services, South Lincolnshire mental handicap services; as well as a number of community services units such as North-West Herts, community services unit. Last but not least, there are about a dozen district health authorities which I understand have made an application for National Health Service trust status in their entirety. Amongst those are Central Manchester Health Authority, Brighton Health Authority, Bristol and Western Health Authority, Bassetlaw Health Authority and Rugby Health Authority.
§ I am trying to establish through this amendment in particular what the Government's attitude is likely to be towards the various applications. As I have already said, it is of great importance for the Government to tell us today how they view these applications and those of other smaller units. I suggest that the statement that they will be considered on their merits is not good enough. I think we have a right to know the Government's general policy in this area, because a trust could be of especial value to rural districts such as those of North Devon and Bassetlaw which perhaps have only one acute hospital and which are particularly anxious to keep their hospital and their community health services together. We wish to know the Government's general policy in this area because it will have a considerable effect on our view of later stages of the Bill.
As currently drafted, the Bill may well allow DHAs to become self-governing. Clause 5 states:
The Secretary of State may by order establish bodies … to assume responsibility … for the ownership and management of hospitals or other establishments or facilities which were previously managed or provided by Regional, District or Special Health Authorities".
§ This could well mean that all the services currently provided by DHAs would be covered, but it is not entirely clear and I submit that it must be clarified.136
§ There are two questions: whether the Bill allows scope for the applications of the type that I have listed and, if so, what the Government's attitude is towards them.
§ I apologise for having taken up some of the time of the Committee. I hope I have explained the intended effect of the amendments and the thinking behind them, but before I sit down perhaps I should also admit that the drafting may be too prescriptive. In particular, I should like to make it clear that it is not my intention that the structures that I propose should be mandatory over the whole service but rather that they should be opened up as possibilities within the experimental framework which I believe many of your Lordships support. Therefore, if these amendments find favour in principle the drafting defects can be remedied before the next stage of the Bill. I beg to move.
I too await with interest the reply of the noble Baroness to the group of amendments moved by the noble Lord, Lord Kilmarnock. I think it is only fair to the noble Lord to say to him that there was a time when I very much agreed with the ideas which he has put forward. He will remember that some of them hark back to the days when Dr. David Owen was Minister of Health. At that time he was much concerned, as were many of us, about the so-called tripartite structure of the National Health Service. In those days it was divided into three parts, like old Gaul: the preventive services, the hospital services and the domiciliary services. The idea at the time was that the three never should meet, and they never seemed to do so. I felt that that was illogical, and I had to do away with it. Therefore, I agreed with some of the ideas which have led to this group of amendments.
However, experience has taught me that there are certain dangers in fusing family health services with the hospital services because very often their interests are in part in conflict. I am sure that the noble Lord, Lord Kilmarnock, will recollect this fact. Whenever the hospitals in a certain area suffer what they believe to be cuts—and let us not argue as to whether they were cuts—or whenever they are short of funds and unable to discharge their duties fully, a much heavier burden immediately falls upon the family practitioner services. That happens automatically because hospitals discharge people sooner, or they cannot admit them, and more and more work is left to the family health services.
In many ways at present our family health services are under threat. They are a unique type of mechanism, and I hope that they can be protected. They will be better able to protect themselves in a rapidly changing world if they are left under a separate administrative structure. Therefore, I make clear the fact that while some of these ideas appealed to me at one time, I am now opposed to the amalgamation of the family health service authority. Whatever such an amalgamation would mean for hospitals, it would certainly be to the detriment of the domiciliary services.
§ Lord Henley
I believe that the noble Lord, Lord Kilmarnock, appreciates some of the aims behind 137 our reforms. However, I am not sure whether the noble Lord, Lord Winstanley, was able to follow his arguments. I was particularly pleased to notice his support for the concept of self-government. For too long the NHS has laboured under a very centralised direction. The move to self-government will free the initiative of all concerned with patient care—namely, doctors, nurses, managers and members—to find local solutions to local problems and to offer the best service within the ever-growing resources available. The amendments recognise the importance of that fact.
However, there is a major difficulty. Unlike our proposals, the amendments do not recognise the important role of the district health authority. Indeed, they do away with it altogether. That is a move which is misguided. Under our proposals, the role of the district health authority will be enhanced rather than diminished. It will no longer be constrained by its operational responsibilities. Instead, it will be free to assess the needs of its resident population and plan to meet them in the most effective way. That will involve intensive work in the planning and community medicine disciplines, both of which have already been strengthened under this Government.
Distri;ts will need to survey all the providers of services within their area in order to ensure that they achieve the best deal for their patients. They will be in an excellent position to influence all providers as they will be able to back their decisions with resources for the first time. The amendments fail to recognise that central role; instead, the new district health trusts combine within themselves the two distinct roles of purchaser and provider of services. That will not lead to clarity. I fear that such organisations would find their plans and aspirations increasingly driven by what services were available, instead of using their purchasing policy to influence providers into meeting precise local needs. In short, many of the benefits which their devolved management would give them would be lost by this fundamental confusion in role.
The noble Lord raised the issue of the DHA and FHSA merger. The White Paper made it clear that the merger of these bodies was possible but only in the longer term. We feel that it would be too destructive in the short term and that it would distract both the district health authorities and the FHSAs from carrying out more important tasks.
While speaking to Amendment No. 95, the noble Lord raised the question of district health authorities becoming NHS trusts. As I said on Second Reading, we are prepared to recognise that it may make sense for the full range of services in a district to become self-governing. We do not wish to prescribe that, nor do we wish to rule it out. The Government will certainly consider applications from whole districts, using benefit to patients as the key criterion. However, as I indicated, we shall ensure that the planning and purchasing functions remain distinct within the district health authority. I hope that the noble Lord will accept that our approach meets his objectives and that he will not press his amendments.
§ 5.15 p.m.
§ Lord Kilmarnock
I am fairly grateful to the noble Lord for his reply. I should stress that I do not intend to press the amendments. However, I should like to clear up one confusion which has arisen. He seemed to suggest that in these amendments we were detracting in some way from the role of the DHA. That was not the intention. Concerning the purchaser and provider, under the proposed structure we would maintain the internal market because one district would be free to trade with another. Therefore there would be some operation of the internal market in some inter-district trading.
The noble Lord is correct to say that we support to a considerable extent the trust concept as it gives greater flexibility over the terms and conditions of employing staff, the freedom to borrow either from the Government or from the private sector, subject to an overall financing limit, and also a freedom to retain notional services and to build up reserves. We agree that those facilities ought to be available to a National Health Service trust and to a district health authority (which became a National Health Service trust) if we see any of these coming into being.
I was glad to hear the noble Lord acknowledge the possibility of a merger in the longer term. It was foreshadowed by the White Paper. I noted that remark with some considerable interest. However, as we are in Committee I should like to probe a little further on one aspect of the matter. The noble Lord went some way to saying that it may make sense for a full range of services embodied in a district to acquire trust status. However, he did not give any idea of the criteria upon which that would be decided. For example, would it be because it made more sense in a rural area that it did in an urban area? That is certainly the view that is held in some of the smaller rural districts which cover the larger areas geographically. They feel that it would be helpful to them to be able to maintain their services together.
As I understand it, a number of other units have applied for trust statues, but they do not extend to the full extent of the district services. In other words, they are community units, mental health units or ambulance units and so on. Before I withdraw the amendments, I wonder whether the noble Lord can help us a little further on how the Government will look at those applications. However, I was not displeased with the latter part of his response.
§ Lord Henley
I shall respond briefly to the noble Lord's remarks. As he said, any unit of whatever kind can apply. Its eligibility for National Health Service trust status will be considered on its merits. To make the position quite clear perhaps I may return to the question of whole districts. As I said, it might make sense for the full range of services in a district to become NHS trusts. However, that will only relate to the services in the district. The DHA's other roles—that is, planning, purchasing and public health—must be kept separate.
§ Lord Kilmarnock
I am grateful to the noble Lord for that clarification. I shall study his reply with great care when it is printed in the Official Report. 139 In the meantime, I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ [Amendment No. 4 had been withdrawn from the Marshalled List.]
§ Clause 2 agreed to.
§ Schedule 1 [Health Authorities and Family Health Services Authorities]:
Baroness Young moved Amendment No. 5:
Page 63, line 7, after ("(1)") insert; ("Subject to sub-paragraph (3) below").
§ The noble Baroness said: I wish to move this amendment and at the same time speak to Amendments Nos. 16, 23 and 31. I regard these as an important series of amendments. They concern the position of universities and in particular the relationship of universities to the National Health Service.
§ I raised this point shortly before Christmas in the debate introduced by the noble Lord, Lord Hunter of Newington. I expressed what I regard as the importance of getting the relationship right. The matter was raised by a great many noble Lords during the debate on the Second Reading of the Bill. I shall leave it to other noble Lords who have attached their names to the amendment to set out in some detail the importance of universities in the health service. I make only three short points.
§ First, universities provide all the undergraduate education and training of all the nation's doctors and dentists. Secondly, they make a significant contribution to post-graduate medical education and continuing medical education. Thirdly, they provide most of the clinical research upon which the future of the National Health Service rests.
§ The purpose of these four amendments—I have others down later on the Marshalled List which apply the same principle to Scotland—is to ensure that universities share the decision-making process with health authorities at the highest level. Amendment No. 16 refers to the regional health authority, Amendment No. 23 to the district health authority and Amendment No. 31 to Wales.
§ I said at the beginning that I regarded this as an important series of amendments. The whole organisation and structure of funding, both of the universities and of the health service which are interlocked, are a complicated matter. The committee under the chairmanship of the noble Lord, Lord Croham, reported on the UGC. At one point it criticised the lack of consultation between the Department of Health and the Department of Education and Science on the subject of medical education. As a result, the steering group on undergraduate medical education was set up. It was greatly welcomed by the universities as an improved way forward but it does not replace the need for universities to be a part of the decision-making process, both at regional and at district level.
§ I believe that great harm can be done not only to teaching and research but also to the service and to 140 patient care—which at the end of the day is what the entire debate is about and which universities provide—if unilateral decisions were to be taken by some authorities without taking account of the views and position of universities. There are examples of that on which I have no doubt others will speak from their personal experience.
§ However, there is one particular aspect of the whole concern which separates this series of amendments from the many others on the Marshalled List concerning representations of one kind or another. I am referring to the straightforward and easily understood fact that universities bring money to the table. They bring some £240 million via the Department of Education and Science. I fully appreciate that in the context of the entire expenditure of the National Health Service this is a small amount. However, it is an important amount. I was about to say that universities are at the cutting edge but that might be regarded as a macabre pun on medical education. Nevertheless, that is exactly where they fall in training, education and research.
§ Perhaps I may add a personal anecdote to illustrate my interest in the matter. One of the jobs that I have taken on over the past two years is the chairmanship of a large medical appeal for the Oxford hospitals. That has not only brought me into contact with medical research but it has shown me the close inter-working between the university department of clinical medicine, the National Health Service and private money. Each is dependent on the others. It is very much a joint project and one that is worthwhile. However, it clearly depends on the close relationship between the universities and both the regions and the districts or the new regions and the new districts when they are set up.
I said in my opening remarks that the matter had been raised by a great many noble Lords in the course of Second Reading speeches. Not only was it raised by a number of noble Lords but I have every reason to believe that the Government recognised the point. I very much hope that my noble friend Lady Hooper will be able to say something positive about this. The Government recognised it when the Bill was going through another place. Perhaps I may quote from the correspondence between the Permanent Secretary of the Department of Health, Sir Christopher France and Sir Edward Parkes, Chairman of the Committee of Vice-Chancellors and Principals. Sir Christopher writes in his letter dated 25th January 1990:
For the future, the White Paper"—
that is to say, the forerunner of the Bill—
recognised the case for University membership of both relevant Health Authorities and NHS Trusts and there are proposals accordingly in the NHS and Community Care Bill.
On NHS Trusts, paragraph 3(1)(d) of Schedule 2 provides that, where a Trust has a significant teaching commitment, someone drawn from the University or Medical School is to be included among the non-executive directors.
That is now on the face of the Bill:
On DHA membership, there will be provision in regulations for teaching District Authorities to continue as now to include a member drawn from the relevant University. Paragraph 2(2) of Schedule 1 of the Bill allows for the relevant regulations to be made and these will specify that one of the non-executive members of the teaching district is to be drawn from the
appropriate University or Medical School. The fact that this is how the power is to be used has been made clear to the members of the S:anding Committee in the 'Notes on Clauses'
That is a reference to the Standing Committee in another place. My noble friend Lady Hooper said on Second Reading regarding these matters at col. 1258 of Hansard of 3rd April 1990:
In the case of districts with significant teaching responsibilities, the membership will also include representation from the relevant university or medical school".
§ I believe that my noble friend has understood the importance of the point. I hope therefore that she will be able to tell the Committee this afternoon that the Government accept the principle behind these amendments. As always on these occasions I shall quite understand if she feels that the amendments are not correctly drafted or if she would like to come back at a later stage with a redraft.
§ I hope that my noble friend will understand the impor:ance of this series of amendments which has been recognised in all parts of your Lordships' House. It is not simply of importance to the universities although that in itself is important; it is very important for the National Health Service itself. It is self-evidently true that without good medical education there will be no future National Health Service. It is also self-evidently true that without clinical research we shall not make the advances on the frontiers of medicine which are so important for the health of everybody in the country.
§ These amendments seek to make the Bill work better and to make the National Health Service work better as regards both the points I have mentioned. For the reasons that I have given I believe that the case of the universities is quite separate and distinct from that of other organisations. I hope therefore that these amendments will be considered in that light. I regard that as an important matter. With those remarks I hope that my noble friend will feel able to accept these amendments. As I said earlier, I am sure that they are in the best interests of the National Health Service. I beg to move.
§ 5.30 p.m.
§ Lord Dainton
Perhaps I can be a little more explicit on the effects of these amendments by reference to my own experience. If this group of amendments—Amendments Nos. 5, 16, 23 and 31—is accepted, it would remove the anomaly to which I drew the attention of the Chamber on Second Reading; namely, that as the Bill is now drafted, a NHS trust which is responsible for a teaching hospital would be compelled to have one of its non-executive directors appointed from the university whose students were taught in that hospital. Health authorities, on the other hand, would not be compelled to have a member from the university. I am sure, as I said on Second Reading, the Committee will agree that that is illogical. I ventured to think that it must be an oversight.
If the Bill is amended in the manner which has been suggested, both health authorities and trusts will gain the benefit of the university experience in their policy making, especially in relation to teaching and research in clinical medicine and dentistry. The argument for extending university membership to the health authorities rests on the fact that, as in 142 the past, they will be the fora in which priorities concerning hospitals are argued and where important decisions are made which will be reflected ultimately in their budgets. By illustration, I hope I may remind the Committee that when a health authority has responsibility for teaching hospitals its planning must take into account a range of facts, of which I shall just choose six important ones.
First, as the noble Baroness has already mentioned, full-time academic staff who are paid by the university will each be responsible for some of the patient care. In some university hospitals that contribution is substantial. In one university hospital that I know all the chiefs of service are full-time academic staff.
Secondly such hospitals will contain so-called "embedded accommodation" which has been provided and is still maintained at the expense of the university. That money is in addition to the some £260 million of which the noble Baroness, Lady Young, has spoken. Thirdly, the teaching and research conducted by those academic staff add to the average patient cost, I made that point on Second Reading. That fact is recognised by an increment of income provided by the Department of Health to health authorities in respect of each student enrolled. That is known as SIFT or a special increment for teaching. In practice that sum is also meant to provide a contribution towards additional research costs and may therefore be better termed as SIFT and R. An important feature of that sum is that it should be agreed precisely in amount and destination between the university and the regional health authority. If there is no such agreement I am afraid that chaos will ensue.
Fourthly, many of the resources of equipment, premises, libraries and other things which are provided by the university are almost always used by the staff of the health service and vice versa. The maintenance of this close and symbiotic relationship is of the highest importance in achieving a high standard of patient care, no less than in maintaining standards of teaching and research.
Fifthly, it is extremely important to maintain that distribution of patients with particular illnesses which is appropriate for the teaching and research that is carried out in a particular university hospital. That is clearly a matter of great importance when authorities are considering bed allocations, tertiary referral policy and other matters.
Finally, it is vitally necessary to maintain a standard of medical care and facilities which demonstrates to clinical students the standards which they should maintain throughout their working lives; in other words it has to be of exemplary quality. If this is done imperfectly, the performance of those students when they become doctors with clinical responsibility will be less than it should be. I am sure the Committee will appreciate that that would have deleterious knock-on effects which would affect many more patients in the subsequent 30 or 40 years during which such students will practise as doctors.
As a consequence of that and many other arguments which I could adduce, if health authorities are to discharge satisfactorily their duties of teaching 143 and research, it is essential for them to contain members who take a full part in the decision-making process, and who are fully cognisant of the issues I have mentioned and others like them and how those issues can be resolved. Indeed I would go further and say that unless the universities have a voice on the health authorities it will be difficult for them—the universities—to discharge their responsibilities as regards being accountable for the public money which they have received to provide an education for future doctors and dentists and also to carry out research in clinical medicine and dentistry. In all those circumstances it seems to me quite essential that membership of the health authorities by persons nominated by the universities should be enshrined in the Bill.
In that context I wish to draw the attention of the Committee to the fact that on a previous occasion reference was made to the requirement on universities and health authorities to have liaison committees. However, unfortunately, those liaison committees were not required to report to the health authority on the one hand and the university on the other. Therefore, the work of many of those liaison committees was in a considerable measure disregarded by both health authorities and universities. I believe that that is a compelling argument for ensuring that we put into the Bill a provision regarding the membership of health authorities to ensure that they incorporate a university element. In that context I should add that I have always regarded the arguments I have deployed as having considerable reciprocal force. By that I mean that there is also a strong case for a university council to have a member, preferably its chairman, drawn from the district health authority or the regional health authority. However, university government is not the subject of the Bill that we have before us. I refer to that point only to establish my own lack of bias.
Having given that background, I do not believe it is necessary for me to rehearse the details of these four amendments other than to emphasise that they provide for an unspecified number of such university people to be on regional health authorities, but for only two to be on a district health authority. The difference is to allow for the fact that there is no district health authority of which I am aware that has more than one university medical or dental school within its district, whereas I can think of some regional health authorities, notably in London and the Trent region which embraces Sheffield, Leicester and Nottingham, which have several medical schools.
I hope that I have put arguments which will enable the Government to recognise the validity of the case and in due course to modify the Bill accordingly. It would be a very great pity if the good relationships between the universities and the health service which are so necessary to the welfare of both, and the great tasks of slightly different kinds which lie ahead for each of them, should not be the best that can be achieved. The amendment will help that progress forward.
§ Lord Jenkin of Roding
I should also like to lend my support to the amendments. My mind goes back to the time—which the noble Lord, Lord Flowers, will remember well—when we had to decide how we were to allocate the London teaching hospitals to the new district health authorities in London. It was only in London that the problem arose. Of all the administrative consequences of the creation of the new district health authorities which I had to deal with, that proved not only the most difficult but intellectually the most stimulating. That was partly because of the quality of the people with whom I was able to consult. I consulted very widely indeed. It was a considerable challenge and I believe that the solutions found at that time have mostly stood the test of time. That example demonstrates exactly what the noble Lord, Lord Dainton, said about the way in which the universities and health authorities established extremely close and satisfactory relationships.
I support the amendment. I shall oppose—not necessarily with my voice on every occasion but certainly with my vote—all the subsequent amendments put down to the Bill which are intended to establish representative members. Without wishing to anticipate those debates, it seems to me that the Government's proposals for dividing purchasers and providers depends crucially upon there not being a conflict of interest on the health authorities through having providers on the boards of the purchasers. Those amendments suffer throughout from that defect. Amendment No. 5 does not.
It is not necessarily a question of merging purchasers and providers but one of recognising the function of a district or regional health authority in administering the teaching and research activities of the hospitals which are part of the universities. I do not see how that could be done satisfactorily without the membership suggested in the amendments. I was interested to hear what the noble Lord, Lord Dainton, had to say about the other side of the matter. How many health authority chairmen have the time to devote to the time-consuming business to university administration is another question and not one which is before us. However, there needs to be very close co-ordination and understanding, and wherever possible there should be complete unanimity of view. That is enormously important.
Perhaps I may end by quoting an example of the problems that can arise. The Committee will remember the position that affected the Hammersmith Hospital. It was an ordinary district general hospital in an ordinary area health authority. I am sure that the noble Lord, Lord Ennals, must have been involved in the discussions just as I was. The Hammersmith Hospital was technically not a teaching hospital, although a postgraduate hospital, and not one of the 12 special health authorities. It created an extremely difficult relationship in what was then the Hammersmith and Fulham Area Health Authority.
In those circumstances the only solution was to take the hospital out of the area health authority and create a new special health authority. That is a solution which, as I told the other place, came to me 145 in my bath as I was pondering the problem. I went into the department the next morning and said that I thought that I had found a solution. My permanent secretary said, "I have been thinking, too. What is your solution?" I said that mine was a special health authority for Hammersmith and he said that, interestingly, he had come to the same conclusion. In his case I do not think that he had done so in his bath.
The point that I am making is that where there is a mixture of general health service and, as in that case, very special teaching functions, something more is required. It should not be regarded merely as an ordinary district hospital. The solution adopted by the amendments at least goes a long way towards perpetuating what has been on the whole a successful relationship in circumstances in which there could otherwise be considerable tension, acrimony and disagreement over policy. I hope that my noble friend will be able to make sympathetic noises regarding the amendments.
I repeat that I do not believe that the amendments propose representative membership in the way that all the subsequent amendments which will be moved seek 1o perpetuate what I believe has not been a satisfactory feature of the health service. I hope that my noble friend may be able to offer us some comfort.
§ Lord Dainton
As the President of the Royal Postgraduate Medical School, perhaps I may offer congratulations to the noble Lord, Lord Jenkin, on taking a bath on that particular evening.
§ 5.45 p.m.
§ Lord Walton of Detchant
I very much support and welcome the amendments. I agree very much with the comments that have been made by the noble Baroness, Lady Young, and the noble Lord, Lord Dainton. As they have said, the universities have a vital and unique role in relation to the health of this nation. Not only do they train all of the doctors and dentists who serve in our National Health Service, but they and their associated hospitals play a crucial role in the research which leads to advances in medical treatment and improvements in the quality of care which patients receive.
As has been said, the working relationships between clinicians employed by universities on the one hand and health service staff on the other have been exceptionally close for many years. When I had the privilege of serving first as a clinical consultant in the Northern region, later in a clinical chair and subsequently as dean of a medical school, the integration between the two became very close. Ultimately it was virtually impossible in the deliberations of the board of the faculty of medicine to distinguish the contributions made by those employed by the university from those of staff employed by the NHS, and in the health authorities' deliberations to distinguish the contribution made by the university-employed staff from those of the staff employed by the NHS. That was because of the knock-for-knock agreement through which all 146 members of clincal departments in universities undertake patient care and NHS staff also teach students and do research in university departments and laboratories as well as caring for patients.
One of the crucial points relating to the regional issue is that the planning and distribution of regional specialties is the responsibility of the regional health authorities and will continue to be in the future. Most of the so-called high-technology clinical units for which specialties are provided regionally, such as neurology, neurosurgery, renal transplant and dialysis, cardiology and cardiac surgery, and the very specialised oncology and cancer care units, including those providing bone marrow transplants, are staffed at the senior level largely by university clinical academic staff One must be concerned that under the proposed system of contracts for services some of those units could be put at risk if only because GP budget holders might choose to send patients to less expensive units than to the high quality units provided on a regional basis.
It is therefore essential that the university has a direct role at regional level in decisions which could have an immediate impact on clinical teaching and research and on patient care in key regional specialties.
It is important also not to forget that nowadays much of the clinical teaching of medical students is undertaken in regional hospitals and not in the traditional teaching hospitals. In most of the regions in this country students, for their clinical teaching, are at times distributed throughout the region. It is therefore essential that appropriate safeguards are written into the Bill, as the noble Baroness, Lady Young, suggested, so that the universities' ability to provide the country with highly trained medical and dental staff, up-to-date research and high levels of patient care is not threatened.
Perhaps I may quote what was said recently by Sir Edward Parkes, chairman of the Committee of Vice-Chancellors and Principals:Effective delivery of high quality medical and dental education, as required by the Medical Acts, depends on unity of purpose between the NHS and universities at all levels. This can only be achieved if a management structure which makes proper provision for university participation is written into the legislation".Hence I wish warmly to commend the amendments to the Committee. It is essential that there should be a member drawn from the university or universities in each region on the regional health authority and one, if not two, members nominated by the associated university on district health authorities which have a significant teaching and research commitment. I hope to see a university member on all district health authorities throughout the region.
§ Earl Russell
On behalf of the Liberal Democrat Benches I should like briefly and without unduly gilding the lily to add support to the amendments.
I listened with interest to the noble Lord, Lord Jenkin of Roding. I am glad that he said that these amendments are distinct from some of those that follow. This is not a case for representation; this is a case of partnership. There is a difference of 147 function, at the same time working, as the noble Lord, Lord Walton of Detchant, said, with unity of purpose.
We have here a good working relationship. The concern of a good many of us is that that working relationship should continue. Once the Bill is on the statute book, I presume that there will be a good deal of change going on within the health service in one way or another. During the progress of that change, it is important that the good working relationship should not be disturbed. It will be much easier to bring that about if consultation can go on at all stages with views heard as early as possible before decisions are taken. In that spirit I should like to support the amendments.
§ Baroness Carnegy of Lour
It has been made clear by noble Lords that a number of the functions of universities and health authorities are inseparable. I am not sure that the solution of the problem is as simple as the amendment suggests. The amendment proposes that there should be grafted on to an arrangement, under which people are not representative, representatives of universities. I do not know whether that is possible while not adopting that method for all the other bodies which long to be represented as can be seen from other amendments. However, I hope that some way will be found for the universities to become part of the health authorities. There is no basis for arguing otherwise. I hope that my noble friend will find a way, although I am not sure that the solution suggested by the noble Lord, Lord Walton of Detchant, would accord with the strategy of the Bill. I shall be interested to hear what my noble friend has to say.
§ Lord Dainton
Perhaps I may make one comment. I hate the word representation and I deliberately avoided it. The test here is simple: if we want the health authorities, in doing their job, to have the highest degree of competence, it is inevitable that that must mean a university representative. Perhaps that word should be deleted from the record; I mean a person who will inevitably be nominated, among others perhaps, by the university and who will ultimately be appointed by the Secretary of State. That is how I look at the matter.
§ Lord Flowers
I should like to support this group of amendments so ably proposed by the noble Baroness, Lady Young. Members of the Committee have made many of the points that I would have wished to put. However, I want to speak for the University of London and its peculiar position with regard to the National Health Service. I thank the noble Lord, Lord Jenkin of Roding, for his kind remarks about our herculean efforts to put our medical affairs in some semblance of order.
The University of London has to deal with four regional health authorities, 14 district health authorities and eight special health authorities. It has 12 medical schools, three of which are wholly postgraduate, and about 30 major university hospitals are involved in its work as well as many smaller ones. Between them they train about a third of the country's doctors.
148 A case which I could perhaps use to illustrate the complexity of the problem involves our work in the North-East Thames region which contains St Bartholomew's Hospital Medical College, the London Hospital Medical College, the University College and Middlesex hospitals, which belong to University College, London, and the Royal Free Hospital Medical School. There are five university hospitals, seven district health authorities, the headquarters of the British Postgraduate Medical Federation, plus several of its seven institutes, seven special health authorities, 12 hospitals and the London School of Hygiene and Tropical Medicine together with another hospital.
In this House, only the noble Lord, Lord Annan, and myself know what it is like to be Vice-Chancellor in such a situation. It is not something that I recommend to any other noble Lords. I shall merely say that it is an extremely honourable burden. However, there have been times in my life as Vice-Chancellor when medical affairs have taken up as much as half my time for many months on end. Normally, they take up about a quarter of my time. I am sure that the noble Lord, Lord Annan, will say much the same.
The problem arises not from having a medical school, but from having to deal with many district health authorities and four regions and having to try to co-ordinate what goes on on the university front across all that. There is no disagreement among us that university medical schools contribute substantially to health service provision because doctors in the National Health Service and in the medical schools work side by side in providing patient care and in teaching and research. It follows that their policies, specialties and resources must be co-ordinated with those of the health authorities. One cannot run such a system if the policies are determined solely by one side of the partnership, by the National Health Service side or by the university side. Each side must have the deepest possible knowledge of the other and there must be collaboration.
Perhaps the most acute and best illustrated situation concerns capital provision in which regional health authorities will continue to have a major voice. For example, in my case, there is serious discussion about whether there will be a new Bloomsbury teaching hospital. That is the most important and largest capital item in the near future affecting the whole of the University of London, whether the medical or non-medical side. It is a large project. For such projects and for discussion of where specialties are to be found in different medical schools, it is essential that universities are involved in all such matters at the earliest planning stage. Happily, good sense has seen to it that there have been and are continuing consultations about the Bloomsbury hospital that I mentioned, but they should be required by law if we are moving in the direction that the Government have in mind.
Many working arrangements will be facilitated by university membership of boards at district and hospital levels rather than at regional level. I also greatly welcome the improved collaborative arrangements between universities and the National 149 Health Service proposed within the 10 key principles of the France steering group. However, I must emphasise that it is essential that the regional health authorities should also statutorily have knowledge of the problems of medical schools in their regions, if any, by including a member nominated by the appropriate university or universities.
I wholly agree with the noble Lord, Lord Dainton, that it is the knowledge of the role played by the medical schools which is of vital importance rather than their representational character. Among the membership of the regional health authority there must be somebody who understands the affairs of a medical school and how they contribute to the National Health Service. Those needs cannot be met simply by the suggestion in the letter of comfort that non-executive members might possibly be drawn from universities. One has to go a little further than that.
I shall not say any more other than summarise by saying that without statutory guarantees, which these amendments will provide, there will be a threat to the ability of universities to provide a secure long-term basis for medical and dental education and research and enable them to make their service contributions, all of which are so vital for the future welfare of the National Health Service.
§ 6 p.m.
§ Lord Adrian
I am the fourth person to put my name to this amendment. As I said at Second Reading, I believe that the proposed management boards need a more specific structure. My direct experience in these matters is nothing like as great as that of either of the noble Lords, Lord Dainton and Lord Flowers, but I have had some brief experience at Cambridge. In effect, as has already been said, many specialties provided at medical schools are made use of by health service patients in the whole of a region.
I agree with what has been said from all sides of the Chamber; namely, that it will lead to very great difficulties if regional management does not have a university presence and an input from the university. I agree also that it should not be specifically a representation of the university.
Cambridge medical school was founded about 20 years ago and has since been developing greatly. It attracts substantial funds from charity and industry to support more than half-a-dozen professorships in specialties of various kinds over and above those provided by the University Funding Council. The posts all carry honorary consultancies at Addenbrooke's Hospital. Also, the regional board has assisted developments in the medical school itself As was pointed out, the university contributes substantial resources and people to the health service. It must be able to join in the management decisions.
In the past that was done by the presence of the regius professor of physic, as we somewhat quaintly call our senior medical professor. Noble Lords will know that the chair was founded by Henry VIII and was recently occupied by the noble Lord, Lord Butterfield (who is sitting immediately in front of 150 me and who I am sure will speak much more knowledgeably than I about what has gone on).
The presence of the regius professor on the regional hospital board has meant that there has been a very productive integration of the joint resources brought to the whole enterprise of the National Health Service by the health service and the university. Services in the eastern region have been developed in a splendid spirit of co-ordination and by agreement. I have to question whether that can continue to be achieved, especially now that resources on both sides are less available than they were in some periods in the past. I question whether that kind of constructive relationship can easily continue without a university presence on the National Health Service authorities.
§ Lord Butterfield
I am tempted to make a few remarks to the Committee. I am very grateful to my colleague and friend, the noble Lord, Lord Adrian, for identifying me as someone in the succession started by Henry VIII in 1540. With great respect, I say to the Minister that it is terribly important that there should be integration between the teaching side and the performing side—the National Health Service and the universities.
I support the remarks made by the noble Baroness, Lady Young, who said that it was absolutely vital that we should get the relationship between the universities and the National Health Service right. In Cambridge we tried what I think may have lain behind the original drafting of this Bill; namely, the university liaison committee, to which the noble Lord, Lord Dainton, referred. It used to meet once or twice a year. The meetings were very unsatisfactory because they were never in phase with the political, planning and financial interests of the regional members. We did not get properly into the planning cycle. Eventually they were given up because we were never able to tie things together.
That is one reason why I believe that the Committee and the Government will give serious consideration to welding together the universities and other members of the new authorities. What really made things go in Cambridge—I am most grateful to the noble Lord, Lord Adrian, for referring to it—was when I had the confidence, as a member of the regional health authority in Cambridge, to become intimately related with its officers, the treasurer and the regional medical officer. We began to integrate and plan our joint use of resources in, to my view, an increasingly better way. Indeed, in the famous France statement about the relationship between the medical schools and the NHS, which I think came out last month, reference was specifically made to the joint planning of the use of resources that had come about in Cambridge.
At this point I should like to pay sincere tribute to those regional medical officers, Dr. Duncan and Dr. O'Brien, who made it easier for us to decide which chairs to set up next. It also gave us a little authority with the benefactors when we could say, "This has been discussed in detail with the regional health authority. It would like to see the development of a chair in, say, clinical gerontology, to get exciting research going in that particular field". So I should 151 like to join with other much more experienced and able noble Lords to urge that this clutch of amendments be looked at very closely.
§ Baroness Masham of Ilton
Eminent noble Lords have moved this amendment. Perhaps I may ask two very brief questions, one of which may be a little wide but is still of interest. Not long ago I had the pleasure of opening a small university unit in Leeds—a paediatric dental unit. The professor in charge of the unit was worried that in the future he might be short of teaching material.
I feel that there should be a link with the regions. What will happen if the teaching material is not available for the doctors and the dentists? My other question is concerned with the universities being short of money. Would it be reasonable for the private sector to contribute something because it benefits from the teaching and research of both doctors and dentists? Those are my questions.
§ Lord Dainton
Perhaps I may answer the noble Baroness from my experience on the question of getting private money into university teaching hospitals. To a certain extent that is achieved by many of the full-time academic staff being allowed to do some private practice provided that it is consonant with the policy of the school concerned and provided that the fees come to the school. There has been some discussion recently—the universities felt rather strongly about it—about the proportion of private practice fees which can be used for personal gain. It was felt that the issue might derogate considerably from the universities' motive in continuing their own research. There is a nice balance to be held. It is another reason for having a forum in which both sides are present as of right to hammer out the problems between them.
§ Baroness Hooper
These amendments are indeed important. We have heard the views of some very important people in the course of our discussion this afternoon.
The Government recognise the need for effective joint working between the National Health Service and universities. Indeed, the Permanent Secretary at the Department of Health chairs the steering group on undergraduate medical and dental education to which my noble friend Lady Young referred when moving the amendment, one of whose main purposes is to achieve just this aim of effective joint working. On 28th February the Permanent Secretary wrote to all health service general managers directing their attention to the importance of ensuring close and effective working between universities and the National Health Service. He enclosed the key principles to be observed and illustrative models for organisational arrangements. The measure was based on recommendations from the steering group which had been endorsed by the Secretaries of State for Health and for Education and Science. Copies were sent to the universities.
My right honourable friend the Secretary of State for Health is fully committed to the maintenance of high standards of medical and dental education and 152 research and recognises that effective collaboration between universities at all levels and parts of the National Health Service is essential to the maintenance of these standards.
I recognise that in a sense universities are a special case when bringing money to the table. They contribute to the National Health Service and the National Health Service also makes a contribution to supporting medical education. That interdependence is reflected in the long established knock-for-knock funding arrangements to which the noble Lord, Lord Walton, referred. It underlines the importance of collaboration between the two areas.
The Permanent Secretary's steering group, to which I have referred, continued to look at the best ways to facilitate and improve that collaboration. The recently promulgated 10 principles which were welcomed by the noble Lord, Lord Flowers, deal with how to achieve that aim. They have been widely distributed.
On regional and district health authorities, as I said in speaking to a previous amendment, our reforms aim to resolve the fundamental confusion which exists at present as to whether these bodies are representative or managerial. A key problem at the moment is that many members seem to regard themselves as representatives of the bodies which nominated or appointed them. Under our proposals both regional and district health authorities will be reduced in size and the managers will also be members of the authority for the first time. We believe that this will provide a single focus for effective decision-making which will enable the newly constituted authorities to tackle the changes and challenges that the remainder of our reforms will introduce.
I repeat that no member will be appointed on a representative basis but solely on the basis of the personal contribution and experience that he or she can bring to the work of the authority. Nevertheless, because of the importance that the Government attach to medical education and research, special provision will be made in regulations so that teaching districts in England must have one of their non-executive members drawn from a university. In Wales, where the structure of the health service is different and there is no regional tier, all nine districts will have a university member. That is why paragraph 2(2) of Schedule 1 to the Bill allows the relevant regulations to be made. The Notes on Clauses which accompany the Bill make that clear and clarify the Government's intention to use them in this way. As now, the details of health authority membership will be set out in regulations. I hope that Members of the Committee will accept my assurance that we intend to use the regulations in that way.
Amendments Nos. 23 and 31 relate to district health authorities. I emphasise once again the Government's intention to create small authorities. While it is our intention to make special provision for university membership of teaching districts, I am afraid that to provide generally for two university members could adversely affect the balance of membership, at the very least on the smaller authorities.
153 We have already in many ways made the universities a special case with regard to district health authority membership. To go further would not be compatible with the reforms that we are making in the health authority membership.
My noble friend Lord Jenkin of Roding referred to Hammersmith Hospital and special health authority status. We may be dealing with that matter in more detail during discussion of Amendment No. 37A. However, I can assure my noble friend that the special health authority for Hammersmith, as the special health authority for all the London postgraduate teaching hospitals, will have a non-executive member drawn from the relevant postgraduate institute of the university.
The noble Lord, Lord Dainton, responded to the questions raised by the noble Baroness, Lady Masham, about the private sector. His responses were very helpful and I thank him. I believe that the question of teaching material is one that can well be dealt with as a result of the collaborative process to which I have referred as a result of the Permanent Secretary's steering committee.
On regional health authorities, I emphasise that then: will be absolutely nothing to prevent someone from the appropriate university being appointed as a non-executive member on a personal basis. I believe that the noble Lord, Lord Flowers, should not discount this. Indeed, in a number of cases we expect that that will be so. However, it is not the Government's wish to be any more prescriptive about health authority membership than is absolutely necessary. I am not convinced that the only way to achieve more effective co-operation between these bodies—which I believe we all earnestly wish for—is to have a statutory university membership of regional health authorities as proposed by the amendment.
I cannot therefore at this stage accept the amendment or the others grouped with it. However, I recognise that some very powerful views have been expressed in the course of the Committee's discussion on these amendments. I shall look very carefully at all the arguments that have been advanced to see whether it is possible at a later stage to receive the general approbation of the Committee for some course of action to allay any anxieties in this respect.
§ Baroness Seear
Before the noble Baroness sits down, perhaps she will clarify one point. There is a grave danger that we shall become bogged down over the use of the word "representative". Surely she agrees—and I should be grateful if she would say so—that there is a great difference between people being representatives on a health authority because they represent a local authority, a trade union or some other worthy body, and being representatives because they are from a teaching university which is part and parcel of the health work of the country. ! They are not animals of the same species. Does the noble Baroness agree that we would be able to think clearly about the matter if we made a distinction and that we should not talk about universities being 154 represented? People from universities should be on the health authority because of their special knowledge and expertise and because they can contribute to the working of the authority. There is no parallel with any of the other groups who might claim to be represented.
§ Baroness Hooper
I hoped that I had made it clear that I consider universities to be a special case.
§ Lord Peston
I did not intervene earlier because the relevant arguments were put most cogently by Members of the Committee who spoke and I had nothing to add. Their arguments were overwhelmingly correct. I also wanted to hear the Minister's reply in the hope that she would accept the amendments or say that the Government intend to draft similar amendments to the same purpose. She did not confirm my worst fears by saying that everything can be done via regulations and ad hoc decisions by the Secretary of State. But she went some way down that road. That is a method which I find quite unacceptable given the overwhelmingly correct nature of the arguments put forward.
However, at the end of her reply, the Minister offered a completely different solution by saying that she would think about the amendments and perhaps they or similar amendments would be acceptable to the Government. If that is the case it would be a correct and rational response to the powerful arguments put to her. In particular, it would remove the suspicion that I often have when dealing with such Bills; that amendments as excellent as this are rejected because the Secretary of State or, even worse, the Civil Service finds them a little inconvenient.
I do not know what is now proposed by those Members who tabled the amendment. In my judgment, if the Minister is saying that she will think about the matter and that the Government might have an open mind about amendments proposing that people from universities would definitely be on the authority—not as a result of regulations or because the Secretary of State said so—then we need not divide at this stage. However, if she is not saying that we cannot let the matter go. Therefore, can the Minister tell the Committee exactly what the Government propose?
§ Baroness Hooper
We are all agreed about the aim of the amendments to ensure effective collaboration between the universities and the National Health Service. I have tried to explain the reason why the Government have approached the matter as set out in the Bill and why we believe it to be unnecessary to introduce such provisions. Nevertheless, having listened to the powerful arguments, I shall do my best to meet as many as possible. It may be that there are more ways than one of dealing with the situation. I shall do my best to come back with an effective solution.
§ Lord Beloff
Before we leave the series of amendments I wish to put forward a point raised most recently by the noble Baroness, Lady Seear. There is a confusion which my noble friend has not 155 wholly allayed to my satisfaction. It is between the notion of representation and what is advocated by the universities. The point is not whether so-and-so is a nominee of a university or a medical school or in some way represents them. Indeed, one cannot represent an institution as large as a medical school or university. The point is that the university contribution to the health service, which the Minister has accepted as being fundamental to our discussions, is a complicated issue. Only someone who has been, and is, personally involved in that can bring to a management board such expertise.
In recent years we have frequently discussed universities in this Chamber. There appears to be a fundamental unwillingness on the part of Her Majesty's Government to accept the fact that expert knowledge may be essential, even for a board of management. One cannot simply produce five people and say, "They will be splendid managers but none of them has ever been in a hospital or discussed with a professor the way in which his research may contribute to the advancement of medical knowledge."
I believe that Members opposite who have spoken are attempting to insist that there should be a statutory provision for such specialised knowledge to be available to any authority which must make decisions in the medical field and that they cannot be made without that.
I wish to bring some balance to this discussion of the universities. Cambridge has had a large share of the debate. When I came up to the University of Oxford in 1932—the noble Lord, Lord Jay, and my noble and learned friend Lord Hailsham, were senior to me—medicine was a relatively small part of the university's affairs. If one mentioned Oxford in the United States or anywhere abroad, medicine was not the first subject that came into people's minds. However, the situation has been transformed by a series of initiatives such as the private munificence of the late Lord Nuffield and the contribution of major, particularly overseas, foundations. Members have spoken of the input of money. A great deal has come from the medical foundations as well as from the Government and the collaboration to which the noble Baroness referred. It is a complex subject which must be at the fingertips of people who are to direct research and teaching in the future.
Finance and the saving of money appears to appeal most to Ministers and perhaps that is understandable. Therefore, I wish to remind the Minister that the way in which we shall reduce spending on health care will be proportional to the results achieved in medical research. For example, medical research has enabled the length of stay of patients to be cut down notably. The impresssion sometimes given, although not by my noble friend this evening, is that medical research is a kind of ornament at the top of the pyramid. That is totally unreal even if thought of in financial terms.
I beg my noble friend to go back to her colleagues and point out that in this Chamber we attach the utmost importance to professional expertise even in managerial bodies.
§ Baroness Carnegy of Lour
It appears that we are arguing about the wrong issue. If we wish to have the expertise of universities involved in the authority it may be that the right way is to have ex officio members. My noble friend may come back with the idea that someone from the universities could be a member on the authority ex officio. We have ex officio the chief officer of the authority and certain other officers who will be prescribed. The style of management and the role of universities which is intended in all of this would indicate to me, were I the chairman, that I should rather like to have an ex officio member and not a representative at all. Perhaps my noble friend regards that as an option. I hope that we shall not vote on this amendment and adopt it because, as I believe I indicated in a previous brief intervention, I am not sure that that is the best way of dealing with the matter. The point has been made and I think my noble friend has accepted it. If she has not, we shall certainly make sure that she accepts it at a later stage; namely, the point that the universities should be there in a managerial function because there is a shared function between university and health authority. It seems to me that there are a number of ways to go about this and the amendment is not necessarily the best way.
§ 6.30 p.m.
§ Lord Dainton
Perhaps I may make a few observations at this point. I do not believe that it is realised that what is proposed in the Bill is an attenuation of what already exists in terms of the universities' involvement in the health authorities. The Minister said—and I believe I heard this correctly—that there is nothing to prevent universities somehow being drawn in as non-executive directors if they were trusts (which is provided for) or drawn into the boards. That is quite different from there being a requirement.
The way to look at this matter is that we have an actual and necessary partnership of two people contributing to the same enterprise. They are making different but overlapping and interlocking contributions. Therefore, it is absolutely essential that both be present when decisions are made which affect the other. That is the reason for wanting a requirement.
I should mention that in many countries that is recognised by the universities carrying out their own teaching in their own hospitals which they run and manage in order to secure that degree of control of policy, educational standards, and so on. We are not arguing for the system which operates in Germany, the Netherlands or indeed in the university hospitals in the United States but merely for the retention of what we already have and enjoy and of which good use has been made.
§ Baroness Young
We have had a very useful debate on this extremely important subject. I begin by thanking particularly the noble Lords, Lord Walton, Lord Dainton and Lord Adrian, who attached their names to this amendment, for all that they have said. They have spoken from a wealth of expertise and knowledge of the relationship between 157 universities and the National Health Service. I also thank the noble Lord, Lord Flowers, for his contribution. He spoke about London and the circumstances there. I also thank the noble Lord, Lord Butterfield, for what he said about the University of Cambridge and its relationship with the National Health Service. I am grateful to all Members of the Committee who have taken part in this debate for their support.
I turn now to what my noble friend on the Front Bench said in winding up this debate. It seems to me that the issue and the problem is that which has been identified by the noble Baroness, Lady Seear, and by my noble friends Lord Jenkin and Lord Beloff; namely, what is the appropriate word to use for the relationship between universities and the National Health Service?
I hope that what I said in my opening remarks made it clear that I fully understand what the Government intend in this Bill and what they propose for both regional and district authorities. That is quite clearly laid down. I realise that people will fuel very strongly about this. They will not wish to support a lot of representatives from organisations, no matter how important or valuable those organisations may be, because that is cutting across the whole principle of the Bill. I see that argument very clearly indeed.
However, the argument about the universities is not that argument at all but is quite separate. I believe that it would be very unfortunate to use the word "representative". I have looked again rather carefully at what the Bill says about trusts. As the noble Lord, Lord Dainton, quite properly pointed out, it is quite illogical to write on the face of the | Bill something about the links with the universities and a trust and not to do it in the case of the regions or the districts. Therefore, if my noble friend considers that point she will see that there is now a real inconsistency on the face of the Bill which needs to be addressed.
As my noble friend Lord Jenkin quite properly pointed out, we are not really talking about representatives but about people who are part of the management of the whole of the National Health Service. They are not representatives but managers. They may not be termed managers on one definition but I believe that I could easily defend the fact that they have a management role. They have such a role in teaching, in research and in the use of money because, as I said, they are the only organisations which bring money to the table. That is money which comes from the DES, charities, trusts, teaching and all sorts of sources. They bring all that into the National Health Service. Therefore, they are a very real part of the management team.
That is the important point which has emerged from this debate. I should like to leave that with my noble friend Lady Hooper. I appreciate what she said. I tried to make a note of it. I shall read it very carefully. She said that collaboration with the universities is essential and that the universities are a special case. She said, and I think the noble Lord, Lord Dainton, repeated it, that there was nothing to prevent a university member being represented in a 158 personal capacity. I believe that that is the anxiety of everybody. What is really needed in this management team is for the universities to be locked into the management team and for that to be set out on the face of the Bill both at regional and district levels so that it is seen in that capacity.
I believe that that is a quite separate case from anything else. It is not only that those people are part of a management team. As the noble Lord, Lord Beloff, quite properly said, they bring specialised knowledge. That is also very important.
Therefore, I was very grateful for what my noble friend said at the end of her remarks. I am grateful to her for saying that she will take back this amendment, think about it again and, I am sure, discuss it with her right honourable friend. I am sure that she will recognise the strength of feeling in this Committee on a matter which is designed to make the Bill work better in the interests of the patients. That is the object of this amendment. It is not aimed in any way at going against the principle set out in the Bill, which I can quite understand my noble friend cannot go against.
On the strength of my noble friend's undertakings and because there will be time between now and Report to consider and discuss the points raised, I shall not press the amendment this evening. I think it is right that this matter should be considered further. However, in withdrawing the amendment I hope that she will appreciate the strength of feeling and that this question will not go away unless we are offered a satisfactory solution. I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
Lord Walton of Detchant moved Amendment No. 5A:
Page 63, line 9, at end insert ("including one hospital consultant, one general medical practitioner, and one nurse, each appointed in consultation with professional advisory bodies within the Region.").
§ The noble Lord said: I fully appreciate that in the terms of the Bill as now drafted it would be anathema in a sense to refer to representation of specific individuals, groups or interests in the health authority's future. Indeed, the noble Lord, Lord Jenkin, has already fired a salvo across the Chamber suggesting that he would be prepared to oppose all amendments which have been proposed suggesting that individuals should be appointed to health authorities representing certain sectarian interests.
§ Let me make quite clear that under this amendment and the others which are grouped with it, to which I shall also speak, it is not intended that these individuals should represent specific interests. The purpose underlying these amendments is that health authorities of the future should have available to them the appropriate professional advice among their membership to enable them to fulfil their functions as defined in the Bill. The intention is to make clear that appropriate professionals should be included within the non-executive membership.
§ For 40 years the basic information on the costings and effectiveness of the NHS has been grossly inadequate, and the case for improving all aspects of 159 management is therefore compelling. Appreciating that need, the recommendation of the Griffiths Report introduced into the service a much stronger management structure and greatly improved the quality of the managers who face, now and in the future, a massive task.
§ Health care management differs from business management in many respects. As well as a continual striving towards rapid cures made possible through the advances of modem medicine, the ethos of medical practice requires humanitarian support of all those individuals who cannot be cured. Patients must not only be treated, but must feel and be seen to be cared for. The best management policy for an individual cannot always be based on currently available scientific data on population groups. That is usually incomplete and sometimes misleading. Epidemiology and statistics are valuable tools, but are not the masters of good medical practice.
§ We heard about the importance of teaching and research in the NHS in the amendments concerning the role of universities, but there continues to be a credibility gap which has unfortunately developed, particularly in certain situations, between management on the one hand and the other professions in the National Health Service on the other.
§ I wish to stress that in moving this amendment and in speaking to those which are coupled with it, I do not seek to have representatives of professional groups within health authorities. The intention, as I said, is to have the appropriate professionals who can advise managers on important medical and other professional aspects of health care in the future. The case for developing and the obvious need to develop a real partnership between managers and health professions at all levels is absolutely crucial to the future of the National Health Service. Until the health professions have an essential role in the basic development of the new system at the policy-making level, especially concerning the quality of services to be provided as well as in the supervision of the practical aspects of the care of patients, the detailed organisation of the system could well fail. It could be based on theory and not on practice.
§ Over the past few years full credit must be given to many managers for warming to the task of trying to understand how doctors care for patients, and to many doctors for attempting to become managerially literate. However, that does not mean that each can do the job of the other. The argument that hospital doctors and other hospital-based professions cannot be a party to district or regional policy-making purchaser decisions because they are providers, is fundamentally flawed as exemplified by the dual role for general practitioners. On the one hand, the GP will be a purchaser, perhaps with a budget; on the other, he will be working side by side in the care of his patients with the providing clinician hospital based.
§ It is important that the wisdom of hospital-based clinicians be available through the membership of health authorities. Promises of seeking their advice from time to time are not adequate. The way forward is that the health professions as a whole must be 160 made a part of the decision-making machinery in the future health service. A real partnership with management and government must include listening, respect and adaptibility that is mutual. Only by harnessing professional expertise and experience can any real progress be made in finding new ways of improving the quality of patient care and preventing illness.
§ The important point underlying my amendment and those coupled with it, to which other noble Lords have added their names, is that there should be the inclusion of a reasonable number of individuals with clinical and teaching experience at every level of management, including units, districts, hospital trusts and regions. There must be an appropriate number of members on district or regional authorities who are clinicians or other members of health caring professions.
§ If one looks at these amendments, essentially Amendment No. 5A is more prescriptive in the sense that it suggests that there should be a hospital consultant, a general medical practitioner and a nurse not appointed as representatives, but appointed in consultation with professional advisory bodies within the region. I hope that every member of health authorities in the future will be prepared to act as an independent voice not representing any particular section or interest, but there simply with the purpose of improving the health care facilities provided in the region or district as a whole.
With regard to the amendments coupled with Amendment No. 5A, Amendment No, 17 is much less prescriptive. It simply requires, as an alternative to Amendment No. 5A that the Secretary of State shall consult, when making appointments:
such bodies as he may recognise as being, either in that region or generally, representative respectively of medical practitioners, dental practitioners
§ and members of the other caring professions. It is much less prescriptive. The amendments coupled with that on the Marshalled List related to similar provisions in district health authorities and the district health authorities in Wales. Amendments Nos. 38, 41, 49 and 52 relate to the family health service authorities.
§ Let me make clear that in moving Amendment No. 5A I do not seek—nor do those who added their names to the amendment—representation on health authorities of specific sectional or professional interests. I simply seek to persuade the Government that in some way it may be prescribed within the Bill that approriate professional knowledge and expertise be made available to the health service in the future through membership of these respective authorities. I beg to move.
§ 6.45 p.m.
§ Baroness Cox
I support these amendments and urge the Committee to consider them sympathetically because I believe their provisions are essential for ensuring appropriate care for the wide range of patients and clients for whom the regional, district and family health service authorities will be responsible.
The amendments specify that certain professions should be included in the groups of people who are 161 to be appointed by the chairmen, those chairmen who themselves will have been appointed by the Secretary of State. That is entirely consistent with the aims and objectives of government policy in general, which include the principle of devolution of responsibility from the centre to the periphery, in this case, to the professionals who will actually be providing the services and be responsible for care. It will enable them to contribute to the formation of the policies which they will be implementing.
The amendments are also entirely consistent with the Government's commitment to the principles of accountability by bringing professionals into the domain of decision-making. Also, and conversely, the exclusion of people with such experience and expertise appears to be not only flying in the face of those principles of devolution and accountability, but is also surely indefensible in that it denies such bodies the benefit of clinical knowledge and experience which are essential for formulating the most appropriate policies and for anticipating the effects of policies which are under consideration.
In complex organisations such as health authorities the repercussions of policy changes are far-reaching and may cause real suffering if all the potential side-effects are not taken into account. Those who are best able to forestall or to anticipate such side effects are those in the front line of care with a clinical knowledge to anticipate unintended consequences.
I offer one example from a local level to illustrate the general point I am trying to make. I was recently very disturbed to receive a letter from a ward sister. She described to me how she had experienced a situation where a local policy decision required elderly patients in a rehabilitation ward to be relocated in a busy surgical ward. It might be argued that hospital beds are hospital beds, and that those elderly people were still receiving nursing care. However, not only was the hurly-burly of a busy surgical ward a totally inappropriate environment for the rehabilitation of long-stay elderly patients; their problems were compounded by the fact that the basic equipment and facilities were totally inappropriate for them. There were no hoists to help them when bathing and the doors leading to the lavatories were too narrow for their wheelchairs. So a decision made on what might appear to be rational management grounds of bed occupancy resulted in dismay and distress for some very vulnerable people.
I quote only one example; I could give many others. I wish simply to illustrate the need for policy makers to have the benefit of members within their bodies who have professional and clinical experience. They should be available to contribute to every stage of policy making. Schedule 1 to the Bill does not exclude the membership of such professionals explicitly; but it does not require it nor provide in any specific way for their inclusion. I echo the points made by the noble Lord, Lord Walton of Detchant. We are not talking about representation in the sense of representing specific sectional interests. What we are talking about is making available to these key decision-making bodies the most appropriate professional and clinical expertise to enable them to be most effective in their policy 162 making and also, in terms of cost effectiveness, the most effective purchasers of resources.
I should like to speak for a moment for my own profession of nursing where it is felt that such an exclusion is ominous in the wake of the exclusion by my right honourable friend the Secretary of State of nurses from his own policy board. The precedent that he has set gives my colleagues in the nursing profession little confidence that their contribution will be valued in the future. Yet nursing has much to contribute to health care planning and to policy making. In many settings nurses are the only staff having direct contact with patients 24 hours a day 365 days a year. The insights they gain from this experience enable them to identify needs for services and also to witness the practical results of policies. That information is invaluable in considering and assessing policies. In addition, in the new more market-driven approach to health care envisaged in the Bill, there are good economic reasons for ensuring a nursing input to health authorities. As authorities draw up their contracts for services they are likely to find that nursing costs represent the single largest element within their budgets. At present nursing costs account for more than one-third of the average district health authority budget, so direct experience of nursing services will therefore be essential if authorities are to manage their affairs most effectively.
In conclusion, my noble friend the Minister may well say that the amendments are not necessary as the chairman of the authorities may choose to include clinical professional staff In that case the amendments merely clarify an intention and are therefore beneficial. They put on the face of the Bill what is intended. But if it is the purpose of the Bill as it now stands to allow chairman not to appoint such professional members, then we believe that the amendments are essential for the provision of adequate care for those who are in real danger of suffering if decisions are made without the benefit of clinical professional expertise and experience.
§ Lord Ennals
I wish to support all that has been said by the noble Baroness and the noble Lord, Lord Walton, who moved the amendment. It may be argued by some that they are doing special pleading on behalf of their own professions. I do not believe that that is the case. I believe that they are doing special pleading on behalf of the patients whom they serve, for whom they care and whom they understand.
I appreciated the earlier intervention of the noble Lord, Lord Beloff, concerning representatives. I wish to examine that point too. No one is suggesting that there should be within the new health authorities some external bodies which appoint people to represent those interests on the authorities. I do not believe that there should be delegates appointed by someone else and reporting back to someone else about how they are fulfilling their duties. I say that, and I shall say it later, in relation to other people whose experience should be available.
At a later stage I shall be arguing the case for experience in a number of different fields. I know that there is some contention across the Committee 163 about the nature of the new health authorities. I believe that health authorities are too large, but I fundamentally disagree with the concept of creating a tightly knit group of managers sitting with non-executive members of the business community and creating a management divorced both from those for whom they work and from those with whom they work. There is a fundamental difference. I do not know the extent to which the noble Lord, Lord Walton, or the noble Baroness, Lady Cox, agree with my view, but we have gone this far regarding the amendment before us.
One of my colleagues in another place spoke about the proposals before us in a manner that I commend. He said:My understanding of the schedule is as follows. The Minister appoints the non-executive members of regional health authorities and the chairs of the district health authorities, who are paid. The members of the regional health authorities appointed by the Minister then appoint a general manager, and together they appoint the rest of the regional health authority, which then appoints the non-executive members of the district health authority, who are also paid. The non-executive members of the district health authority who have been appointed by the regional health authority and the chair of the district health authority whom the Minister himself has appointed, all of whom are paid, then appoint the general manager of the district health authority. Then the district general manager with the non-executive members of the district health authority appoint the other executive members of the district health authority".This is a tightly knit group which can be—
§ Lord Ennals
My noble friend says "politically motivated". But my fear is that this group will be out of touch with reality. We argued earlier that people should come on to the authority, whether as appointees or by invitation because of their experience. In running a health authority one needs the experience of people who know of particular interests. One needs doctors, nurses and people who work in the community who have some knowledge of voluntary organisations. We need people who have some knowledge of the work done by local authorities in community care. If we go too far we shall set up bodies which are out of touch and isolated from those with whom they work, insensitive and too conscious of cost cutting, and cut off from the human needs of the patients whom they serve.
Sometimes it seems that we forget what the health service is about. It is about providing service for patients. It is absolutely essential that the voice of the doctors, of the nurses and perhaps of other professional groups is heard. They cannot all be there. More and more the professions understand each other and work as a team. Of course they should not all be there. The nurses are perhaps the most representative of all. At present too much in the Bill is left to the Secretary of State and his advisers. I believe that we need to open up and not tighten up the management team. It has a lot of resources to manage but I do not believe that it can do its job as if its members were directors of a private firm or public limited company. We are not running a commercial firm. We are running a national health service.
164 If the Government were to say that they were conducting a few experiments of different types of structures, I might say that we should try this type of structure as well as other types of structure. However, that is not the case. They are proposing to introduce right across the country something which is untried and untested. We shall talk about that on a later amendment. I believe that this amendment is absolutely right. One has to start with the patients and those who work with them: their presence is essential.
§ 7 p.m.
§ Lord Hunter of Newington
One is tempted to refer to a report one made in 1973 to a Conservative Government recommending medical managers. The consequence at that time was consensus management. I do not know how much coffee and tea was consumed during that period though I think the amount was substantial.
This amendment is also linked with Amendments Nos. 17 and 28 with which my name is connected. I find this matter very restricted. I wish briefly to refer to the wording of Amendment No. 17, which states that,the Secretary of State shall consult … bodies as he may recognise as being … representative … of medical and other professions".My interpretation is that the movers of this amendment are trying to get the Government to do what we failed to do in 1973; namely, to find medical managers. In those circumstances, can the Minister tell us whether they are looking for professional people to put on the board from any part of the health service and who are managerially competent?
§ Baroness Seear
I support this amendment very strongly primarily because I am a non-medical person. Indeed my personal experience is biased very much more in the direction of the business manager. Many of my best friends can be found in that field and not in the medical world. It is because I claim to know a little about the decision-making process in policy-making and management bodies that I am absolutely convinced that professional medical people should be on the board.
I know that the Minister will tell us that the professional people will be asked to give advice. That is the oldest trick in the book for keeping out the people whose knowledge should be available. Advice can be asked for in a thousand different ways and it can be listened to or not. There is no obligation on the people who ask for the advice to explain why they have accepted or rejected it. To suggest that to ask for the advice of the medical profession is any substitute at all for their being on the board is crass nonsense.
The reason I am so anxious that medical professional people should be on the board is that we in this Committee have all been on boards of one kind or another. We know that what matters is that in the cut and thrust of the arguments that take place before a decision is reached every point of view should be put forward. Unless we are obstinate to a degree, we are all prepared at that stage to adjust our point of view according to the facts and the 165 arguments that are presented as the discussion goes on. Very rarely does one come to a conclusion with which one agrees and which is exactly the same as the point of view one held at the beginning.
It is in the process of decision-making and at that point only that it is absolutely vital for professional opinion to be available. It is no good asking for professional advice beforehand and not taking it; it is no use seeking that advice after the decision has been made and then listening reluctantly to what is said. At that time the decision has been made and it is too late. The professional people have to be involved in that vital, constructive and creative process of working through the objections of all the different groups and listening to all the contributions from people with specialist knowledge. There should be business managers, but there should also be medical professionals as well. In those circumstances a decision can be arrived at and it will be the best decision that can be made.
Do not let us hear any argument that it is a substitute for medical professional people on the board to allow them the opportunity to give advice. The professional people have to be on the board if the decisions are to be right. That is not in their own interests but in order that the decision should be the right one for the patients.
§ Lord Jenkin of Roding
I should like to be the first voice that disagrees with what has so far been a chorus of approval for these amendments. I do not want to speak at length. I have listened to what my noble friend on the Front Bench has said and no doubt she will give a very reasoned refutation. I wish to make two or three short points.
I honestly believe that those who have tabled these amendments and spoken in their support have not yet taken fully on board the fundamental policy that underlies the White Paper for which this Bill provides the legislative framework. The point was made in an earlier debate that it is the distinction beteen the purchaser and the provider. Those who have spoken have tended to see the health authorities as fulfilling much the same function as the existing authorities.
However, under the new dispensation it will be a markedly different function and it will also develop into a markedly different one. The new measures will not start fully fledged on 1st April next and no one would reasonably expect that. People will take time to work into the new system. For the first time under our National Health Service the role of the health authority will be separate and distinct from the role of those who are running the hospitals, the community services and those who will be providing the services under agreements in the manner provided for in the Bill.
In those circumstances it seems to me that there has to be a clear distinction between the purchasers and the providers; otherwise—as I suggested earlier in the point which I made and to which the noble Lord, Lord Walton of Detchant, responded—those involved will be faced with a hopeless conflict of interest. That is perhaps the answer to the point made by the noble Baroness, Lady Seear; namely, 166 there is an inevitable human tendency that one will look after one's own interests. One of the major features of the public services generally, not only in this country but elsewhere, is the innate tendency for those in their employ to identify their own interests with those of the people whom they serve.
One has heard the argument over and over again: "You only need to pay us better and then the patient will get a better service". I need not dwell on the matter in detail. That is the fundamental point that underlies the philosophy of the White Paper and the Bill. I do not believe that the speeches made so far recognise the fact. I will give way to the noble Lord, but I have not finished.
§ Lord Ennals
Can the noble Lord accept that there are some of us who understand the purpose of the White Paper but who believe that the argument is simply unproven?
§ Lord Jenkin of Roding
As long as the noble Lord, Lord Ennals, makes it clear that in moving this amendment he is not trying to approve the scheme in the White Paper but trying to perpetuate the present arrangements, we shall understand what he is saying. He has made it clear that he opposes the scheme put forward in the White Paper. Therefore, the amendments to which he has put his name follow logically.
The noble Lord, Lord Ennals, said at the beginning of his speech that no one is going to suggest, as regards any of these amendments, that any one should be respresentative of particular interests. In a few moments we shall come to Amendment No. 7 concerning staff. It states:which shall include at least one person representative of NHS staff".He has a representative of the users of the service. Whatever he says, he is trying to argue for representative membership and his later amendments make that clear.
The only other point I would make is in answer to a point made by my noble friend Lady Cox who has repeated an argument which I have often heard from her professional colleagues. I have to say that I find myself increasingly puzzled by it and to some extent unsympathetic. The argument is that unless nurses are appointed at every tier of management it means that the Government, the public or the health service do not value their services. I have listened to that argument from the nursing bodies as I am sure has the noble Lord, Lord Ennals. It cannot be right to feel that you have to have a statutory nurse on every body; otherwise they will feel slighted and rejected. That is not true. The question is whether they will make a valuable contribution to the management body, to the work of the body to which one is making appointments. If the answer to that is yes, then it is open to the Secretary of State, or to the chairman as the case may be, to ensure that appropiate people with the necessary professional qualifications, where there are no conflicts of interest, be appointed.
That is the thrust of the White Paper. It is the main thrust of the Bill. Therefore, these amendments are quite inconsistent with it. I hope that my noble 167 friend will not feel seduced by the arguments—powerful and eloquent though they may have been—to depart from those principles.
§ Baroness Seear
Before the noble Lord sits down, perhaps I may make a point which I think comes better from a totally non-medical person with no particular sympathies for the medical profession. I entirely agree with what he has said. I am not asking that nurses be there because they will feel hurt if they are not there. I do not mind whether they feel hurt or not.
I am saying that if you want proper decision making and to arrive at the best decisions you need the ingredient of their knowledge in order to make the decisions. As I understand it, that is what the noble Lord said he wanted. He said that if that is necessary the Secretary of State will appoint them. If the Secretary of State agrees that it is necessary, why is it not in the Bill already? That is why we are trying to put it in. We must assume that the Secretary of State does not believe in it. That is why we want the amendment.
§ Lord Jenkin of Roding
As the noble Baroness has intervened in my speech, it seems to me only right to say that if it is included in the Bill in the form that is sought by this amendment and other subsequent amendments, it then becomes mandatory in every case and is seen as statutory.
That is what the Secretary of State is trying to get away from. I tried to get away from it 10 years ago and singularly failed because I was trying to work within a structure where the purchasers and providers were the same people. The attraction of the White Paper is that it now recognises that there are two separate functions here and that therefore there are separate roles for the various people involved.
§ Baroness Cox
As my noble friend misrepresented me perhaps I may correct him. What I tried to say—the point was made by the noble Baroness, Lady Seear—was that nurses are not interested in being represented for the sake of their own self-interest, self-esteem and self-aggrandizement. Their concern is for the patients and quality of patient care, and for the knowledge, expertise and first-hand experience they can bring, both in terms of the implication of policy making and also, as I tried to indicate, of the financial implications for nursing services, which are enormous.
The contribution of nurses to the policy-making bodies is essential at every stage of the decision-making process, along with other key professional clinical imputs, for the right decisions to be made for patients and also, if we are talking about the bodies as being purchasers, for the purchasers of services to be as well informed as possible about the value of what it is they are purchasing. Their information is crucial to enable the purchasers to do an efficient and effective job.
So to put the record straight on behalf of my profession, that was not their concern. Their concern was for the quality of services provided for patients and clients.
§ 7.15 p.m.
§ Lord Rea
I should like to support this group of amendents, and Amendments Nos. 38, 41, 49 and 52 in particular which relate to the family health services authorities.
I am perfectly well aware, as I think we all are, although Lord Jenkin does not seem to think so, that the Bill aims to separate purchasers from providers. This is a policy to which I am opposed as I am not convinced that it will work. In fact, I think it is likely to create more problems and expense than it would avoid. But I am willing to let it be tried out in a small number of districts.
Even if we want to try that separation policy, it will be extremely difficult to operate in the administration of the family health services authorities. My noble friend Lord Walton said that that would be so with regard to budget holding GPs, but it would also be extremely difficult to maintain such separation for the whole of the family health service. For instance, the new contract requires a close involvement between GPs, the whole of the primary care team and the administering authority.
The amendment to which I have put down my name, Amendment No. 41, is an excessively modest one. It simply suggests that the FHSA should include a specified number of health care professionals appointed in consultation with appropriate professional bodies. It allows the Secretary of State quite a lot of leeway. It allows for representation of those most concerned—I am sorry, "representation" is not a word I am allowed to use—it allows for membership of the authority of those most concerned with the carrying out of the functions of the FHSA. That is in the area where it most matters as regards the actual giving of patient care.
A practitioner, whether a nurse, dentist, pharmacist or GP, is aware of what is necessary at the point of implementation. Such people can give experienced advice to other members of the authority on the practicality of any proposed measures. The noble Baroness, Lady Cox, spelt this out extremely clearly with an example concerning a change in a hospital. I suggest that if professionals are absent the discussions within the FHSA will tend to be unreal, authoritarian and bureaucratic. The noble Baroness, Lady Seear, has given us an extremely good lesson in how management should be carried out and the value of discussions between people from different disciplines. If those professional experts are not there to take a real part in the discussions the decisions will be wrong, and their absence will lead to difficulties, misunderstandings and resentment. In do not think that that is the way to administer a health service, or any service for that matter.
§ Lord McColl of Dulwich
I rise to support my noble friend Lord Jenkin. He said that when he was Secretary of State he tried to depart from the usual structure of management. He has forgotten that in fact he succeeded in one area in doing just that. He replaced an area health authority with five commissioners. Not one of them was a doctor or a nurse. None of them represented anybody except the patients. Three of the five were past vice-chancellors.
169 That brings us back to the original point: we have to have university people in the appropriate place, not as representatives but there in their own right. It is essential that we get away from the business of having representatives on the boards. That is a recipe for disaster and bad management.
§ Lord Kilmarnock
The Committee is becoming completely bogged down with the question of representation. I disagree with the noble Lord, Lord Rea, in that I am in favour to a certain extent of the separation of the function of purchaser-provider. Therefore, to that extent I am sympathetic with the Government. But you could not have any purchasing body in any other business in the world which did not actually have expert purchasers. Surely that is the point. Only the nurse and the doctor who are on the management board of the DHA can know what they are buying and whether they are getting value for money.
It seems to me that the arguments put forward by the noble Lord, Lord Jenkin of Roding, and other noble Lords, do not assist the principle of purchasing and providing as separate functions. They do not cut any ice with me, because what we want is expert purchasing, and for that we need expert voices on the boards.
§ Baroness Hooper
We have had a wide-ranging discussion on the issue of representation. The Government recognise that there is an important professional contribution to be made to decision making. We believe that we provided for that in the most effective way. I do not think that any of the solutions proposed in the amendments now before the Committee add to our proposals; indeed, they might well work against them to the detriment of good management which, at the end of the day, is what will benefit patients most. That is what we all want.
The Government regard it as essential that regional health authorities and district health authorities obtain the best possible medical public health and other professional advice in the way that it—that is, each authority—feels is most effective. Shortly, we shall be debating the specific role of the Director of Public Health. However, we do not believe that the Government should dictate to health authorities how they should obtain that advice. The precise form of advice needed will vary upon the circumstances of the individual authority. Therefore, it would be misleading to try to impose any national blue-print. I should have thought that that would have been welcomed by the noble Baroness, Lady Seear. For that reason, I am not attrac:ed to the proposals put forward in Amendments Nos. 5A, 19 and 30. I do not believe that a single member at the level of the authority can provide the full range of advice needed by that authority. By seeking to enshrine a single source of advice, the amendment may actually limit its scope.
I appreciate that the noble Lord, Lord Walton, did not intend that his amendments should enable representatives to be appointed. However, as I read them, they would have that effect rather than that members were appointed on their own merits in a 170 personal capacity. One of the main advantages of our reforms relating to membership, as I have already said, is the breaking of that representative link. With the best will in the world an individual cannot take a full part in the decision-making of a public body if he feels that he is ultimately there to serve a single interest. On the other hand, appointments made on a personal basis overcome that problem, enabling all members to draw on the full range of their personal experience but not constraining their personal contribution in any way. Similar reasons—
I trust that the noble Baroness will forgive my intervention, but I feel that I should point out that no one has suggested under this amendment that these appointments should not be made on a personal basis. Indeed, they should be made on a personal basis. The issue concerns the description as to what that basis should be.
§ Baroness Hooper
Yes, I understand. However, I believe that the effect of the process which is suggested by these amendments would be that the individual would feel that he was representing the interests which had appointed him.
§ Lord Ennals
I am most grateful to the noble Baroness for giving way. If a non-executive member happens to be associated with a firm, is it then assumed that that person will be representative of that firm on the health authority? Surely you cannot have it both ways.
§ Baroness Hooper
The person concerned will have been appointed for his personal contribution. That is exactly what can happen in this case. There is nothing in the Bill to prevent any professional individual being appointed to make that sort of contribution if he is his personal capacity is seen to be the suitable person for that appointment.
§ Baroness Seear
That is what we have been saying all along. All this talk of representation is completely irrelevant to the main purpose of the amendment. Perhaps we can now return to the main issue of discussion.
§ Baroness Hooper
I am so glad that the noble Baroness agrees with me.
I must deal with these amendments one by one as they have been spoken to by the Members of the Committee involved. Similar reasons about consultation underlie my doubts on Amendments Nos. 17 and 30. If a person is appointed to membership after a specific consultation exercise, there is a real danger that such a person would see himself as a delegate rather than as an individual appointee. For that reason, I am not attracted to statutory consultation.
However, I can assure Members of the Committee that the Government give careful consideration to all suggestions put forward for membership of regional health authorities, and regions likewise do so for appointments at district level. The process will continue under the changes proposed in the Bill. No doubt the professional bodies will take full advantage of the opportunity to feed in their thoughts on the 171 non-executive membership of their local health authorities. As I have already said, there is nothing to prevent GPs, nurses or those from other professions from being appointed in a personal capacity. I should have expected that fact to be welcomed.
The noble Lord, Lord Hunter, referred to medical managers. I agree with the general emphasis of improving the managerial input of doctors. Indeed, some doctors have moved into general management while others contribute to management in other ways; for example, through the resource management initiative which we are seeing throughout the country.
The National Health Service Management Executive is keen to encourage further management training for clinicians. I believe that the input of doctors into such arrangements may well be reflected in authority membership. In many cases that will be from the Director of Public Health. But clearly health professionals who are themselves managerially qualified in addition must be among the best qualified people to make a very positive personal contribution to these authorities.
I turn now to deal with the membership of the family health services authorities. We have made our intention on professional membership quite clear. Each FHSA will contain membership drawn from the contracting professions—that is, a GP, a dentist and a pharmacist, each serving in a personal capacity. In addition, one of the other members will be a nurse with community experience. We shall be enshrining that provision in the regulations as the Notes on Clauses explain in more detail. I hope that that reassures at least to some extent those noble Lords who have questioned our intentions in this connection.
As with health authorities, we intend that those appointments should be made on a personal basis. Therefore, that will obviously receive approval from all quarters of the Committee. It is not the intention that these professional members should act as spokesmen in a single interest, but that decisions should be informed by a professional presence. The key factor in the appointments will not therefore be who nominated the person concerned but whether he is the best person for the job. That provision must have the approval of all Members of the Committee who have spoken to these amendments. In the light of that explanation, I trust that the mover of the amendment will feel able to withdraw it.
§ Baroness Masham of Ilton
Before the noble Lord, Lord Walton of Detchant, rises to speak, I should like to ask him a question. At the beginning of the debate, he said that these people would be chosen from the non-executive members. However, would it not be better if they came from the executive members? I say that because otherwise the health authorities would be very professionally orientated. I hope that he will agree to consider that suggestion.
§ Lord Walton of Detchant
I take note of the point made by the noble Baroness. I should like to express my grateful thanks to the Minister for the careful consideration she has given to Amendment No. 5A.
172 At the outset of the debate I said that it might possibly turn out—and I believe that it has—to be too prescriptive in defining by profession those whom one would wish to see appointed in a personal capacity to health authorities.
However, I am disappointed that the noble Baroness felt similarly not attracted by Amendment No. 17 and those related to it. They simply refer to a consultation process by which the Secretary of State or, in the case of people being appointed to district health authorities, the regional health authority chairman would consult appropriate professional interests before making such appointments. It is disappointing to me that the noble Baroness has not felt able to approve at least in principle the ideas set out there. My personal experience—from membership of my old regional hospital board and then subsequently of an area health authority, of several hospital management committees and district health authorities—is that without question the managerial expertise which has been introduced in increasing substance within the National Health Service has been a remarkably important development.
However, time after time even the most committed and intelligent laymen with long experience in business and many other fields, including—if I may say so in reply to the noble Lord, Lord McColl—vice-chancellors, have repeatedly turned to medical, nursing and other professional advice when specific items were required for consideration and decision. It is absolutely essential that these individuals should be available, not to be consulted and to be advisory, but to be members of health authorities involved in the full discussion and decision-making process.
In the light of the comments made by the noble Baroness, at this stage I beg leave to withdraw Amendment No. 5A. However, I reserve the right to come back with perhaps alternative amendments at the Report stage of the Bill.
§ Amendment, by leave, withdrawn.
§ Baroness Blatch
I beg to move that the House do now resume. I suggest that we reconvene in Committee upon the Bill at half past eight.
Moved accordingly, and, on Question, Motion agreed to.
§ House resumed.